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Moshiri M, Chaeideh B, Ebrahimi M, Dadpour B, Ghodsi A, Haghighizadeh A, Etemad L. Buprenorphine induced opioid withdrawal syndrome relieved by adjunctive Magnesium: A clinical trial. J Subst Use Addict Treat 2024; 160:209307. [PMID: 38309436 DOI: 10.1016/j.josat.2024.209307] [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: 06/27/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Precipitated opioid withdrawal syndrome (OWS) is a severe and intolerable situation that may occur by a pharmaceutical agent. Reactivation of inhibited N-methyl-d-aspartate (NMDA) receptor in person with prolonged opioid use can led to severe OWS. We conducted a double-blind, randomized clinical trial to assess the effect of magnesium sulfate (MGSO4) as an NMDA receptor antagonist on OWS. MATERIALS AND METHODS The study randomly divided forty patients with precipitated OWS due to partial agonist (buprenorphine) use referred to the emergency unit of Toxicology Department of Mashhad University of Medical Sciences, Iran; into two groups. The control group received conventional therapies, including clonidine 0.1 mg tablet each hour, intravenous infusion of 10 mg diazepam every 30 min, and IV paracetamol (Acetaminophen) 1 g, while the intervention group received 3 g of MGSO4 in 20 min and then 10 mg/kg/h up to 2 h, in addition to the conventional treatment. The clinical opiate withdrawal scale (COWS) evaluated OWS at the start of the treatment, 30 min, and 2 h later. RESULTS Both groups had similar demographic, opiate types, and COWS severity at the start of the intervention. COWS was lower in the intervention than the control group at 30 min (11.20 ± 2.86 and 14.65 ± 2.36, respectively, P = 0.002) and at 2 h (3.2 ± 1.61 and 11.25 ± 3.27, respectively, P < 0.001) after treatment. The intervention group received lesser doses of clonidine (0.12 ± 0.51 and 0.17 ± 0.45 mg, P = 0.003) and Diazepam (13.50 ± 5.87, 24.0 ± 6.80 mg, P = 0.001) than the control group. Serum magnesium levels raised from 1.71 ± 0.13 mmol/L to 2.73 ± 0.13 mmol/L in the intervention group. CONCLUSION Magnesium can significantly reduce the severity of OWS. Additional studies are required to confirm these results.
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Affiliation(s)
- Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohsen Ebrahimi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Dadpour
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Ghodsi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atoosa Haghighizadeh
- Department of Pharmaceutical and Food Control, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Etemad
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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Birkebæk S, Lundsgaard LM, Juul N, Seyer-Hansen M, Rasmussen MM, Uhrbrand PG, Nikolajsen L. Intraoperative clonidine in endometriosis and spine surgery: A protocol for two randomised, blinded, placebo-controlled trials. Acta Anaesthesiol Scand 2024; 68:708-713. [PMID: 38462487 DOI: 10.1111/aas.14398] [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: 01/25/2024] [Accepted: 02/10/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND A high proportion of patients who undergo surgery continue to suffer from moderate to severe pain in the early postoperative period despite advances in pain management strategies. Previous studies suggest that clonidine, an alpha2 adrenergic agonist, administered during the perioperative period could reduce acute postoperative pain intensity and opioid consumption. However, these studies have several limitations related to study design and sample size and hence, further studies are needed. AIM To investigate the effect of a single intravenous (IV) dose of intraoperative clonidine on postoperative opioid consumption, pain intensity, nausea, vomiting and sedation after endometriosis and spine surgery. METHODS Two separate randomised, blinded, placebo-controlled trials are planned. Patients scheduled for endometriosis (CLONIPAIN) will be randomised to receive either 150 μg intraoperative IV clonidine or placebo (isotonic saline). Patients undergoing spine surgery (CLONISPINE) will receive 3 μg/kg intraoperative IV clonidine or placebo. We aim to include 120 patients in each trial to achieve power of 90% at an alpha level of 0.05. OUTCOMES The primary outcome is opioid consumption within the first three postoperative hours. Secondary outcomes include pain intensity at rest and during coughing, nausea, vomiting and sedation within the first two postoperative hours and opioid consumption within the first six postoperative hours. Time to discharge from the PACU will be registered. CONCLUSION This study is expected to provide valuable information on the efficacy of intraoperative clonidine in acute postoperative pain management in patients undergoing endometriosis and spine surgery.
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Affiliation(s)
- Stine Birkebæk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Niels Juul
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Seyer-Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Mylius Rasmussen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Gaarsdal Uhrbrand
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Jansson-Rehnberg AS, Drewes AM, Sponheim J, Borgfelt C, Münch A, Graf W, Simrén M, Lindberg G, Hellström PM. Diarrhoea of unknown cause: medical treatment in a stepwise manner Management of Idiopathic Diarrhoea Based on Experience of Step-Up Medical Treatment. Scand J Gastroenterol 2024; 59:543-546. [PMID: 38343268 DOI: 10.1080/00365521.2024.2313061] [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: 10/25/2023] [Accepted: 01/25/2024] [Indexed: 04/26/2024]
Abstract
The basic principle for the treatment of idiopathic diarrhoea (functional diarrhoea K59.1) is to delay transit through the gut in order to promote the absorption of electrolytes and water. Under mild conditions, bulking agents may suffice. With increasing severity, antidiarrhoeal pharmaceuticals may be added in a stepwise manner. In diarrhoea of unknown aetiology, peripherally-acting opioid receptor agonists, such as loperamide, are first-line treatment and forms the pharmaceutical basis of antidiarrheal treatment. As second-line treatment opium drops have an approved indication for severe diarrhoea when other treatment options fail. Beyond this, various treatment options are built on experience with more advanced treatments using clonidine, octreotide, as well as GLP-1 and GLP-2 analogs which require specialist knowledge the field.
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Affiliation(s)
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jon Sponheim
- Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Christer Borgfelt
- Department of obstetrics and gynaecology, Skåne University Hospital, Lund, Sweden
| | - Andreas Münch
- Department of Gastrointestinal Medicine, University Hospital, Linköping, Sweden
| | - Wilhelm Graf
- Department of Surgical Sciences, University of Uppsala, Sweden
| | - Magnus Simrén
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Greger Lindberg
- Department of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Per M Hellström
- Department of Medical Sciences, University of Uppsala, Sweden
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Sun Y, Darmani NA. A Comparative Study of the Antiemetic Effects of α 2-Adrenergic Receptor Agonists Clonidine and Dexmedetomidine against Diverse Emetogens in the Least Shrew ( Cryptotis parva) Model of Emesis. Int J Mol Sci 2024; 25:4603. [PMID: 38731821 PMCID: PMC11083949 DOI: 10.3390/ijms25094603] [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: 03/11/2024] [Revised: 04/09/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
In contrast to cats and dogs, here we report that the α2-adrenergic receptor antagonist yohimbine is emetic and corresponding agonists clonidine and dexmedetomidine behave as antiemetics in the least shrew model of vomiting. Yohimbine (0, 0.5, 0.75, 1, 1.5, 2, and 3 mg/kg, i.p.) caused vomiting in shrews in a bell-shaped and dose-dependent manner, with a maximum frequency (0.85 ± 0.22) at 1 mg/kg, which was accompanied by a key central contribution as indicated by increased expression of c-fos, serotonin and substance P release in the shrew brainstem emetic nuclei. Our comparative study in shrews demonstrates that clonidine (0, 0.1, 1, 5, and 10 mg/kg, i.p.) and dexmedetomidine (0, 0.01, 0.05, and 0.1 mg/kg, i.p.) not only suppress yohimbine (1 mg/kg, i.p.)-evoked vomiting in a dose-dependent manner, but also display broad-spectrum antiemetic effects against diverse well-known emetogens, including 2-Methyl-5-HT, GR73632, McN-A-343, quinpirole, FPL64176, SR141716A, thapsigargin, rolipram, and ZD7288. The antiemetic inhibitory ID50 values of dexmedetomidine against the evoked emetogens are much lower than those of clonidine. At its antiemetic doses, clonidine decreased shrews' locomotor activity parameters (distance moved and rearing), whereas dexmedetomidine did not do so. The results suggest that dexmedetomidine represents a better candidate for antiemetic potential with advantages over clonidine.
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Affiliation(s)
| | - Nissar A. Darmani
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA;
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Entezariasl M, Isazadehfar K, Raesi M. The Effect of Clonidine Premedication on Hemodynamic Changes Following Tracheal Intubation and Co 2 Gas Insufflation and Postoperative Shivering In Patients Undergoing Laparoscopic Cholecystectomy; a Randomized Clinical Trial. Int Tinnitus J 2024; 27:174-182. [PMID: 38507632 DOI: 10.5935/0946-5448.20230027] [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] [Indexed: 03/22/2024]
Abstract
BACKGROUND Laparoscopic cholecystectomy is a proper treatment for cholecystitis but the Carbon dioxide gas which is used in surgery stimulates the sympathetic system and causes hemodynamic changes and postoperative shivering in patients undergoing operations. This study was conducted to evaluate the effects of clonidine on reducing hemodynamic changes during tracheal intubation and Carbon dioxide gas insufflation and postoperative shivering in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS This prospective, randomized, triple-blind clinical trial was conducted on 60 patients between the 18-70 years-old age group, who were candidates of laparoscopic cholecystectomy surgery. The patients randomized into two groups (30 patients received 150 μg oral clonidine) and 30 patients received 100 mg oral Vitamin C). Heart rate and mean arterial pressure of patients were recorded before anesthesia, before and after laryngoscopy, before and after Carbon dioxide gas insufflation. Data were analyzed using Chi-2, student t-test, and analysis of variance by repeated measure considering at a significant level less than 0.05. RESULTS The findings of this study showed that both heart rate and mean arterial pressure in clonidine group after tracheal intubation and Carbon dioxide gas insufflation were lower than patients in the placebo group, but there was not any statistically significant difference between the two groups (p>0.05) and also postoperative shivering was not different in groups. There was no significant statistical difference in postoperative shivering between the two groups (p>0.05). CONCLUSION Using 150 μg oral clonidine as a cheap and affordable premedication in patients undergoing laparoscopic cholecystectomy improves hemodynamic stability during operation.
