Perioperative hypertension

The effects of hypertension on perioperative outcomes are still unclear. No specific systolic or diastolic blood pressure measurement has been determined as the cutoff value to continue with a surgical plan or adjourn. This study is designed as a narrative review of the available scientific evidence on the perioperative management of hypertension. A search was conducted in Pubmed considering the title and abstract; 120 articles were pre-selected of which 55 papers were selected for full-text eligibility and 16 were excluded for a total of 39 articles including ACCF/AHA 2009 and ACC/AHA 2014 on perioperative cardiovascular care; 2013 ESH/ESC, 8 JNC, and the 2017 ACC/AHA/AAPA/ABC Guideline for the Prevention, detection, and management of hypertension in adults. Blood pressure values, target organ damage, and type of surgery should be considered for decision-making in the perioperative period. If surgery is elective, blood pressure fluctuations should be avoided and potential causes should be treated. A patient with mild hypertension with values below SBP 160 and DBP 110 mmHg may be managed in the ambulatory setting during the postoperative period, as long as the clinical conditions are favorable.

Los efectos de la hipertensión sobre los desenlaces durante el periodo perioperatorio aún no han quedado claramente establecidos. No se ha determinado una medición específica para la presión sistólica ni diastólica como punto de corte para continuar con el plan quirúrgico o suspenderlo. El presente estudio está diseñado a manera de revisión narrativa de la evidencia científica disponible sobre el manejo perioperatorio de la hipertensión. Se llevó a cabo una búsqueda en Pubmed, considerando el título y el resumen; se preseleccionaron 120 artículos, de los cuales se seleccionaron 55 para elegibilidad en texto completo y 16 se excluyeron, quedando un total de 39 artículos, incluyendo ACCF/AHA 2009 y ACC/AHA 2014 sobre el cuidado cardiovascular perioperatorio; 2013 ESH/ESC, 8 JNC, y la Guía del 2017 ACC/AHA/AAPA/ABC para la prevención, detección y manejo de la hipertensión en adultos. Se deben considerar los valores de la presión arterial, el daño a órgano diana y el tipo de cirugía para la toma de decisiones en el periodo perioperatorio. Si la cirugía es electiva, deben evitarse las fluctuaciones en la presión arterial y tratar activamente cualquiera de las causas potenciales. Un paciente con hipertensión leve, con valores por debajo de PAS 160 y PAD 110 mmHg puede manejarse de manera ambulatoria durante el período postoperatorio, siempre y cuando las condiciones clínicas sean favorables.

Effect of virtual reality on preoperative anxiety in patients undergoing septorhinoplasty

Abstract Background The aim of this study was to evaluate the effect of a virtual reality video on preoperative anxiety, hemodynamic parameters, and patient satisfaction in patients undergoing septorhinoplasty. Methods This was a prospective, observational cohort trial. Forty patients between the ages of 18-65 who were scheduled for elective septorhinoplasty, with an American Society of Anesthesiologists (ASA) physical status I-II were included in the study. Patients experienced a 15-minute virtual reality (VR) video via a phone using a VR device. A three-dimensional, 360° video depicted the beauty of nature and was accompanied by meditation music. Patients' oxygen saturation values, heart rate, and blood pressure were monitored and recorded. Using the State-Trait Anxiety Inventory scale, anxiety scores and hemodynamic parameters were compared before and after VR application. Results Median anxiety scores decreased significantly from 40.5 to 34 (p< 0.001). VR also had positive effects on hemodynamic parameters. Conclusions VR reduces preoperative anxiety and has positive effects on hemodynamic parameters in patients undergoing septorhinoplasty. We anticipate that VR will be increasingly used as a non-pharmacological preoperative approach in the future.

Effect of Pre-Treatment with Ketorolac Tromethamine on Post-operative Pain Following Periodontal Surgery: A Randomized Crossover Clinical Trial

Background: Periodontal surgeries are often followed by post-operative pain and discomfort which is a major concern to both the clinician and the patient. Every effort is being made to reduce the post-operative pain, one amongst them being the pre-operative medication with NSAIDS like ketorolac tromethamine. This type of agent acts peripherally by inhibiting the release of prostaglandins and minimizing the local inflammatory response hence it may be advantageous in reducing post-operative pain and discomfort. Thus, the efficacy of preoperative ketorolac tromethamine administration on periodontal postoperative pain was evaluated. Material & Methods: Two groups of 15 patients each were selected for the study. One group received 20 mg ketorolac immediately before periodontal flap surgery, and the other group doesn’t received any drug. Combination of Diclofenac sodium 50 mg & Paracetamol 325mg tablets was provided as “rescue analgesic. The visual analog scale modified with using numerical rating scales and Wong-Baker Faces Pain Rating Scale was used to estimate pain. Postoperative pain was assessed hourly for the first 12 h on the day of surgery, and 4 times daily on the 1st and 2nd postsurgical days. Timing and dose of rescue analgesic remedication were also recorded. Results: Results indicated that preoperative treatment with ketorolac significantly reduced initial pain intensity and delayed the onset of postoperative pain as compared to no premedication group. Incidence and amount of rescue medication consumption was small in ketorolac groups. No adverse reactions related to preoperative medication were observed. Conclusion: The results of this study showed that 20-mg ketorolac administered immediately before periodontal surgery was effective for alleviating the early postoperative painful sequelae, affected delayed pain levels and postoperative rescue analgesic consumption.

