Rectal Diazepam Compared to Intramuscular Pethidine/Promethazine/Chlorpromazine with Regard to Gastric Contents in Paediatric Anaesthesia

Sixty children, aged 1—12 years, were investigated with regard to gastric pH and volume before general anaesthesia. Thirty children (group D) received diazepam 0.75 mg/kg b.w. rectally 1 h before anaesthesia. Thirty children (group L) received a "lytic cocktail" (pethidine 28 mg, promethazine 7 mg, chlorpromazine 7 mg per ml) 0.05 ml/kg b.w. intramuscularly 1 h before anaesthesia. The pH values were significantly higher and the amount of gastric juice was significantly lower in group L compared to group D. The number of children in group L with gastric juice volume exceeding 0.4 ml/kg and the number of children with pH less than 2.5 was significantly smaller compared to group D. The number of children with both gastric pH less than 2.5 and gastric juice volume greater than 0.4 ml/kg was significantly smaller in the group receiving "lytic cocktail" intramuscularly compared to the group receiving diazepam rectally. Bile-stained gastric contents was not related to the gastric pH.     

Peroral Diazepam Compared with Parenteral Morphine/Scopolamine with Regard to Gastric Content

In a prospective study, 62 adult patients were studied with respect to the volume and pH of their gastric contents after receiving randomly one of three different premedications. One group received flunitrazepam 2 mg perorally on the night before operation and diazepam 0.2 mg per kg body weight perorally at 7.00 a.m. on the day of operation. The patients in the second group were given flunitrazepam 2 mg perorally the night before operation and morphine/scopolamine i.m. 1 h prior to operation. In the third group no flunitrazepam was given on the night before operation, and the patients were premedicated with morphine/scopolamine i.m. 1 h preoperatively. No statistically significant difference was found between the groups with respect to the volume and pH of gastric contents after induction of anaesthesia.     

Volume and pH of gastric contents following anticholinergic premedication

The effects of anticholinergic premedication with 1.0 mg atropine, 0.5 mg hyoscine and 0.2 mg glycopyrronium on volume and pH of gastric contents were studied and compared with a group receiving no anticholinergic premedication. The antisialogogue effects were also compared. Though the groups receiving atropine and glycopyrronium had the lowest mean aspirated volume and the highest mean pH respectively there was no essential difference between the various groups receiving anticholinergic premedication. However, the pH values were above 2.5 in the majority of these patients in comparison with the control group. The antisialogogue effects of the three anticholinergic drugs were similar.     

Gastric pH and volume after oral fluids in the postpartum patient

The aim of this study was to investigate the relationship between preoperative oral fluids and gastric pH and volume in women undergoing sterilization between one and five days postpartum. Fifty postpartum patients received 150 ml water approximately two to three hours before surgery while 50 postpartum and 50 non-pregnant women were fasted from midnight. After induction of anaesthesia, gastric contents were aspirated using a Salem sump tube and the gastric pH and volume were measured. There were no differences in intragastric pH and volume, median (range), among the postpartum fasted group, 1.19 (0.74–4.57) 22 (1–78) ml, postpartum water group 1.18 (0.70–6.4), 25.5 (3–66) ml and the non-pregnant group 1.27 (0.51–6.63), 25 (3–69) ml. There was no correlation between postpartum interval, 60 (12–120) hr, and intragastric pH or volume. It is concluded that oral water may be given safely two to three hours preoperatively to patients more than one day postpartum. Intragstric volume and acidity were not increased and the findings in postpartum patients were similar to those found in non-pregnant patients.     