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Affiliation(s)
- Masood Entezariasl
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardebil, Iran
| | - Khatereh Isazadehfar
- Determinants of Health Research Center, Department of Community Medicine, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Maryam Raesi
- School of Medicine, Ardabil University of Medical Sciences, Ardebil, Iran
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Wu TT, Steiger G, Smith L, Devlin JW, Slooter AJC. Research letter: Clonidine is associated with faster first resolution of incident ICU delirium than antipsychotics. J Crit Care 2024; 79:154433. [PMID: 37769421 DOI: 10.1016/j.jcrc.2023.154433] [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: 07/10/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Ting Ting Wu
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Gillian Steiger
- School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Louisa Smith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA; The Roux Institute, Northeastern University, Portland, ME, USA
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA; School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
| | - Arjen J C Slooter
- Departments of Psychiatry and Intensive Care Medicine, University Medical Center (UMC) Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Quintin L, Ghignone M. Letter to the editor: "Clonidine is associated with faster first resolution of incident ICU delirium than antipsychotics". J Crit Care 2024; 79:154465. [PMID: 37993386 DOI: 10.1016/j.jcrc.2023.154465] [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: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023]
Affiliation(s)
- L Quintin
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France.
| | - M Ghignone
- Anesthesia/Critical Care, JF Kennedy North Hospital, West Palm Beach, FL, USA
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Yang W, Wang S, Gu W, Bigambo FM, Wang Y, Wang X. Blood pressure response to clonidine in children with short stature is correlated with postural characteristics: a retrospective cross-sectional study. BMC Pediatr 2024; 24:39. [PMID: 38218818 PMCID: PMC10787478 DOI: 10.1186/s12887-023-04506-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/22/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Clonidine stimulation test has been widely used in the diagnosis of growth hormone deficiency in children with short stature with a high level of reliability. However, it may cause hypotension, which usually appears as headache, dizziness, bradycardia, and even syncope. It is well known that elevating the beds to make patients' feet above their cardiac level might relieve this discomfort. However, the real efficiency of this method remains to be proved while the best angle for the elevated bed is still unclear. METHODS A total of 1200 children with short stature were enrolled in this retrospective cross-sectional study. Age, gender, weight, and basic systolic and diastolic blood pressure were collected. Blood pressure at 1, 2, 3, and 4 h after stimulation tests were recorded. The participants were divided into 3 groups based on the angles of the elevated foot of their beds named 0°, 20°, and 40° groups. RESULTS At one hour after the commencement of the tests, participants lying on the elevated beds showed a higher mean increase on the change of pulse pressure. The difference in the angles of the elevated beds did not show statistical significance compared with those who did not elevate their beds (0.13 vs. 2.83, P = 0.001; 0.13 vs. 2.18, P = 0.005; 2.83 vs. 2.18, P = 0.369). When it came to 4 h after the tests began, participants whose beds were elevated at an angle around 20° had a significantly higher mean increase in the change of pulse pressure values compared with those whose beds were elevated at an angle around 40° (1.46 vs. -0.05, P = 0.042). CONCLUSION Elevating the foot of the beds of the patients who are undergoing clonidine stimulation tests at an angle of 20°might be a good choice to alleviate the hypotension caused by the tests.
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Affiliation(s)
- Wentao Yang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China
| | - Shanshan Wang
- Department of Emergency, Pediatric Intensive Care unit, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Wei Gu
- Medical Clinical Research Center, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Francis Manyori Bigambo
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China
| | - Yubing Wang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China.
| | - Xu Wang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China.
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Crispin H, Banting M. Intravenous clonidine infusion for refractory pain and agitation in central nervous system leukaemia. BMJ Support Palliat Care 2024; 13:e774-e775. [PMID: 37290832 DOI: 10.1136/spcare-2023-004355] [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: 04/25/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Helen Crispin
- Palliative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Banting
- Palliative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Prod'homme C, Werbrouck X, Pierrat M, Chevalier L, Lesaffre H, Pasqualini C, Touzet L. Dexmedetomidine and clonidine in palliative medicine: multicentric qualitative evaluation. BMJ Support Palliat Care 2024; 13:e876-e880. [PMID: 37076261 DOI: 10.1136/spcare-2023-004193] [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: 01/26/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES Alpha-2 agonists have analgesic and sedative properties that can prove interesting in palliative care. The main objective of this study was to describe the use of clonidine and dexmedetomidine in palliative care units (PCU). The secondary objective was to identify physicians' perspectives and attitudes toward alpha-2-agonists. METHODS International multicentric qualitative survey of prescribing characteristics and attitudes towards alpha-2 agonist. All 159 PCUs in France, Belgium and French-speaking Switzerland were contacted, and 142 physicians answered the questionnaire (31% participation). RESULTS 20% of the practitioners surveyed prescribe these molecules are mainly for analgesic and sedative indications. There was considerable heterogeneity in the modalities and dosages of administration. The use of clonidine is more frequent and common in Belgium, while dexmedetomidine is only used in France. There is a high level of satisfaction among practitioners who use these molecules, with the desire of the majority of respondents to obtain additional studies and information on alpha-2-agonists. CONCLUSION Alpha-2 agonists are little known and little prescribed by French-speaking palliative care physicians but are of interest because of their potential in this field. Phase 3 studies could justify the use of these molecules in palliative situations and would contribute to harmonising professional practices.
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Affiliation(s)
- Chloé Prod'homme
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
- ULR 2694 METRICS, University of Lille, Lille, Hauts-de-France, France
| | - Xavier Werbrouck
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
| | - Magali Pierrat
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
| | - Luc Chevalier
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
| | - Helene Lesaffre
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
| | - Claire Pasqualini
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
| | - Licia Touzet
- Departement of Palliative Care, Regional and University Hospital Centre Lille, Lille, France
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Varma R, Feuerhak KJ, Mishra R, Chakraborty S, Oblizajek NR, Bailey KR, Bharucha AE. A randomized double-blind trial of clonidine and colesevelam for women with fecal incontinence. Neurogastroenterol Motil 2024; 36:e14697. [PMID: 37890049 PMCID: PMC10842236 DOI: 10.1111/nmo.14697] [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: 06/25/2023] [Revised: 09/11/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Diarrhea and rectal urgency are risk factors for fecal incontinence (FI). The effectiveness of bowel modifiers for improving FI is unclear. METHODS In this double-blind, parallel-group, randomized trial, women with urge FI were randomly assigned in a 1:1 ratio to a combination of oral clonidine (0.1 mg twice daily) with colesevelam (1875 mg twice daily) or two inert tablets for 4 weeks. The primary outcome was a ≥50% decrease in number of weekly FI episodes. KEY RESULTS Fifty-six participants were randomly assigned to clonidine-colesevelam (n = 24) or placebo (n = 32); 51 (91%) completed 4 weeks of treatment. At baseline, participants had a mean (SD) of 7.5 (8.2) FI episodes weekly. The primary outcome was met for 13 of 24 participants (54%) treated with clonidine-colesevelam versus 17 of 32 (53%) treated with placebo (p = 0.85). The Bristol stool form score decreased significantly, reflecting more formed stools with clonidine-colesevelam treatment (mean [SD], 4.5 [1.5] to 3.2 [1.5]; p = 0.02) but not with placebo (4.2 [1.9] to 4.1 [1.9]; p = 0.47). The proportion of FI episodes for semiformed stools decreased significantly from a mean (SD) of 76% (8%) to 61% (10%) in the clonidine-colesevelam group (p = 0.007) but not the placebo group (61% [8%] to 67% [8%]; p = 0.76). However, these treatment effects did not differ significantly between groups. Overall, clonidine-colesevelam was well tolerated. CONCLUSIONS AND INFERENCES Compared with placebo, clonidine-colesevelam did not significantly improve FI despite being associated with more formed stools and fewer FI episodes for semiformed stools.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly J Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Wu S, Han B, Xiong X. Clinical effects of occupational clonidine poisoning and efficacy of extracorporeal blood purification therapies. Clin Toxicol (Phila) 2024; 62:64-65. [PMID: 38277140 DOI: 10.1080/15563650.2024.2302455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/02/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Shan Wu
- Blood Purification Center, Affiliated Suzhou Municipal Hospital of Anhui Medical University, Suzhou, China
| | - Bo Han
- Blood Purification Center, The Fifth Medical Center of PLA General Hospital, Poisoning Treatment Center of PLA, Beijing, China
| | - Xishan Xiong
- Department of Nephrology, Quzhou TCM Hospital at the Junction of Four Provinces Affiliated to Zhejiang Chinese Medical University, Quzhou, China
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13
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Bjørk MH, Borkenhagen S, Oteiza F, Dueland AN, Sørgaard FE, Saether EM, Bugge C. Comparative retention and effectiveness of migraine preventive treatments: A nationwide registry-based cohort study. Eur J Neurol 2024; 31:e16062. [PMID: 37754544 DOI: 10.1111/ene.16062] [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: 12/08/2022] [Revised: 07/28/2023] [Accepted: 08/30/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND PURPOSE Little is known about the comparative effects of migraine preventive drugs. We aimed to estimate treatment retention and effectiveness of migraine preventive drugs in a nationwide registry-based cohort study in Norway between 2010 and 2020. METHODS We assessed retention, defined as the number of uninterrupted treatment days, and effectiveness, defined as the reduction in filled triptan prescriptions during four 90-day periods after the first preventive prescription, compared to a 90-day baseline period. We compared retention and efficacy for different drugs against beta blockers. Comparative retention was estimated with hazard ratios (HRs), adjusted for covariates, using Cox regression, and effectiveness as odds ratios (ORs) using logistic regression, with propensity-weighted adjustment for covariates. RESULTS We identified 104,072 migraine patients, 81,890 of whom were female (78.69%) and whose mean (standard deviation) age was 44.60 (15.61) years. Compared to beta blockers, botulinum toxin (HR 0.43, 95% confidence interval [CI] 0.42-0.44) and calcitonin gene-related peptide pathway antibodies (CGRPabs; HR 0.63, 95% CI 0.59-0.66) were the least likely to be discontinued, while clonidine (HR 2.95, 95% CI 2.88-3.02) and topiramate (HR 1.34, 95% CI 1.31-1.37) were the most likely to be discontinued. Patients on simvastatin, CGRPabs, and amitriptyline were more likely to achieve a clinically significant reduction in triptan use during the first 90 days of treatment, with propensity score-adjusted ORs of 1.28 (95% CI 1.19-1.38), 1.23 (95% CI 0.79-1.90), and 1.13 (95% CI 1.08-1.17), respectively. CONCLUSIONS We found a favorable effect of CGRPabs, amitriptyline, and simvastatin compared with beta blockers, while topiramate and clonidine were associated with poorer outcomes.
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Affiliation(s)
- Marte H Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- NorHEAD, Norwegian Headache Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
| | | | | | - Aud N Dueland
- Sandvika Nevrosenter, Sandvika, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | | | - Christoffer Bugge
- Oslo Economics, Oslo, Norway
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Walsh TS, Aitken LM, McKenzie CA, Boyd J, Macdonald A, Giddings A, Hope D, Norrie J, Weir C, Parker RA, Lone NI, Emerson L, Kydonaki K, Creagh-Brown B, Morris S, McAuley DF, Dark P, Wise MP, Gordon AC, Perkins G, Reade M, Blackwood B, MacLullich A, Glen R, Page VJ. Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B Trial): protocol for a multicentre phase 3 pragmatic clinical and cost-effectiveness randomised trial in the UK. BMJ Open 2023; 13:e078645. [PMID: 38072483 PMCID: PMC10729141 DOI: 10.1136/bmjopen-2023-078645] [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: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care. METHODS AND ANALYSIS Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of -2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40-50 UK ICUs. ETHICS AND DISSEMINATION The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03653832.
