Out of touch? How trauma shapes the experience of social touch - Neural and endocrine pathways

Trauma can shape the way an individual experiences the world and interacts with other people. Touch is a key component of social interactions, but surprisingly little is known about how trauma exposure influences the processing of social touch. In this review, we examine possible neurobiological pathways through which trauma can influence touch processing and lead to touch aversion and avoidance in trauma-exposed individuals. Emerging evidence indicates that trauma may affect sensory touch thresholds by modulating activity in the primary sensory cortex and posterior insula. Disturbances in multisensory integration and oxytocin reactivity combined with diminished reward-related and anxiolytic responses may induce a bias towards negative appraisal of touch contexts. Furthermore, hippocampus deactivation during social touch may reflect a dissociative state. These changes depend not only on the type and severity of the trauma but also on the features of the touch. We hypothesise that disrupted touch processing may impair social interactions and confer elevated risk for future stress-related disorders.

Valerenic acid reduces anxiety-like behavior in young adult, female (C57BL/6J) mice

Extracts from the plant Valeriana officinalis are marketed as an herbal remedy to treat anxiety and insomnia. Valerenic acid (VA) is a major chemical component of Valeriana extracts. To date, there is relatively little information about how VA affects behavior. The purpose of these experiments was to (1) test whether administration of VA induces measurable changes in anxiety-like, depression-like, or locomotor behaviors; (2) determine whether the effects of VA on behavior are dose-dependent; and (3) compare the effects of VA on behavior to those of diazepam, a commonly prescribed treatment for anxiety. Young adult, female mice (C57BL/6J; 3-4 months old; 12 mice/group) were given one of three dosages of VA (3 mg/kg, 6 mg/kg, or 12 mg/kg), diazepam (1 mg/kg), or a vehicle control solution (20% ethanol v/v) by intraperitoneal injection. Thirty minutes after injection, each mouse was tested in the elevated plus maze (EPM), open field test (OFT), and tail suspension test (TST), in that order. All tests were video recorded and analyzed for relevant behavioral parameters. The results demonstrated that VA treatment effectively reduced multiple anxiety-related behaviors measured in the EPM. In fact, at a dose of 12 mg/kg, the anxiolytic effect of VA was just as robust as that of diazepam. Furthermore, the effects of VA on behavior were specifically anxiolytic, as VA did not induce changes in locomotor activity in the OFT, or depression-related behavior as measured in the TST. Our results provide strong support for VA as a putative anxiolytic drug.

Nitrous oxide use in Canadian pediatric emergency departments: a survey of physician's knowledge, attitudes, and practices

OBJECTIVES

Nitrous oxide (N2O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N2O and b) site-specific N2O protocols in Canadian pediatric EDs to help optimize its use nationally.

METHODS

This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N2O policies and procedures.

RESULTS

N2O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N2O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N2O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N2O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use.

CONCLUSIONS

Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N2O in their clinical practice for treating procedure-related pain and distress. Increased availability of N2O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED.

Exposure to an enriched environment exerts anxiolytic effects in Sardinian alcohol-preferring rats

Exposure to an enriched environment (EE) has been reported to generate multiple beneficial effects in rodents, including - among the many - amelioration of anxiety-related behaviors. The present study investigated whether living in an EE produced anxiolytic effects also in selectively bred Sardinian alcohol-preferring (sP) rats. The relevance of this research question relied on two factors: sP rats displayed an inherent, high anxiety-like state under different experimental conditions; exposure to EE reduced operant, oral alcohol self-administration in sP rats. Starting from weaning, male sP rats were kept under 3 different housing conditions: impoverished environment (IE; single housing with no environmental enrichment); standard environment (SE; 3 rats/cage with no environmental enrichment); EE (6 rats/cage with various elements of environmental enrichment). At the age of approximately 80 days, rats were exposed to an elevated plus maze test for assessment of anxiety-related behaviors. Compared to IE and SE rats, EE rats displayed higher basal levels of exploratory activity (i.e., increased number of entries into closed arms). Compared to IE and SE rats, EE rats also displayed a less "anxious" profile, as suggested by the increase in percent number of entries into open arms (OAs), percent time spent in OAs, number of head dips, and number of end-arm explorations in OAs. These data extend the protective (anxiolytic) effects of EE to a proposed animal model of comorbid alcohol use disorder and anxiety disorders.

Real-world data of non-invasive stimulation of the human insula-prefrontal cortices using deep TMS to treat anxiety for occupational stress and generalized anxiety disorder

Activation of the insula is found in all anxiety-related disorders and increased insular-prefrontal cortex (PFC) functional connectivity is associated with reduced anxiety. In this study, the combined stimulation of the insula and PFC using the dTMS H4 (insula+LPFC) and H2 (PFC) coils were used to reduce anxiety in 13 subjects experiencing occupational stress, and 55 participants suffering from generalized anxiety disorder (GAD). The combined HF stimulation of the insula and PFC significantly decreased anxiety scores according to the HARS, CAS, and STAI anxiety scales, leading to a reduction in anxiety according to HARS of 88.7% and 70.7% in participants with occupational stress and the clinical sample of participants diagnosed with GAD, respectively. The findings suggest that the prefrontal-insular axis is critical for the regulation of anxiety and its stimulation can be used for the treatment of anxiety in people suffering from occupational stress and GAD.

