Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department.

STUDY OBJECTIVE: We investigate the effectiveness and safety of ketamine to sedate patients with severe acute behavioral disturbance who have failed previous attempts at sedation. METHODS: This was a prospective study of patients given ketamine for sedation who had failed previous sedation attempts. Patients with severe acute behavioral disturbance requiring parenteral sedation were treated with a standardized sedation protocol including droperidol. Demographics, drug dose, observations, and adverse effects were recorded. The primary outcome was the number of patients who failed to sedate within 120 minutes of ketamine administration or requiring further sedation within 1 hour. RESULTS: Forty-nine patients from 2 hospitals were administered rescue ketamine during 27 months; median age was 37 years (range 20-82 years); 28 were men. Police were involved with 20 patients. Previous sedation included droperidol (10 mg; 1), droperidol (10+10 mg; 33), droperidol (10+10+5 mg; 1), droperidol (10+10+10 mg; 11), and combinations of droperidol and benzodiazepines (2) and midazolam alone (1). The median dose of ketamine was 300 mg (range 50 to 500 mg). Five patients (10%; 95% confidence interval 4% to 23%) were not sedated within 120 minutes or required additional sedation within 1 hour. Four of 5 patients received 200 mg or less. Median time to sedation postketamine was 20 minutes (interquartile range 10 to 30 minutes; 2 to 500 minutes). Three patients (6%) had adverse effects, 2 had vomiting, and a third had a transient oxygen desaturation to 90% after ketamine that responded to oxygen. CONCLUSION: Ketamine appeared effective and did not cause obvious harm in this small sample and is a potential option for patients who have failed previous attempts at sedation. A dose of 4 to 5 mg/kg is suggested, and doses less than 200 mg are associated with treatment failure.

Ondansetron: a review of pharmacokinetics and clinical experience in postoperative nausea and vomiting.

INTRODUCTION: Postoperative nausea and vomiting (PONV) is associated with poor patient satisfaction and delayed recovery after general anesthesia. Multiple neurotransmitters are involved in the mediation of PONV but despite the introduction of new antiemetics, no completely effective drug exists for its prevention or treatment. AREAS COVERED: This review provides a detailed description of ondansetron's chemistry, pharmacokinetics, pharmacodynamics, toxicity and a brief review of clinical trials involving ondansetron and the management of PONV. We searched reviews, meta-analysis and randomized controlled trials (Medline, Embase and article reference lists). EXPERT OPINION: According to current literature, administering ondansetron 4 mg i.v. near the end of surgery provides sufficient protection against PONV in low- and moderate-risk patients, comparable to traditional antiemetics such as antihistamines and droperidol. High-risk patients require a multimodal approach since one quarter of them will not respond to monotherapy. In the future, transdermal formulation or formulations for nasal or buccal delivery will be available. The development of non-racemic mixture consisting of R-ondansetron would enhance the safety profile and probably the efficacy too.

[Influence of acupoint injection with small dose of fentanyl-droperidol mixed liquor on labor analgesia and level of stress hormone in parturient].

OBJECTIVE: To observe the clinical effect of acupoint injection with small dose of fentanyl-droperido mixed liquor at different time stages on labor analgesia, and explore its function mechanism. METHODS: One hundred and fifty cases of full-term primiparas who were intended to take vaginal delivery were randomly divided into 3 groups, 50 cases in each one. The acupoint injection with fentanyl-droperido mixed liquor at different time stages was applied in the group I, where Shenshu (BL 23) was selected in active phase and Ciliao (BL 32) was selected in the 2nd stage of labor. The subcutaneous injection with fentanyl-droperido mixed liquor was adopted in group II. The group III, which was considered as a control group, was treated with subcutaneous injection of 0.9% NaCl at the same time stage as group I and II. The blood pressure, VAS score and level of norepinephrine and adrenaline were observed at different time stages. RESULTS: Compared before the injection, the blood pressure of group III in the active phase and 2nd stage of labor was significantly increased (P < 0.05), and that in group II and III was obviously higher than that in the group I (P < 0.05). The VAS score of group I in the active phase and 2nd stage of labor was significantly lower than that in the group II and III (P < 0.01). After the injection, the level of NE and E was significantly decreased (P < 0.05), which was lower than that in the group II and III (P < 0.05). CONCLUSION: The acupoint injection with small dose of fentanyl-droperido mixed liquor at different time stages has positive effect on labor analgesia, and it could significantly relieve stress reaction of parturient during the labor. Its mechanism could be related to the reduction of stress hormone in parturient.

