Effect of sequential sedation and analgesia in preventing delirium and withdrawal symptoms in children after ventilator weaning / 中国当代儿科杂志

OBJECTIVES@#To investigate the effect of sequential sedative and analgesic drugs in preventing delirium and withdrawal symptoms in children after ventilator weaning.@*METHODS@#A retrospective analysis was performed on 61 children who were admitted and received mechanical ventilation support for ≥5 days in the Pediatric Intensive Care Unit of Dongguan Children's Hospital Affiliated to Guangdong Medical University from December 2019 to September 2021. The children were divided into a control group (30 children with no maintenance of analgesic and sedative drugs after ventilator weaning) and an observation group (31 children with sequential sedative and analgesic drugs maintained for 48 hours after ventilator weaning). The two groups were compared in terms of the Sophia Observation Withdrawal Symptoms Scale (SOS) score, the Pediatric Delirium Scale (PD) score, the Richmond Agitation-Sedation Scale (RASS) score, and the incidence rates of delirium or withdrawal symptoms at 24 and 72 hours after ventilator weaning.@*RESULTS@#There was no significant difference in the incidence rate of delirium at 24 hours and 72 hours after ventilator weaning between the two groups (P>0.05). Compared with the control group, the observation group had significantly lower incidence rate of withdrawal symptoms and scores of SOS, PD, and RASS scales at 24 hours and 72 hours after ventilator weaning (P<0.01).@*CONCLUSIONS@#Sequential sedation and analgesia after ventilator weaning can reduce the incidence of withdrawal symptoms within 72 hours after ventilator weaning, but it cannot reduce the incidence rate of delirium.

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit / Importância do uso de protocolos para manejo da analgesia e sedação em unidade de terapia intensiva pediátrica

Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

Resumo Introdução: analgesia e sedação são elementos necessários no cuidado do paciente em UTI, com o objetivo de promover controle de dor, angústia, agitação e evitar perda de dispositivos, extubação acidental e melhora da sincronia do paciente com a ventilação mecânica. No entanto, o excesso dessas medicações ocasiona um aumento de morbidades e mortalidade. O manejo ideal depende da adoção de medidas clínicas e farmacológicas, guiadas por escalas e protocolos. Objetivo: revisão da literatura sobre principais aspectos da analgesia e sedação, síndrome de abstinência e delirium em unidade de terapia intensiva pediátrica, mostrando a importância do uso de protocolos no manejo dos pacientes criticamente enfermos. Método: artigos publicados nos últimos 16 anos, nas plataformas PubMed, Lilacs e Cochrane Library, com os termos analgesia, sedação, síndrome de abstinência, nível leve de sedação, interrupção diária da sedação e unidade de terapia intensiva. Resultados: foram selecionados 76 artigos relevantes para descrever a importância da utilização do protocolo de sedação e analgesia, preconizando um nível leve de sedação, com uso de escalas de avaliação, interrupção diária e aplicação de teste de respiração espontânea. Essas medidas evidenciam uma diminuição no tempo de ventilação mecânica, no tempo de internação hospitalar, o controle da síndrome de abstinência e delirium, sem implicar em maior risco de morbimortalidade. Conclusão: apesar da falta de estudos controlados e randomizados em pediatria, o uso de protocolo, otimizando um nível leve de sedação, determina uma menor morbidade.

Uso prolongado de benzodiacepinas y estrategias para su deshabituación / Strategies for discontinuing long-term benzodiazepine use

Las benzodiacepinas son uno de los psicofármacos más usados en el mundo y durante estos últimos años ha producido gran atención debido al aumento en su indicación. Esto ha elevado también, los efectos adversos asociados al uso prolongado, especialmente la presencia de dependencia, la asociación con el deterioro cognitivo y el riesgo de caídas. El objetivo de este estudio fue evaluar la prevalencia y el patrón de consumo de benzodiacepinas en el Cesfam Puertas Negras, junto a la efectividad de una intervención sistemática para disminuir o suspender el consumo en aquellos pacientes con dependencia. Método: Se cuantificó el número de pacientes con consumo crónico de benzodiacepinas a través del censo de Salud Mental. Posteriormente se evaluó el grado de dependendencia a través de criterios DMS IV y finalmente se ingresó a estos pacientes a un programa de descenso gradual. Resultados: Al ingreso se contaba con un total de 45 pacientes con consumo crónico de benzodiacepinas. Luego de la intervención para disminuir el consumo crónico, los pacientes disminuyeron en un 81 por ciento el consumo y se logró la suspensión en 12 pacientes. Discusión: Existe un uso indiscriminado de benzodiacepinas en la población del Cesfam Puertas Negras, como también una mala indicación del medicamento. A través de una intervención protocolizada se puede lograr la suspensión en un gran número de pacientes, pero es fundamental la creación de intervenciones a nivel de salud pública para fomentar su uso racional.

