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PubMed1989

Inadvertent diagnosis of pheochromocytoma after endoscopic premedication.

Hypertensive crisis in a patient with pheochromocytoma can be induced by endoscopy premedication. Opiates, glucagon, and metoclopramide are commonly used in the gastrointestinal laboratory and capable of releasing catecholamines from a pheochromocytoma. Patients who have just had endoscopy can display untoward effects such as nausea, weakness, and diaphoresis. Such patients should probably have their blood pressure carefully recorded. Although hypotension is expected, endoscopists should be alert to the finding of severe hypertension and consider pheochromocytoma. The need for this becomes even greater considering that primary gastrointestinal endoscopy is often being done in doctor's offices away from hospitals and more acute resuscitative resources. In the case reported, a life-threatening hypertensive crisis was induced by fentanyl. The hypertensive crisis was correctly ascribed to pheochromocytoma, enabling institution of lifesaving treatment.

Adrenal Gland Neoplasms↗

PubMed1982

Histamine release in anaesthesia and surgery. premedication with H1- and H2-receptor antagonists: indications, benefits and possible problems.

Our clinical and experimental studies have so far demonstrated, that the drugs used in anaesthesia; such as hypnotics, sedatives, narcotics or muscle relaxants, release histamine. The intravenous short acting anaesthetic etomidate has not shown either in experimental studies or in clinical use for 10 years any anaphylactoid reaction. The benzodiazepines are another group of drugs which appear not to release high amounts of histamine. Accurate studies on volunteers as well as on patients on the application of H1- and H2-receptor antagonists have demonstrated an effective inhibition of the anaphylactoid reaction. We suggest that in case of a history of allergy H1- and H2-receptor antagonists should be administered as a prophylactic premedication.

Adjuvants, Anesthesia↗

PubMed1983

Zomepirac as an analgesic premedication: a comparison of three dosage regimens.

Three regimens of oral zomepirac premedication - 100 mg and 200 mg administered one hour preoperatively, and 100 mg administered 30 minutes preoperatively - were compared in terms of the control of postoperative pain. Primary outcomes were postoperative analgesic requirements, pain intensities and side effects. Sixty patients undergoing laparoscopic sterilization by Fallop ring were studied, using a double blind randomized design. All patients received a standardized general anaesthetic in which narcotic supplementation was avoided. Zomepirac 100 mg, when administered 30 minutes preoperatively, was the preferred regimen in terms of postoperative remedication rates, pain intensity, and side effects. However, the overall rate of remedication was high and was probably a result of the severe pain experienced by these patients in the early postoperative period. Plasma levels of zomepirac at termination of anaesthesia were consistent with the differences in remedication profiles and showed significant correlations with initial postoperative pain intensity, as assessed by an ordinal descriptive scale (r = 0.431, p = 0.025) and time to remedication (r = 0.541, p = 0.004), thus adding validity to the model.

Adult↗

PubMed1985

Refraining from cigarette smoking before premedication does not decrease the risk of acid pulmonary aspiration during anaesthesia.

Seventy-four habitual smokers who had refrained overnight from cigarette smoking and were undergoing elective orthopedic surgery were allocated randomly to two groups in order to investigate the effect of smoking two cigarettes before premedication on volume and pH of gastric contents. The smoking group was allowed to smoke two cigarettes while the non-smoking group was not allowed to smoke. There was no significant difference in volume or pH between the groups, either just after intubation or prior to extubation, thus indicating no decreased risk of acid pulmonary aspiration because of refraining acutely from cigarette smoking.

Adolescent↗

PubMed1984

Effect of cimetidine premedication on morphine-induced ventilatory depression.

