A Comparative Study on the Sedative Effect of Oral Midazolam and Oral Promethazine Medication in Lumbar Puncture

How to Cite This Article: Derakhshanfar H, Modanlookordi M, Amini A, Shahrami A. A Comparative Study of the Sedative Effect of Oral Midazolam and Oral Promethazine Medication in Lumbar Puncture. Iran J Child Neurol. 2013 Spring;7(2):11-16. ObjectiveLumbar puncture (LP) essentially is a painful and stressful procedure that indicated for diagnosis and therapeutic purposes. One way to reduce the anxiety is to administer an oral premedication. The aim of this study is to compare clinical effects of oral midazolam and oral promethazine in LP.Materials & MethodsThis prospective randomized controlled clinical trial study wasperformed on 80 children aged 2-7 years that were candidate for LP. They were divided into two randomized equal groups. First group received oral midazolam syrup 0.5 mg/kg and the other group received oral promethazine syrup 1mg/kg. Level of sedation, hemodynamic changes and any other complications were monitored every 5 minutes from 30 minutes before the start of the procedure.ResultsMidazolam group and promethazine group were similar in age, gender and weight. Midazolam had significantly shorter onset of sedation and also shorter duration to maximal sedation. The two groups were similar with respect to sedative effect at all time. The only complication that was significantly more in midazolam group was nausea and vomiting.ConclusionMidazolam syrup and promethazine syrup have same sedative effect in children. Both of these medications are easy to use in preschool children and none of them appeared to be superior to another. References1. Ellenby MS, Tegtmeyer K, Lai S, Braner DA. Lumbar Puncture. N Engl J Med 2006;28;355(13):e12.2. Crock C, Olsson C, Phillips R, Chalkiadis G, Sawyer S, Ashley D, et al. General anesthesia or conscious sedation for painful procedures in childhood cancer: The family’s perspective. Arch Dis Child 2003;88(3):253−7.3. Holdsworth MT, Raisch DW, Winter SS, Frost JD, Moro MA, Doran NH, et al. Pain and distress from Bone marrow aspirations and lumbar punctures. Ann Pharmacother 2003;37(1):17-22.4. Ellis JA, Villeneuve K, Newhook K, Ulrichsen J. Pain Management Practices for Lumbar Punctures: Are We Consistent? J Pediatr Nurs 2007 Dec;22(6):479-87.5. Mathai A, Nazareth M, Raju RS. Preanesthetic sedation of preschool children: comparison of intranasal midazolam versus oral promethazin. Anesth Essays Res 2011;5(1):67-71.6. McCann ME, Kain ZN. The management of preoperative anxiety in children: an update. Anesth Analg 2001; 93(1): 98–105.7. Kain ZN, Caldwell-Andrews AA. Psychological preparation of children undergoing surgery. Anesth Clinic NA 2005;23:597–614.8. Wolf AR, Rosenbarum A, Kain ZN, Larsson P, Lönnqvist PA. The place of premedication in pediatric practice. Paediatr Anaesth 2009;19(9):817-28.9. Yuen VM, Hui TW, Irwin MG, Yuen MK. A Comparison of Intranasal Dexmedetomidine and Oral Midazolam for Premedication in Pediatric Anesthesia: A Double-Blinded Randomized Controlled Trial. Anesth Analg 2008;106(6):1715–21.10. Funk W, Jakob W, Riedl T, Taeger K. Oral preanaestheticmedication for children: double blind randomized study of a combination of midazplam and ketamine vs midazolam or ketamine alone. Br JAnaesth 2000;84(3):355-4011. Mazurek MS. Sedation and Analgesia for Procedures outside the Operating Room. Semin in Pediatr Surg 2004;13(3):166-173.12. Jo SH, Hong HK, Chong SH, Lee HS, Choe H. H1 antihistamine drug promethazine directly blocks hERG K+ channel. Pharmacol Res 2009;60(5):429-37.13. Gutstein HB, Johnson KL, Heard MB, Gregory GA. Oral Ketamine Preanesthetic Medication in children, Anesthesiology 1992;76(1):28-33.14. Almenrader N, Passariello M, Coccetti B, Haiber R, Pietropaoli P. Premedication in children: a comparison of oral midazolam and oral clonidine. Pediatr Anesth 2007;17(12):1143–9.15. Singh N, Pandey RK, Saksena AK, Jaiswal JN. A comparative evaluation of oral midazolam with oral sedatives as  premedication in pediatric dentistry. J Clin Pediatr Dent 2002;26(2):161-4.16. Naziri F, Alijanpour E, Rabei SM, Seifi S, Mir M, Hosseinpour M, et al. Comparison of oral Midazolam with oral Promethazine on decreasing anxiety of children when separated from their parents before anesthesia. J Babol Univ Medl Sci  2007;9(4):29-32.17. Parkinson L, Hughes J, Gill A, Billingham I, Ratcliffe J, Choonara I. A randomized controlled trial of sedation in the critically ill. Paediatr Anaesth 1997;7(5): 405-10. 18. Crean P. Sedation and neuromuscular blockade in paediatric intensive care;practice in the United Kingdom and North America. Paediatr Anaesth 2004;14(6):439-42.19. Schmidt AP, Valinetti EA, Bandeira D, Bertacchi MF, Simões CM, Auler JO Jr. Effects of preanesthetic administration of midazolam, clonidine, or dexmedetomidine on postoperative pain and anxiety in children. Paediatr Anaesth 2007;17(7):667-74.20. Pfeil N, Uhlig U, Kostev K, Carius R, Schröder H, Kiess W, et al. Antiemetic edications in children with presumed infectious gastroenteritis--harmacoepidemiology in Europe and Northern America. J Pediatr 2008;153(5):659-62

