Prediction of Poor Response to Modified Neuroleptanalgesia with Midazolam for Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIMS: Modified neuroleptanalgesia (m-NLA) with midazolam is often used for sedation and analgesia during endoscopic submucosal dissection (ESD) for gastrointestinal neoplasia. However, interruption due to poor response to midazolam is often experienced during ESD for esophageal squamous cell carcinoma (ESCC) because most patients with ESCC have a history of heavy alcohol intake. We examined the incidence and risk factors for poor response to m-NLA with midazolam and pethidine hydrochloride. METHODS: This retrospective cross-sectional study was conducted at a single institution. Between April 2007 and July 2013, 151 patients with superficial ESCC who underwent ESD under sedation using m-NLA with midazolam and pethidine hydrochloride were enrolled. Poor response to sedation was defined as the use of a second drug when Ramsay Sedation Score 1-2. RESULTS: Poor response to sedation occurred in 66.2% patients. Most cases of poor response were controlled by using additional flunitrazepam. Multivariate logistic regression analysis showed that cumulative alcohol intake and major specimen size were independent risk factors for poor response to sedation (OR 3.63, 95% CI 1.20-10.99, and OR 3.23, 95% CI 1.26-8.25). CONCLUSION: Our study indicated that cumulative alcohol intake and major specimen size were associated with poor response to m-NLA with midazolam and pethidine hydrochloride.

Nociceptive thermal threshold testing in horses - effect of neuroleptic sedation and neuroleptanalgesia at different stimulation sites.

BACKGROUND: Aim of the study was to compare the effect of neuroleptic sedation with acepromazine and neuroleptanalgesia with acepromazine and buprenorphine on thermal thresholds (TT) obtained at the nostrils and at the withers. The study was carried out as a randomized, blinded, controlled trial with cross-over design. Thermal thresholds were determined by incremental contact heat applied to the skin above the nostril (N) or the withers (W). Eleven horses were treated with saline (S), acepromazine (0.05 mg/kg) (ACE) or acepromazine and buprenorphine (0.0075 mg/kg) (AB) intravenously (IV). Single stimulations were performed 15 minutes prior and 15, 45, 75, 105, 165, 225, 285, 405 and 525 minutes after treatment. Sedation score, gastrointestinal auscultation score and occurrence of skin lesions were recorded. Data were analysed with analysis of variance for repeated measurements. RESULTS: There were no significant differences in TT between N and W with all treatments. The TT remained constant after S and there was no difference in TT between S and ACE. After AB there was a significant increase above baseline in TT until 405 minutes after treatment. Restlessness occurred 30-90 minutes after AB in 7 horses. All horses had reduced to absent borborygmi after AB administration for 165 to 495 minutes. CONCLUSION: Thermal stimulation at both described body areas gives comparable results in the assessment of cutaneous anti-nociception in horses. There is no differential influence of neuroleptic sedation or neuroleptanalgesia on TTs obtained at N or W. Buprenorphine combined with acepromazine has a long lasting anti-nociceptive effect associated with the typical opioid induced side effects in horses.

[Evaluation of efficacy and safety of optimized based on the ketamine modified neuroleptanalgesia during operations on the biliary tract and liver].

A comparative analysis of efficacy and safety of the neuroleptanalgesia (NLA) and balanced general anesthesia during operations on the biliary tract and liver. Analysis of the results of comprehensive studies of hemodynamic, humoral homeostasis, liver function and clinical anesthesia showed that the optimized on the basis of ketamine modified NLA provides effective neurovegetative protection during operations on the organs of the hepatobiliary system, accompanied by obscure variations in the studied parameters. Traditional methods of the modified NLA is characterized by insufficient anesthesia, accompanied by pronounced physical inactivity circulation and a large number of "critical incidents".

Treatment of medial condylar fractures of the third metatarsus in three horses with fibreglass casts under standing neuroleptanalgesia.

Minimally displaced condylar fractures propagating into the third metatarsal diaphysis were treated conservatively in one thoroughbred and two Arabian racehorses. In each case a neuroleptanalgesic protocol provided adequate pain relief for a rigid fibreglass cast to be applied in a weight-bearing position. The fractures healed completely and the three horses recovered uneventfully. Two of them returned successfully to racing and the third was used for breeding.

[Dexmedetomidine for sedation during voice monitoring surgery in a patient with an episode of seizure].

