Analgesic efficacy of ultrasound-guided bilateral transversus abdominis plane block in children: retrospective analysis of 97 cases.

BACKGROUND: Transversus abdominis plane (TAP) block is a method for postoperative pain management. Studies on children are gradually increasing. The aim of this retrospective study was to evaluate effectiveness of TAP block on pain control, its side effects, and parental satisfaction levels in children. METHODS: Study included patients operated between January 2019 and December 2020 in Gazi University Faculty of Medicine. Total of 97 patients (35 girls, 62 boys) between 5 and 18 years who had an ultrasound guided TAP block for lower abdominal or inguinal surgery were examined retrospectively. TAP block application time, hemodynamic variables, postoperative pain scores, postoperative analgesic requirement, sex, surgical history and satisfaction levels were evaluated. RESULTS: : The average application time of TAP block was 9.48 ± 3.4 and the time between TAP block and surgical incision was 12.06 ± 6.1 min. Pain scores in postanesthesia care unit (PACU) and at the postoperative first hour decreased as the time between TAP block and surgical incision increased (p < 0.05). Girls have higher pain scores at PACU than boys (p < 0.05). Previous surgical history increased postoperative 1st hour pain scores (OR: 13.8; 95% CI 1.7-113.3; p = 0.01). There was a significant negative correlation between pain scores at PACU, postoperative 1st, 2nd, 4th, 6th, 12th and satisfaction levels (r = -0.45, r = -0.56, r = -0.60, r = -0.54, r = -0.52, r = -0,43, respectively, p < 0.05). DISCUSSION: Ultrasound-guided TAP blocks can be performed safely in children in lower abdominal surgeries. However, the efficacy of TAP block on late term postoperative pain scores is limited. Time interval between the TAP block and the incision, sex, and pain memory, as well as other factors that may improve the quality of TAP block should be considered.

Effects of recurrent ketamine exposure on brain histopathology in juvenile rats.

BACKGROUND: Ketamine (KET) is a commonly used anesthetic agent. However, several previous studies reported that KET leads to neuronal damage in neurodevelopmental stages and has neuroprotective effects. The present experimental study aimed to determine the undesirable histopathological effects of KET in the cerebral cortex, striatum, and hippocampus after recurrent KET administration in juvenile rats. METHODS: After ethical approval was obtained, 32 juvenile male Wistar Albino rats were randomized into four groups: 1 mg/kg serum saline intraperitoneally (i.p.), 5 mg/kg KET i.p., 20 mg/kg KET i.p., and 50 mg/kg KET i.p. KET was administered for three consecutive days at three-h intervals in three doses. Ten days after the last KET dose, the rats were sacrificed. Cerebral hemispheres were fixed. Hematoxylin and eosin stain was used for morphometric analysis. Hippocampi were evaluated by immunohistochemistry with anticleaved caspase-3 antibodies. Statistical analysis was conducted with SPSS 21 software using the ANOVA test and Bonferroni post hoc analysis method. RESULTS: The experimental study findings revealed no difference between the groups' cell counts or sizes in cortical morphometry. No degenerative changes were observed in pyramidal and granular cells in the striatum. Mild gliosis was observed in the 20 mg/kg and 50 mg/kg KET administration groups. Immuno-histo-chemical analysis was conducted to determine apoptosis in the CA1 region of the hippocampus and revealed that caspase-3 positivity increased with the KET dose. However, there was no statistical difference between the groups. While it was lower than the control group in the 5 mg/kg KET group, it was similar to the control group in the 20 mg/kg KET group and higher in the 50 mg/kg KET group (p > 0.05). DISCUSSION: : Repetitive KET exposure did not significantly affect juvenile cerebral morphology and apoptosis in hippocampal cells.

Association of Postoperative Nausea and Vomiting Incidence With Neutrophil-Lymphocyte Ratio in Ambulatory Maxillofacial Surgery.

