• Title/Summary/Keyword: Intravenous midazolam

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Safe Sedation and Hypnosis using Dexmedetomidine for Minimally Invasive Spine Surgery in a Prone Position

  • Kim, Kyung Hoon
    • The Korean Journal of Pain
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    • v.27 no.4
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    • pp.313-320
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    • 2014
  • Dexmedetomidine, an imidazoline compound, is a highly selective ${\alpha}_2$-adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties. In order to minimize the patients' pain and anxiety during minimally invasive spine surgery (MISS) when compared to conventional surgery under general anesthesia, an adequate conscious sedation (CS) or monitored anesthetic care (MAC) should be provided. Commonly used intravenous sedatives and hypnotics, such as midazolam and propofol, are not suitable for operations in a prone position due to undesired respiratory depression. Dexmedetomidine converges on an endogenous non-rapid eye movement (NREM) sleep-promoting pathway to exert its sedative effects. The great merit of dexmedetomidine for CS or MAC is the ability of the operator to recognize nerve damage during percutaneous endoscopic lumbar discectomy, a representative MISS. However, there are 2 shortcomings for dexmedetomidine in MISS: hypotension/bradycardia and delayed emergence. Its hypotension/bradycardiac effects can be prevented by ketamine intraoperatively. Using atipamezole (an ${\alpha}_2$-adrenoceptor antagonist) might allow doctors to control the rate of recovery from procedural sedation in the future. MAC, with other analgesics such as ketorolac and opioids, creates ideal conditions for MISS. In conclusion, dexmedetomidine provides a favorable surgical condition in patients receiving MISS in a prone position due to its unique properties of conscious sedation followed by unconscious hypnosis with analgesia. However, no respiratory depression occurs based on the dexmedetomidine-related endogenous sleep pathways involves the inhibition of the locus coeruleus in the pons, which facilitates VLPO firing in the anterior hypothalamus.

CONSCIOUS SEDATIVE DRUGS: A CLINICAL STUDY (의식하 진정에 사용된 약물에 관한 임상적 연구)

  • Kim, Sang-Ryul;Kim, Su-Gwan;Yeo, Hwan-Ho
    • Maxillofacial Plastic and Reconstructive Surgery
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    • v.22 no.4
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    • pp.436-441
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    • 2000
  • The purpose of this retrospective study is to investigate the effects of conscious sedation in an outpatient setting. Data from 292 patients (154 males, 138 females), sedated for minor oral surgery, were studied using various parameters including age and sex distribution, as well as according to procedures and each drug group. Results show that this intravenous conscious sedation technique is a safe and effective method of controlling behaviour, but one has to be prepared to deal with any emergencies or complications. The specific results are as follows: 1. Most procedures (265/292) were used to Valium mixed with Demerol and Midazolam mixed with Demerol. 2. Valium revealed a high incidence of pain upon injection and symptoms limited to daily activity and thrombophlebitis. 3. Nausea and vomiting manifested in the procedure using Demerol. 4. The patient manifested comfort similar in response to the same drugs used in another treatment.

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Propofol and Fentanyl Compared with Midazolam and Morphine for Conscious Sedation During Surgical Extraction of Bilateral Mandibular Impacted Third Molars (양측 하악 매복지치 동시 발치를 위한 의식하 진정의 비교 연구: Propofol, Fentanyl과 Diazepam, Morphine)

  • Kim, Young-Kyun;Chae, Byung-Kook;Choi, Hyun-Kyu
    • Journal of The Korean Dental Society of Anesthesiology
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    • v.3 no.2 s.5
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    • pp.87-91
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    • 2003
  • Background: The purpose of this study was to compare the availability of propofol and fentanyl (P + F) with diazepam and morphine (D + M) for intravenous conscious sedation during third molar surgery. Methods: Forty patients without systemic disease were operated under IV conscious sedation administered by either of the two techniques. Monitoring consisted of continuous observation of pulse rate, blood pressure, oxygen saturation, and the respiratory rate and were recorded every 15 minutes. Cooperation score was measured 5 and 15 minutes after induction of IV sedation. Following the operation, the surgeon and patients completed questionnaires including pain visual analog scale, amnesia, and side effects. Results: The P + F group was significantly more cooperative than the D + M group. The side effects of D + M group included pain on injection, nausea/vomiting and abdominal pain. The side effects of P + F group included talkativeness, nausea/vomiting, temporary apnea, pain on injection and vertigo. Conclusions: In this study, there were following benefits in the P + F group; more cooperative status and less pain perception. But respiratory depression developed in some patients.

