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OBJECTIVE: To determine a conversion factor for use when switching from dexmedetomidine infusion to enteral clonidine in critically ill neonates. METHODS: This was an observational, retrospective review of conversions from dexmedetomidine to -clonidine, performed in a neonatal intensive care unit (NICU) between January 2020 and December 2021. Both initial conversion factors and those resulting after a 48-hour titration period were examined. Sedation and withdrawal scores were measured, and doses were titrated based on a standardized practice within the unit. RESULTS: A total of 43 dexmedetomidine to clonidine conversions were included. The median (IQR) dexmedetomidine dose prior to conversion was 17.4 (11.3-24.0) mcg/kg/day (0.7 mcg/kg/hr) and the median (IQR) enteral clonidine dose post titration was 7.8 (4.7-9.3) mcg/kg/day (2 mcg/kg every 6 hours). This equated to a post-titration conversion factor of approximately 0.42. All neonates had also received opioid infusions while on dexmedetomidine and 60% were on concurrent opioids at the time of the clonidine conversion. CONCLUSIONS: Neonatal clinicians may find the conversion factor identified in this study a useful starting point when converting from dexmedetomidine infusion to enteral clonidine in practice and should be -reminded of the most important steps in conversions (monitoring and follow-up) owing to the variability in this patient group. More studies are needed to elucidate the impact of patient-specific factors on this -conversion process.
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INTRODUCTION: Tourette syndrome (TS) is a childhood-onset neurobehavioral disorder characterized by tics. Pharmacotherapy is advised for patients whose symptoms affect their quality of life. AREAS COVERED: The authors review the tic phenomenology and TS diagnostic criteria. The bulk of this article focuses on pharmacotherapeutic options for treating tics. They also highlight pharmacotherapies in the research pipeline. EXPERT OPINION: Tic treatment must be tailored to individual needs. Behavioral therapy is the first line of treatment. Most with bothersome tics need pharmacotherapy and rarely, for medication-refractory cases, surgical therapy is indicated. Alpha-2 agonists are considered in patients with mild tics, especially in those with attention deficit with or without hyperactivity. Second-generation antipsychotics like aripiprazole and tiapride may be considered for severe tics. However, prescribers should be mindful of potential side effects, especially drug-induced movement disorders. Botulinum toxin injections may be considered for focal motor tics. Topiramate can be considered when other treatments are ineffective, and its benefits outweigh the risks. The same holds true for vesicular monoamine transporter-2 inhibitors, as they are deemed to be safe and effective in real-world use and open-label trials despite not meeting primary endpoints in placebo-controlled trials. Cannabinoids may be considered in adults if the approaches above do not control tics.
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BACKGROUND: The use of intranasal dexmedetomidine is hampered by a limited understanding of its absorption pharmacokinetics. METHODS: We examined the pharmacokinetics and feasibility of intranasal dexmedetomidine administered in the supine position to adult patients undergoing general anaesthesia. Twenty-eight patients between 35 and 80 years of age, ASA 1-3 and weight between 50 and 100 kg, who underwent elective unilateral total hip or knee arthroplasty under general anaesthesia were recruited. All patients received 100 µg of intranasal dexmedetomidine after anaesthesia induction. Six venous blood samples (at 0, 5, 15, 45, 60, 240 min timepoints from dexmedetomidine administration) were collected from each patient and dexmedetomidine plasma concentrations were measured. Concentration-time profiles after nasal administration were pooled with earlier data from a population analysis of intravenous dexmedetomidine (n = 202) in order to estimate absorption parameters using nonlinear mixed effects. Peak concentration (CMAX) and time (TMAX) were estimated using simulation (n = 1000) with parameter estimates and their associated variability. RESULTS: There were 28 adult patients with a mean (SD) age of 66 (8) years and weight of 83 (10) kg. The mean weight-adjusted dose of dexmedetomidine was 1.22 (0.15) µg kg-1. CMAX 0.273 µg L-1 was achieved at 98 min after intranasal administration (TMAX). The relative bioavailability of dexmedetomidine was 80% (95% CI 75-91%). The absorption half-time (TABS = 120 min; 95% CI 90-147 min) was slower than that in previous pharmacokinetic studies on adult patients. Perioperative haemodynamics of all patients remained stable. CONCLUSIONS: Administration of intranasal dexmedetomidine in the supine position during general anaesthesia is feasible with good bioavailability. This administration method has slower absorption when compared to awake patients in upright position, with consequent concentrations attained after TMAX for several hours.
