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Benzocaine-induced methemoglobinemia is a potentially life-threatening complication. We report two cases of methemoglobinemia due to topical benzocaine spray used as premedication for transesophageal echocardiography. A high index of suspicion is needed for this readily treatable condition.
Colonoscopy is often disturbed by poor patient tolerance; benzodiazepines or opiates are routinely used to overcome such problems, despite the possibility of undesired effects. Tramadol, an opiate analogue with potentially fewer side effects, has not been tested yet to this end. The aim of the study was therefore to evaluate the efficacy of tramadol as a premedication for the colonoscopic procedure. Fifty patients were randomly allocated to receive an i.v. infusion of 100 ml saline, with 100 mg tramadol or alone, before endoscopy. At the end of the procedure patients were asked to score the discomfort experienced and to give an exam evaluation. The endoscopist also analyzed his performance. Tramadol patients reported a pain score of 39 +/- 10 (mean +/- SE), compared to 45 +/- 8 for the placebo group (P = 0.25); the evaluation of endoscopy was also similar (tramadol, 66 +/- 12; placebo, 70 +/- 9; P = 0.15). The endoscopist also reported a similar score (65 +/- 4 after tramadol; 69 +/- 4 after placebo; P = 0.2). No significant sex- or age-related differences were detected. We conclude that tramadol, at least as a monotherapy, seems scarcely effective for controlling pain evoked by colonoscopy.
Changes in body temperature were recorded in freely moving rats given phosphate-buffered saline or leukocytic pyrogen (interleukin-1) while the animals were in an infant incubator maintained at 25.5 +/- 0.5 degrees C. The leukocytic pyrogen increased body temperature by at least 1 degree C within 1 h. This rise in temperature was prevented by premedication with indomethacin (10 mg/kg) but not dexamethasone (0.5 mg/kg) given 15 min before the leukocytic pyrogen. Local rates of glucose utilization were measured in 47 regions of the central nervous system. In none of the regions previously reported to have an increased rate of glucose utilization associated with an ambient temperature of 32.5 degrees C (McCulloch et al., 1982b) was an increase found in the present experiments. It was concluded that the intensity of the changes in local cerebral glucose utilization in response to the fever caused by the leukocytic pyrogen was insufficient to be measured. Neither indomethacin nor dexamethasone caused remarkable changes in rates of local glucose utilization.
OBJECTIVE: To determine the safety and efficacy of midazolam premedication to minimize the subjective adverse effects of adenosine. METHODS: Double-blind prospective randomized controlled trial of patients presenting to an urban emergency department. Included were a convenience sample of patients who would have received adenosine by the existing department protocol. Exclusion criteria were pregnancy, benzodiazepine allergy, regular benzodiazepine medication, alcoholism, altered mental state (precluding informed consent), and age less than 18 or greater than 65 years. Subjects received either 1.5 mg of intravenous midazolam or normal saline placebo 5 min prior to the administration of adenosine. Side-effect recall was judged by a questionnaire at 1 h and 24 h postadenosine administration. RESULTS: A total of 34 patients were recruited into the trial, 16 in the placebo group and 18 in the midazolam group. The groups were well matched for demographics, treatment and outcome. There was a significant reduction in the midazolam group for complaint scores of palpitations (P = 0.04) and chest pain (P = 0.02) and a trend to reduction in complaint scores for most other parameters. There were no adverse outcomes in any of the patients studied. CONCLUSIONS: Co-administration of midazolam can safely reduce the recall of the unpleasant adverse effects of adenosine. Its use may be most appropriate in patients who are particularly anxious or have had previous adverse experiences with adenosine.
The purpose of this study was to evaluate various doses of sublingual midazolam premedication in children. In our prospective, double-blind, placebo-controlled trial, children (n = 102, age range 12 to 129 months) scheduled for day surgery were randomized to receive either midazolam in one of three doses (0.25, 0.5, or 0.75 mg.kg-1) or placebo. Injectable midazolam was mixed with a thick grape syrup and placed under the tongue; the patient was asked to hold it as long as possible before swallowing. Children readily accepted the mixture. Analysing all patients randomized, none of the children receiving placebo vs 28% receiving 0.25 mg.kg-1 (P = 0.02), 52% receiving 0.5 mg.kg-1 (P < 0.001), and 64% receiving 0.75 mg.kg-1 (P < 0.001) of midazolam showed satisfactory sedation (drowsy) at 15 min after administration. Children receiving the two higher doses of midazolam (0.5 and 0.75 mg.kg-1) accepted mask induction willingly, while the group receiving 0.25 mg.kg-1 resembled the placebo group (P < 0.05).