Comparison of intranasal midazolam-fentanyl with dexmedetomidine–fentanyl as pre-medication in the paediatric age group

Background & objectives: Intranasal midazolam-fentanyl is commonly used as pre-medication in paediatric patients, but there is a risk of respiratory depression with this combination. Dexmedetomidine is a drug that preserves respiratory function. The objective of this study was to compare the efficacy of intranasal midazolam-fentanyl and dexmedetomidine-fentanyl in paediatric patients undergoing elective surgeries. Methods: Hundred children in the age group of 3-8 yr of American Society of Anaesthesiologists physical status grade 1 were randomized into two groups- group A received intranasal midazolam (0.2 mg/kg)-fentanyl (2 ?g/kg) and group B received intranasal dexmedetomidine (1 ?g/kg)-fentanyl (2 ?g/kg) 20 min before induction of general anaesthesia. Heart rate and SpO2 were monitored. Sedation score, parental separation and response to intravenous cannulation were seen after 20 min. Children were monitored for 2 h for post-operative analgesia by Oucher’s Facial Pain Scale. Results: Sedation scores were satisfactory in both groups, although children in group A were more sedated than in group B. Parental separation and response to intravenous cannulation were comparable in both the groups. The two groups were also haemodynamically comparable intraoperatively. Post-operative heart rate was also comparable at all-time intervals in both the groups except for heart rate at 100 and 120 min which were more in group A. Group A experienced more post-operative pain as assessed by Oucher’s Facial Pain Scale as compared to group B. Children receiving intranasal dexmedetomidine- fentanyl had better post-operative analgesia as compared to those who received intranasal midazolam-fentanyl. Interpretation & conclusions: Both intranasal midazolam with fentanyl and intranasal dexmedetomidine with fentanyl provided satisfactory sedation. Both groups were comparable in separation reaction and response to intravenous cannulation with better post-operative analgesia in children receiving intranasal dexmedetomidine-fentanyl.

Role of melatonin in attenuation of hemodynamic response to intubation and anesthetic requirements: a randomized, controlled, double-blind study

Abstract Background Melatonin has been studied to have anxiolytic, sedative, and analgesic effects. However, there is limited data on the effect of melatonin in the attenuation of hemodynamic response to intubation. We aimed to study whether preanesthetic oral melatonin attenuates hemodynamic responses to intubation and anesthetic requirements. Methods Sixty-four patients scheduled for laparoscopic cholecystectomy were randomized into melatonin or placebo group (n = 32 each). Melatonin group received two tablets (3 mg each) of melatonin, and the placebo group received two tablets of vitamin D3 120 min before induction. Hemodynamic parameters were recorded during induction and postintubation for 15 minutes. Total induction dose of propofol, total intraoperative fentanyl consumption, and adverse effects of melatonin were also noted. Results Postintubation rise in heart rate (HR) was less in the melatonin group compared to the placebo group (10.59% vs. 37.08% at 1 min, respectively) (p< 0.0001). Maximum percentage increase in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) was lesser in melatonin group than placebo group (SBP 9.25% vs. 37.73%, DBP 10.58% vs. 35.51%, MBP 9.99% vs. 36.45% at 1 min postintubation. respectively) (p< 0.0001). Induction dose of propofol (1.42 mg.kg-1 vs. 2.01 mg.kg-1) and the number of patients requiring additional fentanyl intraoperatively (3 vs. 11) were also significantly reduced in the melatonin group. Conclusion Premedication with 6 mg of oral melatonin resulted in significant attenuation of postintubation rise in HR, SBP, DBP, and MBP. It also reduced the induction dose of propofol, total intraoperative fentanyl consumption without any adverse effects.