Aplicabilidad del yoga como recurso terapéutico, junto a las mujeres en el proceso de deshabituación del diazepam / Applicability that yoga how therapeutic use, with women on the process of reducing the doses of diazepam medication

El presente artículo analiza las contribuciones que el yoga puede traer a las mujeres que se encuentran en proceso de deshabituación de Diazepam. Fueron descritas las vivencias de esas mujeres y más específicamente se evalúa el modo como ellas confrontan las situaciones de su estar cotidiano, tanto sobre el efecto de los medicamentos, como también sobre los efectos de la práctica continuada de técnicas de yoga. La investigación fue desarrollada en el Centro de Atención Psicosocial (CAPS) de Maracanaú en el Estado de Ceará - Brasil. Los sujetos de la investigación fueron dos mujeres que estaban en proceso de deshabituación de Diazepam. Se utilizó como método de recolección de datos, al inicio, una anamnesis, y entrevistas semiestructuradas, al medio y al final de la investigación. Los datos fueron analizados a través de la técnica de análisis del discurso. Los resultados obtenidos con la investigación consideraron los beneficios de la práctica del yoga en la vida de las participantes y la posibilidad de la disminución de la ansiedad y el aumento del equilibrio emocional. Fue constatado que las prácticas de yoga condujeron a las participantes a una mejor autopercepción y a la concientización de la dependencia al medicamento. Hubo una reducción significativa en el uso del tranquilizante y hasta la interrupción total por parte de las participantes del estudio en cuestión. Además, se valida la necesidad de una transformación en la conducta de los profesionales de salud, que tratan no solamente las mujeres usuarias del Diazepam, sino también a las mujeres en general.

This paper analyses the contributions that yoga can bring to women who are in the process of Diazepam cessation. Were described the experiences of these women and more specifically it is evaluated the way they confront everyday situations, both on the effects of medicines as well as on the effects of yoga techniques. Research was carried out at the Psicosocial Care Center, in Maracanaú, Ceará -CAPS- Brazil. Subjects in this study were two women in the process of Diazepam cessation. Data collection methods were, anamnesis at the beginning, and the semi-structured interviews in the middle and at the end. Data analysis was carried out through Discourse Analysis technique, Results obtained with the study considered the benefits of yoga practice in participant’s life, such as decrease of anxiety and increase of emotional balance. It was found that yoga practices led participants to a better self-perception and awareness that they were dependant of medicines. There was a significant reduction on the use of Diazepam and also a total cessation by some participants in the study. Furthermore, the need for a transformation in health professional’s behavior is validated, by treating not only women who use diazepam, but also women in general.

O relaxamento respiratório no manejo do craving e dos sintomas de ansiedade em dependentes de crack / Deep breathing in the management of craving and anxiety symptoms of crack-cocaine-dependent patients

