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Almeida AJD, Hobson BA, Saito N, Bruun DA, Porter VA, Harvey DJ, Garbow JR, Chaudhari AJ, Lein PJ. Quantitative T 2 mapping-based longitudinal assessment of brain injury and therapeutic rescue in the rat following acute organophosphate intoxication. Neuropharmacology 2024; 249:109895. [PMID: 38437913 DOI: 10.1016/j.neuropharm.2024.109895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/07/2024] [Accepted: 02/29/2024] [Indexed: 03/06/2024]
Abstract
Acute intoxication with organophosphate (OP) cholinesterase inhibitors poses a significant public health risk. While currently approved medical countermeasures can improve survival rates, they often fail to prevent chronic neurological damage. Therefore, there is need to develop effective therapies and quantitative metrics for assessing OP-induced brain injury and its rescue by these therapies. In this study we used a rat model of acute intoxication with the OP, diisopropylfluorophosphate (DFP), to test the hypothesis that T2 measures obtained from brain magnetic resonance imaging (MRI) scans provide quantitative metrics of brain injury and therapeutic efficacy. Adult male Sprague Dawley rats were imaged on a 7T MRI scanner at 3, 7 and 28 days post-exposure to DFP or vehicle (VEH) with or without treatment with the standard of care antiseizure drug, midazolam (MDZ); a novel antiseizure medication, allopregnanolone (ALLO); or combination therapy with MDZ and ALLO (DUO). Our results show that mean T2 values in DFP-exposed animals were: (1) higher than VEH in all volumes of interest (VOIs) at day 3; (2) decreased with time; and (3) decreased in the thalamus at day 28. Treatment with ALLO or DUO, but not MDZ alone, significantly decreased mean T2 values relative to untreated DFP animals in the piriform cortex at day 3. On day 28, the DUO group showed the most favorable T2 characteristics. This study supports the utility of T2 mapping for longitudinally monitoring brain injury and highlights the therapeutic potential of ALLO as an adjunct therapy to mitigate chronic morbidity associated with acute OP intoxication.
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Affiliation(s)
- Alita Jesal D Almeida
- Department of Biomedical Engineering, University of California-Davis College of Engineering, Davis, CA, 95616, USA; Department of Radiology, University of California-Davis School of Medicine, Sacramento, CA, 95817, USA.
| | - Brad A Hobson
- Center for Molecular and Genomic Imaging, Department of Biomedical Engineering, University of California-Davis College of Engineering, Davis, CA, 95616, USA.
| | - Naomi Saito
- Department of Public Health Sciences, University of California-Davis School of Medicine, Davis, CA, 95616, USA
| | - Donald A Bruun
- Department of Molecular Biosciences, University of California-Davis School of Veterinary Medicine, Davis, CA, 95616, USA.
| | - Valerie A Porter
- Department of Biomedical Engineering, University of California-Davis College of Engineering, Davis, CA, 95616, USA; Department of Radiology, University of California-Davis School of Medicine, Sacramento, CA, 95817, USA.
| | - Danielle J Harvey
- Department of Public Health Sciences, University of California-Davis School of Medicine, Davis, CA, 95616, USA.
| | - Joel R Garbow
- Department of Radiology, Washington University School of Medicine, St Louis, MO, 63110, USA.
| | - Abhijit J Chaudhari
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, CA, 95817, USA; Center for Molecular and Genomic Imaging, Department of Biomedical Engineering, University of California-Davis College of Engineering, Davis, CA, 95616, USA.
| | - Pamela J Lein
- Department of Molecular Biosciences, University of California-Davis School of Veterinary Medicine, Davis, CA, 95616, USA.
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Stevens LJ, van de Steeg E, Doppenberg JB, Alwayn IPJ, Knibbe CAJ, Dubbeld J. Ex vivo gut-hepato-biliary organ perfusion model to characterize oral absorption, gut-wall metabolism, pre-systemic hepatic metabolism and biliary excretion; application to midazolam. Eur J Pharm Sci 2024; 196:106760. [PMID: 38574899 DOI: 10.1016/j.ejps.2024.106760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/03/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
To date, characterization of the first-pass effect of orally administered drugs consisting of local intestinal absorption and metabolism, portal vein transport and hepatobiliary processes remains challenging. Aim of this study was to explore the applicability of a porcine ex-vivo perfusion model to study oral absorption, gut-hepatobiliary metabolism and biliary excretion of midazolam. Slaughterhouse procured porcine en bloc organs (n = 4), were perfused via the aorta and portal vein. After 120 min of perfusion, midazolam, atenolol, antipyrine and FD4 were dosed via the duodenum and samples were taken from the systemic- and portal vein perfusate, intestinal faecal effluent and bile to determine drug and metabolite concentrations. Stable arterial and portal vein flow was obtained and viability of the perfused organs was confirmed. After intraduodenal administration, midazolam was rapidly detected in the portal vein together with 1-OH midazolam (EG-pv of 0.16±0.1) resulting from gut wall metabolism through oxidation. In the intestinal faecal effluent, 1-OH midazolam and 1-OH midazolam glucuronide (EG-intestine 0.051±0.03) was observed resulting from local gut glucuronidation. Biliary elimination of midazolam (0.04±0.01 %) and its glucuronide (0.01±0.01 %) only minimally contributed to the enterohepatic circulation. More extensive hepatic metabolism (FH 0.35±0.07) over intestinal metabolism (FG 0.78±0.11) was shown, resulting in oral bioavailability of 0.27±0.05. Ex vivo perfusion demonstrated to be a novel approach to characterize pre-systemic extraction of midazolam by measuring intestinal as well as hepatic extraction. The model can generate valuable insights into the absorption and metabolism of new drugs.
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Affiliation(s)
- L J Stevens
- Department of Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands; LUMC Transplant Center, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Metabolic Health Research, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - E van de Steeg
- Metabolic Health Research, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands
| | - J B Doppenberg
- LUMC Transplant Center, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - I P J Alwayn
- Department of Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands; LUMC Transplant Center, Leiden University Medical Center (LUMC), Leiden, the Netherlands.
| | - C A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research (LACDR), Leiden & Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein & Utrecht, Leiden University, the Netherlands
| | - J Dubbeld
- Department of Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands; LUMC Transplant Center, Leiden University Medical Center (LUMC), Leiden, the Netherlands
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Sechaud R, Gu H, Rahmanzadeh G, Taylor A, Chiparus O, Sharma GK, Breitschaft A, Menssen HD. Midostaurin drug interaction profile: a comprehensive assessment of CYP3A, CYP2B6, and CYP2C8 drug substrates, and oral contraceptives in healthy participants. Cancer Chemother Pharmacol 2024; 93:439-453. [PMID: 38270613 DOI: 10.1007/s00280-023-04635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE Midostaurin, approved for treating FLT-3-mutated acute myeloid leukemia and advanced systemic mastocytosis, is metabolized by cytochrome P450 (CYP) 3A4 to two major metabolites, and may inhibit and/or induce CYP3A, CYP2B6, and CYP2C8. Two studies investigated the impact of midostaurin on CYP substrate drugs and oral contraceptives in healthy participants. METHODS Using sentinel dosing for participants' safety, the effects of midostaurin at steady state following 25-day (Study 1) or 24-day (Study 2) dosing with 50 mg twice daily were evaluated on CYP substrates, midazolam (CYP3A4), bupropion (CYP2B6), and pioglitazone (CYP2C8) in Study 1; and monophasic oral contraceptives (containing ethinylestradiol [EES] and levonorgestrel [LVG]) in Study 2. RESULTS In Study 1, midostaurin resulted in a 10% increase in midazolam peak plasma concentrations (Cmax), and 3-4% decrease in total exposures (AUC). Bupropion showed a 55% decrease in Cmax and 48-49% decrease in AUCs. Pioglitazone showed a 10% decrease in Cmax and 6% decrease in AUC. In Study 2, midostaurin resulted in a 26% increase in Cmax and 7-10% increase in AUC of EES; and a 19% increase in Cmax and 29-42% increase in AUC of LVG. Midostaurin 50 mg twice daily for 28 days ensured that steady-state concentrations of midostaurin and the active metabolites were achieved by the time of CYP substrate drugs or oral contraceptive dosing. No safety concerns were reported. CONCLUSION Midostaurin neither inhibits nor induces CYP3A4 and CYP2C8, and weakly induces CYP2B6. Midostaurin at steady state has no clinically relevant PK interaction on hormonal contraceptives. All treatments were well tolerated.
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Affiliation(s)
| | - Helen Gu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Amanda Taylor
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Miller C, Sommavilla R, O'Bryant CL, Barve M, Dowlati A, Luke JJ, Khatun M, Morris T, Cullberg M. Pharmacokinetic study of capivasertib and the CYP3A4 substrate midazolam in patients with advanced solid tumors. Cancer Chemother Pharmacol 2024:10.1007/s00280-024-04667-3. [PMID: 38643311 DOI: 10.1007/s00280-024-04667-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE Capivasertib, a potent, selective inhibitor of all three AKT serine/threonine kinase (AKT) isoforms, is being evaluated in phase 3 trials in advanced breast and prostate cancer. This study evaluated the drug-drug interaction risk of capivasertib with the cytochrome P450 3A substrate midazolam in previously treated adults with advanced solid tumors. METHODS Patients received oral capivasertib 400 mg twice daily (BID) on an intermittent schedule (4 days on/3 days off) starting on day 2 of cycle 1 (29 days) and on day 1 of each 28-day cycle thereafter. In cycle 1 only, patients received oral midazolam (1 mg) on day 1 (alone), and days 8 and 12 (3rd day off and 4th day on capivasertib, respectively). Midazolam pharmacokinetics on days 8 and 12 were analyzed versus day 1. Capivasertib, with or without standard-of-care treatment, was continued in patients deemed likely to benefit. Safety and exploratory efficacy analyses were conducted. RESULTS Capivasertib-midazolam coadministration increased midazolam exposure (n = 21): geometric mean ratio (90% confidence interval) AUCinf and Cmax was 1.13 (0.97-1.32) and 1.15 (0.99-1.33) for day 8 versus day 1, and 1.75 (1.50-2.05) and 1.25 (1.08-1.46) for day 12 versus day 1. The capivasertib safety profile was manageable when administered with or without midazolam. Two patients had partial responses to treatment. CONCLUSION The up to 1.75-fold increase in midazolam exposure indicates capivasertib is a weak CYP3A inhibitor at 400 mg BID on an intermittent schedule. Capivasertib was well tolerated; exploratory efficacy analysis demonstrated evidence of clinical activity in this heavily pre-treated population. CLINICALTRIALS gov: NCT04958226.
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Affiliation(s)
- Claire Miller
- Clinical Pharmacology and Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | | | - Minal Barve
- Mary Crowley Cancer Research Centers, Dallas, TX, USA
| | - Afshin Dowlati
- University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Thomas Morris
- Late Developmental Oncology, AstraZeneca, Cambridge, UK
| | - Marie Cullberg
- Clinical Pharmacology and Quantitative Pharmacology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden.
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Dittrich TD, Vock D, Fisch U, Hert L, Baumann SM, Kliem PSC, Rüegg S, Marsch S, De Marchis GM, Sutter R. Efficacy and Tolerability of Intranasal Midazolam Administration for Antiseizure Treatment in Adults: A Systematic Review. Neurocrit Care 2024:10.1007/s12028-024-01971-x. [PMID: 38580802 DOI: 10.1007/s12028-024-01971-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/27/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE The objective of this study was to assess the efficacy and tolerability of intranasal midazolam (in-MDZ) administration for antiseizure treatment in adults. METHODS Embase and Medline literature databases were searched. We included randomized trials and cohort studies (excluding case series) of adult patients (≥ 18 years of age) examining in-MDZ administration for epilepsy, epileptic seizures, or status epilepticus published in English between 1985 and 2022. Studies were screened for eligibility based on predefined criteria. The primary outcome was the efficacy of in-MDZ administration, and the secondary outcome was its tolerability. Extracted data included study design, patient characteristics, intervention details, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS A total of 12 studies with 929 individuals treated with in-MDZ were included. Most studies were retrospective, with their number increasing over time. Administered in-MDZ doses ranged from 2.5 to 20 mg per single dose. The mean proportion of successful seizure termination after first in-MDZ administration was 72.7% (standard deviation [SD] 18%), and the proportion of seizure recurrence or persistent seizures ranged from 61 to 75%. Most frequent adverse reactions to in-MDZ were dizziness (mean 23.5% [SD 38.6%]), confusion (one study; 17.4%), local irritation (mean 16.6% [SD 9.6%]), and sedation (mean 12.7% [SD 9.7%]). CONCLUSIONS Administration of in-MDZ seems promising for the treatment of prolonged epileptic seizures and seizure clusters in adults. Limited evidence suggests that intranasal administration is safe. Further research is warranted because of the heterogeneity of cohorts, the variation in dosages, and the lack of uniformity in defining successful seizure termination.
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Affiliation(s)
- Tolga D Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Dominik Vock
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Urs Fisch
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Lisa Hert
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Sira M Baumann
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Paulina S C Kliem
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Stephan Rüegg
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Clinical Research, University of Basel, Basel, Switzerland.
- Intensive Care Unit, Department of Acute Medical Care, University Hospital Basel and University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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Zhang Y, Zhang N, Hu J, Liu C, Li G. Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP. BMC Gastroenterol 2024; 24:124. [PMID: 38566038 PMCID: PMC10985874 DOI: 10.1186/s12876-024-03197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Proper sedation of patients, particularly elderly individuals, who are more susceptible to sedation-related complications, is of significant importance in endoscopic retrograde cholangiopancreatography (ERCP). This study aims to assess the safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation in elderly patients undergoing ERCP, compared to a group of middle-aged patients. METHODS The medical records of 610 patients with common bile duct stones who underwent elective ERCP under deep sedation with a three-drug regimen, including midazolam, alfentanil, and propofol at Shandong Provincial Third Hospital from January 2023 to September 2023 were retrospectively reviewed in this study. Patients were categorized into three groups: middle-aged (50-64 years, n = 202), elderly (65-79 years, n = 216), and very elderly (≥ 80 years, n = 192). Intraoperative vital signs and complications were compared among these groups. RESULTS The three groups showed no significant difference in terms of intraoperative variation of systolic blood pressure (P = 0.291), diastolic blood pressure (P = 0.737), heart rate (P = 0.107), peripheral oxygen saturation (P = 0.188), bispectral index (P = 0.158), and the occurrence of sedation-related adverse events including hypotension (P = 0.170) and hypoxemia (P = 0.423). CONCLUSION The results suggest that a low-dose three-drug regimen consisting of midazolam, alfentanil, and propofol seems safe and effective for deep sedation of elderly and very elderly patients undergoing ERCP procedures. However, further studies are required to verify these findings and clarify the benefits and risks of this method.