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Affiliation(s)
- Timothy Simon Walsh
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Julia Boyd
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Alix Macdonald
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Annabel Giddings
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No. 9, Bioquarter, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Nazir I Lone
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Benedict Creagh-Brown
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Stephen Morris
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | | | - Paul Dark
- Intensive Care Unit, University of Manchester, Greater Manchester, UK
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick, Birmingham, UK
| | - Michael Reade
- University of Queensland, Brisbane, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | | | - Valerie J Page
- Intensive Care, West Hertfordshire Hospitals NHS Trust, Watford, UK
- Faculty of Medicine, Imperial College London, London, UK
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Padhan M, Maiti R, Mohapatra D, Mishra BR. Efficacy and safety of tramadol in the treatment of opioid withdrawal: A meta-analysis of randomized controlled trials. Addict Behav 2023; 147:107815. [PMID: 37517376 DOI: 10.1016/j.addbeh.2023.107815] [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: 05/26/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Pharmacotherapeutic options for the treatment of opioid withdrawal are limited by abuse potential, adverse effects, and lack of availability of existing drugs. The results from previous clinical trials on tramadol are contradictory and non-conclusive; hence the present meta-analysis was conducted to evaluate the efficacy and safety of tramadol in the treatment of opioid withdrawal. METHODS Reviewers extracted data from eight relevant clinical trials after a literature search on MEDLINE/PubMed, Cochrane databases, and clinical trial registries. Quality assessment was done using the risk-of-bias assessment tool, and the random-effects model was used to estimate effect size in frequentist and Bayesian approaches. Subgroup analysis, meta-regression, and sensitivity analysis were done as applicable. PRISMA guidelines were followed in reporting findings. RESULTS Tramadol significantly reduced opioid withdrawal scale score (SMD: -0.44; 95%CI: -0.76 to -0.13; PI: -1.54 to 0.71; p = 0.006) when all comparators were considered together in the frequentist approach but the reduction was non-significant in Bayesian approach. However, the subgroup analysis revealed no significant difference between tramadol and comparators like placebo (SMD: -1.12; 95%CI: -2.69 to 0.45) buprenorphine (SMD: -0.21; 95%CI: -0.43 to 0.01), clonidine (SMD: -0.26; 95%CI: -0.55 to 0.02) and methadone (SMD: -0.84; 95%CI: -1.78 to 0.10). Meta-regression showed non-significant associations between the SMD in opioid withdrawal score with the duration and dose of tramadol therapy. There were no significant differences in treatment retention at the end of studies between tramadol and comparators. Safety data in the individual studies were inadequate to analyze. CONCLUSION Authors conclude that the efficacy of tramadol in reducing opioid withdrawal symptoms is not significantly different from comparators with low certainty of evidence against placebo, moderate against methadone, whereas with high certainty of evidence against buprenorphine and clonidine.
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Affiliation(s)
- Milan Padhan
- All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India.
| | - Rituparna Maiti
- All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India.
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Kraker JA, Tajfirouz DA, Bhatti MT, Chen JJ. Tachyphylaxis With Sustained Apraclonidine Use in the Treatment of Ptosis Associated With Horner Syndrome. J Neuroophthalmol 2023; 43:e245-e246. [PMID: 36279499 DOI: 10.1097/wno.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jessica A Kraker
- Mayo Clinic Department of Ophthalmology (JAK, DAT, MTB, JJC), Rochester, Minnesota; and Mayo Clinic Department of Neurology (MTB, JJC), Rochester, Minnesota
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Bromfalk Å, Hultin M, Myrberg T, Engström Å, Walldén J. Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine. Paediatr Anaesth 2023; 33:962-972. [PMID: 37528645 DOI: 10.1111/pan.14740] [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: 09/26/2022] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2-6 years. METHODS In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured. RESULTS After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups. CONCLUSIONS No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2 -agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.
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Affiliation(s)
- Åsa Bromfalk
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderbyn), Umeå University, Umeå, Sweden
| | - Åsa Engström
- Division of Nursing and Medical Technology, Department of Health, Education and Technology, Lulea University of Technology, Luleå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Umeå, Sweden
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Maharani ND, Fuadi A, Halimi RA. Comparison of the effect of scalp block analgesia bupivacaine 0.25% and clonidine 2 μg/kg with bupivacaine 0.25% and dexamethasone 8 mg on cortisol levels and Numeric Rating Scale in craniotomy tumour. Med J Malaysia 2023; 78:808-814. [PMID: 38031225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Craniotomy tumour is brain surgery that can induce a stress response. The stress response can be measured using haemodynamic parameters and plasma cortisol concentration. The stress response that occurs can affect an increase in sympathetic response, such as blood pressure and heart rate, which can lead to an increase in intracranial pressure. Scalp block can reduce the stress response to surgery and post-operative craniotomy tumour pain. The local anaesthetic drug bupivacaine 0.25% is effective in reducing post-operative pain and stress in the form of reducing plasma cortisol levels. The adjuvant addition of clonidine 2 μg/kg or dexamethasone may be beneficial. MATERIALS AND METHODS A randomised control clinical trial was conducted at the Central Surgery Installation and Hasan Sadikin General Hospital Bandung and Dr. Mohammad Husein Hospital Palembang from December 2022 to June 2023. A total of 40 participants were divided into two groups using block randomisation. Group I receives bupivacaine 0.25% and clonidine 2 μg/kg, and group II receives bupivacaine 0.25% and dexamethasone 8 mg. The plasma cortisol levels of the patient will be assessed at (T0, T1 and T2). All the patient were intubated under general anesthaesia and received the drug for scalp block based on the group being randomised. Haemodynamic monitoring was carried out. RESULTS There was a significant difference in administering bupivacaine 0.25% and clonidine 2μg/kg compared to administering bupivacaine 0.25% and dexamethasone 8 mg/kg as analgesia for scalp block in tumour craniotomy patients on cortisol levels at 12 hours post-operatively (T1) (p=0.048) and 24 hours post-surgery (T2) (p=0.027), while post-intubation cortisol levels (T0) found no significant difference (p=0.756). There is a significant difference in Numeric Rating Scale (NRS) at post-intubation (T0) (p=0.003), 12 hours post-operatively (T1) (p=0.002) and 24 hours post-surgery (T2) (p=0.004), There were no postprocedure scalp block side effects in both groups. CONCLUSION The study found that scalp block with 0.25% bupivacaine and 2μg/kg clonidine is more effective in reducing NRS scores and cortisol levels compared bupivacaine 0.25% and dexamethasone 8mg in tumour craniotomy patients.
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Affiliation(s)
- N D Maharani
- University of Padjajaran/Dr Hasan Sadikin Hospital, Medical Faculty, Department of Anesthesiology and Intensive Care, Bandung, Indonesia.
| | - A Fuadi
- University of Padjajaran/Dr Hasan Sadikin Hospital, Medical Faculty, Department of Anesthesiology and Intensive Care, Bandung, Indonesia
| | - R A Halimi
- University of Padjajaran/Dr Hasan Sadikin Hospital, Medical Faculty, Department of Anesthesiology and Intensive Care, Bandung, Indonesia
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Hassanzadeh S, Bagheri S, Majid Ahmadi S, Ahmadi SA, Moradishibany I, Dolatkhah H, Reisi S. Effectiveness of oral clonidine and gabapentin on peripheral neuropathy in diabetic patients in southwestern Iran: a randomized clinical trial. BMC Endocr Disord 2023; 23:224. [PMID: 37845651 PMCID: PMC10577942 DOI: 10.1186/s12902-023-01486-0] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Peripheral neuropathy is not only the most prevalent consequence of diabetes but also the main reason for foot ulceration, disability, and amputation. Therefore, the current study aims to determine the effectiveness of oral clonidine and gabapentin on peripheral neuropathy in diabetic patients. METHODS This 12-week, randomized, and parallel-group trial was conducted to compare the efficacy of oral clonidine and gabapentin with gabapentin alone in diabetic patients in southwest Iran during the first half of 2021. Thirty patients with type 2 diabetes with peripheral neuropathy as assessed by a visual analog scale (VAS) and divided into two groups of 15 patients, treated for up to three months. The data were analyzed using SPSS-21 software. In order to report the results, descriptive indices, independent t-test, one-way analysis of covariance (ANCOVA) and analysis of variance with repeated measures were used. RESULTS The mean and standard deviation of the age of the participants in the clonidine + gabapentin group was equal to 50.20 ± 7.44, and in the gabapentin group was equal to 50.47 ± 7.57 (t = 0.10, P-value = 0.923). This research showed a significant difference between the clonidine + gabapentin group and with gabapentin group in terms of neuropathic pain and the severity of neuropathic pain (P < 0.001). CONCLUSIONS According to this research results, clonidine + gabapentin can reduce neuropathic pain and the severity of neuropathic pain in diabetic patients. Therefore, it is recommended that healthcare professionals with diabetes expertise prescribe these medications to reduce neuropathic pain and its severity. TRIAL REGISTRATION This study was registered in the Iranian Clinical Trials System with the ID (IRCT20211106052983N1) on 14/01/2022.
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Affiliation(s)
- Sajad Hassanzadeh
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Soraya Bagheri
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Seyed Majid Ahmadi
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran.
| | | | - Isaac Moradishibany
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Hosein Dolatkhah
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Sajjad Reisi
- Genetic and Environmental Adventures Research Center, School of Abarkouh Paramedicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
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Zammit J, Ferrafiat V. Interest of clonidine for seven inpatient youths with intellectual disability and other severe neurodevelopmental disorders. CNS Spectr 2023; 28:530-533. [PMID: 36398402 DOI: 10.1017/s1092852922001110] [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] [Indexed: 11/21/2022]
Affiliation(s)
- Jessica Zammit
- Department of Child and Adolescent Psychiatry, URHEA, CH Le Rouvray, Sotteville les Rouen, France
| | - Vladimir Ferrafiat
- Reference Center for Inborn Errors of Metabolism, La Timone University Hospital, Assistance Publique-Hopitaux de Marseille, Marseille, France
- Reference Center for Intellectual Disabilities of Rare Causes, La Timone University Hospital, Assistance Publique-Hopitaux de Marseille, Marseille, France
- Pediatric Neurology, La Timone University Hospital, Assistance Publique-Hopitaux de Marseille, Marseille, France
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Dinges HC, Al-Dahna T, Rücker G, Wulf H, Eberhart L, Wiesmann T, Schubert AK. Pharmacologic interventions for the therapy of postanesthetic shivering in adults: a systematic review and network meta-analysis. Minerva Anestesiol 2023; 89:923-935. [PMID: 37458681 DOI: 10.23736/s0375-9393.23.17410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Shivering is a common side effect after general anesthesia. Risk factors are hypothermia, young age and postoperative pain. Severe complications of shivering are rare but can occur due to increased oxygen consumption. Previous systematic reviews are outdated and have summarized the evidence on the topic using only pairwise comparisons. The objective of this manuscript was a quantitative synthesis of evidence on pharmacological interventions to treat postanesthetic shivering. EVIDENCE ACQUSITION Systematic review and frequentist network meta-analysis using the R package netmeta. Endpoints were the risk ratio (RR) of persistent shivering at one, five and 10 minutes after treatment with saline/placebo as the comparator. Data were retrieved from Medline, Embase, Central and Web of Science up to January 2022. Eligibility criteria were: randomized, controlled, and blinded trials comparing pharmacological interventions to treat shivering after general anesthesia. Studies on shivering during or after any type of regional anesthesia were excluded as well as sedated patients after cardiac surgery. EVIDENCE SYNTHESIS Thirty-two trials were eligible for data synthesis, including 28 pharmacological interventions. The largest network included 1431 patients. The network geometry was two-centered with most comparisons linked to saline/placebo or pethidine. The best interventions were after one minute: doxapram 2 mg/kg, tramadol 2 mg/kg and nefopam 10 mg, after 5 minutes: tramadol 2 mg/kg, nefopam 10 mg and clonidine 150 µg and after 10 minutes: nefopam 10 mg, methylphenidate 20 mg and tramadol 1 mg/kg, all reaching statistical significance. Pethidine 25 mg and clonidine 75 µg also performed well and with statistical significance in all networks. CONCLUSIONS Nefopam, tramadol, pethidine and clonidine are the most effective treatments to stop postanesthetic shivering. The efficacy of doxapram is uncertain since different doses showed contradictory effects and the evidence for methylphenidate is based on a single comparison in only one network. Furthermore, both lack data on side effects. Further studies are needed to clarify the efficacy of dexmedetomidine to treat postanesthetic shivering.