[Preventive effect of acupoint injection at neiguan (PC 6) on postoperative nausea and vomiting after laparoscopic gynecologic surgery].

OBJECTIVE: To investigate the method for preventing the postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery. METHODS: One hundred and twenty patients being for laparoscopic gynecologic surgery at I- II grade as American Society of anesthesiologists (ASA) were randomly divided into three groups, 40 cases in each group. Twenty minutes before the operation, the mixture of 2. 5 mg Droperidol (1 mL) and 1 mL 0. 9% sodium chloride solution was injected into the bilateral Neiguan (PC 6) in group I , and an intravenous injection with 1 mL Droperidol was used in group II , while there was no treatment carried out in group Ill'. Twenty four hours after the operation, the frequency and degree of nausea and vomiting were observed and scored according to the criteria standard. RESULTS: The incidence rate of nausea was 10. 0% (4/40) in group I , 57. 5% (23/40) in group II , which was significantly different from 80. 0% (32/40) in group III (P<0. 01, P<0. 05, respectively), while it was lower in group I than in group II (P<0. 01). The incidence rate of vomiting was 7. 5% (3/40) in group I , 52. 5% (21/40) in group II , which was significantly different from 75.0% (30/40) in group III (P<0.01, P<0.05 respectively), while it was lower in group I than in group II (P<0.01). No complication, such as obvious drowsiness, anxiety and extracorticospinal tract reaction, was observed among the three groups. CONCLUSION: Acupoint injection at Neiguan (PC 6) with a small dose of Droperidol can effectively prevent the PONV after laparoscopic gynecologic surgery without other adverse effects.

Ginkgo biloba extract EGb 761 attenuates myocardial stunning in the pig heart.

Myocardial stunning, a transient contractile dysfunction that appears following a brief period of ischemia, is at least partly due to the production of oxygen-derived free radicals. The objective of the present study was to determine whether the Ginkgo biloba extract EGb761, which has antioxidant properties in vitro, can attenuate myocardial stunning in vivo. Forty-seven anesthetized open-chest farm pigs underwent 10 min of occlusion of the left anterior descending coronary artery (LAD), followed by 3 hours of reperfusion. They were pretreated with either physiological saline, 100 mg or 300 mg of EGb 761 (Protocol I) or 3 mg or 9 mg of ginkgolide B (GkB) (Protocol II). Contractile function was assessed by sonomicrometry. Both doses of EGb 761 significantly improved recovery of contractile function in the reperfused myocardium with segment shortening averaging 23 +/- 5 % of baseline values at 3 hours post-reflow in controls versus 81 +/- 10 % and 57 +/- 12 % in the EGb100 and EGb300 groups, respectively (p < 0.05 vs control in both cases). In contrast, neither dose of GkB improved functional recovery during reperfusion. ESR experiments revealed that EGb761 resulted in a 59 % decrease in myocardial spin-adduct release during reperfusion (p < 0.05 versus control and GkB groups). A significant 28 % decrease (p < 0.05 vs control group) was also obtained in GkB-treated animals. These results indicate that EGb 761 can attenuate myocardial stunning following a brief ischemic insult in the in situ pig heart by an effect that involves a decrease in the formation of free radicals. As the effect of EGb 761 on functional recovery cannot be explained by the presence of GkB, the beneficial action of the extract on myocardial stunning likely involves complementary effects of both its non-ginkgolide and ginkgolide constituents.

[Anesthetic management of patients undergoing irrigation and drainage of chronic subdural hematoma--retrospective analysis of analgesia and sedation under locoregional anesthesia].

We retrospectively investigated the relationship between intraoperative hemodynamic variability and variables including patient background, anesthetic profile, and operative profile in 108 patients undergoing irrigation and drainage of chronic subdural hematoma under locoregional anesthesia. Patients were divided into two groups according to the degree of changes in mean arterial blood pressure (MAP) and heart rate (HR) during operation. Group A (n = 66) had MAP and HR changes < 20%, and Group B (n = 42) had MAP or HR changes > or = 20% of preoperative baseline values. Age was significantly higher in group B than Group A (mean +/- SD; 70 +/- 12 vs. 62 +/- 14 years, P < 0.01). In respect to additional anesthetic agents used (none; no additional anesthetic agents, enough; pentazocine > or = 0.3 mg.kg-1 and droperidol > or = 0.05 mg.kg-1, pentazocine > or = 0.5 mg.kg-1 or droperidol > or = 0.15 mg.kg-1, little; less than "enough"), ratio of "little" administered in Group B was significantly higher than that in Group A (64.3% vs. 37.9%, P < 0.05). These findings suggest that intraoperative hemodynamic variability under locoregional anesthesia in patients with chronic subdural hematoma is associated with age and insufficient use of hypnotic and/or analgesic agents.