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Affiliation(s)
- Yanping Zhang
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Ning Zhang
- Department of Cardiopulmonary rehabilitation, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Jing Hu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Changlin Liu
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China
| | - Guanjun Li
- Department of Anesthesiology, Cheeloo College of Medicine, Shandong Provincial Third Hospital, Shandong University, No.12 Wuyingshan Middle Road, Jinan, Shandong, 250000, China.
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Liu W, Ge X, Gao F, Kan Q, Wang S, Wang Y, He C. Safety and efficacy of dexmedetomidine vs. midazolam in complex gastrointestinal endoscopy: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2024; 48:102315. [PMID: 38467278 DOI: 10.1016/j.clinre.2024.102315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/24/2024] [Accepted: 03/06/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE This study aims to perform a meta-analysis to evaluate the safety and efficacy of dexmedetomidine versus midazolam for complex digestive endoscopy procedures, with the goal of offering comprehensive clinical evidence. METHODS Following predefined inclusion criteria, five databases were systematically searched, with a focus on identifying randomized controlled trials (RCTs) that compared the administration of dexmedetomidine and midazolam during complex digestive endoscopy procedures. The statistical software Stata 15.1 was employed for meticulous data analysis. RESULTS Sixteen RCTs were encompassed, involving a total of 1218 patients. In comparison to the midazolam group, dexmedetomidine administration was associated with a reduced risk of respiratory depression (RR=0.25, 95 %CI: 0.11-0.56) and hypoxemia (RR=0.22, 95 %CI: 0.12-0.39). Additionally, the dexmedetomidine group exhibited lower incidence rates of choking (RR=0.27, 95 %CI: 0.16-0.47), physical movement (RR=0.16, 95 %CI: 0.09-0.27), and postoperative nausea and vomiting (RR=0.56,95 %CI: 0.34-0.92). Patients and endoscopists in the dexmedetomidine group reported higher levels of satisfaction (patient satisfaction: SMD=0.73, 95 %CI: 0.26-1.21; endoscopist satisfaction: SMD=0.84, 95 %CI: 0.24-1.44). The incidence of hypotension and anesthesia recovery time did not significantly differ between the two groups (hypotension: RR=1.73,95 %CI:0.94-3.20; anesthesia recovery time: SMD=0.02, 95 %Cl: 0.44-0.49). It is noteworthy that the administration of dexmedetomidine was associated with a significant increase in the incidence of bradycardia in patients. CONCLUSION Compared to midazolam, dexmedetomidine exhibits a favorable safety profile for use in complex gastrointestinal endoscopy by significantly reducing the risk of respiratory depression and hypoxemia. Despite this, dexmedetomidine is associated with a higher incidence of bradycardia. These findings underscore the need for further research through larger, multi-center studies to thoroughly investigate dexmedetomidine's safety and efficacy.
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Affiliation(s)
- Wei Liu
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Xiaoyan Ge
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Fang Gao
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Qingfang Kan
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Shaohua Wang
- Department of Operation, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Yikai Wang
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China
| | - Chuan He
- Department of Anesthesiology, Bozhou People's Hospital, Bozhou, Anhui 236800, China.
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Aldape-Rivas DE, Padilla-Medina JR, Espinosa-Galindo AM, de la Garza-Castro S, Palacios-Ríos D, Peña-Martínez VM, Morales-Avalos R. Epidural administration of ropivacaine and midazolam is superior to intra-articular administration as postoperative analgesia after isolated arthroscopic anterior cruciate ligament reconstruction with hamstrings autograft: a randomized controlled clinical trial. J ISAKOS 2024:S2059-7754(24)00047-6. [PMID: 38460601 DOI: 10.1016/j.jisako.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Reconstructive surgery of the anterior cruciate ligament (ACL) is quite common, previous studies have documented that adequate pain control in the early phases of the postoperative period translates into early mobility and a rapid start of rehabilitation. Therefore, the search for new strategies for postoperative pain control is justified. The aim of this study was to compare intra-articular to the epidural administration of ropivacaine and midazolam as postoperative analgesia after arthroscopic ACL reconstruction with hamstring autograft (HA). MATERIAL AND METHODS Double-blinded, prospective randomized clinical trial included 108 consecutive patients aged from 18 to 50 years that had undergone arthroscopic ACL reconstruction with HA. The patients were randomly assigned to 2 groups. The first group received intraarticular ropivacaine and midazolam. The second group received epidural ropivacaine and midazolam. The need for rescue analgesia, the postoperative pain experienced, side effects and complications of the analgesic drugs were evaluated. RESULTS The intra-articular group received statistically significantly higher mean doses of rescue analgesia on the first two days (2.8 ± 1.0 vs. 1.3 ± 0.6 in the epidural group; p = 0.001). Visual Analogue Scale scores at flexion were statistically significantly higher in the intra-articular group over the entire study period. The intra-articular group also reported a statistically significantly lower range-of-motion 87 ± 15 vs. 102 ± 11 in the epidural group (p = 0.001). CONCLUSIONS Epidural administration of ropivacaine combined with midazolam in patients undergoing primary ACL reconstruction with HA was clinically and significantly better relative to rescue analgesia and the intensity of pain in the first 48 postoperative hours when compared to intraarticular administration. There was no difference in terms of adverse effects and complications. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Dareny Esmeralda Aldape-Rivas
- Department of Anesthesiology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - José Ramón Padilla-Medina
- Department of Orthopedic Surgery and Traumatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - Ana María Espinosa-Galindo
- Department of Anesthesiology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - Santiago de la Garza-Castro
- Department of Orthopedic Surgery and Traumatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - Dionisio Palacios-Ríos
- Department of Anesthesiology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - Víctor M Peña-Martínez
- Department of Orthopedic Surgery and Traumatology, University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico
| | - Rodolfo Morales-Avalos
- Department of Physiology, School of Medicine, Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, 64460, Mexico.
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Huang JX, Zhang SS, Wang SX, Xi DS, Luo FR, Liu CJ, Li H. The role of perioperative sedative anesthetics in preventing postoperative delirium: a systematic review and network-meta analysis including 6679 patients. BMC Cardiovasc Disord 2024; 24:147. [PMID: 38448835 PMCID: PMC10916082 DOI: 10.1186/s12872-024-03783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE Postoperative delirium is a common and debilitating complication that significantly affects patients and their families. The purpose of this study is to investigate whether there is an effective sedative that can prevent postoperative delirium while also examining the safety of using sedatives during the perioperative period. METHODS The net-meta analysis was used to compare the incidence of postoperative delirium among four sedatives: sevoflurane, propofol, dexmedetomidine, and midazolam. Interventions were ranked according to their surface under the cumulative ranking curve (SUCRA). RESULTS A total of 41 RCT studies involving 6679 patients were analyzed. Dexmedetomidine can effectively reduce the incidence of postoperative delirium than propofol (OR 0.47 95% CI 0.25-0.90), midazolam (OR 0.42 95% CI 0.17-1.00), normal saline (OR 0.42 95% CI 0.33-0.54) and sevoflurane (OR 0.39 95% CI 0.18-0.82). The saline group showed a significantly lower incidence of bradycardia compared to the group receiving dexmedetomidine (OR 0.55 95% CI 0.37-0.80). In cardiac surgery, midazolam (OR 3.34 95%CI 2.04-5.48) and normal saline (OR 2.27 95%CI 1.17-4.39) had a higher rate of postoperative delirium than dexmedetomidine, while in non-cardiac surgery, normal saline (OR 1.98 95%CI 1.44-2.71) was more susceptible to postoperative delirium than dexmedetomidine. CONCLUSION Our analysis suggests that dexmedetomidine is an effective sedative in preventing postoperative delirium whether in cardiac surgery or non-cardiac surgery. The preventive effect of dexmedetomidine on postoperative delirium becomes more apparent with longer surgical and extubation times. However, it should be administered with caution as it was found to be associated with bradycardia.
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Affiliation(s)
- Jin-Xiang Huang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shan-Shan Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shu-Xian Wang
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Da-Shuang Xi
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Fang-Ru Luo
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Cheng-Jiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Hong Li
- Department of Anesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China.
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Lazar S, Neufeld-Cohen A, Egoz I, Baranes S, Gez R, Glick P, Cohen M, Gutman H, Chapman S, Gore A. Efficacy of a combined anti-seizure treatment against cholinergic established status epilepticus following a sarin nerve agent insult in rats. Toxicol Appl Pharmacol 2024; 484:116870. [PMID: 38395364 DOI: 10.1016/j.taap.2024.116870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
The development of refractory status epilepticus (SE) following sarin intoxication presents a therapeutic challenge. Here, we evaluated the efficacy of delayed combined double or triple treatment in reducing abnormal epileptiform seizure activity (ESA) and the ensuing long-term neuronal insult. SE was induced in rats by exposure to 1.2 LD50 sarin followed by treatment with atropine and TMB4 (TA) 1 min later. Double treatment with ketamine and midazolam or triple treatment with ketamine, midazolam and levetiracetam was administered 30 min post-exposure, and the results were compared to those of single treatment with midazolam alone or triple treatment with ketamine, midazolam, and valproate, which was previously shown to ameliorate this neurological insult. Toxicity and electrocorticogram activity were monitored during the first week, and behavioral evaluations were performed 2 weeks post-exposure, followed by biochemical and immunohistopathological analyses. Both double and triple treatment reduced mortality and enhanced weight recovery compared to TA-only treatment. Triple treatment and, to a lesser extent, double treatment significantly ameliorated the ESA duration. Compared to the TA-only or the TA+ midazolam treatment, both double and triple treatment reduced the sarin-induced increase in the neuroinflammatory marker PGE2 and the brain damage marker TSPO and decreased gliosis, astrocytosis and neuronal damage. Finally, both double and triple treatment prevented a change in behavior, as measured in the open field test. No significant difference was observed between the efficacies of the two triple treatments, and both triple combinations completely prevented brain injury (no differences from the naïve rats). Delayed double and, to a greater extent, triple treatment may serve as an efficacious delayed therapy, preventing brain insult propagation following sarin-induced refractory SE.
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Affiliation(s)
- Shlomi Lazar
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel.
| | - Adi Neufeld-Cohen
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Inbal Egoz
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Shlomi Baranes
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Rellie Gez
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Pnina Glick
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Maayan Cohen
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Hila Gutman
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Shira Chapman
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel
| | - Ariel Gore
- Department of Pharmacology, Israel Institute for Biological Research, Ness Ziona 74100, Israel.
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11
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Jeong W, Sunwoo J, You Y, Park JS, Min JH, In YN, Ahn HJ, Jeon SY, Hong JH, Song JH, Kang H, Nguyen MTT, Kim J, Kang C. Distribution and elimination kinetics of midazolam and metabolites after post-resuscitation care: a prospective observational study. Sci Rep 2024; 14:4574. [PMID: 38403792 PMCID: PMC10894853 DOI: 10.1038/s41598-024-54968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
Administration of sedatives for post-resuscitation care can complicate the determination of the optimal timing to avoid inappropriate, pessimistic prognostications. This prospective study aimed to investigate the distribution and elimination kinetics of midazolam (MDZ) and its metabolites, and their association with awakening time. The concentrations of MDZ and its seven metabolites were measured immediately and at 4, 8, 12, and 24 h after the discontinuation of MDZ infusion, using liquid chromatography-tandem mass spectrometry. The area under the time-plasma concentration curve from 0 to 24 h after MDZ discontinuation (AUClast) was calculated based on the trapezoidal rule. Of the 15 enrolled patients, seven awakened after the discontinuation of MDZ infusion. MDZ and three of its metabolites were major compounds and their elimination kinetics followed a first-order elimination profile. In the multivariable analysis, only MDZ was associated with awakening time (AUClast: R2 = 0.59, p = 0.03; AUCinf: R2 = 0.96, p < 0.001). Specifically, a 0.001% increase in MDZ AUC was associated with a 1% increase in awakening time. In the individual regression analysis between MDZ concentration and awakening time, the mean MDZ concentration at awakening time was 16.8 ng/mL. The AUC of MDZ is the only significant factor associated with the awakening time.
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Affiliation(s)
- Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Jung Sunwoo
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, Sejong Chungnam National University Hospital, Sejong, 30099, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, Sejong Chungnam National University Hospital, Sejong, 30099, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - So Young Jeon
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Jang Hee Hong
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Pharmacology, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Ji Hye Song
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea
- Department of Medical Science, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea
| | - Hyein Kang
- Department of Food and Nutrition, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - My Tuyen Thi Nguyen
- Department of Food and Nutrition, Chungnam National University, Daejeon, 34134, Republic of Korea
- Department of Food Technology, Can Tho University, Can Tho City, 90000, Vietnam
| | - Jaehan Kim
- Department of Food and Nutrition, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, 35015, Republic of Korea.
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, 35015, Republic of Korea.
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12
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Zarour S, Weiss Y, Kiselevich Y, Iacubovici L, Karol D, Shaylor R, Davydov T, Matot I, Cohen B. The association between midazolam premedication and postoperative delirium - a retrospective cohort study. J Clin Anesth 2024; 92:111113. [PMID: 37280146 DOI: 10.1016/j.jclinane.2023.111113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN Retrospective cohort study. SETTING A single tertiary academic medical center. PATIENTS Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.
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Affiliation(s)
- Shiri Zarour
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossef Kiselevich
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Iacubovici
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Karol
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Shaylor
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamara Davydov
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, OH, United States of America.