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Affiliation(s)
- Hanns-Christian Dinges
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany -
| | - Turfa Al-Dahna
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany
| | - Gerta Rücker
- Faculty of Medicine and Medical Center, Institute of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany
| | - Leopold Eberhart
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany
| | - Thomas Wiesmann
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany
| | - Ann-Kristin Schubert
- Department of Anesthesia and Intensive Care, University Hospital Marburg, Marburg, Germany
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Keskes M, Amouri N, Ketata S, Derbel R, Charfi M, Zouche I, Sallemi M, Elloumi M, Chikhrouhou H. The interest of intranasal clonidine in the prevention of perioperative children's anxiety: a prospective randomized trial. Pan Afr Med J 2023; 46:37. [PMID: 38145196 PMCID: PMC10746874 DOI: 10.11604/pamj.2023.46.37.40310] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 09/08/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction perioperative anxiety in children may lead to psychological and physiological side effects. Clonidine is in increasing use in the pediatric population as an anxiolytic, sedative, and analgesic because of its central alpha2-adrenergic agonist effect. Our study aimed to evaluate the effect of clonidine in the prevention of perioperative children´s anxiety. Methods we conducted a prospective controlled randomized double-blinded clinical trial including children aged between 2 and 15 years undergoing tonsillectomy surgery. The patients were randomly allocated to receive either an intranasal dose of clonidine (4 μg/kg) (clonidine group) or an equal volume dose of saline solution (control group) 30 minutes before entering the operating room. The level of anxiety assessed using the m-YPAS score was recorded before premedication, at the time of parent-child separation, and at the time of installation in the operating room. Acceptance of premedication, degree of sedation on entering the operating room as well as agitation on awakening, and sedation on arrival post-anesthesia care unit were noted. Adverse effects were recorded during the surgical procedure and in the postoperative recovery room. Results the number of patients analyzed was 78 with 39 patients in each group. There were no signification differences in demographic data and premedication acceptance between the two groups. Levels of anxiety before any premedication were similar in the two groups. However, the anxiety level 30 minutes after premedication and in the operating room was significantly lower in the clonidine group (p<0.001). Children who received clonidine showed better sedation on entering the operating room (p=0.002) as well as postoperatively on entering the post-anesthesia unit care (p=0.006). The hemodynamic and respiratory parameters recorded were statistically comparable. Conclusion intranasal clonidine is an interesting premedication to prevent perioperative children´s anxiety with few side effects.
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Affiliation(s)
- Mariem Keskes
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Nouha Amouri
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Salma Ketata
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Rahma Derbel
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Maha Charfi
- Department of Hematology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Imen Zouche
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Moncef Sallemi
- Department of Oto-Rhino-Laryngology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Moez Elloumi
- Department of Hematology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Hichem Chikhrouhou
- Department of Anesthesiology and Intensive Care Unit, Habib Bourguiba University Hospital, Sfax, Tunisia
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Ratnasekara V, Weinberg L, Johnston SA, Fletcher L, Nugraha P, Cox DRA, Hu R, Meyer I, Yoshino O, Perini MV, Muralidharan V, Nikfarjam M, Lee DK. Multimodal intrathecal analgesia (MITA) with morphine for reducing postoperative opioid use and acute pain following hepato-pancreato-biliary surgery: A multicenter retrospective study. PLoS One 2023; 18:e0291108. [PMID: 37682837 PMCID: PMC10490836 DOI: 10.1371/journal.pone.0291108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION The optimal analgesic modality for patients undergoing hepato-pancreato-biliary (HPB) surgery remains unknown. The analgesic effects of a multimodal intrathecal analgesia (MITA) technique of intrathecal morphine (ITM) in combination with clonidine and bupivacaine compared to ITM alone have not been investigated in these patients. METHODS We performed a multicenter retrospective study of patients undergoing complex HPB surgery who received ITM, bupivacaine, and clonidine (MITA group) or ITM-only (ITM group) as part of their perioperative analgesia strategy. The primary outcome was the unadjusted oral morphine equivalent daily dose (oMEDD) in milligrams on postoperative day 1. After adjusting for age, body mass index, hospital allocation, type of surgery, operation length, and intraoperative opioid use, postoperative oMEDD use was investigated using a bootstrapped quantile regression model. Other prespecified outcomes included postoperative pain scores, opioid-related adverse events, major complications, and length of hospital stay. RESULTS In total, 118 patients received MITA and 155 patients received ITM-only. The median (IQR) cumulative oMEDD use on postoperative day 1 was 20.5 mg (8.6:31.0) in the MITA group and 52.1 mg (18.0:107.0) in the ITM group (P < 0.001). There was a variation in the magnitude of the difference in oMEDD use between the groups for different quartiles. For the MITA group, on postoperative day 1, patients in the 25th percentile required 14.0 mg less oMEDD (95% CI: -25.9 to -2.2; P = 0.025), patients in the 50th percentile required 27.8 mg less oMEDD (95% CI: -49.7 to -6.0; P = 0.005), and patients in the 75th percentile required 38.7 mg less oMEDD (95% CI: -72.2 to -5.1; P = 0.041) compared to patients in the same percentile of the ITM group. Patients in the MITA group had significantly lower pain scores in the postoperative recovery unit and on postoperative days 1 to 3. The incidence of postoperative respiratory depression was low (<1.5%) and similar between groups. Patients in the MITA group had a significantly higher incidence of postoperative hypotension requiring vasopressor support. However, no significant differences were observed in major postoperative complications, or the length of hospital stay. CONCLUSION In patients undergoing complex HPB surgery, the use of MITA, consisting of ITM in combination with intrathecal clonidine and bupivacaine, was associated with reduced postoperative opioid use and resulted in superior postoperative analgesia without risk of respiratory depression when compared to patients who received ITM alone. A randomized prospective clinical trial investigating these two intrathecal analgesic techniques is justified.
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Affiliation(s)
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia
| | | | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health, Heidelberg, Australia
| | - Patrick Nugraha
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | | | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Ilonka Meyer
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Osamu Yoshino
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Marcos Vinius Perini
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | | | - Mehrdad Nikfarjam
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Bhenderu LS, Lyon KA, Soto JM, Richardson W, Desai R, Rahm M, Huang JH. Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail as a Local Anesthetic for Lumbar Decompression Surgery: A Single Institutional Experience. World Neurosurg 2023; 176:e515-e520. [PMID: 37263493 DOI: 10.1016/j.wneu.2023.05.091] [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: 03/15/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The goal of this study is to discuss our initial experience with a multimodal opioid-sparing cocktail containing ropivacaine, epinephrine, clonidine, and ketorolac (RECK) in the postoperative management of lumbar decompression surgeries. METHODS Patients were either administered no local anesthetic at the incision site or were administered a weight-based amount of RECK into the paraspinal musculature and subdermal space surrounding the operative site once the fascia was closed. We performed a retrospective chart review of all patients 18 years of age or older undergoing lumbar laminectomy and lumbar diskectomy surgeries between December 2019 and April 2021. Outcomes including total opioid use, measured as morphine milligram equivalent, length of stay, and postoperative visual analog scores for pain, were collected. Relationships between variables were analyzed with Student's t-test, chi-square tests, and Fisher exact tests. RESULTS A total of 121 patients undergoing 52 lumbar laminectomy and 69 lumbar diskectomy surgeries were identified. For lumbar laminectomy, patients who were administered RECK had decreased opioid use in the postoperative period (11.47 ± 12.32 vs. 78.51 ± 106.10 morphine milligram equivalents, P = 0.019). For patients undergoing lumbar diskectomies, RECK administration led to a shorter length of stay (0.17 ± 0.51 vs. 0.79 ± 1.45 days, P = 0.019) and a lower 2-hour postoperative pain score (3.69 ± 2.56 vs. 5.41 ± 2.28, P = 0.006). CONCLUSIONS The RECK cocktail has potential to be an effective therapeutic option for the postoperative management of lumbar decompression surgeries.
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Affiliation(s)
- Lokeshwar S Bhenderu
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA.
| | - Kristopher A Lyon
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Jose M Soto
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - William Richardson
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Ronak Desai
- Department of Orthopedic Surgery, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Mark Rahm
- Department of Orthopedic Surgery, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA
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Merizalde Torres M, Castan Campanera E, Pifarré Paredero J. Clonidine reduces the need for antipsychotics in conduct disorders associated with intellectual disability and mental illness: A case series. Span J Psychiatry Ment Health 2023; 16:204-205. [PMID: 37716847 DOI: 10.1016/j.rpsm.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/10/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
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26
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Nordness MF, Maiga AW, Wilson LD, Koyama T, Rivera EL, Rakhit S, de Riesthal M, Motuzas CL, Cook MR, Gupta DK, Jackson JC, Williams Roberson S, Meurer WJ, Lewis RJ, Manley GT, Pandharipande PP, Patel MB. Effect of propranolol and clonidine after severe traumatic brain injury: a pilot randomized clinical trial. Crit Care 2023; 27:228. [PMID: 37296432 PMCID: PMC10251526 DOI: 10.1186/s13054-023-04479-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 03/06/2023] [Accepted: 05/06/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE To evaluate the safety, feasibility, and efficacy of combined adrenergic blockade with propranolol and clonidine in patients with severe traumatic brain injury (TBI). BACKGROUND Administration of adrenergic blockade after severe TBI is common. To date, no prospective trial has rigorously evaluated this common therapy for benefit. METHODS This phase II, single-center, double-blinded, pilot randomized placebo-controlled trial included patients aged 16-64 years with severe TBI (intracranial hemorrhage and Glasgow Coma Scale score ≤ 8) within 24 h of ICU admission. Patients received propranolol and clonidine or double placebo for 7 days. The primary outcome was ventilator-free days (VFDs) at 28 days. Secondary outcomes included catecholamine levels, hospital length of stay, mortality, and long-term functional status. A planned futility assessment was performed mid-study. RESULTS Dose compliance was 99%, blinding was intact, and no open-label agents were used. No treatment patient experienced dysrhythmia, myocardial infarction, or cardiac arrest. The study was stopped for futility after enrolling 47 patients (26 placebo, 21 treatment), per a priori stopping rules. There was no significant difference in VFDs between treatment and control groups [0.3 days, 95% CI (- 5.4, 5.8), p = 1.0]. Other than improvement of features related to sympathetic hyperactivity (mean difference in Clinical Features Scale (CFS) 1.7 points, CI (0.4, 2.9), p = 0.012), there were no between-group differences in the secondary outcomes. CONCLUSION Despite the safety and feasibility of adrenergic blockade with propranolol and clonidine after severe TBI, the intervention did not alter the VFD outcome. Given the widespread use of these agents in TBI care, a multi-center investigation is warranted to determine whether adrenergic blockade is of therapeutic benefit in patients with severe TBI. Trial Registration Number NCT01322048.