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Managing the behavior of a patient with autism by sedation via submucosal route during dental treatment

  • Jo, Chan-Woo;Park, Chan-Hee;Lee, Jong-Hyug;Kim, Ji-Hun
    • Journal of Dental Anesthesia and Pain Medicine
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    • v.17 no.2
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    • pp.157-161
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    • 2017
  • In sedation via the submucosal route, the drug is administered through the maxillary buccal submucosa. It is time saving, effective, and safe. Patients with autism, a mental disorder, often find it hard to make relationships with other people. These patients display a strong resistance to dental treatment and sedation. This study reports a successful case of behavioral management during dental treatment, using sedation via the submucosal route. The patient was strongly resistant to sedation via the oral, intramuscular, and intravenous routes. The drug used was 9 mg (0.1 mg/kg) of midazolam. Through this case report, we reaffirm the significance of sedation via the submucosal route, and expect that it will be used more frequently for patients with autism, who display behaviors that are difficult to manage, patients with other disabilities, and children.

Propofol as an Adjuvant in the Treatment of Cancer-Related Pain -A case report- (암성 통증 관리에 사용된 부가적 진통제로서의 Propofol -증례 보고-)

  • Han, Tae-Hyung;Hwang, Won-Gyoon
    • The Korean Journal of Pain
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    • v.10 no.1
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    • pp.117-120
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    • 1997
  • Cancer is a devastating disease, and the treatment of related pain is an extremely challenging task. Providing adequate analgesia while avoiding unnecessary drug effects often requires a polypharmacologic approach in cancer pain management. A 36-year old woman with breast cancer metastatic to the axial skeleton and bilateral hip joints was admitted to hemato-oncology service with complaints of intractable abdominal and hip pain. Despite rapidly increasing doses of intravenous morphine up to 350 mg per day; transdermal fentanyl; midazolam; ketorolac; lorazepam; dexamethasone, the patient continued to describe her pain as 10 of 10, refusing all surgical/diagnostic interventions not directly related to pain control. She did, however, consent to lumbar epidural catheter placement. The patient was sedated with titrating doses of propofol to assist with positioning. Even though the procedure was not successful due to significant thoracolumbar scoliosis, the patient admitted feeling better than she has in months during attempted placement. After continuous infusion of propofol was initiated at subhypnotic dose, the patient's analgesic demand was drastically reduced and described her pain as "1 to 3" of "10". Approximately 96 hours after the propofol infusion was started, the patient expired comfortably. There had been no change in her medical regimen during fecal 48 hours. In the case described, propofol was extremely advantageous as an adjuvant in the management of cancer related pain.

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Investigation of Efficacy of Lidocaine Spray for Sedated Esophagogastroduodenoscopy in Children

  • Basturk, Ahmet;Artan, Reha;Yilmaz, Aygen
    • Pediatric Gastroenterology, Hepatology & Nutrition
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    • v.20 no.2
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    • pp.87-93
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    • 2017
  • Purpose: Our aim in this study is to investigate efficacy of topical lidocaine spray for sedated esophagogastroduodenoscopy (EGD) in children. Methods: The endoscopy of children aged between 3-18 years who underwent EGD in our endoscopy unit. Intravenous (IV) midazolam and ketamine were used for sedation. Prior to sedation, endoscopy nurse applied topical lidocaine 10% with pump spray at 1 mg/kg dose in group 1, and distilled water via identically scaled pump spray in group 2, in a double blinded fashion. Results: Sedation was not applied in 24.1% of the cases in topical lidocaine spray group (LS group) and in 5.7% of the cases in distilled water spray group (DS group). Gag reflex was observed in 6.5% of cases in LS group and 33.3% of cases in DS group (p=0.024), increased oral secretion was observed in 9.3% of cases in LS group and 51.7% of cases in DS group (p=0.038), sore throat was observed in 3.7% of cases in LS group and 35.6% of cases in DS group (p=0.019) and the difference was statistically significant. Conclusion: The study showed that topical pharyngeal lidocaine reduces both requirement and amount of IV sedation before EGD in children and sore throat, gag reflex and decreased oral secretion increase.

