小剂量氯胺酮咪唑安定合剂小儿基础麻醉850例临床应用

为改进小儿基础麻醉法，笔者研究了小剂量氯胺酮，咪唑安定合剂的临床效果与副作用，观察８５０例ＡＳＡＩ－Ⅱ级，年龄３ｄ－１４岁，行中小手术的病人。合剂由氯胺酮１００ｍｇ（２ｍｌ）与咪唑安定１５ｍｇ（３ｍｌ）配制而成，剂量为０．１０－０．１３ｍｌ／ｋｇ，咪唑安定０．３０－０．３９ｍｇ／ｋｇ），手术均在基础麻醉与区域阻滞配合不下完成。结果显示，此方法有给药方便，效果迅速而确切，苏醒快及副作用小等优点，比硫     

Premedication in Children

A comparison was made, in children, between four pre-anaesthetic medicants, viz. morphine-atropine, morphine-scopolamine, chlorpromazine-promethazine-pethidine and atropine alone, using the double-blind technique. Morphine-scopolamine and chlorpromazine-promethazine-pethidine had superior sedative properties, but atropine alone had a satisfactory effect in 68 % of the cases. The best drying effect was obtained with morphine-scopolamine. No difference was observed in the incidence of vomiting and time of emergence from anaesthesia.

ZUSAMMENFASSUNG UND SCHLUSSFOLGERUNG

Vier Praemedikationsarten wurden mit Hilfe der Doppelblindtechnik bei Kindern vergleichen, und zwar: Morphin-Atropin, Morphin-Scopolamin, Chlorpromazin-Promethazin-Dolantin und Atropin allein. Morphin-Scopolamin und Chlorpromazin-Promethazin-Dolantin hatten stärkere sedative Eigen-schaften, aber auch Atropin allein zeigte bei 68% der Falle eine zufriedenstel-lende Wirkung. Der beste Austrocknungseffect wurde mit Morphin-Scopolamin erreicht. Bezuglich der Häufigkeit von Erbrechen und der Wiederer-wachungszeit nach der Narkose wurden keine Unterschiede beobachtet.     

氯胺酮复合异丙酚或咪唑安定麻醉效应比较

２０例女性成年患者分别进行异丙酚－氯胺酮麻醉或咪唑安定－氯胺酮麻醉，麻醉效果满意。异丙酚组作用起效时间和清醒时间比咪唑安定组快，麻醉期间两组血流动力学稳定，注药后有短暂低氧血症，异丙酚组比咪唑安定组恢复快。     

咪唑安定和/或氯胺酮全麻诱导的临床效应观察

目的：观察咪唑安定和／或氯胺酮麻醉诱导的临床效应。方法：全麻气管插病人３６例,ＡＳＡⅠ～Ⅱ级,随机分为三组,每组１２例,分别静注咪唑安全０．１ｍｇ／ｋｇ＋氨胺酮１ｍｇ／ｋｇ（Ⅰ组）、氯胺酮２ｍｇ／ｋｇ（Ⅱ组）或咪唑安定０．２ｍｇ／ｋｇ（Ⅲ组）诱导。分别记录诱导前后各组的ＢＩＳ、ＳＥＦ、ＨＲ及ＭＡＰ等变化。结果：（１）Ⅱ组诱导后ＢＩＳ、ＳＥＦ值低于其他组,而Ⅰ组诱志２分钟后的数值≥麻醉前值;（２）２     

Psychological Changes in Children after Anaesthesia: A Comparison between Halothane and Ketamine

The psychological reactions to hospitalization, anaesthesia, and operation in a group of 107 children from 1 to 12 years old, anaesthetized with ketamine or halothane after randomization were investigated through questionnaires, which the parents answered 1 month postoperatively. The percentage of replies was 96.3%. Fifty-three children were anaesthetized with ketamine and 50 with halothane. Thirteen children in the ketamine group and nine in the halothane group reacted with negative personality changes; the reactions were of less than 1 month's duration and were most frequent in the youngest children. The parents' preparation of the children had no influence on the results. The number of personality changes caused by the two anaesthetic agents did not differ significantly. Furthermore, the investigation showed the nine children reacted for the better. Thirty-six per cent of the parents felt insufficiently informed of what the hospitalization implied for their child.     

Postoperative Behavioral Outcomes in Children: Effects of Sedative Premedication

Background: Although multiple studies document the effect of sedative premedication on preoperative anxiety in children, there is a paucity of data regarding its effect on postoperative behavioral outcomes.

