Sevoflurane with opioid or dexmedetomidine infusions in dogs undergoing intracranial surgery: a retrospective observational study

Development and Validation of the Cluster Headache Screening Questionnaire

BACKGROUND AND PURPOSE: Cluster headache (CH) is frequently either not diagnosed or the diagnosis is delayed. We addressed this issue by developing the self-administered Cluster Headache Screening Questionnaire (CHSQ). METHODS: Experts selected items from the diagnostic criteria of CH and the characteristics of migraine. The questionnaire was administered to first-visit headache patients at nine headache clinics. The finally developed CHSQ included items based on the differences in responses between CH and non-CH patients, and the accuracy and reliability of the scoring model were assessed. RESULTS: Forty-two patients with CH, 207 migraineurs, 73 with tension-type headache, and 18 with primary stabbing headache were enrolled. The CHSQ item were scored as follows: 3 points for ipsilateral eye symptoms, agitation, and duration; 2 points for clustering patterns; and 1 point for the male sex, unilateral pain, disability, ipsilateral nasal symptoms, and frequency. The total score of the CHSQ ranged from 0 to 16. The mean score was higher in patients with CH than in non-CH patients (12.9 vs. 3.4, p 8 points, the CHSQ had a sensitivity, specificity, positive predictive value, and negative predictive value of 95.2%, 96%, 76.9%, and 99.3%, respectively. CONCLUSIONS: The CHSQ is a reliable screening tool for the rapid identification of CH.

Adverse Events and Risk Factors Associated with Chloral Hydrate Sedation for Brain Magnetic Resonance Imaging in the Neonatal Intensive Care Unit

PURPOSE: This study investigated the incidence of adverse events (AEs) and risk factors associated with sedation using chloral hydrate (CH) for brain magnetic resonance imaging (MRI) in the neonatal intensive care unit (NICU). METHODS: This was a retrospective study of infants who received CH for brain MRI in the NICU. Among the enrolled infants (n=143), 12.6% (n=18) were included in the AE group and 87.4% (n=125) were in the non-adverse event group (NAE). RESULTS: Gestational age (GA) at birth and corrected GA at sedation were 35+0±7+2 and 39+5±3+1 respectively. The rate of AEs was 12.6%, included oxygen desaturation (5.6%), aspiration (4.9%), paradoxical agitation (0.7%), tachycardia or bradycardia (0.7%), and arrest (0.7%). In univariate analysis, the AE group was younger in corrected GA at sedation than the NAE group (37+2 [range, 36+0 to 40+0] vs. 40+1 [range, 38+2 to 41+4], P=0.015). There was no significant difference in CH dosage (50.0 [range, 50.0 to 50.0] vs. 50.0 [range, 50.0 to 50.0], P=0.092), cardiopulmonary (33.3% [n=6] vs. 17.6% [n= 22], P=0.209) and central nervous system (61.1% [n=11] vs. 65.6% [n=82], P=0.054) morbidity. In multivariate analysis, CH dosage was the only significant risk factor for AEs associated with sedation (odds ratio, 1.04; 95% confidence interval, 1.01 to 1.07; P=0.0186). CONCLUSION: AEs associated with sedation using CH are not uncommon and should be considered when using high dose CH for diagnostic testing in the NICU.

Metoprolol treatment of dual cocaine and bupropion cardiovascular and central nervous system toxicity

Cardiovascular and central nervous system (CNS) toxicity, including tachydysrhythmia, agitation, and seizures, may arise from cocaine or bupropion use. We report acute toxicity from the concomitant use of cocaine and bupropion in a 25-year-old female. She arrived agitated and uncooperative, with a history of possible antecedent cocaine use. Her electrocardiogram demonstrated tachycardia at 130 beats/min, with a corrected QT interval of 579 ms. Two doses of 5 mg intravenous metoprolol were administered, which resolved the agitation, tachydysrhythmia, and corrected QT interval prolongation. Her comprehensive toxicology screen returned positive for both cocaine and bupropion. We believe clinicians should be aware of the potential for synergistic cardiovascular and CNS toxicity from concomitant cocaine and bupropion use. Metoprolol may represent an effective initial treatment. Unlike benzodiazepines, metoprolol directly counters the pharmacologic effects of stimulants without respiratory depression, sedation, or paradoxical agitation. A lipophilic beta-blocker, metoprolol has good penetration of the CNS and can counter stimulant-induced agitation.