Variability in Drug Interaction According to Genetic Polymorphisms in Drug Metabolizing Enzymes

  • Jang, In-Jin;Yu, Kyung-Sang;Cho, Joo-Youn;Chung, Jae-Yong;Kim, Jung-Ryul;Lim, Hyeong-Seok;Shin, Sang-Goo
    • Environmental Mutagens and Carcinogens
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    • v.24 no.1
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    • pp.15-18
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    • 2004
  • There are significant differences in the extent of drug interactions between subjects. The influence of the genetic make up of drug metabolizing enzyme activities (CYP3A5, CYP2C19 and UDP-glucuronosyl transferase) on the pharmacokinetic drug interaction potential were studied in vivo. Nineteen healthy volunteers were grouped with regard to the $CYP3A5^{*}3$ allele, into homozygous wild-type (CYP3A5^{*}1/1^{*}1$, n=6), heterozygous $(CYP3A5^{*}1/^{*}3$, n=6), and homozygous variant-type $(CYP3A5^{*}3/^{*}3$, n=7) subject groups. The pharmacokinetic profile of intravenous midazolam was characterized before and after itraconazole administration (200 mg once daily for 4 days), and also following rifampin pretreatment (600 mg once daily for 10 days), with a washout period of 2 weeks in between. For omeprazole and moclobemide pharmacokinetic interaction study 16 healthy volunteers were recruited. The volunteer group comprised 8 extensive metabolizers and 8 poor metabolizers of CYP2C19, which was confirmed by genotyping. Subjects were randomly allocated into two sequence groups, and a single-blind, placebo-controlled, two-period crossover study was performed. In study I, a placebo was orally administered for 7 days. On the eighth morning, 300 mg of moclobemide and 40 mg of placebo were coadministered with 200 mL of water, and a pharmacokinetic study was performed. During study n, 40 mg of omeprazole was given each morning instead of placebo, and pharmacokinetic studies were performed on the first and eighth day with 300 mg of moclobemide coadministration. In the UGT study pharmacokinetics and dynamics of 2 mg intravenous lorazepam were evaluated before and after rifampin pretreatment (600 mg once daily for 10 days), with a washout period of 2 weeks in between. The subjective and objective pharmacodynamic tests were done before and 1, 2, 4, 6, 8, and 12 hrs after lorazepam administration. The pharmacokinetic profiles of midazolam and of its hydroxy metabolites did not show differences between the genotype groups under basal and induced metabolic conditions. However, during the inhibited metabolic state, the $CYP3A5^{*}3/^{*}3$ group showed a greater decrease in systemic clearance than the $CYP3A5^{*}1/^{*}1$ group $(8.5\pm3.8$ L/h/70 kg vs. $13.5\pm2.7$ L/h/70 kg, P=0.027). The 1'-hydroxymidazolam to midazolam AUC ratio was also significantly lower in the $CYP3A5^{*}3/^{*}3$,/TEX> group $(0.58\pm0.35,$ vs. $1.09\pm0.37$ for the homozygous wild-type group, P=0.026). The inhibition of moclo-bemide metabolism was significant in extensive metabolizers even after a single dose of omeprazole. After daily administration of omeprazole for 1 week, the pharmacokinetic parameters of moclobemide and its metabolites in extensive metabolizers changed to values similar to those in poor metabolizers. In poor meta-bolizers, no remarkable changes in the pharmacokinetic parameters were observed. The area under the time-effect curves of visual analog scale(VAS), choice reaction time, and continuous line tracking test results of lorazepam was reduced by 20%, 7%, 23% respectively in induced state, and in spite of large interindividual variablity, significant statistical difference was shown in VAS(repeated measures ANOVA, p=0.0027).