PURPOSE: Postoperative nausea and vomiting (PONV) constitutes an important factor in ambulatory surgery. The mechanisms of the antiemetic action of potent anti-inflammatory corticosteroids, which are used extensively for the treatment of PONV, as well as the association between PONV and inflammation, have not been investigated sufficiently. We aimed to establish the association between the neutrophil-lymphocyte ratio (NLR) and postoperative antiemetic administration, as well as to investigate whether the NLR would be a biomarker for PONV. MATERIALS AND METHODS: The anesthesia records of American Society of Anesthesiologists (ASA) physical status I or II patients who underwent ambulatory routine oral surgery under general anesthesia were evaluated after we obtained ethical approval from the faculty ethics committee. A 5-point scale was used to score PONV. Metoclopramide (Metpamid, Istanbul, Turkey) was used as the first choice in patients who had a PONV scale score of 1 or higher. Data regarding metoclopramide administration during extubation and discharge periods were analyzed. Sixty-four patients were randomized and enrolled in the study with an NLR less than 2 (group I, n = 37) or an NLR greater than 2 (group II, n = 27), and metoclopramide administration was evaluated in each case. The association between the NLR and metoclopramide administration was analyzed statistically by a descriptive statistical method in detecting frequencies; the χ2 test was used in comparison of the groups and the t test in independent groups. RESULTS: The metoclopramide administration frequency for PONV was 5.4% in group I and 96.3% in group II. The metoclopramide administration frequency in group II was statistically higher than that in group I (P < .001). CONCLUSIONS: We are of the opinion that the NLR can be easily calculated with data obtained from the complete blood count and could be a marker for PONV. Antiemetic prophylaxis could be given after evaluation of the NLR. However, we suggest that this result should be supported with further prospective studies using larger series.

Is age a determinant for nausea and vomiting in disabled patients after dental treatment under sedation?

BACKGROUND AND AIM: Postoperative nausea and vomiting (PONV) is one of most frequently encountered problems after dental treatment of mentally and/or motor disabled patients under sedation or general anesthesia. In this study, we aimed to investigate whether PONV incidence in disabled patients differs between adults (≥18 years) and children/teenage (<18 years). Also investigating complication rates related with anesthesia protocols were additional objectives of the study. MATERIALS AND METHODS: We retrospectively evaluated anesthesia reports of 664 cases undergone different dental treatment procedures under deep sedation with various anesthetic agents. Two study groups (Group 1 consisted from patients with special needs <18 years, while Group 2 consisted from patients ≥18 years) were created. PONV incidence and other complications recorded. RESULTS: There was no statistical difference between groups in terms of used anesthetic agent except midazolam (P < 0.017), while higher female/male ratio and longer duration of anesthesia was recorded in Group 2 (P = 0.043 and P = 0.046, respectively). We found significantly higher PONV rates in disabled patients under 18 years (P = 0.006). Hypoxia (peripheral oxygen saturation (SpO2) <90%) and bradycardia (heart rate <50/minute) were observed in only two patients. CONCLUSION: PONV is more common in disabled patients younger than 18 years and dental treatment procedures under deep sedation can be provided with acceptable complication rates in patients with special needs.

Pediatric tooth extractions under sedoanalgesia.

OBJECTIVE: The present study aims to evaluate intravenous ketamine and inhalation sedation in children, their unwanted side-effects and surgeon satisfaction. METHODS: In this study, data of 922 children aged between 1-18 who underwent tooth extraction under sedoanalgesia in our department between September 2015-January 2016 were gathered and anesthesia approaches, unwanted side effects and surgical satisfaction was investigated. Postoperative recovery emergence agitation or delirium was evaluated with Watcha Behavior Scale (WBS). RESULTS: Patients were grouped and compared according to acceptance of intravenous line placement (Group-1) or not (Group- 2). Group 1 received intravenous ketamine anesthesia (n=822), Group 2 received inhalation anesthesia with sevoflurane (n=100). Number of patients, age, weight and gender was significantly different in two groups. When side effects were investigated nausea was observed in 30 patients (3.6%), skin rashes were observed in 26 patients (3.2%) in Group-1 while skin rashes were observed in one patient (1%) in Group 2. 95% of surgeons reported intravenous anesthesia, 18% of surgeons reported inhalation anesthesia to be the anesthesia of choice. Emergence of postoperative recovery agitation (WBS≥3) was observed more frequent in Group 2 (p<0.05) than Group 1. CONCLUSION: Ketamine, which has analgesic, hypnotic and amnestic effects and which does not alter pharyngeal and laryngeal reflexes thus minimizes aspiration possibility, is a safe and effective anesthetic agent for tooth extractions of the pediatric population under sedoanalgesia.

