Successful Premedication With Sublingual Midazolam Using a Suction Toothbrush.

Premedication is often used to reduce the stress associated with anesthesia-related procedures. However, in some cases, patients may not cooperate with medication delivery because of significant fear and anxiety. We report a case of an uncooperative patient with severe intellectual disabilities who was successfully premedicated with the unique technique of sublingual midazolam administration using a suction toothbrush. The 38-year-old male patient was planned to receive dental treatment under deep intravenous sedation (IVS), but he refused both intravenous cannulation and mask induction. Preanesthetic medication delivery using other routes was attempted but not accepted. As the patient tolerated toothbrushing, we used repeated practice with sublingual water administration through the toothbrush's suction hole to gradually desensitize the patient. Using that same method, sublingual midazolam was administered as a successful premedication to allow placement of a face mask for inhalational induction without distress and completion of the dental treatment under IVS. For patients who refuse other premedication routes, sublingual administration during toothbrushing with a suction toothbrush may provide a successful alternative.

Residual unabsorbed midazolam: a case report.

BACKGROUND: Oral midazolam is commonly administered to reduce anxiety in children presenting for medical procedures or surgery. It is unclear what volume of medication remains unabsorbed in the stomach when the child presents for anesthetic induction prior to these procedures. The presence of any significant residual medication in the stomach has significant clinical implications in the postoperative period. CASE PRESENTATION: A 5-year-old white Caucasian boy presented for upper gastrointestinal endoscopy after receiving oral midazolam liquid. Insertion of the endoscope into the stomach revealed a significant amount of unabsorbed medication remaining within the gastric cavity. CONCLUSION: Clinicians should be aware that the sedative effects of midazolam may be present before the medication is fully absorbed. A significant amount of unabsorbed medication may be present in the stomach during medical procedures/surgery. This may continue to be absorbed in the intraoperative and postoperative period, with unwanted clinical effect.

Oral preanesthetic medication in children ... comparison between midazolam alone and in combination with ketamine: a systematic review and meta-analysis.

BACKGROUND: Up to 60% of pediatric surgical patients develop high levels of preoperative anxiety. This study compared the effects of oral combinations of midazolam and ketamine with oral midazolam alone for pediatric preanesthetic medication. METHODS: The study protocol was registered in PROSPERO as CRD42020172920. A systematic literature search was conducted using Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing oral combinations of midazolam and ketamine with midazolam alone as preanesthetic medication in elective surgical pediatric patients. Meta-analyses included the following outcomes: anxiety and sedation levels, child...s behavior during separation from parents, face mask acceptance, and venipuncture. The quality of evidence was assessed using GRADE criteria. RESULTS: Twenty studies were included. The following effects (RR (95% CI)) were observed for combinations of ketamine and midazolam relative midazolam alone: anxiolysis (1.2 (0.94...1.52); p.ß=.ß0.15; I2.ß=.ß80%; GRADE.ß=.ßvery low); satisfactory sedation (1.2 ( 1.10...1.31); p.ß<.ß0.001; I2.ß=.ß71%; GRADE.ß=.ßvery low); behavior during parental separation (1.2 (1.06...1.36); p.ß=.ß0.003; I2.ß=.ß88%; GRADE.ß=.ßvery low); facial mask acceptance (1.13 (1.04...1.24); p.ß=.ß0.007; I2.ß=.ß49%; GRADE.ß=.ßvery low); behavior during venipuncture (1.32 (1.11...1.57); p.ß=.ß0.002; I2.ß=.ß66%; GRADE.ß=.ßvery low). CONCLUSIONS: While similar probabilities of obtaining anxiolysis were found, adequate sedation, calm behavior during child...s separation from parents, low levels of fear during face mask adaptation, and cooperative behavior during peripheral venous cannulation were more likely with midazolam-ketamine combinations.

Serum concentration of oral midazolam as pediatric preanesthetic medication and factors related to the sedation level.