Evaluation of the efficacy of GnRH-a pretreatment before total hysterectomy for adenomyosis patients: a propensity score matching analysis / 中华妇产科杂志

Objective:To evaluate the efficacy of gonadotropin-releasing hormone agonist (GnRH-a) pretreatment before total hysterectomy for adenomyosis patients with uterine volume ≥12 gestational weeks and moderate or severe anemia.Methods:From January 2018 to March 2023, 689 patients who underwent total hysterectomy for adenomyosis in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed. According to the preoperative medication, they were divided into study group (127 cases) and control group (562 cases). Patients in the study group underwent GnRH-a pretreatment for 3 cycles before surgery, and the control group received operation directly. SPSS 26.0 software was used to perform 1∶1 matching for the two groups of patients through the propensity score matching method. Matching variables included age, body mass index, gravidity, parity, history of pelvic and abdominal surgery, menstrual cycle, menstrual period, dysmenorrhea score, initial diagnosis of cancer antigen 125 (CA 125), uterine volume and hemoglobin value. The dysmenorrhea score, uterine volume, hemoglobin value and CA 125 level before and after GnRH-a pretreatment in the study group were compared. And the duration of operation, intraoperative blood loss, postoperative white blood cell count, perioperative blood transfusion cases, postoperative disease rate, duration of hospitalization, total hospitalization cost between the two groups were compared. Results:With propensity score matching, 119 patients in the study group and 119 patients in the control group were finally enrolled in this study. In the study group, before and after the treatment with GnRH-a, the dysmenorrhea score (7.4±1.7 vs 5.6±1.8), uterine volume [(362±160) vs (233±126) cm 3], hemoglobin value [(74.1±10.7) vs (102.5±13.5) g/L], and CA 125 level [(104±76) vs (64±51) kU/L] were statistically different (all P<0.05). There were statistical differences of operation time [(86±18) vs (116±31) minutes], intraoperative blood loss [(24±9) vs (43±22) ml], white blood cell count after 1 day of operation [(9.80±0.10)×10 9/L vs (9.90±0.10)×10 9/L], number of perioperative blood transfusion case [5.9% (7/119) vs 61.3% (73/119)], postoperative disease rate [5.0% (6/119) vs 16.0% (19/119)], hospitalization duration [(7.1±1.6) vs (7.9±1.6) days], and total hospitalization cost [(35 323±5 275) vs (37 159±5 640) yuan] between the study group and the control group (all P<0.05). Conclusion:The pretreatment of using GnRH-a before total hysterectomy for adenomyosis patients with uterine volume ≥12 gestational weeks and moderate or severe anemia is not only conducive to improving dysmenorrhea, signs of anemia, reducing uterine volume, but also conducive to the implementation of surgery, reducing intraoperative and postoperative complications, and reducing hospital costs.

Mastocytosis: the safety of different COVID-19 vaccines / Mastocitose: segurança de diferentes vacinas contra a COVID-19

The COVID-19 pandemic has forced the development of vaccines to fight SARS-CoV-2. After vaccination began, reports of adverse reactions, including anaphylaxis, emerged. This raised concerns about the safety of COVID-19 vaccines in patients diagnosed with mastocytosis. The authors share their experience in administering different COVID-19 vaccines to patients diagnosed with mastocytosis.

A pandemia por COVID-19 obrigou ao rápido desenvolvimento de vacinas para combate ao SARS-CoV-2. Após o início da vacinação começaram a surgir relatos de reações adversas às vacinas, incluindo reações anafiláticas, surgindo dúvidas sobre a segurança das vacinas em doentes com mastocitose. Os autores apresentam a sua experiência em relação à administração de diferentes vacinas contra a COVID-19 em doentes com diagnóstico de mastocitose.

Comparative Evaluation of Midazolam and Ketamine with Midazolam Alone as Oral Premedication in Children

Introduction: The main aims of preanesthetic medication in children are to reduce anxiety associated with the unfamiliar environment, facilitate the separation of the child from their parent and allow smooth induction of anesthesia. Both oral midazolam and oral ketamine fulfil many of these characteristics and are useful. Method: As 48 patients of ASA grade 1 and 2, aged between 2-10 years undergoing elective surgery were allocated to one of two study groups using random numbers: Group 1 received midazolam 0.5mg/kg and group 2 received midazolam 0.25 mg/kg with ketamine 3 mg/kg. The medications were prepared and mixed with 25% dextrose up to a maximum volume of 0.3 ml/kg. Result: Uniform and acceptable sedation scores were seen in both the groups, without any serious side effects. However, the combination offered significantly more children in an awake, calm and quiet state, who were easily separated from their parents. The induction scores, Recovery room characteristics and time to achieve satisfactory Aldrete score were also comparable between the two groups. Conclusion: Oral midazolam alone and a combination of midazolam with ketamine provide equally effective anxiolysis and separation characteristics. However, the combination provided more Benefits.

