The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial.

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1-subcutaneous and intraperitoneal analgesia; group 2-subcutaneous analgesia and intraperitoneal placebo; group 3-subcutaneous placebo and intraperitoneal analgesia; Group 4-subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov .

The Effect of Anesthetic Regimens on Intestinal Absorption of Passively Absorbed Drugs in Rats.

PURPOSE: Different anesthetic regimens are used during single pass intestinal perfusion (SPIP) experiments for the study of intestinal drug absorption in rats. We examined the ketamine/xylazine anesthetic combination to evaluate its influence on drug absorption compared to older regimens. Additionally, we examined whether supplementary analgesia has any effect on drug absorption and the effect of the different anesthetic regimens on induction time and stress response. METHODS: Rats were anesthetized using four different anesthetic regimens; ketamine/midazolam, pentobarbital, ketamine/xylazine and ketamine/xylazine/butorphanol. Three model drugs were administered to rat intestines and Peff was calculated. Stress response was evaluated by quantifying blood corticosterone levels and induction time was recorded. RESULTS: We found absorption under pentobarbital to be higher or similar to absorption under ketamine/midazolam. These results partly correlate with past literature data. Ketamine/xylazine was found to give similar or higher Peff compared to pentobarbital and ketamine/midazolam. Addition of butorphanol did not affect absorption and reduced induction time and stress. CONCLUSIONS: In studies of intestinal drug absorption, the ketamine/xylazine combination is superior to other anesthetic regimens as it is more convenient and seems to affect absorption to a lesser extent. Addition of butorphanol is highly recommended as it did not affect absorption but led to a more effective and less stress inducing experiment.

Articulation lost in space. The effects of local orobuccal anesthesia on articulation and intelligibility of phonemes.

Motor speech requires numerous neural computations including feedforward and feedback control mechanisms. A reduction of auditory or somatosensory feedback may be implicated in disorders of speech, as predicted by various models of speech control. In this paper the effects of reduced somatosensory feedback on articulation and intelligibility of individual phonemes was evaluated by using topical anesthesia of orobuccal structures in 24 healthy subjects. The evaluation was done using a combination of perceptual intelligibility estimation of consonants and vowels and acoustic analysis of motor speech. A significantly reduced intelligibility was found, with a major impact on consonant formation. Acoustic analysis demonstrated disturbed diadochokinesis. These results underscore the clinical importance of somatosensory feedback in speech control. The interpretation of these findings in the context of speech control models, neuro-anatomy and clinical neurology may have implications for subtyping of dysarthria.

Anesthetic Management During Pediatric Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy With Cisplatin in a Small Child: A Case Report and Systematic Literature Review.

Cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) present a challenging task for anesthesia providers. Anesthesia management may be complicated by hyperthermia, fluid shifts, and distinct inflammatory response. Only a few reports dealing with the anesthesia management of pediatric CS and HIPEC have been published. We report a case of a 2-year-old child with a relapse of an alveolar rhabdomyosarcoma of the uterus and peritoneal carcinomatosis treated with CS and HIPEC. For children, careful temperature measurement, intraoperative prevention of hyperthermia, and sufficient volume management are important, as well as postoperative pediatric intensive care with experience CS and HIPEC patients.

High Patient Satisfaction With Local Anesthesia and Light Sedation in a Novel Fast-Track Setup for Sacrospinous Fixation.

