婴幼儿直肠灌注氯胺酮-咪唑安定-阿托品混合液术前用药的评价

目的评价婴幼儿术前直肠灌注氯胺酮混和咪唑安定、阿托品的可行性。方法106例择期手术患儿，年龄2个月～2岁，随机分为3组：M组（n=39）术前直肠灌注咪唑安定0.5mg/kg、阿托品0．02mg／kg；MK组（n=34）在M组基础上加用氯胺酮4mg／kg；MKK组（n=33）在M组基础上加用氯胺酮8mg／kg。于用药前、用药后15min、与父母分离时、进入手术室时，对患儿进行镇静评分并记录用药期间副反应的发生情况。结果MK组和MKK组用药后各时点镇静评分均高于M组（P〈0．05）。与父母分离及进入手术室时，MK组与MKK组患儿熟睡率高于M组（P〈0．05）；MKK组静脉穿刺时患儿安静率为63％，高于MK组（32％）和M组（18％）（P〈0．05）。结论婴幼儿术前直肠灌注氯胺酮混合咪唑安定、阿托品安全、有效，效果优于单用咪唑安定。     

Comparison of midazolam and flunitrazepam as premedication administered rectally in infants

The present study aimed to assess the pharmaco-clinical profile of infants premedicated with rectal midazolam. The results were compared with those of a reference drug, flunitrazepam. Infants undergoing minor surgery were divided into three groups: group A (n = 30), with a mean age of 15.8 +/- 13.2 months and a mean weight of 8.6 +/- 3.3 kg, receiving 0.33 mg X kg-1 flunitrazepam; group B (n = 15), with a mean age of 11.2 +/- 10.7 months and a mean weight of 9.3 +/- 3.1 kg, receiving 0.3 mg X kg-1 midazolam; and group C (n = 30), with a mean age of 15.5 +/- 9.1 months and a mean weight of 10.7 +/- 2.5 kg, receiving 0.4 mg X kg-1 midazolam. An aqueous solution of each drug was administered with atropine sulfate (0.02 mg X kg-1) 20 min prior to induction of anaesthesia. The drug was well tolerated in 84% of cases. Statistically significant haemodynamic changes consisted of: a 9 c X min-1 decrease in heart rate (p less than 0.05) and a 12 mmHg decrease in systolic and diastolic blood pressures (p less than 0.05) in group C; a 6 mmHg decrease in systolic blood pressure (p less than 0.05) in group B. The tranquilizer action was either excellent or good in 93% of groups B and C compared with only 40% in group A (p less than 0.001 in both cases). Somnolence was attained in 60% of group A, 26.6% of group B and 30% of group C. A mask was much better accepted in group C (86.6%) than in group B (66.6%; p less than 0.05) or in group A (36.6%; p less than 0.01). Therefore, midazolam given rectally at 0.4 mg X kg-1 was better than flunitrazepam, because of a greater therapeutic effect for an equivalent rate of side effects.     

Optimal administration time of intramuscular midazolam premedication

The optimal administration time for intramuscular injection of midazolam as premedication was studied. Sixty patients ranging in age from 40 to 65 were included. A combination of atropine 0.3–0.5 mg and midazolam 0.08 mg·kg⁻¹ was given to four groups of 15 subjects each in intramuscular injections 45, 30, 15 min, and immediately before entering the operating room. Blood pressure, heart rate, respiratory rate, depression of the root of the tongue, eyelash reflex, degree of sedation, and amnestic effect at the time of arriving the operating room were compared among the groups. There was no difference among the groups in blood pressure, heart rate, and respiratory rate. The depression of the root of the tongue, disappearance of verbal response, and eyelash reflex were found in the 30- and 45-min groups. The degree of sedation and amnestic effect were good except for the group who received midazolam immediately before entering the operating room. From the above results, intramuscular injection of midazolam 0.08 mg·kg⁻¹ with atropine 0.3–0.5 mg is considered best when administered 15 min before entering the operating room. This paper was presented at the 40th meeting of the Japan Society of Anesthesiology held in Morioka in 1993     