Effects of preoperative administration of parecoxib sodium on stress reaction and postoperative nausea and vomiting score in patients undergoing laparoscopic cholecystectomy / 中国基层医药

Objective:To investigate the effects of preoperative administration of parecoxib sodium on stress reaction and postoperative nausea and vomiting score in patients undergoing laparoscopic cholecystectomy.Methods:A total of 112 patients undergoing laparoscopic cholecystectomy in Lishui City People's Hospital from January 2020 to January 2021 were included in this study. They were randomly divided into observation group and control group, with 56 patients per group. The observation group was intravenously administered 40 mg parecoxib sodium 30 minutes before surgery, and the control group was identically administered equal amount of 0.9% sodium chloride injection. At 1, 6, 12 and 24 hours after surgery, Visual Analogue Scale (VAS) score, cortisol and adrenocorticotropic hormone levels and postoperative nausea and vomiting score were compared between the two groups.Results:At 1, 6 and 12 hours after surgery, VAS score in the observation group was (3.23 ± 0.85) points, (2.44 ± 0.76) points, (2.37 ± 0.69) points, respectively, which were significantly lower than (4.06 ± 1.12) points, (3.24 ± 0.95) points, (3.10 ± 1.07) points in the control group ( t = 4.41, 4.92, 4.29, all P < 0.001). At 1, 6, 12 and 24 hours after surgery, cortisol level in the observation group was (287.79 ± 35.46) ng/L, (303.55 ± 34.77) ng/L, (368.58 ± 31.22) ng/L, (397.16 ± 32.60) ng/L, respectively, which were significantly lower than (337.64 ± 39.52) ng/L, (364.18 ± 36.90) ng/L, (405.56 ± 37.29) ng/L, (455.51 ± 37.81) ng/L in the control group ( t = 7.02, 8.94, 5.69, 8.74, all P < 0.05). At 1, 6, 12 and 24 hours after surgery, adrenocorticotropic hormone level in the observation group was (59.25 ± 7.63) ng/L, (65.27 ± 8.23) ng/L, (72.29 ± 7.49) ng/L, (83.63 ± 8.57) ng/L, which were significantly lower than (64.48 ± 8.06) ng/L, (71.44 ± 8.59) ng/L, (79.79 ± 8.15) ng/L, (90.08 ± 8.26) ng/L in the control group ( t = 3.52, 3.88, 5.07, 4.05, all P < 0.05). Within 24 hours after surgery, the incidence of postoperative nausea and vomiting in the observation group was significantly lower than that in the control group [12.50% (7/56) vs. 28.57% (16/56), χ2 = 4.43, P < 0.05). Within 2 hours, 2-6 hours, and > 6-24 hours, postoperative nausea and vomiting score in the observation group was (1.31 ± 0.26) points, (1.43 ± 0.32) points, and (1.46 ± 0.41) points, respectively, which was significantly lower than (1.67 ± 0.41) points, (1.83 ± 0.39) points, (1.88 ± 0.44) points in the control group ( t = 2.12, 2.37, 2.14, all P < 0.05). Conclusion:Preoperative administration of parecoxib sodium exhibits a good postoperative analgesic effect in patients undergoing laparoscopic cholecystectomy. It can effectively reduce postoperative stress reactions, decrease the incidence of postoperative nausea and vomiting, and lower the severity of postoperative nausea and vomiting, and thereby can be widely used in clinical practice.

Comparison of the safety and efficacy of dexmedetomidine with midazolam for the management of paediatric dental patients A systematic review

Background: Pain, fear, and anxiety have long been associated with pediatric dentistry. A child's cooperation with a dental.procedure.usually requires various behavioral management strategies conveyed by the entire dental team. The use of sedatives in dental clinics for providing analgesia and anxiolysis allows the patient to respond appropriately to verbal commands and light tactile stimulation., thus making dental treatment more patient friendly and effective. Aim: The aim of this study was to compare the safety and efficacy of dexmedetomidine versus midazolam for the management of pediatric patients in the dental clinic. Materials and Methods: This systematic review was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six articles were selected for this systematic review. Of them, only in four articles, homogeneous data were available which were subjected to meta-analysis. Results: When compared with midazolam, premedication with dexmedetomidine resulted in much lower incidence of emergence delirium (odds ratio = 0.07, 95% confidence interval: 0.01–0.54, P = 0.01). No significant difference was observed with respect to satisfactory behavior of the child, successful parental separation, and satisfactory mask acceptance following sedation. Conclusion: Both dexmedetomidine and midazolam are equally effective for the management of pediatric patients in the dental clinic. In addition, dexmedetomidine premedication is associated with lower incidence of emergence delirium and has a better margin of safety.