OBJECTIVES: Simple prolapse operations can be performed using local anesthesia. However, this has not been the case for advanced pelvic organ prolapse operations. The aim of this study was to investigate the patient-reported feasibility and acceptability of local anesthesia and light sedation for sacrospinous fixation (SSF). METHODS: This is a prospective observational study on 105 women who underwent SSF in a public outpatient setting from April 2016 to October 2017. They received infiltration anesthesia with mepivacaine or lidocaine together with a pudendal nerve block with Marcaine. Local anesthesia was supplemented by intravenous light sedation and pain reliever. A Local Anesthetic Intraoperative Experience Questionnaire was used to evaluate patient experience. RESULTS: One patient was converted to general anesthesia. Eighty-eight women answered the questionnaires. Ninety-nine percent defined themselves as satisfied or very satisfied with the anesthesia. Little or no pain during the operation was reported by 92% and 92% would choose the same type of anesthesia again. No adverse effect of the anesthetic procedure was observed. The median (range) admission time was 12 (4.5-48) hours, and 81% of the patients could be discharged on the day of surgery. At follow-up after 8 weeks and 6 months, no patients reported adverse events to the anesthesia. CONCLUSIONS: The SSF can be performed using local anesthesia and light sedation with high degree of patient satisfaction. These preliminary data indicate that the concept of ambulatory surgery might be implemented more widely if the use of local anesthesia is also applied to more advanced surgical procedures.

The first national survey of anesthesia techniques for fetal therapies in Japan.

PURPOSE: The aim of this study was to survey the frequency of various anesthetic techniques used in the anesthetic management of both the mother and fetus during fetal therapies in Japan. METHODS: We sent a postal survey to the institutions with physicians who held membership of the Japan Society of Fetal Therapy to describe maternal and fetal anesthetic management during fetal therapies performed from January 2016 to March 2017. The therapies included were thoracoamniotic shunting (TAS), intrauterine transfusion (IUT), radiofrequency ablation (RFA), fetoscopic laser photocoagulation (FLP), fetoscopic endotracheal occlusion (FETO), and ex utero intrapartum treatment (EXIT). Survey respondents were asked to specify the standard anesthetic technique used in each of these procedures done during the study period. RESULTS: The most common anesthetic techniques used in each therapy were sedation/analgesia with local anesthesia in TAS (31%), local anesthesia alone in IUT (47%), neuraxial anesthesia in RFA (50%), FLP (66%) and FETO (100%), and general endotracheal anesthesia in EXIT. Fetal analgesia was utilized in 61% of TAS, 33% of IUT, 10% of RFA, 22% of FLP, 100% of FETO, and 50% of EXIT. In all fetal therapies, the most common route of administration for fetal anesthesia was maternal administration. CONCLUSION: In this first published description of the frequency of various anesthetic techniques used during fetal therapies in Japan, we found that anesthetic techniques varied depending on the degree of invasiveness to the mother and fetus. Fetal anesthesia was not always performed, and the most common route for fetal anesthesia was maternal administration.

Clove Oil and AQUI-S Efficacy for Zebrafish Embryo, Larva, and Adult Anesthesia.

Since the use of the zebrafish Danio rerio genetic model organism within the scientific research community continues to grow rapidly, continued procedural refinement to support high-quality, reproducible research and improve animal welfare remains an important focus. As such, anesthesia remains one of the most frequent procedures conducted. Here, we compared the effectiveness of clove oil (active ingredient eugenol) and AQUI-S (active ingredient iso-eugenol) with the currently most commonly used tricaine/MS-222 (ethyl 3-aminobenzoate methanesulfonate) and benzocaine anesthesia. We focused on embryos (1 day postfertilization), larvae (5 days postfertilization), and adults (9-11 months) and for the first time used exposure times that are the most relevant in research settings by using zebrafish as a genetic model system. For each age, tricaine and benzocaine achieved the most reproducible, robust anesthesia with the quickest induction and recovery. For some experimental procedures, specific clove oil concentrations in embryos and larvae may represent suitable alternatives. Although different aquatic species at specific ages respond differentially to these agents, the systematic study of comparable effective dosages for procedures most commonly employed represent an important step toward refinement.

Effect of pretreatment with magnesium sulphate on the duration of intense and deep neuromuscular blockade with rocuronium: A randomised controlled trial.

