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At least 991 records · Page 55Linked to original sources
PubMed1997

Prilocaine/lidocaine patch as a local premedication for skin biopsy in children.

BACKGROUND: Prilocaine-lidocaine emulsion (EMLA) has been used successfully as a local anesthetic in patients undergoing superficial procedures. OBJECTIVE: The purpose of this study was to investigate the analgesic effect of the patch as a local anesthetic for children undergoing a skin biopsy procedure. The effect on both the pain at the injection site and the pain of the biopsy was investigated. METHODS: The study was randomized, double blinded, and placebo controlled. Of the 63 children randomly recruited into the study, 60 children were evaluated; the remaining three were withdrawn from the study. RESULTS: The anesthetic patch was significantly more effective than the placebo patch in decreasing pain at the injection site. No significant difference in pain scores of the biopsy procedure was found between the study groups. No serious side effects were observed. CONCLUSION: The anesthetic patch reduced the pain experienced by children subjected to a skin biopsy procedure.

Administration, Cutaneous↗
PubMed2002

A comparison of oral transmucosal fentanyl and oral midazolam for premedication in children.

Oral transmucosal fentanyl citrate (OTF) was compared with midazolam as a premedicant in a prospective, randomised, placebo-controlled, double-blind trial. Eighty children (ASA grade 1 or 2, aged 3-9 years) who presented for tonsillectomy were randomly allocated to receive either 2.5 ml OTF (15-20 microg.kg(-1)) in a lollipop format and 0.5 ml.kg(-1) placebo syrup, or midazolam syrup (0.5 mg.kg(-1)) and a placebo lollipop (2.5 ml). The acceptability of sedation, anxiety and compliance with anaesthetic induction were assessed. The children were given an 'emergence' score for their recovery. Analgesia requirements, the incidence of vomiting, itching and any behavioural changes were assessed for 6 h postoperatively. Oral transmucosal fentanyl citrate was as effective as midazolam in aiding compliance with anaesthesia, but is significantly better in its appeal to children (p < 0.001) and emergence (p < 0.001) characteristics. In conclusion, OTF may be particularly useful as a premedicant in paediatric practice.

Administration, Oral↗
PubMed1997

Premedication with controlled release diclofenac sodium reduces post-operative pain after minor gynaecological surgery.

The effect of a single pre-operative oral dose of controlled release diclofenac sodium on post-operative pain after minor gynaecological surgery was investigated. Fifty-two women took part in a double-blind controlled study. Pain was assessed by visual analogue scale (VAS), a four-point verbal rating score, and the requirement for post-operative analgesia. Those patients who received diclofenac had significantly less post-operative pain than the placebo group up to 2 h after surgery.

Analgesics, Non-Narcotic↗
PubMed2001

Comparison of medetomidine and dexmedetomidine as premedication in isoflurane anaesthesia for orthopaedic surgery in domestic sheep.

The objective of the present study was to determine the potency of dexmedetomidine in relation to medetomidine in sheep undergoing orthopaedic surgery by comparing the anaesthetic requirements and cardiovascular changes at a dose relationship that represented equipotency in vitro. Twenty-four non-pregnant, female sheep were used. The study was carried out as a blind, randomized, experimental trial. Group 1 received 5 micrograms/kg bodyweight (BW) dexmedetomidine and group 2 received 10 micrograms/kg BW medetomidine intravenously 5 min prior to induction of anaesthesia. Anaesthesia was induced with ketamine (2.0 mg/kg BW intravenously) and maintained with isoflurane in 100% oxygen. End expired anaesthetic concentration (FEIso), end expired carbon dioxide concentration (FECO2), respiratory frequency (fR), direct arterial blood pressures, heart rates (HR) and arterial blood gases were monitored. Data were averaged over time and tested for differences between groups by independent t-tests, and analysis of variance for repeated measures. Average FEIso concentrations required to maintain a surgical plane of anaesthesia were not different between groups (1: 1.02 +/- 0.04%; 2: 0.99 +/- 0.07%). There was no difference in HR, arterial blood pressures, fR, FECO2 and arterial blood gases between groups. Average mean PaO2 were 279.54 +/- 113.37 mmHg and 220.21 +/- 102.15 mmHg with individual minimum values of 27.2 mmHg and 58.5 mmHg in groups 1 and 2, respectively. In conclusion, intravenous dexmedetomidine at 5 micrograms/kg BW and medetomidine at 10 micrograms/kg BW have the same effects on isoflurane requirements and cardiopulmonary parameters in sheep, indicating an equipotent dose relationship. Both preparations induced moderate to severe hypoxaemia in individual sheep.

Anesthetics, Inhalation↗
PubMed1999

Premedication, preparation, and surveillance.

