Propofol for the promotion of sleep in adults in the intensive care unit

BACKGROUND

People in the intensive care unit (ICU) experience sleep deprivation caused by environmental disruption, such as high noise levels and 24-hour lighting, as well as increased patient care activities and invasive monitoring as part of their care. Sleep deprivation affects physical and psychological health, and people perceive the quality of their sleep to be poor whilst in the ICU. Propofol is an anaesthetic agent which can be used in the ICU to maintain patient sedation and some studies suggest it may be a suitable agent to replicate normal sleep.

OBJECTIVES

To assess whether the quantity and quality of sleep may be improved by administration of propofol to adults in the ICU and to assess whether propofol given for sleep promotion improves both physical and psychological patient outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10), MEDLINE (1946 to October 2017), Embase (1974 to October 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to October 2017) and PsycINFO (1806 to October 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials with adults, over the age of 16 years, admitted to the ICU with any diagnoses, given propofol versus a comparator to promote overnight sleep. We included participants who were and were not mechanically ventilated. We included studies that compared the use of propofol, given at an appropriate clinical dose with the intention of promoting night-time sleep, against: no agent; propofol at a different rate or dose; or another agent, administered specifically to promote sleep. We included only studies in which propofol was given during 'normal' sleeping hours (i.e. between 10 pm and 7 am) to promote a sleep-like state with a diurnal rhythm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings.

MAIN RESULTS

We included four studies with 149 randomized participants. We identified two studies awaiting classification for which we were unable to assess eligibility and one ongoing study.Participants differed in severity of illness as assessed by APACHE II scores in three studies and further differences existed between comparisons and methods. One study compared propofol versus no agent, one study compared different doses of propofol and two studies compared propofol versus a benzodiazepine (flunitrazepam, one study; midazolam, one study). All studies reported randomization and allocation concealment inadequately. We judged all studies to have high risk of performance bias from personnel who were unblinded. We noted that some study authors had blinded study outcome assessors and participants for relevant outcomes.It was not appropriate to combine data owing to high levels of methodological heterogeneity.One study comparing propofol with no agent (13 participants) measured quantity and quality of sleep using polysomnography; study authors reported no evidence of a difference in duration of sleep or sleep efficiency, and reported disruption to usual REM (rapid eye movement sleep) with propofol.One study comparing different doses of propofol (30 participants) measured quantity and quality of sleep by personnel using the Ramsay Sedation Scale; study authors reported that more participants who were given a higher dose of propofol had a successful diurnal rhythm, and achieved a greater sedation rhythmicity.Two studies comparing propofol with a different agent (106 participants) measured quantity and quality of sleep using the Pittsburgh Sleep Diary and the Hospital Anxiety and Depression Scale; one study reported fewer awakenings of reduced duration with propofol, and similar total sleep time between groups, and one study reported no evidence of a difference in sleep quality. One study comparing propofol with another agent (66 participants) measured quantity and quality of sleep with the Bispectral Index and reported longer time in deep sleep, with fewer arousals. One study comparing propofol with another agent (40 participants) reported higher levels of anxiety and depression in both groups, and no evidence of a difference when participants were given propofol.No studies reported adverse events.We used the GRADE approach to downgrade the certainty of the evidence for each outcome to very low. We identified sparse data with few participants, and methodological differences in study designs and comparative agents introduced inconsistency, and we noted that measurement tools were imprecise or not valid for purpose.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether administration of propofol would improve the quality and quantity of sleep in adults in the ICU. We noted differences in study designs, methodology, comparative agents and illness severity amongst study participants. We did not pool data and we used the GRADE approach to downgrade the certainty of our evidence to very low.

Use of GABAergic sedatives after subarachnoid hemorrhage is associated with worse outcome-preliminary findings

STUDY OBJECTIVE

Recent experimental evidence identified GABAergic sedation as a possible cause for deprived neuroregeneration and poor outcome after acute brain injury. Patients with aneurysmal subarachnoid hemorrhage are often sedated, and GABAergic sedation, such as midazolam and propofol, is commonly used.

DESIGN

Retrospective cohort study based on a prospectively established database.

SETTING

Single-center neurointensive care unit.

PATIENTS

Twenty-nine patients after subarachnoid hemorrhage.

INTERVENTION

Noninterventional study.

MEASUREMENTS

The relationship between mean GABAergic sedative dose during the acute phase and outcome after 6 months according to the Glasgow Outcome Scale, and initial Glasgow Coma Scale was investigated.

MAIN RESULTS

Use of GABAergic sedatives was negatively correlated with Glasgow Outcome Scale (r²=0.267; P=.008). Administration of sedatives was independent of the initial Glasgow Coma Scale. GABAergic sedatives flunitrazepam, midazolam, and propofol were used differently during the first 10 days after ictus.

CONCLUSION

Administration of GABAergic sedation was associated with an unfavorable outcome after 6 months. To avoid bias (mainly through the indication to use sedation), additional experimental and comparative clinical investigation of, for example, non-GABAergic sedation, and clinical protocols of no sedation is necessary.

Short and long-term outcomes of endoscopic balloon dilatation for Crohn’s disease strictures

AIM: To investigate the short and long-term outcomes of endoscopic balloon dilatation (EBD) for Crohn’s disease (CD) strictures.

METHODS: Between January 1995 and December 2011, 47 EBD procedures were performed in 30 patients (8 females and 22 males) with CD. All patients had strictures through which an endoscope could not pass, and symptoms of these strictures included abdominal pain, abdominal fullness, nausea, and/or vomiting. The 47 strictures included 17 anastomotic and 30 de novo strictures. Endoscopy and dilatation were performed under conscious sedation with intravenous diazepam or flunitrazepam. The dilatations were all performed using through-the-scope balloons with diameters from 8 mm to 20 mm on inflation and lengths of 30-80 mm. Each dilatation session consisted of two to four, 3-min multistep inflations of the balloon, repeated at intervals of 1 wk until adequate dilatation (up to 15-20 mm in diameter) was achieved. The follow-up data were collected from medical records and analyzed retrospectively. Primary success was defined as passage of the scope through the stricture after EBD. Long-term outcomes were analyzed focusing on intervention-free survival and surgery-free survival demonstrated by the Kaplan-Meier method. (Intervention-free meant cases in which neither endoscopic balloon re-dilatation nor surgery was needed after the first dilatation during the observation period). The log rank test was used to evaluate the difference in long-term outcomes between anastomotic and de novo stricture cases.