Analgesic efficacy of prophylactic gabapentin and lornoxicam in preventing postendodontic pain.

OBJECTIVE: In dental applications, as in all other medical applications, pain needs to be prevented or at least controlled. The use of the tooth as a model for studying pain mechanisms is well established. In the current study, we aimed to evaluate and compare the analgesic effects of gabapentin and lornoxicam, respectively, vs a placebo for postendodontic treatment pain. DESIGN AND METHODS: Clinical research was planned as prospective, randomized, and placebo controlled. Each subject was given 600 mg gabapentin (group G: N = 30), 8 mg lornoxicam (group L: N = 30), or a placebo (group C: N = 30) 30 min prior to endodontic treatment. OUTCOME MEASURES: At 4 (T(3)), 8 (T(4)), 12 (T(5)), and 24 (T(6)) h after preoperative (T(0)) time points, the analgesic efficacies of the agents were evaluated by using the visual analog scale (VAS). RESULTS: In group G, VAS values were significantly greater at T(0) time point than at T(5) or T(6). T(0) time point VAS value in group L was lower than at T4 time point and greater than at T(6). In group C, T(0) time point VAS values were significantly lower at T(3) and T(5) time points and greater than at T(6) time point. VAS values in group G at T(5) time point were significantly lower than in group C or group L (P < 0.05). CONCLUSIONS: Based on the obtained data, prophylactic lornoxicam controlled postendodontic treatment pain more effectively than did the placebo drugs, and gabapentin was more effective in controlling the pain than either lornoxicam or the placebo.

Effects of mid­gestational sevoflurane and magnesium sulfate on maternal oxidative stress, inflammation and fetal brain histopathology.

Models of inflammation, oxidative stress, hyperoxia and hypoxia have demonstrated that magnesium sulfate (MgSO4), a commonly used drug in obstetrics, has neuroprotective potential. In the present study, the effects of MgSO4 treatment on inflammation, oxidative stress and fetal brain histopathology were evaluated in an experimental rat model following sevoflurane (Sv) exposure during the mid-gestational period. Rats were randomly divided into groups: C (control; no injections or anesthesia), Sv (exposure to 2.5% Sv for 2 h), MgSO4 (administered 270 mg/kg MgSO4 intraperitoneally) and Sv + MgSO4 (Sv administered 30 min after MgSO4 injection). Inflammatory and oxidative stress markers were measured in the serum and neurotoxicity was investigated histopathologically in fetal brain tissue. Short-term mid-gestational exposure to a 1.1 minimum alveolar concentration of Sv did not significantly increase the levels of any of the measured biochemical markers, except for TNF-α. Histopathological evaluations demonstrated no findings suggestive of pathological apoptosis, neuroinflammation or oxidative stress-induced cell damage. MgSO4 injection prior to anesthesia caused no significant differences in biochemical or histopathological marker levels compared to the C and Sv groups. The present study indicated that short-term exposure to Sv could potentially be considered a harmless external stimulus to the fetal brain.

A Classification for Gastric Outlet Obstruction in Childhood: Extending Beyond Infantile Hypertrophic Pyloric Stenosis.

BACKGROUND/AIMS:  Gastric outlet obstruction (GOO) is a rare condition in childhood, with the exception of infantile hypertrophic pyloric stenosis (IHPS). However, no classification exists from a pediatric gastroenterologist's perspective. MATERIALS AND METHODS:  The patients with a diagnosis of GOO between 2009 and 2020 were reviewed retrospectively. We classified the patients according to GOO: presence of clinical findings accompanied by radiological and/or endoscopic findings; clinical status: intractable nonbilious postprandial vomiting alone or with abdominal pain, early satiety, weight loss, postprandial abdominal distension, and malnutrition; radiology: delayed gastric emptying and dilated stomach; endoscopy: nonbilious gastric contents after 6-8 hours of emptying and/or failed pyloric intubation; physical examination: visible gastric peristalsis. RESULTS:  A total of 30 GOO patients (15 patients with IHPS, 1 patient with annular pancreas, 4 patients with gastric volvulus, 2 patients with duodenal atresia, 2 patients with antral web, 1 patient with late-onset hypertrophic pyloric stenosis (LHPS) had surgical treatment, and remaining 5 patients had medical treatment) were enrolled to the study. The median age was 8 months (range: 3 months-16 years), and 14 patients were female. Mitochondrial disorders, LHPS, metabolic disorders, and eosinophilic gastrointestinal system diseases were added to Sharma's GOO classification, and the classification has been expanded. CONCLUSION:  This is the first and largest study of GOO in children. From the perspective of pediatric gastroenterology, new diseases will be addressed, and definitions will be highlighted with our classification for GOO in childhood.