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13
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Soliman SS, Mahmoud AM, Elghobashy MR, Zaazaa HE, Sedik GA. Eco-friendly electrochemical sensor for determination of conscious sedating drug " midazolam'' based on Au-NPs@Silica modified carbon paste electrode. Talanta 2024; 267:125238. [PMID: 37774450 DOI: 10.1016/j.talanta.2023.125238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/09/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
Benzodiazepines (BZDs) are a group of drugs prescribed for their sedating effect. Their misuse and addictive properties stipulate different authorities for developing simple, fast and accurate analytical methods for instantaneous detection. Differential pulse voltammetric technique (DPV) was utilized for the selective assay of midazolam hydrochloride (MDZ) in the pure, parenteral dosage forms and plasma samples. A chemically modified carbon paste electrode (CPE) was implemented during the study. The method depended on the electroreduction of MDZ on the surface of the electrode over a potential range of 0.0 V to -1.6 V. The electrode was fabricated using silica nanoparticles (Si-NPs) which were incorporated into the composition of the CPE and used to enhance the electrode performance. Then, to enhance the sensitivity of the method, a chronoamperometric modification step was applied for depositing gold nanoparticles (Au-NPs) on the carbon paste electrode surface. Modification with Au-NPs showed a higher reduction current peak for MDZ with well-defined peaks. Various parameters such as pH of the media and measurements scan rate were investigated and optimized to enhance the sensor sensitivity. The sensor showed a dynamic linear response over a concentration range of 4.0 × 10-7 M to 2.9 × 10-4 M of MDZ with a LOD of 2.24 × 10-8 M using 0.1 M acetate buffer (pH 5.6). The sensor was validated in accordance with the ICH guidelines regarding accuracy, precision and specificity for the selective assay of MDZ in the presence of excipients. A greenness evaluation was performed using three different assessment tools, namely, the "Green Analytical Procedure Index" (GAPI), the "Analytical Greenness metric" (AGREE) and the "Whiteness Analytical Chemistry tool" (WAC) using the RGB12 model.
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Affiliation(s)
- Shymaa S Soliman
- Analytical Chemistry Department, Faculty of Pharmacy, October 6 University, October 6 City, Giza, 12858, Egypt
| | - Amr M Mahmoud
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Mohamed R Elghobashy
- Analytical Chemistry Department, Faculty of Pharmacy, October 6 University, October 6 City, Giza, 12858, Egypt; Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Hala E Zaazaa
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt
| | - Ghada A Sedik
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, El-Kasr-El Aini Street, Cairo, 11562, Egypt.
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14
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Hirschinger H, Jaeger E, Nittka S, Hetjens S, Lorenz C, Remi C, Saussele S, Hofmann WK, Gencer D, Boch T. Treatment of agitation in terminally ill patients with intranasal midazolam versus subcutaneous midazolam: study protocol for a randomised controlled open-label monocentric trial (MinTU Study). BMC Palliat Care 2024; 23:8. [PMID: 38172871 PMCID: PMC10763309 DOI: 10.1186/s12904-023-01330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Intranasal (i.n.) drug application is a widely known and low-invasive route of administration that may be able to achieve rapid symptom control in terminally ill patients. According to the German S3 guideline "Palliative care for patients with incurable cancer", benzodiazepines, such as midazolam, are recommended for the treatment of terminal agitation. To the best of our knowledge there is no evidence for i.n. midazolam in terminally ill patients. We aim to assess the use of i.n. midazolam as an alternative to subcutaneous administration of the drug. METHODS In this monocentric, randomised, controlled, open-label investigator initiated trial, n = 60 patients treated at the palliative care unit of a University Hospital will be treated with 5 mg midazolam i.n. versus 5 mg subcutaneous (s.c.) midazolam in the control arm when terminal agitation occurs (randomly assigned 1:1). The estimated recruitment period is 18 months. Treatment efficacy is defined as an improvement on the Richmond Agitation Sedation Scale (Palliative Version) (RASS-PAL) and a study specific numeric rating scale (NRS) before and after drug administration. Furthermore, plasma concentration determinations of midazolam will be conducted at t1 = 0 min, t2 = 5 min, and t3 = 20 min using liquid chromatography/mass spectrometry (LC-MS). The primary objective is to demonstrate non-inferiority of midazolam i.n. in comparison to midazolam s.c. for the treatment of agitation in terminally ill patients. DISCUSSION Midazolam i.n. is expected to achieve at least equivalent reduction of terminal agitation compared to s.c. administration. In addition, plasma concentrations of midazolam i.n. are not expected to be lower than those of midazolam s.c. and the dynamics of the plasma concentration with an earlier increase could be beneficial. TRIAL REGISTRATION German Clinical Trials Registry DRKS00026775, registered 07.07.2022, Eudra CT No.: 2021-004789-36.
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Affiliation(s)
- Hanna Hirschinger
- 3rd Department of Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- Pharmacy, Mannheim University Hospital, Theodor-Kutzer- Ufer 1-3, 68167, Mannheim, Germany.
| | - Evelyn Jaeger
- Institute for Clinical Chemistry, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefanie Nittka
- Institute for Clinical Chemistry, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics, Biomathematics and Information Processing, University Medical Center, Heidelberg University, Mannheim, Heidelberg, Germany
| | - Christine Lorenz
- Pharmacy, Mannheim University Hospital, Theodor-Kutzer- Ufer 1-3, 68167, Mannheim, Germany
| | - Constanze Remi
- Hospital Pharmacy, Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Susanne Saussele
- 3rd Department of Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Wolf-K Hofmann
- 3rd Department of Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Deniz Gencer
- Centre for Integrative Oncology, Pain and Palliative Medicine, Oeschelbronn Clinic, 75223, Niefern-Oeschelbronn, Germany
| | - Tobias Boch
- 3rd Department of Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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15
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Wang X, Ma L, Yang X, Zhou Y, Zhang X, Han F. Efficacy of intranasal administration of dexmedetomidine in combination with midazolam for sedation in infant with cleft lip and palate undergoing CT scan: a randomized controlled trial. BMC Anesthesiol 2024; 24:10. [PMID: 38166622 PMCID: PMC10759416 DOI: 10.1186/s12871-023-02397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/25/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND There is a great challenge to sedation for infants with cleft lip and palate undergoing CT scan, because there is the younger age and no consensus on the type, dosage, and route of drug administration. OBJECTIVE This study aimed to evaluate the efficacy of intranasal administration of dexmedetomidine combined with midazolam as a sedative option for infants with cleft lip and palate under imaging procedures. METHODS Infants scheduled for cleft lip and palate repair surgery were randomly assigned to the IND group (intranasal dexmedetomidine 2 µg/kg alone) and the INDM group (intranasal dexmedetomidine 2 µg/kg combined with midazolam 0.05 mg/kg). The primary outcome was the proportion of infants underwent successful computed tomography (CT) scans under intranasal sedation. The secondary outcomes included onset time and duration of sedation, recovery time, Ramsay sedation scale, hemodynamic parameters during sedation, and adverse events. Data analyses involved the unpaired t-test, the repeated-measures analysis of variance test, and the continuity correction χ2 test. RESULTS One hundred five infants were included in the analysis. The proportion of infants underwent successful CT scans under sedation was significantly greater in the INDM group than in the IND group (47 [95.9%] vs. 45 [80.4%], p = 0.016). Additionally, the INDM group had a shorter onset time and a longer duration of sedation statistically (12 [8.5, 17] min vs. 16 [12, 20] min, p = 0.001; 80 [63.6, 92.5] min vs. 68.5 [38, 89] min, p = 0.014, respectively), and their recovery time was significantly longer (43 [30, 59.5] min vs. 31.5 [20.5, 53.5] min, p = 0.006). The difference in Ramsay sedation scale values 20 min after administration was statistically significant between the groups. No statistically significant difference was found between the groups in changes in heart rate and respiratory rate. CONCLUSION Intranasal administration of dexmedetomidine in combination with midazolam resulted in higher sedation success in comparison with sole dexmedetomidine. However, it has a relatively prolonged duration of sedation and recovery time. TRIAL REGISTRATION ChiCTR2100049122, Clinical trial first registration date: 21/07/2021.
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Affiliation(s)
- Xiaodong Wang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Lian Ma
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, Beijing, China
| | - Xudong Yang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Yi Zhou
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Xiang Zhang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Fang Han
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China.
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16
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Kipchumba B, Gitonga F, Jepchirchir C, Gitau GW, Okanya PW, Amwayi PW, Isaac AO, Nyabuga NJ. Alcohol spiked with zolpidem and midazolam potentiates inflammation, oxidative stress and organ damage in a mouse model. Forensic Toxicol 2024; 42:45-59. [PMID: 37814103 DOI: 10.1007/s11419-023-00674-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Crime-related spiking of alcoholic drinks with prescription drugs is quite common and has been happening for centuries. This study, therefore, evaluated the effects of oral administration of alcohol spiked with the zolpidem and midazolam potent sedatives on inflammation, oxidative stress and various organ damage in male Swiss albino mice. METHODS Mice were randomly assigned into six treatment groups; the first group constituted the normal control, the second group received 50 mg/kg body weight of zolpidem only, the third group received 50 mg/kg body weight zolpidem dissolved in 5 g/kg alcohol, the fourth group received 50 mg/kg midazolam only, the fifth group received midazolam (50 mg/kg) dissolved in 5 g/kg alcohol and the sixth group received 5 g/kg alcohol. RESULTS Alcohol-induced significant reduction in neurological function and altered blood hematological indicators. Such neurological impairment and negative effects on blood were exacerbated in mice administered with spiked alcohol. Additionally, midazolam and zolpidem enhanced alcohol-driven elevation of liver function markers; the serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) gamma glutamyltransferase (GGT), total bilirubin and alkaline phosphatase. Exposure to alcohol and/or spiked alcohol led to significant augmentation of nitric oxide and malonaldehyde, with concomitant depletion of liver glutathione (GSH) levels. Similarly, serum levels of pro-inflammatory cytokines tumor necrosis factor alpha and interferon-gamma were increased by co-exposure with midazolam or zolpidem. Alcohol-induced hepatotoxicity and nephrotoxicity were amplified by exposure to alcohol spiked with midazolam/zolpidem. CONCLUSION Exposure to alcohol spiked with midazolam or zolpidem appears to exacerbate neurological deficits, inflammation, oxidative stress, and organ damage.
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Affiliation(s)
- Biwott Kipchumba
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Francis Gitonga
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Careen Jepchirchir
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Grace Wairimu Gitau
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Patrick W Okanya
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Peris Wanza Amwayi
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Alfred Orina Isaac
- Department of Pharmaceutical Technology, School of Health Sciences and Technology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya
| | - Nyariki James Nyabuga
- Department of Biochemistry and Biotechnology, Technical University of Kenya, 52428, Nairobi, 00200, Kenya.
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Abdelrady MM, Fathy GM, Abdallah MAM, Ali WN. Comparison of the effect of adding midazolam versus fentanyl to intrathecal levobupivacaine in patients undergoing cesarean section: double-blind, randomized clinical trial. Braz J Anesthesiol 2024; 74:744385. [PMID: 35700752 PMCID: PMC10877347 DOI: 10.1016/j.bjane.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Many adjuvants are added to prolong the effects of spinal analgesia. We investigated the postoperative analgesic efficacy of the addition of midazolam or fentanyl to intrathecal levobupivacaine in women undergoing cesarean delivery. METHODS Eighty patients were randomly assigned to two groups (n = 40). Group M received 10 mg of 0.5% levobupivacaine plus 2 mg of midazolam. Group F received 10 mg of 0.5% levobupivacaine plus 25 μg of fentanyl. Assessments included motor and sensory block, APGAR score, time to first request for analgesia, postoperative pain score, total consumption of rescue analgesics, and adverse effects. RESULTS Sensory blockade was prolonged in Group M compared with Group F (215.58 ± 27.94 vs. 199.43 ± 19.77 min; p = 0.004), with no differences in other characteristics of the spinal block in intraoperative hemodynamics or APGAR score. The mean time to first request for rescue analgesia was longer in Group M (351.45 ± 11.05 min) than in Group F (268.83 ± 10.35 min; p = 0.000). The median total consumption of rescue analgesics in the first 24 hours postoperatively was 30 mg in Group M vs. 60 mg in Group F (p = 0.003). The median Visual Analog Scale (VAS) scores were lower in Group Ethan in Group F from the 8th to the 12th hour postoperatively, with no differences between the groups at other time points. The incidence of adverse effects was higher in Group F than in Group M. CONCLUSION Intrathecal midazolam (2 mg) was superior to intrathecal fentanyl (25 μg) in increasing the duration of the sensory blockade and postoperative analgesia with lower postoperative pain scores and decreasing the incidence of adverse effects.