BACKGROUND: Preanesthetic medication is important to eliminate surgical anxiety in pediatric patients and facilitate their smooth transfer to the operating room. Midazolam is the most commonly used preanesthetic medication. However, it has been reported that the sedative effect varies from patient to patient. In this study, the pharmacokinetics of midazolam were examined, and the aim was to assess the factors affecting the quality of sedation. METHODS: The participants were children ranging in age from 6 months to 8 years scheduled for surgery. Midazolam 0.5 mg/kg was administered orally 30 min before entering the operating room, and the sedation level was evaluated at the time of mask application. Blood was collected after slow induction, and the serum concentration of midazolam was measured using high-performance liquid chromatography. RESULTS: A total of 98 patients were registered. There was no difference in serum concentrations between the effective sedation group and the ineffective sedation group (48.0 vs. 49.1 ng/mL), regardless of the effect of midazolam. Percentages of ineffective sedation by age (0 to 7 years) were 66.6%, 60%, 33.3%, 11.1%, 0%, 0%, 12.5%, and 0%, respectively. On multivariate logistic regression analysis, siblings (OR = 3.9, CI: 1.1-14.0, p = .03) and age (OR = 3.2, CI:1.2-8.5, p = .02) were related to an insufficient sedative effect. CONCLUSION: The serum concentration of oral midazolam reached effective levels even in patients in whom the sedative effect was inadequate. It is important to manage the perioperative period with appropriate concurrent premedication taking into account patient age and social background characteristics. CLINICAL TRIAL REGISTRATION: Clinical trial registry: UMIN R000052504.

Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam.

BACKGROUND: This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children. METHODS: This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age >5 years and weight >20 kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5 mg/kg (max 15 mg) or intranasal dexmedetomidine at a dose of 2 mcg/kg (max 100 mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug. RESULTS: The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P = .03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P = 1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure. CONCLUSIONS: Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.

Comparative evaluation of dexmedetomidine and labetalol for attenuating hemodynamic stress responses during laparoscopic cholecystectomy in borderline hypertensive patients. / Evaluación comparativa de dexmedetomidina y labetalol para atenuar las respuestas de estrés hemodinámico durante la colecistectomía laparoscópica en pacientes con hipertensión limítrofe.

OBJECTIVE: Various pharmacological agents have been tried to attenuate the pressor response in laparoscopic cholecystectomy patients. We have compared single pre-induction intravenous injection of dexmedetomidine with labetalol for attenuation of haemodynamic stress response. METHODS: A total of 160 patients were considered for this prospective, randomized, double blind clinical study done in a single tertiary care institution. Patients were either included in group D, to receive 1.0µg·kg-1 i.v. dexmedetomidine or group L, to receive 0.3 mg·kg-1 i.v. labetalol in 100ml of normal saline before induction of anaesthesia. Patient's hemodynamic parameters were noted pre-operatively before starting infusion and at fixed intervals afterwards till extrubation. RESULTS: After intubation, mean systolic blood pressure (SBP) was higher in patients of group L (128.0 ± 13.866) as compared to group D (123.2 ± 10.672). Afterwards the SBP was comparable until extrubation. Similarly, after intubation patients in group D tended to have lower diastolic pressure (73.1 ± 9.683 vs. 79.2± 14.153, P value .0017) compared to patients in group L. Also, the relative incidence of bradycardia and hypotension was higher in patients who had received inj. labetalol. CONCLUSION: In patients predisposed to significant fluctuations in blood pressure or heart rate dexmedetomidine may be more suitable than labetalol due to better preservation of normal haemodynamics especially during periods of stress showing a relatively lower incidence of side effects.

Influence of anxiolytic premedication on vasovagal reactions and home readiness following outpatient intrathecal anaesthesia-A retrospective analysis.