BACKGROUND: Magnesium sulphate is an important adjuvant drug in multimodal anaesthesia. In combination with rocuronium it can enhance neuromuscular blockade (NMB). Limited data exist concerning the effect of magnesium sulphate on the duration of deep or intense NMB and the period of no response. OBJECTIVE(S): To determine the role of magnesium sulphate on the duration of rocuronium-induced deep and intense NMB, and the period of no response to nerve stimulation. DESIGN: A randomised controlled trial. SETTING: A public tertiary care hospital, Rio de Janeiro, Brazil, from February 2017 to March 2018. PATIENTS: All patients between 18 and 65 years of age scheduled to undergo elective otorhinolaryngological surgery, with a BMI between 18.5 and 24.9 kg m and an American Society of Anesthesiologists physical status classification of I or II. INTERVENTION(S): Before induction of anaesthesia 60 patients were pretreated with an intravenous infusion of either 100 ml 0.9% saline (saline group), or 60 mg kg magnesium sulphate (magnesium group). After loss of consciousness, a bolus of rocuronium (0.6 mg kg) was administered. Neuromuscular function was measured by TOF-Watch SX monitor. MAIN OUTCOME MEASURES: The primary and secondary outcomes were the duration of the period of no response to nerve stimulation and intense and deep NMB, respectively. An additional outcome was the NMB onset time. RESULTS: Median [IQR] durations of deep NMB were 20.3 [12.0 to 35.4] and 18.3 [11.2 to 26.3] min in the magnesium and saline groups, respectively (P = 0.18). Median durations of intense NMB were 21.7 [0.0 to 32.2] min and 0.0 [0.0 to 6.2] min (P = 0.001) in the magnesium and saline groups, respectively. Median durations of the period of no response were 40.8 [51.4 to 36.0] min and 28.0 [21.9 to 31.6] min (P = 0.0001) in the magnesium and saline groups, respectively. CONCLUSION: Magnesium sulphate increased both the duration of intense NMB and the period of no response. The duration of deep NMB was similar in the magnesium sulphate group and saline group. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02989272.

Preoperative Anesthetic Considerations in the Podiatric Surgical Candidate.

There are multiple challenges the podiatric surgeon faces while attempting to treat patients in the perioperative setting. Given the aging and increasingly complex surgical population, preoperative evaluation is of utmost importance to mitigate unnecessary risks and to optimize patient outcomes. This article reviews key preoperative considerations, patient evaluation, and factors affecting selection of anesthetic technique.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract.

OBJECTIVE: Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications. MATERIAL AND METHODS: A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed. RESULTS: Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare. CONCLUSIONS: By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.

[Prevention of cognitive dysfunction in elderly cancer patients operated on the pelvic organs in conditions of multimodal anesthesia]. / Profilaktika kognitivnoi disfunktsii u pozhilykh onkologicheskikh bol'nykh, operirovannykh na organakh malogo taza v usloviiakh mul'timodal'noi anestezii.

The aim of the study was to evaluate the impact of various variants of multimodal anesthesia on the cognitive functions of elderly patients after surgical interventions on pelvic organs, the development of preventive measures for POCD. MATERIAL AND METHODS: A study was conducted in 76 elderly patients aged 62 to 84 years with an increased risk of developing POCD. Of these, 46 women and 30 men. Patients were divided into two groups, depending on the type of anesthesia. The 1st group consisted of 37 patients who had low-flow anesthesia with sevoflurane combined with epidural analgesia. 2nd - 39 patients who had anticipated multimodal analgesia on the basis of systemic administration of lidocaine, sulphate magnesia, verapamil. In each group, patients are divided into subgroups - the main (O) and control (K). In the main subgroups anesthetics were supplemented with 20 ml. Cytoflavin, administered 20-25 minutes before the end of surgery and on the 1-3 days of the perioperative period. Cognitive functions were assessed by standardized scales: Mini Mental State Examination (MMSE), Montreal Cognitive Evaluation Scale (MoCA), Frontal Assessment Batteries (FAB). The level of anxiety and depression was determined by the hospital scale of anxiety and depression (HADS). RESULTS: At oncological patients of advanced age in 52.5% of cases there is a moderate degree of cognitive impairment. In the perioperative period, in the study groups, when using different variants of multimodal anesthesia, there is an equivalent transient decrease in cognitive functions by 12.5 and 12.8%. The use of cytoflavin can reduce the manifestation of POCD from 1-day perioperative period, improve the cognitive status of patients. CONCLUSION: In cancer patients of advanced age, cognitive impairment is observed, aggravated after surgical treatment, regardless of the variant of multimodal anesthesia. Protection by Cytoflavin allows to restore the cognitive functions of elderly cancer patients, reduce the manifestations of POCD.