Effects of the Recurrent and Different Doses of Ketamine Exposure on Anxiety-like Behaviors and Locomotor Activity in Juvenile Rats.

BACKGROUND: Ketamine is a widely used anesthetic agent. Although the potential adverse effects of ketamine use in juvenile age are uncertain, certain studies reported that children exposed to recurrent anesthesia could face an increased risk of neurodevelopmental deficits in motor function and behavioral risks. We aimed to investigate the long-term effects of repeated exposure to various ketamine doses on anxious behavior and locomotor activity in juvenile rats. OBJECTIVE: We aimed to investigate the long-term effects of repeated exposure to various ketamine doses on anxious behavior and locomotor activity in juvenile rats. METHODS: Thirty-two Wistar Albino juvenile male rats were randomized into 5 mg/kg, 20 mg/kg, and 50 mg/kg ketamine (KET) and saline (Group C) Groups and KET was administered for 3 consecutive days at 3-hour intervals in 3 doses. Ten days after the last KET dose, behavioral parameters were analyzed with an open field test (OFT), elevated plus maze (EPM), and light-dark box (LDB). Satistical analysis was conducted with Kruskall-Wallis test followed by Dunn's Multiple Comparison Test. RESULTS: Unsupported rearing behavior decreased in 50 mg/kg KET Groups when compared to Group C. Incorrect transition time, total grooming time, and transfer latency time increased significantly in the 50 mg/kg KET Group when compared to Group C. CONCLUSION: These results suggested that 50 mg/kg KET led to anxiety-like behavior and destroyed memory and spatial navigation. Ketamine doses were associated with late effects of ketamine on anxiety- like behavior in juvenile rats. Further studies are needed to determine the mechanisms that play a role in the different effects of ketamine doses on anxiety and memory.

A study to investigate the relationship between difficult intubation and prediction criterion of difficult intubation in patients with obstructive sleep apnea syndrome.

BACKGROUND AND AIM: Obstructive sleep apnea (OSA) syndrome is predisposed to the development of upper airway obstruction during sleep, and it poses considerable problem for anesthetic management. Difficult intubation (DI) is an important problem for management of anesthesia. In this clinical research, we aim to investigate the relationship between DI and prediction criteria of DI in cases with OSA. MATERIALS AND METHODS: We studied 40 [OSA (Group O, n = 20) and non-OSA, (Group C, n = 20)] ASA I-II, adult patients scheduled tonsillectomy under general anesthesia. Same anesthetic protocol was used in two groups. Intubation difficulties were assessed by Mallampati grading, Wilson sum score, Laryngoscopic grading (Cormack and Lehane), a line joining the angle of the mouth and tragus of the ear with the horizontal, sternomental distance, and tyromental distance. Demographic properties, time-dependent hemodynamic variables, doses of reversal agent, anesthesia and operation times, and recovery parameters were recorded. RESULTS: Significant difference was detected between groups in terms of BMI, Mallampati grading, Wilson weight scores, Laryngoscopic grading, sternomental distance, tyromental distance, doses of reversal agent, and recovery parameters. CONCLUSION: OSA patient's DI ratio is higher than that of non-OSA patients. BMI Mallampati grading, Wilson weight scores, Laryngoscopic grading, sternomental distance, and tyromental distance evaluation might be predictors for DI in patients with OSA.

Comparison of pre-emptive ibuprofen, paracetamol, and placebo administration in reducing post-operative pain in primary tooth extraction.