BACKGROUND: Vasovagal reactions during application of intrathecal anaesthesia (IA) are associated with high anxiety levels. A high percentage of patients undergoing outpatient surgery suffer from anxiety. Anxiolytic premedication in day-surgery is suspected to delay recovery and discharge and is, therefore, not routinely used. The aim of this retrospective analysis was to detect the influence of anxiolytic premedication on the incidence of vasovagal reactions and time until discharge home. METHODS: Anaesthesia records of all patients undergoing outpatient surgery under low-dose IA from January 2008 to June 2017 were analysed. Incidences of vasovagal reactions with a decrease in blood pressure and/or heart rate and need for cardiovascular activating medications were documented. Patients were categorised as having received an anxiolytic premedication or not. The time from intrathecal injection of the local anaesthetic until readiness for discharge was recorded. RESULTS: The records of 2747 patients were analysed. One thousand two hundred and ninety-one of them received an anxiolytic premedication of 1-2 mg midazolam intravenously. Three hundred and fourteen patients had vasovagal incidents during application of IA (no premedication n = 217 [15.0%], premedication n = 97 [7.5%], P < 0.0001). Premedication did not prolong time to achieve readiness for discharge (mepivacaine: P = 0.5886, chloroprocaine: P = 0.1555). However, in the prilocaine group, premedication led to a significantly earlier achievement of readiness for discharge (P = 0.0002). CONCLUSION: Anxiolytic premedication significantly reduces the incidence of vasovagal reactions during the application of IA and does not affect time until readiness for discharge.

Sedation of children undergoing dental treatment.

BACKGROUND: Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012. OBJECTIVES: To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed. MAIN RESULTS: We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both. AUTHORS' CONCLUSIONS: There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Premedicación con ketamina en el paciente pediátrico ante una cirugía de urgencia / Premedication with ketamine in the pediatric patient before emergency surgery

Introducción: la ketamina se utiliza como premedicación anestésica.Objetivo: evaluar el efecto de la premedicación con ketamina intramuscular en el nivel de ansiedad del paciente pediátrico ante una cirugía de urgencia. Método: se realizó un estudio preexperimental con preprueba y posprueba en el Hospital Provincial de Ciego de Ávila (2013-2014). El universo estuvo constituido por la totalidad de niños entre cinco y ocho años sometidos a cirugía de urgencia. La muestra quedó conformada por 80 infantes que cumplieron los criterios de inclusión. Se administraron 5 mg/kg de ketamina 30 minutos antes de la intervención quirúrgica. Se evaluó: nivel de ansiedad antes y después de la premedicación, aceptación a la medicación, tiempo de inicio de la acción del fármaco, cooperación durante la venopunción, conducta ante la separación de los padres y reacciones adversas. Se utilizó la prueba U de Mann-Whitney para demostrar la diferencia entre variables ordinales.Resultados: antes de la premedicación prevaleció un nivel de ansiedad alto (45,0 por ciento) y después solo en una ínfima minoría (5,0 porciento) un nivel moderado. Predominaron un nivel de aceptación bueno (56,3 por ciento), un tiempo de inicio de acción del medicamento menor de cinco minutos (91,3 por ciento), cooperación del niño con la venopunción (93,3 por ciento), mayor cantidad de niños dormidos (56,3 por ciento) al ser separados de los padres para trasladar al quirófano. Solo fue reportada una reacción adversa.Conclusiones: se confirmó la utilidad de la ketamina como premedicación anestésica del paciente pediátrico ante una cirugía de urgencia(AU)

Introduction: ketamine is used as an anesthetic premedication.Objective: to evaluate the effect of premedication with intramuscular ketamine in the level of anxiety of the pediatric patient before an emergency surgery.Method: a pre-experimental study was performed with a before and after at the Provincial Hospital of Ciego de Ávila (2013-2014). The universe consisted of all children between five and eight years of age undergoing emergency surgery. The sample consisted of 80 infants who met the inclusion criteria. 5 mg/kg of ketamine was administered 30 minutes before surgery. It was evaluated: level of anxiety before and after premedication, acceptance of medication, time of onset of action of the drug, cooperation during venipuncture, behavior in the separation of parents and adverse reactions. The Mann-Whitney U test was used to demonstrate the difference between ordinal variables.Results: before premedication, a high level of anxiety prevailed (45,0 percent) and then only in a very small minority (5,0 percent) a moderate level. A good level of acceptance predominated (56,3 percent), a medication start time of less than five minutes (91,3 percent), a child's cooperation with venipuncture (93,3 percent), a greater number of sleeping children (56,3 percent) to be separated from the parents to move to the operating room. Only one adverse reaction was reported.Conclusions: the usefulness of ketamine as an anesthetic premedication of pediatric patients before emergency surgery was confirmed(AU)