During the last two years, the well-known positive role of benzodiazepines (midazolam and diazepam) in conscious sedation, both in adults and pediatric patients, has been confirmed by several studies. However, problems concerning the role of sedation and analgesia in nonoperative endoscopy are still a matter of debate. Particular attention has focused on attempts to identify the "ideal candidate" for conscious sedation, and on the importance of providing patients with information before the procedure, which should be matched to each patient's style of coping. Before detailed information about a medical procedure is given blindly, the clinician should investigate whether such information will benefit or adversely affect the patient receiving it. An important aspect of the sedation procedure is the prevention of hypoxia and cardiopulmonary complications. Recent endoscopic experience has provided little additional information concerning the well-known risk of oxygen desaturation during conscious sedation. Performing endoscopy in sedated patients reduces, but does not eliminate, the risk of hypoxia. Some independent variables capable of predicting severe desaturation have been recognized, such as basal SaO2 < 95%, respiratory disease, more than one attempt needed for intubation, emergency procedure, and an American Society of Anesthesiologists score of III or IV. As far as preparation is concerned, some light has been cast by a meta-analysis of available studies concerning the role of sodium phosphate and polyethylene glycol electrolyte lavage solution (PEG-ELS). The former preparation has been found to be as effective and less costly compared with the latter. In particular, sodium phosphate may be preferable in patients without cardiovascular or renal co-morbidity, and in those with a tendency to develop nausea or bloating.

Adult↗
PubMed2000

Premedication, preparation, and surveillance.

Once again the staggering variation in IV sedation practice between different countries is highlighted. This year the "to sedate or not sedate" debate focuses on colonoscopy. Several papers on the use of Propofol are reviewed. It remains this authors' opinion that propofol is an anaesthetic agent to be used by (or at least in the presence of) an anaesthetist. Informed consent and the question of what to do if a patient withdraws consent halfway through the procedure are discussed. Predictably further recent papers on the relative merits of midazolam and diazepam are presented plus another report on the use of flumazenil in the recovery period. The use of 3% hydrogen peroxide solution to aid the visualization of acutely bleeding gastro-duodenal lesions is presented in two papers along with a discussion of its possible mode of action. The use of antispasmodics to aid colonoscopy is further discussed: this year concentrating on the use of hyoscyamine sulphate (as opposed to hyoscine butylbromide, the preferred agent in the UK). The patients receiving hyoscyamine sulphate had significantly shorter caecal intubation times, better sedation and easier colonic insertion. The "downside" was drug-induced tachycardia and the authors caution against the widespread use of this drug until this situation is further clarified. The subject of hypoxaemia at the time of gastroscopy, colonoscopy and ERCP was reviewed last year and further papers are presented in which the incidence of various levels of hypoxia are given. In anaesthetic circles it would be considered totally unacceptable to allow a patient's oxygen saturation to fall below 85 %, and yet we continue to have papers reporting its incidence. This level of desaturation is potential dangerous and the routine use of supplemental oxygen would greatly reduce this unneccessary risk to patients.

Procedural Sedation↗
PubMed2001

Preparation, premedication, and surveillance.

The endoscopic literature published during the past year has once again confirmed that there is significant variation from country to country regarding whether or not patients wish to receive conscious sedation during endoscopy (and particularly colonoscopy) - and there may even be variation from one endoscopic unit to another within the same country. Particular attention has been given to attempts to identify "ideal" candidates for conscious sedation, and to the importance of providing patients with information before the procedure. It has been shown that patients who receive detailed information about a medical procedure beforehand are able to benefit from this. The role of benzodiazepines, particularly midazolam, was investigated in studies emphasizing that the dosage should be kept to the minimum that is compatible with patient comfort and successful performance of the procedure. There have been few publications comparing propofol with midazolam. As expected, in view of the known pharmacological properties of the two drugs, the quality of sedation was better and the recovery time was shorter in patients who were treated with propofol. However, important questions are still open regarding the narrow therapeutic range of propofol and the methods by which it is administered (by endoscopists or by anesthesiologists). An important aspect of sedation procedures is the prevention of hypoxia and cardiopulmonary complications. Recent endoscopic reports have added little further information concerning the well-known risk of oxygen desaturation during conscious sedation. Performing endoscopy in unsedated patients reduces, but does not eliminate, the risk of hypoxia. Among the various risk factors, it has been found that chronic respiratory failure and coronary heart disease are factors predictive of severe desaturation and relevant electrocardiographic changes. The use of electronic monitoring techniques with pulse oximetry is recommended as a standard procedure during digestive endoscopy; however, it has been observed that when supplemental oxygen is administered, pulse oximetry no longer reflects normal ventilatory function and does not detect episodes of severe CO2 retention. Transcutaneous measurement of PCO2 therefore seems more reliable as a means of assessing hypoventilation. Several papers have proposed "ideal formulas" for bowel preparation for endoscopic procedures. Various regimens have been proposed as alternatives to polyethylene glycol electrolyte lavage solution (PEG-ELS) and sodium phosphate compounds, with different results. On the whole, there is still little information regarding the best and most cost-effective method of bowel cleansing for colonoscopy and flexible sigmoidoscopy.