The potential respiratory interaction between morphine and cimetidine was studied by determining resting ventilation, PETCO2 and ventilatory response to added carbon dioxide in eight healthy volunteers on three separate occasions following administration of : (1) cimetidine 600 mg p.o., (2) morphine 10 mg IM, (3) morphine 10 mg IM preceded by cimetidine 600 mg p.o. Individual entry into the study was randomized and separated by at least one week. All measurements were determined at time 0, 30, 60, 120, 180, 240, 360, 480, 600, 720 minutes and at the end of 24 hours. In addition, serum morphine levels were measured in six subjects during the first six hours following morphine administration. Cimetidine alone had negligible respiratory effects. Morphine alone reduced resting ventilation, elevated PETCO2 and reduced the ventilatory response to added CO2, while the morphine-cimetidine combination caused a more profound depression of the CO2 response and delay in its recovery. No significant difference between resting ventilation and PETCO2 was observed. We conclude that cimetidine premedication interacts with morphine to prolong the respiratory depression but the magnitude of this interaction is small and clinically insignificant in healthy subjects. Caution, however, should be exercised in susceptible patients.

Adult↗

PubMed1995

[Multidimensional psychometric assessment of preoperative mood. Effects of zolpidem compared to phenobarbital combined with promethazine as premedication].

The following double-blind, randomised study dealt with three questions: (1) Is a multidimensional psychometric rating scale suitable for the measurement of mood before anaesthesia? (2) What are the effects of the new benzodiazepine-like drug zolpidem on preoperative mood compared with phenobarbital? (3) Is the combination with Promethazine suggestive? METHODS. Three hundred and four patients were assigned to four groups (group 1: zolpidem 8.03 mg/promethazine 50 mg; group 2: zolpidem 8.03 mg/placebo; group 3: phenobarbital 100 mg/promethazine 50 mg; group 4: phenobarbital 100 mg/placebo). The drugs were given the evening before anaesthesia (09:30-10:00 p.m.). The sample was shifted by age and sex. Mood was measured by a multidimensional rating scale, which assessed aspects of elated mood, anxiety, hostility, deactivation, vigilance, and introversion. Statistics were performed using analysis of variance (ANOVA). RESULTS. Zolpidem led to significantly higher expressions of hostility (negative mood, irritability, aggressiveness) than phenobarbital. Compared with placebo, promethazine led to greater deactivation (more tiredness and numbness, lower level of wakefulness). Specific emotions and somatic aspects were not affected. Patients who had received promethazine received a lower dose of thiopentone for induction of anaesthesia than patients with placebo. CONCLUSIONS. Zolpidem and phenobarbital have many common effects on preoperative mood. Differences were found in the unspecific emotional aspects of agitation and hostility. These negative effects must be weighed against the pharmacokinetic and pharmacodynamic advantages of zolpidem when this drug is administered for premedication. The effects of zolpidem seem to be more sedative than anxiolytic. The study shows that a combination with promethazine is suggestive, because promethazine has a selective deactivating effect. The finding that promethazine lowers the dose of thiopentone required for induction of anaesthesia is an additional interesting point. The results of this study highlight the importance of using multidimensional rating scales for the measurement of mood before anaesthesia.

Adolescent↗

PubMed1993

Premedication and pain relief with Nubain during second trimester therapeutic pregnancy terminations.

OBJECTIVE: To determine the analgesic efficacy of the opioid agonist-antagonist Nubain during midtrimester therapeutic terminations with intra-amniotic PGF2 alpha or i.m. administration of the PGE2 derivative sulprostone. METHOD: Following osmotic predilatation with laminaria tents patients were given as a premedication 10 mg Valium, 10 mg Nubain and 0.5 mg atropine i.m. prior to prostaglandin treatment, and sequential doses of Nubain during the uterine contractility period. Patients indicated their own perception of uterine pain on a differential graphic rating scale, and the attending physician also evaluated patients' discomfort on a 5-grade scale. RESULT: In 55% of the cases patients experienced only 'mild' or 'moderate' pain. The mean induction-to-abortion interval was short (11.6 +/- 1.3 h). The well known gastrointestinal side-effects of the prostaglandins were avoided. CONCLUSION: Nubain proved effective in stabilizing patients' condition during intra-amniotic instillation of prostaglandin, effectively relieved uterine pain during the myometrial contractility period, prevented the occurrence of prostaglandin-related side-effects, and provided simple and good anesthesia during instrumental removal of the already detached but retained placenta.

Abortion, Therapeutic↗

PubMed1990

Nalbuphine hydrochloride (Nubain, DuPont) as premedication for radiological procedures.