Introdução: O objetivo deste estudo foi verificar a efetividade do relaxamento respiratório no manejo do craving e dos sintomas de ansiedade em dependentes de crack internados para tratamento em uma unidade de desintoxicação. Método: Ensaio clínico do tipo quase-experimental de análise quantitativa. A amostra foi por conveniência, sendo composta por 32 homens dependentes de cocaína (crack). Eles tinham a cocaína como a droga de escolha e haviam utilizado esta substância por última vez entre 2 e 3 semanas antes do início do tratamento, conseguindo realizar a técnica do relaxamento respiratório adequadamente do ponto de vista biomecânico. Os instrumentos aplicados foram: Cocaine Craving Questionnaire-Brief (CCQB), escala analógica visual (EAV), Inventário Beck de ansiedade (BAI) e ficha com dados sociodemográficos e referentes ao padrão de consumo de substâncias psicoativas (FSD). Foi realizada uma intervenção em grupo na qual, inicialmente, foram aplicados o CCQB, a EAV e o BAI. Depois, foram apresentadas imagens relacionadas ao uso do crack e foram reaplicados os mesmos instrumentos. A seguir, foi realizado o relaxamento respiratório durante 10 minutos e foram aplicados, pela terceira vez, os instrumentos. Após esta intervenção, foi realizada uma entrevista individual com aplicação da FSD. Resultados: Os resultados desta pesquisa demonstraram uma redução dos escores do CCQB, da EAV e do BAI pelo relaxamento respiratório em uma amostra cujo perfi l corresponde ao padrão geral dos usuários de crack. Conclusão: Este estudo, apesar de ter algumas limitações metodológicas, sugere que o relaxamento respiratório pode ser uma estratégia efetiva no manejo do craving e dos sintomas de ansiedade em dependentes de crack.

Introduction: The objective of this study was to verify the effectiveness of deep breathing in the management of craving and anxiety symptoms in crack-cocaine-dependent patients hospitalized for treatment in a detoxification unit. Method: This is a quasi-experimental clinical trial using a quantitative analysis. The convenience sample comprised 32 crack-cocaine-dependent males. These subjects had cocaine as their drug of choice, having used this substance between 2 and 3 weeks prior to the beginning of the treatment, and were able to adequately perform the deep breathing technique. The instruments used were: the Cocaine Craving Questionnaire-Brief (CCQB), the visual analogue scale (VAS), the Beck Anxiety Inventory (BAI), and a form containing sociodemographic information and data related to the pattern of consumption of psychoactive substances (SDF). A group intervention was conducted with the administration of the CCQB, the VAS, and the BAI. After that, images related to the use of crack-cocaine were shown to the subjects and the same instruments were administered again. Next, the participants performed the deep breathing technique for 10 minutes, and the instruments were administered one more time. Finally, an individual interview was done and the SDF was completed. Results: Our findings demonstrated a decrease in the scores on the CCQB, the VAS and the BAI after the deep breathing technique was performed in a sample whose profile represents the general pattern of crack-cocaine users. Conclusion: In spite of some methodological limitations, the present study suggests that the deep breathing technique is effective in the management of craving and anxiety symptoms in crack-cocaine-dependent patients.

effect of aqueous extracts of purtulaca oleracea on withdrawal syndrome in mice

Purtulaca pleracea [PO] overgrows in the different parts of Iran. In previous studies, the extract of P.O showed antinociceptive, anxiolytic and anti inflammation effects in Mice and rats. This study was designed to evaluate different doses of the aqueous extracts of PO on withdrawal syndrome on mice. In this study, 40 male albino mice [25-30 gr] were used. Morphine was used to produce drug dependency by Marshall Method [10 doses of drug in four days]. Different doses of the extract. [25, 50, 75 mg/kg IP] were injected to the separated groups and saline [10 ml/kg-ip] were injected to the one control group 30 min before of noloxone 2 mg/kg. The number of Jumping and amount of weight losses were used for assessment of classic withdrawal syndrome sign. The results indicated that the extract of PO significantly decreased the number of Jumping [p= 0.000] and also weight losses in 25 mg doses of extract [dose-dependent] in mice [p=0.045] It is concluded that the aqueous extract of PO may be play an important role on the modulation of withdrawal syndrome in mice

[Preventive effect of grapefruit juice [Citrus Paradisi Macf.] on morphine withdrawal symptom in male rats]

Addiction to opiates such as morphine is one of major public health problems. It has been shown that in addicted animals, administration of antioxidant agents such as vitamin C can reduce the withdrawal symptoms [WDS]. The aim of this study was to evaluate the preventional effect of grapefruit juice [Citrus Paradisi Macf.] on withdrawal symptoms in rats. In this experimental study, Sixteen male Wistar rats [250-300g] randomly divided into two groups [n=8]. All animals were addicted by intraperitoneal [i.p] injection of morphine [the 1-3 days: 10 mg/kg, the 4-6 days: 20 mg/kg and the 7-9 days 40 mg/kg; daily] for 9 days. The first group received 2 ml Citrus Paradisi Macf. orally 1 hour before morphine administration. The sham group received 2 ml of normal saline. Naloxone [10mg/kg, s.c] was administrated 45 minutes after of an additional dose of morphine [40 mg/kg] in the tenth day for withdrawal symptoms inducing. Then withdrawal symptoms such as frequency of wet-dog shaking, teeth chattering, defecation and penis licking were evaluated for 30 minutes. All withdrawal symptoms including frequency of wet-dog shaking, teeth chattering, defecation and penis licking were reduced in the Citrus Paradisi Macf. group in comparison with the sham group significantly [p < 0.05]. Our results showed that presumably antioxidant activity of Citrus Paradisi Macf. can reduce withdrawal symptoms. Although the exact mechanisms of its effect in brain need to be elucidate

