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Background and Aims: Melatonin (MT), a naturally occurring pituitary hormone has a sleep promoting effect. There are very few studies on pre-operative oral MT (0.2-0.5 mg/kg) in children. We planned a study to assess the efficacy of oral MT in two doses and compare it with oral midazolam and placebo for pre-operative anxiolysis, sedation, maintenance of cognition and psychomotor skills, parental separation behaviour and venepuncture compliance. Methods: This prospective double-blind randomised study was conducted after ethical committee approval on 100 children aged 5-15 years, American Society of Anaesthesiologists physical status I and II undergoing elective surgery at our hospital from January 1, 2014, to December 31, 2014. Mentally disordered children were excluded from the study. They were randomised into four groups of 25 each (A, B, C, D) to receive either oral MT 0.5 mg/kg or 0.75 mg/kg or oral midazolam 0.5 mg/kg or placebo 45-60 min, respectively, before induction. The child's anxiety, cognition and psychomotor function before and after pre-medication, behaviour during the parental separation and venepuncture were appropriately scored. Kruskal-Wallis analysis of variance for intergroup and Wilcoxon matched pairs tests for intragroup comparisons of data were applied. Results: The four groups were comparable regarding mean age, weight and sex. The anxiety score reductions in the three groups when compared to placebo were statistically significant. Children receiving MT 0.75 mg/kg had maximum anxiolysis and venepuncture compliance (P < 0.05). Cognition was decreased with maximum sedation, successful parental separation and psychomotor impairment in the midazolam group (P < 0.05). Conclusion: Oral MT (0.5 mg/kg and 0.75 mg/kg) in children decreases pre-operative anxiety without impairing cognitive and psychomotor functions, the 0.75 mg/kg dose being most effective.

BACKGROUND: Pre anaesthetic medication is a real challenge specially in cases of paediatric age group. A good quality oral preanaesthetic must fulfill criteria like easily application, rapid absorption, short duration of action and have minimal side effect. Present study carried out with objective of evaluation of oral Midazolam as a pre-anaesthetic in elective surgical cases in paediatric age group. METHODS: Paediatric cases for elective surgery were included for receiving oral midazolam (0.5/kg) pre anaesthetic medication in prospective observational study. Total 50 cases from age group (01-10 yrs), weight (13-23kg), ASA grading I & II, normo-tensive patients were selected. Evaluation of drug was assessed with a scale from 1-4 which includes sedation, separation from parent, and child behaviour at induction. Data analyzed with percentage and mean standard deviation of the scale score. RESULTS: Sedation score mean after pre medication was 2.76+ 0.58. Child behaviour at the time of separation from parents score mean was 2.96+ 0.44. Mean score of behaviour of child during induction was 2.80+0.49. 70% of the cases achieved sedation, 86 % of the cases achieved separation from parents while 76% of the cases had more than 2 score of child behaviour at the time of induction. CONCLUSION: Oral midazolam as a preanaesthetic medication in children allay the anxiety & facilitate separation of children from their parents when they enter surgical unit. These can be overcome by lower degree of sedation in our study.

Background Bone marrow aspiration and/or biopsy (BMAB) is often an unpleasant and painful procedure in spite of local anaesthetic infiltration. This randomized placebo-controlled trial compared the pain relieving effect of sublingual fentanyl and placebo during BMAB. Methods One hundred sixty patients were randomized to receive either sublingual fentanyl 200 μg, 100 μg (patients ≥ 70 years old, weight ≤ 50 kg or in poor health) or placebo before BMAB. The grade of anxiety before the procedure and the grade of pain during local anaesthetic infiltration, aspiration, biopsy and immediately after the BMAB were assessed using the Numeral Rating Scale (0–10). Possible side effects of the study drugs were recorded. Results Sublingual fentanyl proved inadequate in relieving pain during BMAB as no significant differences in the pain scores of the fentanyl and placebo patients were observed. However, fentanyl caused significantly more dizziness than placebo. Conclusions The results suggest that sublingual fentanyl in a dose of 200 μg (100 μg in infirm patients) is not a feasible preventive analgesic during BMAB. Pain scores were similar and side effects more frequent in the fentanyl group than in the placebo group.

