Cerebral Oxygenation and Activity During Surgical Repair of Neonates With Congenital Diaphragmatic Hernia: A Center Comparison Analysis

Background and aim: Neonatal brain monitoring is increasingly used due to reports of brain injury perioperatively. Little is known about the effect of sedatives (midazolam) and anesthetics (sevoflurane) on cerebral oxygenation (rScO2) and cerebral activity. This study aims to determine these effects in the perioperative period.Methods: This is an observational, prospective study in two tertiary pediatric surgical centers. All neonates with a congenital diaphragmatic hernia received perioperative cerebral oxygenation and activity measurements. Patients were stratified based on intraoperatively administrated medication: the sevoflurane group (continuous sevoflurane, bolus fentanyl, bolus rocuronium) and the midazolam group (continuous midazolam, continuous fentanyl, and continuous vecuronium).Results: Intraoperatively, rScO2 was higher in the sevoflurane compared to the midazolam group (84%, IQR 77–95 vs. 65%, IQR 59–76, p = < 0.001), fractional tissue oxygen extraction was lower (14%, IQR 5–21 vs. 31%, IQR 29–40, p = < 0.001), the duration of hypoxia was shorter (2%, IQR 0.4–9.6 vs. 38.6%, IQR 4.9–70, p = 0.023), and cerebral activity decreased more: slow delta: 2.16 vs. 4.35 μV2 (p = 0.0049), fast delta: 0.73 vs. 1.37 μV2 (p = < 0.001). In the first 30 min of the surgical procedure, a 3-fold increase in fast delta (10.48–31.22 μV2) and a 5-fold increase in gamma (1.42–7.58 μV2) were observed in the midazolam group.Conclusion: Sevoflurane-based anesthesia resulted in increased cerebral oxygenation and decreased cerebral activity, suggesting adequate anesthesia. Midazolam-based anesthesia in neonates with a more severe CDH led to alarmingly low rScO2 values, below hypoxia threshold, and increased values of EEG power during the first 30 min of surgery. This might indicate conscious experience of pain. Integrating population-pharmacokinetic models and multimodal neuromonitoring are needed for personalized pharmacotherapy in these vulnerable patients.Trial Registration:https://www.trialregister.nl/trial/6972, identifier: NL6972.

Effect of Adding Midazolam to Dual Prophylaxis for Preventing Postoperative Nausea and Vomiting

Multimodal prophylaxis for postoperative nausea and vomiting (PONV) has been recommended, even in low-risk patients. Midazolam is known to have antiemetic properties. We researched the effects of adding midazolam to the dual prophylaxis of ondansetron and dexamethasone on PONV after gynecologic laparoscopy. In this prospective, randomized, double-blinded trial, 144 patients undergoing gynecological laparoscopic surgery under sevoflurane anesthesia were randomized to receive either normal saline (control group, n = 72) or midazolam 0.05 mg/kg (midazolam group, n = 72) intravenously at pre-induction. All patients were administered dexamethasone 4 mg at induction and ondansetron 4 mg at the completion of the laparoscopy, intravenously. The primary outcome was the incidence of complete response, which implied the absence of PONV without rescue antiemetic requirement until 24 h post-surgery. The complete response during the 24 h following laparoscopy was similar between the two groups: 41 patients (59%) in the control group and 48 patients (72%) in the midazolam group (p = 0.11). The incidence of nausea, severe nausea, retching/vomiting, and administration of rescue antiemetic was comparable between the two groups. The addition of 0.05 mg/kg midazolam at pre-induction to the dual prophylaxis had no additive preventive effect on PONV after gynecologic laparoscopy.