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Variability in Drug Interaction According to Genetic Polymorph isms in Drug Metabolizing Enzymes

  • Jang, In-Jin;Yu, Kyung-Sang;Cho, Joo-Youn;Chung, Jae-Yong;Kim, Jung-Ryul;Lim, Hyeong-Seok;Shin, Sang-Goo
    • Environmental Mutagens and Carcinogens
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    • v.23 no.4
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    • pp.131-134
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    • 2003
  • There are significant differences in the extent of drug interactions between subjects. The influence of the genetic make up of drug metabolizing enzyme activities (CYP3A5, CYP2C19 and UDP-glucuronosyl transferase) on the pharmacokinetic drug interaction potential were studied in vivo. Nineteen healthy volunteers were grouped with regard to the $CYP3A5^{*}3$ allele, into homozygous wild-type (CYP3A5^{*}1/1^{*}1$, n=6), heterozygous $(CYP3A5^{*}1/^{*}3$, n=6), and homozygous variant-type $(CYP3A5^{*}3/^{*}3$, n=7) subject groups. The pharmacokinetic profile of intravenous midazolam was characterized before and after itraconazole administration (200 mg once daily for 4 days), and also following rifampin pretreatment (600 mg once daily for 10 days), with a washout period of 2 weeks in between. For omeprazole and moclobemide pharmacokinetic interaction study 16 healthy volunteers were recruited. The volunteer group comprised 8 extensive metabolizers and 8 poor metabolizers of CYP2C19, which was confirmed by genotyping. Subjects were randomly allocated into two sequence groups, and a single-blind, placebo-controlled, two-period crossover study was performed. In study I, a placebo was orally administered for 7 days. On the eighth morning, 300 mg of moclobemide and 40 mg of placebo were coadministered with 200 mL of water, and a pharmacokinetic study was performed. During study n, 40 mg of omeprazole was given each morning instead of placebo, and pharmacokinetic studies were performed on the first and eighth day with 300 mg of moclobemide coadministration. In the UGT study pharmacokinetics and dynamics of 2 mg intravenous lorazepam were evaluated before and after rifampin pretreatment (600 mg once daily for 10 days), with a washout period of 2 weeks in between. The subjective and objective pharmacodynamic tests were done before and 1, 2, 4, 6, 8, and 12 hrs after lorazepam administration. The pharmacokinetic profiles of midazolam and of its hydroxy metabolites did not show differences between the genotype groups under basal and induced metabolic conditions. However, during the inhibited metabolic state, the $CYP3A5^{*}3/^{*}3$ group showed a greater decrease in systemic clearance than the $CYP3A5^{*}1/^{*}1$ group $(8.5\pm3.8$ L/h/70 kg vs. $13.5\pm2.7$ L/h/70 kg, P=0.027). The 1'-hydroxymidazolam to midazolam AUC ratio was also significantly lower in the $CYP3A5^{*}3/^{*}3$,/TEX> group $(0.58\pm0.35,$ vs. $1.09\pm0.37$ for the homozygous wild-type group, P=0.026). The inhibition of moclo-bemide metabolism was significant in extensive metabolizers even after a single dose of omeprazole. After daily administration of omeprazole for 1 week, the pharmacokinetic parameters of moclobemide and its metabolites in extensive metabolizers changed to values similar to those in poor metabolizers. In poor meta-bolizers, no remarkable changes in the pharmacokinetic parameters were observed. The area under the time-effect curves of visual analog scale(VAS), choice reaction time, and continuous line tracking test results of lorazepam was reduced by 20%, 7%, 23% respectively in induced state, and in spite of large interindividual variablity, significant statistical difference was shown in VAS(repeated measures ANOVA, p=0.0027).

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A Survey of Sedation Practices in the Korean Dentistry (치과 치료 시 진정법 시행에 대한 실태 조사 연구)