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BACKGROUND: Dexmedetomidine is a sedative drug with a wide safety margin. CASE PRESENTATION: We present a case of accidental iatrogenic dexmedetomidine overdose in an adult patient during high-intensity focused ultrasound (HIFU) treatment. This is the first case report of an adult patient receiving an intravenous push of dexmedetomidine. Overdose resulted in severe oversedation, but symptoms receded spontaneously over time. CONCLUSIONS: Dexmedetomidine overdoses are infrequent, and they are usually the result of an administration error.
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BACKGROUND: Postoperative pain after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is important. It appears essential to reduce postoperative pain and morphine consumption. METHODS: Retrospective study in a university hospital comparing patient benefiting from CRS-HIPEC under opioid-free anesthesia (OFA; dexmedetomidine) to those anesthetized with opioid anesthesia (OA; remifentanil) using a propensity score matching method. The main objective was the impact of OFA on postoperative morphine consumption in the first 24 h after surgery. RESULTS: 102 patients were included, matching on the propensity score allowed selecting 34 unique pairs analyzed. Morphine consumption was lower in the OFA group than in the OA group (3.0 [0.00-11.0] mg/24 h vs. 13.0 [2.5-25.0] mg/24 h; p = 0.02). In multivariable analysis, OFA was associated with a reduction of 7.2 [0.5-13.9] mg of postoperative morphine (p = 0.04). The rate of renal failure with a KDIGO-score > 1 was lower in the OFA group than in the OA group (12% vs. 38%; p = 0.01). There was no difference between groups concerning length of surgery/anesthesia, norepinephrine infusion, volume of fluid therapy, post-operative complications, rehospitalization or ICU readmission within 90 days, mortality, and postoperative rehabilitation. CONCLUSION: Our results suggest that OFA for CRS-HIPEC patients appears safe and is associated with less postoperative morphine use and acute kidney injury.
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Anestesia , Hipertermia Induzida , Humanos , Analgésicos Opioides/uso terapêutico , Estudos Retrospectivos , Procedimentos Cirúrgicos de Citorredução/métodos , Pontuação de Propensão , Dor Pós-Operatória/prevenção & controle , Hipertermia Induzida/métodos , Derivados da Morfina/uso terapêutico , Terapia CombinadaRESUMO
OBJECTIVE: The aim of this study was to identify patterns of ADHD care, including factors that guide selection and sequencing of treatments in a large nationwide sample of preschool-aged youth over the past 6 years. METHOD: A retrospective cohort study utilizing a large electronic health record (TriNetX) of nearly 24,000 children ages 3 to 6 diagnosed with ADHD. RESULTS: One in three preschoolers with ADHD were prescribed psychotropic medication, most commonly methylphenidate and guanfacine. One in 10 had at least one psychotherapy billing code during the entire assessment with most youth starting medication before psychotherapy. Rates of most treatments, including polypharmacy, increased with comorbid psychiatric disorders or sleep problems and over the course of the coronavirus pandemic. CONCLUSION: Rates of treatment have increased over time but are still largely inconsistent with published care guidelines that advise therapy before medication. Clinicians appear to prioritize psychiatric comorbidity and sleep problems when selecting treatments.
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Transtorno do Deficit de Atenção com Hiperatividade , Estimulantes do Sistema Nervoso Central , Metilfenidato , Transtornos do Sono-Vigília , Adolescente , Humanos , Pré-Escolar , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Estimulantes do Sistema Nervoso Central/uso terapêutico , Estudos Retrospectivos , Metilfenidato/uso terapêuticoRESUMO
Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α2-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using these drugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.