Optimizing anxiolysis and analgesia for percutaneous intervention by the abdominal radiologist

Abdominal radiologists perform a wide variety of image-guided interventions. Procedures performed by abdominal radiologists can be broadly categorized into paracentesis, thoracentesis, superficial and deep soft tissue biopsy, drain placement, and ablation. As these procedures continue to develop as an alternative to more invasive and potentially morbid interventions, and with continued improvements in minimally invasive technologies, it becomes increasingly important for abdominal radiologists to be familiar with options for peri-procedural analgesia and anxiolysis, as well as when to consult anesthesiology. In this review, we discuss analgesic, anxiolytic, and nonpharmacologic options available to the abdominal radiologist. We focus on practical agents that are relatively safe for general use, special populations, and considerations for post-procedural monitoring.

Randomised clinical trial evaluating the effect of a single preappointment dose of gabapentin on signs of stress in hyperthyroid cats

Objectives

The aim of this study was to evaluate the efficacy of gabapentin as an anxiolytic in hyperthyroid cats.

Methods

Cats (n = 47) with confirmed hyperthyroidism were successfully enrolled. The cat owner allocated a temperament score and a transport stress score at their first visit. For the second visit the cat owner (blinded to treatment) administered either liquid gabapentin 20 mg/kg (n = 22) or an indistinguishable placebo solution (n = 25) 1 h prior to leaving home. A second transport score was allocated by the cat owner at this visit. Upon admission a compliance score was independently assigned by two veterinary nurses blinded to treatment. Excess blood from routine blood draw was analysed for gabapentin plasma concentration from cats in the gabapentin group.

Results

There were no significant differences in baseline transport score between groups (P = 0.13), but significant differences were noted in the second visit transport score between cats medicated with gabapentin compared with placebo (P = 0.018). Mean compliance scores were significantly different between cats in the treatment group compared with placebo (P = 0.019). Further sedation was required to complete the procedures in 24% of cats in the placebo group compared to 9% in the gabapentin group (P = 0.25). Mean plasma gabapentin concentrations were 10.1 mg/l (range 1.7–22.7) in the gabapentin group within a 1–3 h time frame post-administration.

Conclusions and relevance

Hyperthyroid cats medicated with 20 mg/kg gabapentin 1 h prior to leaving home were more relaxed during transport and more compliant with veterinary procedures than cats administered a placebo solution.

Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada

OBJECTIVES

Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption.

METHODS

We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics.

RESULTS

The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%).

CONCLUSIONS

Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

A Review of Sedation Agents

The oral and maxillofacial surgery model of anesthesia delivery is the subject of some controversy. However, a long track record of patient safety provides compelling support for the dual role of the oral and maxillofacial surgeon as proceduralist and anesthetist. Among the elements critical to continued success is a clear understanding of the pharmacology of the agents used to produce sedation and general anesthesia. This review highlights 6 sedation agents used as part of a balanced anesthesia technique in oral and maxillofacial surgery.

Update on Medications for Oral Sedation in the Oral and Maxillofacial Surgery Office

Dental anxiety is a leading cause of postponing treatment and/or complete avoidance of professional oral care. Therefore, effective sedation and pain control are integral components of dental care for the fearful and anxious patient. The application of oral sedation aids the trained practitioner to provide care to the anxious dental patient and remains the safest, most established, and most commonly used route of drug administration. Proper training and understanding of pharmacologic properties allows for safe and effective application of analgesics and sedatives for oral sedation.

Sedation and Anesthesia for the Adolescent Dental Patient

This article focuses on sedation/anesthesia of adolescent patients in the dental setting. Preoperative evaluation, treatment planning, monitoring, and management are critical components to successful sedation. The authors discuss commonly administered agents and techniques to adolescents, including nitrous oxide/oxygen analgesia. The levels and spectrum of sedation and anesthesia are reviewed. Common comorbidities are also presented as they relate to sedation of the adolescent dental patient.

Atrial natriuretic peptide (ANP) as an endogenous anxiolytic in patients with heart failure? - No replication of previous results showing an inverse association of anxiety and plasma ANP parameters

OBJECTIVE

An acute anxiolytic-like effect of atrial natriuretic peptide (ANP) has been demonstrated in several preclinical and clinical studies. In a so far singular study (Herrmann-Lingen et al., 2003), patients with congestive heart failure, who pathognomonicly display increased plasma ANP, showed a significant inverse association of anxiety symptoms and pro-ANP levels, giving rise to speculations about ANP as an endogenous anxiolytic. We tried to replicate and extend this preliminary finding.

METHODS

In 56 patients suffering from heart failure with reduced left ventricular ejection fraction we measured ANP, mid-regional pro-ANP (MR-proANP) and cyclic guanosine monophosphate (cGMP) as plasma parameters of ANP functioning and characterized anxiety symptoms using the Hospital Anxiety and Depression Scale (HADS) and in addition the State Trait Anxiety Inventory (STAI) for state anxiety. Spearman rank correlation coefficients were calculated.

RESULTS

None of our plasma ANP parameters showed a significant association with anxiety symptoms as per HADS ratings. The same picture emerged with STAI state anxiety. ANP, MR-proANP and cGMP significantly correlated with each other.

CONCLUSION

In another sample of patients with heart failure we were unable to replicate previous and preliminary cross-sectional findings of low anxiety in subjects with high plasma pro-ANP. Direct measurement of effector hormone ANP and its second messenger as well did not support our hypothesis. Chronically elevated ANP in heart failure might attenuate its potential anxiolytic effects. Longitudinal studies experimentally increasing ANP levels in anxious heart failure patients are needed to test if this approach has clinical psychotropic utility.

A systematic review of the use of virtual reality or dental smartphone applications as interventions for management of paediatric dental anxiety

Background

Virtual reality (VR) has been used successfully in medicine both as a distraction tool during procedures, and as an acclimatisation tool to prepare for a procedure or experience. It has not yet become widely used in dentistry, but could theoretically have a role in exposure-based acclimatisation for dental experiences.