A comparison of midazolam and zolpidem as oral premedication in children, a prospective randomized double-blinded clinical trial.

BACKGROUND: Anxiety associated with pediatric surgery can be stressful. Midazolam is a well-accepted anxiolytic in this setting. However, there are cases in which this medication is not effective. Zolpidem is a short-acting nonbenzodiazepine hypnotic drug that is administered orally and has quick onset of action (~15 minutes), and 2-3 hour duration. AIMS: Based on the theory that impaired perception following oral zolpidem administration would suppress the development of anxiety, we sought to compare zolpidem to midazolam for pediatric preoperative anxiety. METHODS: This prospective randomized double-blinded clinical trial was designed to compare the effectiveness of oral midazolam and zolpidem for anxiety premedication. Eighty ASA class I-II pediatric patients between 2 and 9 years old, surgery >2 hours, and at least 23 hours postoperative admission were included in the study. Randomization was done with 0.5 mg/kg midazolam or 0.25 mg/kg zolpidem administered orally. The primary outcome measure was between group difference in patient anxiety at the time of separation using the Modified Yale Preoperative Anxiety Scale. Secondary outcomes included emergence delirium and mask acceptance at induction. RESULTS: There was no significant difference in Modified Yale Preoperative Anxiety Scale scores at separation between midazolam (median/interquartile range = 26.7/23.3-36.6) and zolpidem (median/interquartile range = 30.0/23.3-56.6) groups, difference 0.01 (95% CI -3E-5 , 3E-2 ; P = 0.07). Mask acceptance score was significantly better in the midazolam group. There was no significant difference in emergence delirium scores between groups. CONCLUSION: This study demonstrates that zolpidem, as dosed, was similar to midazolam with regard to anxiety scoring, and inferior with regard to mask acceptance scores.

Randomized controlled trial assessing the effectiveness of midazolam premedication as an anxiolytic, analgesic, sedative, and hemodynamic stabilizer.

BACKGROUND: Midazolam premedication is widely used before general anesthesia, but lacks clinical evidence of effectiveness. The present study aimed to evaluate the effectiveness of midazolam premedication following 4 aspects: anxiety reduction, sedation, hemodynamic stabilization, and analgesia. METHODS: In a randomized, single-blind, prospective study, a total of 128 women were allocated to the midazolam premedication group (Group P, n = 64) or the control group (Group N, n = 64). The patients were asked to complete the Beck anxiety inventory (BAI) 2 times: on the day before surgery (BS) and 30 minutes after midazolam premedication (T0). Depth of anesthesia using state entropy (SE), conventional hemodynamic data using heart rate (HR) and mean blood pressure (MBP), and analgesic profiles using surgical pleth index (SPI) were acquired at the following 4 points: T1-pre-induction, T2-prior to intubation, T3-intubation, and T4-20 minutes after intubation. RESULTS: No change in BAI score was observed between BS and T0 in both groups P and N (median and interquartile range [IQR], Group P: BS-4.5 [2.0-7.0], T0-4.0 [1.0-9.0], P = .603; Group N: BS-4.0 [1.0-8.5], T0-3.5 [1.0-6.0], P = .066). Midazolam premedication reduced SE at T2-4 (mean difference with 95% confidence interval [95% CI], T2-7.1 [1.6-12.6], P = .012; T3-10.4 [6.5-14.4], P < .001; T4-9.2 [5.0-13.4], P < .001). Midazolam premedication also reduced HR (mean differences [95% CI], T1-7.3 [2.5-12.1], P = .003; T3-6.6 [1.1-12.2], P = .020) and MBP at T1 and T3 (mean differences [95% CI], T1-7.3 [2.5-12.1], P = .003; T3-8.6 [1.3-15.9], P = .021), and lowered SPI at T1-3 (mean differences [95% CI]: T1-12.7 [6.1-19.4], P < .001; T2-6.0 [0.5-11.5], P = .033; T3-7.9 [1.7-14.1], P = .012). CONCLUSION: Midazolam premedication did not reduce the level of anxiety. However, midazolam premedication reduced the entropy values, stabilized hemodynamics, and provided analgesia during the induction of anesthesia. The purpose of midazolam premedication needs to be reconsidered.