BACKGROUND: This study investigates preliminary investigations that a pre-emptive analgesia administration may reduce post-extraction pain. AIM: This prospective, placebo-controlled, randomized, double-blind trial was planned to compare the efficacy of the pre-emptive administration of ibuprofen, paracetamol, and placebo in reducing post-extraction pain in children. DESIGN: Forty-five children, ages 6-12, who needed primary mandibular molar tooth extraction were treated in paediatric dental clinics, with treatment preceded by local anaesthesia and analgesic drugs during the preoperative period. A five-face scale was used to evaluate pain reaction during the injection, extraction, and post-operative period. Self-report scores were recorded when the local anaesthesia had been administered in soft tissues and both before and after the extraction was completed. The Kruskal-Wallis and Mann-Whitney U tests (with Bonferroni correction paired t-test as the post hoc test) were used at a confidence level of 95%. RESULTS: The use of pre-emptive analgesics showed lower scores compared to the placebo, irrespective of the age, weight, gender of the child, and the number of teeth extracted during the study period. Additionally, ibuprofen exhibited lower pain scores (P < 0.05) compared to paracetamol at the 15-min (P < 0.001) and 4-h (P < 0.009) periods. CONCLUSIONS: Preoperative use of ibuprofen and paracetamol may provide a pre-emptive analgesic effect in paediatric patients who receive adequate analgesia during mandibular primary tooth extraction.

Effectiveness of premedication agents administered prior to nitrous oxide/oxygen.

BACKGROUND AND OBJECTIVE: In paediatric dentistry, when anxiety, fear of dental procedures or behavioural impairment precludes the conduct of dental treatments, sedation procedures are required. However, sedation at the desired level might not be achieved despite administration of various agents. The present study aimed to evaluate the effectiveness of oral premedication with different agents on children scheduled for dental treatment under nitrous oxide/oxygen (N2O/O2) sedation. METHODS: The present research was approved by the Ethics Committee of Gazi University Faculty of Medicine. Sixty children aged between 5 and 8 years, ASA I or II, having no mental or motor retardation, requiring at least two-visit dental treatment, having no sedation or general anaesthesia experience, and incompliant with dental treatment (Frankl Behaviour Scale>or=3), were enrolled into the study after obtaining informed parental consent. The children were then randomly assigned to one of four groups. The treatment regimen according to the study groups was as follows: oral administration of 1 mg kg(-1) hydroxyzine hydrochloride suspension (Atarax) 1 h preoperatively (group I, n=15), oral administration of 0.7 mg kg(-1) midazolam (Dormicum) 15 min preoperatively (group II, n=15), oral administration of 3 mg kg(-1) ketamine (Ketalar) with 0.25 mg kg(-1) midazolam (Dormicum) 15 min preoperatively (group III, n=15), and no oral premedication administration [group IV (controls), n=15]. Peripheral oxygen saturation (SpO2) and heart rate were monitored with a pulse oximeter during treatment. The sedation level was monitored with the bispectral index. Following premedication, 40% N2O and 60% O2 was administered to all groups by means of a nasal mask. Sedation depth was evaluated using the Ramsay Sedation Scale and data were recorded at 5 min intervals. Sedation success and other sedation-related events were recorded. RESULTS: The evaluation of the findings of this study revealed that treatment procedures were completed without any serious complications. Achievement of sedation in terms of satisfactory/mid-level satisfactory/unsatisfactory was as follows: 13.3/53.3/33.3% in group I; 54/20/26% in group II; 33.3/33.3/33.3% in group III, and 6.7/60/33.3% in group IV, respectively. Ramsay Sedation Scale results revealed that the most effective medication was 0.7 mg kg(-1) midazolam. CONCLUSION: It is concluded that 0.7 mg kg(-1) midazolam is more effective than 0.25 mg kg(-1) midazolam with 3 mg kg(-1) ketamine and 1 mg kg(-1) hydroxyzine hydrochloride in terms of oral premedication prior to N2O/O2 sedation in children scheduled for dental treatments.

The effects of temperament and behaviour problems on sedation failure in anxious children after midazolam premedication.