Anaphylactic reaction with hydroxyethyl starch during anesthesia: A case report

BACKGROUND: Hydroxyethyl starch (HES), a class of synthetic colloid solutions, has been widely used to treat perioperative hypovolemia. The use of HES, however, is associated with the risk of allergic reactions.CASE: An 83-year-old man was scheduled to undergo an open reduction and internal fixation of a pertrochanteric fracture under spinal anesthesia. He had no history of allergy. Five minutes after HES administration, hypotension, agitation, and skin rash were developed. HES infusion was terminated due to a suspected anaphylactic reaction. The vital signs recovered following administration of phenylephrine, dexamethasone, and hydrocortisone. Serum tryptase and total immunoglobulin E levels were elevated in plasma samples collected following the commencement of the allergic reaction during surgery.CONCLUSIONS: In the present report, the risk of anaphylactic reaction with HES and the laboratory tests needed to support the diagnosis are highlighted.

Postoperative emergence agitation and intraoperative sevoflurane sedation under caudal block in children: a randomized comparison of two sevoflurane doses

BACKGROUND: Sub-umbilical surgery under caudal block in conjunction with sevoflurane sedation may be safe in terms of maintaining spontaneous breathing and avoiding complications associated with general anesthesia. However, sevoflurane-induced emergence agitation (EA) continues to be a clinically important phenomenon in children. To compare the incidence of EA in children undergoing sub-umbilical surgery under caudal block with two different doses of sevoflurane.METHODS: Forty children (aged 1–5 years) scheduled to undergo inguinal hernia repair under caudal block with sevoflurane sedation via a face mask were randomized into either the low-dose (1.0%) end-tidal sevoflurane concentration group (Group LS) or the high-dose (2.5%) end-tidal sevoflurane concentration group (Group HS). We monitored EA episodes at 5 and 30 min in the post-anesthetic care unit (PACU) by using the four-point agitation scale and the Pediatric Anesthesia Emergence Delirium (PAED) scale.RESULTS: The four-point agitation scale scores and PAED scores were not different between the groups at 5 min. However, the agitation score was higher in Group HS than in Group LS at 30 min after arriving in the PACU. The time required to recover from sedation was longer in Group HS than in Group LS.CONCLUSIONS: Face-mask sedation with 1.0% sevoflurane in conjunction with caudal block may be more effective than that with 2.5% sevoflurane in preventing EA.

Evaluation of Propofol in Comparison with Other General Anesthetics for Surgery in Children Younger than 3 Years: a Systematic Review and Meta-Analysis

BACKGROUND: Despite well-known advantages, propofol remains off-label in many countries for general anesthesia in children under 3 years of age due to insufficient evidence regarding its use in this population. This study aimed to evaluate the efficacy and safety of propofol compared with other general anesthetics in children under 3 years of age undergoing surgery through a systematic review and meta-analysis of existing randomized clinical trials. METHODS: A comprehensive literature search was conducted of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to find all randomized clinical trials comparing propofol with another general anesthetic that included children under 3 years of age. The relative risk or arcsine-transformed risk difference for dichotomous outcomes and the weighted or standardized mean difference for continuous outcomes were estimated using a random-effects model. RESULTS: A total of 249 young children from 6 publications were included. The children who received propofol had statistically significantly lower systolic and diastolic blood pressures, but hypotension was not observed in the propofol groups. The heart rate, stroke volume index, and cardiac index were not significantly different between the propofol and control groups. The propofol groups showed slightly shorter recovery times and a lower incidence of emergence agitation than the control groups, while no difference was observed for the incidence of hypotension, desaturation, and apnea. CONCLUSION: This systematic review and meta-analysis indicates that propofol use for general anesthesia in young healthy children undergoing surgery does not increase complications and that propofol could be at least comparable to other anesthetic agents.