Methods: After screening for recent stressful life events, children undergoing anesthesia and surgery were assigned randomly to receive either 0.5 mg/kg midazolam in 15 mg/kg acetaminophen orally (n = 43) or 15 mg/kg acetaminophen orally (n = 43). Using validated measures of anxiety, children were evaluated before and after administration of the intervention and during induction of anesthesia. On postoperative days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed using the Post Hospitalization Behavior Questionnaire.

Results: The intervention group demonstrated significantly lower anxiety levels compared with the placebo group on separation to the operating room and during induction of anesthesia (F[1,77] = 3.95, P = 0.041). Using a multivariate logistic regression model, the authors found that the presence or absence of postoperative behavioral changes was dependent on the group assignment (R = 0.18, P = 0.0001) and days after operation (R = -0.20, P = 0.0001). Post hoc analysis demonstrated that during postoperative days 1-7, a significantly smaller number of children in the midazolam group manifested negative behavioral changes. At week 2 postoperatively, however, there were no significant differences between the midazolam and placebo groups.     

Midazolam: Effects on Amnesia and Anxiety in Children

Background: The minimum time interval between administration of oral midazolam and separation of children from their parents that ensures good anterograde amnesia has not been previously determined. This is of particular importance in a busy operating room setting where schedule delays secondary to midazolam administration may not be tolerated.

Methods: Children (n = 113) undergoing general anesthesia and surgery completed preoperative baseline memory testing using a validated series of picture cards and were randomly assigned to one of three midazolam groups or a control group. Exactly, 5, 10, or 20 min after receiving oral midazolam (0.5 mg/kg) or 15 min after receiving placebo, children were administered a second memory test that used pictures. Anxiety of children was assessed during induction of anesthesia with use of a validated anxiety measurement tool. Postoperatively, recall and recognition for picture cards seen during baseline testing and postintervention testing were assessed.

Results: Postoperatively, recall and recognition of pictures presented to patients after drug administration (anterograde amnesia) showed significant group differences (P = 0.0001), with recall impaired in the 10- (P = 0.004) and 20-min groups (P = 0.0001). Similarly, recognition memory was impaired in the 5- (P = 0.0008), 10- (P = 0.0001) and 20-min (P = 0.0001) groups. Significant anxiolytic effects of midazolam were observed as early as 15 +/- 4 min after midazolam administration (P = 0.02).     

Preanaesthetic Medication with Rectal Diazepam in Children

With the purpose of avoiding injections to children, the quality of rectal premedication with a solution of diazepam (Apozepam) was investigated in a double-blind study. Compared with a lytic cocktail (containing pethidine, promethazine and chlorpromazine), adequate preanaesthetic sedation was obtained with rectally administered diazepam in a dose of 0.75 mg kg^-1. However, following rectal diazepam, the majority of the children were very restless during recovery, but the combination of diazepam premedication and a small dose of lytic cocktail given i. m. during anaesthesia secured a smooth recovery in practically all children. The proportion of cases classified as "unsatisfactory" was higher in children below the age of 5 years than in the older children.     