RESULTS: Primary success was achieved in 44 of the 47 strictures (93.6%). Balloon dilatations failed in 3 cases (6.4%). In 1 case, EBD was a technical failure because the guide-wire could not be passed through the stricture which showed severe adhesion and was a flexural lesion of the intestine. In 2 cases, unexpected perforations occurred immediately after balloon dilatation. Of the 47 treatments, complications occurred in 5 (10.6%). All 5 patients had de novo strictures. One suffered bleeding, two high fever and there were colorectal perforations. One of the patients with a colorectal perforation was treated surgically, the other was managed conservatively. These 2 cases correspond to the two aforementioned EBD failures. Long-term outcomes were evaluated for the 44 successfully-treated strictures after a median follow-up of 26 mo (range, 2-172 mo). During the observation period, re-strictures after EBDs occurred in 26 cases (60.5%). Fourteen of these 26 re-stricture cases underwent EBD again, but in two EBD failed and surgery was ultimately performed in both cases. Twelve of the 26 re-stricture cases were initially treated surgically when the re-strictures occurred. Finally, 30 of the 47 strictures (63.8%) were successfully managed with EBD, allowing surgery to be avoided. Intervention-free survival evaluated by the Kaplan-Meier method was 75% at 12 mo, 58% at 24 mo, and 43% at 36 mo. There was no significant difference between the anastomotic strictures (n = 16) and de novo strictures (n = 28) in the intervention-free survival as evaluated by the log-rank test. Surgery-free survival evaluated by the Kaplan-Meier method was 90% at 12 mo, 75% at 24 mo, and 53% at 36 mo. The 16 anastomotic strictures were associated with significantly better surgery-free survivals than the 28 de novo strictures (log-rank test: P < 0.05).

CONCLUSION: Anastomotic strictures were associated with better long-term outcomes than de novo strictures, indicating that stricture type might be useful for predicting the long-term outcomes of EBD.

Treatment with flunitrazepam of continuous spikes and waves during slow wave sleep (CSWS) in children

We describe our treatment of two boys with continuous spikes and waves during slow wave sleep (CSWS). One of the boys was suffering from non-convulsive status epilepticus and the other from conscious disturbance with automatism. Their ictal EEG readings showed continuous diffuse spike and wave complexes, which were considered to show electrical status. The boys were diagnosed as having CSWS, and were later diagnosed with Landau-Kleffner syndrome (LKS). EEG readings returned to normal on intravenous injection of flunitazepam (FZP) at a dose of 0.02 mg/kg, suggesting that FZP is an effective treatment for CSWS.

Drug-induced sweat gland necrosis in a non-comatose patient: a case presentation

BACKGROUND

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity often associated with drug-induced coma.

SUBJECT

We report a case with clinical and histopathologic findings characteristic of blisters and sweat gland necrosis occurring in a non-comatose patient.

CONCLUSIONS

Skin blisters with underlying sweat gland necrosis is an entity previously reported to occur in comatose patients, our findings open new questions about the role of the drugs in the pathogenesis of those conditions.

Comparison of hangover effects among triazolam, flunitrazepam and quazepam in healthy subjects: a preliminary report

The aim of the present study was to compare the hangover effects of night-time administration of triazolam (0.25 mg), flunitrazepam (1 mg) and quazepam (15 mg) in healthy subjects. Daytime sleepiness and performance level following the night-time administration of the drugs were assessed using Standford Sleepiness Scale (SSS), Sleep Evaluation Questionnaire (SEQ), Multiple Sleep Latency Test (MSLT), actigraphy recordings and Continuous Performance Test (CPT). Fifteen healthy volunteers were given one of the three hypnotics at each drug session, which lasted for 1 week, in a single-blind cross-over fashion. No significant between-drug difference was observed for the psychomotor performance assessed by CPT. Subjective hangover effects assessed by SSS and SEQ in the morning were prominent for flunitrazepam and quazepam relative to triazolam, whereas objective indices such as MSLT or activity counts obtained in actigraphy indicated a marked hangover effect of quazepam compared with the other two compounds restrictively in the afternoon, which were nearly in accordance with their pharmacokinetic profiles.

Clonidine premedication improves metabolic control in type 2 diabetic patients during ophthalmic surgery

BACKGROUND

In stressful conditions, increasing blood glucose concentrations are closely related to an increase in catecholamines and cortisol release. Clonidine, a centrally acting alpha(2)-adrenoceptor agonist, has neuroendocrine effects, including inhibition of sympathoadrenal activity. We therefore evaluated the effect of clonidine on blood glucose control and insulin requirements during ophthalmic surgery when given as premedication in type 2 diabetic patients.

METHODS

After randomization, patients were premedicated with clonidine or flunitrazepam (control). Patients were given insulin by continuous i.v. infusion to maintain blood glucose in the range 5.5-11.1 mmol litre(-1). Blood glucose concentrations were measured every 15 min during surgery, and hourly for 6 h after surgery. Plasma C-peptide and counter-regulatory hormones were also measured.

RESULTS

Glycaemia was significantly lower in the clonidine group (P<0.01) and the median amount of insulin administered was significantly reduced: clonidine group 9.0 (interquartile range 5.1) units; control 18.6 (10.2) units; P<0.01). Plasma catecholamine concentrations were lower in patients given clonidine (P<0.05) but there was no difference in cortisol concentrations.

CONCLUSION

Premedication of type 2 diabetic patients with clonidine 90 min before surgery improves blood glucose control and decreases insulin requirements during ophthalmic surgery.