Sedation and Anesthesia of Galapagos (Chelonoidis nigra), Aldabra (Aldabrachelys gigantea), and African Spurred Tortoises (Centrochelys sulcata): A Retrospective Review (2009–2019)

Tortoises belong to the taxonomic family Testudinidae, which is considered one of the most imperiled families of the order Testudines. Anesthesia is often required for the medical and surgical management of large tortoises. The objectives of this retrospective study were to review drug regimens used to successfully anesthetize Galapagos (Chelonoidis nigra), Aldabra (Aldabrachelys gigantea) and African spurred (Centrochelys sulcata) tortoises, and to compare the times to effect and to extubation in tortoises administered different premedication protocols. Anesthetic records of giant tortoises admitted to the University of Florida College of Veterinary Medicine between January 2009 and December 2019 were reviewed. A total of 34 tortoises (six Aldabra, 23 Galapagos, and five African spurred) were included, resulting in 64 anesthetic events. Frequently used premedication protocols included an α-adrenergic agonist and ketamine combined with either midazolam (group αadrenergic agonist, midazolam, ketamine, AMK; n = 34), a μ-opioid receptor agonist (group αadrenergic agonist, μ-opioid receptor agonist, ketamine, AOK; n = 13), or a μopioid receptor agonist and midazolam (group αadrenergic agonist, midazolam, μ-opioid receptor agonist, ketamine, AMOK; n = 10). Inhalant anesthetics (isoflurane, n = 21; sevoflurane, n = 23) were frequently used for maintenance of anesthesia following premedication. Out of the 34 total tortoises, 22 had only one anesthetic event, five had two anesthetic events, three had three anesthetic events, and four had four or more anesthetic events. Few adverse effects were observed and there was no mortality reported during the peri-anesthetic period. Sedation and general anesthesia of giant tortoises can be successfully performed with a combination of an α-adrenergic agonist and ketamine in combination with midazolam and/or a μopioid receptor agonist.

Propofol Autocoinduction and Midazolam Co-induction for Propofol Induction

Intoduction: The problem with induction during anaesthesia is decrease in blood pressure, apnea which could be detrimental to patient. Co-induction and autocoinduction are one of the modalities that are developed to overcome hypotension during induction. The study was carried out to observe heart rate, blood pressure response and propofol consumption following midazolam as co-induction or propofol autocoiniduction for propofol induction. Methods: This study was a conducted in 52 patients of ASA I and ASA II undergoing elective surgical procedures with general anesthesia. Patients were randomly allocated and group P received 0.5 mg/ kg of propofol and group M received 0.04 mg/ kg of midazolam intravenously as autocoindution and coinduction respectively. Results: The two groups were identical regarding age, weight, ASA status and base line vitals. This study showed that there was significant difference between 2 groups in terms of blood pressure. Decrease in blood pressure from baseline is more in Midazolam group compared to propofol. In terms of Heart Rate there was no statistically significant between two groups at any time of observation. Decrease in HR from baseline was almost similar in both groups. Consumption of Propofol was not statistically significant different between two groups. Propofol group required 8% lesser Propofol than Midazolam group. Conclusions: Our study concluded that blood pressure was decreased significantly in Midazolam group compared to Propofol group but heart rate was decreased almost similar in both groups and was not statistically significant. Consumption of Propofol was not statistically significant but Propofol group had 8 % lesser Propofol consumption than Midazolam group.

Comparative Study of Hemodynamic Infusion of Dexmedetomidine With Alternative Sufentanil-Midazolam Injection for Sedation of Patients Undergoing Cataract Surgery