BACKGROUND AND OBJECTIVE: Midazolam is one of the most frequently used agents for sedation in paediatric dentistry. It is unclear how temperament traits and behaviour problems are related to sedation failure in children. We investigated whether sedation failure after premedication with oral midazolam can be predicted by behaviour problems and temperament traits. METHODS: Sixty children (aged 4-8 years) referred for dental treatment under sedation (40/60% N2O/O2), who had a Frankl Behaviour Scale score of at least 3, were premedicated with oral midazolam (0.75 mg kg(-1)). The level of sedation was assessed at defined time intervals, according to the Houpt Sedation Rating Scale. Children's sedation success during dental treatment was classified as satisfactory or unsatisfactory. Heart rate and oxygen saturation were evaluated by an oxygen saturation monitor in the sedation period. On the treatment day, parents completed 'The Revised Conners' Parent Rating Scale' and 'Short Temperament Scale for Children' to assess their child's behaviour problems and temperament, respectively. RESULTS: The rates of sedation success were found to be satisfactory in 78.4% and unsatisfactory in 21.6%. Student's t-test demonstrated that in addition to the Short Temperament Scale for Children Inflexibility subscale being significant the Revised Conners' Parent Rating Scale: Long Form Psychosomatic subscale was also found to be a significant predictor of sedation failure. CONCLUSION: Psychosomatic behaviour problems and an inflexible temperament trait might contribute to sedation failure in children undergoing dental treatment under midazolam premedication and N2O/O2 sedation. Appropriate patient selection based on the evaluation of childhood behavioural problems and temperament characteristics might increase midazolam sedation success in children.

Effects of the general anaesthetic agent, propofol, on erythrocyte deformability.

OBJECTIVES: Propofol is an anesthetic agent frequently used for sedation and general anesthesia. The purpose of our study was to investigate the effect of propofol, a general anesthetic, on erythrocyte deformability in rats. METHODOLOGY: The study was performed on 20 male and 20 female rats, with 10 rats in each study group and 10 rats in each control group. The rats in the study group were administered propofol (150 mg.kg(-1)) intraperitoneally, and the rats in the control group were administered SF. Erythrocyte packs were prepared using heparinized total blood samples. Deformability measurements were done by erythrocyte suspensions in PBS buffer. A constant flow filtrometer system was used to measure erythrocyte deformability, and the relative resistance was calculated. RESULTS: The use of propofol resulted in the increase in the relative resistance, which is an indicator for the erythrocyte deformability in both male and female rats (p = 0.002, p = 0.042, respectively). CONCLUSION: A negative change in the erythrocyte deformability may cause a functional deterioration in blood flow and tissue perfusion (Fig. 1, Ref. 23).

Effects of preoperative lornoxicam versus tramadol on postoperative pain and adverse effects in adult tonsillectomy patients.

OBJECTIVES: This study assessed the efficacy and adverse effects of preoperatively administered lornoxicam versus tramadol in adults, for post-tonsillectomy pain. METHODS: This prospective, double blind, randomized, clinical research was performed in the Ear, Nose and Throat Surgery Room in the Department of Anesthesia and Reanimation, Gazi University Faculty of Medicine. Forty American Society of Anesthesiologists (ASA) status I-II patients of both gender, aged 18-55 years, were included. RESULTS: Tonsillectomy patients were divided into two groups: Those in Group L received 8 mg lornoxicam and in Group T received 50 mg tramadol intravenously just before induction of general anesthesia. Induction and maintenance of anesthesia (propofol, atracurium, nitrous oxide and sevoflurane) were standardized. Heart rate and systolic and diastolic arterial pressure data were monitored during the anesthesia. Intra-operative bleeding was scored by the same operator using a 5-point scale at the end of the surgery. Postoperative pain on swallowing was scored by a blinded anesthesiologist using Verbal Rating Scale (VRS) on arrival in the Post Anesthesia Care Unit (T(0)), at 30 min (T(1)), 1h (T(2)), 2h (T(3)), 3h (T(4)), 4h (T(5)), 5h (T(6)), and 6h (T(7)) thereafter. During the first postoperative 6 hours, when VRS >/=2, 1mg.kg(-1) im meperidine was used as a rescue analgesic. Adverse effects in the postoperative 6h period were noted. T(1) and T(2) pain scores in Group T were higher than in Group L (p=0.049, p=0.007, respectively). The number of patients requiring rescue analgesics during the first 6 hours in Group L was lower than in Group T. Nausea-vomiting, bleeding and postoperative hemorrhage values were similar between Group L and Group T. CONCLUSION: Preoperative 8 mg lornoxicam was more effective than 50 mg tramadol with respect to early postoperative tonsillectomy pain in adult patients, and side effects were similar.

Premedication with melatonin vs midazolam in anxious children.