The flunitrazepam abuse prevention program at a general hospital in Taiwan: a descriptive study

The Bureau of Controlled Drugs at Ministry of Health, Executive Yuan in Taiwan announced, on 1 April 2000, the schedules of controlled drugs with abuse potential and implemented a policy on 1 October 2000 to control them. Flunitrazepam (FM2), along with other two benzodiazepines (triazolam and brotizolam), is placed on Schedule III. The aim of the present study was to analyze the pattern of flunitrazepam prescriptions across all medical subspecialty departments at Taipei Medical University-Wan Fang Hospital (TMU-WFH), Taiwan. We analyzed 1170 prescriptions over 12 month period from 1 July 2000 to 31 May 2001. All prescription data were divided into three 4 month periods: period I was when the flunitrazepam prescription was not controlled, period II represented the time when flunitrazepam was placed on Schedule III and when physicians were required to use a special duplicated prescription form and period III was when the TMU-WFH started to set a stricter control for the prescription of flunitrazepam. The results indicated that the number of flunitrazepam prescriptions during period III had decreased significantly compared with period I (P < or = 0.05). Eventually, 45.7% of flunitrazepam-medicated patients were followed up monthly with a restriction of their flunitrazepam supply to no more than 14 days, 22.9% of patients were followed up fortnightly at clinics with a 14 day supply of flunitrazepam, 15.7% were followed up fortnightly with a 14 day restriction of flunitrazepam plus a non-flunitrazepan benzodiazepine supplement, 10.7% were referred to clinics within the Department of Psychiatry and 5% were switched from flunitrazepam to other drugs.

Buprenorphine prescription by general practitioners in a French region

Since 1996 French general practitioners (GPs) may prescribe sublingual buprenorphine tablets as maintenance treatment for opiate dependence. The computerised data management of the main French health reimbursement system now allows surveillance of the use of this drug, and how it is prescribed. The purpose of this study is to determine the profile of maintained patients, prescribed doses, associated psychotropic treatments and how practitioners prescribe these treatments. This study analyses the 11186 buprenorphine prescriptions electronically transmitted for reimbursement between September and December 1999 in a specific French region. It was found that the 2078 treated patients consumed a mean of 11.5 mg of buprenorphine per day and 12% of them procured prescriptions from more than two prescribers. 43% of maintained patients had an associated benzodiazepine prescription, mainly flunitrazepam, often on the same prescription form. 61% of patients had regular follow-up, others had occasional consultations (21%) and another 18% had deviant maintenance treatment (more than two prescribers or more than 20 mg per day of daily buprenorphine dose). Benzodiazepine consumption was much higher in the 'deviant group' (71.4%). 85% of buprenorphine prescriptions were made by GPs. 21% of GPs prescribed buprenorphine and 61% of those had only one or two maintained patients. Buprenorphine prescription by French GPs is a procedure with no particular requirements, allowing many patients to easily access maintenance treatments. However, a high risk of abuse exists, which demands extensive investigation and evaluation of these practices.

The association between intravenous haloperidol and prolonged QT interval

Although intravenous haloperidol (HAL) is an effective medication that is often prescribed to treat agitation, several instances of torsade de pointes or prolonged QT interval have been reported. To investigate the association between intravenous HAL and QT prolongation and between intravenous HAL and ventricular tachyarrhythmia, a cross-sectional cohort study was performed that included measuring corrected QT intervals (QTc) on an emergency basis before intravenous HAL and continuously monitoring electrocardiographic (ECG) findings after intravenous HAL. During a 2-month period, 47 patients received intravenous injections to control psychotic disruptive behavior. According to clinical practice, patients were divided as follows. The FZ-alone group was treated with intravenous flunitrazepam (FZ), and the FZ-plus-HAL group received intravenous FZ followed by intravenous HAL. Although the difference in the mean QTc immediately after intravenous FZ between the two groups was not significant, the mean QTc after 8 hours in the FZ-plus-HAL group was longer than that in the FZ-alone group (p < 0.001). Four patients in the FZ-plus-HAL group had a QTc of more than 500 msec after 8 hours. The change in QTc during 8 hours significantly differed between the two groups (t = 2.64, p > 0.05). Furthermore, the change in QTc was moderately correlated with the dose of intravenous HAL, as evidenced by a coefficient of correlation of 0.48 (p < 0.001). However, ventricular tachyarrhythmia was not detected among 307 patients within a 1-year period, although the ECG was continuously monitored for at least 8 hours after intravenous HAL. The modest nature of QTc prolongation and the apparent absence of ventricular tachyarrhythmia under continuous ECG monitoring indicate that QTc prolongation associated with intravenous HAL is not necessarily dangerous. However, in an emergency situation, clinicians cannot exclude patients predisposed to torsade de pointes, such as those with inherited ion channel disorders. Therefore, clinicians should be aware of the association between intravenous HAL and QT prolongation.

Nocturnal melatonin secretion and its modification by treatment in patients with sleep disorders

Data on the circadian melatonin secretion in sleep disordered patients and effects of sleep medication on melatonin are still missing. We studied plasma melatonin concentration, sleep, and effects of some hypnotics in 15 patients and 10 controls. Nocturnal melatonin levels were significantly decreased in patients with a more than five years history of sleep complaints compared to controls or patients with a shorter duration of illness. Independent of their sleep promoting properties drugs increased or decreased nocturnal melatonin in controls and patients. Patients with chronic sleep-wake rhythm disorders showed altered relations between their circadian melatonin secretion pattern and sleep. We conclude that nocturnal melatonin secretion is primarily independent of sleep regulation but represents a neuroendocrine feature of chronically disturbed sleep.

A pilot study of naltrexone-accelerated detoxification in opioid dependence

OBJECTIVE

1. To determine whether naltrexone-accelerated detoxification with minimal sedation is an acceptable and effective form of induction onto naltrexone. 2. To monitor outcomes of detoxified patients.

DESIGN

Observational study.

SETTING

Medical ward of a general hospital (for detoxification) and a community clinic (for follow-up) in Sydney, NSW, 1998.

PATIENTS

15 heroin users and 15 people seeking withdrawal from methadone.

INTERVENTION

Detoxification used naltrexone (12.5 or 50 mg), with flunitrazepam (2-3 mg), clonidine (150-750 micrograms) and octreotide (300 micrograms) for symptomatic support. Patients remained awake and were discharged when they felt well enough. Follow-up was daily for four days and then weekly for up to three months for supportive care.