In order to induce sedation during cataract surgery, various medications with different side effects are used in separation or in combination. Dexmedetomidine has no effect on the respiratory system, but being dependent on dosage, it may cause cardiovascular disorders. The present study aims to compare the hemodynamic and sedative effects of dexmedetomidine and the combination of sufentanil-midazolam on patients undergoing cataract surgery. In a randomized clinical trial study, 60 patients were randomly divided into two dexmedetomidine and sufentanil-midazolam groups. In sufentanil-midazolam group, dexmedetomidine (DEX infusion at 0.5 μg/ kg for 10 minutes, then adjusted to 0.2 µg/kg/h) was prescribed. In the sufentanil-midazolam group, sufentanil (0.1 μg/kg for 5 minutes) and midazolam (0.2 µg/kg) were injected five minutes before the operation. Hemodynamic variables (Systolic blood pressure, diastolic blood pressure, heart rate), complications (nausea, vomiting, hypoxia), sedation level, and pain intensity were recorded (at the beginning of the study, 5, 10 minutes after anesthesia, at the start of surgery, 5, 10, 15 minutes after the surgery) as well as patient’s satisfaction, surgeon's satisfaction, and complications. Results suggest that apart from gender, other primary characteristics of patients, including age, history of blood pressure, diabetes history, ASA score, mean of systolic, diastolic blood pressure, heart rate, and SPO2 levels, were similar in both groups (P>0.05). Systolic blood pressure patients receiving dexmedetomidine declined significantly more than that of patients receiving sufentanil-midazolam (P>0.5). Diastolic blood pressure suddenly fell 5 minutes after the infusion of sufentanil-midazolam (P>0.05), but then a relative increase and finally a relative decrease occurred, while diastolic blood pressure in patients receiving dexmedetomidine decreased steadily. The mean heart rate in patients receiving dexmedetomidine and sufentanil-midazolam declined gently (P>0.05). SPO2 was reduced significantly in the sufentanil-midazolam group (P<0.05). Drugs used in both groups reduced pain intensity equally (P>0.05). From the beginning of the study, dexmedetomidine produced a relatively stable sedation level (score 2) based on Ramsay's criteria, while the combination of sufentanil-midazolam-medications causes deeper sedation (score 3) in patients (P<0.05). Despite this fact, 23.33% of the patient receiving sufentanil-midazolam could have movements during the surgery, which was 6.66% higher in patients receiving dexmedetomidine (P=0.071). The satisfaction of patients receiving dexmedetomidine was significantly higher (P=0.044), while the surgeon's satisfaction was almost identical in both anesthesia procedures (P=0.94). In the end, the results of the present study showed that although dexmedetomidine is associated with few respiratory problems and higher satisfaction of patients, it decreases blood pressure and heart rate progressively. However, it seems that this medicine is more effective than a combination of midazolam-sufentanil because of more patient satisfaction, lack of hypoxia, fewer complications, and more suitable immobility.

Comparison of Midazolam and Dexmedetomidine for sedation in Postoperative intubated patients of head and neck surgery on spontaneous ventilation in Intensive care unit

Introduction: Sedation is important in the care of the critically ill and postoperative patients. Amount of drug and duration for which it is given, is important in determining patient outcome. Aim: Study aimed to compare the safety and efficacy of injection midazolam and injection dexmedetomidine for sedation in postoperative patients of oromaxillofacial surgery with endotracheal tube in-situ, on spontaneous ventilation in ICU. Methodology: This prospective, randomized, comparative study was conducted on 60 patients undergoing oromaxillofacial surgery who were randomized in two groups of 30 patients each. Group D received injection demedetomidine loading dose of 1μg/kg over 15 minutes, followed by infusion at the rate of 0.2-0.7µg/kg/hr (microgram/kilogram/hour) and Group M received injection midazolam loading dose of 0.05mg/kg over 15 minutes followed by maintenance infusion at the rate of 0.02-0.06mg/kg/hr (milligram/kilogram/hour). The monitored indices included heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, SpO2 and Ramsay sedation score at the start of sedation when the Ramsay sedation score (RSS) was I and time to extubation after stopping sedation. Results: Target sedation range was achieved in a mean duration of 10.36 ± 3.05 minutes in dexmedetomidine group and that in midazolam group was 7.43±2.06 minutes. Highest value of RSS score in dexmedetomidine group was 2.43±0.50, which was observed at the 4th and 10th hour whereas in midazolam group it was 2.83±0.38 which was observed at 6th hour of the study period. Total dose of rescue analgesic required was more in midazolam group as compared to the dexmedetomidine group. The mean duration of extubation after cessation of sedation was 33.27±11.37 minutes in dexmedetomidine group and 49.43±5.58 minutes in midazolam group. Conclusion: Injection dexmedetomidine is better as compared to injection midazolam for postoperative sedation.

