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

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

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 Accuracy of Plain Radiography in Detection of Traumatic Intrathoracic Injuries

Introduction: Rapid diagnosis of traumatic intrathoracic injuries leads to improvement in patient management. This study was designed to evaluate the diagnostic value of chest radiography (CXR) in comparison to chest computed tomography (CT) scan in diagnosis of traumatic intrathoracic injuries. Methods: Participants of this prospective diagnostic accuracy study included multiple trauma patients over 15 years old with stable vital admitted to emergency department (ED) during one year. The correlation of CXR and CT scan findings in diagnosis of traumatic intrathoracic injuries was evaluated using SPSS 20. Screening characteristics of CXR were calculated with 95% CI. Results: 353 patients with the mean age of 35.2 ± 15.8 were evaluated (78.8% male). Age 16-30 years with 121 (34.2%), motorcycle riders with 104 (29.5%) cases and ISS < 12 with 185 (52.4%) had the highest frequency among patients. Generally, screening performance characteristics of chest in diagnosis of chest traumatic injuries were as follows: sensitivity 50.3 (95% CI: 44.8 – 55.5), specificity 98.9 (95% CI: 99.5 – 99.8), PPV 97.8 (95% CI: 91.5 – 99.6), NPV 66.4 (95% CI: 60.2 – 72.03), PLR 44.5 (95% CI: 11.3 175.3), and NLR 0.5 (95% CI: 0.4 – 0.6). Accuracy of CXR in diagnosis of traumatic intrathoracic injuries was 74.5 (95% CI: 69.6 – 78.9) and its area under the ROC curve was 74.6 (95% CI: 69.3 – 79.8). Conclusion: The screening performance characteristics of CXR in diagnosis of traumatic intrathoracic injuries were higher than 90% in all pathologies except pneumothorax (50.3%). It seems that this matter has a great impact on the general screening characteristics of the test (74.3% accuracy and 50.3%sensitivity). It seems that, plain CXR should be used as an initial screening tool more carefully

Quality of Life in Emergency Medicine Specialists of Teaching Hospitals

Introduction: Quality of life (QOL) of emergency medicine specialists can be effective in providing services to patients. The aim of the present study was evaluating the lifestyle of emergency medicine practitioners, understanding their problems, and addressing the solutions to enhance and improve their lifestyles, in teaching hospitals in Iran. Method: This descriptive cross-sectional study was conducted on emergency medicine physicians in 10 teaching hospitals of Iran in 2011. Emergency physicians with at least three years of experience who interested in the study, were enrolled in the project. All participants filled out the consent form and QOL questionnaires, then underwent physical examinations and some medical laboratory tests. Categorical variables were reported as percentages, while continuous variables expressed as means and standard deviations. p <0.05 was considered statistically significant. Results: Totally, 100 subjects participated in the study, of whom 48 were male. The mean and standard deviation of the physicians’ age were 38.7±5.1 years. 43% of physicians had an average QOL, while 37% good. 96% of studied physicians had a good condition regarding habitual history, while 93% of them had a poor condition in performing screening tests. Exercise program and personal health in individuals with normal BMI were correlated with higher levels of QOL. BMI was higher in 40-50 years old subjects than youngers. Hypertension was present in five cases (5%), hypercholesterolemia in six (6%), hypertriglyceridemia in six (6%), increased LDL in four (4%), low HDL in four (4%), and impaired FBS in 4 (4%). Conclusion: The findings showed that 63% of studied emergency physicians had an average level of QOL and other ones good. The majority of physicians had undesirable situation regarding the performance of screening tests