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a reliable and commonly established technique, enabling real-time guidance of transbronchial needle aspiration of mediastinal and hilar structures and parabronchial lung masses. As EBUS-TBNA became more available and adopted by clinicians, questions emerged about the optimal performance of the procedure. Although EBUS is considered safe, there are few complications that could occur during the test, correlated with both the procedure itself and the patient’s characteristics. Moreover, this technique is often addressed to patients with overlapping airways diseases, which might have higher risk of complications during the procedure. Chronic obstructive pulmonary disease (COPD) patients could experience EBUS-TBNA with a relative high frequency due to their risk of developing lung cancer. The irreversible bronchial constriction characteristic of the disease raises some questions on premedication before bronchoscopic procedures. It is mandatory to optimize every aspect of the procedure in order to minimize the risk of complications, especially for fragile patients. Whether the use of inhaled bronchodilators before the procedure could improve the outcome of the procedure in COPD patients is reviewed in this article. No clear indication emerged from the literature suggesting the need of more studies in order to clarify this point.

Introduction: The duration of action of sub-arachnoid block is short, and one of the ways to overcome this is the use of oral clonidine. Methods: 108 patients of ASA I and II, aged 18 to 65 years undergoing lower abdominal surgeries under spinal anaesthesia were randomized into three groups.. Control group A (n=36) no oral clonidine pre-medication, Group B (n=36) and group C (n=36) received 100 μg and 200 μg of oral clonidine pre-medication respectively, 1hr before spinal anaesthesia. Haemodynamic parameters were recorded. Sensory block, degree of motor blockage, and sedation were assessed. Results: Clonidine prolonged the mean duration of motor block by 189.98±26.93 min (100μg) and 191.89±28.13 min (200μg) compared to 117.92±25.13 min in the control group p

Background Inviting the child to participate in medical decisions regarding common medical procedures might influence the child's behaviour during the procedures. We wanted to study nurse decision ...

Ultrasonography is a non-invasive, accurate and low-cost technique used to study the upper abdomen, but it has reduced reliability in the study of the pancreas and retroperitoneum. Simethicone is a well-known emulsifying agent that has been used to improve ultrasonographic visualization. The aim of this study was to identify anthropometric parameters that are able to predict a good response to simethicone in improving ultrasonographic visualization of abdominal structures. One hundred twenty-seven patients were recruited. After basal examination, their anthropometric parameters were collected. Patients with an incomplete upper abdominal examination because of gastrointestinal gas have greater body mass index, waist circumference and abdominal wall thickness. In our study, the best anthropometric parameter for identifying patients with poor visualization at abdominal ultrasound examination is waist circumference. Using a cutoff of 84 cm, we can identify patients with poor visibility at abdominal ultrasound examination (group B) with a sensitivity of 90%.

This study was designed to compare the effects of alfentanil and midazolam pre-medication on patient comfort during and after flexible bronchoscopy. A randomised, double-blind study was performed; 40 patients received alfentanil and 29 midazolam. Subjects completed questionnaires about discomfort and adverse effects immediately post-procedure and 24 h later. The bronchoscopist also completed a questionnaire. No difference in patient discomfort was found immediately post-procedure and no differences were found for amount of topical lignocaine used or minimum oxygen saturation. Operators reported no overall difference between the agents for ease of procedure but about 20% less cough was reported in the alfentanil group (P = 0.02). Patient discomfort scores in the 24h questionnaire were significantly lower in patients given midazolam (P = 0.01 for nasal discomfort, P = 0.003 for throat discomfort) but drowsiness was commoner in this group (P = 0.04). There was no significant difference in patients' reports of cough, nausea or vomiting or their willingness to have a repeat procedure. In conclusion, cough during bronchoscopy was slightly less marked with alfentanil than midazolam pre-medication but this made no difference to the ease of procedure or to overall patient discomfort. Patients given midazolam reported less discomfort when asked about the test 24 h later.