Comparison of nebulised dexmedetomidine, ketamine, or midazolam for premedication in preschool children undergoing bone marrow biopsy.

BACKGROUND: The aim of our study was to compare the efficacy of dexmedetomidine, ketamine, and midazolam for sedative premedication administered by nebuliser 30 min before general anaesthesia in preschool children undergoing bone marrow biopsy and aspiration. METHODS: Ninety children aged 3-7 yr were randomly allocated into three equal groups to be premedicated with either nebulised ketamine 2 mg kg-1 (Group K), dexmedetomidine 2 µg kg-1 (Group D), or midazolam 0.2 mg kg-1 (Group M). The primary endpoint was a five-point sedation score on arrival in the operating room 30 min after end of study drug administration. Secondary outcomes included: parental separation anxiety scale; medication and mask acceptance scales; haemodynamic variables; recovery time; postoperative face, legs, activity, cry, and consolability scale; emergence agitation scale; and adverse effects. RESULTS: The median (range) sedation score on arrival in the operating room was 3.5 (1-4), 2.0 (2-3) and 2.0 (1-3) in Groups M, D, and K, respectively (P=0.000). Subjects in Group D showed higher medication (P<0.03) and mask acceptance scores (P<0.015) and more satisfactory parental separation anxiety scale (P<0.044). The median (range) recovery time was significantly shorter in Group D [5.5 (4-8) min] compared with Group K [10.0 (5-15) min, P=0.000] and M [8.0 (6-15) min, P=0.000]. The incidence of emergence agitation was lower in Group D (P<0.008). CONCLUSIONS: Preschool children premedicated with nebulised dexmedetomidine had more satisfactory sedation, shorter recovery time, and less postoperative agitation than those who received nebulised ketamine or midazolam. CLINICAL TRIAL REGISTRATION: NCT02935959.

Effect of Nonsteroidal Anti-inflammatory Drug as an Oral Premedication on the Anesthetic Success of Inferior Alveolar Nerve Block in Treatment of Irreversible Pulpitis: A Systematic Review with Meta-analysis and Trial Sequential Analysis.

INTRODUCTION: Successful anesthesia with an inferior alveolar nerve block (IANB) is imperative for treating patients with irreversible pulpitis in mandibular teeth. This systematic review assessed the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) as oral premedications on the success of IANBs in irreversible pulpitis. METHODS: Three databases were searched to identify randomized clinical trials (RCTs) published up until September 2017. Retrieved RCTs were evaluated using the revised Cochrane Risk of Bias Tool. The primary efficacy outcome of interest was the success rate of IANB anesthesia. Meta-analytic estimates (risk ratio [RR] with 95% confidence intervals [CIs]) performed using a random effects model and publication bias determined using funnel plot analysis were assessed. Random errors were evaluated with trial sequential analyses, and the quality of evidence was appraised using a Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS: Thirteen RCTs (N = 1034) were included. Eight studies had low risk of bias. Statistical analysis of good-quality RCTs showed a significant beneficial effect of any NSAID in increasing the anesthetic success of IANBs compared with placebo (RR = 1.92; 95% CI, 1.55-2.38). Subgroup analyses showed a similar beneficial effect for ibuprofen, diclofenac, and ketorolac (RR = 1.83 [95% CI, 1.43-2.35], RR = 2.56 [95% CI, 1.46-4.50], and RR = 2.07 [95% CI, 1.47-2.90], respectively). Dose-dependent ibuprofen >400 mg/d (RR = 1.85; 95% CI, 1.39-2.45) was shown to be effective; however, ibuprofen ≤400 mg/d showed no association (RR = 1.78; 95% CI, 0.90-3.55). TSA confirmed conclusive evidence for a beneficial effect of NSAIDs for IANB premedication. The Grading of Recommendations, Assessment, Development and Evaluation approach did not reveal any concerns regarding the quality of the results. CONCLUSIONS: Oral premedication with NSAIDs and ibuprofen (>400 mg/d) increased the anesthetic success of IANBs in patients with irreversible pulpitis.