Effects of Two Music Therapy Methods on Agitation and Anxiety among Patients Weaning off Mechanical Ventilation: A Pilot Study / 기본간호학회지

PURPOSE: The feasibility and differential effects of two music therapy methods (interventions with preferred music vs. classical relaxation music) were done to examine the effects on agitation and anxiety in patients weaning off mechanical ventilation. METHODS: This pilot study was conducted using a crossover design. Six patients listened to preferred music choices and classical relaxation music. Anxiety scores were measured using the Richmond Agitation Sedation Scale (RASS), State-Trait Anxiety Inventory (STAI), and visual analog scale (VAS). RESULTS: Patients showed a significant decrease in agitation and anxiety after both the preferred and classical relaxation music interventions. The difference in the effects of preferred music and that of classical relaxation music was not significant. As for feasibility, patients exhibited a change in agitated behaviors after the music interventions by not trying to take off medical devices and quietly listening to the music, and by smiling and moving lips along with the lyrics while listening. CONCLUSION: Music interventions which centered on either patients' preferences or classical relaxation music to enhance relaxation, helped reduce agitation and anxiety during the mechanical ventilation weaning process.

Effects of Aromatherapy on Agitation in Patients with Dementia: A Systematic Literature Review and Meta-analysis

PURPOSE: The purpose of this study is to identify the effects of aromatherapy on agitation in patients with dementia using a meta-analysis and systemic literature review. METHODS: The EMBASE, CINAHL, MEDLINE, and other databases were searched up to November 2017. RESULTS: Of 419 publications identified, 12 met inclusion criteria, and 9 studies were used to estimate the effect size of aromatherapy. A total of 837 participants across all studies were included. The commonly applied methods were massage (50%), type of oil lavender (75%), and instrument Cohen-Mansfield Agitation Inventory (75%). A medium effect size of aromatherapy on agitation was identified (d=−0.56, I2=65.0%, p=.001). The massage group has lower effect size than the other group (d=−0.98, I2=0.0%, p=.001). CONCLUSION: Aromatherapy appears to be effective in improving agitation in patients with dementia. However, further studies for home-dwelling patients with dementia and with different types of aroma oil should be conducted in the future. In addition, research with well-designed are needed to assess the effects or aromatherapy on agitation.

Antimicrobial effect of toothbrush with light emitting diode on dental biofilm attached to zirconia surface: an in vitro study

PURPOSE: The purpose of this study was to evaluate the antimicrobial effects of a toothbrush with light-emitting diodes (LEDs) on periodontitis-associated dental biofilm attached to a zirconia surface by static and dynamic methods. MATERIALS AND METHODS: Zirconia disks (12 mm diameter, 2.5 mm thickness) were inserted into a 24-well plate (static method) or inside a Center for Disease Control and Prevention (CDC) biofilm reactor (dynamic method) to form dental biofilms using Streptococcus gordonii and Fusobacterium nucleatum. The disks with biofilm were subdivided into five treatment groups-control, commercial photodynamic therapy (PDT), toothbrush alone (B), brush with LED (BL), and brush with LED+erythrosine (BLE). After treatment, the disks were agitated to detach the bacteria, and the resulting solutions were spread directly on selective agar. The number of viable bacteria and percentage of bacterial reduction were determined from colony counts. Scanning electron microscopy (SEM) was performed to visualize alterations in bacterial morphology. RESULTS: No significant difference in biofilm formation was observed between dynamic and static methods. A significant difference was observed in the number of viable bacteria between the control and all experimental groups (P < 0.05). The percentage of bacterial reduction in the BLE group was significantly higher than in the other treated groups (P < 0.05). SEM revealed damaged bacterial cell walls in the PDT, BL, and BLE groups, but intact cell walls in the control and B groups. CONCLUSION: The findings suggest that an LED toothbrush with erythrosine is more effective than other treatments in reducing the viability of periodontitis-associated bacteria attached to zirconia in vitro.