Cohortes de premedicación en endoscopia alta con simeticona, N-acetilcisteína, Hedera helix y validación de la escala visual / Cohorts of premedication for endoscopy of the upper gastrointestinal tract with simethicone, N-acetylcysteine, Hedera helix and visual scale validation

Resumen Los parámetros de calidad para endoscopia digestiva alta han introducido indicadores intraprocedimiento, dentro de los cuales la adecuada visibilidad de la mucosa, libre de saliva, moco o burbujas, puede aumentar la posibilidad de detección de lesiones en fase temprana. Sin embargo, el uso de mucolíticos y antiburbujas ha mostrado gran variabilidad de eficiencia según las soluciones, concentraciones, tiempos de exposición y escala de visibilidad aplicados. Objetivos: determinar la efectividad de diferentes soluciones de premedicación para la limpieza de la mucosa digestiva; validar, mediante una prueba de concordancia interobservador, una nueva escala de adecuada visualización de la mucosa (TVMS) para el esófago, estómago y duodeno; y reportar eventos adversos o complicaciones relacionadas con las soluciones utilizadas y los procedimientos realizados. Material y métodos: estudio de cohortes prospectivas comparativas. Se incluyeron 412 pacientes adultos, ASA I y ASA II, para endoscopia diagnóstica bajo sedación consciente, distribuidos en 6 cohortes similares, divididas en dos grupos: no premedicación, 2 cohortes C1 (ayuno de 6 a 8 horas)y C2 (agua 100 mL); premedicación, 4 cohortes C3 a C6 (C3: agua 100 m L + simeticona 1000 mg; C4: agua 100 mL + simeticona 200 mg + N-acetilcisteína 600 mg; C5: agua 100 mL + simeticona 200 mg + N-acetilcisteína 1000 mg; C6: agua 100 mL + simeticona 200 mg + Hedera helix 70 mg). Se ingirió la solución 15 a 30 minutos antes del paso por cricofaríngeo. Se realizó la prueba de Kappa para medir la concordancia interobservador de la escala TVMS. Resultados: De 412 pacientes, 58% fueron de sexo femenino; 23% (136) fue de cohortes C1 y C2 y 67% (276) fue de cohortes C3 a C6. El tiempo medio de exposición a cada solución fue de 24,4 minutos. El volumen de lavado para lograr una adecuada visualización fue significativamente diferente entre ambos grupos: en los pacientes con premedicación se utilizaron 75,6 mL, mientras que en los pacientes sin premedicación se utilizaron 124 mL (p = 0,000), con una calidad de TVMS excelente de 88,7% frente al 41,4%, respectivamente. La cohorte C4 (agua 100 mL + simeticona 200 mg + N-acetilcisteína 600 mg) mostró ser la más efectiva con una diferencia significativa (p = 0,001) frente a C1 (ayuno) y C2 (placebo con agua 100 mL), y también tuvo una eficiencia superior frente a C3, C5 y C6 en su orden. No se presentaron eventos adversos o complicaciones en relación con la endoscopia, la sedación y los productos usados en la premedicación. Conclusiones: la solución más efectiva como premedicación para lograr una excelente visibilidad de la mucosa digestiva correspondió a la cohorte C4 (SIM 200 + NAC 600 + H2O 100 mL). La escala TVMS propuesta es una herramienta muy completa y fácil de aplicar por más de un observador. La premedicación ingerida, con antiburbuja, mucolítico y agua hasta 100 mL, entre 15 y 30 minutos previos a endoscopia, es segura en las condiciones descritas en este estudio.

Abstract Quality parameters for upper gastrointestinal endoscopy have introduced intraprocedural indicators, including adequate mucosal visualization free of saliva, mucus, or bubbles, which may increase the possibility of early-stage injury detection. The use of mucolytics and anti-foaming agents has shown great efficiency variability depending on the type of solution, concentrations, exposure times and visibility scale applied. Objectives: To determine the effectiveness of different premedication solutions for cleaning the digestive mucosa; to validate, by means of an interobserver concordance test, a new scale for the adequate visualization of the mucosa (TVMS) for the esophagus, stomach, and duodenum; and to report adverse events or complications associated with the solutions used and the procedures performed. Material and methods: Prospective, comparative cohort study. 412 adult patients, ASA I and ASA II, were included for diagnostic endoscopy under conscious sedation. They were distributed in 6 similar cohorts and divided into two groups: non-premedication, 2 in C1 (fasting 6 to 8 hours) and C2 (water 100 mL) cohorts; premedication, 4 C3 to C6 cohorts (C3: water 100 mL + simethicone 1000 mg; C4: water 100 ml + simethicone 200 mg + N-acetylcysteine 600 mg; C5: water 100 ml + simethicone 200 mg + N-acetylcysteine 1000 mg; C6: water 100 ml + simethicone 200 mg + Hedera helix 70 mg). The solution was swallowed 15 to 30 minutes passing through the cricopharyngeus muscle. The Kappa test was performed to measure interobserver concordance of the TVMS scale. Results: Of 412 patients, 58% were female; 23% (136) were included in the C1 and C2 cohorts; and 67% (276) were in the C3 to C6 cohorts. The average exposure time to each solution was 24.4 minutes. The wash volume for proper visualization was significantly different between the two groups. In premedicated patients, 75.6 mL of solution were used, while in patients without premedication, 124 mL were used (p = 0.000), with an excellent quality of TVMS of 88.7% versus 41.4%, respectively. The C4 cohort (water 100 mL + simethicone 200 mg + N-acetylcysteine 600 mg) was the most effective with a significant difference (p= 0.001) compared with the C1 (fasting) and C2 (placebo with water 100 mL) cohorts. It also had better efficiency compared to the C3, C5 and C6 cohorts in that order. There were no adverse events or complications associated with endoscopy, sedation, or premedication products. Conclusions: The most effective solution as a premedication to achieve excellent visibility of the digestive mucosa was that used in the C4 cohort (SIM 200 + NAC 600 + H2OR 100 mL). The proposed TVMS scale is a very complete and easy tool to apply by more than one observer. Premedication ingested, with anti-foam, mucolytic and water up to 100 mL, between 15 and 30 minutes before endoscopy, is safe under the conditions described in this study.