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Affiliation(s)
- Marwa Mahmoud Abdelrady
- Assiut University, Faculty of Medicine, Anesthesia and Intensive Care Department, Assiut, Egypt.
| | - Golnar Mohammed Fathy
- Assiut University, Faculty of Medicine, Anesthesia and Intensive Care Department, Assiut, Egypt
| | | | - Wesam Nashat Ali
- Assiut University, Faculty of Medicine, Anesthesia and Intensive Care Department, Assiut, Egypt
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Zhou X, Zhao J, Tu H, Chen K, Hu Y, Jin Y. The effect of age on outpatient pediatric procedural sedation with intranasal dexmedetomidine and oral midazolam. Eur J Pediatr 2024; 183:169-177. [PMID: 37855928 PMCID: PMC10858144 DOI: 10.1007/s00431-023-05240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/29/2023] [Accepted: 09/23/2023] [Indexed: 10/20/2023]
Abstract
Procedural sedation for diagnostic examination is a common practice in children. The study aims to analyze the sedative effect and safety of intranasal dexmedetomidine combined with oral midazolam in outpatient pediatric procedural sedation across different age groups and to assess the incidence of sedation failure. From February 2021 to September 2021, children who underwent procedural sedation were retrospectively enrolled. The children were divided into 4 groups based on age: the infant group (0 to 1 year old), toddler group (1 to 3 years old), preschool group (3 to 6 years old), and school-age group (6 to 12 years old). Two-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam were used for sedation. The sedation success rate after rescue, sedation success rate, onset time of sedation, and the sedation time were recorded. The incidence of adverse events and the risk factors for sedation failure were also analyzed. A total of 4758 patients were identified. After exclusion, 3149 patients were ultimately enrolled. The combination of 2-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam resulted in a total success rate of 99.7% and a sedation success rate of 91.4%. The sedation success rate varied among the four groups: 90.2% in the infant group, 93.1% in the toddler group, 92.7% in the preschool group, and 78.4% in the school-age group. The sedation success rate was significantly lower in the school-age group compared to the other three groups (P < 0.001). The onset time of sedation was shorter in infant (22 min, IQR: 18-28 min, P < 0.001) and longer in the school-age group (30 min, IQR: 25-35 min, P < 0.05). Additionally, the infants had a longer sedation time (110 min, IQR: 90-135 min, P < 0.001) and a higher rate of delayed recovery (27.5%, all P < 0.001). The incidence of adverse events was low (4.70%), which bradycardia (2.03%) being the most common. Age (0-1 year and > 6 years), weight, ASA class II, and history of failed sedation were identified as risk factors of sedation failure. Conclusion: Intranasal administration of 2-mcg/kg dexmedetomidine combined with oral administration of 0.5-mg/kg midazolam was found to be efficient and safety for pediatric procedural sedation. Different age groups of children exhibited distinct sedation characteristics, and age was identified as a risk factor affecting the efficacy of sedation. What is Known: • Procedural sedation for diagnostic examination is a common practice in children. • The combination of dexmedetomidine with midazolam can improve sedative effects. What is New: • The success rate of sedation using a combination of 2-mcg/kg intranasal dexmedetomidine and 0.5-mg/kg oral midazolam was significantly lower in school-age children as compared to infants, toddlers, and preschoolers. • The onset time of sedation increased with age, and the sedation time was found to be longer in infant patients.
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Affiliation(s)
- Xiaqing Zhou
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jialian Zhao
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiya Tu
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kunwei Chen
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yaoqin Hu
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yue Jin
- Department of Anesthesiology, the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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Rondagh M, De Vries LS, Peeters-Scholte CM, Tromp SC, Steggerda SJ. Efficacy of Levetiracetam as Add-On Therapy in the Treatment of Seizures in Neonates. Neonatology 2023; 121:233-243. [PMID: 38113859 PMCID: PMC10994567 DOI: 10.1159/000535499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION There is no consensus regarding the efficacy of add-on therapy with levetiracetam (LEV) in the treatment of seizures in neonates. The aim of this study was to evaluate the efficacy of add-on therapy with LEV for achieving >80% seizure reduction after phenobarbital (PB) treatment. METHODS Retrospective cohort study of near term neonates admitted to the neonatal intensive care unit with EEG-confirmed seizures despite treatment with PB as first-line therapy and using LEV as 2nd-, 3rd- or 4th-line treatment. Antiseizure medication was administered according to national guidelines. All neonates were monitored with 2-channel amplitude-integrated electroencephalography. The total seizure burden in minutes, 2 h before and 4 h after administration of LEV, was calculated using raw EEG. Primary outcome was the efficacy of LEV in achieving >80% seizure reduction. The efficacy of additional midazolam (MDZ) and lidocaine (LDC) was also calculated. RESULTS A total of 47 full-term neonates were included. The mean total loading dose of LEV was 40 mg/kg (36-44 mg/kg). Seizure etiology consisted of hypoxic-ischemic encephalopathy (n = 11), hemorrhagic or ischemic stroke (n = 16), central nervous system infection (n = 8), genetic (n = 8), metabolic disorders (n = 3), and unknown (n = 1). Following LEV administration, >80% seizure reduction was observed in 17% (8/47) of neonates, whereas it was 23% (6/26) after MDZ and 92% (23/25) after LDC administration. DISCUSSION Although the cumulative loading dose of LEV was low and the group of infants studied was heterogeneous, the efficacy of LEV as add-on therapy for the treatment of seizures in neonates was limited. The highest seizure reduction rate was seen after LDC administration.
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Affiliation(s)
- Mathies Rondagh
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda S. De Vries
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Selma C. Tromp
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J. Steggerda
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Taneja S, Jain A. Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures. Oral Maxillofac Surg 2023; 27:547-557. [PMID: 35759132 DOI: 10.1007/s10006-022-01087-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature. METHODOLOGY A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model. RESULTS Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I2=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I2=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I2=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I2=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents. CONCLUSION DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.
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Affiliation(s)
- Saumya Taneja
- Department of Pedodontics and Preventive Dentistry, Inderprastha Dental College and Hospital, Ghaziabad, Uttar Pradesh, India
| | - Anuj Jain
- Department of Oral and Maxillofacial Surgery, Dr. H.S.R.S.M. Dental College, Hingoli, Maharashtra, India.
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Jelovac A, McCaffrey C, Terao M, Shanahan E, Mohamed E, Whooley E, McDonagh K, McDonogh S, Igoe A, Loughran O, Shackleton E, O'Neill C, McLoughlin DM. Study protocol for Ketamine as an adjunctive therapy for major depression (2): a randomised controlled trial (KARMA-Dep [2]). BMC Psychiatry 2023; 23:850. [PMID: 37974160 PMCID: PMC10655414 DOI: 10.1186/s12888-023-05365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Depression is a common psychiatric disorder and a leading cause of disability worldwide. Conventional monoaminergic antidepressants have limited efficacy and take weeks to exert a therapeutic effect. Single infusions of subanaesthetic doses of ketamine exhibit rapid antidepressant action but effects are transient and relapse is common. One potential strategy for increasing ketamine's antidepressant efficacy and/or prolonging its therapeutic benefit may be serial infusions. There is limited evidence on the efficacy and safety of repeated ketamine infusions against an active comparator. METHODS This protocol describes an ongoing pragmatic, randomised, controlled, parallel-group, patient- and rater-blind, superiority trial. Eligible adult inpatients with a confirmed DSM-5 diagnosis of a major depressive episode (unipolar or bipolar) are randomly allocated in a 1:1 ratio to a course of up to eight infusions of ketamine or midazolam twice-weekly over four weeks. The primary objective is to assess the efficacy of serial adjunctive ketamine infusions versus active comparator midazolam by measuring Montgomery-Åsberg Depression Rating Scale score difference between arms from before the first infusion to 24 h after the final infusion, supplemented by a 95% confidence interval. To facilitate generalisability of results, the trial takes place under "real world" conditions with both groups continuing to receive regular inpatient care including treatment-as-usual pharmacotherapy, nursing care, and psychological and other therapies during the randomised treatment phase and regular outpatient care thereafter. Participants are monitored for relapse during a 24-week follow-up after the end of the randomised phase. Secondary objectives of the trial are to assess: response and remission rates at the end of randomised phase; relapse status during the 24-week follow-up after the end of the randomised phase; the safety and tolerability of repeated ketamine infusions regarding psychotomimetic and other psychiatric side effects, cognitive side effects, as well as withdrawal symptoms, haemodynamic stability, neurological, urological, and other physical side effects; and quality of life and cost-effectiveness. DISCUSSION There is an unmet clinical need for rapidly-acting novel antidepressants. This trial will provide efficacy, safety and health economic data on serial ketamine infusions and thus help inform clinical practice on the potential role of this treatment in the management of depression. TRIAL REGISTRATION EudraCT 2019-003109-92. Registered 2 October 2019. CLINICALTRIALS gov NCT04939649. Registered 25 June 2021.
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Affiliation(s)
- Ana Jelovac
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Cathal McCaffrey
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Masashi Terao
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Enda Shanahan
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Enas Mohamed
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Emma Whooley
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Kelly McDonagh
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Sarah McDonogh
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Anna Igoe
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Orlaith Loughran
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Ellie Shackleton
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Ciaran O'Neill
- Centre for Public Health, Global Research Institute for Health Sciences, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Declan M McLoughlin
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland.
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.
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Zhang MQ, Xu MZ, He Y, Su YW, Ma J, Zuo YX. Comparison of S-ketamine and midazolam for intravenous preoperative sedative and anxiolytic effects in preschool children: study protocol for a randomized controlled clinical trial. Trials 2023; 24:724. [PMID: 37957769 PMCID: PMC10644481 DOI: 10.1186/s13063-023-07767-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Preoperative anxiety management is gaining particular attention in paediatric anaesthesia. Pharmacological and non-pharmacological resorts can be implemented to address this special issue. Despite the various approaches currently used for preoperative sedation in children, the different sedative and anti-anxiety effects between the newly marketed anaesthetic, S-ketamine, and the traditional sedative, midazolam, are still unclear. METHODS This is a patient- and assessor-blinded randomized controlled clinical trial. Participants (n = 110) will receive S-ketamine (0.5 mg/kg) or midazolam (0.08 mg/kg) intravenously administrated at a ratio of 1:1 in the anaesthesia holding area. The primary outcome of this study is the sedative effect evaluated via the change in the modified Yale preoperative anxiety scale. It will be performed at two timepoints: in the pre-anaesthetic holding area before premedication (baseline, marked as T0) and about 5 min after premedication in the operating room without the existence of their guardians (marked as T1). Our secondary objectives include the parent separation anxiety score, postoperative agitation, caregivers' and anaesthesia care providers' satisfaction, and mask compliance. DISCUSSION This randomized controlled trial is the first study to compare the anti-anxiety effect of intravenous S-ketamine and midazolam. We will provide a new approach for the clinical management of preoperative anxiety in preschool children posted for elective surgery. TRIAL REGISTRATION ChiCTR2300069998. Registered on 30 March 2023.
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Affiliation(s)
- Meng-Qiu Zhang
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Zhe Xu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi He
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yong-Wei Su
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Ma
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yun-Xia Zuo
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Bode CM, Kristensen SB, Olsen HT, Cornwall CD, Roberg L, Monsson O, Krøigård T, Toft P, Beier CP. Postictal Encephalopathy After Status Epilepticus: Outcome and Risk Factors. Neurocrit Care 2023:10.1007/s12028-023-01868-1. [PMID: 37940836 DOI: 10.1007/s12028-023-01868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Postictal encephalopathy is well known after status epilepticus (SE), but its prognostic impact and triggers are unknown. Here, we aimed to establish risk factors for the development of postictal encephalopathy and to study its impact on survival after discharge. METHODS This retrospective cohort study comprised adult patients diagnosed with first nonanoxic SE at Odense University Hospital between January 2008 and December 2017. Patients with ongoing SE at discharge or unknown treatment success were excluded. Postictal symptoms of encephalopathy were estimated retrospectively using the West Haven Criteria (WHC). WHC grade was determined for postictal day 1 to 14 or until the patient died or was discharged from the hospital. Cumulative postictal WHC during 14 days after SE-cessation was used to quantify postictal encephalopathy. Clinical characteristics, patient demographics, electroencephalographic and imaging features, and details on intensive care treatment were assessed from medical records. RESULTS Of all eligible patients (n = 232), 198 (85.3%) had at least WHC grade 2 postictal encephalopathy that lasted for > 14 days in 24.5% of the surviving patients. WHC grade at discharge was strongly associated with poor long-term survival (p < 0.001). Postictal encephalopathy was not associated with nonconvulsive SE, postictal changes on magnetic resonance imaging, or distinct ictal patterns on electroencephalography. Although duration of SE and treatment in the intensive care unit showed an association with cumulative postictal WHC grade, they were not independently associated with the degree of encephalopathy when controlling for confounders. In a linear regression model, etiology, duration of sedation, age, and premorbid modified Rankin Scale were significant and consistent predictors for higher cumulative postictal WHC grade. Exploratory analyses showed an association of a cumulative midazolam dosage (mg/kg/h) with higher cumulative postictal WHC grade. DISCUSSION In this cohort, postictal encephalopathy after SE was common and associated with poor long-term survival. Seizure characteristics were not independently associated with postictal encephalopathy; the underlying etiology, long (high-dose midazolam) sedation, high age, and poor premorbid condition were the major risk factors for its development.
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Affiliation(s)
- Clara Marie Bode
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Simon Bruun Kristensen
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | | | - Camilla Dyremose Cornwall
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lars Roberg
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Olav Monsson
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Neurophysiology, Odense University Hospital, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
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Smeets TJL, de Geus HRH, Valkenburg AJ, Baidjoe L, Gommers DAMPJ, Koch BCP, Hunfeld NGM, Endeman H. The Clearance of Midazolam and Metabolites during Continuous Renal Replacement Therapy in Critically Ill Patients with COVID-19. Blood Purif 2023; 53:107-113. [PMID: 37926072 PMCID: PMC10836747 DOI: 10.1159/000534538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Midazolam-based continuous intravenous sedation in patients admitted to the intensive care unit (ICU) was a necessity during the COVID-19 pandemic. However, benzodiazepine-based sedation is associated with a high incidence of benzodiazepine-related delirium and additional days on mechanical ventilation. Due to the requirement of high midazolam doses in combination with the impaired renal clearance (CL) of the pharmacological active metabolite 1-OH-midazolam-glucuronide (10% compared to midazolam), ICU patients with COVID-19 and continuous renal replacement therapy (CRRT) were at risk of unintended prolonged sedation. Several CRRT-related factors may have influenced the delivered CL of midazolam and its metabolites. Therefore, the aim of the study was to identify and describe these CRRT-related factors. METHODS Pre-filter blood samples and ultrafiltrate samples were collected simultaneously. Midazolam, 1-OH-midazolam, and 1-OH-midazolam-glucuronide plasma samples were analyzed using an UPLC-MS/MS method. The prescribed CRRT dose was corrected for downtime and filter integrity using the urea ratio (urea concentration in effluent/urea concentration plasma). CL of midazolam and its metabolites were calculated with the delivered CRRT dose (corrected for downtime and saturation coefficient [SD]). RESULTS Three patients on continuous venovenous hemodialysis (CVVHD) and 2 patients on continuous venovenous hemodiafiltration (CVVHDF) were included. Midazolam, 1-OH-midazolam, and 1-OH-midazolam-glucuronide concentrations were 2,849 (0-6,700) μg/L, 153 (0-295) μg/L, and 27,297 (1,727-39,000) μg/L, respectively. The SD was 0.03 (0.02-0.03) for midazolam, 0.05 (0.05-0.06) for 1-OH-midazolam, and 0.33 (0.23-0.43) for 1-OH-midazolam-glucuronide. The delivered CRRT CL was 1.4 (0-1.7) mL/min for midazolam, 2.7 (0-3.5) mL/min for 1-OH-midazolam, and 15.7 (4.0-27.7) mL/min for 1-OH-midazolam-glucuronide. CONCLUSIONS Midazolam and 1-OH-midazolam were not removed during CVVHD and CVVHDF. However, 1-OH-midazolam-glucuronide was removed reasonably, approximately up to 43%. CRRT modality, filter integrity, and downtime affect this removal. These data imply a personalized titration of midazolam in critically ill patients with renal failure and awareness for the additional sedative effects of its active metabolites.