We present a rare case of 26-year-old male patient without a history of epilepsy, who underwent a voice monitoring surgery under local anesthesia plus sedation using modified neuroleptanalgesia. As he developed generalized tonic-clonic seizure probably due to pentazocine, the operation was cancelled. Later, the same surgery was rescheduled. After a premedication with intramuscular phenobarbital, the patient was sedated with dexmedetomidine and locally anesthetized, showing sedation of high quality with no respiratory depression and no seizure. Dexmedetomidine was used succesfully for voice monitoring surgery.

[Clinical application of brain hypothermia therapy for acute brain insults].

Brain hypothermia therapy has been expected to lead to good neurological outcome in acute brain insults. There are a few positive results which have been proven by multicenter randomized clinical trials (RCT) in the cardiopulmonary arrest (CPA) in patients with ventricular fibrillation. Among these clinical trials, early application of hypothermia, maintenance of cerebral blood flow during hypothermia therapy and prevention of quick rewarming are pointed out to result in good outcome from clinical experiences. For brain hypothermia therapy to become an effective method for acute brain insults, indications, brain oriented intensive cares and biomarkers for the therapy must be established. RCT in acute brain insults beside CPA victims are needed in the near future.

[Anesthetic management of laser surgery with bronchial stenting for a tracheal tumor].

Anesthetic management during surgery for a tracheal tumor is extremely difficult in terms of airway management. We managed a patient with a tracheal tumor who was successfully treated without complication. The trachea of a 66-year-old woman was narrowed by a tumor to one-third of its original diameter, for which Nd-YAG laser surgery with insertion of an intratracheal Dumon stent was performed. Anesthesia was maintained with neuroleptanalgesia using fentanyl and droperidol, supplemented with a TCI infusion of propofol under spontaneous breathing. High frequency jet ventilation (HFJV) was prepared for intraoperative poor oxygenation and/or ventilation. The patient was able to maintain a good respiratory condition throughout the operation without special respiratory support, including use of HFJV. We conclude that the maintenance of spontaneous breathing is essential for anesthetic management in the present case, while an intraoperative airway strategy based on the preoperative breathing condition of the patient is also important.

[Comparative analysis of antiarrhythmic and proarrhythmogenic effects of drugs for neuroleptanalgesia, ataralgesia, and antidepranalgesia in experimental acute myocardial infarction].

Proarrhythmogenic and antiarrhythmic effects of drugs for neuroleptanalgesia (NLA), ataralgesic (ATA) and antidepranalgesia (ADA) in chronic experiments on sleepless rabbits with acute myocardial infarction, with and without tachyarrhythmias, were studied using ECG, intraventricular electromanometry and tetropolar rheography. NLA (phentanylum, 1 microg/kg + droperidol, 5 microg/kg), ADA (pyrazidole, 1 mg/kg + tramal, 1 mg/kg) and ATA (diazepam, 1 mg/kg + promedol 0.5 mg/kg) produce antiarrhythmic effect with maximum manifestation of NLA on the 3rd day, and of ATA and ADA on 3-5th day. This medication increased blood supply and contractility of ischemic myocardium. Proarrhythmogenic effects of this medication were not observed.

[Effect of neuroleptnarcosis on the change of hemodynamic parameters during tissues transplantation].

Changes of the central and peripheral hemodynamics indexes during operation for the tissues purulent-trophic defects closure by free muscular--nerve--vascular flap, arising during neuroleptnarcosis and in immediate postoperative period, were discussed.

Effect of fentanyl and naloxone on human somatic and auditory-evoked potential components.

The effect of fentanyl (a morphine agonist) and naloxone (a morphine antagonist) on early and late components of somatic (SEP)- and auditory (AEP)-evoked potentials was studied in patients undergoing minor surgical procedures, in which these compounds were used in producing and regulating a state of neuroleptanalgesia. Fentanyl (2.5, 5.0 and 10.0 micrograms/kg), naloxone (1.5 and 3.0 micrograms/kg) and isotonic saline (for comparative purposes) were injected just before surgery, intravenously through a catheter and following a single blind procedure and three different pharmacological paradigms with four consecutive conditions each: (1) Initial baseline (C), first saline (S), second saline (S') and late baseline (C'). (2) C, First fentanyl (F), second naloxone (N') and C. (3) C, First naloxone (N), second fentanyl (F') and C'. Special care was taken in controlling the constancy of the muscular and cochlear receptor activation concomitant to somatic-evoked potentials and auditory-evoked potentials, determined by the amplitude of the muscular response at the tenar muscles (MP) and component I of the brain stem potentials ( ABSP ). Evaluation by the patients pain, topognoses and hearing and other somatic and autonomic indicators of the level of the analgesic response were also controlled. Fentanyl significantly reduced, while naloxone increased, the amplitude of late components P150 of somatic-evoked potentials and auditory-evoked potentials. Concomitantly, fentanyl increased, while naloxone decreased, the spatial threshold (two point discrimination test) at finger tip and arm. These effects were observed in patients taking various doses, although they were more consistent with larger doses of these compounds.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of ozone on reactivity of upper and lower airways in guinea-pigs.