MAIN OUTCOME MEASURES

Acute side effects; patient ratings of severity and acceptability of withdrawal; nights of hospitalisation; rates of induction onto naltrexone; retention in treatment over three months; and relapse to opioid use.

RESULTS

Acute withdrawal with delirium lasted about four hours. Octreotide was crucial for controlling vomiting; with octreotide no patient required intravenous fluids. There were no major complications. Eighteen patients (60%) reported that it was a "quite" acceptable procedure, 18 (60%) required only one night's hospitalisation, and 24 (80%) were successfully inducted onto naltrexone (defined as taking naltrexone on Day 8). Three months later, six (20%) were still taking naltrexone (with four of these occasionally using heroin) and seven (23%) were abstinent from opioids, including five not taking naltrexone. Eleven had gone onto methadone maintenance, seven had relapsed to heroin use, and one had died of a heroin overdose.

CONCLUSIONS

Rates of induction onto naltrexone were comparable with those reported for accelerated detoxification under sedation, suggesting that it can be performed successfully with minimal sedation. As in other studies of naltrexone maintenance, retention was low, and relapse to heroin use was common.

Drugs used in acquaintance rape

OBJECTIVE

To describe gamma-hydroxybutyrate (GHB), flunitrazepam, and ketamine and their purported uses to facilitate acquaintance rape. Patient presentation characteristics, treatment regimens, processes to detect the presence of the medications by toxicology screening, and methods to avoid exposure are discussed.

DATA SOURCES

MEDLINE search from 1985 to 1998; additional references found within the articles; information obtained from the Internet.

STUDY SELECTION

Clinical trials, reviews, and press releases concerning the use of GHB, flunitrazepam, and ketamine to facilitate acquaintance rape. Trials and reviews describing clinical effects, adverse effects, pharmacokinetics/pharmacodynamics, and usage trends were evaluated. Literature judged to be pertinent by the author was included in the discussion. DATA EXTRACTION/DATA SYNTHESIS: Reports of the use of GHB, flunitrazepam, and ketamine in acquaintance rape appear in the medical literature and lay press. Many health care professionals may not be familiar with these medications, and information about caring for patients under their influence is limited. Victims lose their ability to ward off attackers, develop amnesia, and are unreliable witnesses. Because symptoms caused by these agents mimic those of alcohol, not all victims are screened for their presence. Legislative efforts to further limit the use of or access to GHB, flunitrazepam, and ketamine have been initiated at the state and federal levels. Pharmacists should know the symptoms of exposure to the three agents; they should understand treatment regimens, methods to detect the presence of these and other drugs that may have been used in a sexual assault, and techniques individuals can use to avoid becoming victims of drug-assisted acquaintance rape.

CONCLUSION

Because of their extensive drug knowledge and frequent access to patients, pharmacists are uniquely positioned to educate patients and other health care professionals about the dangers of acquaintance rape drugs and methods to reduce their risk of becoming victims.

[Gamma-hydroxybutyrate for treatment of alcohol withdrawal syndrome in intensive care patients. A comparison between with two symptom-oriented therapeutic concepts]

Seeing as gamma-hydroxybutyrate (GHB) and benzodiazepines interact with the GABA-transmitter system, we investigated whether GHB can replace the conventional therapy, which uses benzodiazepines in the treatment of alcohol withdrawal syndrome in ICU settings.

METHODS

42 chronic alcoholics were included in this prospective and randomized study. Following the development of alcohol withdrawal syndrome, the patients were randomly allocated to the GHB or to the flunitrazepam group. In addition to this, clonidine was administered in order to treat autonomic signs of withdrawal. In cases were hallucinations occurred, haloperidol was administered.

RESULTS

There was no significant difference in the efficacy of treatment used in the duration of mechanical ventilation and intensive care unit stay between groups. The patients in the GHB-group required significantly higher dosages of haloperidol and significantly lower dosages of clonidine. 14 out of 21 patients from the GHB-group developed hypernatriaemia and 15 out of 21 developed a metabolic alkalosis.

CONCLUSIONS

Symptoms of the autonomic nervous system were more effectively prevented by GHB as evident in the lower dosage requirement of clonidine. However, GHB may not sufficiently block the hyperactivity of the dopaminergic system or may have an hallucinogenic effect itself. This may be evident from the higher dosages of haloperidol which were necessary. Due to the latter fact, the administration of GHB cannot be recommended in all patients suffering from AWS in ICU settings.

Intramuscular flunitrazepam versus intramuscular haloperidol in the emergency treatment of aggressive psychotic behavior

OBJECTIVE

The authors examined the efficacy of intramuscular flunitrazepam compared with intramuscular haloperidol for the immediate control of agitated or aggressive behavior in acutely psychotic patients.

METHOD

Twenty-eight actively psychotic inpatients, aged 20-60 years, who were under treatment with neuroleptic agents were selected for the study. Each was randomly assigned on a double-blind basis to receive either 5 mg i.m. of haloperidol (N=13) or 1 mg i.m. of flunitrazepam (N=15) during an aggressive event. Verbal and physical aggression was measured over time with the Overt Aggression Scale. Patients were also rated with the Brief Psychiatric Rating Scale and the Clinical Global Impression scale.

RESULTS

Both flunitrazepam and haloperidol exhibited acute antiaggressive activity. This beneficial effect, as assessed by the Overt Aggression Scale, was obtained within 30 minutes.

CONCLUSIONS

Intramuscular flunitrazepam may serve as a convenient, rapid, safe, and effective adjunct to neuroleptics in reducing aggressive behavior in emergency psychiatric settings.

Comparison of the effects of zolpidem and flunitrazepam on sleep structure and daytime cognitive functions. A study of untreated unsomniacs

The effects of zolpidem 10 mg, flunitrazepam 1 mg, and placebo, administrated at bedtime, were studied in 12 healthy male insomniac patients. The assessments included polygraphic sleep recordings during the night and a battery of cognitive tests (sign crossing test, dichotic listening test, digit span test, visual recognition test and free recall test during four times during the following day. Compared with placebo, both active drugs improved sleep parameters. However, with zolpidem, the results were not statistically different from placebo. Zolpidem dit not alter sleep architecture in contrast to flunitrazepam, which significantly increased stage 2 and decreased slow wave sleep and REM sleep. No significant interaction was found between time of day for the evaluation of cognitive function. Flunitrazepam significantly impaired attention and memory compared with zolpidem and placebo, while zolpidem did not differ from placebo. These results indicate that zolpidem 10 mg preserved sleep structure and daytime cognitive functions in contrast to flunitrazepam.