Efficacy of combination of intranasal dexmedetomidine and esketamine for preoperative sedation in pediatric patients with congenital heart diseases / 中华麻醉学杂志

Objective:To evaluate the efficacy of combination of intranasal dexmedetomidine and esketamine for preoperative sedation in pediatric patients with congenital heart disease.Methods:Fifty American Society of Anesthesiologists physical status Ⅱ or Ⅲ pediatric patients, aged 1-3 yr, undergoing elective cardiac surgery for left-to-right shunt type congenital heart diseases, were divided into dexmedetomidine group (group D, n=25) or dexmedetomidine combined with esketamine group (group DK, n=25) using a random number table method.Dexmedetomidine 3.9 μg/kg was intranasally delivered in group D. Dexmedetomidine 3.3 μg/kg combined with esketamine 2 mg/kg was intranasally administered in group DK.The Children′s Hospital of Wisconsin Sedation Scale score, SpO 2, HR, and pulmonary artery systolic pressure (PAP) were recorded before and at 30 min after administration, and the rate of decrease in SpO 2, HR and PAP after administration was calculated.The onset time of sedation and occurrence of adverse effects such as nausea and vomiting, bradycardia and respiratory depression during sedation were recorded. Results:Inadequate sedation and over-sedation were not observed in either group.Compared with group D, Children′s Hospital of Wisconsin Sedation Scale scores were significantly decreased at 30 min after administration, the onset time of sedation was shortened, and the decrease rate of HR was decreased in group DK ( P<0.05), and there were no significant changes in HR, SpO 2 and PAP before and after administration ( P>0.05). In group DK, nausea and vomiting occurred in 2 cases, but the symptoms were mild and no medication intervention was needed.No other adverse effects such as bradycardia and respiratory depression were found in either group. Conclusion:Combination of intranasal dexmedetomidine and esketamine can optimize the efficacy of preoperative sedation in pediatric patients with congenital heart disease, esketamine may induce nausea and vomiting, and the fasting time should be strictly controlled during sedation.

Effects of Intramuscular Dexmedetomidine Versus Clonidine on the Duration of Subarachnoid Block and Analgesia for Lower Limb Orthopedic Surgeries

Background: Alpha-2adrenergic agonists, when used simultaneously as systemic adjuvants to local anesthetics show synergisticaction and improve the quality of spinal anesthesia and prolong the post-operative analgesia. We aimed to study the effects ofintramuscular dexmedetomidine versus clonidine on the duration of bupivacaine sub-arachnoid block, post-operative analgesia,and sedation in patients undergoing lower limb orthopedic surgeries.Materials and Methods: The study design was a prospective, randomized, and double-blind study. Eighty adult consentedpatients of ASA I or II, scheduled for orthopedic lower limb surgeries under spinal block were randomized to two groups of40 patients per group. Group D received IM dexmedetomidine 1 μgkg−1, Group C received IM clonidine 2 μgkg−1, and 30 minbefore the bupivacaine subarachnoid block. The time of onset of sensory and motor block, the time required for completesensory and motor recovery, time of the first request of rescue analgesia, and sedation levels were compared between thegroups. Collected data were analyzed using the student “t” test, Chi-square test/Fisher exact test, and P < 0.05 was consideredstatistically significant.Results: The mean onset time of sensory and motor block was reduced, the mean time required for complete sensory recoverywas increased and the time of the first request of rescue analgesia was prolonged in the dexmedetomidine group comparedto clonidine group with a significant P < 0.05. Ramsay sedation score was higher in the dexmedetomidine group compared toclonidine group (P = 0.003)Conclusion: Premedication with a single dose of intramuscular dexmedetomidine before bupivacaine spinal anesthesia actsas an effective adjuvant and potentiates the quality of block and prolongs post-operative analgesia more than intramuscularclonidine.