Methods

To examine the use of VR or bespoke dental smartphone applications pre- or perioperatively in dentistry, to decrease anxiety in a paediatric population attending for dental examination or treatment, compared with children/adolescents who receive no intervention, or more conventional behavioural management techniques.

Searches were made of eight electronic databases: the Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE(PubMed), EMBASE, PsycINFO, CINAHL, Scopus and Web of Science. Further searches reference cross‐checks were performed to identify studies that were not discovered online.

Results

Systematic reviews and randomised control trials have demonstrated the successful use of VR to both distract patients perioperatively during medical procedures, and also preoperatively to prepare them for these interventions. However, to date, VR has only been applied to dentistry in a very limited number of studies. Three studies using virtual reality in a dental setting demonstrated decreased pain and anxiety compared with no intervention. All three of these studies were carried out in the perioperative period. A fourth study used a bespoke dental app and imagery to prepare patients with Autism Spectrum Disorder (ASD) for dental treatment, finding statistically significant decreases in both the number of appointments and number of attempts required to carry out a procedure.

Conclusion

VR is a promising tool which to date has been under-utilised in dentistry. High quality, clinical studies are required to assess the use of preoperative VR and smartphone applications to prepare patients for dental examination and procedures under local or general anaesthetic.

The Pediatric Burn: Current Trends and Future Directions

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.

Involvement of the GABAA receptor α subunit in the mode of action of etifoxine

Etifoxine (EFX) is a non-benzodiazepine psychoactive drug which exhibits anxiolytic effects through a dual mechanism, by directly binding to GABA_A receptors (GABA_ARs) and to the mitochondrial 18-kDa translocator protein, resulting in the potentiation of the GABAergic function. The β subunit subtype plays a key role in the EFX-GABA_AR interaction, however this does not explain the anxiolytic effects of this drug. Here, we combined behavioral and electrophysiological experiments to challenge the role of the GABA_AR α subunit in the EFX mode of action. After single administrations of anxiolytic doses (25-50 mg/kg, intraperitoneal), EFX did not induce any neurological nor locomotor impairments, unlike the benzodiazepine bromazepam (0.5-1 mg/kg, intraperitoneal). We established the EFX pharmacological profile on heteropentameric GABA_ARs constructed with α1 to α6 subunit expressed in Xenopus oocyte. Unlike what is known for benzodiazepines, neither the γ nor δ subunits influenced EFX-mediated potentiation of GABA-evoked currents. EFX acted first as a partial agonist on α2β3γ2S, α3β3γ2S, α6β3γ2S and α6β3δ GABA_ARs, but not on α1β3γ2S, α4β3γ2S, α4β3δ nor α5β3γ2S GABA_ARs. Moreover, EFX exhibited much higher positive allosteric modulation towards α2β3γ2S, α3β3γ2S and α6β3γ2S than for α1β3γ2S, α4β3γ2S and α5β3γ2S GABA_ARs. At 20 μM, corresponding to brain concentration at anxiolytic doses, EFX increased GABA potency to the highest extent for α3β3γ2S GABA_ARs. We built a docking model of EFX on α3β3γ2S GABA_ARs, which is consistent with a binding site located between α and β subunits in the extracellular domain. In conclusion, EFX preferentially potentiates α2β3γ2S and α3β3γ2S GABA_ARs, which might support its advantageous anxiolytic/sedative balance.

Comparative Analysis of Intravenous Midazolam with Nasal Spray for Conscious Sedation in Minor Oral and Maxillofacial Surgeries

Aim:

The aim of the current study was to evaluate the efficacy of nasal spray midazolam by collating it with conventional intravenous midazolam for conscious sedation in minor oral surgeries.

Materials and Methods:

Sixty patients were selected randomly and divided into two groups: group A for intranasal midazolam atomized spray (n = 30) and group B for intravenous midazolam (n = 30). Physiological parameters, anxiety score, sedation rating, patient’s cooperation score, and retrograde and anterograde amnesia were recorded for each patient during preoperative, intraoperative, and postoperative period. Final evaluation of safety and efficacy in the nasal and intravenous routes of midazolam drug during minor oral surgery was compared.

Results:

In this study, both intranasal and intravenous groups showed decrease in systolic blood pressure and diastolic blood pressure intraoperatively but within physiological limits and increase in the average pulse rates in both the groups. The average oxygen saturation levels were maintained to normal range in both the groups. The average respiratory rate decreased in both intranasal and intravenous groups during surgical procedure. The preoperative to postoperative anxiety scores were decreased significantly in the both groups and there was no significant difference in pre- to postoperative anxiety scores between the groups.

Conclusion:

Both intravenous and intranasal administration of midazolam showed better patient cooperation, satisfaction, and clinical effectiveness. Intranasal midazolam spray is effective in the reduction of subjective stress, reliable anxiolysis while preserving protective reflexes.

Efficacy and cost savings with the use of a minimal sedation / anxiolysis protocol for intra-articular corticosteroid injections in children with juvenile idiopathic arthritis: a retrospective review of prospectively collected data

BACKGROUND

Intra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution.

METHODS

The MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol.

RESULTS

The procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0-10) reported by the patient was 1 (IQR 0-2.5), by the parent 1 (IQR 0-2), by the rheumatologist 1 (IQR 0-1), and by the sedationist 1 (IQR 0-1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room.

CONCLUSIONS

A minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.

A Comparative Evaluation of the Sedative Effects of Nitrous Oxide-oxygen Inhalation and Oral Midazolam-Ketamine Combination in Children

Aims

To compare nitrous oxide-oxygen inhalation and low dose oral midazolam-ketamine combination for anxiolysis in the management of children aged between 3 to 10 years for dental treatment.