Effects of buprenorphine, butorphanol or tramadol premedication on anaesthetic induction with alfaxalone in common marmosets (Callithrix jacchus).

OBJECTIVE: To investigate the clinical and physiological effects of intravenous (IV) alfaxalone alone or in combination with buprenorphine, butorphanol or tramadol premedication in marmosets. STUDY DESIGN: Prospective, randomized, blinded, crossover design. ANIMALS: Nine healthy marmosets (391 ± 48 g, 3.7 ± 2.2 years old). METHODS: Meloxicam 0.20 mg kg-1 subcutaneously, atropine 0.05 mg kg-1 intramuscularly (IM) and either buprenorphine 20 µg kg-1 IM (BUP-A), butorphanol 0.2 mg kg-1 IM (BUT-A), tramadol 1.5 mg kg-1 IM (TRA-A) or no additional drug (control) were administered to all marmosets as premedication. After 1 hour, anaesthesia was induced with 16 mg kg-1 alfaxalone IV. All animals received all protocols. The order of protocol allocation was randomized with a minimum 28 day wash-out period. During anaesthesia, respiratory and pulse rates, rectal temperature, haemoglobin oxygen saturation, arterial blood pressure, palpebral and pedal withdrawal reflexes and degree of muscle relaxation were assessed and recorded every 5 minutes. Quality of induction and recovery were assessed. Duration of induction, immobilization and recovery were recorded. Blood samples were analysed for aspartate aminotransferase, creatine kinase and lactate dehydrogenase concentrations. The protocols were compared using paired t tests, Wilcoxon's signed-rank test with Bonferroni's corrections and linear mixed effect models where appropriate. RESULTS: Out of nine animals, apnoea was noted in eight animals administered protocol BUP-A and two animals administered protocol BUT-A. With TRA-A and control protocols, apnoea was not observed. No other significant differences in any of the parameters were found; however, low arterial blood pressures and hypoxia occurred in TRA-A. CONCLUSIONS AND CLINICAL RELEVANCE: Our study employing different premedications suggests that the previously published dose of 16 mg kg-1 alfaxalone is too high when used with premedication because we found a high incidence of complications including apnoea (BUP-A), hypotension and hypoxaemia (TRA-A). Appropriate monitoring and countermeasures are recommended.

Effect of oral premedication on the anaesthetic efficacy of inferior alveolar nerve block in patients with irreversible pulpitis - A systematic review and network meta-analysis of randomized controlled trials.