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Affiliation(s)
- Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hilde R H de Geus
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Abraham J Valkenburg
- Department of Anesthesiology and Intensive Care, Isala Hospital, Zwolle, The Netherlands
| | - Lauren Baidjoe
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Hosgorler F, Akkaya EC, Ilgin R, Koc B, Kizildag S, Gumus H, Uysal N. The ameliorative effect of midazolam on empathy-like behavior in old rats. Naunyn Schmiedebergs Arch Pharmacol 2023; 396:3183-3193. [PMID: 37209151 DOI: 10.1007/s00210-023-02526-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/09/2023] [Indexed: 05/22/2023]
Abstract
Although studies suggest that cognitive functions in the elderly are impaired, elderly people tend to be more successful and wiser in solving emotional problems. In empathy-like behavior models, the observer rat rescues the distressed cage mate by displaying emotional and cognitive ability. The aim of the study was to investigate the changes in empathy-like behavior in older rats in comparison to adult rats. In addition, we wanted to determine the effects of alterations in neurochemicals (such as corticosterone, oxytocin, vasopressin, and their receptor levels) and emotional situations on this behavior. In our study, we initially completed empathy-like behavior tests and emotional tests (open field, elevated plus maze) and performed neurochemical examinations in the serum and brain tissues. In the second step of research, we applied a midazolam (benzodiazepine) treatment to examine the effect of anxiety on empathy-like behavior. In the old rats, we observed that empathy-like behavior deteriorated, and anxiety signs were more pronounced. We detected a positive correlation between the latency in empathy-like behavior and corticosterone levels and v1b receptor levels. The midazolam effect on empathy-like behavior was attenuated by flumazenil (a benzodiazepine receptor antagonist). The recordings of ultrasonic vocalization showed frequencies around 50 kHz emitted by the observer and this was associated with the expectation of social contact. Our results state that compared to adult rats, old rats were more concerned and failed during empathy-like behavior. Midazolam may improve this behavior by anxiolysis.
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Affiliation(s)
- Ferda Hosgorler
- Department of Physiology, School of Medicine, Dokuz Eylül University, Balçova, Izmir, Turkey.
| | - Erhan Caner Akkaya
- Department of Physiology, School of Medicine, Dokuz Eylül University, Balçova, Izmir, Turkey
| | - Rabia Ilgin
- Department of Physiology, School of Medicine, Dokuz Eylül University, Balçova, Izmir, Turkey
| | - Basar Koc
- Department of Physiology, School of Medicine, Dokuz Eylül University, Balçova, Izmir, Turkey
| | - Servet Kizildag
- College of Vocational School of Health Services, Dokuz Eylül University, Izmir, Turkey
| | - Hikmet Gumus
- School of Sport Sciences and Technology, Dokuz Eylül University, Izmir, Turkey
| | - Nazan Uysal
- Department of Physiology, School of Medicine, Dokuz Eylül University, Balçova, Izmir, Turkey
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Domínguez-Rodríguez A, Hernandez-Vaquero D, Suero-Mendez C, Burillo-PutzE G, Gil V, Calvo-Rodriguez R, Piñera-Salmeron P, Llorens P, Martín-Sánchez FJ, Abreu-Gonzalez P, Miró Ò. Effects of MIdazolam versus MOrphine in acute cardiogenic pulmonary edema and chronic obstructive pulmonary disease: An analysis of MIMO trial. Am J Emerg Med 2023; 73:176-181. [PMID: 37703629 DOI: 10.1016/j.ajem.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023] Open
Abstract
AIMS Chronic obstructive pulmonary disease (COPD) is an important comorbidity in heart failure. The MIMO trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. In this post hoc analysis, we examined whether the presence/ absence of COPD modifies the reduced risk of midazolam over morphine. METHODS Patients >18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine. In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without COPD. Calculating the CochranMantel-Haenszel interaction test, we evaluated if COPD modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. RESULTS Overall, 25 (22.5%) of the 111 patients randomized had a history of COPD. Patients with COPD were more commonly men with a history of previous episodes of heart failure, than participants without COPD. In the COPD group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.36 (95%CI, 0.1-1.46). In the group without COPD, the RR was 0.44 (95%CI, 0.22-0.91). The presence of COPD did not modify the reduced risk of serious adverse events in the midazolam arm compared to morphine (p for interaction =0.79). CONCLUSIONS The reduced risk of serious adverse events in the midazolam group compared with morphine is similar in patients with and without COPD.
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Affiliation(s)
- Alberto Domínguez-Rodríguez
- Department of Cardiology, Hospital Universitario de Canarias, Universidad Europea de Canarias, Tenerife, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Daniel Hernandez-Vaquero
- Cardiac Surgery Department, Central University Hospital of Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | | | | | - Victor Gil
- Emergency Department, Hospital Clinic, Barcelona, Institutd' Investigación Biomèdica August Pi iSunyer (IDIBAPS); University of Barcelona. Barcelona, Catalonia, Spain
| | | | | | - Pere Llorens
- Emergency Department, Short-Stay Unit and Home Hospitalization, Hospital General de Alicante, Spain
| | | | - Pedro Abreu-Gonzalez
- Department of Physiology, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Institutd' Investigación Biomèdica August Pi iSunyer (IDIBAPS); University of Barcelona. Barcelona, Catalonia, Spain
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Asada R, Hori H, Iida H, Kawasaki H. Benzodiazepine withdrawal catatonia after discontinuing midazolam in young patient with intellectual developmental disorder: A case report. Asian J Psychiatr 2023; 89:103768. [PMID: 37769543 DOI: 10.1016/j.ajp.2023.103768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Ryo Asada
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jyonan-ku, Fukuoka city, Fukuoka 8140180, Japan
| | - Hikaru Hori
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jyonan-ku, Fukuoka city, Fukuoka 8140180, Japan
| | - Hitoshi Iida
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jyonan-ku, Fukuoka city, Fukuoka 8140180, Japan
| | - Hiroaki Kawasaki
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jyonan-ku, Fukuoka city, Fukuoka 8140180, Japan
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Yao Z, Liao Z, Li G, Wang L, Zhan L, Xia W. Remimazolam tosylate's long-term sedative properties in ICU patients on mechanical ventilation: effectiveness and safety. Eur J Med Res 2023; 28:452. [PMID: 37865799 PMCID: PMC10590506 DOI: 10.1186/s40001-023-01440-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023] Open
Abstract
OBJECTIVE This study compared remimazolam tosylate with propofol or midazolam to assess its safety and effectiveness for long-term sedation of intensive care unit (ICU) patients requiring mechanical ventilation. METHODS Adult patients in the ICU receiving sedation and mechanical ventilation for longer than 24 h were included in this single-center, prospective, observational study. Depending on the sedatives they were given, they were split into two groups (midazolam or propofol group; remimazolam group). ICU mortality was the main result. Laboratory tests, adverse events, and the length of ICU stay were considered secondary outcomes. RESULTS A total of 106 patients were involved (46 received propofol or midazolam versus 60 received remimazolam). Age (P = 0.182), gender (P = 0.325), and the amount of time between being admitted to the ICU and receiving medication infusion (P = 0.770) did not substantially differ between the two groups. Multivariate analysis revealed no statistically significant difference in ICU mortality between the two groups. The remimazolam group showed less variability in heart rate (P = 0.0021), pH (P = 0.048), bicarbonate (P = 0.0133), lactate (P = 0.0002), arterial blood gas analyses, liver, and kidney function. The Richmond Agitation and Sedation Scale scores, length of ICU stay, and occurrence of adverse events did not exhibit significant differences between the two groups. CONCLUSION Remimazolam tosylate did not increase the total inpatient cost, the incidence of adverse events, and ICU mortality in patients with mechanical ventilation. These findings suggest that remimazolam may represent a promising alternative for sedation in the ICU setting.
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Affiliation(s)
- Zhiyuan Yao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Zhaomin Liao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Guang Li
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Lu Wang
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Liying Zhan
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Wenfang Xia
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China.
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Nie J, Chen C, Xie J, Ding G. Oral midazolam vs. intranasal dexmedetomidine plus oral midazolam for sedation of pediatric outpatients: a double-blinded randomized controlled trial. BMC Anesthesiol 2023; 23:341. [PMID: 37817075 PMCID: PMC10563331 DOI: 10.1186/s12871-023-02289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Moderate to deep sedation is required for dental treatment of children with dental anxiety. Midazolam is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric sedation. OBJECTIVE The aim of this trial was to compare the sedative efficacy of oral midazolam alone with that of intranasal dexmedetomidine plus oral midazolam during dental treatment of children with dental anxiety. DESIGN In total, 83 children (aged 3-12 years) scheduled to undergo dental sedation were randomized to receive oral midazolam (0.5 mg/kg) and intranasal placebo, or oral midazolam (0.5 mg/kg) plus intranasal dexmedetomidine (2 µg/kg). The primary outcome was the rate of successful sedation for dental treatment. Secondary outcomes were the onset time and adverse events during and after treatment. Data analyses involved descriptive statistics and nonparametric tests. RESULTS The rate of successful sedation was significantly higher in combination group (P = 0.007), although the sedation onset time was significantly longer in combination group (17.5 ± 2.4 min) than in monotherapy group (15.7 ± 1.8) (P = 0.003). No children required medical intervention or oxygen therapy for hemodynamic disturbances, and the incidences of adverse events had no significant difference between groups (P = 0.660). CONCLUSION Combined treatment with oral midazolam (0.5 mg/kg) and intranasal dexmedetomidine (2 µg/kg) is more significantly effective for managing the behavior of non-cooperative children during dental treatment, compared to oral midazolam (0.5 mg/kg) alone. (Chinese Clinical Trial Registry: ChiCTR2100042300) TRIAL REGISTRATION: ChiCTR2100042300, Clinical trial first registration date: 17/01/2021.
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Affiliation(s)
- Juan Nie
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
- Department of Pediatric Dentistry, Sichuan Hospital of Stomatology, Chengdu, 61000, China
| | - Chanchan Chen
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
| | - Jing Xie
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
| | - Guicong Ding
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China.
- Department of stomatology, Shenzhen Children's Hospital, China Medical University, Yitian Road 7019, Shenzhen, 518000, P.R. China.
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Vogt KM, Ibinson JW, Burlew AC, Smith CT, Aizenstein HJ, Fiez JA. Brain connectivity under light sedation with midazolam and ketamine during task performance and the periodic experience of pain: Examining concordance between different approaches for seed-based connectivity analysis. Brain Imaging Behav 2023; 17:519-529. [PMID: 37166623 PMCID: PMC10543548 DOI: 10.1007/s11682-023-00782-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
This work focused on functional connectivity changes under midazolam and ketamine sedation during performance of a memory task, with the periodic experience of pain. To maximize ability to compare to previous and future work, we performed secondary region of interest (ROI)-to-ROI functional connectivity analyses on these data, using two granularities of scale for ROIs. These findings are compared to the results of a previous seed-to-voxel analysis methodology, employed in the primary analysis. Healthy adult volunteers participated in this randomized crossover 3 T functional MRI study under no drug, followed by subanesthetic doses of midazolam or ketamine achieving minimal sedation. Periodic painful stimulation was delivered while subjects repeatedly performed a memory-encoding task. Atlas-based and network-level ROIs were used from within Conn Toolbox (ver 18). Timing of experimental task events was regressed from the data to assess drug-induced changes in background connectivity, using ROI-to-ROI methodology. Compared to saline, ROI-to-ROI connectivity changes under ketamine did not survive correction for multiple comparisons, thus data presented is from 16 subjects in a paired analysis between saline and midazolam. In both ROI-to-ROI analyses, the predominant direction of change was towards increased connectivity under midazolam, compared to saline. These connectivity increases occurred between functionally-distinct brain areas, with a posterior-predominant spatial distribution that included many long-range connectivity changes. During performance of an experimental task that involved periodic painful stimulation, compared to saline, low-dose midazolam was associated with robust increases in functional connectivity. This finding was concordant across different seed-based analyses for midazolam, but not ketamine. The neuroimaging drug trial from which this data was drawn was pre-registered (NCT-02515890) prior to enrollment of the first subject.
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Affiliation(s)
- Keith M Vogt
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, 3459 Fifth Avenue, UPMC Montefiore - Suite 467, Pittsburgh, PA, 15213, USA.
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA.