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Dexmedetomidina , Bloqueio Nervoso , Estados Unidos , Adjuvantes Imunológicos , Anestésicos Locais , Agonistas de Receptores Adrenérgicos alfa 2 , Nervos PeriféricosRESUMO
Objective: To describe the use of a low dose dexmedetomidine infusion as preoperative treatment for hypoglycemia secondary to a functional pancreatic tumor in a dog. Case summary: An 8.7-year-old castrated male Hungarian Vizsla presented for further evaluation of persistent hypoglycemia after the referring veterinarian established a tentative diagnosis of insulinoma based on paired insulin and glucose measurements. Abdominal ultrasound and computed tomography demonstrated evidence of a pancreatic mass with possible hepatic metastases. Attempts to aspirate the lesions under ultrasound guidance were unsuccessful, and the dog was hospitalized overnight for planned surgical resection of the presumed pancreatic tumor and biopsy of the hepatic lesions the following day. In response to a progressive increase in patient anxiety and agitation trazodone was prescribed ~5 mg/kg orally every 8 h and gabapentin at ~7 mg/kg every 8 h. As the dog continued to remain anxious dexmedetomidine at a dose of 1 mcg/kg was administered intravenously immediately followed with an infusion of dexmedetomidine at 1 mcg/kg/h. The anxious behaviors were successfully controlled with minimal cardiovascular side effects. Serial blood glucose measurements obtained during this time demonstrated euglycemia. The dog remained euglycemic while receiving dexmedetomidine for the remainder of the pre-operative period and for duration of hospitalization following surgical resection and biopsy. New or unique information provided: This case report demonstrates a possible role for dexmedetomidine to counteract hypoglycemia in dogs with insulinomas.
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The purpose of this study was to assess perioperative analgesia provided by the combination of epidural dexmedetomidine and morphine in bitches undergoing elective ovariohysterectomy. Twenty-four bitches were included in the study and allocated into 3 groups: GM, morphine 0.1 mg/kg; GD, dexmedetomidine 2 µg/kg; and GDM, dexmedetomidine and morphine at the same doses. All solutions were diluted in saline to a total of 0.36 mL/kg. Heart rate (HR), respiratory rate (FR) and systolic blood pressure (SAP) were recorded prior to epidural analgesia (TB), immediately following epidural analgesia (TEA), at surgical incision (TSI), at the first ovarian pedicle clamping (TOP1), at the second pedicle clamping (TOP2), at uterine stump clamping (TUC), at the start of abdominal cavity closure (TSC) and at the end of skin closure (TEC). Rescue analgesia with fentanyl was administered at 2 µg/kg IV if nociception corresponding to a 20% increase of any cardiorespiratory variables was noted. Postoperative pain assessment was performed using a modified composite Glasgow pain scale along the first 6 hours following the end of surgery. Numeric data were compared using ANOVA for repeated measures followed by Tukey test and ovarian ligament relaxation was analyzed using chi-square test under 5% significance. No differences were found on FR among times or groups, although HR showed significant differences between GM and GD at TSI, TOP1, TOP2, TSC and TEC and between GM and GDM at TEA and TSI (significantly lower HR values recorded in dexmedetomidine groups). Differences among time points were found on HR between TB and TEA in GD and on PAS between TOP1 and TSC in GM and between TOP1 and TUC in GDM (P < .05). Ovarian ligament relaxation was significantly more present in groups using dexmedetomidine, although the number of rescue analgesia administrations did not differ among groups. Kaplan-Meyer analysis failed to show significant differences on time of rescue analgesia administration among groups (P > .05). In conclusion, the combination of epidural dexmedetomidine and morphine is a more interesting choice for elective ovariohysterectomy in bitches for producing analgesia comparable to that of each drug alone, with noticeable relaxation of ovarian ligaments and lesser cardiovascular consequences.
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Analgesia Epidural , Anestesia Epidural , Dexmedetomidina , Feminino , Animais , Morfina , Dexmedetomidina/farmacologia , Histerectomia/veterinária , Analgesia Epidural/veterinária , Anestesia Epidural/veterináriaRESUMO
Dexmedetomidine is a preferred agent for light sedation with minimal adverse effects. We report a case of acute colonic pseudo-obstruction following dexmedetomidine use in a patient with alcohol withdrawal. He was treated with benzodiazepines first to control the withdrawal symptoms, then escalated to dexmedetomidine once delirium tremens ensued. Later on, the patient developed abdominal distension and vomiting. Imaging showed dilated bowel loops and absence of peristalsis on ultrasound. Decompression with the nasogastric (NG) tube was done, with high output from the NG tube. Dexmedetomidine infusion was used twice, and once it was stopped, the NG tube output was reduced, with the resumption of gastrointestinal motility and improvement of the abdominal distension. Recent similar reports of functional intestinal obstruction following alpha-2 (α2) agonist use necessitate further studies of intestinal motility following dexmedetomidine use and awareness of the possible side effect of dexmedetomidine on intestinal motility.