Materials and methods

A comparative clinical study with equal number of subjects in both the groups evaluating efficacy of oral ketamine-midazolam combination and nitrous oxide-oxygen inhalation in children with Frankl behavior rating score 2 and ASA1.

A total of 30 children were equally divided into 2 groups, oral midazolam-ketamine (MK) group which received 0.25mg/ kg midazolam with 3mg/kg ketamine in combination and the Nitrous oxide-oxygen (N) group which received nitrous oxide-oxygen inhalation. The parameters evaluated were the drug/ mask acceptance, need for the use of a physical restraint. Houpt’s sedation scale, faces pain score, sedation duration, time taken to achieve the maximum sedation and adverse reactions were assessed. Student t-test was used for comparison between the groups and proportions were compared using Chi-square test.

Results

The results found no statistically significant differences between the groups in all the parameters except for the duration of sedation and the time taken to achieve maximum sedation which were higher in oral MK group than the Nitrous-oxide oxygen inhalation group.

Conclusion

Both oral-midazolam and ketamine combination and nitrous oxide-oxygen inhalation sedation were found to have similar clinical success among 3 to 10-year-old children in bringing about anxiolysis during dental treatment.

Clinical Significance

Both oral ketamine-midazolam combination, nitrous oxide-oxygen inhalation are equally effective for anxiolysis in children during dental treatment.

How to cite this article: Ilasrinivasan, Setty JV, Shyamachalam, Mendiretta P. A Comparative Evaluation of the Sedative Effects of Nitrous Oxide-oxygen Inhalation and Oral Midazolam-Ketamine Combination in Children. Int J Clin Pediatr Dent., 2018;11(5):399-405.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Oral Pregabalin as Premedication on Anxiolysis and Stress Response to Laryngoscopy and Endotracheal Intubation in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Double-Blind Study

Background

Direct laryngoscopy and tracheal intubation lead to increase in heart rate and blood pressure. This can cause serious complications in patients with coronary artery disease, reactive airways, or intracranial neuropathology. Preoperative anxiety is associated with greater level of postoperative pain. Attenuation of anxiety and hemodynamic response to laryngoscopy and intubation are cornerstone of better anesthetic outcome. Gabapentinoids (gabapentin and pregabalin) have been known to possess anxiolytic, analgesic, and anticonvulsant properties.

Aim

The aim of this study is to determine the effects of oral pregabalin on anxiolysis and attenuation of stress response to laryngoscopy and endotracheal intubation.

Study Design

This was a prospective randomized double-blind placebo controlled study.

Materials and Methods

A total of 60 patients ASA physical status Class I and II, undergoing elective laparoscopic cholecystectomy, were randomly allocated into two groups receiving either oral placebo or oral pregabalin 150 mg, 60 min before induction of anesthesia. Visual analog scale (VAS) for anxiety was recorded before, and 60 min after giving the drug. Hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were recorded before, and 60 min after giving drug, during and 2, 4, 6, 8, and 10 min after intubation.

Results

During preinduction, pregabalin showed a decrease in VAS and attenuation of stress response to laryngoscopy and intubation compared to that of placebo. The premedicated patients were hemodynamically stable perioperatively without side effects.

Conclusion

Pregabalin is effective in attenuating preoperative anxiety and stress response to endotracheal intubation.

Oral Management of Steinert's Disease and Role of Anxiolysis

BACKGROUND

Myotonic dystrophy type I (DM1) is a genetic autosomal dominant disorder; malignant hyperthermia is a possible complication. It may occur following administration of some halogenated general anesthetics, muscle relaxants, or surgical stress.

AIM

The purpose of this case report is to evaluate the dental management of patients with Steinert's disease.

CASE REPORT

The patient needed dental extraction. A locore-gional paraperiosteal anesthesia was performed using bupiva-caine without vasoconstrictor and sedation with nitrous oxide. The syndesmotomy of the elements 3.1, 4.1, and 4.2 was executed. The elements were dislocated through a straight lever and avulsed with an appropriate clamp. The socket was courted, washing with saline solution, inserting a fibrin sponge, and applying sutures (silk 3-0).

CONCLUSION

Dental treatment of the patient with Steinert's dystrophy must be carried out under a hospital environment and the use of local anesthetic without vasoconstrictor and with use of nitrous oxide; anxiolysis is recommended.

CLINICAL SIGNIFICANCE

This case report describes the precautions to perform oral surgery in patients with Steinert's disease and emphasizes the role of anxiolysis to avoid episodes of malignant hyperthermia.

Attaining in vivo selectivity of positive modulation of α3βγ2 GABAA receptors in rats: A hard task!

It is unclear whether GABA_A receptors (GABA_ARs) that contain the α3-subunit are substantially involved in the anxiolytic effects of benzodiazepines (BDZs). In the present study, we tested YT-III-31, a newer BDZ ligand with functional preference for α3βγ2 GABA_ARs, in two paradigms of unconditioned anxiety, the open field and elevated plus maze in rats. The effective dose of YT-III-31 (2 mg/kg) displayed a clear anxiolytic-like profile, unhampered by sedative action, in both tests. At a higher dose (10 mg/kg), YT-III-31 induced ataxia in the rotarod and sedation in spontaneous locomotor activity test. The latter effect was preventable by flumazenil and βCCt, the non-selective and α1βγ2 GABA_AR affinity-selective antagonist, respectively, demonstrating that sedative properties of YT-III-31, when attained, are mediated by the α1γ2 site. To elucidate the receptor substrate of subtle behavioral differences between YT-III-31 and diazepam, we approximated in vivo receptor potentiation for both ligands, based on estimated unbound concentrations in rat brains. Far different from diazepam, YT-III-31 has significantly lower affinity for the α1γ2 over other BDZ-sensitive sites, and at lower doses (1-2 mg/kg) was devoid of potentiation at α1βγ2 GABA_ARs. The approximation approach revealed a modest selectivity of YT-III-31 for α3γ2- in comparison to α2γ2 and α5γ2 binding sites, suggesting that its anxiolytic-like activity may not necessarily or predominantly reflect potentiation at α3βγ2 GABA_ARs. Nonetheless, as the anxiolytic effects are achievable at a dose devoid of any sedative potential, and having favorable safety (cytotoxicity) and metabolic stability profile, YT-III-31 represents a valuable candidate for further translational research.

Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children

PURPOSE

Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED.

OBJECTIVE

To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores.

METHODS

A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction.

RESULTS

112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale.

CONCLUSION

Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.

Gabapentine 300 mg vs. 450 mg as anesthetic premedication for reactive hypertension, anxiety and analgesia

Objective

Observe the behavior of gabapentin to reduce reactive hypertension secondary to anxiety and pain in patients undergoing ophthalmic surgery as well as opioid consumption between groups.

Method

Clinical randomized double blind controlled trial that analyzed 125 patients divided into three groups: Group A, gabapentin 300 mg; Group B, gabapentin 450 mg; and Group C, amaranth dragees as a control 2 h before the surgical procedure. Chi-squared test was used in sociodemographic variables and one-way ANOVA for continuous numeric variables. It was considered as significant a p < 0.05 for a study of two tails with a power of 80% beta.

Results

Anxiety and analgesia intraoperative and postoperative had significant differences between groups. Lower consumption of opioid was found in the groups that used gabapentin.

Conclusions

Gabapentin orally 300 or 450 mg h prior to surgery reduces pain, anxiety and postoperative opioid consumption in patients undergoing ophthalmic surgery.

The Role of Endogenous Oxytocin in Anxiolysis: Structural and Functional Correlates

BACKGROUND

Oxytocin is anxiolytic, and administration of synthetic oxytocin in humans reduces amygdala reactivity to negative stimuli. However, it is unknown whether endogenous oxytocin levels-which are heritable and stable across time-attenuate anxiety via similar mechanisms.

METHODS

In this study, we used plasma assays and structural and functional neuroimaging to examine potential anxiolytic effects of endogenous oxytocin in 73 participants.

RESULTS

We found that higher endogenous oxytocin levels are associated with reduced central amygdala volume and blood oxygen level-dependent activity in response to aversive stimuli. In contrast to previous reports, we found that oxytocin was not related to patterns of functional connectivity between the amygdala and other brain regions.

CONCLUSIONS

Together, our results underscore the importance of considering individual differences in participants' endogenous oxytocin with respect to anxiety-related neural activity and neuromorphology.

Oral Sedation in the Dental Office

This article highlights the commonly used medications used in dentistry and oral surgery. General dentists and specialists must be knowledgeable about the pharmacology of the drugs currently available along with their risks and benefits. Enteral sedation is a useful adjunct for the treatment of anxious adult and pediatric patients. When enteral sedation is used within the standards of care, the interests of the public and the dental profession are served through a cost-effective, effective service that can be widely available. Oral sedation enables dentists to provide dental care to millions of individuals who otherwise would have unmet dental needs.

Investigation of the Anxiolytic and Antidepressant Effects of Eucalyptol (1,8-Cineole), a Compound From Eucalyptus, in the Adult Male Sprague-Dawley Rat

Anxiety and depression are debilitating, costly psychological disorders that account for $133 billion in direct medical expenses per year in the United States. Finding alternative means of treatment to reduce the personal and financial burden for patients with these disorders, while maintaining patient safety, is vital for overall patient wellness. The purposes of this study were 2-fold: (1) to determine if pure eucalyptol (1,8-cineole) produces anxiolytic and/or antidepressant effects using rat models for anxiety and behavioral despair and (2) to determine the effects of eucalyptol at the benzodiazepine site on the γ-aminobutyric acid (GABA) A receptor in the rat central nervous system. Fifty-five male Sprague-Dawley rats were randomly assigned to 1 of 5 groups: vehicle (dimethyl sulfoxide), eucalyptol, midazolam, flumazenil plus eucalyptol, and midazolam plus eucalyptol. Behavioral analyses were conducted on the elevated plus-maze and in the forced swim test. Data were analyzed using a 2-tailed multivariate analysis of variance and a least significant difference post hoc test. Data from the maze suggested eucalyptol may produce anxiolytic effects by acting at the benzodiazepine site on the GABA_A receptor while not affecting psychomotor activity. However, no effects on behavioral despair were demonstrated in the Forced Swim test.

Premedication with melatonin vs midazolam: efficacy on anxiety and compliance in paediatric surgical patients

Preoperative anxiety is a major problem in paediatric surgical patients. Melatonin has been used as a premedicant agent and data regarding effectiveness are controversial. The primary outcome of this randomized clinical trial was to evaluate the effectiveness of oral melatonin premedication, in comparison to midazolam, in reducing preoperative anxiety in children undergoing elective surgery. As secondary outcome, compliance to intravenous induction anaesthesia was assessed. There were 80 children undergoing surgery randomly assigned, 40 per group, to receive oral midazolam (0.5 mg/kg, max 20 mg) or oral melatonin (0.5 mg/kg, max 20 mg). Trait anxiety of children and their mothers (State-Trait Anxiety Inventory) at admission, preoperative anxiety and during anaesthesia induction (Modified Yale Pre-operative Anxiety Scale), and children's compliance with anaesthesia induction (Induction Compliance Checklist) were all assessed. Children premedicated with melatonin and midazolam did not show significant differences in preoperative anxiety levels, either in the preoperative room or during anaesthesia induction. Moreover, compliance during anaesthesia induction was similar in both groups.