A prospective pilotstudy comparing the anesthetic effects of an alpha-2 agonist during holmium laser resection of the prostate and transurethral resection for prostate surgery for benign prostatic hyperplasia patients using selective alpha-1 blockers.

BACKGROUND: To examine the response to an α2receptor agonist used as a sedative for patients using long-term selective α1 blockers. METHODS: Sixty-nine consecutive patients undergoing transurethral prostate resection or holmium laser resection of the prostateunder spinal anesthesia were divided into two groups; group N (n = 37), which did not receive α1 blockers, and group T (n = 32), which was administered tamsulosin for at least 1 month before the study. Bispectral index scores, Modified Observer's Assessment of Alertness/Sedation scale scores, heart rate, and mean blood pressure were obtained under sedation using dexmedetomidine for 30 min during surgery. RESULTS: The only significant difference found between the groups were mean bloodpressure 15 min after the first loading dose injection of dexmedetomidine. Differencesbetween both groupswere noted at 15 min(group T: 100.2 ± 12.9 mmHg; group N: 90.0 ± 17.5 mmHg; P = 0.08), 20 min (group T: 99.8 ± 12.3 mmHg; group N: 87.4 ± 15.0 mmHg; P < 0.00), 25 min (group T: 99.3 ± 13.4 mmHg; group N: 85.4 ± 13.8 mmHg; P < 0.00), and 30 min (group T: 98.8 ± 13.1 mmHg; group N: 84.5 ± 13.5 mmHg; P < 0.00). CONCLUSIONS: The use of α2 agonists is appropriate during surgery for benign prostatic hyperplasia patients using tamsulosin, and there is no need to alter the dose. Alertness with anesthesia involving α2 agents was maintained for patients using long-term tamsulosin and patients who did not use tamsulosin. TRIAL REGISTRATION: The study was retrospectively registered with the Clinical Research Informational Service ( KCT0002967 , July 2, 2018).

Activation in the auditory pathway of the gerbil studied with 18F-FDG PET: effects of anesthesia.

Here, we present results from an 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) study in the Mongolian gerbil, a preferred animal model in auditory research. One major issue in preclinical nuclear imaging, as well as in most of the neurophysiological methods investigating auditory processing, is the need of anesthesia. We compared the usability of two types of anesthesia which are frequently employed in electrophysiology, ketamine/xylazine (KX), and fentanyl/midazolam/medetomidine (FMM), for valid measurements of auditory activation with 18F-FDG PET. Gerbils were placed in a sound-shielding box and injected with 18F-FDG. Two acoustic free-field conditions were used: (1) baseline (no stimulation, 25 dB background noise) and (2) 90 dB frequency-modulated tones (FM). After 40 min of 18F-FDG uptake, a 30 min acquisition was performed using a small animal PET/CT system. Blood glucose levels were measured after the uptake phase before scanning. Standardized uptake value ratios for relevant regions were determined after implementing image and volume of interest templates. Scans demonstrated a significantly higher uptake in the inferior colliculus with FM stimulation compared to baseline in awake subjects (+ 12%; p = 0.02) and with FMM anesthesia (+ 13%; p = 0.0012), but not with KX anesthesia. In non-auditory brain regions, no significant difference was detected. Blood glucose levels were significantly higher under KX compared to FMM anesthesia (17.29 ± 0.42 mmol/l vs. 14.30 ± 1.91 mmol/l; p = 0.024). These results suggest that valid 18F-FDG PET measurements of auditory activation comparable to electrophysiology can be obtained from gerbils during opioid-based anesthesia due to its limited effects on interfering blood glucose levels.