[Matricaria chamomilla extract infusion in to nucleus paragigantocellularis attenuates most of morphine withdrawal syndrome signs in rats]

Some reports show that co-administration of Matricaria chamomilla [MC] extract with morphine, greatly attenuate the development of morphine dependence and inhibit the expression of abstinence syndrome in morphine-dependent animals. Locus Coeruleus [LC] and nucleus paragigantocellularis [PGi] play an important role in developing symptoms of opiate withdrawal. The objective of this study was to determine the effects of Matricaria chamomilla extract infusion into PGi on morphine withdrawal syndrome signs [MWS] of rats. Thirty male rats [weight: 250-300gr] were surgically implanted with cannula at the PGi and then tested in 2groups: saline [control group] and morphine [twice daily for 7 days]. The dose of morphine on the first and second days was 2.5 mg/kg and was doubled every day. On 7[th] day, the animals received the last injection of morphine [50mg/kg] and divided in 4 subgroups: the morphine group [which only received morphine] and three MC groups [which received 1 micro l of MC extract with the concentrations of 10, 25, 50 micro g/micro l, 5 min before naloxone administration]. In the end of the training day [7[th] day] all groups were received naloxone [5mg/kg IP] 3h after last injection of morphine and then the frequencies of withdrawal behavior [jumping, climbing] were assessed for 30 minute. Our results showed that central administration of MC extract, especially at high doses [25 micro g/micro l], significantly attenuates most signs of the morphine withdrawal syndrome. These results suggest that the injection of MC extract into the PGi may be helpful for morphine withdrawal syndrome treatment

[Effects of Matricaria chamomilla extract injection into paragigantocellularis nucleus on morphine withdrawal signs in rats]

Reports suggest that co-administration of Matricaria Chamomilla [MC] extract with morphine greatly attenuates the dependence on morphine and its injection prior to naloxan inhibits the withdrawal syndrome. Locus Ceruleus [LC] and paragigantocellularis [PGi] nuclei play a key role in appearance of withdrawal syndrome. Thus, this study was conducted to determine the effects of MC extract injection into pGi nucleus on morphine withdrawal in rats. 30 rats [Weighing 250-300gr] were divided into two groups of control [receiving saline] and morphine-treated. Following surgical implantation of cannula, morphine-treated group received morphine twice daily for 7 days. This group was classified into 4 sub-groups.The first sub-group received only morphine while the three remaining sub-groups were administed with Matricaria Chamomilla on day 7, five minutes prior to 1 microliter naloxan injection, with 10, 25, and 50 micro gr/lit, respectively. In all groups 5 mg/kg naloxan was injected 3 hours after the final injection of morphine and withdrawal behavior [jumping and climbing] was investigated for 30 minutes. The results showed that injection of all three high doses of MC extract particulary 25 microgr/microlit into PGi nuclens could significantly decline the symptoms of withdrawal syndrome. It seems that injection of MC extract into PGi nucleus could be beneficial to the treatment of morphine withdrawal syndrome in rats

Is hypnotherapy effective in relapse rates of drug dependence and reducing withdrawal symptoms?