Anestesia balanceda en la cirugía maxilofacial del niño / Balanced anesthesia in pediatric maxillofacial surgery

Sesenta pacientes pediátricos tratados con cirugía maxilofacial fueron operados con anestesia general endotraqueal, utilizando un tipo de"anestesia balanceda". Como agente de inducción se empleó el tiopental sódico, como agentes de mantenimiento al oxígeno y al óxido nitroso combinados con la administración de fentanilo y dehidrobenzoperidol, y como relajante muscular succinilcolina. Además, se utilizó anestesia local infiltrativa en el área quirúrgica. Con esta ténica se logró de una forma armónica y equilibrada la estabilidad en el nivel de anestesia y en el aparato cardiovascular, que permitió ademá una fase posanestésica tranquila, necesaria para proteger las reparaciones quirúrgicas (AU)

Anestesia balanceda en la cirugía maxilofacial del niño / Balanced anesthesia in pediatric maxillofacial surgery

Sesenta pacientes pediátricos tratados con cirugía maxilofacial fueron operados con anestesia general endotraqueal, utilizando un tipo de"anestesia balanceda". Como agente de inducción se empleó el tiopental sódico, como agentes de mantenimiento al oxígeno y al óxido nitroso combinados con la administración de fentanilo y dehidrobenzoperidol, y como relajante muscular succinilcolina. Además, se utilizó anestesia local infiltrativa en el área quirúrgica. Con esta ténica se logró de una forma armónica y equilibrada la estabilidad en el nivel de anestesia y en el aparato cardiovascular, que permitió ademá una fase posanestésica tranquila, necesaria para proteger las reparaciones quirúrgicas

An evaluation of three neuroleptanalgesic combinations in rabbits.

In this study, novel combinations of analgesics and neuroleptics were used in the rabbit in an attempt to produce a surgical level of anesthesia. A commercially available mixture of fentanyl (0.06 mg/kg) and droperidol (3.0 mg/kg; F/D) was evaluated alone and in combination with either the benzodiazepine derivative, diazepam (2 mg/kg) or the alpha-2 adrenoceptor agonist, detomidine (20 micrograms/kg). Rabbits were anesthetized on consecutive weeks with one of the three regimens. Heart rate, respiratory rate, blood pressure, and arterial blood gases (pH, PCO2, PO2) were measured throughout each trial. The times of loss and return of palpebral, righting, and pedal reflexes were recorded. The addition of diazepam to the F/D combination caused marked prolongation of the duration of reflex loss for all reflexes. If the duration of reflex loss for F/D is considered to be 100%, then F/D plus diazepam (F/D/diazepam) prolonged the duration of reflex loss to 547% and 204% for righting and pedal reflex, respectively. The combination of F/D/diazepam produced significantly different results from those for either of the other combinations for righting reflex and palpebral reflex. The results for F/D/diazepam were also markedly different from F/D for pedal reflex, but were not significantly different from those for F/D/detomidine. Prolongation of the duration of reflex loss was more moderate with the addition of detomidine (148% and 174% for righting and pedal reflexes, respectively). Reflexes persisted in some rabbits for each anesthetic regimen. Palpebral reflex was preserved in one of the rabbits given F/D/diazepam, four of five rabbits given F/D, and in two rabbits given F/D/detomidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Anestesia balanceda en la cirugía maxilofacial del niño / Balanced anesthesia in pediatric maxillofacial surgery

Sesenta pacientes pediátricos tratados con cirugía maxilofacial fueron operados con anestesia general endotraqueal, utilizando un tipo de"anestesia balanceda". Como agente de inducción se empleó el tiopental sódico, como agentes de mantenimiento al oxígeno y al óxido nitroso combinados con la administración de fentanilo y dehidrobenzoperidol, y como relajante muscular succinilcolina. Además, se utilizó anestesia local infiltrativa en el área quirúrgica. Con esta técnica se logró de una forma armónica y equilibrada la estabilidad en el nivel de anestesia y en el aparato cardiovascular, que permitió además una fase posanestésica tranquila, necesaria para proteger las reparaciones quirúrgicas.