Rectal premedication with midazolam in children. A comparative clinical study

Anesthetic premedication by injection is usually poorly accepted by children, especially those under 10 years of age. Less disturbing for the child is oral premedication, but this increases the risk of aspiration and must be administered 1.5-2 h before anesthetic induction. This double-blind study was performed in children to investigate the efficacy, acceptance, and general safety of midazolam given rectally. METHOD. Rectal premedication was administered to a total of 80 healthy children between 2 and 10 years of age undergoing elective operations. The children were divided randomly into two groups: group I received 0.4 mg/kg and group II 0.5 mg/kg midazolam with the addition of 0.015-0.02 mg/kg atropine. Premedication was carried out on the pediatric ward. The calculated dose was drawn from the ampule and diluted to 8-10 ml with distilled water. This dose was instilled immediately behind the anal sphincter using a suitable plastic applicator (Stanylan). The following parameters were recorded: immediate reaction to the rectal medication, sedative-hypnotic signs, and acceptance of the anesthetic mask. Heart rate and blood pressure were measured before premedication and before the induction of anesthesia. Observations were made for 5 h post-operatively. Any unusual side effects of the treatment were also noted. The existence of any anterograde amnesia was investigated in 20 children (10 in each group) between 6 and 10 years of age. RESULTS. There was no significant difference between the children allocated to the two groups with regard to age, body weight, sex, type of operation, and duration of anesthesia (Table 2). Of the total of 80 children, 66 (82.5%) accepted the rectal instillation well, 12 (15%) moderately well, and 2 (2.5%) poorly. Signs of respiratory depression or allergic reaction to midazolam were not observed in any case. The observations made before induction of anesthesia are presented in Table 3. The children in group II exhibited significantly greater (P less than 0.05) slurred speech than those in group I. A low incidence of hiccup was seen in both groups. Most of the children (27 in group I, 67.5%; 37 in group II, 92.5%: P less than 0.05) were delivered to the operating room lying down, whereas the others were sitting up in bed but showed no desire to get up. Between 10 and 55 min after the premedication, a total of 5 children (12.5%) in group I and 2 (5%) in group II were restless or crying on arrival in the induction room. Most, however, were quiet to tired/drowsy. The optimal sedative-hypnotic action was observed after 20-30 min (Fig. 1). At this time 21.7% of the children in group I were tired/drowsy, whereas 50% in group II were tired/drowsy and 9.1% were asleep but easy to arouse. This effect was significantly greater in group II (P less than 0.01). Acceptance of the mask was comparable in both groups (Table 4) and was tolerated well to very well by 92-97% of the children. (ABSTRACT TRUNCATED AT 400 WORDS)     

Accidental overdose of midazolam as intramuscular premedication

We report two cases of overdoses of intramuscular midazolam used as a premedication. Both cases had no resedation or complications, but the accidents happened as a result of a resident and nurse's lack of experience with midazolam. The intramuscular doses, given at four times the normal quantity, fortunately caused no harm in our cases. However, the situations suggest that we should carefully check the dosage and review the correct procedures, even when using a drug that is considered to be familiar with most practitioners.     

Comparative evaluation of midazolam and ketamine with midazolam alone as oral premedication

BACKGROUND: Oral premedication with midazolam and ketamine is widely used in pediatric anesthesia to reduce emotional trauma and ensure smooth induction. However, various dosing regimens when used alone or in combination have variable efficacy and side effect profile. The aim of our study was to investigate and compare the efficacy of oral midazolam alone with a low-dose combination of oral midazolam and ketamine. METHODS: We performed a prospective randomized double-blind study in 100 children who were randomly allocated into two groups. Group M received 0.5 mg.kg(-1) oral midazolam and group MK received 0.25 mg.kg(-1) oral midazolam with 2.5 mg.kg(-1) oral ketamine. The preoperative sedation score, ease of parental separation and ease of mask acceptance were evaluated on a 4-point scale. The time to recovery from anesthesia and to achieve satisfactory Aldrete score was also noted. RESULTS: Uniform and acceptable sedation scores were seen in both the groups (group M 95.9%; group MK 97.96%), without any serious side effects. However, the combination offered significantly more children in an awake, calm and quiet state, who were easily separated from their parents (73.46% in MK vs 41% in group M). The induction scores were comparable between the groups. The recovery room characteristics and time to achieve satisfactory Aldrete score were also comparable between the two groups. CONCLUSIONS: Oral midazolam alone and a combination of midazolam with ketamine provide equally effective anxiolysis and separation characteristics. However, the combination provided more children in an awake, calm and quiet state who could be separated easily from parents.     