1. The effect of ozone inhalation on the responsiveness of upper and lower airways to histamine was examined in guinea-pigs. 2. The exposure of conscious guinea-pigs to 3.5 p.p.m. ozone for 30 min rendered their lower airways 2-3 fold more sensitive to the bronchoconstrictor action of i.v. histamine, as assessed subsequently under anaesthesia. 3. The development of lower airway hyperreactivity was not modified by bilateral cervical vagotomy or pretreatment with BW 755C, FPL 55712 or SC-39070. 4. Under the conditions used, ozone exposure produced a mild inflammatory response as monitored by bronchoalveolar lavage, characterized by epithelial damage and prostaglandin E2 generation, but no cellular infiltration or oedema. 5. In contrast to the lower airways, upper airway resistance was reduced by i.v. histamine. This response was not affected by ozone exposure. 6. Isolated tracheal preparations taken from ozone-exposed guinea-pigs were not significantly more sensitive to histamine than control tissues. 7. The mechanism of hyperreactivity in this model is unknown but does not depend on leukotriene generation or a vagal reflex.

Neurolept analgesia for bronchoscopic examinations.

In 38 patients requiring diagnostic bronchoscopy, three different procedures of anesthesia have been investigated. Of the three, neurolept analgesia combined with topical anesthesia of the airway proved by far the best form. It is followed by psychic indifference without lessening the patient's voluntary control, thus facilitating intricate technical manipulations on the bronchial system. No severe side effects arise when suitable equipment for diagnosing and treating respiratory and cardiovascular depression is available.

Carotid surgery under local anesthesia in the elderly.

Carotid endarterectomy in 39 elderly patients was carried out under local anesthesia and neuroleptic analgesia. There were no deaths within 30 days. Two patients required an intraoperative shunt because of signs of ischemic changes (aphasia, motor changes) during two-minute test cross-clamping. In two patients, transient vocal cord paresis was observed, and seven patients (18%) experienced immediate postoperative hypertension. Our results support the contention that in awake elderly patients the need for an intraoperative shunt can be accurately assessed by simple neurological monitoring. Carotid surgery under local anesthesia and neuroleptic analgesia appears to be a safe procedure, and is especially recommended for elderly patients with hypertension, diabetes mellitus or ischemic heart disease.

Anesthetic and analgesic considerations in the experimental animal.

Many new compounds and combinations of many of the more traditional drugs have been used in a wide range of species. This, plus the rapid development in equipment for inhalational anesthesia, has simplified the restraint, anesthetic, post-surgical, and analgesic management of experimental animals.

Ataralgesia in outpatient urology. Clinical evaluation.

The combination of fentanyl citrate (Sublimaze) and diazepam (Valium) was evaluated for efficacy of analgesia, sedation, and safety in 1,008 predominately outpatient urologic procedures. These procedures included prostate biopsies, basket extractions of ureteral calculi, internal urethrotomies, and cystourethroscopies. Ninety-two per cent were judged to be successful with regard to adequate tranquilization and relief of pain. No detrimental effects were seen with the recommmended method and dosage. This drug combination provides the clinician with an effective and safe alternative to local, general, or spinal anesthesia for many routine urologic procedures and allows them to becom true office procedures.

Differential participation of some 'specific' and 'non-specific' thalamic nuclei in generalized spike and wave discharges of feline generalized penicillin epilepsy.