High-dose droperidol protects against experimental coronary thrombosis in dogs and pigs and attenuates aggregation of porcine platelets and Ca2+ mobilization in human platelets.

BACKGROUND: Activation of platelets after contact with thrombogenic substrates may be an early factor leading to coronary artery thrombosis and myocardial infarction. Haloperidol, a butyrophenone, possesses weak in vitro platelet inhibitory activity. Experiments were designed to determine whether droperidol, a butyrophenone adjunct to anesthesia, protected against experimental coronary thrombosis in intravenously anesthetized open-chest dogs and pigs, attenuated ex vivo porcine platelet aggregation, and inhibited agonist-induced increases in [Ca2+]i in human platelets. METHODS: In dogs and pigs, a lesion consisting of deendothelialization, deep vessel wall injury, and critical stenosis was created in the proximal circumflex arteries, resulting in coronary thrombus formation accompanied by decreased circumflex artery blood flow. Embolization of the thrombus restored flow, but the cycle then repeated, resulting in repetitive cyclical flow reductions (CFRs). These were measured using an electromagnetic flow probe. RESULTS: In dogs, droperidol 0.2 mg/kg intravenous rapidly abolished CFRs in all ten animals, with frequency decreasing from 0.22 +/- 0.01 cycles/min to 0. Droperidol 0.8 mg/kg intravenous rapidly abolished CFRs in seven of eight pigs, with frequency decreasing from 0.15 +/- 0.01 to 0.02 cycles/min (P < 0.005). In both species, additional doses of droperidol were effective against CFRs augmented with intravenous epinephrine, a catecholamine that stimulates thrombosis. Ex vivo platelet aggregation studies were performed in platelet-rich plasma obtained from pigs before and after droperidol 0.8 mg/kg intravenous. Pretreatment with the drug resulted in marked inhibition of aggregation evoked by collagen, modest attenuation of that elicited by adenosine diphosphate (ADP), but no effect on that evoked by arachidonic acid. In human platelets, apparent [Ca2+]i was estimated using the fluorescent indicator indo-1 and flow cytometry. Droperidol 10(-7), 10(-6), and 10(-5)M had a dose-dependent inhibitory effect on the amplitude of increases in [Ca2+]i evoked by 10(-5)M serotonin (plus 10(-7)M epinephrine). The higher droperidol concentration decreased the response to as much as 30% of control (P < 0.001). Droperidol lacked effect on Ca2+ mobilization elicited with 10(-6)M ADP. CONCLUSIONS: The results from three experimental models indicate that droperidol attenuates experimental coronary thrombosis in animals and suggest that this inhibition may result, in part, from a direct droperidol depressant effect on platelet activation and aggregation.

Comparison of P6 acupoint injection with 50% glucose in water and intravenous droperidol for prevention of vomiting after gynecological laparoscopy.

Postoperative vomiting causes patients distress and delays discharge after outpatient surgery. Although P6 electroacupuncture is recognized as having an antiemetic effect, its inconvenient instrumentation may limit its clinical applicability. The purpose of this study was to explore a simple and effective alternative method for control of postoperative vomiting in outpatient surgery. We prospectively compared the effect of P6 acupoint injection with 0.2 ml 50% glucose in water (G/W) and intravenous injection of 20 micrograms/kg droperidol for prevention of vomiting in 120 consecutive outpatients undergoing gynecological laparoscopy with general anesthesia. Patients were randomly allocated to receive P6 acupoint injection, i.v. droperidol, or nothing as control group. Both P6 acupoint injection and i.v. droperidol 20 micrograms/kg were found to have a significant antiemetic effect when compared with the control group. We conclude that P6 acupoint injection with 50% G/W is a simple and effective method for reducing the incidence of postoperative emesis in outpatient surgery.

Ineffectiveness of acupuncture and droperidol in preventing vomiting following strabismus repair in children.