AIM: Failure of dental treatment caused by anxiety is a common problem in children. Oral midazolam has been the most commonly used premedication for pediatric patient but the use of midazolam may be associated with paradoxical reactions in children. Melatonin may induce a natural sleepiness and improve sedation. We have investigated premedication with melatonin compared with midazolam in children under nitrous oxide/oxygen (N(2)O/O(2)) sedation for dental treatment. METHODS: In a randomized study, 60 children received either 3 mg of melatonin [Melatonina (3 mg(R)) 60 min before the procedure (n = 15); group I], 0.5 mg.kg(-1) melatonin 60 min before the procedure (n = 15; group II), 0.75 mg.kg(-1) midazolam [Dormicum (15 mg/3 ml (R)) 15 min before the procedure (n = 15); group III] or 3 ml of 0.09 NaCl 15 min (n = 7) or 60 min before the procedure (n = 8; group IV) orally. The children were sedated with 40/60% N(2)O/O(2) inhalation. The heart rate and O(2) saturation were monitored during the treatment period. The level of sedation was assessed according to the Ramsay Sedation Scale. The children's sedation success during dental treatment was classified. The sedation success and other sedation-related events recorded. Comparisons among the four groups were made using one-way anova or Kruskal-Wallis test, and if any significant differences were noted, the Tukey's HSD or Mann-Whitney U-test were used for intergroup comparisons. All differences were considered significant at P < 0.05. RESULTS: The evaluation of sedation success was as follows: group I: satisfactory (n = 1), average satisfactory (n = 4), and unsatisfactory (n = 10); group II: satisfactory (n = 2), average satisfactory (n = 3), and unsatisfactory (n = 10); group III: satisfactory (n = 9), average satisfactory (n = 6); and group IV: satisfactory (n = 1), average satisfactory (n = 3), and unsatisfactory (n = 11). CONCLUSION: In these doses and clinical conditions, melatonin was similar to that of placebo and did not contribute to N(2)O/O(2) sedation of anxious children.

Effect of drinks that are added as flavoring in oral midazolam premedication on sedation success.

BACKGROUND: Midazolam is one of the most frequently used agents for sedation in pediatric dentistry. The injectable form of midazolam can also be given orally. However, its bad taste has negative effects on ingestion of the drug. In this study, we aimed to evaluate the effect of drinks which were added to mask the bitter taste of midazolam for drug acceptance and sedation. METHODS: In the laboratory; the pH values of 2.5 ml midazolam (15 mg x 3 ml(-1)) and the mixtures of Pepsi Cola, 10% sodium citrate, fresh pomegranate juice, and fresh grapefruit juice in equal volumes were measured. Seventy-five patients between 2 and 8 years of age who were assessed to have anxiety with the Frankl Behavior Scale and whose dental treatment was planned under sedation were randomly divided into five groups. Pepsi Cola (Group I), 10% sodium citrate (Group II), pomegranate juice (Group III), and grapefruit juice (Group IV) which were added to 0.75 mg x kg(-1) midazolam in equal volumes, and (Group V) 0.75 mg x kg(-1) midazolam given orally to children. The drug compliance of children was evaluated. After 15 min, 4-5 l x min(-1) of N(2)O : O(2) (40 : 60) inhalation was started via a nasal hood. During the procedure, heart rate, and SpO2 were monitored with pulse oximetry and sedation levels with the Ramsay Sedation Scale (RSS). Anesthetist, dentist, and parental satisfaction levels were recorded. RESULTS: The groups had similar demographics, drug ingestion was better in Groups I and II, but the mean RSS was the highest in Group II (P < 0.05). CONCLUSIONS: As well as making drug ingestion much simpler, the addition of sodium citrate to the midazolam administered orally to the children increased the effectiveness of sedation.