Effect of Adding Magnesium Sulphate to Epidural Bupivacaine and Morphine on Post-Thoracotomy Pain Management: A Randomized, Double-Blind, Clinical Trial.

Post-thoracotomy pain is very severe and may cause pulmonary complications. Thoracic epidural analgesia can greatly decrease the pain experience and its consequences. However, finding new methods to decrease the amount of administered opioids is an important issue of research. We aimed to evaluate the effect of adding epidural magnesium sulphate to bupivacaine and morphine on pain control and the amount of opioid consumption after thoracotomy. Eighty patients undergoing thoracotomy at a tertiary cardiothoracic referral centre were enrolled in a randomized, double-blind trial. Patients were randomly allocated to two groups. Bupivacaine (12.5 mg) and morphine (2 mg) were administered epidurally to all patients at the end of operation. Patients in the magnesium (Mg) group received epidural magnesium sulphate (50 mg), and patients in the control (C) group received normal saline as an adjuvant. Visual analogue scale (VAS) score and the amount of morphine consumption were measured during 24 hr post-operation. Thirty-nine patients in the Mg group and 41 patients in the C group completed the study. Patients in the Mg group had significantly less VAS score at recovery time (p < 0.05), 2 hr (p < 0.01) and 4 hr (p < 0.05) after surgery. The patient-controlled analgesia pump was started earlier in the C group than in the Mg group (p < 0.05). The amount of morphine needed in the Mg group was significantly lower than in the C group (5.64 ± 1.69 mg/24 hr versus 8.44 ± 3.98 mg/24 hr; p < 0.001). Pruritus was seen in the C group (9.7%) and absent in the Mg group (p < 0.05). Co-administration of magnesium sulphate with bupivacaine and morphine for thoracic epidural analgesia after thoracotomy leads to a reduction in post-operative pain score and the need for opioid administration.

A time course study of glucose levels and innate immune response in gilthead seabream (Sparus aurata L.) after exposure to clove oil-eugenol derived anaesthetic.

Clove oil is used as an anaesthetic for many species of fish worldwide; however, relatively few studies have assessed its effects on the innate immune response on these species. The present work aimed to investigate the effects of clove oil-eugenol derived anaesthetic on some humoral and cellular immune response in gilthead seabream (Sparus aurata L.). To compare with an unexposed control group, fish were exposed to 55 ppm clove oil for 5 min, before being sampled at 1, 24 and 48 h post-exposure. Serum glucose level was also measured to obtain information on the fish physiological response after clove oil anaesthesia. One hour after exposure the haemolytic complement activity of fish was lower than in the unexposed group. By contrast, the leucocyte peroxidase activity in head-kidney was significantly stimulated 24 h after exposure to clove oil-eugenol. The rest of innate immune parameters evaluated and the glucose levels not were affected by clove oil exposure at any sampling point. Overall, the use of clove oil at 55 ppm as anaesthetic did not seem to alter the innate immune response and neither did it trigger a stress response. The use of clove oil-eugenol derived had become common practice in aquaculture, and its use with gilthead seabream can be considered safe as it does not cause immunodepression in anesthetized fish.

Anesthetic activity of plant essential oils on Cyprinus carpio (koi carp).

The aims of this study were to investigate the anesthetic and cytotoxic effects of essential oils (EOs) of Ocimum basilicum (OBO), O. canum (OCO), and O. sanctum (OSO) on Cyprinus carpio (koi carp). For anesthetic effect, induction time to surgical anesthesia and recovery time were determined. For cytotoxicity effect, viability of fish peripheral blood nuclear cells (PBMCs) was investigated. Results indicated that increasing oil concentration caused significant (p < 0.01) decrease of induction time. OSO at 100, 200, and 300 mg/L gave the induction time of 169.5 ± 10.2, 62.8 ± 2.3, 45.3 ± 2.2 sec, respectively, significantly shorter than OCO, and OBO. The recovery time of anesthetized fish was dose dependent (p <0.01). Among them, OCO showed the longest recovery time of 313.0 ± 8.1, 420.7 ± 12.6, 616.6 ± 12.1 sec for concentrations of 100, 200, and 300 mg/L, respectively, followed by OSO and OBO, respectively. Within 10 min contact time of the EOs and fish PBMCs, the fish PBMC viability was higher than 80%. Increase contact time and EO concentration caused an increase in cytotoxicity to fish PBMC. OBO showed less toxic than OSO and OCO. Based on the desired induction and recovery times for anesthetizing koi carp, OBO, OCO, and OSO at 300, 200, and 100 mg/L, respectively were suggested to be the most suitable. It was concluded that OBO, OCO, and OSO can be used as natural anesthetics for fish.