The Effect of Oxygen Therapy on Oxidative Stress Index in Patients with Acute Myocardial Infarction; a Letter to the Editor

Tissue hypoxia is a key factor for cell death after acute myocardial infarction (MI). It seems that increase in the relative oxygen pressure in inhaled air can be an effective treatment option for treating acute MI. However, contradicting findings and results have been published regarding using oxygen therapy in patients with acute MI (1, 2). Some researchers have believed that generation of free radicals, induction of oxidative stress, and damage to cell membrane are among side effects of O2 consumption (3, 4). It has been shown that O2 therapy can increase microvascular resistance, result in a decrease in coronary blood flow and cardiac output, and bring about numerous negative effects such as increase in the risk of arrhythmia and cellular damage (4)

Short Term Omeprazole Use and Markers of Calcium Homeostasis

Introduction: Several studies indicate a higher prevalence of fracture following long term utilization of proton pump inhibitors, among them omeprazole is the most widely used. However, the exact mechanisms lead to this complication are largely unknown. We studied short term effects of omeprazole on some markers of calcium metabolism. Materials and Methods: In thirty young adult patients with gastroesophageal reflux, omeprazole was prescribed at 20 mg twice daily for thirty days. Baseline characteristics as well as data after treatment with omeprazole were compared. We also measure important parameters in sixty age and sex match healthy individuals at baseline. Results: Mean age of patients was 31.8 year and there was no significant difference regarding age, sex, body mass index, serum calcium, serum alkaline phosphatase, and parathyroid hormone between cases and controls. Although, most of the patients were vitamin D deficient (mean = 29.7 nmol/l); compared to controls serum 25 OH Vitamin D was higher (P= 0.005) and serum phosphate was lower (P= 0.001) in patients. In addition, there was significant increase in alkaline phosphatase (P=0.01) and borderline decrease in serum calcium (P= 0.057), thirty days after treatment with omeprazole. Conclusions: High dose omeprazole after thirty days in the presence of vitamin D deficiency affects bone turnover probably by decreasing calcium absorption

Evaluation of Morning Report Sessions in Emergency Departments of Teaching Hospitals Affiliated With Shahid Beheshti University of Medical Sciences