Emotion regulation and premedication success relationship in children who underwent general anesthesia

Background/aim: This study aims to investigate the relationship between emotion regulation characteristics and the efficacy of midazolam premedication. Materials and methods: Sixty-three children, aged 3 to 8 years old, with tonsillectomy and/or adenoidectomy and taking premedication with midazolam (Group 2) or without premedication (Group 1), were included in this study. The behavioral and emotional status of the children was evaluated with the Conners Parent Rating Scale-48 (CPRS-48) and Emotion Regulation Checklist (ERC). Age, sex, body weight, response to intravenous (IV) cannulation and mask, hemodynamic data, preoperative sedation scores [Wilton Sedation Scale (WSS)], postoperative pain intensity [Objective Pain Scale (OPS)], and emergence agitation (EA) level [Pediatric Anesthesia Emergence Delirium (PAED)] were recorded. Results: A total of 90.6% patients were quiet and sleepy in Group 2, and 25.8% in Group 1. The mean scores of OPS and PAED were higher in Group 1, and the percentage of patients with PAED score of >10 was 51.6% in Group 1 and 18.8% in Group 2 (P < 0.05). In Group 1, a significant correlation was found between PAED scores and WSS and the subfactors of the CPRS-48 (P < 0.05). A correlation was found between WSS and subfactors of ERS in Group 1 (P < 0.05). Conclusion: The incidence of anxiety and postoperative EA is increased in children with emotion regulation disorder, and midazolam premedication reduced the frequency of EA.

Clinically suspected anaphylaxis induced by sugammadex in a patient with Weaver syndrome undergoing restrictive mammoplasty surgery: A case report with the literature review.

RATIONALE: Sugammadex is a cylodextrin derivate that encapsulates steroidal neuromuscular blocker agents and is reported as a safe and well-tolerated drug. In this case report, we present a patient who developed grade 3 anaphylaxis just after sugammadex administration. PATIENT CONCERNS: A 22-year-old woman with diagnosis of Weaver syndrome was scheduled for bilateral mammoplasty and resection of unilateral accessory breast tissue resection. Anesthesia was induced and maintained by propofol, rocuronium, and remifentanil. At the end of the operation, sugammadex was administered and resulted in initially hypotension and bradycardia then the situation worsened by premature ventricular contraction and bigeminy with tachycardia, bronchospasm, and hypoxia. DIAGNOSIS: The Ring and Messmer clinical severity scale grade 3 anaphylactic reaction occurred just after sugammadex injection and the patient developed prolonged hypotension with recurrent cardiac arrhythmias in postoperative 12 hours. INTERVENTIONS: Treatment was initiated bolus injections of ephedrine, epinephrine, lidocaine, steroids and antihistaminic and continued with lidocaine bolus dosages and norepinephrine infusion for the postoperative period. OUTCOMES: The general condition of the patient improved to normal 3 hours after the sugammadex injection, and she was moved to the intensive care unit. At 2nd and 8th hours of intensive care unit follow-up, she developed premature ventricular contraction and bigeminy with the heart rate of 130 to 135 beats/min, which returned to sinus rhythm with 50 mg lidocaine. After that, no symptoms were observed and the patient was discharged to plastic surgery clinic at the following day. LESSONS: Sugammadex may result in life-treating anaphylactic reaction even in a patient who did not previously expose to drug. Moreover, prolonged cardiovascular collapse and cardiac arrhythmias may occur.

The effect of nicotine on the recovery of rats receiving anesthesia.

OBJECTIVE: To determine the effect of intraperitoneal (ip) nicotine on the recovery of rats receiving general anesthesia compared with placebo. METHODS: The placebo controlled experimental study was conducted in the Faculty of Medicine, Gazi University, Turkey, between April and May 2005. Twenty-one male and 21 female rats were randomly divided into 3 groups. Group C (n=14), comprising a female group CF (n=7), and male group CM (n=7) received ip 0.9% sodium chloride (NaCl), group P (n=14), comprising a female group PF (n=7), and male group PM (n=7) received ip propofol 150 mg/kg, and group NP (n=14), comprising a female group NPF (n=7), and male group NPM (n=7) received 0.4 mg/kg ip nicotine followed by 150 mg/kg propofol after 15 minutes. For the evaluation of recovery period, tail pinch test was used, and for cognitive performance, the radial arm maze test was used. RESULTS: The number of entrances and exits decreased in group P significantly compared to group C (p<0.05), and the decrease in group PF was higher than it was in group PM. Entrance and exit in group NP increased significantly compared to group P (p<0.05). The increase in entrance and exit in group NPF was much higher compared to group NPM. The recovery period in group NP was significantly shorter than in group P (p<0.05). CONCLUSION: The ip administration of nicotine in rats shortens the recovery from propofol anesthesia and improves cognitive performance.