Summary Background : Gastric mucus usually induces artefacts during endoscopic ultrasonography. Aim : To investigate the effectiveness of pre-medication with the proteolytic enzyme, pronase, before endoscopic ultrasonography. Methods : Out-patients scheduled for endoscopic ultrasonography were randomly assigned to oral pre-medication with the anti-foam agent, dimethylpolysiloxane, alone (treatment A; n = 29), with dimethylpolysiloxane plus sodium bicarbonate (treatment B; n = 29) or with dimethylpolysiloxane, sodium bicarbonate and pronase (treatment C; n = 29). All drinks were given about 10 min before the start of the procedure. After insertion of the endoscope, endoscopists recorded visibility scores before the procedure, imaging scores at endoscopic ultrasonography and the numbers of high-echo spots in the gastric cavity and on the gastric wall surface after the procedure. Results : Pre-medication with pronase (treatment C) significantly reduced (both at P

We investigated the effect of midazolam pre-medication on rocuronium-induced neuromuscular blockade during sevoflurane anaesthesia. Twenty-two patients scheduled for elective surgery were randomly divided to receive either no pre-medication (control group) or pre-medication with 0.1 mg/kg midazolam intramuscularly (midazolam group). Anaesthesia was induced with fentanyl and propofol, and maintained with sevoflurane and nitrous oxide in oxygen. Neuromuscular responses were monitored using acceleromyography. The onset and clinical duration of action, time to recovery of first twitch of train-of-four (TOF) response to 75% of control, recovery index and time for TOF recovery to 25% and 50% were recorded. Patient-related data were similar in both groups. The parameters recorded were not significantly different between the groups. Midazolam pre-medication does not influence the time-course of action of rocuronium during sevoflurane anaesthesia.

Despite the fact that pre-medication, in a number of different drug combinations, has been used for a long time in endoscopy units, and has been subject to extended clinical studies, it is still not possible to claim that it has attained an ideal state with regard to patient tolerance to endoscopy procedures. In this clinical study, we have investigated the effects of psychological intervention in addition to medication, which we used on patients with intolerance to endoscopy. Intolerance was very high in all endoscopic procedures (15.8% total). It was observed that average midazolam doses were significantly higher in intolerant than in tolerant patients. It was found that in patients who had received psychiatric intervention, the decrease in midazolam dose was statistically significant in a subsequent endoscopy procedure.

Rush and cluster immunotherapy schedules are accelerated immunotherapy build-up schedules. A cluster immunotherapy schedule involves the patient receiving several allergen injections (generally 2–4) sequentially in a single day of treatment on nonconsecutive days. The maintenance dose is generally reached in 4–8 weeks. In rush immunotherapy protocols, higher doses are administered at 15- to 60-min intervals over a 1- to 3-day period until the maintenance dose is achieved. This review will serve as an update for accelerated immunotherapy schedules. The review will include recent investigations demonstrating the safety of cluster schedules in atopic dermatitis, pediatric patients, and inhalant allergen mixtures and an accelerated protocol utilizing an infusion pump for allergen delivery. There has also been further elucidation on the immunological changes which occur during accelerated immunotherapy. Finally, new studies analyzing systemic reaction risk factors are discussed.