Sedation in cardiac arrhythmias management.

INTRODUCTION: Procedural sedation is of paramount importance for a plethora of electrophysiological procedures. From electrical cardioversion to electrophysiology studies, device implantations, and catheter ablations, intraprocedural sedation and anesthesia have a pivotal role in allowing procedural success while ensuring patient safety and avoiding discomfort. Areas covered: The present review will discuss the current state-of-the-art in sedation and anesthesia during electrical cardioversion, cardiac implantable electronic device implantation, catheter ablation and electrophysiology studies. Specific information will be provided for each procedure in order to reach the core of this important clinical issue, and specific protocols will be compared. The main pro-arrhythmic and anti-arrhythmic effects of the most commonly used sedatives will also be discussed. Expert commentary: According to much recent evidence, the cardiologist can be the only person responsible for sedation administration in many settings, highlighting few safety issues associated with the absence of a dedicated anesthesiologist thus a concomitant reduction in costs. However, many concerns have been raised in allowing non-anesthesiologists to manage sedatives, as adverse events, while rare, could have catastrophic consequences. The present paper will highlight when a cardiologist-directed sedation is considered safe, how it should be performed, and the pros and cons related to this strategy.

Anesthetic Considerations for Patients on Antidepressant Therapy-Part I.

Millions of patients take antidepressant medications in the United States for the treatment of depression or anxiety disorders. Some antidepressants are prescribed off-label to treat problems such as chronic pain, low energy, and menstrual symptoms. Antidepressants are a broad and expansive group of medications, but the more common drug classes include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. A miscellaneous or "atypical" category covers other agents. Some herbal supplements that claim to have antidepressant activity will also be discussed. In Part I of this review, antidepressant pharmacology, adverse effects, and drug interactions with adrenergic agonists will be discussed. In part II, drug interactions with sedation and general anesthetics will be reviewed. Bleeding effects and serotonin syndrome implications in anesthetic practice will also be highlighted.

Self-microemulsifying drug delivery system and nanoemulsion for enhancing aqueous miscibility of Alpinia galanga oil.

Alpinia galanga oil (AGO) possesses various activities but low aqueous solubility limits its application particularly in aquatic animals. AGO has powerful activity on fish anesthesia. Ethanol used for enhancing water miscible of AGO always shows severe side effects on fish. The present study explores the development of self-microemulsifying drug delivery systems (SMEDDS) and nanoemulsions (NE) to deliver AGO for fish anesthesia with less or no alcohol. Pseudoternary phase diagrams were constructed to identify the best SMEDDS-AGO formulation, whereas NE-AGO were developed by means of high-energy emulsification. The mean droplet size of the best SMEDDS-AGO was 82 ± 0.5 nm whereas that of NE-AGO was 48 ± 1.6 nm. The anesthetic effect of the developed SMEDDS-AGO and NE-AGO in koi (Cyprinus carpio) was evaluated and compared with AGO ethanolic solution (EtOH-AGO). It was found that the time of induction the fish to reach the surgical stage of anesthesia was dose dependent. NE-AGO showed significantly higher activity than SMEDDS-AGO and EtOH-AGO, respectively. EtOH-AGO caused unwanted hyperactivity in the fish. This side effect did not occur in the fish anesthetized with SMEDDS-AGO and NE-AGO. In conclusion, SMEDDS and NE are promising delivery systems for AGO.