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Affiliation(s)
- Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, VUMC, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN, 37212, USA
| | - Amelia W Maiga
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, VUMC, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN, 37212, USA
- Surgical Services at the Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN, 37212, USA
| | - Laura D Wilson
- Department of Hearing & Speech Sciences, VUMC, 1215 21st Avenue South, Medical Center East, Room 8310, Nashville, TN, 37232, USA
- College of Health Sciences & Communication Sciences and Disorders at the University of Tulsa, 800 S Tucker Drive, Tulsa, OK, 74104, USA
| | - Tatsuki Koyama
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Department of Biostatistics, VUMC, Room 11133B, 2525 West End Avenue, Nashville, TN, 37203, USA
| | - Erika L Rivera
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, VUMC, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN, 37212, USA
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, VUMC, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN, 37212, USA
| | - Michael de Riesthal
- Department of Hearing & Speech Sciences, VUMC, 1215 21st Avenue South, Medical Center East, Room 8310, Nashville, TN, 37232, USA
| | - Cari L Motuzas
- Department of Radiology and Radiological Sciences, VUMC, Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Madison R Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Meharry Medical College, 1005 Dr. DB Todd Jr Blvd, Nashville, TN, 37208, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt Translational and Clinical Cardiovascular Research Center, VUMC, 2525 West End, Suite 300-A, Nashville, TN, 37203, USA
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
| | - William J Meurer
- University of Michigan Emergency Medicine, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-University of California Los Angeles, 1000 W Carson St, Torrance, CA, 90502, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave, Room M779, Box 0112, San Francisco, CA, 94143, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA
- Center for Health Services Research, Institute for Medicine and Public Health, VUMC, 2525 West End Avenue, Nashville, TN, 37203, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, VUMC, 1211 Medical Center Drive, Nashville, TN, 37232, USA
- Geriatric Research, Education and Clinical Center (GRECC), Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN, 37212, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center (VUMC), Suite 450, 4th Floor, 2525 West End Avenue, Nashville, TN, 37203, USA.
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, VUMC, 1211 21st Avenue South, Medical Arts Building, Suite 404, Nashville, TN, 37212, USA.
- Department of Hearing & Speech Sciences, VUMC, 1215 21st Avenue South, Medical Center East, Room 8310, Nashville, TN, 37232, USA.
- Center for Health Services Research, Institute for Medicine and Public Health, VUMC, 2525 West End Avenue, Nashville, TN, 37203, USA.
- Vanderbilt Brain Institute, VUMC, 7203 Medical Research Building III, 465 21st Avenue South, Nashville, TN, USA.
- Geriatric Research, Education and Clinical Center (GRECC), Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN, 37212, USA.
- Surgical Services at the Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN, 37212, USA.
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Bang Madsen K, Robakis TK, Liu X, Momen N, Larsson H, Dreier JW, Kildegaard H, Groth JB, Newcorn JH, Hove Thomsen P, Munk-Olsen T, Bergink V. In utero exposure to ADHD medication and long-term offspring outcomes. Mol Psychiatry 2023; 28:1739-1746. [PMID: 36759544 DOI: 10.1038/s41380-023-01992-6] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
Attention Deficit Hyperactivity Disorder (ADHD) medication is increasingly being used during pregnancy. Concerns have been raised as to whether ADHD medication has long-term adverse effects on the offspring. The authors investigated whether in utero exposure to ADHD medication was associated with adverse long-term neurodevelopmental and growth outcomes in offspring. The population-based cohort study in the Danish national registers included 1,068,073 liveborn singletons from 1998 to 2015 followed until any developmental diagnosis, death, emigration, or December 31, 2018. Children of mothers who continued ADHD medication (methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine, modafinil, atomoxetine, clonidine) during pregnancy and children of mothers who discontinued ADHD medication before pregnancy were compared using Cox regression. Main outcomes were neurodevelopmental psychiatric disorders, impairments in vision or hearing, epilepsy, seizures, or growth impairment during childhood or adolescence. In total, 898 children were exposed to ADHD medication during pregnancy compared to 1270 children whose mothers discontinued ADHD medication before pregnancy. After adjustment for demographic and psychiatric characteristics of the mother, no increased risk of any offspring developmental disorders was found combined (aHR 0.97, 95% CI 0.81 to 1.17) or for separate subcategories. Similarly, no increased risk was found for any sub-categories of outcomes in the negative control or sibling controlled analyses. Neurodevelopment and growth in offspring do not differ based on antenatal exposure to ADHD medication. These findings provide reassurance for women with ADHD who depend on ADHD medication for daily functioning and who consider continuing medication in pregnancy.
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Affiliation(s)
- Kathrine Bang Madsen
- NCRR - National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark.
| | - Thalia K Robakis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiaoqin Liu
- NCRR - National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Natalie Momen
- NCRR - National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Henrik Larsson
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Julie Werenberg Dreier
- NCRR - National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Helene Kildegaard
- Hans Christian Andersen's Children's Hospital, Odense University Hospital, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Jane Bjerg Groth
- Department of Otorhinolaryngology and Audiology, Zealand University Hospital, Universty of Copenhagen, Køge, Denmark
| | - Jeffrey H Newcorn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Per Hove Thomsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Center at the Department for Child- and Adolescent Psychiatry, Aarhus University Hospital, Skejby, Denmark
| | - Trine Munk-Olsen
- NCRR - National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- Research Unit of Psychiatry, Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Veerle Bergink
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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Xu YQ, Yuan K, Zhu JF, Fang YL, Wang CL. [Hematuria in association with combined simultaneous arginine clonidine stimulation test in 3 children]. Zhonghua Er Ke Za Zhi 2022; 60:1336-1338. [PMID: 36444442 DOI: 10.3760/cma.j.cn112140-20220616-00559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Y Q Xu
- Department of Pediatrics, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
| | - K Yuan
- Department of Pediatrics, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
| | - J F Zhu
- Department of Pediatrics, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
| | - Y L Fang
- Department of Pediatrics, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
| | - C L Wang
- Department of Pediatrics, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 311100, China
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Cochrane Database Syst Rev 2022; 11:CD015023. [PMID: 36354070 PMCID: PMC9647594 DOI: 10.1002/14651858.cd015023.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life. OBJECTIVES To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. SEARCH METHODS We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine. AUTHORS' CONCLUSIONS We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Carlsen Misic M, Eriksson M, Normann E, Pettersson M, Blomqvist Y, Olsson E. Clonidine as analgesia during retinopathy of prematurity screening in preterm infants (cloROP): protocol for a randomised controlled trial. BMJ Open 2022; 12:e064251. [PMID: 36137627 PMCID: PMC9511565 DOI: 10.1136/bmjopen-2022-064251] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Preterm infants are at risk of negative consequences from stress and pain at the same time as they often are in need of intensive care that includes painful interventions. One of the frequent painful procedures preterm infants undergo is eye examination screening to detect early signs of ROP (retinopathy of prematurity). These examinations are both stressful and painful, and despite a multitude of research studies, no conclusive pain-relieving treatment has been demonstrated. The main aim of this trial is to investigate the analgesic effect of clonidine during ROP eye examinations. METHODS AND ANALYSIS The planned study is a multicentre randomised controlled trial with a crossover design. Infants will be recruited from two different neonatal intensive care units (NICUs) in Sweden. Infants born before gestation week 30 (and therefore eligible for ROP screening) and cared for in either of the NICUs will be eligible for inclusion in the study. The primary outcome will be Premature Infant Pain Profile-Revised score within 30 s after starting the examination. Secondary outcomes will be changes in the galvanic skin response parameters (area small peaks, area huge peaks, peaks per second and average rise time) within 30 s after starting the eye examination, together with the number and evaluation of adverse events reported within 72 hours after the examination and the examining physician's assessment of how easy the infant was to examine. ETHICS AND DISSEMINATION Approval from the Swedish Ethical Review Authority and the Swedish Medical Products Agency has been obtained for the study. Parents of eligible infants will be getting both verbal and written information about the study including that participation is voluntary. Data will be collected and treated in accordance with the European general data protection regulations. The results will be reported on group level and published in a scientific journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT04902859).EudraCT (2021-003005-21).
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Affiliation(s)
- Martina Carlsen Misic
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Erik Normann
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Miriam Pettersson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ylva Blomqvist
- University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Criaud M, Laurencin C, Poisson A, Metereau E, Redouté J, Thobois S, Boulinguez P, Ballanger B. Noradrenaline and Movement Initiation Disorders in Parkinson’s Disease: A Pharmacological Functional MRI Study with Clonidine. Cells 2022; 11:cells11172640. [PMID: 36078048 PMCID: PMC9454805 DOI: 10.3390/cells11172640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/13/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Slowness of movement initiation is a cardinal motor feature of Parkinson’s disease (PD) and is not fully reverted by current dopaminergic treatments. This trouble could be due to the dysfunction of executive processes and, in particular, of inhibitory control of response initiation, a function possibly associated with the noradrenergic (NA) system. The implication of NA in the network supporting proactive inhibition remains to be elucidated using pharmacological protocols. For that purpose, we administered 150 μg of clonidine to 15 healthy subjects and 12 parkinsonian patients in a double-blind, randomized, placebo-controlled design. Proactive inhibition was assessed by means of a Go/noGo task, while pre-stimulus brain activity was measured by event-related functional MRI. Acute reduction in noradrenergic transmission induced by clonidine enhanced difficulties initiating movements reflected by an increase in omission errors and modulated the activity of the anterior node of the proactive inhibitory network (dorsomedial prefrontal and anterior cingulate cortices) in PD patients. We conclude that NA contributes to movement initiation by acting on proactive inhibitory control via the α2-adrenoceptor. We suggest that targeting noradrenergic dysfunction may represent a new treatment approach in some of the movement initiation disorders seen in Parkinson’s disease.
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Affiliation(s)
- Marion Criaud
- Institute of Psychiatry Psychology & Neuroscience, Department Child & Adolescent Psychiatry, Kings College London, London SE24 9QR, UK
| | - Chloé Laurencin
- Université de Lyon, 69622 Lyon, France
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
- INSERM U1028, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
- CNRS UMR5292, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
- Hôpital Neurologique Pierre Wertheimer, Service de Neurologie C, Centre Expert Parkinson, Hospices Civils de Lyon, 69677 Bron, France
| | - Alice Poisson
- Hôpital Neurologique Pierre Wertheimer, Service de Neurologie C, Centre Expert Parkinson, Hospices Civils de Lyon, 69677 Bron, France
| | - Elise Metereau
- Hôpital Neurologique Pierre Wertheimer, Service de Neurologie C, Centre Expert Parkinson, Hospices Civils de Lyon, 69677 Bron, France
| | | | - Stéphane Thobois
- Hôpital Neurologique Pierre Wertheimer, Service de Neurologie C, Centre Expert Parkinson, Hospices Civils de Lyon, 69677 Bron, France
- CNRS UMR5229, Institute of Cognitive Science Marc Jeannerod, 69500 Bron, France
| | - Philippe Boulinguez
- Université de Lyon, 69622 Lyon, France
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
- INSERM U1028, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
- CNRS UMR5292, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
| | - Bénédicte Ballanger
- Université de Lyon, 69622 Lyon, France
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France
- INSERM U1028, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
- CNRS UMR5292, Lyon Neuroscience Research Center (CRNL), 69000 Lyon, France
- Correspondence:
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Chen J, Zhang J, Yang DD, Li ZC, Zhao B, Chen Y, He Z. Clonidine ameliorates cerebral ischemia-reperfusion injury by up-regulating the GluN3 subunits of NMDA receptor. Metab Brain Dis 2022; 37:1829-1841. [PMID: 35727521 DOI: 10.1007/s11011-022-01028-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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
This study aimed to investigate the protective effects of the alpha-2 adrenergic receptor (α2-AR) agonist, clonidine, on the cerebral ischemia-reperfusion (I/R) injury and elaborate the underlying mechanisms. Cerebral I/R model was established by middle cerebral artery occlusion (MCAO) for 2 h followed by reperfusion for 4 h in adult male SD rats. Saline, clonidine and yohimbine (an α2-AR antagonist) were intraperitoneally administered each day for one week before surgery. Neurological deficit was evaluated just before decapitation. TTC staining was applied for correlation of cerebral infarction volume. HE staining was performed to observe the neuron morphology. Immunohistochemical staining was performed to detect the localization and expression of GluN3 proteins. Western blot analysis also was used to detect the expression levels of GluN3 proteins. Our data showed that clonidine ameliorated neurological deficit and reduced the cerebral infarction volume of the rats with cerebral I/R. It is worth noting that treatment with clonidine up-regulated the protein expression of GluN3 in the rats with the cerebral I/R, especially in the cell membrane. Moreover, clonidine also up-regulated the transposition from cytoplasm to cell membrane of GluN3 after cerebral I/R. In addition, yohimbine abolished the neuroprotective effects of clonidine. The results indicated that clonidine played a protective role in cerebral I/R injury through regulation of the protein expression of GluN3 subunits of N-methyl-D-aspartate (NMDA) receptor.