Made available in DSpace on 2017-07-24T19:22:10Z (GMT). No. of bitstreams: 1 Joao Paulo Steffens.pdf: 979707 bytes, checksum: 43532f7a8e6d7bf7316592291f073a4b (MD5) Previous issue date: 2009-12-11 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior Several anti-inflammatory drugs have been used to reduce pain and discomfort after periodontal surgeries. The purpose of this study was to evaluate the efficacy of etoricoxib and dexamethasone on pain prevention after open flap debridement surgery. For this prospective, double-masked, cross-over, placebo-controlled randomized clinical trial, open flap debridement surgeries were performed on 15 patients who presented chronic periodontitis after nonsurgical periodontal therapy at three sextants. Each patient was submitted to three surgical procedures with intervals of 30 days and received one of the premedication protocols one hour before surgery: G1- placebo; G2- 8 mg dexamethasone; G3- 90 mg etoricoxib. Pain intensity and discomfort were evaluated by visual analog scale (VAS), 101-point numerical rate scale (NRS-101) and a 4-point verbal rate scale (VRS-4) during 8 hours after surgery and three times a day on the 3 following days. Data were submitted to appropriate statistical analysis. The results demonstrated that G2 and G3 presented reduced postoperative pain intensity levels than G1. There were statistically significant differences at 4, 5, 6, 7 and 8 hour-period after surgery (Friedman test; p

Typically, old patients scheduled to undergo a surgical procedure take many medications for various disorders. The anaesthetist must consider the benefits and/or risks of continuation or withdrawal of such chronic medications. This chapter reviews these issues in respect of cardiovascular drugs (calcium channel blockers, beta adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists) and of psychotropic and antiparkinson medications and insulin. Focus is put on the few scientific studies available and on the recommendations given by experts in the field.

An examination of the use of the therapy within the theatre environment would be a useful extension of the care we already give our patients. It would be interesting to explore the cost effectiveness of oils versus conventional medication, and even though there may be a negative result the desire to provide holistic care may overshadow the cost. If this care can be achieved through therapeutic touch such as massage, and enhanced by the addition of aromatic oils, then perhaps theatre nurses should be training to meet the needs of the patient. It may be appropriate therefore for studies to be undertaken into the suggested benefits of aromatherapy. If, as it has been implied, this therapy is beneficial in reducing the levels of anxiety, it would seem sensible to introduce it to preoperative patients who suffer varying degrees of anxiety.

Objective: To analyze the diagnoses and management of children presenting with Headaches as a chief complaint. Background Headaches in Children and adolescents are common presenting complaints in emergency department. The prevalence of headache ranges from 37-51% during the elementary school years and gradually rises to 57-82% by the high school years. Headaches have a significant impact on the lives of children and adolescents, resulting in school absence, decreased extracurricular activities, and poor academic achievement.There is wide variation among acute treatments and their effectiveness. Design/Methods: Retrospective chart review of patients presenting with headache to St. Louis Children9s Hospital ER between 2007 to 2010. 1499 charts with presenting diagnosis of Headache according to ICD 9 code were reviewed.Headaches were classified in to Primary, Secondary and non classifiable.Migraine patients were further analyzed to review Pre medication pain score (PRPS), Post medication pain score (POPS), and type of medication used ( Oral, IV or combination). Kruskal-wallis test, Rank Analysis of Covariance tests were used for statistical analysis. Results: Oral medications had statistically significant lower mean pre-pain score (p=0.01). Triptans and combination of triptans and Ibuprofen were given to patients with higher PRPS (p Conclusions: Majority of ER visits were due to migraine or other minor illnesses that required outpatient analgesic treatment. Cost of healthcare and use of ER resources could be significantly reduced if they could be treated in Non ER setting. Prospective, controlled trials are needed. Disclosure: Dr. Peche has nothing to disclose. Dr. Lenox has nothing to disclose. Dr. Isbell has nothing to disclose. Dr. Kale has nothing to disclose. Dr. Mar has nothing to disclose. Dr. Prensky has nothing to disclose.