Factors associated with Pediatric Delirium in the Pediatric Intensive Care Unit

PURPOSE: This study aimed to investigate incidence of delirium in the pediatric intensive care unit (PICU) and to analyze associated risk factors. METHODS: The participants were 95 patients, newborn to 18 years, who were admitted to the PICU. The instruments used were the Richmond Agitation Sedation Scale (RASS), and the Cornell Assessment of Pediatric Delirium. Data analysis was performed using the descriptive, χ² test, t-test, and logistic regression analyses. RESULTS: The incidence of delirium in children admitted to the PICU was 42.1%. There were significant differences according to age (χ²=14.10, p=.007), admission type (χ²=7.40, p=.007), use of physical restraints (χ²=26.11, p<.001), RASS score (χ²=14.80, p=.001), need for oxygen (χ²=5.31, p=.021), use of a mechanical device (χ²=9.97, p=.041), feeding (χ²=7.85, p=.005), and the presence of familiar objects (χ²=29.21, p<.001). Factors associated with the diagnosis of delirium were the use of physical restraint (odds ratio [OR]=13.82, 95% confidence interval [CI]=4.16~45.95, p<.001) and the presence of familiar objects (OR=0.09, 95% CI=0.03~0.30, p=.002). CONCLUSION: Periodic delirium assessments and intervention should be actively performed. The use of restraints should be minimized if possible. The caregiver should surround the child with familiar objects and ensure a friendly hospital environment that is appropriate for the child.

Postoperative pain control by ultrasound guided brachial plexus block reduces emergence delirium in pediatric patients

BACKGROUND: Pediatric patients awakening from general anesthesia may experience emergence delirium (ED), often due to inadequate pain control. Nerve block completely inhibits innervation of the surgical site and is superior to systemic analgesics. This study assessed whether pain control through nerve block relieves ED after general anesthesia. METHODS: Fifty patients aged 2–7 years with humerus condyle fractures were randomly assigned to receive ultrasound guided supraclavicular brachial plexus block (BPB group) or intravenous fentanyl (Opioid group). The primary outcome was score on the pediatric anesthesia emergence delirium (PAED) scale on arrival at the postanesthesia care unit (PACU). Secondary outcomes were severity of agitation and pain in the PACU, the incidence of ED, and postoperative administration of rescue analgesics over 24 h. RESULTS: PAED scale was significantly lower in the BPB group at arrival in the PACU (7.2 ± 4.9 vs. 11.6 ± 3.2; mean difference [95% confidence interval (CI)] = 4.4 [2.0–6.8], P < 0.001) and at all other time points. The rate of ED was significantly lower in the BPB group (36% vs. 72%; relative risk [95% CI] = 0.438 [0.219–0.876], P = 0.023). The BPB group also had significantly lower pain scores and requiring rescue analgesics than Opioid group in the PACU. CONCLUSIONS: Ultrasound guided BPB, which is a good option for postoperative acute phase pain control, also contributes to reducing the severity and incidence of ED.

Korean Treatment Guideline on Pharmacotherapy of Co-existing Symptoms and Antipsychotics-related Side Effects in Patients with Schizophrenia / 대한정신분열병학회지

OBJECTIVES: The current study covers a secondary revision of the guidelines for the pharmacotherapy of schizophrenia issued by the Korean Medication Algorithm for Schizophrenia (KMAP-SCZ) 2001, specifically for co-existing symptoms and antipsychotics-related side-effects in schizophrenia patients. METHODS: An expert consensus regarding the strategies of pharmacotherapy for positive symptoms of schizophrenia, co-existing symptoms of schizophrenia, and side-effect of antipsychotics in patients with schizophrenia was retrieved by responses obtained using a 30-item questionnaire. RESULTS: For the co-existing symptoms, agitation could be treated with oral or intramuscular injection of benzodiazepine or antipsychotics; depressive symptoms with atypical antipsychotics and adjunctive use of antidepressant; obsessive-compulsive symptoms with selective serotonin reuptake inhibitors and antipsychotics other than clozapine and olanzapine; negative symptoms with atypical antipsychotics or antidepressants; higher risk of suicide with clozapine; comorbid substance abuse with use of naltrexone or bupropion/ varenicline, respectively. For the antipsychotics-related side effects, anticholinergics (extrapyramidal symptom), propranolol and benzodiazepine (akathisia), topiramate or metformin (weight gain), change of antipsychotics to aripiprazole (hyperprolactinemia and prolonged QTc) or clozapine (tardive dyskinesia) could be used. CONCLUSION: Updated pharmacotherapy strategies for co-existing symptoms and antipsychotics-related side effects in schizophrenia patients as presented in KMAP-SCZ 2019 could help effective clinical decision making of psychiatrists as a preferable option.