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Affiliation(s)
- Jing Chen
- Third-Grade Pharmacological Laboratory On Traditional Chinese Medicine, State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang, 443002, People's Republic of China
- Medical College, China Three Gorges University, Yichang, 443002, People's Republic of China
| | - Juan Zhang
- The First People's Hospital of Yichang, Yichang, 443000, People's Republic of China
| | - Dan-Dan Yang
- The Second People's Hospital of China Three Gorges University, Yichang, 443000, People's Republic of China
| | - Zi-Cheng Li
- Third-Grade Pharmacological Laboratory On Traditional Chinese Medicine, State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang, 443002, People's Republic of China
- Medical College, China Three Gorges University, Yichang, 443002, People's Republic of China
| | - Bo Zhao
- Third-Grade Pharmacological Laboratory On Traditional Chinese Medicine, State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang, 443002, People's Republic of China
- Medical College, China Three Gorges University, Yichang, 443002, People's Republic of China
| | - Yue Chen
- Third-Grade Pharmacological Laboratory On Traditional Chinese Medicine, State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang, 443002, People's Republic of China
- Medical College, China Three Gorges University, Yichang, 443002, People's Republic of China
| | - Zhi He
- Third-Grade Pharmacological Laboratory On Traditional Chinese Medicine, State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang, 443002, People's Republic of China.
- Medical College, China Three Gorges University, Yichang, 443002, People's Republic of China.
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Neerland BE, Busund R, Haaverstad R, Helbostad JL, Landsverk SA, Martinaityte I, Norum HM, Ræder J, Selbaek G, Simpson MR, Skaar E, Skjærvold NK, Skovlund E, Slooter AJ, Svendsen ØS, Tønnessen T, Wahba A, Zetterberg H, Wyller TB. Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e057460. [PMID: 35725264 PMCID: PMC9214392 DOI: 10.1136/bmjopen-2021-057460] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status. METHODS AND ANALYSIS This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery. ETHICS AND DISSEMINATION This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT05029050.
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Affiliation(s)
| | - Rolf Busund
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Jorunn L Helbostad
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Ieva Martinaityte
- Institute of Clinical Medicine, UiT The Artic University of Norway, Tromsø, Norway
- Department of Geriatric Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Hilde Margrethe Norum
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Johan Ræder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir Selbaek
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway
| | - Melanie R Simpson
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Skaar
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Nils Kristian Skjærvold
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anesthesia and Intensive Care Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arjen Jc Slooter
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussel, Brussel, Belgium
| | - Øyvind Sverre Svendsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Theis Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Alexander Wahba
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Cardiothoracic Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute, UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, People's Republic of China
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Laffer CL, Elijovich F. Is Clonidine Contraindicated for the Treatment of Hypertensive Urgencies in Hospitalized Patients? Am J Hypertens 2022; 35:391-392. [PMID: 35134819 DOI: 10.1093/ajh/hpac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Cheryl L Laffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Fernando Elijovich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Schwartz RH, Hernandez S, Noor N, Topfer J, Farrell K, Singh N, Sharma A, Varrassi G, Kaye AD. A Comprehensive Review of the Use of Alpha 2 Agonists in Spinal Anesthetics. Pain Physician 2022; 25:E193-E201. [PMID: 35322971] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Spinal Anesthesia was the first regional anesthetic technique to be performed. It was performed by Dr. August Bier, known for the Bier block, and his colleagues on August 16, 1898. Dr. Bier opted for, what he referred to at the time as "cocainization of the spinal cord" by introducing 15 mg of cocaine intrathecally prior to the operation. The surgery was largely uneventful and painless. The patient only experienced some vomiting and a headache postoperatively. Dr. Bier's use of neuraxial anesthesia aimed to directly inject local anesthetics in and around the central nervous system (CNS) for more direct control of pain and anesthesia. Local anesthetics were an important discovery in anesthesiology. However, since the advent of local anesthetics and spinal anesthesia as an alternative technique to general anesthesia, much has been learned about both the benefits and adverse effects of local anesthetics. It was quickly learned that use of local anesthetics would be limited by their potential for life-threatening toxic effects. For this reason, there was a push towards development of novel local anesthetics that had a larger therapeutic window with less likelihood of serious side effects. In addition to developing newer local anesthetics, the idea of adding adjuvants provided an opportunity to potentially limit the life-threatening events. These adjuvants would include medications such as epinephrine and alpha-2 agonists, such as clonidine and dexmedetomidine. Other adjuvants include opioids, glucocorticoids, and mineralocorticoids. OBJECTIVES In this review, we will delve further into the indications, contraindications, uses, mechanisms, and future of spinal anesthesia and its adjuvants. STUDY DESIGN A literature review of recent publications in the field of alpha 2 agonists used in spinal anesthetics was carried out from 2015 to present day. Consensus opinions were formulated in various areas. SETTING This literature review was carried out at various medical universities throughout the nation and Europe. LIMITATIONS As research has only just begun in this field data is limited at this time. CONCLUSIONS The use of spinal anesthesia provides a reliable dermatome blockade to facilitate many different surgical procedures. The combination of local anesthetics with opioid medications within the subarachnoid space has been the standard of care. Adjuvant medications like alpha 2 agonists may play a significant role in prolonging spinal blockade as well as limiting cardiovascular complications such as hypotension and bradycardia. The use of alpha 2 agonists instead of opioid medications intrathecally decreases pruritus and delayed respiratory depression. Animal models have demonstrated the synergistic effects of utilizing alpha 2 agonists with opioids in the subarachnoid space. The addition of clonidine to fentanyl and local anesthetic demonstrated a shorter time to neural blockade, but no significant change in duration of the spinal. Interestingly alpha 2 agonists with local anesthetics showed increase block duration compared to opioid with local anesthetics. Further human trials need to be undertaken to analyze the effectiveness of alpha 2 agonists in the intrathecal space, but preliminary data does indicate it is an exemplary alternative to opioids.
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Affiliation(s)
- Ruben H Schwartz
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL
| | - Stephanie Hernandez
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami, FL
| | - Jacob Topfer
- University of Miami School of Medicine, Department of Anesthesiology, Miami, FL
| | - Kyle Farrell
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Naina Singh
- Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA
| | - Ayushi Sharma
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
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Abraham J, Varadharajan N, Spalzang ST, Nachiyar S, Menon V. Clonidine in Lieu of Electroconvulsive Therapy (ECT) for Control of Acute Manic Excitement Amidst the COVID-19 Pandemic. Psychiatr Danub 2022; 34:612-613. [PMID: 36257016 DOI: 10.24869/psyd.2022.612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Jerry Abraham
- Department of Psychiatry, Jawaharlal Institute, of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
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Miller DL, Dou C, Raghavendran K, Dong Z. The Influence of Xylazine and Clonidine on Lung Ultrasound-Induced Pulmonary Capillary Hemorrhage in Spontaneously Hypertensive Rats. Ultrasound Med Biol 2021; 47:2331-2338. [PMID: 33972153 PMCID: PMC8243848 DOI: 10.1016/j.ultrasmedbio.2021.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 05/21/2023]
Abstract
Induction of pulmonary capillary hemorrhage (PCH) by lung ultrasound (LUS) depends not only on physical exposure parameters but also on physiologic conditions and drug treatment. We studied the influence of xylazine and clonidine on LUS-induced PCH in spontaneously hypertensive and normotensive rats using diagnostic B-mode ultrasound at 7.3 MHz. Using ketamine anesthesia, rats receiving saline, xylazine, or clonidine treatment were tested with different pulse peak rarefactional pressure amplitudes in 5 min exposures. Results with xylazine or clonidine in spontaneously hypertensive rats were not significantly different at the three exposure pulse peak rarefactional pressure amplitudes, and thresholds were lower (2.2 MPa) than with saline (2.6 MPa). Variations in LUS PCH were not correlated with mean systemic blood pressure. Similar to previous findings for dexmedetomidine, the clinical drug clonidine tended to increase susceptibility to LUS PCH.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA.
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Krishnan Raghavendran
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Michot T, Duysinx P, Belle F, Dresse C, Montupil J, Bonhomme V, Defresne A. [Intracerebroventricular infusion of morphine, bupivacaine and clonidine for the management of refractory neoplasic pain in a palliative care setting : a case report]. Rev Med Liege 2021; 76:614-619. [PMID: 34357714] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Intracerebroventricular (ICV) infusion of morphine is a well-known technique to relieve intractable neoplasic pain when conventional analgesic strategies reach their limits. Through this case report, we present indications, assets, and drawbacks of this procedure in such conditions. We also describe the adaptation of the systemic analgesic treatment to allow discharge from the hospital to home settings. Thanks to the ICV infusion of a mixture of morphine, bupivacaine and clonidine, the patient was weaned from oral opioid medications and reached an acceptable level of comfort. This allowed him to be discharged from the hospital to go back home with a specific setting of mobile palliative care structure. The patient's family followed training about the device to prevent any technical trouble and to react in case of unwanted events.