Rectal versus intramuscular morphine-scopolamine as premedication in children

Intramuscular morphine-scopolamine for premedication was compared with a hydrogel of the same drugs for rectal administration in 205 healthy children scheduled for minor ENT surgery. The intramuscular dose was 0.15±0.006 mg × kg^-1 compared to 0.25±0.015 mg×kg^-1 rectally. Reaction at administration and anaesthetic induction, incidence of intraoperative airway difficulties, Spo₂, ECG changes, postoperative pain and incidence of nausea were recorded. The administration for the rectal hycrogel group worked better and resulted in less postoperative nausea and slightly more postoperative pain. The children's behaviour at anaesthesia induction and the frequency of perioperative complications were similar in both groups. We conclude that for minor ENT surgery on children, premedication with rectal hydrogel of morphine-scopolamine is a good alternative to intramuscular morphine-scopolamine.     

Rectal premedication in children

Two hundred and eight healthy children who were to undergo minor elective surgery during halothane, nitrous oxide, oxygen anaesthesia were studied in a double blind investigation to evaluate the sedative and anticholinergic effects of two rectal premedications. Group I received diazepam 0.75 mg/kg rectally; Group II received a mixture of diazepam 0.5 mg/kg, morphine 0.15 mg/kg and hyoscine 0.01 mg/kg rectally. No significant difference was found between the two groups in sedative or anticholinergic effects during induction of anaesthesia or in the postoperative period. No adverse effects were seen.     

Oral high-dose midazolam premedication for infants and children undergoing cardiovascular surgery

BACKGROUND: The purpose of this study was to determine whether oral midazolam 1.5 mg x kg(-1) is a safe and effective alternative to standard-dose midazolam (0.5-1.0 mg x kg(-1)) premedication for infants and children with congenital heart disease. METHODS: A total of 193 infants and children (4 months to 2 years) undergoing cardiovascular surgery were studied. Each patient received 0.5, 1.0, or 1.5 mg x kg(-1) of oral midazolam. The level of sedation was assessed with a 5-point scale and vital signs were measured including blood pressure (BP), heart rate (HR) and oxyhaemoglobin saturation (SpO2) before and after the medication. RESULTS: Infants and children premedicated with oral midazolam 1.5 mg x kg(-1) were better sedated than those with standard-dose midazolam: 4% of infants and children given 1.5 mg x kg(-1) of midazolam became agitated compared with 14% given 1.0 mg x kg(-1) and 26% in those given 0.5 mg x kg(-1). Ninety percentage of infants and children given 1.5 mg x kg(-1) of midazolam achieved satisfactory sedation (calm, drowsy, or asleep) in 30 min, whereas 68% in those given 1.0 mg x kg(-1) and 35% in those given 0.5 mg x kg(-1). Midazolam 1.5 mg x kg(-1) did not cause any statistically significant decrease in BP, HR, or SpO2, although eight infants and children showed > or =20% drop in systolic BP and six infants and children showed >5% drop in SpO2. No 'spelling attacks', seizure-like activity, apnoea, nor laryngospasm were observed in any infants and children during and after the medication. CONCLUSIONS: Oral midazolam 1.5 mg x kg(-1) is excellent for preanaesthetic medication for infants and children undergoing cardiovascular surgery.     

Oral midazolam in paediatric premedication

In a premedication study involving 135 children, aged 1-10 years, four regimens were investigated: (i) no premedication; (ii) oral trimeprazine tartrate 2 mg/kg, methadone 0.1 mg/kg, droperidol 0.15 mg/kg (TMD); (iii) intramuscular midazolam (Dormicum; Roche) 0.15 mg/kg; and (iv) oral midazolam 0.45 mg/kg. All premedications were given 60 minutes before a standard halothane anaesthetic. No impairment of cardiovascular stability occurred but after premedication the mean oxygen saturation decreased by 1.6% and 1.1%, respectively, in the intramuscular midazolam and TMD groups. Overall, children under 5 years of age behaved less satisfactorily in the holding room and at induction, than those over 5 years (P less than 0.01). Midazolam, intramuscularly and orally, produced more satisfactory behaviour than the other two regimens (P less than 0.05) and, combined with a 70% more rapid recovery than the TMD regimen (P less than 0.05), suggests that oral midazolam is a more effective paediatric premedication agent than placebo or TMD.     