Three minutes propofol after sevoflurane anesthesia to prevent emergence agitation following inguinal hernia repair in children: a randomized controlled trial / 대한마취과학회지

BACKGROUND: Emergence agitation (EA) is a common problem after sevoflurane anesthesia among children. There have been mixed results with control of EA using propofol 1 mg/kg bolus following sevoflurane anesthesia. An infusion of 3 mg/kg of propofol over 3 min following sevoflurane anesthesia has been found to be promising in children undergoing magnetic resonance imaging scans. However, no studies have been conducted during surgical procedures. We aimed to examine the efficacy of transition to propofol for 3 min after cessation of sevoflurane anesthesia in children undergoing inguinal hernia repair. METHODS: In this prospective randomized controlled trial, 64 children aged 1–12 years, scheduled for inguinal hernia repair, were randomized to receive either propofol 3 mg/kg over 3 min (propofol group) or no propofol (control group), after the cessation of sevoflurane anesthesia. EA was assessed using the Paediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale. Emergence time and the duration of post-anesthesia care unit (PACU) stay were also recorded. RESULTS: The incidence of ED was lower in the propofol group on both the PAED (81.3% vs. 15.6%, P < 0.001) and the Watcha (78.1% vs. 15.6%, P < 0.001) scales. The mean emergence time was 6.37 minutes longer in the propofol group with no significant difference in PACU times. CONCLUSIONS: Transition to propofol 3 mg/kg over 3 min following sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. Although emergence times were longer, the duration of stay in the PACU was similar with propofol use.

Low-dose intravenous ketamine versus intravenous ketorolac in pain control in patients with acute renal colic in an emergency setting: a double-blind randomized clinical trial / 대한통증학회지

BACKGROUND: This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED). METHODS: This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter. RESULTS: The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group. CONCLUSIONS: Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.

A Systematic Review and Meta-Analysis of Nonpharmacological Interventions for Moderate to Severe Dementia

OBJECTIVE: Due to limited efficacy of medications, non-pharmacological interventions (NPI) are frequently co-administered to people with moderate to severe dementia (PWMSD). This systematic review and meta-analysis investigated the effects of NPI on activities of daily living (ADL), behavioral and psychological symptoms of dementia (BPSD), and cognition and quality of life (QoL) of PWMSD. METHODS: A literature search was conducted in the following databases: Cochrane CENTRAL, EMBASE, Medline, CIHNAL, PsycINFO, KoreaMED, KMbase, and KISS. We conducted a meta-analysis on randomized controlled trials and used the generic inverse variance method with a fixed-effects model to calculate the standardized mean difference (SMD). The protocol had been registered (CRD42017058020).

Psychiatric Consultations at an Emergency Department in a Metropolitan University Hospital in Northern Japan

Many patients with mental disorders visit emergency departments (EDs). However, the majority of these patients do not receive psychiatric assessment. In the present study, we investigated the detailed proportion of patients with mental disorders visiting an urban ED in the largest northern city in Japan. A retrospective chart review study was performed at a University Hospital from January 2012 to December 2015. The reasons for psychiatric consultations made by ED staff, and the primary psychiatric diagnoses were investigated. Among all living patients, 20% of them received consultations. The most common reason for consultation was suicide attempt followed by agitation or insomnia. Of all diagnoses, organic mental disorder was the most frequent and the mean age was significantly higher than the other diagnostic groups. Our study indicated that the frequency of psychiatric consultation was high. This indicates the high demand for mental health services at the ED. A thorough psychiatric assessment can provide adequate psychiatric services to acute patients; thereby possibly preventing suicide attempters from later actually dying by suicide.