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Affiliation(s)
- T Michot
- Département d'Anesthésie-Réanimation, CHU Liège, Belgique
| | - P Duysinx
- Service d'Anesthésie-Réanimation, CHR Citadelle, Liège, Belgique
| | - F Belle
- Service de Neurochirurgie, CHR Citadelle, Liège, Belgique
| | - C Dresse
- Service d'Anesthésie-Réanimation, CHR Citadelle, Liège, Belgique
| | - J Montupil
- Département d'Anesthésie-Réanimation, CHU Liège, Belgique
- Service d'Anesthésie-Réanimation, CHR Citadelle, Liège, Belgique
| | - V Bonhomme
- Département d'Anesthésie-Réanimation, CHU Liège, Belgique
- Service d'Anesthésie-Réanimation, CHR Citadelle, Liège, Belgique
| | - A Defresne
- Département d'Anesthésie-Réanimation, CHU Liège, Belgique
- Service d'Anesthésie-Réanimation, CHR Citadelle, Liège, Belgique
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using a sedative versus control (placebo, usual treatment or non-pharmacological treatment) for NAS due to withdrawal from opioids and determine which type of sedative is most effective and safe for NAS due to withdrawal from opioids. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included trials enrolling infants with NAS born to mothers with an opioid dependence with more than 80% follow-up and using randomised, quasi-randomised and cluster-randomised allocation to sedative or control. DATA COLLECTION AND ANALYSIS Three review authors assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 10 trials (581 infants) with NAS secondary to maternal opioid use in pregnancy. There were multiple comparisons of different sedatives and regimens. There were limited data available for use in sensitivity analysis of studies at low risk of bias. Phenobarbital versus supportive care: one study reported there may be little or no difference in treatment failure with phenobarbital and supportive care versus supportive care alone (risk ratio (RR) 2.73, 95% confidence interval (CI) 0.94 to 7.94; 62 participants; very low-certainty evidence). No infant had a clinical seizure. The study did not report mortality, neurodevelopmental disability and adverse events. There may be an increase in days' hospitalisation and treatment from use of phenobarbital (hospitalisation: mean difference (MD) 20.80, 95% CI 13.64 to 27.96; treatment: MD 17.90, 95% CI 11.98 to 23.82; both 62 participants; very low-certainty evidence). Phenobarbital versus diazepam: there may be a reduction in treatment failure with phenobarbital versus diazepam (RR 0.39, 95% CI 0.24 to 0.62; 139 participants; 2 studies; low-certainty evidence). The studies did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be little or no difference in days' hospitalisation and treatment (hospitalisation: MD 3.89, 95% CI -1.20 to 8.98; 32 participants; treatment: MD 4.30, 95% CI -0.73 to 9.33; 31 participants; both low-certainty evidence). Phenobarbital versus chlorpromazine: there may be a reduction in treatment failure with phenobarbital versus chlorpromazine (RR 0.55, 95% CI 0.33 to 0.92; 138 participants; 2 studies; very low-certainty evidence), and no infant had a seizure. The studies did not report mortality and neurodevelopmental disability. One study reported there may be little or no difference in days' hospitalisation (MD 7.00, 95% CI -3.51 to 17.51; 87 participants; low-certainty evidence) and 0/100 infants had an adverse event. Phenobarbital and opioid versus opioid alone: one study reported no infants with treatment failure and no clinical seizures in either group (low-certainty evidence). The study did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be a reduction in days' hospitalisation for infants treated with phenobarbital and opioid (MD -43.50, 95% CI -59.18 to -27.82; 20 participants; low-certainty evidence). Clonidine and opioid versus opioid alone: one study reported there may be little or no difference in treatment failure with clonidine and dilute tincture of opium (DTO) versus DTO alone (RR 0.09, 95% CI 0.01 to 1.59; 80 participants; very low-certainty evidence). All five infants with treatment failure were in the DTO group. There may be little or no difference in seizures (RR 0.14, 95% CI 0.01 to 2.68; 80 participants; very low-certainty evidence). All three infants with seizures were in the DTO group. There may be little or no difference in mortality after discharge (RR 7.00, 95% CI 0.37 to 131.28; 80 participants; very low-certainty evidence). All three deaths were in the clonidine and DTO group. The study did not report neurodevelopmental disability. There may be little or no difference in days' treatment (MD -4.00, 95% CI -8.33 to 0.33; 80 participants; very low-certainty evidence). One adverse event occurred in the clonidine and DTO group. There may be little or no difference in rebound NAS after stopping treatment, although all seven cases were in the clonidine and DTO group. Clonidine and opioid versus phenobarbital and opioid: there may be little or no difference in treatment failure (RR 2.27, 95% CI 0.98 to 5.25; 2 studies, 93 participants; very low-certainty evidence). One study reported one infant in the clonidine and morphine group had a seizure, and there were no infant mortalities. The studies did not report neurodevelopmental disability. There may be an increase in days' hospitalisation and days' treatment with clonidine and opioid versus phenobarbital and opioid(hospitalisation: MD 7.13, 95% CI 6.38 to 7.88; treatment: MD 7.57, 95% CI 3.97 to 11.17; both 2 studies, 91 participants; low-certainty evidence). There may be little or no difference in adverse events (RR 1.55, 95% CI 0.44 to 5.40; 2 studies, 93 participants; very low-certainty evidence). However, there was oversedation only in the phenobarbital and morphine group; and hypotension, rebound hypertension and rebound NAS only in the clonidine and morphine group. AUTHORS' CONCLUSIONS There is very low-certainty evidence that phenobarbital increases duration of hospitalisation and treatment, but reduces days to regain birthweight and duration of supportive care each day compared to supportive care alone. There is low-certainty evidence that phenobarbital reduces treatment failure compared to diazepam and very low-certainty evidence that phenobarbital reduces treatment failure compared to chlorpromazine. There is low-certainty evidence of an increase in days' hospitalisation and days' treatment with clonidine and opioid compared to phenobarbital and opioid. There are insufficient data to determine the safety and incidence of adverse events for infants treated with combinations of opioids and sedatives including phenobarbital and clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Taheri P, Khosrawi S, Ramezani M. Extracorporeal Shock Wave Therapy Combined With Oral Medication and Exercise for Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil 2021; 102:1294-1299. [PMID: 33453192 DOI: 10.1016/j.apmr.2020.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 05/29/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare extracorporeal shock wave therapy combined with oral medication and an exercise program vs sham treatment with medication and exercise for the treatment of chronic low back pain (CLBP). DESIGN Randomized controlled trial. SETTING Outpatient clinic at a university hospital. PARTICIPANTS Eligibility criteria were age older than 18 years and duration of CLBP exceeding 3 months. Exclusion criteria were concurrent treatment or history of surgery for CLBP, cancer, fractures, infections, and disk degeneration. INTERVENTION The intervention group received extracorporeal shock wave therapy once a week for 4 weeks along with oral medications and an exercise program. The control group received sham extracorporeal shock wave therapy along with oral medications and an exercise program. MAIN OUTCOME MEASURES Visual analog scale and Oswestry Disability Index (ODI) were used to assess pain and disability at baseline and after 3 months. RESULTS The pain score in the intervention group (N=16) was 6.6 at baseline and 3.0 after 1 month (P<.0001) and 1.8 after 3 months (P<.0001). In the control group (N=16), the pain score was 6.8 at baseline, 4.6 after 1 month (P<.0001), and 1.1 after 3 months (P<.0001). ODI scores decreased significantly in both groups compared with baseline values (first month: P<.001, third month: P<.05). The mean ODI score did not differ significantly between the groups (P=.942). CONCLUSION Extracorporeal shock wave therapy combined with oral medication and exercise was safe and effective in the short-term treatment of chronic low back pain.
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Affiliation(s)
- Parisa Taheri
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Khosrawi
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mitra Ramezani
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran.
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Abstract
BACKGROUND Anxiety in relation to surgery is a well-known problem. Melatonin offers an alternative treatment to benzodiazepines for ameliorating this condition in the preoperative and postoperative periods. OBJECTIVES To assess the effects of melatonin on preoperative and postoperative anxiety compared to placebo or benzodiazepines. SEARCH METHODS We searched the following databases on 10 July 2020: CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science. For ongoing trials and protocols, we searched clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA We included randomized, placebo-controlled or standard treatment-controlled (or both) studies that evaluated the effects of preoperatively administered melatonin on preoperative or postoperative anxiety. We included adult patients of both sexes (15 to 90 years of age) undergoing any kind of surgical procedure for which it was necessary to use general, regional, or topical anaesthesia. DATA COLLECTION AND ANALYSIS One review author conducted data extraction in duplicate. Data extracted included information about study design, country of origin, number of participants and demographic details, type of surgery, type of anaesthesia, intervention and dosing regimens, preoperative anxiety outcome measures, and postoperative anxiety outcome measures. MAIN RESULTS We included 27 randomized controlled trials (RCTs), involving 2319 participants, that assessed melatonin for treating preoperative anxiety, postoperative anxiety, or both. Twenty-four studies compared melatonin with placebo. Eleven studies compared melatonin to a benzodiazepine (seven studies with midazolam, three studies with alprazolam, and one study with oxazepam). Other comparators in a small number of studies were gabapentin, clonidine, and pregabalin. No studies were judged to be at low risk of bias for all domains. Most studies were judged to be at unclear risk of bias overall. Eight studies were judged to be at high risk of bias in one or more domain, and thus, to be at high risk of bias overall. Melatonin versus placebo Melatonin probably results in a reduction in preoperative anxiety measured by a visual analogue scale (VAS, 0 to 100 mm) compared to placebo (mean difference (MD) -11.69, 95% confidence interval (CI) -13.80 to -9.59; 18 studies, 1264 participants; moderate-certainty evidence), based on a meta-analysis of 18 studies. Melatonin may reduce immediate postoperative anxiety measured on a 0 to 100 mm VAS compared to placebo (MD -5.04, 95% CI -9.52 to -0.55; 7 studies, 524 participants; low-certainty evidence), and may reduce delayed postoperative anxiety measured six hours after surgery using the State-Trait Anxiety Inventory (STAI) (MD -5.31, 95% CI -8.78 to -1.84; 2 studies; 73 participants; low-certainty evidence). Melatonin versus benzodiazepines (midazolam and alprazolam) Melatonin probably results in little or no difference in preoperative anxiety measured on a 0 to 100 mm VAS (MD 0.78, 95% CI -2.02 to 3.58; 7 studies, 409 participants; moderate-certainty evidence) and there may be little or no difference in immediate postoperative anxiety (MD -2.12, 95% CI -4.61 to 0.36; 3 studies, 176 participants; low-certainty evidence). Adverse events Fourteen studies did not report on adverse events. Six studies specifically reported that no side effects were observed, and the remaining seven studies reported cases of nausea, sleepiness, dizziness, and headache; however, no serious adverse events were reported. Eleven studies measured psychomotor and cognitive function, or both, and in general, these studies found that benzodiazepines impaired psychomotor and cognitive function more than placebo and melatonin. Fourteen studies evaluated sedation and generally found that benzodiazepine caused the highest degree of sedation, but melatonin also showed sedative properties compared to placebo. Several studies did not report on adverse events; therefore, it is not possible to conclude with certainty, from the data on adverse effects collected in this review, that melatonin is better tolerated than benzodiazepines. AUTHORS' CONCLUSIONS When compared with placebo, melatonin given as premedication (as tablets or sublingually) probably reduces preoperative anxiety in adults (measured 50 to 120 minutes after administration), which is potentially clinically relevant. The effect of melatonin on postoperative anxiety compared to placebo (measured in the recovery room and six hours after surgery) was also evident but was much smaller, and the clinical relevance of this finding is uncertain. There was little or no difference in anxiety when melatonin was compared with benzodiazepines. Thus, melatonin may have a similar effect to benzodiazepines in reducing preoperative and postoperative anxiety in adults.
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Affiliation(s)
- Bennedikte K Madsen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Dennis Zetner
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
| | - Ann Merete Møller
- Cochrane Anaesthesia, Critical and Emergency Care Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, Denmark
- Cochrane Colorectal Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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Urits I, Patel A, Zusman R, Virgen CG, Mousa M, Berger AA, Kassem H, Jung JW, Hasoon J, Kaye AD, Viswanath O. A Comprehensive Update of Lofexidine for the Management of Opioid Withdrawal Symptoms. Psychopharmacol Bull 2020; 50:76-96. [PMID: 32733113 PMCID: PMC7377538] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding the use of Lofexidine for opiate withdrawal symptoms. It covers the background and necessity of withdrawal programs and the management of withdrawal symptoms and then covers the existing evidence of the use of Lofexidine for this purpose. RECENT FINDINGS Opiate abuse leads to significant pain and suffering. However, withdrawal is difficult and often accompanied by withdrawal symptoms and renewed cravings. These symptoms are driven mostly by signaling in the locus coeruleus and the mesolimbic system and a rebound increase in noradrenaline, producing symptoms such as anxiety, gastrointestinal upset, and tension. Lofexidine, an alpha-2 agonist, can be used to manage acute withdrawal symptoms before starting maintenance treatment with either methadone or buprenorphine. Lofexidine, if FDA approved for management of withdrawal symptoms and has been proved to be both effective and safe. SUMMARY Opiate addiction is increasing and plaguing the western world and specifically the U.S. It takes a large toll on both a personal and societal level and carries a high cost. Withdrawal is difficult, both related to withdrawal symptoms and renewed cravings. Lofexidine has been shown to be effective in reducing the former and could potentially aid in recovery and withdrawal.