Use and abuse of flunitrazepam

Flunitrazepam is not available in the US, and it is presently illegal to import it. Flunitrazepam has no therapeutic advantage over benzodiazepines presently marketed in the US. Its quick onset of sedation, amnesic properties, and additive effects with alcohol have led to its reputation as a party drug, club drug, or date rape drug. Several measures have been undertaken to curb its illicit use. It is unclear whether flunitrazepam poses a greater public health risk than other benzodiazepines.

Lateralized neuropsychological functioning in depressive patients before and after drug therapy

Several decades of research have led to different hypotheses about cognitive functioning in depression; one of the hypotheses states that there is altered functioning of the hemispheres during a depressive episode. Lateralization studies have found diminished neuropsychological functioning in depressive patients; especially right-hemisphere functions seem impaired. In our study we used conventional neuropsychological tests to study shifts in hemispheric functioning. Neuropsychological testing before and after therapy in 52 (for the most part therapy-resistant) depressives showed no substantial effects in lateralized functioning. None of the measures enabled prediction of response to treatment; however 17 different interaction variables were identified, five of which make an unique contribution.

Shoplifting and robbery in a fugue state

The case of a 26-year-old Chinese woman with a history of benzodiazepine dependence and shoplifting who committed an act of robbery is presented. The various aetiological factors implicated in this complicated case are discussed in the light of the recent literature.

[Sedation with flunitarazepam at magnetic resonance imaging in the elderly patients with dementia]

Magnetic resonance imaging (MRI) of the brain is useful in diagnosing senile dementia, but to avoid the creation of artifacts the patient should be kept immobile. We studied the effects of pretreatment with flunitrazepam, a sleep inducer of the benzodiazepine class, as a sedative prior to imaging. The subjects consisted of 108 patients with senile dementia admitted to the Dementia Ward of Kyoto Higashiyama Geriatric Hospital. Their ages ranged from 64-95 years (mean, 81) and the mean body weights of the 76 women and 32 men were 36 and 47 kg, respectively. Immediately before undergoing MRI the patients were given a slow intravenous injection of flunitrazepam (2 mg/ml diluted in 19 ml of saline). Immediately before the patients fell asleep, administration was discontinued and the dose was noted: mean 0.008 mg/kg. In all patients sleep induction and sedation were achieved. No adverse reactions such as apnea were observed. The flunitrazepam dose in our study was much lower than that in previous reports on adults. As body weights of the elderly are also lower than those of younger adults, the optimum dose of flunitrazepam for the elderly may be much lower. Intravenous flunitrazepam may be a useful and safe premedication for MRI in elderly patients with dementia. To avoid serious adverse reactions the dose should be minimized by: 1) determining body weight before MRI, 2) administering diluted flunitrazepam, and 3) discontinuing the drug before the patient falls asleep.

Prophylaxis of alcohol withdrawal syndrome in alcohol-dependent patients admitted to the intensive care unit after tumour resection

Prophylaxis of alcohol withdrawal syndrome (AWS) in alcohol-dependent patients shortens the duration of stay in the intensive care unit (ICU). The objective of this study was to assess the effect of four different prophylactic regimens on the duration of ICU stay, prevention of AWS and rate of major intercurrent complications in alcohol-dependent patients admitted to the ICU after tumour resection. A total of 197 alcohol-dependent patients, diagnosed by the Diagnostic and Statistical Manual of Mental Disorders (third revised edition) with a daily ethanol intake of 60 g, were allocated randomly to one of the following regimens which were commenced on admission to the ICU: flunitrazepam-clonidine, chlormethiazole-haloperidol, flunitrazepam-haloperidol or ethanol. The duration of ICU stay, prevention of AWS, incidence of tracheobronchitis and major intercurrent complications such as pneumonia, sepsis, cardiac disorders, bleeding disorders and death were documented. On admission, patients did not differ significantly in age, APACHE II and multiple organ failure scores. ICU stay, incidence of AWS, severity of AWS (revised clinical institute withdrawal assessment for alcohol scale > 20) and major intercurrent complication rate did not differ significantly between groups. Although there was no advantage in any of the four regimens with respect to the primary outcome measures, pulmonary and cardiac patients were not included in the study. Patients in the chlormethiazole-haloperidol group had a significantly increased incidence of tracheobronchitis (P = 0.0023), probably because of an increased incidence of hypersecretion.

Pharmacokinetics of cetirizine in 2- to 6-year-old children

Eight children (3.84 +/- 1.17 years old) received a single oral 5 mg cetirizine dose (0.32 +/- 0.07 mg.kg-1) as a 10 mg.ml-1 solution, 1.73 (+/- 0.64) hours before a minor surgical intervention (mean duration +/- SD = 0.90 +/- 0.25 h). Seven venous blood samples were collected before administration (t0) and 0.5 h, 1.5 h, 4 h, 8 h, 12 h and 24 h after dosing, and urine samples were collected up to 24 hours after the dose. The mean +/- SD kinetic parameters were: peak plasma level (Cmax) 607 +/- 231 micrograms.l-1 reached in 1.93 +/- 1.39 h (tmax), elimination half-life (t1/2) 5.55 +/- 0.98 h, area under the plasma concentration time curve (AUC0-infinity) 4,772.1 +/- 1,318.4 micrograms.l-1.h, mean residence time (MRT) 8.13 +/- 1.31 h, apparent plasma clearance (Cl/f) 1.27 +/- 0.80 ml.min-1.kg-1, apparent volume of distribution (Vz/f) 0.60 +/- 0.38 l.kg-1. Urinary recovery was 38.4 +/- 9.9% (n = 4) of the dose. Renal clearance was 0.42 +/- 0.10 ml.min-1.kg-1 (n = 6). No influence of age on the cetirizine parameters was evidenced among this group, except for MRT (p < 0.05) which decreases with age. When compared with results in adults, elimination half-life (t1/2) was twice as short and apparent clearance twice as great. These results suggest that a higher dosage b.i.d. may be required in children.