BACKGROUND: We sought to determine the influence of preoperative oral midazolam on: (i) measures of anaesthetic emergence; (ii) recovery times and (iii) intraoperative bispectral index (BIS) measurements during sevoflurane/N2O anaesthesia in paediatric patients. METHODS: Fifty-two patients, aged 1-10 years, ASA I-II, were enrolled in a prospective double-blinded study. Patients were randomized to receive either midazolam 0.5 mg.kg(-1) (M) or midazolam vehicle (P) as premedication. After inhalation induction and intubation, expired sevoflurane was stabilized at 3% in 60% N2O and the corresponding BIS (BIS I) recorded. At the completion of surgery, sevoflurane was stabilized at 0.5% and the BIS (BIS E) again recorded. Awakening time, expired sevoflurane/N2O awakening concentrations and recovery times were recorded. RESULTS: There were no significant differences between groups in awakening time, sevoflurane or N2O awakening concentrations, time to PACU discharge, time to hospital discharge or in BIS I and BIS E measurements.
Flunitrazepam or diazepam with atropine and a combination of phenoperidine, droperidol and cyclizine (neuroleptanalgesia) were compared as premedication in three groups of 25 patients undergoing routine upper gastrointestinal endoscopy. Drug doses were titrated carefully against response and all three regimes were found to be similar in terms of safety, patient co-operation, relaxation and speed of recovery. Neuroleptanalgesia however produced a statistically significant rise in endtidal pCO2 and systolic blood pressure. The benzodiazepines, and in particular flunitrazepam, produced a significantly greater amnesia for the procedure, patients given these drugs being more willing to undergo repeat endoscopy.
In a double blind study 30 male patients subjected to peroral endoscopy were given 0.5 mg glucagon (G) and 50 mg pethidine plus 0.5 mg atropine (PA) intravenously for premedication. The results showed that the PA group of patients had less discomfort, vomiting, salivary and gastric secretion during the examination than the G group. The arrestment of motility was significantly more prolonged in the G group of patients; otherwise no difference was found regarding the relaxation of the antrum, pylorus and duodenal bulb. This suggests glucagon to be superior to pethidine plus atropine when examinating these regions except in anxious patients which probably should have a sedative in addition to glucagon as premendication for peroral endoscopy.
BACKGROUND: Inhalation of l-menthol inhibits cough and has been shown to reduce respiratory discomfort associated with loaded breathing. We investigated the effect of the inhalation of a 1% l-menthol solution in the premedication of fiberoptic bronchoscopy (FB) on the frequency of cough and the irritability of the tracheobronchial mucosa during FB in a blinded, randomized and placebo controlled study. METHODS: 64 pat. (30-78 yrs, 55 males) underwent routine FB. Premediction: atropine and hydrocodone s.c., inhalation of oxybuprocain by means of a jet nebulizer, sedation on demand. Verum-group: inhalation of 3 ml 1% l-menthol-solution. Placebo-group: 3 ml 0.05% l-menthol (to provide the typical smell). Before and after inhalation peak respiratory flow (PEF) was registered, during FB the frequency of cough was measured. The bronchoscopist scored the irritability of the tracheobronchial mucosa using a visual analog scale. The patients answered a questionnaire addressing their perception of dyspnea and cough on the day after FB compared to the day before. RESULTS: The cough counts didn't show a significant difference between the groups. The irritability of the mucosa was increased in the verum group (main bronchus verum 62.2 +/- 22, placebo 48.6 +/- 23 [mm vissual analog scale, p = 0.03]). Cough and dyspnea reported by the patients decreased on the day after FB significantly compared to the day before (no difference between the groups). The inhalation of 1% l-menthol induced a significant increase of the PEF (verum 307 +/- 103 pre, 329 +/- 84 post [l/min, p = 0.003]) compared to placebo. CONCLUSIONS: The inhalation of 1% l-menthol did not enhance the tolerability of the FB. However, l-menthol induced a significant increase of the PEF immediately after inhalation. Finally sensation of dyspnea was decreased in both groups at the day post FB.
Two commercially available preparations of dimethycon with different galenic properties (Paractol flüssig, Sab simplex) were tested for their usefulness as a premedication for abdominal sonography. According to the recommendations of the manufacturers each of 20 patients was pretreated with four different galenic preparations of the two substances that were administered in a randomly assigned sequence. 13 abdominal regions of interest were investigated for visualisation of organs and gas interposition. Both groups of drugs clearly improved the quality of imaging of the abdominal vessels and the epigastric structures, but Paractol proved to have significantly better effects. This is possibly due to a higher dosage of dimethycon in Paractol.
A double-blind study was carried out to compare the effects of a premedication with 4 x 500 mg dimethylpolysiloxane (DPS)/24 hours and with 2 x 500 mg/12 hours before abdominal ultrasonography. The investigations covered 13 abdominal regions in specified planes. The incidence of the unobscured presentation of the selected organs and organ sections per patient served as a basis for a sonography index. This index was 67%, without significant difference between the two groups. We believe that the optimal conditions for sonography are given when the patient is fasting and two 500 mg doses of DPS are administered, one in the evening before and one in the morning at the day of investigation.
A rare hyperkinetic syndrome in a child after premedication with Thalamonal has been known for some time. The triad: unconsciousness, opisthothonus and conjugate deviation should be considered by surgeon and anesthetist and it looks like the somnolent-ophthalmoplegic-hyperkinetic type of Economo's Encephalitis lethargica. The therapy is simple: 1 ml Biperiden i.v.