This systematic review (SR; PROSPERO database: CRD42017075160) and network meta-analysis (NMA) identified the most effective oral premedication for anaesthetic success of inferior alveolar nerve blocks (IANB) in cases of irreversible pulpitis. Medline and Ebscohost databases were searched up until 10/2017. Randomized controlled trials (RCT) studying the effect of oral premedication, alone or in combination, on the success of IANB for cases of irreversible pulpitis, compared to placebo or other oral premedications, were included. Quality of the included studies was appraised by the revised Cochrane risk of bias tool for randomized trials. Pairwise analysis, NMA and quality of evidence assessment using GRADE criteria were performed. Nineteen studies (n = 1654 participants) were included. NMA demonstrated that compared to placebo, dexamethasone was most effective in increasing anaesthetic success (RR, 2.92 [95% CI 1.74,4.91]; SUCRA = 0.96), followed by NSAIDs (RR, 1.92 [95% CI 1.63,2.27], SUCRA = 0.738) and Tramadol (RR, 2.03 [95% CI 1.18,3.49], SUCRA = 0.737). Premedication with acetaminophen added to NSAIDs demonstrated similar efficacy as NSAIDs alone (RR, 1.06 [95% CI 0.79,1.43]). Sensitivity analyses proved the superiority of dexamethasone or NSAIDs over any other premedications. Subgroup analyses of specific dosages in comparison with placebo demonstrated that dexamethasone 0.5 mg was most effective, followed by ketorolac 10 mg, piroxicam 20 mg, ibuprofen 400 mg + acetaminophen 500 mg and Tramadol 50 mg. Ibuprofen 400 mg, 600 mg and 800 mg had a significantly improved IANB success, while Ibuprofen 300 mg had no effect. Oral premedication with dexamethasone, NSAIDs or Tramadol significantly increased anaesthetic success. More trials are needed to evaluate the premedication effects of dexamethasone or Tramadol for improved anaesthetic success of IANB when treating irreversible pulpitis.

Intravenous dexmedetomidine pre-medication reduces the required minimum alveolar concentration of sevoflurane for smooth tracheal extubation in anesthetized children: a randomized clinical trial.

BACKGROUND: It has been known that Dexmedetomidine pre-medication enhances the effects of volatile anesthetics, reduces the need of sevoflurane, and facilitates smooth extubation in anesthetized children. This present study was designed to determine the effects of different doses of intravenous dexmedetomidine pre-medication on minimum alveolar concentration of sevoflurane for smooth tracheal extubation (MACEX) in anesthetized children. METHODS: A total of seventy-five pediatric patients, aged 3-7 years, ASA physical status I and II, and undergoing tonsillectomy were randomized to receive intravenous saline (Group D0), dexmedetomidine 1 µg∙kg-1 (Group D1), or dexmedetomidine 2 µg∙kg-1 (Group D2) approximately 10 min before anesthesia start. Sevoflurane was used for anesthesia induction and anesthesia maintenance. At the end of surgery, the initial concentration of sevoflurane for smooth tracheal extubation was determined according to the modified Dixon's "up-and-down" method. The starting sevoflurane for the first patient was 1.5% in Group D0, 1.0% in Group D1, and 0.8% in Group D2, with subsequent 0.1% up or down in next patient based on whether smooth extubation had been achieved or not in current patient. The endotreacheal tube was removed after the predetermined concentration had been maintained constant for ten minutes. All responses ("smooth" or "not smooth") to tracheal extubation and respiratory complications were assessed. RESULTS: MACEX values of sevoflurane in Group D2 (0.51 ± 0.13%) was significantly lower than in Group D1 (0.83 ± 0.10%; P < 0.001), the latter being significantly lower than in Group D0 (1.40 ± 0.12%; P < 0.001). EC95 values of sevoflurane were 0.83%, 1.07%, and 1.73% in Group D2, Group D1, and Group D0, respectively. No patient in the current study had laryngospasm. CONCLUSION: Dexmedetomidine decreased the required MACEX values of sevoflurane to achieve smooth extubation in a dose-dependent manner. Intravenous dexmedetomidine 1 µg∙kg-1 and 2 µg∙kg-1 pre-medication decreased MACEX by 41% and 64%, respectively. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR): ChiCTR-IOD-17011601 , date of registration: 09 Jun 2017, retrospectively registered.

Effect of rate of administration of propofol or alfaxalone on induction dose requirements and occurrence of apnea in dogs.