CONCLUSIONS

This study adds new encouraging data, further supporting the potential use of melatonin premedication in reducing anxiety and improving compliance to induction of anaesthesia in children undergoing surgery. Nevertheless, further larger controlled clinical trials are needed to confirm the real effectiveness of melatonin as a premedicant agent in paediatric population. What is Known: • Although midazolam represents the preferred treatment as a premedication for children before induction of anaesthesia, it has several side effects. • Melatonin has been successfully used as a premedicant agent in adults, while data regarding effectiveness in children are controversial. What is New: • In this study, melatonin was as effective as midazolam in reducing children's anxiety in both preoperative room and at induction of anaesthesia.

Comparison of Intranasal Dexmedetomidine with Intranasal Clonidine as a Premedication in Surgery

OBJECTIVES

To compare effectiveness of intranasal dexmedetomidine and clonidine as anxiolytics and sedatives in pediatric patients undergoing various surgeries.

METHODS

This double blind randomized placebo controlled study was conducted on 105 surgical patients of American Society of Anesthesiologist (ASA) physical status І-ІІ, aged between 2 and 9 y in a tertiary-care hospital (February 2014 to September 2015). Participants were randomly allocated to three groups to receive either intranasal dexmedetomidine 2 μg/kg (Group І) or intranasal clonidine 3 μg/kg (Group ІІ) or intranasal saline 0.5 ml (Group ІІІ). The primary outcome measure was proportion of patients with satisfactory anxiolysis and sedation at 30 min after drug administration. Secondary outcome measures included time taken to achieve Aldrete score of 9 and number of doses of rescue analgesia required in 12 h after surgery.

RESULTS

Satisfactory anxiolysis was achieved by 88.5% in Group І vs. 60% in Group ІІ (p = 0.001) and satisfactory sedation by 57.1% in Group І vs. 25.7% in Group ІІ (p = 0.001) 30 min after premedication. Rescue analgesia requirement was significantly less in Group І as compared to Group ІІ (p = 0.001) while time taken to achieve Aldrete score was comparable between the study groups (p = 0.185).

CONCLUSIONS

Intranasal dexmedetomidine is a better anxiolytic and sedative as compared to clonidine. Postoperative analgesic requirement was also significantly decreased after intranasal dexmedetomidine. Thus, it can be preferred as compared to clonidine for premedication in pediatric surgical patients.

The Potential Role of Amygdaloid MicroRNA-494 in Alcohol-Induced Anxiolysis

BACKGROUND

The antianxiety effects of ethanol appear to be a crucial factor in promoting alcohol intake. Regulation of gene expression by microRNA (miRNA) is an important epigenetic mechanism that affects neuronal pathways and behaviors. We investigated the role of miRNAs underlying the mechanisms of ethanol-induced anxiolysis.

METHODS

Acute ethanol-induced anxiolysis was measured in adult rats, and amygdaloid tissues were used for miRNA profiling by microarray analysis. The expression of miR-494 and its target genes in the amygdala was measured using real-time quantitative polymerase chain reaction. The direct role of miR-494 in the anxiety phenotype was also investigated via infusion of a miR-494 antagomir into the central nucleus of amygdala.

RESULTS

Microarray profiling of miRNAs in the amygdala showed significant alteration of several miRNA expression levels by acute ethanol exposure. Expression of miR-494 was significantly decreased, whereas expression of the binding protein of cyclic adenosine monophosphate response element binding protein (CBP), p300, and Cbp/p300-interacting transactivator 2 (Cited2) was increased in the amygdala during ethanol-induced anxiolysis. Inhibition of miR-494 in the central nucleus of amygdala, through infusion of a specific antagomir, provoked anxiolysis, mimicking the action of ethanol. Also, expression of Cited2, CBP, and p300 as well as histone H3-lysine 9 acetylation was significantly increased by miR-494 antagomir infusion, indicating their regulation by miR-494 in the amygdala.

CONCLUSIONS

These novel results suggest that acute ethanol-induced reduction in miR-494 expression in the amygdala can serve as a key regulatory mechanism for chromatin remodeling possibly leading to anxiolysis.

Midazolam plasma concentration after anesthesia premedication in clinical routine - an observational study : Midazolam plasma concentration after anesthesia premedication

BACKGROUND

Midazolam is commonly used as a pre-anesthesia anxiolytic. It`s elimination may not be fast enough for short procedures. In orally premedicated patients we obtained midazolam plasma concentrations at the end of surgical procedures and compared those to concentrations at anesthesia induction.

METHODS

The study was conducted prospectively with consent of the local ethics committee (Ethikkomission Kanton Thurgau, Switzerland) and carried out with written informed consent of each patient. Female patients aged 20 to 60 years undergoing elective procedures with general anesthesia were included, and were divided in two groups according to the planned surgical time: group S (<30 min) and group L (90-120 min), respectively. All patients received 7.5 mg Midazolam po as premedication. Blood samples were drawn at anesthesia induction, and at the end of surgery. Data were compared with t-test (independent samples; significance level p <0.05).

RESULTS

Twenty-five patients per group were included. Four patients were excluded from analysis, since midazolam was not detectable in any samples. Time of premedication to the 1st blood sample was not statistically different between groups, neither were Midazolam plasma levels at this time point (p = 0.94). None of the patients from group L (n = 24), but five patients in group S (n = 22) did have a higher plasma level of Midazolam at the end of the case compared to the beginning.

CONCLUSIONS

The elimination half-life of oral Midazolam can lead to higher plasma levels at the end of a short procedure compared to those at induction of anesthesia.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00005429 ; date of registration 3^rd January 2014.