The antiemetic effects and side-effects of P6 acupuncture and droperidol pre-treatment were evaluated in a randomized, patient- and observer-blinded study. Ninety unpremedicated children of ASA physical status I or II undergoing outpatient strabismus repair, and aged over one year, were studied. All patients received intravenous thiopentone 5 mg.kg-1, atropine 0.02 mg.kg-1 and succinylcholine 1.5 mg.kg-1, and the trachea was intubated. Patients then received either intravenous droperidol 0.075 mg.kg-1, droperidol plus five minutes' P6 acupuncture, or acupuncture alone. Anaesthesia was maintained with nitrous oxide 66% and halothane 1.5-2.0% in oxygen with spontaneous ventilation. There was no difference in the incidence of vomiting in the droperidol group (17% before discharge from hospital and 41% up to 48 hours after discharge), combined treatment group (17% and 34% respectively) and acupuncture group (27% and 45% respectively). Corresponding figures for the incidence of vomiting before discharge were 17%, 17% and 27% respectively; these values were also not different. The incidence of restlessness was significantly greater in children receiving droperidol (63%) or both treatments (67%) than in those receiving acupuncture alone (30%; P = 0.007). P6 acupuncture and droperidol are equally ineffective in preventing vomiting within 48 hours of paediatric strabismus repair. Droperidol is associated with increased incidence of postoperative restlessness.

[Maintenance of best needle sensation and small dose of fentanyl and droperidol applied in herniotomy (clinical analysis of 30 cases)].

In 30 cases of herniotomy under acupuncture anesthesia, a series of methods was applied, such as acupoint selection and needle manipulation which based on differentiation of symptoms and signs of TCM, maintenance of best needle sensation and small dose of fentanyl (less than 3 micrograms/kg), droperidol (less than 0.1 mg/kg) which were obviously synergistic with acupuncture. Because of the adjuvants and improvement of the operative technique, the rate of success reaches 93.3%, the rate of excellent results (Grade I) came to 66.6%, and the rate of good results (Grade II) 26.7%. The fluctuation of blood pressure was lower than that of the control group. Especially the approach of acupuncture anesthesia was superior in the cases of senile patients with hypertension.

[Effects of hyperbaric oxygenation, thalamonal and their combination on pulmonary edema in experimental embolism of blood vessels of the lesser circulation]. / Vliianie giperbaricheskoi oksigenatsii, talamonala i ikh sochetaniia na otek legkikh pri éksperimental'noi émbolii sosudov malogo kruga.

Hyperbaric oxygenation leads to 100% survival of albino rats in development of fatal under normobaric conditions pulmonary edema induced by embolism of the vessels of the lesser circulation by olive oil. The degree of lung hydration and the amount of pleural effusion diminish significantly in this case but hyperemia of the pulmonary tissue persists. Thalamonal produces a moderate protective effect in fat embolism, which is manifested by reduced steeping of the lungs in fluid. Under the condition of hyperbaric oxygenation thalamonal fails to change the degree of edema and reduces slightly blood filling of the lungs in fat embolism. Hyperbaric oxygenation, thalamonal and their combination do not protect the lungs from edema and hyperemia in mechanical embolism of the vessels of the lesser circulation by lycopodium.

Short-term effects of ether, equithesin and droperidol/fentanyl on catecholamine and indolamine metabolism in the brain of the rat.

Levels of biogenic amines and their major metabolites were measured in the frontal cortex, dorsal striatum (caudate nucleus) and ventral striatum (nucleus accumbens and olfactory tubercle) of rats which had received anaesthetic or analgesic drugs or no treatment, shortly before decapitation. Apart from a reduced level of homovanillic acid in the ventral striatum after ether, no differences were observed between ether- or Equithesin-treated and untreated animals in the levels of dopamine, dihydroxyphenylacetic acid, homovanillic acid, 3-methoxytyramine, noradrenaline, serotonin or 5-hydroxyindoleacetic acid. The neuroleptic analgesic droperidol/fentanyl, on the other hand, increased the levels of dihydroxyphenylacetic acid in the frontal cortex and dorsal and ventral striatum and of homovanillic acid in the ventral striatum; additionally, a reduced level of serotonin was observed in the frontal cortex. It is concluded that both ether and Equithesin can be used as short-term anaesthetics prior to sacrificing rats, when the levels of biogenic amines are to be analyzed in the frontal cortex or ventral or dorsal striatum.

[Intraosseous anesthesia in combination with neuroleptanalgesia in surgery of the extremities]. / Vnutrikostnaia anesteziia v sochetanii s neiroleptanal'geziei pri operatsiiakh na konechnostiakh.

Intraosseous anesthesia and associated anesthesia (a combination of intraosseous anesthesia and neuroleptic analgesia) were used in 120 traumatological patients. A comparative assessment of the anesthesia degree and the reaction of the organism to the operative agression was performed. The analysis of the results obtained shows advantages of the associated anesthesia over intraosseous anesthesia "per se". Fractionated infusion of phentanyl should be given in the dose 0,001 mg/kg of the body weight. The above variation of the associated anesthesia is supposed to be a perspective method in mass admission of patients.