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Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.
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Background: Although clonidine and dexmedetomidine are used as alpha-2 agonists to improve the quality and duration of blockade induced by local anesthetics, no study has been reported to compare their associated adverse events in local anesthesia. The aim of this study is to compare the adverse events associated with the adjuvant use of dexmedetomidine and clonidine in local anesthesia. Methods: A comprehensive search was performed to retrieve any reported adverse event associated with adjuvant use of dexmedetomidine and clonidine in local anesthesia from published literature up to 1 July 2020. Assessment of the quality of included studies was performed by the Jadad score. A comparison of any reported adverse event was made between interventions by pooling data from studies using a direct meta-analysis technique. Dichotomous outcomes were summarized as risk ratios. The review was performed according to PRISMA guideline. Results: From 121 articles retrieved from the search finally 14 articles including 1,120 patients had eligibility criteria for including in the meta-analysis. No significant difference was observed between bradycardia/hypotension (OR = 1.17; 95 % CI = 0.66-2.10; P = 0.580; I 2 = 53.78 %, P = 0.027), nausea/vomiting (OR = 0.91; 95% CI = 0.59-1.42; P = 0.706; I 2 = 0.0 %, P = 0.940) dizziness/headache (OR = 1.10; 95% CI = 0.44-2.75; P = 0.831; I 2 = 0.0 %, P = 0.882) shivering (OR = 0.95 % CI = 0.50-1.66; P = 0.831; I 2 = 0.0 %, P = 0.920) and dry mouth (OR = 1.00; 95 % CI = 0.50-1.96; P = 0.996; I 2 = 0.0%, P = 0.900). No significant difference was observed in subgroup comparison of adverse events in the intravenous or local adjuvant use of the study drugs (p > 0.05). Conclusion: There is no difference in adverse events associated with the intravenous or local adjuvant use of dexmedetomidine and clonidine in local anesthesia.
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WHAT IS KNOWN AND OBJECTIVE: Brimonidine is increasingly used in the treatment of intraocular hypertension. CASE SUMMARY: We report on five paediatric patients suffering from brimonidine eye drop intoxication. The most frequent signs of the intoxication were a lowered level of consciousness and hypotonia. Other complications were apnea, bradycardia, hypotension and seizure. One of the patients needed cardiopulmonary resuscitation. Apnea in one of the cases was resistant to naloxone. Pupils were unremarkable in two cases. WHAT IS NEW AND CONCLUSION: Brimonidine is potentially lethal for young infants. The absence of miosis and absence of response to naloxone is not a reason to rule out brimonidine poisoning.
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Tartarato de Brimonidina/efeitos adversos , Feminino , Humanos , Lactente , Pressão Intraocular/efeitos dos fármacos , Masculino , Soluções OftálmicasRESUMO
BACKGROUND: Clinically significant attention-deficit/hyperactivity disorder (ADHD) symptoms are common and impairing in children and youth with autism spectrum disorder(ASD). The aim of this systematic review and meta-analysis was to (a) evaluate the efficacy and safety of pharmacotherapy for the treatment of ADHD symptoms in ASD and (b) distil findings for clinical translation. METHODS: We searched electronic databases and clinical trial registries (1992 onwards). We selected randomized controlled trials conducted in participants <25 years of age, diagnosed with ASD that evaluated ADHD outcomes (hyperactivity/impulsivity and inattention) following treatment with stimulants (methylphenidate or amphetamines), atomoxetine, alpha-2 adrenergic receptor agonists, antipsychotics, tricyclic antidepressants, bupropion, modafinil, venlafaxine, or a combination, in comparison with placebo, any of the listed medications, or behavioral therapies. Data were pooled using a random-effects model. RESULTS: Twenty-five studies (4 methylphenidate, 4 atomoxetine, 1 guanfacine, 14 antipsychotic, 1 venlafaxine, and 1 tianeptine) were included. Methylphenidate