The clinical introduction of a third generation lithotriptor: Modulith SL 20

The Modulith SL 20* was designed as a third generation lithotriptor with outstanding disintegrative efficacy in vitro, and equipped with a combined fluoroscopic and ultrasound localization system integrated in a multifunctional table. Its introduction to clinical extracorporeal shock wave lithotripsy took place in 3 phases. In phase 1 (49 patients) only in line ultrasound localization was possible. The many caliceal stones were adequately disintegrated with restricted generator voltage. In phase 2 (81 patients) fluoroscopic localization with the virtual focus of an adapted x-ray C-arm unit enabled in situ lithotripsy of ureteral stones in 33% of all patients. Phase 3 (549 patients) was characterized by additionally increasing the generator voltage to 20 kv. This development of the lithotriptor by improving the localization system and shock wave energy resulted in the possibility for successful disintegration of stones in the entire upper urinary tract (including the complete ureter), decreased treatment time (52 to 39 minutes) and an improved efficiency quotient (0.45 to 0.67). During phase 3 auxiliary measures were performed before lithotripsy in 24% of the cases. After 1.8% of the treatments minor or moderate perirenal fluid collection or bleeding was detected by routine followup sonography. A 91% stone-free rate was achieved with only 9.3% curative auxiliary measures after extracorporeal shock wave lithotripsy, including a 23% retreatment rate. Thus, the Modulith device had a high efficacy quotient compared with other lithotriptors.

Double-blind comparison of zopiclone and flunitrazepam in elderly insomniacs with special focus on residual effects

In a double-blind study of 102 patients with a mean age of 79 years, zopiclone was compared to flunitrazepam. The patients rated their sleep in a diary. There was no statistically significant difference between the relatively low dose of 5 mg zopiclone and 1 mg flunitrazepam for eleven out of the twelve variables measuring subjective sleep quality and quantity. There was no differences between the drugs as regards patients' feelings of being rested or alertness.

Flunitrazepam for sleep disturbance in children with intractable epilepsy

Add-on therapy with flunitrazepam (FNZ) was performed in 5 children with marked sleep disturbance and intractable seizures. Correction of the sleep disturbance was attained immediately after the start of FNZ administration in all patients. Furthermore, a significant decrease in the seizure frequency (3 patients) and improved quality of life (4 patients) were concomitantly observed. There was no adverse effect or interaction with conventional AEDs on long-term use.

Zolpidem: clinical experience in psychiatric settings

Zolpidem, a new short-acting non benzodiazepine hypnotic with high selectivity for benzodiazepine--1/Omega-I receptors and with lack of tolerance and physical dependence in animal models and lack of withdrawal phenomena even after up to 180 days treatment has recently been introduced. Data from clinical trials show a comparable effectiveness in inducing and maintaining sleep to comparative drugs (benzodiazepines) and besides that, it seems to preserve--even improve sleep-architecture and lastly preserve daytime wakefulness. Very few studies have been conducted in psychiatric patients, but also in this group effectiveness has been shown, and from daily clinical experience, this picture seems to hold. It must be remembered, that psychiatric patients have a high level of symptomatic benzodiazepine and/or alcohol misuse disposing to withdrawal and abstinence states in which zolpidem is less effective presumedly reflecting its selectivity. Having passed the withdrawal states, zolpidem can be used as an effective and safe hypnotic.

Zopiclone improves sleep quality and daytime well-being in insomniac patients: comparison with triazolam, flunitrazepam and placebo

In a randomized, double-blind, parallel group study in private practice, zopiclone given for 28 days was compared with flunitrazepam, triazolam and placebo in its effect on quality of sleep and daytime well-being in 1507 patients suffering from insomnia. For quantitative assessment, patients were defined as responders according to either a shortening of sleep latency by at least 15 min, or prolongation of total sleep time by at least 20%, or reduction of the number of nocturnal awakenings to three or less and a fresh feeling in the morning, as well as lack of impairment in daytime well-being as a result of tiredness or anxiety. The responder rate tended to be higher with zopiclone (37.4%) than with flunitrazepam (30%) and triazolam (32.2%) and was significantly greater (p = 0.0017) than with placebo (26.8%). Daytime well-being was particularly responsive to zopiclone and most responsive in severe insomniacs. With the exception of those to triazolam, rates of response were most pronounced in patients with insomnia of a short duration (< or = 1 year) than in those with insomnia of a longer duration (> or = 1 year). Following discontinuation of treatment, all groups showed a moderate reduction in therapeutic effect, but no rebound insomnia occurred.

[Treatment of insomnia related to depressive disorders. Effects of zolpidem versus flunitrazepam administration and withdrawal evaluated in a double-blind study]

The effects of a 15 day treatment with zolpidem (10 mg) and with flunitrazepam (1 mg) on Insomnia Disorders Related to Depressive Disorders (DSM-III-R) have been evaluated on 30 depressive in-patients (mean age 42.3 +/- 9.8). The trial has been carried out on double blind condition after 5 days of single blind placebo administration. Withdrawal effects have been evaluated in single blind condition on a 10 day period after drugs discontinuation. Patient's diagnosis was Major Depression or Dysthymia according to DSM-III-R; inclusion criteria were insomnia (total sleep time < or = 6 h, sleep latency > or = 30 min, wake after sleep onset > or = 30 min, No of awakenings > or = 3) refractory to clomipramine administration at constant dose (75-150 mg/day among patients). Both drugs have been followed by a rapid, significant diminution of insomnia as demonstrated by significant changes at Stanford Sleepiness Scale and Saint Mary Hospital Sleep Questionnaire and by a significant reduction of HDRS total scores. No clinical phenomena of rebound insomnia were detected after zolpidem and flunitrazepam withdrawal. Drug discontinuation however was followed by the slow increase of the score on insomnia items, approximating basal values at the end of the 10 day period after zolpidem and flunitrazepam withdrawal. A parallel increase of HDRS total score was also detected; HDRS changes were mainly due to the increase of the items anxiety somatic, general somatic symptoms, gastrointestinal somatic symptoms, hypochondriasis. The study confirms the therapeutic efficacy of zolpidem and of flunitrazepam in the treatment of insomnia resistant to antidepressant drugs in depressed patients. They also suggest that early drug discontinuation is frequently associated with clinical relapse of insomnia and of several other symptoms correlated with the affective pathology.