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA.
| | - James W Ibinson
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, 3459 Fifth Avenue, UPMC Montefiore - Suite 467, Pittsburgh, PA, 15213, USA
- Department of Anesthesiology, Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alex C Burlew
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - C Tyler Smith
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, 3459 Fifth Avenue, UPMC Montefiore - Suite 467, Pittsburgh, PA, 15213, USA
| | - Howard J Aizenstein
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julie A Fiez
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
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Becker DA, Wheless JW, Sirven J, Tatum WO, Rabinowicz AL, Carrazana E. Treatment of Seizure Clusters in Epilepsy: A Narrative Review on Rescue Therapies. Neurol Ther 2023; 12:1439-1455. [PMID: 37341903 PMCID: PMC10444935 DOI: 10.1007/s40120-023-00515-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023] Open
Abstract
Epilepsy is a common neurological disorder in the United States, affecting approximately 1.2% of the population. Some people with epilepsy may experience seizure clusters, which are acute repetitive seizures that differ from the person's usual seizure pattern. Seizure clusters are unpredictable, are emotionally burdensome to patients and caregivers (including care partners), and require prompt treatment to prevent progression to serious outcomes, including status epilepticus and associated morbidity (e.g., lacerations, fractures due to falls) and mortality. Rescue medications for community use can be administered to terminate a seizure cluster, and benzodiazepines are the cornerstone of rescue treatment. Despite the effectiveness of benzodiazepines and the importance of a rapid treatment approach, as many as 80% of adult patients do not use rescue medication to treat seizure clusters. This narrative review provides an update on rescue medications used for treatment of seizure clusters, with an emphasis on clinical development and study programs for diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray. Results from long-term clinical trials have shown that treatments for seizure clusters are effective. Intranasal benzodiazepines provide ease of use and patient and caregiver satisfaction in pediatric and adult patients. Adverse events attributed to acute rescue treatments have been characterized as mild to moderate, and no reports of respiratory depression have been attributed to treatment in long-term safety studies. The implementation of an acute seizure action plan to facilitate optimal use of rescue medications provides an opportunity for improved management of seizure clusters, allowing those affected to resume normal daily activities more quickly.
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Affiliation(s)
- Danielle A Becker
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
| | - James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joseph Sirven
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Hudec J, Kosinova M, Horak O, Repko M, Gal R. Challenging anesthesia of the patient on ketogenic diet therapy scheduled for scoliosis surgery under motor evoked potentials monitoring: a case report. J Anesth 2023; 37:815-817. [PMID: 37558835 DOI: 10.1007/s00540-023-03226-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/09/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Jan Hudec
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martina Kosinova
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
- Department of Pediatric Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Jihlavska 20, 62500, Brno, Czech Republic.
| | - Ondrej Horak
- Brno Epilepsy Centre (ERN EpiCARE), Department of Pediatric Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Repko
- Department of Orthopedic Surgery, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Gal
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Hayashi T, Asahina Y, Takeda Y, Miyazawa M, Takatori H, Kido H, Seishima J, Iida N, Kitamura K, Terashima T, Miyagi S, Toyama T, Mizukoshi E, Yamashita T. Necessity of pharyngeal anesthesia during transoral gastrointestinal endoscopy: a randomized clinical trial. Clin Endosc 2023; 56:594-603. [PMID: 37041735 PMCID: PMC10565444 DOI: 10.5946/ce.2022.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND/AIMS The necessity for pharyngeal anesthesia during upper gastrointestinal endoscopy is controversial. This study aimed to compare the observation ability with and without pharyngeal anesthesia under midazolam sedation. METHODS This prospective, single-blinded, randomized study included 500 patients who underwent transoral upper gastrointestinal endoscopy under intravenous midazolam sedation. Patients were randomly allocated to pharyngeal anesthesia: PA+ or PA- groups (250 patients/group). The endoscopists obtained 10 images of the oropharynx and hypopharynx. The primary outcome was the non-inferiority of the PA- group in terms of the pharyngeal observation success rate. RESULTS The pharyngeal observation success rates in the pharyngeal anesthesia with and without (PA+ and PA-) groups were 84.0% and 72.0%, respectively. The PA- group was inferior (p=0.707, non-inferiority) to the PA+ group in terms of observable parts (8.33 vs. 8.86, p=0.006), time (67.2 vs. 58.2 seconds, p=0.001), and pain (1.21±2.37 vs. 0.68±1.78, p=0.004, 0-10 point visual analog scale). Suitable quality images of the posterior wall of the oropharynx, vocal fold, and pyriform sinus were inferior in the PA- group. Subgroup analysis showed a higher sedation level (Ramsay score ≥5) with almost no differences in the pharyngeal observation success rate between the groups. CONCLUSION Non-pharyngeal anesthesia showed no non-inferiority in pharyngeal observation ability. Pharyngeal anesthesia may improve pharyngeal observation ability in the hypopharynx and reduce pain. However, deeper anesthesia may reduce this difference.
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Affiliation(s)
- Tomoyuki Hayashi
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Yasuhito Takeda
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Hajime Takatori
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Hidenori Kido
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Jun Seishima
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Noriho Iida
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Kazuya Kitamura
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Takeshi Terashima
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Sakae Miyagi
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Tadashi Toyama
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Eishiro Mizukoshi
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
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Aghili M, AkhavanHejazi H, Naderpour Z, Vahidi E, Saeedi M. Haloperidol-Midazolam vs. Haloperidol-Ketamine in Controlling the Agitation of Delirious Patients; a Randomized Clinical Trial. Arch Acad Emerg Med 2023; 11:e61. [PMID: 37840867 PMCID: PMC10568945 DOI: 10.22037/aaem.v11i1.2095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Introduction Agitation management in delirious patients is crucial in a crowded emergency department (ED) for both patient and personnel safety. Benzodiazepines, antipsychotics, and newly derived ketamine are among the most commonly used drugs in controlling these cases. This study aimed to compare the effectiveness of haloperidol-midazolam with haloperidol-ketamine combination in this regard. Methods In this double-blind randomized clinical trial, delirious patients with agitation in ED were randomly assigned to a group: group A: haloperidol 2.5 mg IV and midazolam 0.05 mg/kg IV or group B: haloperidol 2.5 mg IV and ketamine 0.5 mg/kg IV. Sedative effects as well as side effects at 0, 5, 10, 15, 30 minutes and 1, 2, 4 hours after the intervention were compared between the 2 groups. Results We enrolled 140 cases with Altered Mental Status Score (AMSS)≥+2 and mean age of 52.819.4 years (78.5% male). Agitation was significantly controlled in both groups (p<0.05). In group B, AMSS score was more significantly and rapidly reduced 5 (p = 0.021), 10 (p = 0.009), and 15 (p = 0.034) minutes after drug administration. After intervention, oxygen saturation was significantly decreased in group A 5 (p = 0.031) and 10 (p = 0.019) minutes after baseline. Time required to the maximum effect was significantly lower in group B versus group A (p=0.014). Less patients in group B had major side effects (p=0.018) and needed physical restraint (p=0.001). Conclusions Haloperidol-ketamine can control agitation in delirium more rapidly than haloperidol-midazolam. This combination had lower adverse events with lower need for physical restraint.
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Affiliation(s)
- Mehrad Aghili
- Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - HamidReza AkhavanHejazi
- Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Naderpour
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Vahidi
- Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Saeedi
- Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Wabelo ON, Schmartz D, Giancursio M, De Pooter F, Caruso G, Fils JF, Van der Linden P. Prospective, randomized, double-blind, double-dummy, active-controlled, phase 3 clinical trial comparing the safety and efficacy of intranasal dexmedetomidine to oral midazolam as premedication for propofol sedation in pediatric patients undergoing magnetic resonance imaging: the MIDEX MRI trial. Trials 2023; 24:518. [PMID: 37568242 PMCID: PMC10422697 DOI: 10.1186/s13063-023-07529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Children under 6 years who need magnetic resonance imaging usually require sedation to obtain best quality images, but the optimal sedation protocol remains to be determined. In 2018, we showed a 22% interruption in image acquisition during magnetic resonance imaging when performing a propofol-based sedation using a bolus approach. As non-pharmacological premedication is often insufficient to reduce the anxiety of children related to parental separation, pharmacological premedication may be useful to facilitate the induction of anesthesia. In our institution, effective premedication is obtained oral intake of midazolam, though its administration relies on patients' compliance and could also lead to paradoxical reaction. Dexmedetomidine has a safe profile in the pediatric population and can therefore represent an interesting alternative. The primary objective of this trial is to demonstrate the superiority of intranasal dexmedetomidine compared to oral midazolam as premedication in reducing the occurrence of any event requiring temporary or definitive interruption of the examination to allow anesthesiologist intervention in children undergoing magnetic resonance imaging under propofol sedation. METHODS In this single-center, prospective, randomized, double-blind, double-dummy, active comparator-controlled, superiority trial, we planned to include 250 patients, aged 6 months to 6 years, undergoing a scheduled magnetic resonance imaging requiring the presence of an anesthesiologist. After informed consent, the patients will be randomized to receive either oral midazolam or intranasal dexmedetomidine as premedication. The data will be analyzed in intention to treat, using Kolmogorov-Smirnov Z, chi-square, Wilcoxon, and Mann-Whitney U tests. A P-value < 0.05 will be considered statistically significant. DISCUSSION The MIDEX MRI study will assess the efficacy of intranasal dexmedetomidine compared to oral midazolam to improve the quality of a propofol-based sedation prior to magnetic resonance imaging, without negative repercussion on the postoperative period. TRIAL REGISTRATION ClinicalTrial.gov NCT05192629 . Registered on 14 January 2022. Protocol version 2.1.
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Affiliation(s)
- Olivia Nzungu Wabelo
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - Denis Schmartz
- Université Libre de Bruxelles, Brussels, Belgium.
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium.
| | - Mario Giancursio
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
| | - Françoise De Pooter
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
| | - Giulia Caruso
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
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Hauge MS, Willumsen T, Stora B. Changes in symptoms of anxiety, depression, and PTSD in an RCT-study of dentist-administered treatment of dental anxiety. BMC Oral Health 2023; 23:415. [PMID: 37349747 PMCID: PMC10288821 DOI: 10.1186/s12903-023-03061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/19/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Educating dentists in treatment methods for dental anxiety would increase the patients' access to treatments that are important to their oral health. However, to avoid adverse effects on comorbid symptoms, involvement by a psychologist has been considered necessary. The objective of the present paper was to evaluate whether a dentist could implement systematized treatments for dental anxiety without an increase in comorbid symptoms of anxiety, depression or PTSD. METHODS A two-arm parallel randomised controlled trial was set in a general dental practice. Eighty-two patients with self-reported dental anxiety either completed treatment with dentist-administered cognitive behavioural therapy (D-CBT, n = 36), or received dental treatment while sedated with midazolam combined with the systemized communication technique "The Four Habits Model" (Four Habits/midazolam, n = 41). Dental anxiety and comorbid symptoms were measured pre-treatment (n = 96), post-treatment (n = 77) and one-year after treatment (n = 52). RESULTS An Intention-To-Treat analysis indicated reduced dental anxiety scores by the Modified Dental Anxiety Scale (median MDAS: 5.0 (-1,16)). The median scores on the Hospital Index of Anxiety and Depression (HADS-A/D) and the PTSD checklist for DSM-IV (PCL) were reduced as follows: HADS-A: 1 (-11, 11)/HADS-D: 0 (-7, 10)/PCL: 1 (-17,37). No between-group differences were found. CONCLUSIONS The study findings support that a general dental practitioner may treat dental anxiety with Four Habits/Midazolam or D-CBT without causing adverse effects on symptoms of anxiety, depression or PTSD. Establishing a best practice for treatment of patients with dental anxiety in general dental practice should be a shared ambition for clinicians, researchers, and educators. TRIAL REGISTRATION The trial was approved by REC (Norwegian regional committee for medical and health research ethics) with ID number 2017/97 in March 2017, and it is registered in clinicaltrials.gov 26/09/2017 with identifier: NCT03293342.
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Affiliation(s)
- Mariann Saanum Hauge
- Faculty of Dentistry, University of Oslo, Oslo, Norway.
- Oral Health Centre of Expertise, Rogaland, Stavanger, Norway.
| | | | - Bent Stora
- Oral Health Services Agder, Kristiansand, Norway
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Falsaperla R, Collotta AD, Sortino V, Marino SD, Marino S, Pisani F, Ruggieri M. The Use of Midazolam as an Antiseizure Medication in Neonatal Seizures: Single Center Experience and Literature Review. CNS Neurol Disord Drug Targets 2023:CNSNDDT-EPUB-132399. [PMID: 37291779 DOI: 10.2174/1871527322666230608105206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Existing therapeutic alternatives for neonatal crises have expanded in recent decades, but no consensus has been reached on protocols based on neonatal seizures. In particular, little is known about the use of midazolam in newborns. AIM The aim of our study is to evaluate the response to midazolam, the appearance of side effects, and their impact on therapeutic decisions. METHODS This is a STROBE-conformed retrospective observational study of 10 patients with neonatal seizures unresponsive to common antiseizure drugs, admitted to San Marco University Hospital's neonatal intensive care (Catania, Italy) from September 2015 to October 2022. In our database search, 36 newborns were treated with midazolam, but only ten children met the selection criteria for this study. RESULTS Response was assessed both clinically and electrographic. Only 4 patients at the end of the treatment showed a complete electroclinical response; they were full-term infants with a postnatal age greater than 7 days. Non-responders and partial responders are all premature (4/10) or full-term neonates who started therapy in the first days of life (<7th day) (2/10). CONCLUSION Neonatal seizures in preterm show a lower response rate to midazolam than seizures in full-term infants, with poorer prognosis. Liver and renal function and central nervous system development are incomplete in premature infants and the first days of life. In this study, we show that midazolam, a short-acting benzodiazepine, appears to be most effective in full-term infants and after 7 days of life.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
- Pediatrics and Pediatric Emergency Operative Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
| | - Ausilia Desiree Collotta
- Pediatrics and Pediatric Emergency Operative Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
| | - Vincenzo Sortino
- Pediatrics and Pediatric Emergency Operative Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
| | - Simona Domenica Marino
- Pediatrics and Pediatric Emergency Operative Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
| | - Silvia Marino
- Pediatrics and Pediatric Emergency Operative Unit, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", San Marco Hospital, University of Catania, Catania, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Human Neuroscience Department, Sapienza University of Rome, Italy
| | - Martino Ruggieri
- Unit of Clinical Pediatrics, Department of Clinical and Experimental Medicine, AOU Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Ghomeishi A, Akhondzadeh R, Baghbanian R, Mahmoudi K, Bakhtiari N. A Comparison of the Sedative Effect of Dexmedetomidine and Midazolam on Patients Undergoing Gastrointestinal Endosonography Outside the Operating Room. Anesth Pain Med 2023; 13:e109721. [PMID: 38021337 PMCID: PMC10664169 DOI: 10.5812/aapm-109721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background Patients may experience anxiety, discomfort, and pain during endoscopy, which cannot be tolerated without sedative drugs. Objectives This study aimed to compare the sedative effects of dexmedetomidine and midazolam on patients undergoing endosonography outside the operating room. Methods This randomized, double-blind clinical trial was conducted on 126 patients aged 18 - 65 years old with American Society of Anesthesiologists (ASA) physical status I - II undergoing elective endosonography. Patients were randomly divided into 2 groups. The dexmedetomidine group received dexmedetomidine (1 μg/kg) for 25 minutes with propofol (0.5 mg/kg) and fentanyl (1 μg/kg) at the start of the procedure. The midazolam group received midazolam (0.03 mg/kg) with propofol (0.5 mg/kg) and fentanyl (1 μg/kg). Heart rate, mean arterial pressure (MAP), and oxygen saturation (SpO2) were recorded before and 5, 10, and 15 minutes after starting the procedure. The Ramsay Sedation Scale (RSS) and the need for an additional dose of propofol were recorded during the procedure. The Numeric Pain Rating scale (Ambesh score) scores were recorded at the beginning, immediately after, and 1 hour after the procedure. Nausea and vomiting were assessed using the Visual Analogue Scale in cooperation with the patient. Results The dexmedetomidine group had significantly higher SpO2 and RSS scores during sedation than the midazolam group (P = 0.02). Overall, specialist satisfaction was higher in the dexmedetomidine group than in the midazolam group. There was no clinically significant difference in pain score and nausea and vomiting frequencies between the 2 groups. Conclusions Dexmedetomidine is more effective than midazolam for sedation during gastrointestinal endosonography.