  • Bae, Chi-Hoon;Kim, Hyuk;Cho, Kyoung-Ah;Kim, Mi-Seon;Seo, Kwang-Suk;Kim, Hyun-Jeong
    • Journal of The Korean Dental Society of Anesthesiology
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    • v.14 no.1
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    • pp.29-39
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    • 2014
  • Background: Dental phobia or anxiety of patients is the serious impediment to appropriate and effective dental treatment. Sedative technique helps to mitigate patients' fear and anxiety thus make them more cooperative and familiar to dental practices. With increasing attention to sedative dentistry in dentists, educational requirements and technical qualification also become stricter but actual survey on recent sedative dentistry has not been reported yet. Especially there is insufficient study reporting the survey of sedative dentistry subjected to Korean adults. In this paper, we conducted a survey study on the actual condition and practice related to sedation with a questionnaire to dentists in South Korea. Methods: The survey was done for members of The Korean Dental Society of Anesthesiology (KDSA), who had great interest in sedation and for whom survey-by-mail was convenient. 472 members of The KDSA having dental license and solid address and contact information were subjected to the survey by sending them survey questions about their sedative techniques and knowledge. In order to increase the response rate, small gifts were presented to those who accurately responded to the survey questions and text messages and phone calls were made to encourage their participation. We collected their responses over two months and examined the returned surveys. Statistical analysis was performed using IBM SPSS Statistics 21 for each question. Results: Out of 472 dentists, 181 responded (38.4% response rate). 63.0% (114 dentists; 77 male and 37 female) of respondents had experience on sedative technique and their average age was $39.8{\pm}7.6$ year. 74 of them were private practitioners, 17 of them were professors (14.9%), 11 of them were dentists-in-service (9.6%), 11 of them were residents (specialist training) (9.6%) and 1 of them was military doctors (0.9%). There were 89 dentists (78.1%) who were specialists or receiving trainings to be specialist, most of whom were pediatric dentists (55, 48.2%) and oral surgeon (31, 27.2%). The most popular route for drug medications was orderly oral, inhalational, intravenous medication. Combination of oral and inhalational medications or single use of intravenous medication was the most common. The most preferred sedative drug was pocral in oral sedation and midazolam in intravenous sedation. 48.2% of practitioners responded that they experienced side effects and emergency situations. Airway obstruction was the most frequent. Conclusions: Results from the survey show that the protocol and system for sedative dentistry have been improved compared to the past. Nevertheless, quality of emergency protocol, monitoring devices and preparation of sedative drugs was still insufficient to achieve safe sedative procedure. This study acquires novelty since actual survey on recent sedative dentistry for adult patients has not been reported yet.

Efficacy of ketamine in the treatment of migraines and other unspecified primary headache disorders compared to placebo and other interventions: a systematic review

  • Chah, Neysan;Jones, Mike;Milord, Steve;Al-Eryani, Kamal;Enciso, Reyes
    • Journal of Dental Anesthesia and Pain Medicine
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    • v.21 no.5
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    • pp.413-429
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    • 2021
  • Background: Migraine headaches are the second leading cause of disability worldwide and are responsible for significant morbidity, reduction in the quality of life, and loss of productivity on a global scale. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of ketamine on migraines and other primary headache disorders compared to placebo and other active interventions, such as midazolam, metoclopramide/diphenhydramine, and prochlorperazine/diphenhydramine. Methods: An electronic search of databases published up to February 2021, including Medline via PubMed, EMBASE, Web of Science, and Cochrane Library, a hand search of the bibliographies of the included studies, as well as literature and systematic reviews found through the search was conducted to identify randomized controlled trials (RCTs) investigating ketamine in the treatment of migraine/headache disorders compared to the placebo. The authors assessed the risk of bias according to the Cochrane Handbook guidelines. Results: The initial search strategy yielded 398 unduplicated references, which were independently assessed by three review authors. After evaluation, this number was reduced to five RCTs (two unclear risk of bias and three high risk of bias). The total number of patients in all the studies was 193. Due to the high risk of bias, small sample size, heterogeneity of the outcomes reported, and heterogeneity of the comparison groups, the quality of the evidence was very low. One RCT reported that intranasal ketamine was superior to intranasal midazolam in improving the aura attack severity, but not duration, while another reported that intranasal ketamine was not superior to metoclopramide and diphenhydramine in reducing the headache severity. In one trial, subcutaneous ketamine was superior to saline in migraine severity reduction; however, intravenous (I.V.) ketamine was inferior to I.V. prochlorperazine and diphenhydramine in another study. Conclusion: Further double-blind controlled studies are needed to assess the efficacy of ketamine in treating acute and chronic refractory migraines and other primary headaches using intranasal and subcutaneous routes. These studies should include a long-term follow-up and different ketamine dosages in diagnosed patients following international standards for diagnosing headache/migraine.