Hypnotics as concurrent medication in depression. A placebo-controlled, double-blind comparison of flunitrazepam and lormetazepam in patients with major depression, treated with a (tri)cyclic antidepressant

The addition of benzodiazepine hypnotics to a treatment with tricyclic antidepressants has received little systematic study. In a double-blind placebo-controlled design, the effects on mood and on sleep of two benzodiazepine hypnotics (lormetazepam and flunitrazepam) were studied in patients with major depression who were also treated with maprotiline or nortriptyline. After 4 weeks of combined treatment, lormetazepam resulted in a significantly greater decrease in the score on the Hamilton Depression Subscale than placebo, while there was a non-significant trend in favour of lormetazepam in comparison with flunitrazepam. With respect to sleep EEGs, lormetazepam resulted in a significantly greater suppression of REM sleep. The differences between lormetazepam and flunitrazepam may be partly explained by the shorter half-live of lormetazepam.

Therapeutic effects of flunitrazepam in dystonias and torticollis. Preliminary communication

A new form of clinical treatment is proposed for dystonias and torticollis using flunitrazepam (FN), a powerful agonist of all benzodiazepine receptors of GABA neurons. FN has a specific effect in dystonic patients, specially those in which the hypnotic effect of this drug is absent or diminished, thus suggesting the existence of two different neurochemical categories of dystonias.

Flunitrazepam in terminal care

Flunitrazepam is a benzodiazepine of long half-life with sedative, anxiolytic, muscle relaxant and anticonvulsant properties. It has proved effective in controlling terminal agitation, confusion, restlessness, dystonia and fitting in adults and can be given by subcutaneous infusion in combination with other drugs. Its use in children during their terminal illness is described. Good symptom control without excessive sedation was achieved over the 24 h prior to death.

Does preoperative anxiety influence gastric fluid volume and acidity?

Preoperative anxiety may increase gastric fluid acidity and volume. To pursue this possibility we evaluated the relationship between peroral premedication, preoperative anxiety, and gastric content in 246 consecutive patients presenting for elective gynecologic surgery. All patients fasted overnight and received either flunitrazepam 1 mg, oxazepam 25 mg, or placebo with 20 mL of water on the morning of surgery in a randomized, double-blind fashion. The patients assessed relief of anxiety using a four-graded scale (excellent, good, fair, poor). Both flunitrazepam and oxazepam decreased anxiety (P less than 0.01) compared with placebo. However, no correlations between type of premedication or level of anxiety and gastric contents were found. The proportion of patients with gastric fluid volume greater than 25 mL and pH less than 2.5 was not significantly different in any of the groups studied. These results suggest that neither peroral benzodiazepine premedication nor preoperative anxiety have a clinically important impact on gastric content in patients presenting for elective gynecologic surgery.

[Clinical evaluation of pre-surgical anxiety: changes in plasma levels of the anxiety peptide (diazepam binding inhibitor)]

The score scale of anxiety (STAI, Y, 1-2) and haematic levels of DBI (diazepam binding inhibitor) were used in 48 surgical patients for clinical evaluation of preoperative anxiety, before and after drugs for preoperative medication. After randomization, were clinically and statistically compared 6 groups according to premedicant drugs (diazepam 0.3 mg/kg; flunitrazepam 0.03 mg/kg; saline; prometazine 0.7 mg/kg); before and after preoperative medication were evaluated the anxiety relief with the score scale, haematic levels of DBI and haemodynamics (systolic and diastolic AP and HR). The results show that DBI can objectively measure the anxiety relief, that not are correlate haematic levels of DBI and score scale, that the best benzodiazepines are diazepam (0.3) and flunitrazepam (0.015) and that the prometazine might give anxiety relief for 5-HT antagonist action. Even if there are limits to study (scanty cases, are missing the range and the brain values of DBI and blood test of DBI is slow method) may be useful the use of score scale and haematic levels of DBI in clinical evaluation of preoperative anxiety relief.

Does opiate premedication influence postoperative analgesia? A prospective study

The influence of opiate premedication on analgesic requirements postoperatively was investigated. Out of 98 patients with a lumbar disc prolapse 50 were premedicated with flunitrazepam orally, 48 with pethidine and triflupromazine intramuscularly. The operations were performed under inhalational anaesthesia. The average time up to the first demand for an analgesic was longer following opiate premedication (351 vs. 219 min). Only 45.8% of the patients treated with opiates demanded analgesics postoperatively, compared to 80.0% of those who had a benzodiazepine premedication (P less than 0.01). These clinical data confirm the experimental evidence that pretreatment with opiates diminishes the sustained hyperexcitation of the central nervous system caused by peripheral lesions.

Effects of zolpidem and flunitrazepam on nocturnal sleep of women subjectively complaining of insomnia

Eighteen non-pregnant woman complaining about insomnia were polysomnographically investigated for 3 nights with weekly intervals. They received placebo, 2 mg flunitrazepam or 10 mg zolpidem according to a cross-over double blind design. The patients were selected by general practitioners on the basis of subjective complaints. Zolpidem is a recently introduced short-acting imidazopyridine hypnotic, binding to a subunit of the benzodiazepine 1 receptor. Flunitrazepam is a well-known hypnotic, binding to both the benzodiazepine 1 and 2 receptor subtypes. Objective recording did not substantiate the subjective complaint of insomnia. Sleep patterns during placebo differed only little from that expected from age matched healthy persons. Both flunitrazepam and zolpidem significantly shortened sleep onset (5 min of continuous sleep beginning with NREM 1 sleep). The sleep composition following flunitrazepam was characterized by an increase in NREM 2, a prolongation of the time of REM sleep, a reduction of REM sleep and an increase in NREM 3-4 sleep during the first 2 h of sleep. The sleep composition following zolpidem resembled more than seen in persons without sleep complaints. However, as compared to placebo, there was a decrease of the time spent awake during sleep and an increase in NREM 3-4 during the first 2 of sleep.