Preoperative anxiety and behavioral stress response in children is a common and vexing problem in the surgical arena as well as other heath care environments. Risk factors associated with this response include: Young age, especially pre-school, previous surgery, especially one associated with a “poor quality encounter,” lack of pre-operative visit/orientation, shy and inhibited temperament, anxious parents, and parental prediction of uncooperative behavior. The stress response has been shown repeatedly to be undesirable on the day of surgery for the child, family and hospital personnel but also to have long-term psychologically traumatic consequences. A general and reasonable assumption has been made that any procedure that will reduce the child’s fear of the anesthesia/surgical experience will tend to reduce its traumatic effect. Approaches to reduce anxiety fall into two categories: psychological and pharmacological. Psychological factors tend to focus on pre-operative preparation/orientation programs for child and family, parental presence during the induction of anesthesia, and induction sequence techniques, including a variety of distraction methods. Pharmacological factors include using a sedative or anxiolytic agent. All of the above psychological approaches effectively reduce anxiety and therefore improve the surgical/anesthetic experience for all involved. Preoperative preparation programs tend to enhance coping skills and provide a sense of control and mastery over the procedures.

The first administration of rituximab can cause important side effects due to cytokine release into the blood. It is therefore recommended to administer it over 4–6 hours. According to the manufacturer subsequent doses can be given in approximately 3 hours, but this is demanding for the patient (pt) and facilities and resources-consuming. A Canadian study has recently shown that rituximab can be given safely over 90 minutes from the second administration in combination with CHOP, provided that steroids and chemotherapy are administered before the antibody. We are conducting an infusion speed-escalation trial to verify if rituximab can be given in one hour without steroids pre-medication, in pts having received at least two previous doses of rituximab (with or without chemotherapy) in the previous 3 months. Further inclusion criteria include a normal cardiac function as evaluated by ECG and echocardiography. Cohorts of 3 patients are assigned to receive rituximab at a given initial infusion speed, to be increased by 100 mg /hour every 30 minutes. All receive standard anti-hystamine and paracetamol pre-medication. At every subsequent rituximab administration the initial speed is increased by 100 mg/h (intra-patient speed-escalation). If a pt experiences serious adverse events (SAE), then 6 pts are treated in the same cohort, in case of SAE in 2 of them the trial is discontinued. In each new cohort the initial speed is 100 mg/hr higher than in the previous cohort. Pts are monitored every 15 minutes for symptoms, blood pressure and hearth rate, hourly for temperature and an ECG is performed after treatment. For patients receiving chemo-immunotherapy, rituximab is given first and chemotherapy only later on the same day. Fifteen pts have so far been included (14 evaluable), with the first 4 cohorts complete. Median age was 60 (range 41–76), lymphoma type was diffuse large cell (8 pts), follicular (4 pts) and other indolent (3 pts). Two patients were treated with single agent rituximab and 12 in combination with chemotherapy. The median time from the last rituximab to inclusion in the study was 3 weeks (range 1–11). Overall, 3 cycles were given at a starting infusion speed of 200 mg/hr, 7 cycles at 300 mg/hr, 11 cycles at 400 mg/hr, 11 cycles at 500 mg/hr, 8 cycles at 600 mg/hr and 7 cycles at 700 mg/hr. The latter schedule allowed the administration of the whole prescribed drug in one hour. All pts tolerated the increased-speed infusion without major side effects. The blood pressure dropped by a median 10–15% of baseline, without symptoms and without significant differences between cohorts. The highest blood pressure drops were of respectively 25% and 29% without symptoms and spontaneously resolving within 15 minutes. There was no variation in the hearth frequency and no elevation of body temperature above 37°C. No relevant ECG changes were seen. We conclude that rituximab can be given in one hour without steroids pre-medication in pts who have already received at least two previous rituximab doses. The study is ongoing to evaluate the maximum infusion speed and will further explore if the latter is applicable from the second infusion on.

The effects of giving atropine, pentazocine or pethidine, 30--45 minutes before intravenous diazepam have been assessed and compared with a control group given diazepam alone in a double-blind controlled trial of pre-medication for upper gastrointestinal endoscopy involving 143 patients and 6 endoscopists. Atropine or pentazocine increased the success rate of the procedure (p 0.007) but gave no other definite benefit. Pethidine improved the degree of sedation (p 0.01) and the success rate (p 0.007); the combination of pethidine given before diazepam ranked first of all the four treatment regimes. The patients' opinion of the procedure correlated with the duration of endoscopy and the experience of the endoscopist.