Nalbuphine hydrochloride, a semi-synthetic agonist antagonist opioid, has been used in an intravenous injection of 20 mg followed by Diazemuls not less than five minutes later as a premedication in 462 patients undergoing a range of radiological procedures over a 2 year period. In all but two patients excellent sedation was obtained and there were no episodes of respiratory depression nor cardiovascular disturbances.

Adult↗

PubMed1983

Efficacy of atropine as an endoscopic premedication.

To determine the efficacy of atropine as an endoscopic premedication, we prospectively evaluated in double-blind fashion 196 elective endoscopies performed on 189 consecutive consenting patients. Group 1 (95 endoscopies) received meperidine, 1.5 mg/kg, intramuscularly 30 min prior to endoscopy. Group 2 (101 endoscopies) additionally received atropine, 0.6 mg, in the same injection. Endoscopy was performed by one of two investigators using a 13-mm fiberoptic instrument. Endoscopists and patients filled out postendoscopy questionnaires. Both endoscopists (p less than 0.01) and patients (p less than 0.05) noted less oral secretions after atropine. Endoscopists noted less gastric motility after atropine (p less than 0.05) and guessed correctly whether or not atropine had been given in two thirds of cases. They noted no overall difference, however, in the ease of the endoscopy (p greater than 0.05). Moreover, there were no differences in the patients' assessments of the acceptability of the procedure between the two groups (p greater than 0.05). We concluded that although atropine does not improve patients' tolerance for the examination or the endoscopists' ability to do an adequate examination, it does objectively decrease the amount of gastric motility and oral secretions. This latter effect could potentially decrease the hazard of aspiration, but such a benefit could not be demonstrated in our series.

Adolescent↗

PubMed1987

Low dose aminophylline accelerates recovery from diazepam premedication for digestive endoscopy.

The value of intravenous aminophylline in accelerating recovery from premedication with diazepam was assessed against placebo in a randomized, double-blind trial. One hundred ten patients undergoing routine diagnostic upper gastrointestinal endoscopy received diazepam intravenously in a dosage sufficient to achieve adequate sedation. On completion of the endoscopy, patients received either aminophylline (1.5 mg/kg) or placebo. Recovery from sedation was assessed on clinical grounds by a nurse, objectively using a serial reaction time test, and by the patient on a visual analogue scale. The number of patients judged to be fully alert at 30 and 60 min after the procedure was significantly greater in the aminophylline group than in the placebo group. Compared with values obtained before sedation, the placebo group had significantly prolonged reaction times 30 min after completion of the endoscopy, whereas patients who received aminophylline did not. However, according to their self-assessments, patients in both groups felt more uncoordinated following sedation. Aminophylline appears to hasten recovery from sedation with diazepam, and its use may permit earlier mobilization of patients after endoscopy.

Adult↗

PubMedDate not supplied

Midazolam versus diazepam as premedication for upper gastrointestinal endoscopy: a randomized, double-blind, crossover study.

The effectiveness of midazolam as premedication for upper gastrointestinal endoscopy was examined and compared with that of diazepam in a double-blind crossover study involving 23 patients. The degree of sedation and cooperation of patients during the procedure and the speed of recovery from sedation were comparable for the two drugs. The effects of both compounds on arterial blood pressure and heart rate were quite similar. However, midazolam induced significantly more amnesia than diazepam (91% vs. 39%). Also, patients' acceptability for the procedure was significantly higher in the midazolam than in the diazepam group (78% vs. 26%). Therefore, when amnesia is desirable, as in the case of repeated endoscopies, midazolam should be the drug of choice.

Adult↗

PubMed1996

Pharmacokinetics of propofol infusions, either alone or with ketamine, in sheep premedicated with acepromazine and papaveretum.