Limbic Encephalitis Manifesting as Selective Amnesia and Seizure-like Activity: A Case Report

Limbic encephalitis (LE) is characterized by short-term memory loss, disorientation, agitation, seizures, and histopathological evidence of medial temporal lobe inflammation. Leucine-rich, glioma inactivated 1 (LGI-1) is an auto-antigen associated with LE. We report a 37-year-old male patient with LGI-1-related LE who presented with recurrent episodes of selective amnesia, seizure-like activity, confusion, and personality change. His symptoms were significantly improved with steroid therapy. Thorough differential diagnosis with consideration for autoimmune encephalitis should be in patients with presentation of symptoms, such as memory impairment, personality change and seizure-like activity, especially when other neurological diagnoses are excluded.

Strategies of Using Antipsychotics in Patients with Bipolar Disorders / 신경정신의학

Bipolar disorder is a recurrent chronic condition and patients usually continue long-term medication from young age to prevent the recurrence of mood episodes. Antipsychotics play an important role in acute and maintenance treatment of bipolar disorder, even when patients experience no psychotic symptoms. Antipsychotics are also used in monotherapy and combination therapy involving mood stabilizers such as lithium or valproate. However, limited antipsychotics are currently approved by the US Food & Drug Administration ; 10 kinds of antipsychotics were approved for manic or mixed episodes, 3 for bipolar depression, and 5 for maintenance therapy. Before and after the use of antipsychotics, psychiatrists should carefully monitor baseline weight, pulse, blood pressure, fasting blood glucose or HbA1c, blood lipid profile, and electrocardiogram to evaluate QTc prolongation. During manic episodes or mixed features, antipsychotics rapidly control agitation, aggression, and impulsivity. Repetitive injections of typical antipsychotics are not implemented in bipolar patients as this practice is not evidence-based. However, long-acting injectable atypical antipsychotics are approved and feature support on maintenance therapy for bipolar patients. Although recent studies have shown the benefits of aripiprazole and olanzapine on rapid-cycling bipolar patients, few studies support the effectiveness of antipsychotics in suicide prevention. Moreover, while there is extensive evidence on the effectiveness of lithium in suicide or self-harm prevention. In conclusion, antipsychotics, especially aripiprazole, quetiapine, olanzapine, and risperidone, are effective to manage bipolar disorder in clinical settings. But weight gain and cardiac conductance should be carefully monitored before and during the use of antipsychotics.

Antipsychotic-Induced Oculogyric Crisis and Paroxysmal Perceptual Alteration / 대한정신분열병학회지

During antipsychotic drug treatment, clinicians occasionally encounter sudden attacks of oculogyric crisis (OGC) and/or paroxysmal perceptual alteration (PPA) which occur mostly in the afternoon or early evening lasting for minutes to hours and are eventually remitted with rests or short sleep and/or medications such as benzodiazepines, anticholinergics and so forth. Moreover, these attacks are usually accompanied with psychiatric symptoms such as various modalities of hallucinations and illusions, delusions, obsessive thoughts, panic attacks, agitation as well as autonomic symptoms. These accompanying psychiatric symptoms can be perceived as a worsening of psychiatric symptoms if the clinician does not understand the symptoms due to the side effects of antipsychotic drugs, which may result in increasing the dosage of antipsychotics instead of reducing doses or switching to less offending drugs. On the other hand, patients could easily recognize the symptoms as the adverse effects of drugs. This literature review and case-series study is aimed to raise awareness of OGC and PPA by providing clinical cases and author's views with the literature reviews about concepts, recognitions and managements from the works of Japanese authors who first reported the clinical importance of these attacks, particularly PPA.