reduced hyperactivity (parent-rated: standardized mean difference [SMD] = -.63, 95%CI = -.95,-.30; teacher-rated: SMD = -.81, 95%CI = -1.43,-.19) and inattention (parent-rated: SMD = -.36, 95%CI = -.64,-.07; teacher-rated: SMD = -.30, 95%CI = -.49,-.11). Atomoxetine reduced inattention (parent-rated: SMD = -.54, 95%CI = -.98,-.09; teacher/investigator-rated: SMD = -0.38, 95%CI = -0.75, -0.01) and parent-rated hyperactivity (parent-rated: SMD = -.49, 95%CI = -.76,-.23; teacher-rated: SMD = -.43, 95%CI = -.92, .06). Indirect evidence for significant reductions in hyperactivity with second-generation antipsychotics was also found. Quality of evidence for all interventions was low/very low. Methylphenidate was associated with a nonsignificant elevated risk of dropout due to adverse events. CONCLUSIONS: Direct pooled evidence supports the efficacy and tolerability of methylphenidate or atomoxetine for treatment of ADHD symptoms in children and youth with ASD. The current review highlights the efficacy of standard ADHD pharmacotherapy for treatment of ADHD symptoms in children and youth with ASD. Consideration of the benefits weighed against the limitations of safety/efficacy data and lack of data evaluating long-term continuation is undertaken to help guide clinical decision-making regarding treatment of co-occurring ADHD symptoms in children and youth with ASD.
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Transtorno do Deficit de Atenção com Hiperatividade , Transtorno do Espectro Autista , Estimulantes do Sistema Nervoso Central , Metilfenidato , Adolescente , Cloridrato de Atomoxetina/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Espectro Autista/tratamento farmacológico , Estimulantes do Sistema Nervoso Central/efeitos adversos , Criança , Guanfacina , Humanos , Metilfenidato/efeitos adversosRESUMO
BACKGROUND: Hospitalized newborn infants may require analgesia and sedation either for the management of procedural pain, during or after surgery, and other painful conditions. The benefits and harms of opioids administered at different doses and routes of administration have been reported in numerous trials and systematic reviews. The use of alpha-2-agonists such as clonidine and dexmedetomidine in newborn infants is more recent, and they might be prescribed to reduce the total amount of opioids which are thought to have more side effects. Moreover, alpha-2-agonists might play an important role in the management of agitation and discomfort. METHODS: We will conduct a systematic review and meta-analysis on the use of opioids, alpha-2-agonists, or the combination of both drugs. We will include randomized controlled trials to assess benefits and harms and observational studies to assess adverse events and pharmacokinetics; preterm and term infants; studies on any opioids or alpha-2-agonists administered for any indication and by any route except spinal, intraosseous, or administration for nerve blocks and wound infusions. The use of opioids or alpha-2-agonists will be compared to no intervention; placebo with normal saline or other non-sedative, non-analgesic drug; control with oral sugar solution or non-pharmacological intervention; same drug of different dose or route; or a different drug (not limiting to opioids and alpha-2-agonists) or combinations of such drugs. The primary outcomes for this review will be all-cause mortality during initial hospitalization and hypotension requiring medical therapy. We will conduct a search in the following databases: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, Embase, and CINAHL. Two review authors will independently screen records for inclusion, undertake data abstraction using a data extraction form and assess the risk of bias of all included trials using the Cochrane "Risk of bias" tool. DISCUSSION: This systematic review will summarize and update our knowledge about neonatal analgesia and sedation including pharmacokinetics/pharmacodynamics, and provide a platform for developing evidence-based guidelines that we can immediately apply to our clinical practice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2020 CRD42020170852.