OBJECTIVE: To evaluate the effect of rate of administration of propofol or alfaxalone on induction dose requirements and incidence of postinduction apnea (PIA) in dogs following premedication with methadone and dexmedetomidine. STUDY DESIGN: Prospective, randomized clinical trial. ANIMALS: Thirty-two healthy American Society of Anesthesiologists class I client-owned dogs (seven females, 25 males), aged between 5 and 54 months, weighing between 2.0 and 48.2 kg. METHODS: Dogs were premedicated intramuscularly with 0.5 mg kg-1 methadone and 5 µg kg-1 dexmedetomidine. Thirty minutes after premedication, dogs were preoxygenated for 5 minutes before the induction agent was administered intravenously via a syringe driver until orotracheal intubation was achieved. Dogs were randomized to receive alfaxalone 0.5 mg kg-1 minute-1 (A-Slow), alfaxalone 2 mg kg-1 minute-1 (A-Fast), propofol 1 mg kg-1 minute-1 (P-Slow), or propofol 4 mg kg-1 minute-1 (P-Fast). Oxygen saturation of hemoglobin (SpO2), end-tidal carbon dioxide and respiratory rate were monitored. If PIA (≥30 seconds without a breath) occurred, the time to the first spontaneous breath was measured. If SpO2 decreased below 90%, the experiment was stopped and manual ventilation initiated. RESULTS: The mean±standard deviation induction doses of alfaxalone and propofol were lower in the A-Slow [A-Slow 0.9±0.3 mg kg-1, A-Fast 2.2±0.5 mg kg-1 (p≤0.001)] and P-Slow [P-Slow 1.8±0.6 mg kg-1, P-Fast 4.1±0.7 mg kg-1 (p≤0.001)] groups, respectively. The incidence of PIA was 25% for the A-Slow and P-Slow groups and 100% for the A-Fast and P-Fast groups (p = 0.007). CONCLUSIONS AND CLINICAL RELEVANCE: Both propofol and alfaxalone following methadone and dexmedetomidine premedication caused PIA. Induction dose requirement and incidence of PIA were affected by the rate of administration of both drugs. When possible, propofol and alfaxalone doses should be reduced and administered slowly to reduce PIA.

Effect of premedication with butorphanol or methadone on ease of endoscopic duodenal intubation in dogs.

OBJECTIVE: The effect of premedication with butorphanol or methadone on ease of endoscopic duodenal intubation. STUDY DESIGN: Prospective, randomized, blinded clinical trial. ANIMALS: A group of 20 client-owned dogs. METHODS: Dogs were assigned randomly to be administered intravenous (IV) premedication with either butorphanol (0.4 mg kg-1) or methadone (0.3 mg kg-1). General anaesthesia was induced with propofol to effect and maintained with isoflurane in 100% oxygen. Sedation score 20 minutes after premedication administration and induction dose of propofol were recorded. Heart rate, mean arterial pressure, haemoglobin oxygen saturation, respiratory rate and end-tidal isoflurane concentration were recorded every 5 minutes. Spontaneous lower oesophageal and pyloric sphincter opening, presence of gastro-oesophageal and duodeno-gastric reflux, antral peristaltic contractions and response to endoscopy were recorded as yes or no. Ease of duodenal intubation (EDI) was graded on a scale ranging from 1 (immediate entry with minimal manoeuvring required) to 4 (no entry after 2 minutes). Time (seconds) from the start of pyloric intubation to successfully entering the duodenum was recorded. RESULTS: Median EDI score [3 ± 1 (butorphanol), 4 ± 1 (methadone), p = 0.035], time [65 ± 36 seconds (butorphanol), 120 ± 38 seconds (methadone), p = 0.028] and number of dogs with spontaneous pyloric sphincter opening [7/10 (butorphanol), 2/10 (methadone), p = 0.035] differed between groups. No other significant differences were found. CONCLUSIONS AND CLINICAL RELEVANCE: In these clinical cases, duodenal intubation was performed with greater ease, shorter time and more frequent spontaneous opening of the pyloric sphincter after premedication with butorphanol in comparison to methadone. The use of butorphanol facilitated the passage of the endoscope and is therefore recommended for premedication prior to upper gastrointestinal tract endoscopy.