Dexmedetomidine,Ketamine, and Midazolam for Oral Rehabilitation: A Case Report

Intravenous sedation is frequently provided by anesthesiologists for phobic patients undergoing elective dental treatment in outpatient settings. Propofol is one of the most commonly used anesthetic agents that can result in apnea and respiratory depression, thereby posing potential difficulties with perioperative airway management. Dexmedetomidine has been utilized successfully in intravenous sedation for a wide variety of procedures and holds potential as an alternative to propofol in outpatient dental settings. However, as a single agent, it may not provide adequate depth of sedation and analgesia for oral rehabilitation. In this case report we demonstrate an effective alternative intravenous deep-sedation technique for an adult phobic patient undergoing oral rehabilitation utilizing 3 agents in combination: dexmedetomidine, ketamine, and midazolam. This combination of agents may be especially useful for those patients with a history of substance abuse, where administration of opioids may be undesirable or contraindicated.Key Words: Ketamine, Midazolam, Intravenous deep sedation, Outpatient anesthesia, DentistryDexmedetomidine is a selective alpha-2 receptor agonist that has been demonstrated to have sedative, analgesic, and anxiolytic effects when administered intravenously.^1,2 Its specificity is known to be 8 times greater for the alpha-2 receptor than that of clonidine, and its elimination half-life is 2 hours compared to 8 hours for clonidine.¹ Its mechanism of action has been described to involve the hyperpolarization of noradrenergic neurons in the locus ceruleus, resulting in inhibitory action on the release of both norepinephrine and histamine, leading to a hypnotic state that is similar to that observed in normal sleep.^3,4 Unlike opioids, benzodiazepines, and propofol, dexmedetomidine has been shown not to depress respiration.^2,5 Dexmedetomidine has also been associated with reduced overall requirement for opioids, benzodiazepines, and propofol during intravenous sedation.⁵ In addition, dexmedetomidine has been shown to potentiate opioids and reduce postoperative shivering.^6,7Dexmedetomidine was initially recognized as an effective sedative in the intensive care unit for intubated patients. Since then its clinical application has expanded to include neurosurgery, pediatric procedural sedation, awake fiber-optic intubation, cardiac surgery, bariatric surgery, and dental procedures.^5,8–14 Its use as a single agent during dental procedures under intravenous sedation has been reported in several studies. Dexmedetomidine has been shown to be comparable to or better than midazolam as a single agent in third-molar extractions^15,16; however, it does not produce consistent amnestic effects.¹⁶ More recently, a case report described the use of intravenous dexmedetomidine and ketamine for dental extraction in children with cyanotic heart disease with positive results.¹⁷Both midazolam and ketamine are intravenous sedative agents used most commonly in combination with other drugs for dental procedures. Midazolam is a good anxiolytic, amnestic agent but is known to pose difficulties to the operator for longer and more complex dental procedures when used alone.¹⁸ It also poses the risk of respiratory depression at high doses and has minimal analgesic effects,^19,20 limiting its utility as a single agent for longer, more extensive dental procedures. Ketamine is a widely used dissociative anesthetic with analgesic, amnestic, and bronchodilatory effects.^21,22 However, its cardiostimulatory effects and unfavorable side effects including hypersalivation, emergence delirium, and postoperative agitation^21,23 present limitations to its use as a single intravenous agent for dental procedures. Although midazolam may attenuate the emergence delirium and postoperative agitation produced by ketamine,¹⁹ it has not been shown to predictably antagonize the central sympathetic stimulation that causes tachycardia and hypertension.Combining the beneficial effects of midazolam, ketamine, and dexmedetomidine may be effective during open-airway intravenous deep sedation for relatively longer, more extensive dental procedures in outpatient dental settings. The use of the 3 agents in combination may reduce the total dose of each individual agent required as well as their negative side effects. This combination may also be beneficial for patients with a history of opioid abuse in which administration of opioids may be undesirable or contraindicated. We describe an intravenous sedation technique with dexmedetomidine, ketamine, and midazolam in combination for an adult phobic patient with a history of oxycodone abuse who underwent an elective oral rehabilitation in our outpatient dental clinic.     

Midazolam for Induction of Anaesthesia in Outpatients: A Comparison with Thiopentone

Midazolam, a new water-soluble benzodiazepine, with an elimination half-life of approximately 2 h, was compared with thiopentone for induction of general Anaesthesia in a randomized, single-blind study. The patients were 60 healthy women undergoing legal abortion as outpatients. Midazolam provided smooth and reliable induction of Anaesthesia with few side-effects. However, the induction time was considerably longer in the midazolam group (82.3 + 6.1) than in the thiopentone group (45.9 ±1.7 s). The dose of midazolam required for induction was 0.36±0.01 mg/kg, while that of thiopentone was 6.43 ±0.21 mg/kg. Apnoea occurred with a frequency of 10 % in the midazolam group and 55 % in the thiopentone group, but was of equal duration in both groups. Circulatory conditions were more stable during induction with midazolam, with a slower fall in blood pressure and no change in heart rate. The patients were breathing O₂/N₂O in proportions of 1:2.
To ensure adequate surgical anaesthesia, it was necessary to add halothane for short periods for all patients in the midazolam group and for 79% of the thiopentone group. Postoperatively, all patients who had received midazolam, but none induced with thiopentone, had anterograde amnesia; this lasted for more than 1 h. All patients in both groups could leave the hospital after routine postoperative observation for 3–4 h. Venous tolerance was good for both drugs.     

Anaesthesia with Midazolam/Medetomidine/Fentanyl in Chinchillas (Chinchilla lanigera) Compared to Anaesthesia with Xylazine/Ketamine and Medetomidine/Ketamine