Gastric fluid volume pH,and emptying in elective inpatients Influences of narcoticatropine premedication oral fluid,and ranitidine

One hundred and twenty healthy, elective surgical inpatients were randomly assigned to one of four groups. Between two and three hours before the scheduled time of surgery all patients ingested a marker dye, phenol red, 50 mg in 10 ml water, with placebo tablet alone (Groups 1 and 2), placebo tablet with 150 ml oral fluid (Group 3), or oral ranitidine 150 mg with oral fluid 150 ml (Group 4). Patients in Group 1 received oral diazepam or no premedication, while those in Groups 2, 3, and 4 received IM narcotic and atropine one hour preoperatively. Following induction of anaesthesia the residual gastric fluid was aspirated through a Salem sump tube and its volume, pH, and phenol red content measured. Mean volumes were Group 1: 24 ml; Group 2: 13 ml; Group 3: 17 ml; Group 4: 14 ml. Mean pH values were Group 1: 2.99; Group 2: 3.03; Group 3: 3.44; Group 4: 5.28. The amount of phenol red in the samples indicated at least 90 per cent gastric emptying had occurred in 90 per cent of patients. We conclude that, in healthy patients, 150 ml oral fluid is almost completely emptied from the stomach within two hours of ingestion, even when followed one hour later by narcotic-atropine premedication.     

Hemodynamic effects of oral clonidine premedication in lumbar epidural anesthesia

Clonidine, an α₂-adrenergic agonist, has a potent sympatholytic effect and augments the pressor effect of ephedrine during general anesthesia. We evaluated whether oral clonidine premedication would alter the hemodynamic changes and enhance the pressor response to intravenous ephedrine during epidural anesthesia in 35 adult patients. They were randomly administered either premedication with clonidine approximately 5 μg·kg⁻¹ po (n=17) or no clonidine medication (n=18). After establishment of epidural anesthesia, the hemodynamic response to ephedrine iv was measured in the awake state at 1-min intervals for 10 min. Then, the same hemodynamic measurement was repeated in the asleep state induced with midazolam iv. There were no differences in blood pressure (BP) and heart rate values between groups during the onset of epidural anesthesia, except that BP before epidural anesthesia was lower in the clonidine group than the control group (P<0.05). The magnitude and duration of pressor responses to ephedrine were comparable between groups in awake and asleep states. In conclusion oral clonidine premedication 5 μg·kg⁻¹ alters neither the hemodynamic changes nor the pressor response to intravenous ephedrine during epidural anesthesia. Presented at the Annual Meeting of the Japan Society for Clinical Anesthesia, Oita City, Oita, November, 1994     

Lorazepam as night sedation and premedication: a comparison with diazepam

Fifty healthy female patients scheduled for surgery were randonly allocated into two groups in a double-blind study. One group received lorazepam 2.5 mg orally at 2200 h on the evening before surgery as night sedation, and again at 0800 h on the morning before surgery as premedication. The second group received diazepam 10 mg orally at the samte times. The quality of sleep the night before surgery was superior in the lorazepam group (p less than 0.02). The frequency of effective sedation produced pre-operatively was similar in both groups. Although the incidence of amnesia for visual stimuli following lorazapam was higher (p less than 0.05) than with diazepam, there was no difference in the recall of auditory and painful stimuli. The overall incidence of side effects was similar for each drug and at the dosage used no difference was found in the time to awaken from anaesthesia.     

Gastric contents in pediatric patients following bone marrow transplantation

Background: Graft versus host disease (GVHD) of the gut is thought to delay gastric emptying and so may increase the risk of aspirating retained contents while under anesthesia. Knowing that gastric emptying is delayed in patients with GVHD might lead one to choose to intubate the trachea for all patients with suspected GVHD, who present for diagnostic esophagogastricduodenoscopy (EGD). We are not aware of published data that gives specific guidance as to the need for intubation in the pediatric bone marrow or stem cell transplantation (BMT) population. This review was intended to evaluate the gastric contents (pH and volume) in this group of patients, to provide anesthesiologists with data that would inform their decisions about airway management for these patients. Methods: Retrospective chart review of patients ≤19 years of age undergoing EGD between 2004 and 2006. Gastric content volume and pH were measured in addition to underlying disease state and treatment. We compared BMT patients with suspected GVHD to nontransplant patients with other underlying gastrointestinal conditions. Results: Data were obtained for 77 patients post‐BMT undergoing EGD, including 40 patients whose biopsies and endoscopic findings were positive for GVHD, and 37 patients with no demonstrable GVHD. Records of 144 non‐BMT patients undergoing EGD within the same study period were also reviewed. Conclusion: Patients in the BMT group overall did not have higher volumes when compared to non‐BMT patients. A secondary comparison of BMT patients who were found to have GVHD vs BMT patients without GVHD suggests that gastric content volume may be elevated with GVHD. Patients in the BMT group had statistically significantly higher gastric pH than patients in the non‐BMT group. It is possible that the higher gastric volume in the GVHD‐positive group could put them at slightly higher risk for aspiration, but the severity of any pneumonitis, should aspiration occur, might be mitigated, by the tendency toward a higher gastric pH in the BMT patients.     