مقدمه: معاونت آموزشی و امور دانشجویی وزارت بهداشت و درمان و آموزش پزشکی کشور پروژه ملی تحت عنوان "پروژه تعیین معیارها و شاخص های آموزش بالینی در مراکز و بیمارستانهای آموزشی" با هدف ارائه مجموعه استانداردهای آموزش بالینی طراحی و اجرا نمود که حاصل آن استخراج و معرفی استانداردهای آموزش بالینی پزشکی در مورد کلینیک سرپایی، راندهای آموزشی، گراند راند، گزارش صبحگاهی و ژورنال کلاب بود که پائیز سال 1388 ابلاغ گردید. در این مجموعه 96 استاندارد با قید "باید" و 139 استاندارد با قید "بهتر است" به عنوان استانداردهای مناسب کشور ایران پیشنهاد شده است. مطالعه حاضر با هدف ارزشیابی جلسات گزارش صبحگاهی گروه طب اورژانس بیمارستانهای آموزشی تحت پوشش دانشگاه علوم پزشکی شهید بهشتی بر اساس استانداردهای اعلام شده از سوی معاونت آموزشی وزارت بهداشت درمان و آموزش پزشکی انجام گرفت. روش کار: مطالعه مقطعی حاضر جهت ارزشیابی استانداردهای آموزش بالینی در حیطه گزارش صبحگاهی با استفاده از 3 فهرست وارسی و یک لیست مستندات جمع آوری اطلاعات صورت گرفت که در مجموع 54 استاندارد گزارش صبحگاهی را پوشش می داد. فهرست وارسی اول بصورت حضوری و با مشاهده مستقیم در گزارش صبحگاهی تکمیل شد و شامل 37 سوال بود. فهرست وارسی دوم که شامل 26 سوال بود، ضمن مصاحبه با معاون آموزشی یا رئیس بخش های اورژانس تکمیل شد. فهرست وارسی سوم شامل 10 سوال بود که با پرسش از دستیار ارشد بخش تکمیل گردید. سپس نمره نهایی مطلق و درصد آن در استانداردهای اجباری و ترجیحی تعیین و رتبه بندی شد. برای آنالیز داده ها از نرم افزار 21  SPSS و سطح معنی داری 05/0 استفاده شد. يافته ها: یافته های حاصل از 50 مورد گزارش صبحگاهی در در بخش اورژانس بیمارستان امام حسین و 94 مورد گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش مورد تجزیه و تحلیل قرار گرفت. در بخش اورژانس بیمارستان امام حسین میانگین امتیاز در استانداردهای اجباری 5/89 درصد و استانداردهای ترجیحی 7/45 درصد بود. در بخش اورژانس بیمارستان شهدا تجریش میانگین امتیاز در استانداردهای اجباری 6/73 درصد و استانداردهای ترجیحی 60 درصد بود. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود (025/0=p). وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی این اختلاف از نظر آماری معنی دار نبود (1/0=p). در مجموع میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش 8/66 درصد و بخش اورژانس بیمارستان امام حسین 6/67 درصد بود که اختلاف معنی دار نداشتند (92/0=p). نتيجه گيری: بر اساس یافته های مطالعه حاضر میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان های شهدا تجریش و امام حسین در سطح متوسطی قرار داشتند. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود. وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی اختلاف از نظر آماری معنی دار نبود.Introduction: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Methods: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Results: Findings resulting from 50 morning reports in ED of Imam Hossein Hospital and 94 morning reports in ED of Shohadaye Tajrish Hospital were analyzed. In ED of Imam Hossein Hospital, mean score was 89.5% regarding obligatory standards and 45.7% in preferred standards. In ED of Shohadaye Tajrish Hospital, mean score was 73.6% for obligatory standards and 60% for preferred standards. Mean score of Imam Hossein Hospital was significantly higher than Shohadaye Tajrish Hospital regarding obligatory standards (p = 0.025). Although preferred standards were carried out better in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant (p = 0.1). In total, mean score of the hospitals considering all standards of morning report, was 66.8% in Shohadaye Tajrish Hospital and 67.6% in Imam Hossein Hospital, which were not significantly different (p = 0.92). Conclusion: Based on the findings of the present study, mean total score of all the standards regarding morning report in EDs of Shohadaye Tajrish and Imam Hossein Hospitals was average. Mean score of obligatory standards was significantly higher in ED of Imam Hossein Hospital, compared to ED of Shohadaye Tajrish Hospital. Although the score regarding preferred standards was higher in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant.

Utility of Vascular Endothelial Growth Factor Inhibitors in the Treatment of Ovarian Cancer: From Concept to Application

Despite recent advances in the management of ovarian cancer, it remains the most lethal gynecologic malignancy. Vascular endothelial growth factor (VEGF) has been shown to play a pivotal role in the progression of ovarian cancer leading to the eventual development of malignant ascites. On this basis, agents rendering VEGF ineffective by neutralizing VEGF (bevacizumab), blocking its receptors (aflibercept), or interfering with the postreceptor signaling pathways (sunitinib) provide us with the rational treatment options. These agents are generally used in combination with the standard chemotherapeutic drugs. Here, we discuss the basis of and the logic behind the use of these agents in the treatment of epithelial ovarian cancer, as well as their evaluation in different preclinical and clinical studies