[Sedation with flunitrazepam and its antagonism with flumazenil in endoscopic urological procedures: our clinical experience]

Patients, especially males, do not easily stand endoscopic urological diagnostic examinations. So flunitrazepam (0.01 mg/kg IV) has been used to insure a suitable sedation. At the end of such examination flumazenil, a selective benzodiazepine antagonist has been injected. The levels of sedation and orientation so obtained and the cardiorespiratory parameters have been collected during a one hour follow-up from the intravenous injection of the antagonist. This method presents minimal side effects (a marginal, but statistically significative, systolic arterial pressure reduction), a completely normal coordination of movements and awareness of space and time relationship at the end of the observation period. Therefore it is a very good solution for short time examinations giving the chance to safely and shortly dismiss the patient.

Surgical treatment of carcinoid heart disease

Right heart failure in patients with carcinoid heart disease is a serious prognostic sign. Consideration and adequate timing of valvular operations seem essential for the postoperative outcome. Without any relation to duration or progression of the metastasizing tumor disease, right heart failure developed and increased rapidly for a period of 12 to 17 months in four patients with classic carcinoid syndrome. Invasive hemodynamic and cardiac ultrasound investigations revealed severe carcinoid heart disease, and medical decompensation treatment gradually failed. Tricuspid and pulmonic valve replacement operations resulted in dramatic improvement in three of the patients, and these patients were still free of cardiac symptoms 10, 12, and 38 months postoperatively. One patient died 5 days postoperatively probably of septicemia. The preoperative and postoperative development of the cardiac disease is evaluated clinically, by cardiac ultrasound and plasma atrial natriuretic peptide concentrations, and related to the tumor disease. Surgical anatomy and operative technique are reported, and the beneficial value of prophylactic treatment of the effects of tumor-released vasoactive substances by a somatostatin analog is emphasized.

[Effectiveness of chlormezanone and flunitrazepam in treatment of difficult children]

Out of a total of 366 preschoolers, aged 3-5 years old, from the urban area of Curacautín, a sample of 46 children is selected using a behavioral classification to choose those children difficult to manage. A double-blind type investigation is realized using a posology of the drugs: Chlormezanone and Flunitrazepam as well as a placebo. The distribution of the doses is in accordance with the so called "Latin Table". The results obtained indicate that both drugs are effective, with a 90.6% success rate case of Chlormezanone and 92.8% effectiveness in the case of Flunitrazepam. In terms of the placebo, the success rate was 15% with a higher rate in the third medication, possibly due to better psychological predisposition on the child's part.

The effects of nitrazepam and flunitrazepam on oxygen desaturation during sleep in patients with stable hypoxemic nonhypercapnic COPD

Serious respiratory depression has been described in COPD patients receiving hypnotics during acute exacerbations. There are few studies quantifying the effects of hypnotics on oxygenation during sleep in patients with stable hypoxemic COPD. In this study, the effects of single therapeutic doses of nitrazepam and flunitrazepam on SaO2, apneas during sleep and other sleep variables were measured in 14 COPD patients. All patients used theophylline. Sleep-induced decrease in mean SaO2 was 1.3 percent after placebo, 1.4 percent after nitrazepam and 1.9 percent after flunitrazepam (no significant differences). Sleep apneas were not more common or longer after nitrazepam or flunitrazepam, but sleep quality seemed to improve. It is concluded that oxygenation during sleep in these nonobese patients with stable hypoxemic nonhypercapnic COPD, all on maintenance theophylline therapy, was affected very little by single therapeutic doses of nitrazepam or flunitrazepam.

Intravenous injection of flunitrazepam for status epilepticus in children--two case reports

Two cases of status epilepticus are reported, whose seizures responded well to the injection of flunitrazepam. One patient had generalized tonic clonic seizures and the other had partial seizures. The improvement of their condition was confirmed by both clinical and electroencephalographic examinations. There were no serious side effects observed. Flunitrazepam might have a potential efficacy for the treatment of status epilepticus of both generalized and partial seizures.

Temazepam versus flunitrazepam as an oral premedication in adult surgical patients

In a randomized study, 20 patients received temazepam 20 mg orally the night before and 20 mg in the morning of an operation performed under spinal analgesia (Group I); 20 patients received flunitrazepam I mg similarly (Group 2). Different aspects of the premedication were evaluated verbally, with the aid of a visual analogue scale, Maddox wing apparatus, the critical flicker fusion threshold test, blood pressure and heart rate measurements, serum and CSF cortisol and plasma ADH measurements, as well as CSF drug level determinations. Clinically, temazepam 20 mg proved to be comparable with flunitrazepam I mg, although the latter more effectively prevented cardiovascular changes and pre-operative hormonal stress reaction. No correlation was found between the CSF drug level (bioassayed by radioreceptor assay) and the clinical response of the two benzodiazepines, nor was there any correlation between the cortisol or ADH levels versus the CSF drug levels. On the whole, flunitrazepam proved to be marginally better than temazepam as an oral premedicant.

Aspects of driving after hypnotic therapy with particular reference to temazepam

In a double-blind study, 32 outpatients with sleep disorders received oral doses of temazepam 20 mg (n = 16) or flunitrazepam 2 mg (n = 16) once a night for 7 days. On the morning after the first and seventh doses, patients completed psychomotor tests and a real driving test on the road over a 25 km course. The road test included a 1 km straight stretch driven at constant speed. In the car, various parameters were automatically recorded every second for approximately 60 minutes. These included angular velocity of steering, lateral acceleration and velocity. An optimization quotient, a measure of the efficiency of information processing in the driver-vehicle-road interaction, was derived from these parameters. An observer recorded driving performance by scoring standardized tasks. After a single dose of temazepam, the improvement in driver performance as shown by a decreased optimization quotient was significantly different to the deterioration seen after flunitrazepam (p less than 0.05). After the seventh dose, this trend was still apparent but was not statistically significant. After both one and seven doses, the angular velocity of steering was significantly decreased in the temazepam group compared with an increase after flunitrazepam (p less than 0.001). Over the straight, this deterioration in steering ability in the flunitrazepam group was apparent after one dose and reached statistical significance compared with temazepam after seven doses (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)