Gastric volume and pH in children for emergency surgery

The volume and pH of gastric contents aspirated prior to anaesthesia were measured in 101 children admitted for emergency surgery. The children were aged between 3 months and 15 years. If we define potential patients at risk by means of the volume and pH of the gastric contents, then 50.0% of the children were at risk of aspiration into the lungs. The number of patients at risk was higher in children aged between 6 and 10 years. There was almost the same risk in the groups with abdominal-, urogenital-, and orthopaedic diseases, while the number of patients at risk was less in the group with superficial lesions. The length of fasting time in the child considerably influenced the volume of gastric contents in emergency surgical cases. It is concluded that in children admitted for emergency surgery there is a risk of aspiration of gastric contents into the lungs. The risk is reduced by preanaesthetic fasting. All children admitted for emergency surgery must be carefully evaluated prior to anaesthesia with special reference to gastric aspiration.     

Effect of clonidine premedication on postoperative sore throat and hoarseness after total intravenous anesthesia

To determine the effect of oral clonidine premedication on postoperative sore throat and hoarseness, we evaluated the incidence and severity of each of these complications in patients who underwent elective surgery in the supine position. The subjects were 82 patients, American Society of Anesthiologists (ASA) status I–III, aged 15–82 years. They were premedicated with either 150 μg oral clonidine and 20 mg raftidine (clonidine group; n = 41) or with 20 mg raftidine only (control group; n = 41) 2 h before anesthesia induction. General anesthesia was maintained with propofol, ketamine, fentanyl, and vecuronium, with or without epidural anesthesia. Postoperative sore throat and hoarseness were evaluated immediately after surgery and on the day after surgery. The incidences of sore throat and hoarseness tended to be higher in the clonidine group than in the control group; however, the difference did not reach statistical significance. There were no significant differences in the severity of these symptoms between the two groups. In conclusion, oral premedication with 150 μg clonidine did not prevent postoperative sore throat or hoarseness, and may have exacerbated these symptoms.     

Usefulness of oral hypnotic premedication for volatile induction of anesthesia in adults

Purpose. We investigated the effects of oral hypnotic premedication for smooth anesthetic induction and for the patient's comfort under anesthesia, using sevoflurane without nitrous oxide. Methods. Adult patients were divided into four groups: control (n= 12), triazolam (0.25 mg; n= 12), zopiclone (7.5 mg; n= 12), and clonidine (0.15 mg; n= 12) groups. Each premedication was given to each patient 1 h before the anesthesia. The patients breathed out to residual volume and then the anesthetic mask was fitted. The repeated vital capacity breathing technique was used, with 5% sevoflurane in 10 l·min⁻¹ oxygen. Induction time, specific induction side effects, and acceptability of this technique by the patients were recorded by an independent observer. Results. Induction time in the premedicated groups ranged from 66 ± 12 s (mean ± SD) to 76 ± 14 s, and these values were significantly shorter than that in the control group (92 ± 16 s). The number of patients in whom adverse effects occurred during anesthetic induction was significantly greater in the control group (4 patients; 33%) than in the premedicated groups (1 patient each; 8%). Acceptability of the smell of sevoflurane was significantly higher in the premedicated groups (8–10 patients; 67%–83%) than in the control group (5 patients; 42%). Conclusion. Oral hypnotic premedications with either triazolam (0.25 mg), zopiclone (7.5 mg), or clonidine (0.15 mg) are recommended for smoother volatile anesthetic induction and for the patient's comfort in adults. Received: January 28, 2002 / Accepted: April 26, 2002     