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Affiliation(s)
- Ali Ghomeishi
- Pain Research Center, Imam Khomeini Hospital Research and Development Unit, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Anesthesiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Reza Akhondzadeh
- Depapartment of Anessthesiology, Pain Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Reza Baghbanian
- Depapartment of Anessthesiology, Pain Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kamran Mahmoudi
- Depapartment of Anessthesiology, Pain Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nima Bakhtiari
- Pain Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Mesbah Kiaei M, Movassaghi G, Mohaghegh Dolatabadi M, Zamani MM, Ahmadi H. Comparison of the Effectiveness of Dexmedetomidine-Ketamine and Midazolam-Ketamine Regimens in Sedation of Children Treated with Extracorporeal Shock Wave Lithotripsy. Anesth Pain Med 2023; 13:e129776. [PMID: 38021338 PMCID: PMC10664165 DOI: 10.5812/aapm-129776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Despite the high acceptability of the extracorporeal shock wave lithotripsy (ESWL) procedure in the treatment of urinary stones at all ages, it is necessary to use a variety of analgesic drugs during the procedure, especially among children. Objectives We aimed to evaluate the effect of dexmedetomidine-ketamine (DK) and midazolam-ketamine (MK) compounds in the sedation of children (2-6 years old) undergoing ESWL. Methods This randomized, double-blind clinical trial was performed on children aged 2 to 6 years with renal stones undergoing ESWL. The participants were randomly assigned to the DK and MK regimen groups (dexmedetomidine, 0.05 mcg/kg within 10 minutes infusion; midazolam, 0.05 mg/kg within 3 minutes infusion; ketamine, 0.5 mg/kg bolus injection). The patients were assessed with respect to sedation degree, post-procedure hemodynamic status, recovery time and awakening, and operator satisfaction. Results Recovery time was significantly shorter in the DK group than in the MK group. Also, the DK regimen was more analgesic than the MK regimen; therefore, the need to repeat ketamine administration was less. There was no difference between the 2 methods in terms of cooperation at the time of separation of children from their parents, patient cooperation during the procedure, average verbal response time and average cooperation time after entering recovery, and operator satisfaction with the operation. No side effects were observed in the 2 groups. Conclusions Ketamine with dexmedetomidine is associated with greater analgesia and shorter recovery time; however, sedation time was longer (insignificant) in ketamine with midazolam than in ketamine with dexmedetomidine. Thus, ketamine with dexmedetomidine is more preferred.
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Affiliation(s)
- Mehrdad Mesbah Kiaei
- Assistant Professor of Anesthesiology, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Movassaghi
- Assistant Professor of Anesthesiology, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Moahmoodreza Mohaghegh Dolatabadi
- Assistant Professor of Anesthesiology, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Zamani
- Anesthesiologist, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadi
- Assistant Professor of Anesthesiology, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
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Li X, Liu Y, Li C, Wang J. Sedative and adverse effect comparison between oral midazolam and nitrous oxide inhalation in tooth extraction: a meta-analysis. BMC Oral Health 2023; 23:307. [PMID: 37210490 DOI: 10.1186/s12903-023-02965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/13/2023] [Indexed: 05/22/2023] Open
Abstract
OBJECTIVE Oral midazolam and nitrous oxide inhalation were commonly used sedative and analgesic techniques during tooth extraction. It is still controversial whether oral midazolam can replace the nitrous oxide inhalation for sedative and analgesic treatment of tooth extraction. Therefore, we conducted this study in order to provide a reference for doctors to choose effective sedative and analgesic treatment in tooth extraction. METHODS We searched the Chinese and English databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Wanfang and VIP information databases. RESULTS Through this meta-analysis, we found that the success rate of sedation and analgesia treatment with oral midazolam during tooth extraction was 75.67% and the incidence of adverse reactions was 21.74%. The success rate of sedation and analgesia treatment using nitrous oxide inhalation during tooth extraction was 93.6% and the incidence of adverse reactions was 3.95%. CONCLUSION The use of nitrous oxide inhalation for sedation and analgesia during tooth extraction is very effective, and oral midazolam can be used as an alternative to nitrous oxide inhalation.
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Affiliation(s)
- Xia Li
- Ambulatory Surgical Center, West China Shool/Hospital of Stomatology Sichuan University, Sichuan Province, No. 14 The Renmin South Road, Chengdu, 610041, China
| | - Yali Liu
- Ambulatory Surgical Center, West China Shool/Hospital of Stomatology Sichuan University, Sichuan Province, No. 14 The Renmin South Road, Chengdu, 610041, China
| | - Chengjun Li
- Ambulatory Surgical Center, West China Shool/Hospital of Stomatology Sichuan University, Sichuan Province, No. 14 The Renmin South Road, Chengdu, 610041, China
| | - Jiexue Wang
- Ambulatory Surgical Center, West China Shool/Hospital of Stomatology Sichuan University, Sichuan Province, No. 14 The Renmin South Road, Chengdu, 610041, China.
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Peng J, Ma X, Chen Y, Yan J, Jiang H. C57BL/6J and C57BL/6N mice exhibit different neuro-behaviors and sensitivity to midazolam- and propofol-induced anesthesia. Physiol Behav 2023; 264:114146. [PMID: 36889487 DOI: 10.1016/j.physbeh.2023.114146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/18/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023]
Abstract
Phenotypes of inbred mice are strain-dependent, indicating the important influence of genetic background in biomedical research. C57BL/6 is one of the most commonly used inbred mouse strains, and its two closely related substrains, C57BL/6J and C57BL/6N, have been separated for only about 70 years. These two substrains have accumulated genetic variations and exhibit different phenotypes, but it remains unclear whether they respond to anesthetics differently. In this study, commercially acquired wildtype C57BL/6J or C57BL/6N mice from two different sources were analyzed and compared for their response to a spectrum of anesthetics (midazolam, propofol, esketamine or isoflurane anesthesia) and their performance in a series of behavioral tests associated with neurological functions including open field test (OFT), elevated plus maze (EPM), Y maze, prepulse inhibition (PPI), tail strain test (TST) and forced swimming test (FST). Loss of the righting reflex (LORR) is used to measure the anesthetic effects. Our results suggested that the anesthesia induction time induced by either of the four anesthetics were comparable for the C57BL/6J and C57BL/6N mice. However, C57BL/6J or C57BL/6N mice do exhibit different sensitivity to midazolam and propofol. The anesthesia duration of midazolam of C57BL/6J mice was about 60% shorter than that of the C57BL/6N mice, while the LORR duration induced by propofol in C57BL/6J mice was 51% longer than that of the C57BL/6N. In comparison, the two substrains were anesthetized by esketamine or isoflurane similarly. In the behavioral analysis, the C57BL/6J mice exhibited a lower level of anxiety- and depression-like behaviors in OFT, EPM, FST and TST than the C57BL/6N mice. Locomotor activity and sensorimotor gating of these two substrains remained comparable. Our results stress the point that when selecting inbred mice for allele mutation or behavioral testing, the influence of even subtle differences in genetic background should be fully considered.
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Affiliation(s)
- Jiali Peng
- Department of Anaesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaofan Ma
- Department of Anaesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yelin Chen
- Interdisciplinary Research Center on Biology and Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai, China
| | - Jia Yan
- Department of Anaesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Hong Jiang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Annborn M, Ceric A, Borgquist O, During J, Moseby-Knappe M, Lybeck A. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest; The effect on post-intervention serum concentrations of sedatives and analgesics and time to awakening. Resuscitation 2023; 188:109831. [PMID: 37178902 DOI: 10.1016/j.resuscitation.2023.109831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND This study investigated the association of two levels of targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) with administered doses of sedative and analgesic drugs, serum concentrations, and the effect on time to awakening. METHODS This substudy of the TTM2-trial was conducted at three centers in Sweden, with patients randomized to either hypothermia or normothermia. Deep sedation was mandatory during the 40-hour intervention. Blood samples were collected at the end of TTM and end of protocolized fever prevention (72 hours). Samples were analysed for concentrations of propofol, midazolam, clonidine, dexmedetomidine, morphine, oxycodone, ketamine and esketamine. Cumulative doses of administered sedative and analgesic drugs were recorded. RESULTS Seventy-one patients were alive at 40 hours and had received the TTM-intervention according to protocol. 33 patients were treated at hypothermia and 38 at normothermia. There were no differences between cumulative doses and concentration and of sedatives/analgesics between the intervention groups at any timepoint. Time until awakening was 53 hours in the hypothermia group compared to 46 hours in the normothermia group (p=0.09). CONCLUSION This study of OHCA patients treated at normothermia versus hypothermia found no significant differences in dosing or concentration of sedatives or analgesic drugs in blood samples drawn at the end of the TTM intervention, or at end of protocolized fever prevention, nor the time to awakening.
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Affiliation(s)
- Martin Annborn
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden.
| | - Ola Borgquist
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Joachim During
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Marion Moseby-Knappe
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Anna Lybeck
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
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Osama NA, Mohamed MK, Aboul Fetouh IS, Sherif NA. Ketamine versus midazolam as an adjuvant to peribulbar block using a single inferonasal injection in patients undergoing vitreoretinal surgery: A randomized controlled trial. Rev Esp Anestesiol Reanim (Engl Ed) 2023; 70:276-283. [PMID: 36934847 DOI: 10.1016/j.redare.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/13/2022] [Indexed: 04/23/2023]
Abstract
INTRODUCTION AND OBJECTIVES This study aimed to assess the safety and efficacy of midazolam and ketamine as adjuvants to the peribulbar block in vitreoretinal surgeries. PATIENTS AND METHODS This randomized controlled trial included 93 adult patients undergoing vitreoretinal surgeries performed with peribulbar anaesthesia. Patients were randomly allocated to 3 groups (31 participants each): control (standard anaesthetic mixture), midazolam (standard mixture + midazolam), and ketamine (standard mixture + ketamine). The primary outcomes were onset of globe akinesia and duration of analgesia. Secondary outcomes were duration of motor blockade, onset of corneal anaesthesia and lid akinesia, and changes in vital data (blood pressure, oxygen saturation, and pulse rate). RESULTS The ketamine group vs. the control and midazolam groups showed the most rapid onset of lid and globe akinesia (p < 0.001) and corneal anaesthesia (0.7 ± 0.2 vs. 1.5 ± 0.5 and 1.2 ± 0.4, respectively; p < 0.001) and the longest duration of both analgesia (3.7 ± 0.6 vs. 2.3 ± 0.4 and 3.1 ± 0.6, respectively; p < 0.001) and akinesia (3.8 ± 0.5 vs. 3.0 ± 0.4, and 3.7 ± 0.5, respectively; p < 0.001). The midazolam group showed better outcomes than controls, but the drug was less effective than ketamine. There were no significant differences in vital data among groups (p > 0.05). CONCLUSIONS Ketamine is an effective adjuvant for peribulbar blockade. It enhances both motor and sensory blockade by hastening onset and prolonging duration. These effects are desirable in lengthier ophthalmic procedures such as vitreoretinal surgeries. The effects of ketamine were superior to those of midazolam.
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Affiliation(s)
- Noha A Osama
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt.
| | - Mayada K Mohamed
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt
| | | | - Norhan A Sherif
- Department of Anesthesia, Research Institute of Ophthalmology, Giza, Egypt
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Penna HDM, Paiva APM, Romano AJM, Alves RL, Nascimento Junior PD, Módolo NSP. Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial. Braz J Anesthesiol 2023; 73:283-290. [PMID: 36183860 DOI: 10.1016/j.bjane.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 05/28/2023]
Abstract
BACKGROUND Conventional dental care is often impossible in patients with Autism Spectrum Disorder (ASD). Non-collaborative behaviors, sometimes associated with aggressiveness, are usual justifications for premedication in this population. Thereby, this research focuses on the effects of oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in ASD. METHODS The sample included 64 persons with ASD, aged 2-59 years, scheduled for dental care under general anesthesia. The primary objective of this study was to compare degrees of sedation between two parallel, double-blinded, equally proportional groups randomized to receive oral midazolam (0.5 mg.kg-1, maximum 15 mg) or oral midazolam (0.5 mg.kg-1) associated with oral S(+)-ketamine (3 mg.kg-1, maximum 300 mg). The secondary outcomes were the need of physical stabilization to obtain intravenous line, awakening time, and occurrence of adverse events. RESULTS According to the dichotomous analysis of sedation level (Ramsay score 1 and 2 versus Ramsay ≥ 3), oral association of S(+)-ketamine and midazolam improved sedation, with increased probability of Ramsay ≥ 3, Relative Risk (RR) = 3.2 (95% Confidence Interval [95% CI] = 1.32 to 7.76) compared to midazolam alone. Combined treatment also made it easier to obtain venous access without physical stabilization, RR = 2.05 (95% CI = 1.14 to 3.68). There were no differences between groups regarding awakening time and the occurrence of adverse events. CONCLUSION The association of oral S(+)-ketamine with midazolam provides better preanesthetic sedation rates than midazolam alone and facilitates intravenous line access in patients with autism.