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Analgesia , Analgésicos Opioides , Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Analgésicos Opioides/efeitos adversos , Clonidina , Humanos , Lactente , Recém-Nascido , Metanálise como Assunto , Manejo da Dor , Revisões Sistemáticas como AssuntoRESUMO
Objectives: The National Survey of Children's Health reported a concerning increase in children 2-5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns include both the increase in diagnosing and potential deviations from published guidelines for the treatment of ADHD in preschoolers. The present study aims to describe the epidemiology and factors associated with receiving the diagnosis and treatment types for low-income preschoolers. Methods: Using Kentucky Medicaid claims from 2012 to 2017, a retrospective cohort study of children 2-5 years of age (n = 337,631) with a diagnosis of ADHD (n = 11,712) was completed. Trends in demographics, comorbidities, and treatment and provider types are presented. Multinomial logistic regression was used to determine predictors of receipt of the diagnosis and treatment type (a stimulant only, an alpha-2 agonist [A2A] only, both, or neither) based on nonmissing 2017 data (n = 2394). Results: The number of children in the cohort diagnosed with ADHD and receiving a stimulant decreased from 2012 to 2017, but the use of A2As increased. Primary care physicians were the most frequent prescribers of both medications. The adjusted odds ratios (AORs) of receipt of an A2A alone, stimulant alone, or both medications over receiving no ADHD medication were associated with specific demographics and comorbid conditions for each medication regimen. Race/ethnicity is associated with receiving the diagnosis of ADHD and treatment with A2A. Comorbid mental health conditions and provider type are associated with treatment type. Conclusion: Use of stimulants for preschoolers in Kentucky has decreased and A2A use has increased since 2012. Continued vigilance and long-term follow-up of preschoolers with ADHD are warranted. The appropriateness of the diagnosis and treatment type could not be determined.
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Agonistas de Receptores Adrenérgicos alfa 2/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade , Estimulantes do Sistema Nervoso Central/uso terapêutico , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Pré-Escolar , Comorbidade , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Kentucky/epidemiologia , Masculino , Medicaid/estatística & dados numéricos , Pobreza , Estudos Retrospectivos , Estados UnidosRESUMO
Tourette syndrome is a complex neuropsychiatric disorder with a wide phenotypic spectrum, including tics and psychiatric comorbidities, such as obsessive-compulsive disorder and attention-deficit disorder. Often considered a neurodevelopmental disorder, it is most prevalent during childhood and treatment strategies can vary according to degree of severity and patient-specific symptom manifestations. This review focuses on established and emerging management options for tics, including behavioral interventions and nonpharmacologic therapies, medication management, and promising surgical approaches.
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Síndrome de Tourette/terapia , Criança , Humanos , Tiques/etiologia , Tiques/terapia , Síndrome de Tourette/complicaçõesRESUMO
In recent anesthetic practice, peripheral nerve blocks (PNBs) are used extensively for surgical anesthesia and nonsurgical analgesia. PNBs offer many benefits over other anesthetic techniques in a certain population of patients, and in some specific clinical setting, that may contribute to faster and safer pain relief, increased patient satisfaction, reduced hospital stay, and decreased overall healthcare cost. The technique involves the injection of the anesthetic in the vicinity of a specific nerve or bundle of nerves to block the sensation of pain transmitting to a specific portion of the body. However, the length of analgesia when a single anesthetic is used for PNB may not last long. Therefore, the practice of adding an additional agent called adjuvant has been evolved to prolong the analgesic effect. There are many such adjuvants available that are clinically being used for this purpose imparting great efficacy and safety to the anesthetic process. The adjuvants molecules are generally classified as opioids, alpha-2 agonist, steroids, etc. Most of them are safe to use and show little or no adverse event related to neurotoxicity and tissue damage. Although there is extensive use of such adjuvants in the clinical field, none of the molecules is approved by the FDA and is used as an off-label drug. The risk to benefit ratio must be assessed while using such an agent. This review will try to delineate the basic need of adjuvant in peripheral nerve block and will discuss the advantages and limitations of using different adjuvants and will discuss the future prospect of such application.
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The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.
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Introduction: Gilles de la Tourette syndrome (GTS) is a neurodevelopmental disorder, characterized by the presence of multiple motor and, at least one, phonic tics, for more than one year, beginning before 18 years of age; its treatment is often a challenge for the clinicianAreas covered: GTS treatment requires a multidisciplinary management to treat each patient's symptom. Although individuals with GTS often have comorbid psychiatric disorders, the focus of this review will only be on the management of tics.Expert opinion: The authors summarized the steps that clinicians should follow treating GTS patient; the impact of the tics on a patients' life should be the first step; different patients could present different levels of tolerance to the symptoms. Second, comorbidities should be considered before starting a treatment for tic. Finally, clinicians must focus the attention of the patient and family, on the length of the treatment and the duration of time after which the effects of the drug will occur. Before the treatment, the potential side effects must be mentioned to the parents, and the choice of treatment must be made in the light of the patient's tolerance to these.