Amnesic effect of oral midazolam as premedication in children]

We evaluated the sedative and amnesic effects of oral midazolam as premedication in children. Sixteen children, aged 4-12 yr, undergoing elective minor surgery were divided into 2 groups. One group received midazolam 0.5 mg.kg-1 with atropine 0.03 mg.kg-1 orally. The other control group received only atropine 0.03 mg.kg-1. There was no significant difference in the sedative scale at induction between the 2 groups. Doll-recall was used to assess the amnesic effects. In the midazolam group, 75% of the children forgot dolls they had seen on entering the operating room. Midazolam produced significant anterograde amnesia but no retrograde amnesia. This result suggests that children who received midazolam as premedication forget unpleasant memories at induction and their postoperative emotional responses are least influenced by their memories. We conclude that oral midazolam 0.5 mg.kg-1 is an effective preanesthetic medication in children.     

Rectal administration of midazolam versus diazepam for preanesthetic sedation in children

Sixty children were included in the trial. Each subject received midazolam 0.4 mg/kg body weight of diazepam 0.75 mg/kg body weight rectally in a double-blind randomized order. The degree of sedation of the children was assessed on arrival in the operating unit and during the induction of anesthesia. Adequate sedation on arrival in the operating unit and during induction of anesthesia was obtained in 84% and 67%, respectively, following administration of midazolam compared with 80% and 70% in the diazepam group. No side effects were noted. It is concluded that rectally administered midazolam 0.4 mg/kg is comparable to diazepam 0.75 mg/kg with respect to preanesthetic sedation in children.     

The use of midazolam in premedication

Socio-psychological factors, such as increased anxiety in developed societies and cultures, and separation anxiety, particularly in children, justify the use of premedicants. In addition, the link between a central nervous "anxiety centre" and biochemical stress responses is blocked by an efficient anxiolytic. The elimination half-life of midazolam is longer in the elderly than in the young and in the obese than in the thin, which demands longer intervals between repeated doses in old and fat patients. The hypoxic ventilatory response is depressed in most patients and the ventilatory CO₂ response in patients with chronic pulmonary disorders, which justifies increased monitoring of O₂ saturations. It is important for the choice of dose and for estimating the duration of recovery time to know that midazolam is at least four times as potent as diazepam.     

Intramuscular midazolam premedication in small children

Midazolam 0.2 mg/kg was compared as an intramuscular premedication in small children with papaveretum and hyoscine 0.4 and 0.008 mg/kg. Midazolam produced satisfactory sedation and anxiolysis and in the early postoperative period patients were significantly more awake (p less than 0.05).     

Comparison of rectal to intramuscular administration of midazolam and atropine for premedication of children

The effectiveness of midazolam and atropine as anaesthetic premedication was investigated, comparing rectal to intramuscular administration. A total of 202 children varying in age from 10 months to 9 years, who had been admitted to the Day Surgery Department for short ENT procedures, were assigned to one of two groups on a random basis. The first group (n = 102) was given 0.5 mg/kg midazolam and 0.05 mg/kg atropine as a rectal solution 30 to 75 min prior to induction, while the second group (n = 100) was given 0.15 mg/kg midazolam and 0.02 mg/kg atropine as an intramuscular injection 20 to 60 min prior to induction. The levels of sedation and salivation were compared, as was the degree of tolerance to intravenous induction. The parents of children older than 3 years of age were given a questionnaire designed to determine the degree of amnesia. We found this combination of drugs to be effective in the relief of anxiety, the inhibition of salivary secretion and the promotion of memory loss, regardless of the route of administration. We feel that rectal administration is preferable because it is not associated with pain or anxiety.