Benzodiazepine and neuroactive steroid combinations in rats: anxiolytic-like and discriminative stimulus effects

RATIONALE

Benzodiazepines are effective anxiolytics, hypnotics, and anticonvulsants but unwanted side effects, including abuse potential, limit their use. A possible strategy to increase the therapeutic index of this drug class is to combine benzodiazepines with neuroactive steroids.

OBJECTIVES

The present study evaluated the extent to which combinations of benzodiazepines (triazolam, clonazepam) and neuroactive steroids (pregnanolone, ganaxolone) induced additive, supra-additive, or infra-additive effects in an elevated zero maze and a drug discrimination procedure in rats.

METHODS

Male Sprague-Dawley rats (N = 7/group) were placed into an elevated zero maze apparatus following injections of multiple doses of triazolam and pregnanolone, alone and combined, or clonazepam and ganaxolone, alone and combined. These drugs/drug combinations also were evaluated in rats (N = 8) trained to discriminate triazolam (0.1 mg/kg, i.p.) from vehicle. Drug interactions were evaluated using isobolographic and dose-addition analysis.

RESULTS

In the elevated zero maze, all drugs engendered dose-dependent increases in time spent in the open quadrant when administered alone. Triazolam and pregnanolone, as well as clonazepam and ganaxolone combinations produced additive or supra-additive effects depending on the fixed-proportion that was tested. In triazolam discrimination, all drugs engendered dose-dependent increases in triazolam-lever responding. In combination, triazolam and pregnanolone and clonazepam and ganaxolone produced predominantly additive discriminative stimulus effects, except for one fixed proportion of clonazepam and ganaxolone which had supra-additive effects.

CONCLUSIONS

Although drug interactions depended on the constituent drugs, the combination tested, and the behavioral endpoint; a combination was identified that would be predicted to result in supra-additive anxiolytic-like effects with predominantly additive discriminative stimulus effects.

Cortical and subcortical gamma amino acid butyric acid deficits in anxiety and stress disorders: Clinical implications

Anxiety and stress disorders are a major public health issue. However, their pathophysiology is still unclear. The gamma amino acid butyric acid (GABA) neurochemical system has been strongly implicated in their pathogenesis and treatment by numerous preclinical and clinical studies, the most recent of which have been highlighted and critical review in this paper. Changes in cortical GABA appear related to normal personality styles and responses to stress. While there is accumulating animal and human neuroimaging evidence of cortical and subcortical GABA deficits across a number of anxiety conditions, a clear pattern of findings in specific brain regions for a given disorder is yet to emerge. Neuropsychiatric conditions with anxiety as a clinical feature may have GABA deficits as an underlying feature. Different classes of anxiolytic therapies support GABA function, and this may be an area in which newer GABA neuroimaging techniques could soon offer more personalized therapy. Novel GABAergic pharmacotherapies in development offer potential improvements over current therapies in reducing sedative and physiologic dependency effects, while offering rapid anxiolysis.

Ethnopharmacology of Souroubea sympetala and Souroubea gilgii (Marcgraviaceae) and identification of betulinic acid as an anxiolytic principle

The neotropical lianas Souroubea gilgii and Souroubea sympetala (Marcgraviaceae) were chosen for study as part of a phytochemical discovery strategy focusing on rare plant families in Central America. In participatory research, Q'eqchi' healers in Belize reported the use of these plants to reverse psychological symptoms inflicted by witchcraft. Extracts of two Souroubea species showed significant anti-anxiety activity in the elevated plus maze, a standardized test paradigm. Bioassay guided isolation led to the active principle, the pentacyclic triterpene, betulinic acid, which had activity in the elevated plus maze at 0.5mg/kg. Other phytochemicals isolated included α- and β-amyrin, 2-hydroxyursolic acid, taraxenyl trans-4-hydroxy-cinnamate, naringenin, methyl ursolate, eriodytiol, methyl 2-α-hydroxyursolate, methyl 2-α-hydroxymaslinate, methyl betulinate, and condrilla sterol.

Preoperative anxiolysis in pediatric population: A comparative study between oral midazolam and oral ketamine

Context:

Preoperative anxiety is synonymous with pediatric surgery. Anxiolysis is of crucial importance and poses a significant challenge to the pediatric anesthesiologist. Orally administered midazolam and ketamine can be used as anxiolytic premedication in children.

Aim:

To compare the efficacy of orally administered midazolam and ketamine for preoperative sedation and anxiolysis in children and determine the minimum interval required between premedication and parental separation.

Setting and Design:

Prospective, randomized, double-blind study.

Materials and Methods:

A total of 70 children aged 2-8 years, belonging to ASA grade 1 and 2, scheduled to undergo elective infraumbilical and peripheral surgeries were randomized into two groups of 35 each to receive either midazolam (0.5 mg/kg) or ketamine (5 mg/kg) orally. They were assessed at an interval of 5 minutes up to 40 minutes, at the time of parental separation, intravenous cannulation, and application of face mask for ventilation. Sedation was noted according to Ramsay Sedation Scale and anxiolysis was noted according to Anxiolysis Scores used in previous published studies.

Statistical Analysis Used:

Skewed data between groups were analyzed by Mann Whitney U Test. Data within a group were analyzed using Friedman's Analysis of variance and a post hoc test.

Results:

No statistically significant difference in sedation and anxiolysis scores were obtained between the groups at any point of time. Maximum sedation score was achieved at 20 minutes in both the groups, with no statistically significant difference with scores obtained thereafter. Statistically significant difference occurred in anxiolysis score at study points in group receiving midazolam.

Conclusion:

The study documents the rapid achievement of preoperative sedation and anxiolysis in children with orally administered midazolam or ketamine, with the latter producing a superior quality of anxiolysis. An interval of 20 minutes is sufficient between premedication and parental separation.