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Affiliation(s)
- Ivan Urits
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Anjana Patel
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Robbie Zusman
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Celina Guadalupe Virgen
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Mohammad Mousa
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Amnon A Berger
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Hisham Kassem
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jai Won Jung
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jamal Hasoon
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Alan D Kaye
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Omar Viswanath
- Urits, MD, Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Patel, Won Jung, Georgetown University School of Medicine, Washington, DC. Zusman, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Virgen, Mousa, Viswanath, MD, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Viswanath, MD, Louisiana State University Health Sciences Center, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
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Thomas B, Jacques J, Stiel H. Clonidine for the Management of Refractory Distressing Hallucinations, a Case Report. J Pain Symptom Manage 2020; 59:e1-e3. [PMID: 32169538 DOI: 10.1016/j.jpainsymman.2020.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Benjamin Thomas
- Illawarra Shoalhaven Local Health District, University of Wollongong, Wollongong, New South Wales, Australia.
| | - Judith Jacques
- Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Hilary Stiel
- Central Coast Local Health District, Gosford, New South Wales, Australia
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Koskinen LOD, Sundström N, Hägglund L, Eklund A, Olivecrona M. Prostacyclin Affects the Relation Between Brain Interstitial Glycerol and Cerebrovascular Pressure Reactivity in Severe Traumatic Brain Injury. Neurocrit Care 2020; 31:494-500. [PMID: 31123992 PMCID: PMC6872514 DOI: 10.1007/s12028-019-00741-4] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Cerebral injury may alter the autoregulation of cerebral blood flow. One index for describing cerebrovascular state is the pressure reactivity (PR). Little is known of whether PR is associated with measures of brain metabolism and indicators of ischemia and cell damage. The aim of this investigation was to explore whether increased interstitial levels of glycerol, a marker of cell membrane damage, are associated with PR, and if prostacyclin, a membrane stabilizer and regulator of the microcirculation, may affect this association in a beneficial way. Materials and Methods Patients suffering severe traumatic brain injury (sTBI) were treated according to an intracranial pressure (ICP)-targeted therapy based on the Lund concept and randomized to an add-on treatment with prostacyclin or placebo. Inclusion criteria were verified blunt head trauma, Glasgow Coma Score ≤ 8, age 15–70 years, and a first measured cerebral perfusion pressure of ≥ 10 mmHg. Multimodal monitoring was applied. A brain microdialysis catheter was placed on the worst affected side, close to the penumbra zone. Mean (glycerolmean) and maximal glycerol (glycerolmax) during the 96-h sampling period were calculated. The mean PR was calculated as the ICP/mean arterial pressure (MAP) regression coefficient based on hourly mean ICP and MAP during the first 96 h. Results Of the 48 included patients, 45 had valid glycerol and PR measurements available. PR was higher in the placebo group as compared to the prostacyclin group (p = 0.0164). There was a positive correlation between PR and the glycerolmean (ρ = 0.503, p = 0.01) and glycerolmax (ρ = 0.490, p = 0.015) levels in the placebo group only. Conclusions PR is correlated to the glycerol level in patients suffering from sTBI, a relationship that is not seen in the group treated with prostacyclin. Glycerol has been associated with membrane degradation and may support glycerol as a biomarker for vascular endothelial breakdown. Such a breakdown may impair the regulation of cerebrovascular PR.
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Affiliation(s)
- Lars-Owe D Koskinen
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden.
| | - Nina Sundström
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Linda Hägglund
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden
- Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro University, Örebro, Sweden
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Abstract
BACKGROUND Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. OBJECTIVES To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non-ventilated neonates. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. SELECTION CRITERIA Randomised controlled trials, quasi-randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non-pharmacological pain-reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. DATA COLLECTION AND ANALYSIS Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. MAIN RESULTS Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. AUTHORS' CONCLUSIONS We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates.
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Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
| | - Elisabeth Norman
- Lund University, Skåne University HospitalDepartment of PaediatricsLundSweden
| | - Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, First FloorRoom 11‐221LundSweden22185
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47
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Abstract
OBJECTIVE The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial, failed to demonstrate a benefit of renal artery stenting (RAS) over medical therapy in patients with renal artery stenosis and hypertension. However, there are patients for whom RAS is a consideration because of failure of medical therapy. Unfortunately, selection of patients for RAS is complicated by a lack of validated predictors of blood pressure (BP) response. A previous single-center study identified three preoperative markers of BP response to RAS: requirement for four or more antihypertensive medications, preoperative diastolic BP >90 mm Hg, and preoperative clonidine use. To date, these markers of outcome have not been independently validated. The aim of this study was to validate these markers using data from the CORAL trial. METHODS All patients randomized in the CORAL trial to RAS were included. American Heart Association guidelines were used to categorize patients as BP responders or nonresponders to RAS. BP responders were defined by a postoperative BP <160/90 mm Hg with a reduced number of antihypertensive medications or a reduction in diastolic BP to <90 mm Hg with the same medications after RAS. Patients with stable or worsened BP were labeled nonresponders. Variables associated with a favorable BP response were identified by multivariable logistic regression analysis. RESULTS There were 436 patients who underwent RAS with a median age of 70 years (interquartile range [IQR], 63-76 years). The median systolic and diastolic BPs of the stented cohort at baseline were 149 mm Hg (IQR, 132-164 mm Hg) and 78 mm Hg (IQR, 70-87 mm Hg), respectively. A positive BP response occurred in 284 of 436 (65.1%) stented patients. Multivariable logistic regression analysis identified three independent markers of a positive BP response: requirement for four or more medications (odds ratio, 5.9; P < .001), preoperative diastolic BP >90 mm Hg (odds ratio 13.9; P < .001), and preoperative clonidine use (odds ratio, 4.52; P = .008). The percentage of patients with a positive BP response increased incrementally as the number of markers per patient increased, based on the Cochran-Armitage test for trend (P < .0001). CONCLUSIONS In patients from the CORAL trial who underwent RAS, the previously reported clinical markers of BP response were validated. A prospective trial to validate their utility as predictors of BP response to RAS is warranted.
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Affiliation(s)
- J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex; Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, Tex.
| | - Hong Zhu
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Fred A Weaver
- Division of Vascular and Endovascular Surgery, Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, Calif
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Clemans-Cope L, Holla N, Lee HC, Cong AS, Castro R, Chyi L, Huang A, Taylor KJ, Kenney GM. Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey. J Perinatol 2020; 40:463-472. [PMID: 31911649 PMCID: PMC7042156 DOI: 10.1038/s41372-019-0568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 11/22/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.
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Affiliation(s)
- Lisa Clemans-Cope
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA.
| | - Nikhil Holla
- George Washington University, Washington, DC, USA
| | - Henry C Lee
- Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA
| | - Allison Shufei Cong
- California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA, USA
| | - Robert Castro
- Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Chyi
- Walnut Creek Medical Center, Kaiser Northern California NAS Workgroup Co-chair, Walnut Creek, CA, USA
| | - Angela Huang
- Department of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Kimá Joy Taylor
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA
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Dunn KE, Weerts EM, Huhn AS, Schroeder JR, Tompkins DA, Bigelow GE, Strain EC. Preliminary evidence of different and clinically meaningful opioid withdrawal phenotypes. Addict Biol 2020; 25:e12680. [PMID: 30295400 PMCID: PMC6546557 DOI: 10.1111/adb.12680] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 02/09/2018] [Revised: 07/06/2018] [Accepted: 08/25/2018] [Indexed: 11/28/2022]
Abstract
Opioid use disorder (OUD) is a public health crisis. Differences in opioid withdrawal severity that predict treatment outcome could facilitate the process of matching patients to treatments. This is a secondary analysis of a randomized controlled trial (RCT) that enrolled treatment seeking heroin-users (N = 89, males = 78) into a residential study. Participants maintained on morphine (30 mg, subcutaneous, four-times daily) underwent a naloxone (0.4 mg, IM = intramuscular) challenge session to precipitate withdrawal. Area-under-the-curve (AUC) values from self-reported withdrawal ratings during the challenge session were analyzed using K-means clustering, revealing two phenotype groups. Withdrawal and retention from the subsequent 14-day double-blind, double-dummy RCT comparing three study medications (clonidine, tramadol-ER, and buprenorphine) were evaluated as a function of phenotype. Cluster analyses suggested HIGH (N = 37; mean [SD] subjective opiate withdrawal scale [SOWS]-AUC 123.7 [65.8]) and LOW (N = 52; SOWS-AUC 68.0 [47.7]) withdrawal phenotype groups. HIGH participants were significantly more female and had lower body mass indices than LOW participants; no drug-use variables were significant. Regarding RCT outcomes, HIGH phenotype participants were less likely to be retained in the study (P = 0.02) and had higher mean self-reported withdrawal (P = 0.05) than LOW phenotype participants. A significant interaction in RCT retention was observed between phenotype (P = 0.02) and study medication (P < 0.01). Self-reported withdrawal was significant for phenotype (P = 0.02); study medication trended towards significance (P = 0.07). Results suggest patients have meaningfully different experiences of opioid withdrawal that may predict differential response to opioid pharmacotherapies during supervised withdrawal. Additional prospective research to replicate and more thoroughly evaluate withdrawal phenotype correlates and sex differences is warranted.
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Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elise M Weerts
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer R Schroeder
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - George E Bigelow
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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50
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Choudhry DK, Brenn BR, Sacks K, Shah S. Evaluation of Gabapentin and Clonidine Use in Children Following Spinal Fusion Surgery for Idiopathic Scoliosis: A Retrospective Review. J Pediatr Orthop 2019; 39:e687-e693. [PMID: 31503225 DOI: 10.1097/bpo.0000000000000989] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Opioids are the mainstay of therapy for pain relief following posterior spinal fusion (PSF) surgery. Various adjunctive medications are being used to augment analgesia and to reduce opioid-related side effects. At our institution, we have sequentially added 2 adjuncts to a standard morphine patient-controlled analgesia (PCA) regimen. The goal of our study was to evaluate pain control and the benefit of gabapentin and the combination of gabapentin and clonidine, whereas morphine PCA was in use in children following PSF surgery. METHODS Following Institutional Review Board approval, data were collected retrospectively from the charts of 127 patients who underwent PSF for idiopathic scoliosis. Children were divided into the 3 following groups: group P, morphine PCA only (42 patients), group G, morphine PCA+gabapentin (45 patients), and group C, morphine PCA+gabapentin+clonidine (40 patients). RESULTS Addition of gabapentin to our regimen improved the outcome, but the addition of transdermal clonidine and gabapentin together were found to be significantly better in some aspects. Children in group G and C used less morphine on postoperative day 1 following surgery, had more PCA demand-free hours, were able to take orals, were able to ambulate sooner, and had a shorter hospital stay than group P. There were no differences in side effects or sedation between the 3 groups. CONCLUSIONS In conclusion, additions of postoperative transdermal clonidine and perioperative oral gabapentin together were found to improve functional outcomes following PSF surgery. Group G and C had reduced opioid use and shorter hospital stay than group P. Addition of these adjuncts together was found to be better since group C patients made fewer PCA attempts to obtain morphine over the first 10-hour period postoperatively and were able to ambulate sooner than group G. The PCA pump usage pattern provides useful information about patient comfort and efficacy of adjunctive medications. LEVEL OF EVIDENCE Level II-retrospective study.
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Affiliation(s)
| | | | | | - Suken Shah
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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