Neuromuscular and haemodynamic effects of mivacurium in patients with hepatic cirrhosis

Forty patients who underwent intermediate elective surgeries were included in the present study. Ten patients were free from hepatic disease [group A], and thirty patients had evident hepatic cirrhosis, [group B]. Using Child-Pugh score, group B patients were further subdivided into three equal subgroups, group B1 was Child A, group B2 patients were Child B and group B3 patients were Child C. Induction of anesthesia was carried out by propofol, fentanyl NO2-O2 and isoflurane. After stabilization of control response using a force displacement transducer and neuromuscular function analyzer, all patients received a bolus of mivacurium 0.15 mg/ kg over 15 seconds [2x ED95] and spontaneous recovery was recorded. Mivacurium infusion was started at T1 of 10% [first response of TOF] and the block was maintained at T1 depression of 95%. Haemodynamic changes were recorded before start of anesthesia and throughout surgery. After bolus injection of mivacuirium, both lag time and onset time didn't show any significant change among groups. Recovery indices were comparable between group A and sub group BO1 [Child A], whereas, there were significant increase of T1 to 10%, 25%, 75% and 90% of control in patients with moderate to severe liver cirrhosis [group B2 and B3] in comparison to group A. TOF ratio of 0. 7 showed the same pattern of change, it was significantly higher in subgroups B2 and B3 in comparison to control group A. Similarly, recovery index was significantly higher in subgroups B2 and B3. The mean infusion requirements of mivacurium were generally less in group B in comparison to group A. Steady state infusion rates were achieved over 10 mm in all groups. Differences in mean mivacurium requirements from 10 min and forward were significantly less in subgroups B2 and B3 in comparison to control A. At end of surgery, residual neuromuscular blockade was antagonized and a TOF ratio of 0.7 was reached in about 7 minutes. None of patients experienced any signs of recurarization in the recovery room. In conclusion, mivacurium has a stable neuromuscular and haemodynamic profile in patients free from hepatic disease and patients of child score A. However, in child score B and C patients the drug profile is unstable and even unpredictable. Therefore, the use of mivacurium is only recommended, if ever, for short procedures in cases of mild liver cirrhosis

Conscious sedation by oral administration of midazolam versus midazolam plus ketamine for treatment of uncooperative pediatric dental patients

The purpose of this study was to assess the effectiveness of oral midazolam versus oral midazolam and ketamine in sedating uncooperative and young children for dental treatment. Fifteeen children who needed two comparable restorative interventions that could be done on separate visits, participated in this study. The patients were assigned double blindly to receive 0.35 mg/kg midazolam or 0.35 mg/kg midazolam + 3 mg/kg ketamine with the alternate regimen administered at the second visit. Degree of alertness, crying and movement were assessed at the beginning of the session and at 5 minutes interval throughout the procedure. Overall patient behavior and operator's level of satisfaction were assessed on a special rating scale. Heart rate, respiratory rate, arterial oxygen saturation and blood pressure were recorded as a baseline and then every 5 minutes,; thereafter, during the operative session. Statistical analysis showed no difference in mean scores of crying and movement between both groups, although the midazolam and ketamine always scored higher means. Sedation was deeper during the first 10 minutes in the midazolam + ketamine group [P <0.05] as evidenced by higher mean scores for alertness. Overall mean patient's behavior and operator's satisfaction were higher in the midazolam + ketamine group with no statistical difference. No adverse effects were observed. Blood pressure, heart rate, respiratory rate and arterial saturation were all maintained at normal level