Antiemetics↗
PubMed2002

Premedication, preparation, and surveillance.

The vigorous debate over whom to sedate, when to sedate, and how to sedate shows no sign of running out of steam. There is a general consensus that patients should be more involved in the decision-making process for the sedation "menu". A move away from the take-it-or-leave-it attitude of all or nothing to an "à la carte" choice is to be encouraged. A new textbook and several further guidelines have appeared. The particular problems associated with sedating the elderly are briefly presented. The pros and cons of using local pharyngeal anaesthesia are discussed. Enthusiasm for the use of intravenous propofol is gathering momentum, despite continuing worries about its safety in the hands of the nonanaesthetist. For many endoscopists, the combination of a benzodiazepine plus (or minus) an opioid with which they are most familiar is still the best compromise in terms of efficacy, cost, and safety. Fatal drug-induced cardiopulmonary complications continue to occur, despite a general trend toward using smaller doses of sedation than we did 5 - 10 years ago. Monitoring techniques that are at present considered as research tools may one day become commonplace. These include: the use of an electroencephalography parameter known as bispectral analysis; transcutaneous CO(2) measurement; and a modified continuous capnographic waveform trace to monitor ventilatory effort. Bispectral analysis may be of use in monitoring central nervous system depression and helping to distinguish between conscious sedation and deep sedation. If the measurement of CO(2) levels, either transcutaneously or in breath samples, was as easy and inexpensive as measuring SpO(2) with a pulse oximeter, then undoubtedly such technology would enhance the early detection of sedative-induced hypoventilation and apnoea. Further evidence regarding droperidol's possible role in conscious sedation is presented. Pain during colonoscopy remains a problem, and the possible role for intraluminal injection of peppermint oil, as well as the value of variable-stiffness colonoscopes, in reducing the need for intravenous sedation is discussed. Case reports of hyponatraemic encephalopathy and hypocalcaemic tetany as complications of oral bowel preparation are presented, as is the challenge associated with adequate bowel preparation in diabetic patients.

Administration, Topical↗
PubMed2003

Preparation, premedication and surveillance.

The main end points for sedation during endoscopy are patients' satisfaction, short duration of the procedure, and safety. During the last year, attention has focused on attempting to identify the "ideal" candidate for moderate sedation/analgesia and on the importance of providing the patient with appropriate information before the procedure. The increasing pressure to perform more procedures, reduce costs, and achieve shorter patient turnaround times has affected recent approaches to sedation during endoscopy, focusing attention on alternatives to pharmacological sedation such as providing relaxing music, using small-caliber endoscopes for unsedated peroral gastroscopy, and using magnetic endoscopic imaging to increase tolerance and reduce discomfort during colonoscopy. The results, however, have not been convincing. The role of benzodiazepines was discussed in some studies, highlighting the well-known effect of midazolam on postprocedural amnesia, its pharmacological profile and tolerability after intranasal spraying in healthy volunteers, and the efficacy and safety of this route of administration as an alternative to intravenous administration in diagnostic upper gastrointestinal endoscopy. The form of sedation for gastrointestinal endoscopy that has attracted great interest over the last year is the use of intravenous propofol, either alone or with concomitant benzodiazepines or opioids. As expected in view of the drug's known pharmacological properties, the quality of sedation was better and recovery time was shorter in patients treated with propofol. However, important questions involving the narrow therapeutic range and the mode of administration of propofol (by endoscopists or nurses, or by anesthesiologists) remain open. One important aspect of sedation procedures is prevention of cardiopulmonary complications. The use of electronic monitoring techniques, with a pulse oximeter, has been recommended as a standard procedure during digestive endoscopy; however, pulse oximetry no longer reflects the normal ventilatory functions and does not detect episodes of severe CO2 retention. CO2 monitoring by transcutaneous measurement - or better, by capnography - appears to be useful, as an alternative to pulse oximetry, as a measure of hypoventilation, and for detecting potentially important abnormalities in respiratory activity in patients undergoing sedation for gastrointestinal endoscopy. With regard to preparation for endoscopic procedures, several "ideal" formulas for bowel preparation have been presented. These include the use of sodium phosphate compounds as an alternative to polyethylene glycol electrolyte lavage solutions (PEG-ELS); however, the results so far have been conflicting. The best and most cost-effective bowel cleansing procedure for colonoscopy and sigmoidoscopy has yet to be established.

