Oral Clonidine and Midazolam as Premedication in Pediatric Anesthesia- Efficacy and Outcome in Comparison with Oral Promethagine.

Background: In most of the centers of developing country no premedication is used in cases of anesthesia in paediatric population. Many centers use oral promethagine on the night before to ensure good sleep. Th ere is dilemma of using premedication with a fear of losing control over baby. Th ere are controversial results regarding the eff ectiveness of clonidine compared with midazolam as premedication in children. Aim: Th e aim of this study is to evaluate the effi cacy of oral clonidine and midazolam as a premedication and compare to with that of conventional promethagine in pediatric patients. Methods: Th is prospective randomized controlled study was carried out in Combined Military Hospital, Dhaka, among 90 children aged 2 to 7 years of ASA grade I & II scheduled for elective surgery under general anaesthesia during the period of Jan 2012 to Dec 2013. All the children were randomly divided in three groups, 30 children received only syrup promethagine as per body weight (Group-P, n=30) at night. In the study groups, after the syp promethagine at night in addition they were also given oral clonidine 4 μg/kg mixed with honey (Group-C, n=30) and midazolam 0.5 mg/kg mixed with honey (Group-M, n=30) at 60 and 20 min before separation of baby from parents lap respectively. Th e protocol of general anesthesia like induction, intubation, maintenance, reversal and postoperative analgesia was the same for all three groups. Patient’s sedation status, separation anxiety, venipuncture, mask acceptance, anesthetics requirement, salivation, analgesia, post operative nausea vomiting (PONV) and emergence agitation were recorded by an observer blind of the patient’s group. Results: Children characteristics were similar in all three groups. Children who had received clonidine as well as midazolam had more satisfactory sedation upon parent separation and less separation anxiety than promethazine; compared with midazolam & promethazine, clonidine premedication was associated with better mask acceptance; children who had received clonidine had signifi cantly less incidence of salivation and less rescue antisialagogue; children received clonidine were better managed both intra & post operatively and needed less rescue analgesics; children who had received clonidine had signifi cantly less episodes of PONV and also required less rescue antiemetic; incidence of emergence agitation was less in clonidine group in comparison with other two groups. Conclusion: Th e fi ndings of the study suggest that both midazolam and clonidine are safe and eff ective as anaesthetic premedication in paediatric population. It can be concluded that oral midazolam premedication is eff ective as far as sedation is concern but considering multifarious anesthetic function oral clonidine is much superior premedicant. However, the risks of heart rate and blood pressure decreases, and the prolonged onset of sedation associated with clonidine should be considered. We recommend further multi-centre studies with larger samples to validate fi ndings of our study.

Rapid tranquilization for agitated patients in emergency psychiatric rooms: a randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone / Tranquilização rápida para pacientes agitados nos serviços de emergência psiquiátrica: um ensaio clínico randomisado de olanzapina, ziprasidona, haloperidol mais prometazina, haloperidol mais midazolam e haloperidol em monoterapia

OBJECTIVE: To compare the effectiveness of intramuscular olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone as the first medication(s) used to treat patients with agitation and aggressive behavior. METHOD: One hundred fifty patients with agitation caused by psychotic or bipolar disorder were randomly assigned under double-blind conditions to receive olanzapine, ziprasidone, haloperidol plus midazolam, haloperidol plus promethazine or haloperidol alone. The Overt Agitation Severity Scale, Overt Aggression Scale and Ramsay Sedation Scale were applied within 12 hours after the first dosage. RESULTS: All medications produced a calming effect within one hour of administration, but only olanzapine and haloperidol reduced agitation by less than 10 points, and only olanzapine reduced aggression by less than four points in the first hour. After twelve hours, only patients treated with haloperidol plus midazolam had high levels of agitation and aggression and also more side effects. Ziprasidone, olanzapine and haloperidol alone had more stable results for agitation control, while ziprasidone, haloperidol plus promethazine and olanzapine had stable results for aggression control. CONCLUSION: Olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol were effective in controlling agitation and aggression caused by mental illness over 12 hours. Although all the drugs had advantages and disadvantages, haloperidol plus midazolam was associated with the worst results in all the observed parameters.

OBJETIVO: Comparar a eficácia da olanzapina, ziprasidona, haloperidol associado ao midazolam, haloperidol associado à prometazina e haloperidol isoladamente por via intramuscular como primeira escolha no tratamento de pacientes em agitação e agressividade. MÉTODO: Cento e cinquenta pacientes com agitação psicomotora por transtorno psicótico ou transtorno bipolar foram recrutados para estudo duplo-cego e receberam olanzapina, ziprasidona, haloperidol associado a midazolam, haloperidol associado a prometazina ou haloperidol isoladamente. Foram aplicadas as escalas Overt Agitation Severity Scale, Overt Aggression Scale e Ramsay Sedation Scale no período de 12 horas após a primeira aplicação. RESULTADOS: Todas as medicações foram capazes de acalmar os pacientes após uma hora da administração. Apenas a olanzapina e o haloperidol reduziram a agitação para menos de 10 pontos e apenas a olanzapina reduziu a agressividade para menos de quatro pontos nesse período. Doze horas depois, apenas o haloperidol com midazolam apresentou valores altos para a agitação e agressividade, e também esteve relacionado com maior proporção de efeitos colaterais. A ziprasidona, a olanzapina e o haloperidol apresentaram resultados mais estáveis para o controle da agitação e a ziprasidona, haloperidol associado a prometazina e olanzapina para o controle da agressividade. CONCLUSÃO: A olanzapina, a ziprasidona, o haloperidol associado a prometazina, o haloperidol associado ao midazolam e o haloperidol isoladamente foram efetivos no controle da agitação e da agressividade secundária a transtornos mentais dentro de 12 horas. Todas as drogas apresentaram vantagens e desvantagens, exceto pela associação haloperidol e midazolam que demonstrou os piores resultados em todos os parâmetros.