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Affiliation(s)
- Heber de Moraes Penna
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil; Hospital Santa Terezinha, Goiânia, GO, Brazil.
| | | | | | - Rodrigo Leal Alves
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
| | - Paulo do Nascimento Junior
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Anestesiologia, Botucatu, SP, Brazil
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Uno Y, Jikuya S, Noda Y, Oguchi A, Murayama N, Kawaguchi H, Tsukiyama-Kohara K, Yamazaki H. Newly identified cytochrome P450 3A genes of tree shrews and pigs are expressed and encode functional enzymes. Comp Biochem Physiol C Toxicol Pharmacol 2023; 267:109579. [PMID: 36822299 DOI: 10.1016/j.cbpc.2023.109579] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
Novel cytochrome P450 3A5 (CYP3A5) cDNA in tree shrews (which are non-rodent primate-like species) and pig CYP3A227 cDNA were identified, along with known pig CYP3A22, CYP3A29, and CYP3A46 cDNAs. All five cDNAs contained open reading frames encoding a polypeptide of 503 amino acids that shared high sequence identity (72-78 %) with human CYP3A4 and were more closely related to human CYP3As than rat CYP3As by phylogenetic analysis. CYP3A5 was the only CYP3A in the tree shrew genome, but pig CYP3A genes formed a CYP3A gene cluster in the genomic region corresponding to that of human CYP3A genes. Tree shrew CYP3A5 mRNA was predominantly expressed in liver and small intestine, among the tissues analyzed, whereas pig CYP3A227 mRNA was most abundantly expressed in jejunum, followed by liver. Metabolic assays established that tree shrew CYP3A5 and pig CYP3A proteins heterologously expressed in Escherichia coli metabolized typical human CYP3A4 substrates nifedipine and midazolam. These results suggest that novel tree shrew CYP3A5 and pig CYP3A227 were functional enzymes able to metabolize human CYP3A4 substrates in liver and small intestine, similar to human CYP3A4, although pig CYP3A227 mRNA was minimally expressed in all tissues analyzed.
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Affiliation(s)
- Yasuhiro Uno
- Department of Basic Veterinary Science, Joint Faculty of Veterinary Medicine, Kagoshima University, Kagoshima-city, Kagoshima 890-0065, Japan.
| | - Shiori Jikuya
- Department of Basic Veterinary Science, Joint Faculty of Veterinary Medicine, Kagoshima University, Kagoshima-city, Kagoshima 890-0065, Japan
| | - Yutaro Noda
- Showa Pharmaceutical University, Machida, Tokyo 194-8543, Japan
| | - Asuka Oguchi
- Showa Pharmaceutical University, Machida, Tokyo 194-8543, Japan
| | - Norie Murayama
- Showa Pharmaceutical University, Machida, Tokyo 194-8543, Japan
| | - Hiroaki Kawaguchi
- School of Veterinary Medicine, Kitasato University, Towada, Aomori 034-8628, Japan
| | - Kyoko Tsukiyama-Kohara
- Department of Basic Veterinary Science, Joint Faculty of Veterinary Medicine, Kagoshima University, Kagoshima-city, Kagoshima 890-0065, Japan; Transboundary Animal Diseases Center, Joint Faculty of Veterinary Medicine, Kagoshima University, Kagoshima 890-0065, Japan; Laboratory of Animal Hygiene, Joint Faculty of Veterinary Medicine, Kagoshima University, Kagoshima 890-0065, Japan
| | - Hiroshi Yamazaki
- Showa Pharmaceutical University, Machida, Tokyo 194-8543, Japan.
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Mohamed EH, Mahmoud AM, Nashat NW, El-Mosallamy SS. Fabrication of novel electropolymerized conductive polymer of hydrophobic perfluorinated aniline as transducer layer on glassy carbon electrode: application to midazolam as a model drug of benzodiazepines. BMC Chem 2023; 17:30. [PMID: 37016406 PMCID: PMC10074816 DOI: 10.1186/s13065-023-00945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/27/2023] [Indexed: 04/06/2023] Open
Abstract
The objective of this study is to fabricate solid-contact ion selective electrodes (SC-ISEs) that have long term stable potential. Various conducting polymers such as polyaniline and its derivatives have been successfully employed to improve the potential stability in SC-ISEs. Recently, the role of hydrophobicity at the interface between the conducting polymer solid contact and the ion sensing membrane has been investigated and figured out that the hydrophobic interfaces preclude water layer formation that deteriorate the SC-ISEs potential stability and reproducibility. In this work, a hydrophobic polyaniline derivative was fabricated on the surface of a glassy carbon electrode by electropolymerization of perfluorinated aniline monomers in acidic solution. The electropolymerized hydrophobic polymer was characterized by electrochemical impedance spectroscopy and X-ray photoelectron spectroscopy. The fabricated electrode was employed for determination of midazolam-a model drug-in pharmaceutical formulation without prior extraction. The SC-ISEs performance was optimized, and the potential drift was compared to control SC-ISEs, the SC-ISE linear range was 1 × 10-6-1 × 10-2 M, LOD was estimated to be 9.0 × 10-7 M, and potential drift was reduced to 100 μV/h.
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Affiliation(s)
- Ekram H Mohamed
- Pharmaceutical Analytical Chemistry Department, Faculty of Pharmacy, The British University in Egypt, El-Shorouk City, 11837, Egypt
| | - Amr M Mahmoud
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El Aini, Cairo, 11562, Egypt
| | - Nancy W Nashat
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El Aini, Cairo, 11562, Egypt.
| | - Sally S El-Mosallamy
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El Aini, Cairo, 11562, Egypt
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Agarwal A, Ansari AA, Nath R, Chak RK, Singh RK, Khanna R, Singh PR. Comparative evaluation of intranasal midazolam-ketamine, dexmedetomidine-ketamine, midazolam-fentanyl, and dexmedetomidine-fentanyl combinations for procedural sedation and analgesia in pediatric dental patients: a randomized controlled trial. J Dent Anesth Pain Med 2023; 23:69-81. [PMID: 37034838 PMCID: PMC10079769 DOI: 10.17245/jdapm.2023.23.2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/07/2023] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background In order to assess the effectiveness of various analgesio-sedative combinations for pain relief and sedation in pediatric dental patients, a thorough evaluation of clinical studies and patient outcomes is necessary. Methods A total of 128 healthy, uncooperative pediatric dental patients were randomly allocated to receive one of the four combinations of drugs via the intranasal (IN) route: Group I received midazolam-ketamine (MK), Group II received dexmedetomidine-ketamine (DK), Group III received midazolam-fentanyl (MF), and Group IV received dexmedetomidine-fentanyl (DF) in a parallel-arm study design. The efficacy and safety of the combinations were evaluated using different parameters. Results The onset of sedation was significantly faster in the DF group than in the DK, MF, and MK groups (P < 0.001). The depth of sedation was significantly higher in the DK and DF groups than in the MK and MF groups (P < 0.01). DK and DF produced significant intra- and postoperative analgesia when compared with combinations of MK and MF. No significant adverse events were observed for any of the combinations. Conclusions The DK and DF groups showed potential as analgesio-sedatives in view of their anxiolytic and analgesic effects.
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Affiliation(s)
- Abhilasha Agarwal
- Department of Pediatric and Preventive dentistry, Faculty of Dental Sciences, King George Medical University, U.P., Lucknow, India
| | - Afroz Alam Ansari
- Department of Pediatric and Preventive dentistry, Faculty of Dental Sciences, King George Medical University, U.P., Lucknow, India
| | - Rajendra Nath
- Department of Pharmacology & Therapeutics, King George Medical University, U.P., Lucknow, India
| | - Rakesh Kumar Chak
- Department of Pediatric and Preventive dentistry, Faculty of Dental Sciences, King George Medical University, U.P., Lucknow, India
| | - Rajeev Kumar Singh
- Department of Pediatric and Preventive dentistry, Faculty of Dental Sciences, King George Medical University, U.P., Lucknow, India
| | - Richa Khanna
- Department of Pediatric and Preventive dentistry, Faculty of Dental Sciences, King George Medical University, U.P., Lucknow, India
| | - Prem Raj Singh
- Department of Department of Anesthesiology and Critical Care, King George Medical University, U.P., Lucknow, India
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Krauss GL, Elizebath R, Mwendaweli N. Seizure Rescue Therapies: Comparing Approved and Commonly Used Benzodiazepine Formulations. Neurotherapeutics 2023; 20:758-766. [PMID: 36928590 PMCID: PMC10275833 DOI: 10.1007/s13311-023-01359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
Acute seizure therapies given out of the hospital are important for interrupting acute repetitive and prolonged seizures and preventing hospitalization. These vary in their administration routes, indications for children and adults, pharmacologic profiles, and efficacy. We reviewed and compared the uses of current formulations available to treat acute seizures, including newly released intranasal (IN) benzodiazepines and older formulations which are widely used for interrupting seizures.
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Affiliation(s)
- Gregory L Krauss
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Reena Elizebath
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Naluca Mwendaweli
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
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Kang H, Lim T, Lee HJ, Kim TW, Kim W, Chang HW. Comparison of the effect of dexmedetomidine and midazolam under spinal anesthesia for cesarean delivery: a randomized controlled trial, single center study in South Korea. Anesth Pain Med (Seoul) 2023; 18:159-168. [PMID: 37183284 PMCID: PMC10183612 DOI: 10.17085/apm.22257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/28/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Cesarean section under spinal anesthesia may cause anxiety and hypotension. Administration of sedative drugs after delivery can diminish these side-effects, but may increase hemodynamic instability. We evaluated the effect of the administration of 0.7 μg/kg dexmedetomidine and compared it with that of 0.03 mg/kg midazolam for usefulness of sedation of the parturient after delivery during cesarean section. METHODS After obtaining written consent and the ethics board approval, 60 parturients aged 20-43 years who underwent elective cesarean delivery under spinal anesthesia were recruited. A total of 0.5% hyperbaric bupivacaine (8-10 mg) and intrathecal fentanyl (10 μg) was given to induce anesthesia. Parturients were then randomly allocated to receive either midazolam (0.03 mg/kg; group M) or dexmedetomidine 0.7 (μg/kg; group D) after delivery. The primary outcome measure was patient satisfaction score. Secondary outcomes included vital signs; vasopressor dosage; incidence of shivering, nausea, and vomiting; incidence of bradycardia; time to sensory and motor recovery; postoperative nausea and vomiting score; and postoperative pain visual analog scale at 6, 24, and 48 h. RESULTS Satisfaction scores for sedation were similar between the two groups. The systolic blood pressure, heart rate, oximetry saturation, and tympanic temperature were comparable between the two groups. The predicted mean systolic blood pressure of group D was 106.3 mmHg and that of group M was 107.5 mmHg. Both groups showed comparable adverse intraoperative and postoperative outcomes. CONCLUSIONS Dexmedetomidine and midazolam showed similar hemodynamic effects and patient satisfaction in parturients under spinal anesthesia.
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Affiliation(s)
- Hyoseok Kang
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
| | - Taeha Lim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
| | - Hyun Jeong Lee
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
| | - Tae Wan Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
| | - Wan Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
| | - Hae Wone Chang
- Department of Anesthesiology and Pain Medicine, Nowon Eulji University Hospital, Seoul, Korea
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50
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Nguyen NM, Meyer D, Meyer L, Chand S, Jagadesan S, Miravite M, Guda C, Yelamanchili SV, Pendyala G. Identification of YWHAH as a Novel Brain-Derived Extracellular Vesicle Marker Post Long-Term Midazolam Exposure during Early Development. Cells 2023; 12:966. [PMID: 36980307 PMCID: PMC10047367 DOI: 10.3390/cells12060966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Recently, the long-term use of sedative agents in the neonatal intensive care unit (NICU) has raised concerns about neurodevelopmental outcomes in exposed neonates. Midazolam (MDZ), a common neonatal sedative in the NICU, has been suggested to increase learning disturbances and cognitive impairment in children. However, molecular mechanisms contributing to such outcomes with long-term MDZ use during the early stages of life remain unclear. In this study, we for the first time elucidate the role of brain-derived extracellular vesicles (BDEVs), including mining the BDEV proteome post long-term MDZ exposure during early development. Employing our previously established rodent model system that mimics the exposure of MDZ in the NICU using an increasing dosage regimen, we isolated BDEVs from postnatal 21-days-old control and MDZ groups using a differential sucrose density gradient. BDEVs from the control and MDZ groups were then characterized using a ZetaView nanoparticle tracking analyzer and transmission electron microscopy analysis. Next, using RT-qPCR, we examined the expression of key ESCRT-related genes involved in EV biogenesis. Lastly, using quantitative mass spectrometry-based proteomics, we mined the BDEV protein cargo that revealed key differentially expressed proteins and associated molecular pathways to be altered post long-term MDZ exposure. Our study characterized the proteome in BDEV cargo from long-term MDZ exposure at early development. Importantly, we identified and validated the expression of YWHAH as a potential target for further characterization of its downstream mechanism and a potential biomarker for the early onset of neurodevelopment and neurodegenerative diseases. Overall, the present study demonstrated long-term exposure to MDZ at early development stages could influence BDEV protein cargo, which potentially impact neural functions and behavior at later stages of development.
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Affiliation(s)
- Nghi M. Nguyen
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Daniel Meyer
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Luke Meyer
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Subhash Chand
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Sankarasubramanian Jagadesan
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Maireen Miravite
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Chittibabu Guda
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Sowmya V. Yelamanchili
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
| | - Gurudutt Pendyala
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
- Child Health Research Institute, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
- National Strategic Research Institute, University of Nebraska Medical Center (UNMC), Omaha, NE 68198, USA
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