Gastric emptying of a light hospital breakfast

While intake of clear fluids 2–3 h before surgery is considered safe as it does not influence gastric content, it is not known if the same applies to a light breakfast meal. We therefore studied gastric emptying of a light breakfast in healthy, female volunteers without evidence of gastrointestinal motility disorders. The test meal consisted of one slice of buttered toast with jam, one cup of coffee without milk or sugar and one glass of pulp-free orange juice taken together with a paracetamol mixture. Using gastric ultrasonography, the stomach was identified without problems in all subjects, and gastric emptying curves using changes in gastric antral area and serum-paracetamol were obtained. Emptying of the fluid phase started immediately after intake of the meal. All subjects had solid particles in the stomach 120 min after the meal, 3 patients were considered empty after 180 min, 6 after 210 min and all after 240 min. The gastric antral area returned to fasting value significantly faster than the disappearance of solid particles; median 150 min versus 210 min; P =0.01. Our results show that in healthy subjects the stomach cannot be considered empty for solid particles the first 4 h after a light breakfast meal. To secure some safety limits, we suggest a 6-h mandatory preoperative fast after a light breakfast.     

A comparison of triazolam and diazepam as premedication agents for minor gynaecological surgery

Triazolam 0.25 mg, diazepam 10 mg and placebo were compared in a randomized double-blind trial of oral premedication in 90 patients undergoing minor gynaecological surgery. Both triazolam and diazepam produced a significant sedative effect as measured by patient self assessment linear analogue scales but only diazepam was more anxiolytic than placebo. Psychomotor performance assessed by the letter-search test at 3 and 6 hours after awakening showed a decrement in performance in patients receiving triazolam at 3 hours compared with the two other groups. Triazolam was shown to have a pronounced amnesic effect and whilst it might be used for premedication, its lack of anxiolysis coupled with a significant impairment of psychomotor performance at 3 hours after awakening, render the drug unsuitable for premedication in the short stay patient.     

Oxycodone and ketobemidone for oral premedication

In a prospective, randomised and double-blinded study the preoperative sedative effect and the postoperative use of analgesics were compared in 90 patients undergoing inguinal hernia repair under general anaesthesia, premedicated orally with ketobemidone 10 mg, sustained-release oxycodone 10 mg or placebo. All patients had a local infiltration with bupivacaine after wound closure. Oral paracetamol 1 g×4 and dextropropoyphene 100 mg×4 were given postoperatively and iv ketobemidone was added if the pain score was >3 on a visual analogue scale from 0 to 10. Oxycodone, ketobemidone and placebo had a similar sedative effect before surgery. The use of ketobemidone after surgery was reduced by 40% in the oxycodone group compared to placebo (P<0.05). No reduction was noted in the ketobemidone group. Conclusion: Sustained-release oxycodone—but not ketobemidone—for oral premedication reduced the postoperative use of opioids after surgery.     

Relation between bispectral index and plasma catecholamines after oral diazepam premedication.

The efficacy of anaesthetic premedication has been assessed using sedative scores or a visual analogue scale. However, in both it may be difficult to exclude evaluators' subjectivity or a placebo effect. Plasma concentration of catecholamines may also be useful for the assessment of patient anxiety. Recently bispectral electro-encephalographic analysis has been developed, and the bispectral index monitor has been reported to give measurements which correlate well with the depth of sedation. In the present study, we have examined the relation between bispectral index values and plasma catecholamine concentrations after oral diazepam premedication. Twenty-eight patients scheduled for elective surgery were randomly assigned to one of two groups: diazepam premedication group (group D(+), n = 14) and no premedication group (group D(-), n = 14). The patients were premedicated orally with diazepam 10 mg and roxatidine 75 mg in group D(+), and with roxatidine 75 mg only in group D(-) 90 min before arrival in the operating theatre. After patients arrived in the operating theatre, the bispectral index monitor was applied. Venous blood samples (6 mL) were collected in the case of patients in group D(+) for the measurement of plasma catecholamines levels using high-performance liquid chromatography. The bispectral index level (mean +/- SD) in group D(+): 93.5 +/- 773.5 was significantly lower than that in group D(-): 96.1 +/- 1.8 (P < 0.05). There was a significant correlation between bispectral index and plasma norepinephrine levels (r = 0.567, P < 0.05). The present study suggests that the bispectral index monitor may detect the effect of oral diazepam premedication.     