The pharmacokinetics of propofol were investigated in two groups of five Scottish blackface sheep undergoing surgery for the implantation of subcutaneous tissue pouches. After premedication with acepromazine and papaveretum, anaesthesia was induced with either propofol at 4 mg kg-1 intravenously (group 1) or with a mixture of propofol at 3 mg kg-1 and ketamine at 1 mg kg-1 intravenously (group 2). Anaesthesia was maintained with a variable infusion rate of either propofol alone (group 1) or propofol and ketamine (group 2). Both regimens produced satisfactory conditions for superficial surgery of the body surface. The mean (SD) duration of anaesthesia was 64.8 (3.1) minutes for group 1 and 60 (0) minutes for group 2; the mean total dose of propofol given to the sheep in group 1 was 801 (84) mg, and the sheep in group 2 received 470 (46) mg of propofol and 267 (30) mg of ketamine. The mean elimination half-life of propofol was 56.6 (13.1) minutes in group 1 and 50.3 (21.4) minutes in group 2; the mean volume of distribution at steady state was 1.037 (0.480) litre kg-1 in group 1 and 1.515 (0.939) litre kg-1 in group 2; the mean body clearance was 85.4 (28.0) ml kg-1 min-1 in group 1 and 128.0 (35.0) ml kg-1 min-1 in group 2; the mean residence time corrected for a bolus injection was 12.1 (4.2) minutes in group 1 and 11.9 (6.6) minutes in group 2; for the infusion, the mean residence time was 72.1 (4.2) minutes in group 1 and 69.9 (7.9) minutes in group 2. There were wide variations in the blood propofol concentrations reached in individual sheep by using this standard dosing regimen. All the sheep recovered quickly from anaesthesia; the mean times to extubation, sternal recumbency and standing for the animals in group 1 were 2.8 (0.4), 6.3 (1.2) and 10.9 (1.6) minutes from the end of the infusion, and the times for group 2 were 5.3 (0.9), 11.2 (1.7) and 15.1 (2.2) minutes.

Acepromazine↗

PubMed1996

Simultaneous infusions of propofol and ketamine in ponies premedicated with detomidine: a pharmacokinetic study.

The pharmacokinetics of propofol and ketamine administered together by infusion were investigated in four ponies. Blood propofol and plasma ketamine and norketamine concentrations were measured by high performance liquid chromatography. After premedication with detomidine (20 micrograms kg-1) anaesthesia was induced with ketamine (2.2 mg kg-1 intravenously). The trachea was intubated and the ponies were allowed to breathe 100 per cent oxygen. A bolus dose of propofol (0.5 mg kg-1) was then administered intravenously and propofol and ketamine were infused for 60 and 45 minutes, respectively. The average mean infusion rate of propofol was 0.136 mg kg-1 min-1, and the ketamine infusion rate was maintained at 50 micrograms kg-1 min-1. The mean (SD) elimination half-lives of propofol and ketamine were 69.0 (8.0) and 89.8 (26.7) minutes, the mean volumes of distribution at steady state were 0.894 (0.161) litre kg-1 and 1.432 (0.324) litre kg-1; the mean body clearances were 33.1 (4.5) and 23.9 (3.8) ml kg-1 min-1 and the mean residence times for the infusion were 87.1 (4.1) and 110.7 (8.2) minutes, respectively. Norketamine, the main metabolite of ketamine, was detected throughout the sampling period. The mean residence time for norketamine was 144 (16) minutes. All the ponies recovered quickly from the anaesthesia; the mean times to sternal recumbency and standing were 11.1 (5.3) and 30.0 (20.8) minutes, respectively, from the end of the infusion.

Anesthetics, Dissociative↗

PubMed1980

Patients appreciate premedication for endoscopy.

Upper gastrointestinal endoscopy without sedation by means of a small diameter (9 mm) instrument is feasible but patients often remember the procedure as unpleasant, do not wish to have it repeated, and compare it unfavourably with a barium meal. In contrast, endoscopy with a larger instrument (13 mm) after diazepam sedation is usually well tolerated and often regarded as no more uncomfortable than a barium meal. Even when a narrow instrument is used, patients still benefit from premedication with diazepam, although return to normal activity is slower because of drowsiness.

Barium Sulfate↗

PubMed1984

[Premedication using intrarectal midazolam. Study of effective dosage in pediatric anesthesia].