A Comparative Study of Oral Clonidine and Oral Midazolam as Premedicants for General Anaesthesia

Preanaesthetic medication should be effective and pleasant to be taken orally, have analgesic and non-emetic properties, should not impair cardiovascular stability or depress respiration and produce adequate sedation and anxiolysis. We wanted to compare the effectiveness of oral clonidine and oral midazolam as preanaesthetic medicants.METHODSAfter obtaining the institutional ethical committee clearance and written informed consent, 60 patients, selected for surgery under general anaesthesia were divided by computer generated randomization in Group C (n=30): received Tablet clonidine 150 mcg (0.15 mg) and Group M (n=30): received Tablet midazolam 7.5 mg. Noninvasive blood pressure (systolic, diastolic & mean), respiratory rate, heart rate, degree of sedation, degree of anxiolysis, were recorded at, just before the administration of the any study drug which was 90 minutes before to the induction of anaesthesia, just before to induction of anaesthesia, three minutes after the orotracheal intubation, every 10 minutes for 3 such readings, and three minutes after the orotracheal extubation, and were statistically analysed.RESULTSOral clonidine produced significant attenuation of systolic, diastolic & mean arterial pressure, and reduced respiratory rate, than oral midazolam. Oral midazolam was able to attenuate the pulse rate in a better way than oral clonidine. Oral clonidine produced significant sedation and anxiolysis in comparison to patients who receiving oral midazolam.CONCLUSIONSOral clonidine is the better attenuator amongst the two drugs studied as premedicants to attenuate the cardiovascular responses to laryngoscopy and intubation.

Randomized placebo controlled study of diclofenac as premedication for endoscopic retrograde cholangiopancreatography

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure which is commonly performed at various centres. It causes considerable amount of pain and discomfort to patients, and various centres have their own protocols regarding its management. Authors aim to study the efficacy of intravenous diclofenac as a premedication to reduce the pain and discomfort during and after ERCP.Methods: This was a randomized placebo-controlled trial evaluating 40 patients. The pain and degree of discomfort was investigated using a 4- point ordinal scale questionnaire.Results: The use of intravenous diclofenac as premedication for ERCP significantly reduces pain and discomfort during and after the procedure.Conclusions: Intravenous diclofenac should be used as a premedication for ERCP procedure as it significantly reduces the pain and discomfort during and after the procedure.

Effectiveness of Midazolam Compared to Diazepam and Placebo For Reducing Anxiety after Premedication at Sylhet Women’s Medical College

Introduction: Anxiolytic premedication is debated most of thetime in the outpatient surgical community. The management ofanxiety reducing medications may be considered unnecessaryby anesthesiologists when anxiety rates are small inoutpatients with minor operations. Thanks to its rapid onsetand short halflife, intravenous (IV) midazolam is the mostwidely used premedicant in ambulatory environments, but itspersistent effects in the prompt postoperative period may leadto postoperative sedation, as well as delayed recovery anddischarge readiness after brief ambulatory surgery.Objective: This research is carried out specifically to checkwhether the use of the medicine for preanesthesia midazolamquantifiably decreases pain as opposed to having nopreanesthesia drug (placebo) or diazepam prior to medicalprocedures.Method: The examination's inclusion requirements arepatients aged between 18 and 68 years scheduled for electivesurgery or diagnostic procedures involving anesthesia. Aninterventional (clinical trial) study with 160 patients scheduledfor surgical or diagnostic procedures involving anesthesiatechniques was performed at a neighbourhood emergencyclinic called Sylhet Women’s Medical College located in Sylhet,Bangladesh. Research length from Aug 2018 to Aug 2019.Results: After multiple investigations of knowledge andanalysis it was discovered that diazepam with little or nosymptoms placed ahead of midazolam and placebo.Conclusion: It can be clearly inferred that in case of adecrease in anxiety, diazepam ranks first compared tomidazolam or placebo.

Study of intranasal midazolam versus intranasal ketamine as a premedication in children undergoing surgical procedures

Background: Usage of premedication in children undergoing surgery is almost imperative and various medications have been used with varying success. The present study was aimed at comparison of intranasal midazolam and intranasal ketamine as a premedication in children by assessing acceptability of the drug by patients, ease at parent separation, level of sedation at the time of induction and facilitation of intravenous cannulation.Methods: In this comparative observational study, 60 eligible participants were randomly divided into two groups of 30 each on the basis of preanaesthetic medication received: those intranasal midazolam group and intranasal ketamine group. At 30 minutes after intranasal dose, sedation, separation from parents and intravenous cannula acceptance was evaluated on four point score scale. Children were constantly observed for occurrence of possible adverse effects and the same were duly noted.Results: The two groups were similar with respect to age, gender and body weight distribution. Twenty four patients (80%) in both ketamine and midazolam groups were observed to become drowsy, while 6 patients (20%) in ketamine group were asleep, compared to 0 patients in midazolam group (p=0.024). Thirteen (43.3%) patients from midazolam group had poor parenteral separation, as compared to 0 patients from ketamine group. And Comparison of intravenous cannula acceptance revealed the acceptance to be good in 26 (86.7%) patients in ketamine group as compared to 10 (33.3%) patients in midazolam group (p<0.001).Conclusions: Ketamine when given in a dose of 5 mg/kg via intranasal route is better than midazolam given in a dose of 0.2mg/kg intranasally, as a premedication in children.