New evidence of ethanol's anxiolytic properties in the infant rat

Ethanol induces appetitive, aversive, and anxiolytic effects that are involved in the development of ethanol use and dependence. Because early ethanol exposure produces later increased responsiveness to ethanol, considerable effort has been devoted to analysis of ethanol's appetitive and aversive properties during early ontogeny. Yet, there is a relative scarcity of research related to the anxiolytic effects of ethanol during early infancy, perhaps explained by a lack of age-appropriate tests. The main aim of this study was to validate a model for the assessment of ethanol's anxiolytic effects in the infant rat (postnatal days 13-16). The potentially anxiolytic effects of ethanol tested included: i) amelioration of conditioned place aversion, ii) ethanol intake in the presence of an aversive conditioned stimulus, iii) the inhibitory behavioral effect in an anxiogenic environment, and iv) innate aversion to a brightly illuminated area in a modified light/dark paradigm. Ethanol doses employed across experiments were 0.0, 0.5, and 2.0 g/kg. Results indicated that a low ethanol dose (0.5 g/kg) was effective in attenuating expression of a conditioned aversion. Ethanol intake, however, was unaffected by simultaneous exposure to an aversive stimulus. An anxiogenic environment diminished ethanol-induced locomotor stimulation. Finally, animals given 0.5 g/kg ethanol and evaluated in a light/dark box showed increased time spent in the illuminated area and increased latency to escape from the brightly lit compartment than rats treated with a higher dose of ethanol or vehicle. These new results suggest that ethanol doses as low as 0.5 g/kg are effective in ameliorating an aversive and/or anxiogenic state in preweanling rats. These behavioral preparations can be used to assess ethanol's anxiolytic properties during early development.

Pediatric ambulatory anesthesia

Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. The relative merits of caudal and dorsal penile nerve block for pain after circumcision are also discussed.

Comparative evaluation of midazolam and butorphanol as oral premedication in pediatric patients

Background:

To compare oral midazolam (0.5 mg/kg) with oral butorphanol (0.2 mg/kg) as a premedication in 60 pediatric patients with regards to sedation, anxiolysis, rescue analgesic requirement, and recovery profile.

Materials and Methods:

In a double blinded study design, 60 pediatric patients belonging to ASA class I and II between the age group of 2–12 years scheduled for elective surgery were randomized to receive either oral midazolam (group I) or oral butorphanol (group II) 30 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of facemask application for induction of anesthesia. Rescue analgesic requirement, postoperative recovery, and complications were also recorded.

Results:

Butorphanol had better sedation potential than oral midazolam with comparable anxiolysis at the time of separation of children from their parents. Midazolam proved to be a better anxiolytic during venepuncture and facemask application. Butorphanol reduced need for supplemental analgesics perioperatively without an increase in side effects such as nausea, vomiting, or unpleasant postoperative recovery.

Conclusion:

Oral butorphanol is a better premedication than midazolam in children in view of its excellent sedative and analgesic properties. It does not increase side effects significantly.

A comparison of midazolam and clonidine as an oral premedication in pediatric patients

Background:

To compare oral midazolam (0.5 mg/kg) versus oral clonidine (4 μg/kg) as a premedication in pediatric patients aged between 2-12 years with regard to sedation and anxiolysis.

Methods:

Sixty pediatric patients belonging to the American Society of Anesthesiologists class I and II between the age group of 2-12 years scheduled for elective surgery were randomly allocated to receive either oral midazolam (group I) 30 min before induction or oral clonidine (group II) 90 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of mask application for induction of anesthesia.

Results:

After premedication, the percentage of children who were sedated and calm increased in both the groups. The overall level of sedation was better in the children in the clonidine group, but children in the midazolam group had a greater degree of anxiolysis at times of venepuncture and mask application. In addition, midazolam did not cause significant changes in hemodynamics unlike clonidine where a significant fall in blood pressure was noted, after premedication, but preinduction.

Conclusion:

We conclude that under the conditions of the study, oral midazolam is superior to clonidine as an anxiolytic in pediatric population. Clonidine with its sedative action especially at the time of separation from parents along with its other perioperative benefits cannot be discounted.

A comparison of equisedative infusions of propofol and midazolam for conscious sedation during spinal anesthesia - a prospective randomized study

BACKGROUND

Supplemental sedation with an intravenous agent is often required to allay fear and anxiety in patients subjected to spinal anesthesia .We studied and compared the properties of propofol and midazolam as equisedative continuous infusions. PATIENTS #ENTITYSTARTX00026;

METHODS

100, ASA grade 1 and 2 patients, 18 to 60 years of age, undergoing spinal anesthesia, were randomly allocated to receive either propofol 1mg/ml or midazolam 0.1mg/ml in 50ml syringes through syringe pump. The infusion rates were titrated in order to maintain a desired sedation score of 4 on the Observer's assessment of alertness/ sedation scale. Anxiety score was assessed at regular intervals by a single observer in all cases, using a 100mm visual analog scale.Intraoperative and postoperative amnesia was assessed using visual task of recall of pictures and verbal task of recall of words.

RESULTS

Propofol infusion was found to be superior to that of midazolam as it showed a statistically significant faster onset in achieving the desired sedation score, significantly lower mean anxiety scores, a clear headed, rapid recovery and significantly lesser postoperative impairment of recall, but midazolam infusion was seen to be associated with deeper intraoperative amnesia over the former which was beneficial.

CONCLUSION

Equisedatine infusion of propofol & midazolam as an adjunct & spinal anesthesia offer good anxiolysis and cardio respiratory stability. Propofol her faster onset & recovery while midazolam provides better intraoperative annesia.