Anesthesia Recovery Period↗
PubMed2004

Preparation, premedication, and surveillance.

The main criteria for assessing conscious sedation (perhaps now more correctly termed "moderate sedation/analgesia") continue to be patient satisfaction and comfort, short duration, amnesia, and above all, patient safety. The problems reviewed last year - including the increasing pressure on endoscopy units to perform yet more procedures, reduce costs, and achieve shorter patient turn-around times - certainly have not gone away. Studies reviewed this year suggest that although many endoscopic procedures, such as oesophagogastroduodenoscopy (OGD), colonoscopy, and endoscopic ultrasonography (EUS) can indeed be performed without intravenous sedation, many patients still prefer to be sedated. Further papers on the possible role of ultrathin endoscopes in unsedated OGD are reviewed here. A study in Italy comparing virtual computed-tomographic (CT) colonography and conventional colonoscopy suggests that unsedated colonoscopy is unlikely to meet with wide acceptance. Audits of colonoscopy in both the United States and the United Kingdom suggest that there is still a long way to go before caecal intubation rates of more than 90 % are regularly attained. The evidence suggests that some endoscopists are using larger doses of a midazolam and pethidine combination than are generally recommended (particularly in elderly patients), and sedation-related deaths are still occurring. Impressively large clinical studies, particularly those from Switzerland, on the use of propofol administered by nonanaesthetists are leading to reconsideration of the earlier view that propofol should only be used by anaesthetists. If propofol is to be used more widely and become an agent administered by endoscopists (or nursing staff), then considerable improvements in the standard of airways management will be needed. Several new studies relating to bowel-cleansing agents and the use of a carbohydrate/electrolyte "cholera mixture" to prevent the associated intravascular volume contraction have been published. Warm water is a cheap and effective way of reducing colonic spasm during colonoscopy, and intraluminal peppermint oil is a good antispasmodic in the stomach as well as the colon. Sedation should still be regarded as one part of an overall "endoscopy package". Finally, more attention needs to be given to patients' complaints regarding what are often considered by endoscopists to be "trivial complications" if the patients are to have a positive experience of their examination that will lead to them being prepared to come back a second time.

Clinical Trials as Topic↗
PubMed2005

Preparation, premedication, and surveillance.

In the year since the last review, continuing pressure on endoscopy suites to improve efficiency and reduce costs without compromising patient care has led to growing interest in alternatives to pharmacological sedation and in the use of short-acting sedatives. Relaxation music, acupuncture, and the use of small-caliber endoscopes for unsedated peroral gastroscopy have therefore been suggested as ways of increasing tolerance and reducing discomfort. With regard to ultrathin and superthin endoscopes, the results are interesting, but further data from controlled trials and in studies including larger numbers of patients are still needed. The form of sedation for gastrointestinal endoscopy that has attracted greatest interest over the last year is the use by nonanesthetists of intravenous propofol, administered either alone at standard doses to achieve deep sedation, or at lower doses combined with benzodiazepines and opioids to achieve moderate sedation/analgesia. In comparison with benzodiazepines/opioids, the results were in favor of propofol: the mean time to sedation was shorter and the depth of sedation was greater. In addition, patients receiving propofol reached full recovery earlier and were discharged sooner. However, in the survey of patient satisfaction at discharge, it was found that the sedation methods did not have a significant impact on overall patient satisfaction. Some important issues concerning the narrow therapeutic range of propofol and the need for adequate training of endoscopists to deal with any problems related to deep sedation are still open - despite the growing amount of data suggesting that the drug is safe even when administered by registered nurses, an approach that is possibly more cost-effective than delivery by gastroenterologists or anesthetists. The morbidity and mortality associated with cardiopulmonary complications continue to be a significant concern during gastrointestinal endoscopy. Professional societies and national expert peer groups have issued practice guidelines for sedation and analgesia that call for continuous monitoring of the patient's hemodynamic and ventilatory status and consciousness. Direct observation is facilitated by electronic devices (pulse oximetry, capnography), directly indicating the patient's ventilatory status and the depth of sedation. Recently, it has been proposed that the bispectral index (BIS), an electroencephalography-based technique, can be used to monitor the depth of sedation during gastrointestinal endoscopy. However, the results of a recent study cast some doubt on the usefulness of the BIS, in its current version, for titrating boluses of propofol to an adequate level of sedation. Further data therefore appear to be needed to assess whether or not BIS values can help avoid unnecessary propofol dosage and can replace continuous assessment of the ventilatory effort.

Procedural Sedation↗