The object of this study was to determine the optimal dose of midazolam given per rectum which would produce sedation adequate for inducing inhalational anaesthesia in paediatric practice. Five doses were studied: 0.15, 0.25, 0.30, 0.35 and 0.40 mg X kg-1. The criteria used to appreciate the effectiveness of the sedation at 30 min were the change in the child's behaviour, with a scale of 6 levels, and the acceptance of the mask and anaesthetic vapours. There was a significant correlation between the dose administered and the degree of sedation, as well as between the dose administered and the lack of reaction to the mask. Significantly better results were found with the higher doses of 0.35 and 0.40 mg X kg-1, when compared with the children who had received 0.15 and 0.25 mg X kg-1. Only in the groups who received 0.35 and 0.40 mg X kg-1 were the degrees of sedation and acceptance of induction considered as adequate. The dose of 0.35 mg X kg-1 seemed to be the best dose for adequately premedicating a child.

Age Factors↗

PubMed1997

Sublingual lorazepam as premedication in peribulbar anesthesia.

PURPOSE: To assess the efficacy of sublingual lorazepam in inducing amnesia when used as a premedication for peribulbar anesthesia. SETTING: Department of Ophthalmology in a large district general hospital. METHODS: Following local ethical committee approval, a prospective, randomized, placebo-controlled, double-blind study of patients having routine cataract or glaucoma surgery under local anesthetic was undertaken. Patients older than 90 years of age or who were frail, confused, or unfit for surgery were excluded, as were those who weighed less than 50 kg, swallowed the tablet, or had missing data. Sixty volunteer patients were randomly given 1 mg of lorazepam or a placebo tablet by sublingual route 1 hour preoperatively. All patients were assessed for sedation, akinesia, intraoperative analgesia, and patient response including amnesia. RESULTS: There was no significant difference between groups in sedation, analgesia, or akinesia. Overall patient response was better in the lorazepam group (P = .05). Patient-reported incidence of amnesia was significantly higher in the lorazepam than in the placebo group (P < .05). CONCLUSIONS: Sublingual lorazepam improved patient comfort by inducing amnesia, and in the low dose used in this study, did not adversely affect surgery by undue heavy sedation.

Administration, Sublingual↗

PubMed2000

Effects of oral clonidine premedication on side effects of intravenous ketamine anesthesia: a randomized, double-blind, placebo-controlled study.

STUDY OBJECTIVE: To determine the effects of oral clonidine premedication on hemodynamic changes during the entire course of ketamine anesthesia and incidence of postoperative adverse reactions. DESIGN: Randomized, prospective, double-blind, placebo-controlled study. SETTING: Department of Anesthesiology, University of Tsukuba Hospital, Ibaraki, Japan. PATIENTS: 39 ASA physical status I and II patients undergoing superficial surgeries. INTERVENTIONS: Placebo, clonidine 2.5 micrograms/kg, and clonidine 5 micrograms/kg groups received respective doses of oral clonidine 90 minutes prior to surgery. Anesthesia was induced with ketamine 2 mg/kg intravenously (i.v.), trachea was intubated, and anesthesia was maintained with 67% nitrous oxide, oxygen, and supplemental ketamine (1 mg/kg) when systolic blood pressure and heart rate (HR) exceeded 180 mmHg and 100 bpm, respectively. MEASUREMENTS AND MAIN RESULTS: In the clonidine 2.5 micrograms/kg group, HR response to tracheal intubation was significantly less, while in the clonidine 5 micrograms/kg group both mean arterial pressure and HR responses were significantly suppressed, compared with the placebo group. Intraoperative coefficients of variations of HR were significantly less in both clonidine groups than the placebo group. Incidence of nightmare and degree of salivation were significantly less in the clonidine 5 micrograms/kg group than in the placebo group. CONCLUSION: Oral clonidine 2.5 micrograms/kg and clonidine 5 micrograms/kg attenuates cardiostimulatory effects, while clonidine 5 micrograms/kg was associated with reduced incidence and severity of nightmare and salivation attributable to i.v. ketamine.

Administration, Oral↗

PubMed2006

Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department.

INTRODUCTION: Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department. METHODS: We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) > 85 mm Hg. Contraindications to fentanyl included MAP < 85 mm Hg or allergy to fentanyl. RESULTS: Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (+/- standard deviation) was 52.3+/-20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%-91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%-46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of delta 2 mcg/kg, which is the lower limit considered effective. CONCLUSIONS: Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.

British Columbia↗