This study was performed to assess the effect of hypnotherapy on withdrawal symptoms and the relapse rates of substance use. In a clinical trial, 22 subjects at the detoxification stage who were eligible for the study were randomly assigned to the case and control groups. Each group similarly took part in the cognitive therapy sessions. Additionally, the case group took five sessions of hypnotherapy. After six months of follow-up, relapse rates of the two groups were compared. Also, in the case group, the effect of autohypnosis on symptoms of withdrawal was evaluated. By the end of the study, there were 40% and 73% relapse in the case and control groups, respectively. Subjective reports on positive effects of autohypnosis were 88% on insomnia, 80% on restlessness, 60% on pain, and 33% on autonomic symptoms. According to the findings of this study, autohypnosis has no significant effect on the relapse rates in opium users, but the effect was clinically prominent

Amitriptyline efficacy in control of acute opioid withdrawal syndrome

This study was conducted to evaluate the efficacy of Amitriptyline treatment in opioid withdrawal syndrome. A total of 44 opium dependent patients who met the DSMIV-TR criteria for opioid dependency were randomly assigned to treat with Amitriptyline or placebo during a 25-day double blind clinical trial. Opioid misuse was replaced by oral methadone during a 3 days stabilization period. Methadone was reduced to zero from the beginning of the study to 10th day and Amitriptylin or placebo also was administered. Amitriptylin prescribed as 25 mg tablets or placebo tablets that were completely similar to Amitriptylin tablet prescribed too. Amitriptylin group were prescribed 25 mg tablet per day and placebo tablet too. From second week, drug dosages for both groups were doubled. Rapid detoxification was performed by naloxon after 5 days washout period. The severity of opioid withdrawal and pain was measured by sows and MPQ at days 7/15/17 and 25. There was significant difference between Amitriptyline and placebo in reduction of opioid - withdrawal pain and mental symptoms. No significant difference was noted between the two groups on physical symptoms of withdrawal syndromes. Amitriptyline can be considered as an adjuvant drug for opioid withdrawal pain Management

Ultra-rapid opioid detoxification: current status and controversies.

Opioid dependence is a major health problem and a cause of increasing concern to physicians and other health professionals worldwide. A crucial first step in intervention is detoxification. Recent trends in medical practice have seen the emergence of newer techniques that claim to accelerate the detoxification procedure and ensure prevention of relapse by rapid induction onto maintenance treatment with opioid antagonists such as naltrexone. This review delves into the theoretical and methodological aspects related to ultra-rapid opioid detoxification (opioid detoxification procedure using opioid antagonists, performed under general anaesthesia or heavy sedation) and discusses the status of the same in light of the available evidence regarding its applicability, safety and effectiveness. Although useful in some respects (especially in completion rates for detoxification and subsequent induction onto naltrexone maintenance), the justification of this procedure lies in (a) the resolution of the ethical conflicts surrounding the procedure and (b) conduction of methodologically sound long-term studies to demonstrate greater efficacy over routine/standard detoxification procedures beyond the short-term detoxification period.

Clonidine for smoking cessation.

Clonidine was used to reduce withdrawal symptoms of nicotine and increase the success rate of smoking cessation in the smoking cessation clinic of Siriraj Hospital. One hundred and fourteen subjects enrolled in a double-blind, randomised, placebo-controlled trial. Subjects were divided as clonidine group (n = 58) with the mean age of 38 years and placebo group (n = 56) with the mean age of 33 years. Both groups received information about harmful effects of smoking as well as behavioral modification protocol. The dose of clonidine used in this study was 300 micrograms and the duration of the trial was 5 weeks. Both subject groups attended the clinic weekly and received identical counselling. Clonidine did not reduce withdrawal symptoms of nicotine when compared to the placebo and the success rate of smoking cessation at the end of the 5 weeks' period was identical between the two groups (clonidine 50%; placebo 48%, p > 0.05). No significant side effects of clonidine were found. There was no correlation between background educational level, income, amount of cigarettes smoked per day and the success rate in both groups. In conclusion, clonidine did not show any beneficial effect on smoking cessation.

Influence of gossypin on the development of acute tolerance to morphine induced antinociception.

Gossypin, a flavonoid is known to induce opioid mediated anti nociceptive response in experimental models. Unlike morphine, tolerance to and dependence on gossypin does not develop and it is known to attenuate the withdrawal signs induced in morphine dependent animals. In this study, the influence of gossypin on the development of acute tolerance to morphine was investigated using acetic acid induced writhing assay procedure in mice. Gossypin pre-treatment significantly attenuated the acute tolerance development to morphine induce antinociceptive response. All these evidences suggest that the therapeutic potential of gossypin as a substitute to morphine.