Premedication for coronary angiography: effects on anxiety and hemodynamic status.

AIM: This study was designed to compare the outcomes of two current methods of premedication, for coronary angiography with placebo, on the level of anxiety and hemodynamic status. METHODS AND RESULTS: In all, 151 patients referring for coronary angiography were randomized into three groups with equal populations. The first group (group M) received 0.02 mg/kg intravenous midazolam; the second (group DP7rpar; received intramuscular injection of 5mg diazepam + 25 mg promethazine; and the third (group P) received 2cc of intravenous normal saline solution. Vital signs, blood pressure, and peripheral O2 saturation were recorded in specifically-designed questionnaires. The level of anxiety before and after angiography was documented according to the Visual Analog Scale. Patients in the group M accidentally had higher pre-procedural anxiety level (p < 0.05). There was no significant difference in pulse rate, respiratory rate, and mean blood pressure (BP) between these groups prior to angiography. In the group M, diastolic BP decreased more significantly than the other 2 groups during angiography (p < 0.05). Although number of punctures, pain at catheterization site, dose of lidocaine, level of consciousness, and patient satisfaction did not show a significant difference between the three groups; midazolam induced higher level of amnesia than the other 2 groups and the physicians were more satisfied with it only compared with diazepam + promethazine (p < 0.05). CONCLUSION: Because of the importance of hemodynamic stability and comfort during angiography, non-pharmacologic approaches are preferred. In case of severity and persistence of autonomic system stimulation, the least effective dose of midazolam for a short period of time may be used.

Contraindicación de la prometazina en menores de dos años / Contraindication of the prometazine in minors of two years

Tomando como escenario la reciente noticia de la suspensión de la autorización del uso de prometazina en menores de dos años, resumiendo los reportes de sus efectos adversos de las últimas década y repasando las actuales indicaciones de la droga, la autora se pregunta si está establecida su seguridad en niños y en ancianos; y discute las políticas de inclusión de algunos fármacos dentro del subgrupo de ôventa libreõ, así como la agilidad de los mecanismos de regulación frente la evidencia que surge de los sistemas de fármacovigilancia.

Profilaxis a las reacciones alérgicas de las pruebas contrastadas en Rayos X: descripción de la técnica / Prophylaxis for allergic reactions due to contrast tests in X-Rays: description of the technique

A 101 pacientes entre los 20 y 60 años de edad se lesaplicó la técnica de la profilaxis a las reacciones alérgicas de las pruebas contrastadas en Rayos-X, para lo cual se inyectó por vía intravenosa un antihistamínico (prometacina 25 mg) y un corticosteroide (hidrocortisona 100 mg o 1 bulbo de prednisol 60), previo a la prueba. Se describe la técnica de la profilaxis, y se muestran, resultados satisfactorios en todos los pacientes a quienes se les realizó la prueba contrastada. Con este método se evitaron efectos indeseables de las sustancias yodadas en pacientes sin historia de alergia al yodo, en pruebas como urograma descendennte, cistografía, fistulografía, etcétera. Se indica que existen textos donde se apoya el uso de medicamentos para el tratamiento sintomático frente a efectos indeseables del yodo en pruebas contrastadas

La anestesia en oftalmología pediátrica / Anesthesia in pediatric opthalmology

El trabajo se realizó en 140 pacientes pediatrícos. La corrección del estrabismo es la intervención quirúrgica más frecuente en el niño y como complicación común en este tipo de cirugía se cita el vómito posoperativo. Distintos autores han usado diversos medicamentos para prevenirlo como el dimenhidrinato, drogas antieméticas activas centralmente como la prometazina, el dehidrobenzoperidol y la hydroxyzina, también la lidocaina, la metoclopramida, la dixyrazina, etcétera. Los resultados que muestran son variables en cuanto a la ocurrencia de esta complicación. En nuestro trabajo no se presentó en ningún paciente después de la anestesia general con tiopental, succinilcolina, intubación endotraqueal, 02-N20 y halotano. Se describe el efecto antiemético de la medicación preanestésica usada por nosotros que consistió en la combinación de atropina 0,05 mg, prometazina 2,5 mg y clorpromazina 2,5 mg por cada 25 libras de peso corporal (hasta una dosis de atropina 0,2 mg, prometazina 10 mg y clorpromacina 10 mg (IV)