We studied four different drug regimes for anaesthetic management in chinchillas and evaluated and compared their cardiovascular and respiratory effects. In this randomized, cross‐over experimental study, seven adult chinchillas, five females, two males [515 ± 70 (SD) g] were randomly assigned to one of the following groups: group 1 [midazolam, medetomidine and fentanyl (MMF), flumazenil, atipamezole and naloxone (FAN); MMF–FAN] received 1.0 mg/kg midazolam, 0.05 mg/kg medetomidine and 0.02 mg/kg fentanyl i.m., and for reversal 0.1 mg/kg flumazenil, 0.5 mg/kg atipamezole and 0.05 mg/kg naloxone s.c. after 45 min; group 2 (MMF) 1.0 mg/kg midazolam, 0.05 mg/kg medetomidine and 0.02 mg/kg fentanyl i.m.; group 3 [xylazine/ketamine (X/K)] 2.0 mg/kg xylazine and 40.0 mg/kg ketamine i.m.; and group 4 [medetomidine/ketamine (M/K)] 0.06 mg/kg medetomidine and 5.0 mg/kg ketamine i.m. Reflexes were judged to determine anaesthetic stages and planes. Anaesthesia with X/K and M/K was associated with a prolonged surgical tolerance and recovery period. By reversing MMF, recovery period was significantly shortened (5 ± 1.3 min versus 40 ± 10.3 min in MMF without FAN, 73 ± 15.0 min in X/K, and 31 ± 8.5 min in M/K). Without reversal, MMF produced anaesthesia lasting 109 ± 16.3 min. All combinations decreased respiratory and heart rate but compared with X/K and M/K, respiratory and cardiovascular complications were less in the MMF groups. Focussing on the clinical relevance of the tested combinations, completely reversible anaesthesia showed two major advantages: anaesthesia can be antagonized in case of emergency and routinely shortens recovery. In small animals particularly these advantages lead to less complications and discomfort and thus often can be lifesaving. As all analgesic components (medetomidine and fentanyl) are reversed, postoperative analgesia should be provided before reversal of anaesthesia.     

Electroencephalographic Study of Children During Ketamine Anesthesia

EEG was recorded on nine occasions of ketamine anesthesia in eight children. Two of the patients were neurologically normal and six were under investigation for various neurological disorders. The EEG during the catatonic phase of ketamine anesthesia is characterized by alternating high amplitude delta complexes and periods of fast activity. The two cases which in the routine EEG showed focal paroxysmal activity did not show any electroencephalographic aggravation or clinical seizure during ketamine influence. One case exhibiting a subcortical type of epileptiform activity showed a marked potentiation of this activity with ketamine. On routine neurological examination during the catatonic phase of ketamine anesthesia the pharyngeal reflex was generally weak and failed altogether in two cases and corneal reflexes were absent in three cases.     

Twenty-four-Hour Pharmacokinetics of Rectal Acetaminophen in Children: An Old Drug with New Recommendations

Background: Rectal acetaminophen is often administered during operation to provide supplemental analgesia or antipyresis in children. Recent studies examining current dose guidelines are limited by short sampling times. The authors extended the drug sampling period to more clearly define acetaminophen pharmacokinetics in children having surgery.

Methods: Children (n = 28) were randomized to receive a single dose of 10, 20, or 30 mg/kg rectal acetaminophen after induction of anesthesia. Venous blood samples were taken every 30 min for 4 h, every 60 min for 4 h, and every 4 h for 16 h. Data were analyzed using a mixed-effects modeling technique (using NONMEM software) to determine the volume of distribution and clearance normalized for bioavailability. Additional models accounted for suppository dissolution followed by acetaminophen absorption.

Results: Age, weight, estimated blood loss, volume of intravenous fluid administered, and anesthesia time were similar in the three groups. Most patients did not achieve peak or sustained serum values in the 10-20 micro gram/ml serum concentration range associated with antipyresis. The volume of distribution was 385 ml/kg, and clearance normalized for bioavailability, F, was 5.46 ml [center dot] kg sup -1 [center dot] min sup -1. Pharmacokinetic models suggest that absorption of acetaminophen is a function of zero-order dissolution of suppositories and first-order absorption from the rectum. Suppository dose size also may affect absorption characteristics.     

Midazolam as Induction Agent Prior to Inhalational Anaesthesia: A Comparison with Thiopentone

Midazolam, a new water-soluble benzodiazepine, was compared with thiopentone as an induction agent prior to inhalational anaesthesia. Induction time, cardiovascular response and venous sequelae were studied in 100 healthy in-patients randomly divided into two groups. Midazolam proved to be a good alternative to thiopentone, the longer induction time being compensated by a lower incidence and duration of apnoea.     

Closed Rectosacropexy for Rectal Prolapse in Children

This report describes a simple, effective, and permanent surgical solution for persistent rectal prolapse (RP). The technique simply involves passing multiple U-shaped sutures through the stab incisions made in the skin posterior to the anus, into the sacral fascia, then into the wall of rectum, down to the anal canal, and out through the stab incisions. The strands of the suture are tied subcutaneously through the stab incisions. This operation was successfully performed in 42 children (mean age, 3.5 years) who had suffered from recurrent RP for 3–5 months. None of the children experienced any further recurrence or specific complications during follow-up ranging from 1 to 3 years. Thus, I believe that closed rectosacropexy offers a simple, minimally invasive, and effective method of treating complete RP in children.