Clinical Evaluation of Oral Midazolam Containing Cyclodextrin in Pediatric Magnetic Resonance: A Retrospective Cohort Study.

BACKGROUND: Reducing a child's level of anxiety before magnetic resonance imaging (MRI) procedures allows for better behavioral outcomes. The aim of this retrospective study was to evaluate anxiolytic efficacy of Midazolam/γ-cyclodextrin oral formulation. METHODS: We retrospectively reviewed 100 medical charts of children who, between 1 February and 31 July 2022, underwent MRI under general anesthesia with or without premedication with midazolam/γ-cyclodextrin. Primary outcome was comparison of behavior to facemask positioning, while secondary endpoints were degree of drugs acceptance, anxiolytic effect evaluation, child's behavior on separation, and sevoflurane need. RESULTS: Facemask positioning was accepted by 58% of the midazolam/γ-cyclodextrin group compared to 22% of children in the control group. The rate of acceptance was >90%. At the moment of separation from parent, none of the premedicated children needed to be restrained compared to 18% in the control group. A lower percentage of sevoflurane was needed for eye-closure at induction of anesthesia and for anesthesia maintenance. At emergence from anesthesia, 46% of children in the premedicated group compared to 66% of children in the control group showed transient agitation. CONCLUSIONS: Midazolam/γ-cyclodextrin showed a good profile of acceptance, satisfactory anxiolytic properties, and reduced need for anesthetics when administered to children before MRI under general anesthesia.

Sedation in digestive endoscopy: innovations for an old technique.

Patient complexity, along with duration, number and invasiveness of procedures, increase every year in digestive endoscopy; so deep sedation, analgesia or general anesthesia requests are rising. The need for a safe, flexible, low cost and high-profile service play a central role in drugs, devices and monitoring development. The patient's degree of comfort and anxiety are also critical. On the other hand, the role of the anesthesiologist is still debated, and many European countries are promoting non-anesthesiologist administration of propofol (NAAP). For high risk patients, anesthesiologists play an important role in choosing sedative drugs, kind of anesthesia/analgesia and devices for airway control. New drugs with safe profile, low costs, and favorable pharmacokinetics are now available for digestive endoscopy. Among these, fospropofol, a water-soluble prodrug of Propofol, is a very promising compound. Moreover, new devices and different modalities of ventilation can help anesthesiologists in management of high-risk patients, like obese patients and others patients at risk of hypopnea/apnea. The main challenges for anesthesiologists in this setting are endoscopic retrograde cholangiopancreatography, management of obese patients and recovery time after procedure, since digestive endoscopies are frequently performed as outpatient procedures. Nevertheless, these short and at low risk procedures can induce cognitive impairment. Currently, only anesthesiologists seem to have the competences to maintain high levels of safety by an appropriate evaluation and sedatives' choice, and a detailed protocol should be present in each gastrointestinal endoscopy department. In conclusion, the role of the anesthetist should be to supervise endoscopy activities at every level.

Ultrasound-guided genitofemoral nerve block for inguinal hernia repair in the male adult: a randomized controlled pilot study.

BACKGROUND: Ultrasound-guided (USG) ilioinguinal/iliohypogastric nerve (II/IHN) block is a widely validated anesthetic technique for inguinal herniorrhaphy. As the spermatic cord, scrotum, and adjacent thigh receive sensory innervation from the genital branch of genitofemoral nerve (GFN), the addition of GFN block has been suggested to improve the quality of perioperative anesthesia and analgesia. The aim of this study is to compare GFN block plus II/IHN block with II/IHN block alone for intraoperative anesthesia and post-operative pain management. METHODS: We enrolled 80, ASA I-III, male adults scheduled for elective open herniorrhaphy. Patients were randomized to receive either USG II/IHN plus GFN block (Case Group) or USG II/IHN block alone (Control Group). The outcome measures were the assessment of postoperative VAS scores on coughing and the adequacy of anesthesia, measured with intraoperative requirement for extra local anesthetic (LA) infiltration and number of patients needing systemic sedation. RESULTS: The requirement of intraoperative additional doses of LA was significantly lower in the Case Group (median LA volume administered by the surgeon: 13.8±5.6 mL vs. 20.7±9.1 mL, P<0.05). Two patients in the Control Group needed systemic sedation. VAS scores at 15 minutes, 30 minutes, 1 hour, 2 hours, pre-discharge, and 24 hours were significantly lower in the Case Group (P<0.005). Four cases of femoral nerve block were reported, three in the Control Group, one in the Case Group (2.2% vs. 7.7%, P>0.05). CONCLUSIONS: The combination of GFN block and II/IHN block is associated with lower postoperative VAS scores and lower doses of intraoperative additional LA.

Utility of ultrasound-guided transversus abdominis plane block for day-case inguinal hernia repair.

BACKGROUND: The transversus abdominis plane (TAP) block is a regional anesthesia technique that effectively reduces the pain intensity and use of analgesia in abdominal surgery. The aim of this study was to determine the utility of the ultrasound-guided TAP block in improving the efficacy of the ultrasound-guided ilioinguinal/iliohypogastric nerve (IIN/IHN) block for intraoperative anesthesia and postoperative pain control in day-case inguinal hernia repair (IHR). METHODS: We conducted a descriptive study of patients undergoing elective primary unilateral open IHR. Fifty-nine patients were divided into two groups according to the anesthetic technique used: ultrasound-guided TAP block plus ultrasound-guided IIN/IHN block (TAP group) vs. ultrasound-guided IIN/IHN block alone (IIN/IHN group). The outcome measures were the adequacy of anesthesia during surgery and postoperative analgesia. RESULTS: Four patients (12.5%) in the TAP group and 10 patients (37.0%) in the IIN/IHN group experienced inadequate anesthesia and needed systemic sedation (P < 0.05). No significant differences in additional local anesthetic volume were found between the two groups. Patients in the TAP group reported lower pain scores at the end of surgery (0.4 ± 0.8 vs. 2.1 ± 2.5, P < 0.01), at 2 hours after surgery (0.8 ± 1.3 vs. 3.0 ± 2.2, P < 0.01), at discharge (1.4 ± 1.2 vs. 4.3 ± 2.2, P < 0.01), and at 24 hours (1.5 ± 1.1 vs. 4.5 ± 2.3, P < 0.01). CONCLUSIONS: The combination of the TAP and IIN/IHN blocks is associated with better intraoperative anesthesia and lower postoperative pain scores compared with the IIN/IHN block alone.