Efficacy and safety of premedication with oral ketamine for day-case adenoidectomy compared with rectal diazepam/diclofenac and EMLA

BACKGROUND: Because of its pain-attenuating and sedative properties oral ketamine has been used as premedication in children and adults. We wanted to compare in children scheduled for adenoidectomy safety and efficacy of oral ketamine with a premedication that causes similar preoperative sedation and relief of pain at the venepuncture site. We also evaluated the effect of i.v. glycopyrrolate added to these combinations. METHODS: One hundred children between 10 and 15 kg of body weight scheduled for day-case adenoidectomy were randomly assigned to one of four groups: groups DG and DS received diclofenac 12.5 mg and diazepam 0.5 mg/kg rectally, EMLA cream at the venepuncture site, and placebo orally; groups KG and KS received ketamine 6.0 mg/kg orally, placebo cream at the puncture site, and placebo rectally; additionally, groups DG and KG received glycopyrrolate 5 microg/kg, and groups DS and KS received placebo intravenously. We recorded perioperatively scores (open scale 1-9) for stridor, sedation, bleeding, nausea, pain, heart rate, the need for analgesics and registered psychotomimesis and well-being at home. RESULTS: The children of the K-groups became more tearful during separation from their parents (P=0.0072). No other differences were found between the ketamine and diazepam/diclofenac groups before and after premedication until induction of anaesthesia. Oral ketamine produced unpleasant psychotomimesis in four out of 59 children. During the first 10 min postoperatively, the score for stridor was significantly higher in group KS than in the D-groups; stridor scores > or = 6 were seen in one child of the D-groups (DS) and in six children of the K-groups (n.s.), of whom three developed laryngospasm (one reintubation). Glycopyrrolate diminished salivation in all groups, but had no effect on stridor scores. Additionally, glycopyrrolate delayed the onset of eating at home. CONCLUSION: Premedication with racemic oral ketamine 6 mg/kg does not seem to be suitable for upper airway procedures. Addition of i.v. glycopyrrolate before the induction of anaesthesia significantly reduced the scores for salivation.     

Predictive factors of PACU stay after herniorraphy in infant: a classification and regression tree analysis

Introduction: Herniorraphy is a common surgical intervention in infants, particularly in those born prematurely. Prematurity and perioperative sedation have been shown to be risk factors for postoperative apnea. However, their influence upon PACU stay duration has not been evaluated. The goal of this study was to investigate predictive factors for PACU stay in infants undergoing herniorraphy. Material and Methods: This study is a retrospective analysis of perioperative data in infants <6 months of age undergoing herniorraphy during the period November 2007–November 2009. Collected data included age, gestational age at birth, post‐conceptional age, weight, weight at birth, type of anesthesia (spinal vs general), perioperative administration of opioids and paracetamol, duration of surgery, duration of PACU stay, and apnea in PACU. Data analysis used classification and regression trees (CART) with a 10‐fold cross‐validation. Results: Two hundred and ninety‐six patients were included in the analysis. Five parameters were found to predict the duration of PACU stay: a post‐conceptional age below 45 weeks, prematurity, general anesthesia, postoperative opioid administration, and the use of intraoperative regional analgesia. CRT method allows constructing a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross‐validation were 79.7% and 76.6%, respectively. Discussion: Our study allows construction of an accurate predictive tree for PACU stay during herniorraphy in infants <6 months. Parameters found to influence the duration of PACU stay were related to anesthesia techniques and perinatal outcomes.