Midazolam for conscious sedation in transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography

Objectives: To investigate the safety and feasibility of midazolam for conscious sedation in transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography. Methods: A retrospective analysis was performed on 55 patients who underwent transcatheter device closure of atrial septal defects from October, 2019 to May, 2020. All patients received intravenous midazolam and local anesthesia with lidocaine to maintain sedation. A group of previous patients with unpublished data who underwent the same procedure with general anesthesia was set as the control group. The relevant clinical parameters, the Ramsay sedation scores, the numerical rating scale, and the post-operative satisfaction questionnaire were recorded and analyzed. Results: In the midazolam group, the success rate of atrial septal defect closure was 98.2%. Hemodynamic stability was observed during the procedure. None of the patients needed additional endotracheal intubation for general anesthesia. Compared with the control group, the midazolam group had no statistically significant differences in the Ramsay sedation score and numerical rating scale scores. Patients in the midazolam group experienced more post-operative satisfaction than those in the control group. Conclusions: Conscious sedation using midazolam is a safe and effective anesthetic technique for transcatheter device closure of atrial septal defects guided solely by transthoracic echocardiography.

Midazolam for sedation before procedures in adults and children: a systematic review update

Background Midazolam is used for sedation before diagnostic and therapeutic medical procedures by several routes including oral, intravenous, intranasal and intramuscular. This is an update of a Cochrane review published in 2016, which aimed to determine the evidence on the effectiveness of midazolam for sedation when administered before a diagnostic or therapeutic procedure in adults and children. Methods We searched CENTRAL, MEDLINE, Embase and two trials registers up to May 2020 together with reference checking to identify additional studies. We imposed no language restrictions. Randomized controlled trials of midazolam in comparison with placebo or other medications used for sedation were included. Two authors independently extracted data and assessed risk of bias for each included study. Results Eight new trials were included in this update, which resulted in changed conclusions for the intravenous midazolam versus placebo, oral midazolam versus chloral hydrate and oral midazolam versus placebo comparisons. Effect estimates for all outcomes within the intravenous midazolam versus placebo (7 trials; 633 adults and 32 children) are uncertain due to concerns about imprecision and risk of bias. Midazolam resulted in a higher level of sedation than placebo (mean difference (MD) 1.05; 95% confidence interval (95% CI) 0.69 to 1.41; 1 study; 100 adults). There was no difference in anxiety (RR 0.43, 95% CI 0.09 to 1.99; I2 = 75%; 2 studies; 123 adults). Risk of difficulty performing procedures was lower in the midazolam group (RR 0.5; 95% CI 0.29 to 0.86; I2 = 45%; 3 studies; 191 adults and 32 children). There was no difference in discomfort (RR 0.51; 95% CI 0.25 to 1.04; I2 = 0%; 2 studies; 190 adults). Five trials with 336 children were included in the oral midazolam versus chloral hydrate comparison. Midazolam was less likely to result in moderate sedation (RR 0.30, 95% CI 0.11 to 0.82; I2 = 64%; 2 studies, 228 participants). This effect estimate is highly uncertain due to concerns about the risk of bias, imprecision and inconsistency. There was no difference in ratings of anxiety (SMD − 0.26; 95% CI − 0.75 to 0.23; I2 = 0%; 2 studies; 68 participants). Midazolam increased risk of incomplete procedures (RR 4.01; 95% CI 1.92 to 8.40; I2 = 0%; 4 studies, 268 participants). This effect estimate is uncertain due to concerns about the risk of bias. There were four trials with 359 adults and 77 children included in the oral midazolam versus placebo comparison. Midazolam reduced ratings of anxiety (SMD − 1.01; 95% CI − 1.86 to − 0.16; I2 = 92%; 4 studies; 436 participants). It is unclear if midazolam has an effect on difficulty performing procedures. Meta-analysis was not performed because there was only one incomplete procedure in the midazolam group in one of the trials. Midazolam reduced pain in one study with 99 adults (MD − 2; 95% CI − 2.5 to − 1.6; moderate quality). The effect estimate is uncertain due to concerns about the risk of bias. Conclusion The additional evidence arising from inclusion of new studies in this updated review has not produced sufficient high-quality evidence to determine whether midazolam produces more effective sedation than other medications or placebo in any specific population included in this review. For adults, there was low-quality evidence that intravenous midazolam did not reduce the risk of anxiety or discomfort/pain in comparison to placebo, but the sedation level was higher. By combining results from adults and children, there was low-quality evidence of a large reduction in the risk of procedures being difficult to perform with midazolam in comparison to placebo. The effect estimates for this comparison are uncertain because there was concern about risk of bias and imprecision. There is moderate-quality evidence suggesting that oral midazolam produces less-effective sedation than chloral hydrate for completion of procedures for children undergoing non-invasive diagnostic procedures. Ratings of anxiety were not different between oral midazolam and chloral hydrate. The extent to which giving oral midazolam to adults or children decreases anxiety during procedures compared with placebo is uncertain due to concerns about risk of bias and imprecision. There was moderate-quality evidence from one study that oral midazolam reduced the severity of discomfort/pain for adults during a brief diagnostic procedure in comparison with placebo.