Intravenous urography using Telebrix was performed on 500 patients. Two hundred patients (group I) received no pre-medication; 300 patients (group II) were premedicated with H1 and H2 receptor antagonists. All patients were examined for signs of contrast reactions, blood pressure, pulse rate and plasma histamine levels. These were measured before and three minutes after the administration of the antihistamine substances and/or the contrast medium, and also at the end of the examination. Following the administration of H1 and H2 receptor antagonists, a slight, transient and insignificant rise in plasma histamine could be demonstrated. Both groups showed a significant rise in plasma histamine levels after the injection of the contrast medium. Although the pre-medicated group contained a higher percentage of high risk patients, there were significantly fewer patients with contrast reactions. Pre-medication with H1 and H2 receptor antagonists in high risk patients is therefore advisable.
The aim of this study was to evaluate the efficacy and toxicity of paclitaxel given at the same dose intensity and administered weekly (arm A) or every 3 weeks (arm B). and to assess the safety of intravenous steroids versus standard peroral premedication. Two hundred and eight patients with advanced ovarian cancer previously treated with no more than one platinum-containing regimen were randomized to receive either a weekly infusion of paclitaxel or an infusion every 3 weeks. The median delivered dose intensity was 77.6 mg/m2/week in the weekly arm, and 72.7 mg/m2/week in the every 3 weeks arm. WHO grade 3-4 hematological and non-hematological toxicity occurred more frequently in arm B. No difference in number of severe events of hypersensitivity, response rate, time to progression or survival between arms was observed. Weekly paclitaxel at a dose of 67 mg/m2/week was found to have a better safety profile and seemed to be as effective as the equivalently dosed schedule every 3 weeks. Intravenous steroids are a safe alternative to oral steroids.
An oral preparation of dichloralphenazone and paracetamol (Paedosed) was used as an alternative premedication to i.m. morphine and atropine in 562 children undergoing day-care surgery. From a series of observations made, both in hospital and at home, it appears that morphine has several disadvantages when compared with this mixture, provided that the latter is supplemented with i.v. analgesia for the more painful procedures.
In 14 intubated, spontaneously breathing children with body weight (bw) ranging from 8.3 to 25.6 kg, the influence of midazolam 0.1 mg kg-1 i.m. (group M0.1, n = 7) and 0.2 mg kg-1 i.m. (group M0.2, n = 7) as premedication, on sedation, ventilation, ventilatory response to carbon dioxide and hormonal stress response was studied in connection with minor surgical procedures during halothane anaesthesia. The concentrations of catecholamines, ACTH and cortisol were measured immediately after induction, during undisturbed anaesthesia, during surgery and 15 min after the end of the surgical procedure. Sedation was better and plasma catecholamine concentrations during undisturbed anaesthesia were less in children receiving the larger dose of midazolam. During surgery and in recovery there were no differences in hormone concentrations. In recovery, the concentrations of all hormones were significantly greater compared with during undisturbed anaesthesia. During surgery, VE and respiratory rate were somewhat lower in group M0.2 while E' CO2 was similar. A dose dependent depression of the response to carbon dioxide was found. However, clinically, the ventilatory response to carbon dioxide after surgery was considered to be adequate in both groups.
The effects of i.m. dexmedetomidine 1.0 micrograms kg-1, a new alpha 2-adrenoceptor agonist, were compared with those of i.m. midazolam 0.08 mg kg-1 and placebo on vigilance, anaesthetic requirements, haemodynamic state and plasma catecholamine concentrations in a double-blind placebo-controlled study in 107 healthy (ASA physical status I-II) women undergoing cervical dilatation and uterine curettage. The premedicants were administered i.m. 60 min before induction of anaesthesia with thiopentone. Nitrous oxide 70% in oxygen and thiopentone were used for maintenance. Both premedicants were tolerated well and no serious haemodynamic or other adverse events occurred. Dexmedetomidine caused moderate reductions in arterial pressure (maximally by 20%) and heart rate (maximally by 15%). Atropine was administered to two dexmedetomidine-premedicated patients because of bradycardia less than 45 beat min-1. Both premedicants decreased the plasma concentrations of noradrenaline by about 50%, but only dexmedetomidine attenuated the catecholamine response to anaesthesia and surgery. The thiopentone requirements were decreased significantly (P = 0.003) by both dexmedetomidine (17%) and midazolam (19%). Recovery times were 11.3 (SD 4.2) min after midazolam, 8.5 (5.2) min after dexmedetomidine and 5.6 (11.4) min after placebo (P = 0.006 between midazolam and placebo groups, other differences ns).
We have compared the incidence of postoperative nausea and vomiting up to 48 h after day-case gynaecological laparoscopy after oral premedication with ondansetron 4 mg, metoclopramide 10 mg or a placebo allocated randomly and assessed blindly. Emetic symptoms (nausea or vomiting) occurred in 26% of patients who received ondansetron, 42% of those who received metoclopramide and 50% of those given placebo.