Oral Clonidine Premedication and its effect on Subarachoid block: A Randomised Study

Oral clonidine has been reported to prolong the sub arachnoid block and postoperative analgesia. The study was conducted to evaluate the effectiveness of oral clonidine as premedication on subarachnoid block. Methods: 100 patients of aged 20-60 years (ASA-1 and ASA-2 ) undergoing infraumbilical surgeries were included in this prospective, double blind randomized study. Patients divided in to two ( n = 50 ) groups. Group Ι patients receiving oral clonidine 150 μg one hour before surgery and Group ΙΙ patients receiving oral placebo. Post-op motor block and pain was assessed by using Bromage Scale and Visual Analogue Scale respectively. Statestical analysis used: Both groups were compared by using paired t test. Results: the onset of sensory block in group II 4.40±0.11 min. Vs 3.58±0.10 min. in group I (p < 0.001) , the onset of motor block 5.47±0.12 min. in group II Vs 5.37±0.15 min. in group I (p < 0.001). the duration of sensory block in group II 154.8±13.01 min VS 211.1±10.37min. of group I duration of motor block 138.9±12.5 min. in group II VS 184.2±11.31 min. of group I. (p< 0.001). Total duration of Analgesia for group I 399.46 ± 6.12 vs 149.92 ± 4.14 for group I (P < 0.001). Conclusion: Clonidine as oral premedication hastens the onset of sensory block, motor block and increases duration of sensory and motor block as well as total duration of analgesia.

Are acute infusion reactions after rituximab underreported?

Background: Rigorous premarketing trials may fail to capture safety issues associated with new drugs. This is more likely to happen in case of biopharmaceuticals. We take the case of rituximab, and anti CD20 monoclonal antibody, which was the first monoclonal antibody to get approval. This open label observational study was done with the objective of estimating the incidence of acute infusion reaction associated with rituximab infusion.Methods: The study population consisted of patients hospitalized for receiving rituximab, in day care centre(s) of a tertiary care hospital. Number and type of acute infusion reactions (AIR) were recorded on a case record form along with patient characteristics and medical history.Results: A total of 50 infusions were observed and all infusions were followed by at least one AIR. Total 71 AIRs were recorded among these 50 infusions (1.4 AIR per infusion). Non-Hodgkin’s lymphoma was the commonest indication for which patients were receiving rituximab. In a subset analysis, incidence of AIR was statistically lower in patients having received corticosteroids as premedication. However, brand of rituximab, gender of the patient and first or second cycle had no bearing on incidence of AIRs.Conclusions: AIRs are more common in real time clinical settings than what is reported. There is a need to formulate appropriate risk management plan depending on post marketing clinical data. Use of corticosteroids as premedication may be one such strategy. New drugs, esp biopharmaceuticals, may have unidentified/under reported safety issues and there is a need to undertake focussed pharmacovigilance endeavours to unravel them.

A comparative evaluation of effect of intravenous premedication with ondansetron versus granisetron on hemodynamics and sensory-motor blockade produced by intrathecal hyperbaric 0.5% bupivacaine

Background: Bezold Jarisch reflex is important cause of hypotension and bradycardia which occur after spinal anaesthesia. This reflex is elicited by stimulation of peripheral serotonin receptors 5- hydroxytryptamine (5- HT3 type). These receptors have antinociceptive effect, which is confirmed by many studies.The two most commonly used 5HT3 antagonist are ondansetron and granisetrone. Very few comparative studies of the two drugs on the effect after spinal anaesthesia are available.Methods: Ninety adulted patients of either sex aged 18-58 years scheduled for elective infraumbilical surgeries were randomly allocated in three groups to receive intravenous ondansetron 4mg, granisetrone 2mg or normal saline in equal volume 5mins before spinal anesthesia. Hemodynamic changes and time to sensory motor onset and regression were evaluated.Results: There was statistically significant difference in fall of systolic diastolic and mean blood pressure among the three groups. Time to two segment regression of sensory block and time to regression to S1 was faster in ondansentron (76.6±17.2mins, 176±22mins) and granisetrone group (69±17.3mins, 165±19.2mins) in comparision to control group(77.4±24.3mins, 178±21mins) which was statistically significant also p value-0.019, 0.0001 respectively.Conclusions: The prophylactic therapy with 4mg i.v. ondansetron, given five minutes before spinal anaesthesia appears to be significantly most effective and safe for attenuating haemodynamic response after spinal anaesthesia without affecting the duration of sensory block in patients undergoing infraumbilical surgeries.