A comparative study of dexmedetomidine propofol and midazolam with respect to changes in mean arterial pressure and SpO2 after sedation at tertiary health care centre

Background: Sedation is an important component of compassionate care in ICU patients to promote rest and sleep. The sedatives used most often include propofol and midazolam. These medications provide adequate sedation but also can cause oversedation. The α2 agonist dexmedetomidine have unique sedative properties that it produces only mild cognitive impairment, allowing easy communication between health-care provider and patient in the ICU. We therefore compared the sedative and analgesic properties, cardiovascular responses, ventilation and extubation characteristics, and patient perceptions of dexmedetomidine with those of the commonly used i.v. sedative agent propofol in the ICU. Material and Methods: Present study was a randomized. open label trial conducted in the ICU ppatients >18 years of age, who required immediate sedation as to permit the initiation and tolerance of mechanical ventilation. 30 patients each were randomly allocated to dexmedetomidine, propofol & midazolam group. Results: Male predominance was noted, in all groups (dexmedetomidine, propofol & midazolam), M:F ratio was 1.3 : 1. According to age distribution most common age group in dexmedetomidine, propofol & midazolam group was 31-45 years (40 %). At all times the difference in systolic blood pressure, diastolic blood pressure, SpO2, mean arterial blood pressure among all the three groups calculated by ANOVA test was not statistically significant (P>0.05). The mean time (hours) from cessation of sedation to extubation for dexmedetomidine is 7.4 hours, for propofol is 5.6 hours and for midazolam is 16.9 hours. P-value of dexmedetomidine, propofol and midazolam group is <0.001, which is statistically significant. Conclusion: Dexmedetomidine provides hemodynamic stability and have no clinically important adverse effects on respiration in terms of mean SpO2. Tracheal extubation was earlier in patients receiving dexmedetomidine and propofol than from midazolam.

Treatment of Supraventricular Tachycardia in Patients with Non-Cardiac Surgery by Dexmedetomidine During the Perioperative Period. A Randomized Trial

Background: Previous studies have shown that application of dexmedetomidine (Dex) combined anesthesia during surgery can significantly reduce cardiovascular system complications and mortality of patients with cardiac disease during the perioperative period. The aim of this study was to explore the therapeutic effect of Dex on perioperative supraventricular tachycardia (SVT) in adult patients with non-cardiac surgery.Methods: Forty-six patients with SVT undergoing elective non-cardiac surgery were randomly divided into two groups, intravenously infused Dex (Dex group, 1.0 µg/kg) or midazolam (midazolam group, 0.06 mg/kg) for 10 minutes, respectively. The observation indexes containing the treatment efficiency of SVT, heart rate (HR) and and heart rate variability (HRV) including normalized low frequency power (LFnorm), normalized high frequency power (HFnorm) and LFnorm/HFnorm were recorded.Results: Treatment rates of SVT were 21/23 (91.3%) in Dex group vs 2/23 (8.7%) in midazolam group (P<0.001). In Dex group, LFnorm and LFnorm/HFnorm were decreased, and HFnorm were elevated and HR were decreased after twenty-three patients infused Dex (P < 0.05). However, there was no difference for HFnorm, LFnorm and LFnorm/HFnorm in midazolam group (P > 0.05). Conclusion: Perioperative use of dexmedetomidine has a significant therapeutic effect for SVT, and its mechanism is related to adjust cardiac autonomic nervous system and has no obvious connection with sedation.Trial registration: This trial was registered at ClinicalTrials.gov. registry number: NCT04284150 on February 13, 2020.