Extracellular single unit and electroencephalographic (EEG) activity during generalized spike and wave discharges (SW) induced by i.m. penicillin was recorded simultaneously in the cortex, in a 'specific' thalamic nucleus (n. lateralis posterior, LP) and in some 'non-specific' thalamic nuclei (n. centralis medialis, NCM; n. centrum medianum, CM; n. centralis lateralis, CL) Computer-generated EEG averages and histograms of single unit activity were triggered by either peaks of EEG transients or action potentials. The time at which cortical neurons (66/66) were most likely to fire was during the 'spike' of the SW complex while absence of firing was the rule during the 'wave'. Most LP neurons (23/26) showed a similar pattern, 3 cells firing preferentially during the 'wave'. In NCM only 17 of 39 neurons fired during the 'spike', 8 of 39 neurons during the 'wave' while the others showed no change in their firing pattern during SWs. Twenty-six of 30 CM and 20 of 24 CL neurons fired during the 'spike' of SW; the other cells in these nuclei did not change their firing pattern during SWs. When present, rhythmic fluctuations in firing linked to SW discharge were less prominent in these 'non-specific' thalamic nuclei than in cortex and LP. Furthermore, participation of NCM, CM and CL neurons in the SW rhythm occurred only after neurons in cortex and LP had become involved in it. Thus, as is the case for cortical neurons, the main firing pattern of thalamic cells during SWs consists of an oscillation between 'excitation' during the 'spike' and 'inhibition' during the 'wave' of the SW complex. However, the coupling between cortical and thalamic neuronal firing is less intimate for cells of the 'non-specific' thalamic nuclei than for a 'specific' nucleus such as LP. Thus, at least some 'specific' thalamic nuclei are more intimately involved in the mechanism of SW discharge than the midline intralaminar nuclei.

Outpatient keratoplasty.

Outpatient keratoplasty in 103 patients (46 males and 57 females ranging in age from 1 to 90 years) produced no instances of infection, shallow or flat anterior chambers, or anterior synechia formation. Postoperative discomfort was minimal.

Electrophysiological effects of droperidol in different cardiac tissues.

The effect of droperidol in concentrations between 0.05 and 5 mg/I was evaluated on different electrophysiological variables in auricular preparations of the guinea-pig, papillary muscles of dog and cat, Purkinje fibres of the dog, cow and sheep. At low concentration (0.25 to 0.5mg/I) droperidol decreased pacemaker activity and prolonged the effective refractroy period. The inhibition of pacemaker activity was not accompanied by a reduction in the rate of early diastolic depolarization, but was related to an inhibition of the depolarization process during late diastole. At high concentrations (5mg/I) resting potential, action potential amplitude, (dV/dt)max and conduction velocity were reduced. Reduction of dV/dt during the upstroke was more pronounced at lower membrane potentials, the inactivation curve was shifted to more negative membrane potentials. The action potential was lengthened or shortened, the effect being dependent on the frequency, dose, exposure time and animal species. Droperidol had no deleterious effect on Ca-mediated action potentials. The antiarrhythmic activity of droperidol in therapeutic concentrations (0.25 and 0.5mg/I) can be explained by the reduction of pacemaker activity and the lengthening of the effective refractory period. In terms of changes in ion conductance most effects can be explained by a reduction in Na conductance. No simple explanation can be offered for the complex changes in action potential duration.

Neuroleptanalgesia and extracapsular cataract extraction.

Peribulbar and retrobulbar anaesthesia are commonly used techniques in cataract extraction. They offer satisfactory analgesia and akinesia but serious complications although uncommon are consistently reported. Intravenous sedation combined with a facial nerve block offers an alternative method of anaesthesia. This is a retrospective study of patients who underwent extracapsular cataract extraction using this technique between 1 January 1986 and 1 September 1990. The operating conditions were judged to be very suitable with minimal peroperative complications. The postoperative ocular complication rate was low (minimum follow-up 3 months) and no serious medical complications were noted: 93.8% of patients achieved 6/12 vision or better. This study demonstrates that it is possible to achieve satisfactory ocular analgesia and akinesia during cataract extraction under local anaesthesia without the use of a periocular injection.

Aspects of anaesthetic management of heterologous extracorporeal hepatic support in patients with acute liver failure.

Some anaesthetic aspects of heterologous extracorporeal hepatic support for patients with acute liver failure have been investigated in animals and men. Two types of anaesthesia during hepatectomy in pigs were performed in 20 experiments divided into two groups. A convenient anaesthetic technique was found to be the combined use of neuroleptanalgesics, gamma-OH, small doses of thiopental sodium and nitrous oxide--oxygen mixture. The necessity for care in the procedure of temporary liver support for 'poor-risk' patients is outlined. A minimal use of drugs which are metabolized by the liver, and avoidance of potent analgesics, narcotics, hypotension and hypoxia are the main principles for safe extracorporeal hepatic assistance to critically ill patients.