Correlation of waist to hip ratio and intra abdominal injury after blunt trauma

زمینه و هدف: تروما یکی از شایع ترین علل مراجعات اورژانس است. حدود 7 تا 10 از مرگ و میر ناشی از تروما به دنبال ضایعات داخل شکمی اتفاق می افتد. به نظر می رسد که نسبت بالاتر دور شکم به لگن بتواند اثر محافظتی در کاهش احتمال آسیب های داخل شکمی ایفا کند. مطالعه حاضر به بررسی ارتباط میزان وقوع آسیب های شکمی ناشی از ترومای بلانت با نسبت دور شکم به لگن پرداخته است. روش بررسی: در این مطالعه توصیفی-تحلیلی 222 نفر از مبتلایان ترومای بلانت شکمی مراجعه کننده به اورژانس بیمارستان امام حسین (ع) تهران از جهت اطلاعات دموگرافیک، نسبت دور شکم به لگن و نهایتاً ارتباط آن با پیامدهای کلینیکی، پاراکلینیکی و تصویربرداری مورد بررسی قرار گرفتند. آزمون های کای دو و فیشر جهت آنالیز داده ها استفاده شد. یافته ها: اطلاعات دموگرافیک نشان داد متوسط سن مبتلایان 2/14 ± 7/28 سال و 8/74 از آنان مرد بودند. اقدامات آزمایشگاهی و تصویربرداری برای این سری از بیماران، تنها برای 13 نفر (5) شواهدی واضح از آسیب احشاء و ارگان های داخل شکمی را نشان داد. در هر دو جنس هیچ گونه ارتباط معنی داری بین نسبت دور شکم به لگن با میزان وقوع آسیب های شکمی بر اساس نتایج نهایی حاصل از سونوگرافی، سی تی اسکن، آنالیز ادراری و لاپاراتومی وجود نداشت(05/0 P>). نتیجه گیری: به نظر می رسد ارتباطی بین نسبت دور شکم به لگن با احتمال آسیب شکمی به دنبال ترومای بلانت وجود نداشته باشد اما اظهار نظر قطعی در این مورد نیاز به مطالعات بیشتر دارد

Effect of Positive End-Expiratory Pressure on Central Venous Pressure in Patients under Mechanical Ventilation

Introduction: Finding the probable governing pattern of PEEP and CVP changes is an area of interest for in-charge physicians and researchers. Therefore, the present study was designed with the aim of evaluating the relationship between the mentioned pressures. Methods: In this quasi-experimental study, patients under mechanical ventilation were evaluated with the aim of assessing the effect of PEEP change on CVP. Non-trauma patients, over 18 years of age, who were under mechanical ventilation and had stable hemodynamics, with inserted CV line were entered. After gathering demographic data, patients underwent 0, 5, and 10 cmH2O PEEPs and the respective CVPs of the mentioned points were recorded. The relationship of CVP and PEEP in different cut points were measured using SPSS 21.0 statistical software. Results: 60 patients with the mean age of 73.95 ± 11.58 years were evaluated (68.3% male). The most frequent cause of ICU admission was sepsis with 45.0%. 5 cmH2O increase in PEEP led to 2.47 ± 1.53 mean difference in CVP level. If the PEEP baseline is 0 at the time of 5 cmH2O increase, it leads to a higher raise in CVP compared to when the baseline is 5 cmH2O (2.47 ± 1.53 vs. 1.57 ± 1.07; p = 0.039). The relationship between CVP and 5 cmH2O (p = 0.279), and 10 cmH2O (p = 0.292) PEEP changes were not dependent on the baseline level of CVP. Conclusion: The findings of this study revealed the direct relationship between PEEP and CVP. Approximately, a 5 cmH2O increase in PEEP will be associated with about 2.5 cmH2O raise in CVP. When applying a 5 cmH2O PEEP increase, if the baseline PEEP is 0, it leads to a significantly higher raise in CVP compared to when it is 5 cmH2O (2.5 vs. 1.6). It seems that sex, history of cardiac failure, baseline CVP level, and hypertension do not have a significant effect in this regard

Erythrocyte Sedimentation Rate Measurement Using as a Rapid Alternative to the Westergren Method

Introduction: Erythrocyte sedimentation rate (ESR) remains as one of the most reliable tests in clinical practices. Yet its use is time consuming and requires a large blood sample. The aim of this study was assessing a faster and reliable method of ESR estimation. Methods: An ESR estimation method was described and performed on 108 patients using capillary tube (micro ESR) and capillary peripheral blood. Micro ESR results at different intervals were measured and compared with Westergren ESR (conventional ESR) estimation by Pearson and Spearman’s coefficients. A regression equation was derived to predict conventional ESR values based on micro ESR results. The agreement of two measurements was demonstrated using the Bland-Altman plot. Results: Micro ESR results at 20 minutes showed the earliest close correlation with conventional ESR results at one hour (0.99). The presented regression equation was able to closely predict ESR values (r2 = 0.974) and the Bland-Altman plot showed an acceptable agreement between converted and conventional ESR measurements. Conclusion: Using capillary tube and capillary blood sample (micro ESR) appears to be a faster, cheaper, more reliable, and precise tool for ESR measurement in the ED. The results have acceptable correlation with conventional ESR, especially at 20 minutes of measurement

The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency Department Patients

Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often complicates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p<0.001) and MADRS (df: 3, 46; F=87.2; p<0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclusion: It seems that Ketamine couldn't be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients