piperidines and Pneumonia--Aspiration

Hospital malnutrition continues to be a serious problem. Although enteral feeding of hospitalized patients is safe and less expensive than parenteral feeding, it is associated with side effects involving the gastrointestinal tract and respiratory systems.

Topics: Bethanechol; Cisapride; Enteral Nutrition; Gastroesophageal Reflux; Humans; Nutrition Disorders; Parasympathomimetics; Piperidines; Pneumonia, Aspiration

Remifentanil is widely used for monitored anesthesia care in spontaneously breathing patients. However, the authors' previous studies have shown that remifentanil induces subjective swallowing difficulties, which may increase the risk of aspiration.. Twenty-five healthy volunteers participated in a double-blind, randomized, crossover trial at the University Hospital in Örebro, Örebro, Sweden. The volunteers were studied on two different occasions during which they received either remifentanil with an effect-site target concentration of 3 ng/ml or saline over 1 h. A radionuclide tracer was infused simultaneously into the nasopharynx at a rate of 0.1 ml/min. Aspiration was determined by lung scans, and subjective swallowing difficulties and grip strength were evaluated. The primary outcome was the difference in occurrence of aspiration between remifentanil and placebo treatments. The secondary outcomes were differences in swallowing difficulty and grip strength and the association between aspiration and swallowing difficulty.. During remifentanil and placebo infusion, 48 and 12% of the volunteers aspirated, respectively, difference: 36% (95% CI, 10 to 62%). A similar significant difference was found for swallowing difficulties but not for the association between aspiration and swallowing. No difference was found in grip strength between the two treatments.. Remifentanil infusion at concentrations used in monitored anesthesia care increases the incidence of aspiration. However, the subjective swallowing difficulty induced by remifentanil is not indicative of the aspiration risk.

Topics: Adolescent; Adult; Anesthetics, Intravenous; Cross-Over Studies; Data Interpretation, Statistical; Deglutition; Double-Blind Method; Female; Hand Strength; Humans; Infusions, Intravenous; Lung; Male; Middle Aged; Muscle Strength; Piperidines; Pneumonia, Aspiration; Radiography; Remifentanil; Respiratory Mechanics; Risk Assessment; Young Adult

Recent preanesthetic fasting practice allows patients to take clear fluids up to 2 h before surgery without taking any antacid for the prophylaxis of aspiration pneumonia; this practice is defined as oral rehydration therapy (ORT). It has been reported that with ORT the gastric volume may be significantly lower than that with a standard fasting regimen, although in a standard fasting regimen without preanesthetic antacid, gastric pH and volume values could be critical for causing aspiration pneumonia. In this study we compared gastric fluid status in patients with ORT and those with a standard fasting regimen; patients in both groups received a preanesthetic H(2) antagonist. One hundred and four patients were randomly assigned to either the ORT or standard fasting group, and all were given roxatidine 75 mg 2 h before surgery. After the induction of anesthesia, the gastric contents were collected via a gastric tube to measure gastric volume and pH. Neither gastric volume nor pH differed between the groups (ORT 9.6 ± 8.2 ml and 5.6 ± 1.7, respectively, vs. standard fasting 8.5 ± 6.8 ml and 5.5 ± 1.7, respectively). These data suggest that ORT may not reduce gastric volume in patients receiving a preanesthetic H(2) antagonist.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Fasting; Female; Fluid Therapy; Gastric Acidity Determination; Histamine H2 Antagonists; Humans; Hydrogen-Ion Concentration; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Preoperative Care; Stomach; Young Adult

The H(2) receptor antagonist roxatidine is routinely used as an oral pre-anesthetic medication in surgical patients at night and 2 h before surgery. In the present study, we have compared the effects of roxatidine, rabeprazole and lansoprazole given singly at night as an alternative to the standard double roxatidine medication.. 120 adult patients undergoing urological surgery were randomly assigned to three groups: roxatidine, rabeprazole and lansoprazole (n = 40 each). Following induction of anesthesia, gastric fluid was obtained by aspiration using a syringe to measure pH and volume of gastric contents.. Gastric volume (14.1 +/- 1.9 mL) in the lansoprazole group was significantly larger than that in roxatidine (8.6 +/- 1.7 mL) and rabeprazole (7.5 +/- 1.1 mL) groups (P < 0.05). Gastric pH in lansoprazole group (4.10 +/- 0.38) was also significantly lower than that in the roxatidine group (5.41 +/- 0.31, P < 0.05). The numbers of patients with critical factors for acid aspiration pneumonia (gastric pH < 2.5 or volume > 25 mL) in the lansoprazole group was significantly higher than in the roxatidine group (P < 0.05). Gastric pH and volume in all groups were constant even in the afternoon.. Single rabeprazole (but not lansoperazole) medication may be a suitable alternative to standard roxatidine for prophylaxis of acid aspiration pneumonia.

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Administration, Oral; Aged; Drug Administration Schedule; Female; Gastric Acidity Determination; Histamine H2 Antagonists; Humans; Lansoprazole; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication; Proton Pump Inhibitors; Rabeprazole; Respiratory Aspiration; Risk Factors; Treatment Outcome; Urologic Surgical Procedures

Roxatidine acetate hydrochloride capsule is slowly absorbed from the gastrointestinal tract, and its acid suppressive effect on the stomach is long-lasting compared with other H2-blockers. The reduction of gastric juice in perioperative period is considered advantageous for patients not only because it decreases the risk for aspiration pneumonia but also because it reduces the risk of bronchial spasm induced by gastroesophageal reflux of acidic gastric content. The effects of single oral administration of roxatidine acetate hydrochloride 150 mg at night before the operation on the volume and pH of gastric juice were investigated during anesthesia using two types of anesthetic agents (isoflurane and propofol) in 93 patients of three age groups (group Y: age 20-40, group M: age 41-64, group O: age 65 <). The effect of roxatidine on reduction of gastric juice was found at the time of anesthetic induction and 2 hours after the induction in any age group with either anesthetic agent. The serum concentration of roxatidine at the time of induction was much higher in group O. The value of residual concentration of roxatidine 20 hours after oral intake was estimated from the intraoperative measurements of serum concentration. The results suggest that single administration at night before the operation is sufficient for the oldest group, but an additive dose is recommended for the younger groups.

Topics: Adult; Age Factors; Aged; Anesthesia, General; Bronchial Spasm; Delayed-Action Preparations; Depression, Chemical; Female; Gastric Acid; Histamine H2 Antagonists; Humans; Intraoperative Complications; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication

The effects of single intravenous administration of roxatidine acetate hydrochloride 75 mg on the volume and pH of gastric juice were investigated in 43 patients undergoing elective surgery under general anesthesia. The drug was given 1 hour before anesthesia. The percentages of patients with gastric pH above 2.5 and gastric juice volume under 25 ml were 95.3% and 97.7% at the time of induction of anesthesia and at the time of extubation, respectively. As for overall assessment on gastric secretion, 93.0% was judged as very effective. In 2 cases, pricking sensations were observed at the time of injection, but these symptoms disappeared without any treatment within a few minutes. No other adverse reactions nor abnormal laboratory test findings were observed. In conclusion, roxatidine acetate hydrochloride administered intravenously 1 hour prior to anesthesia is thought to be useful to prevent acid aspiration pneumonitis.

Topics: Adult; Female; Histamine H2 Antagonists; Humans; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication

Aspiration pneumonitis is one of the major causes of anaesthesia related deaths. H2-receptor antagonists are effective drugs for the prevention of the acid aspiration syndrome (Mendelson's syndrome). The new long-acting H2-receptor antagonist roxatidine acetate may be the first H2-receptor antagonist which could effectively reduce acid secretion following a single bedtime premedication on the evening before an operation. A prospective controlled randomised double-blind study was conducted in 60 elective patients undergoing gynaecological operations requiring tracheal intubation. 30 patients received oral roxatidine acetate 150 mg at 10 pm, the other 30 patients received placebo. Immediately after intubation, at 15 minutes and at the end of the operation gastric pH and the volume of the aspirate were measured. In the placebo group, 13 patients (43%) had gastric pH values below the critical value of 2.5, while in the roxatidine acetate group gastric pH values were raised above 2.5 in all but 3 patients (10%) [p less than 0.05]. In the roxatidine acetate group pH values were significantly higher than in the placebo group (p less than 0.01). The mean gastric volume in the placebo group was 23.3 +/- 27.1 ml, compared to 14.5 +/- 9.4 ml for roxatidine acetate. The 5 highest gastric volumes were observed in the placebo group (max 146 ml). A single bedtime oral premedication with roxatidine acetate 150 mg ensures a gastric pH above 2.5 until 11 am the following day.

Topics: Adult; Clinical Trials as Topic; Double-Blind Method; Gastric Acid; Histamine H2 Antagonists; Humans; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication; Random Allocation

Topics: Anesthetics, Intravenous; Female; Humans; Male; Piperidines; Pneumonia, Aspiration

Topics: Anesthetics, Intravenous; Female; Humans; Male; Piperidines; Pneumonia, Aspiration

Moderate to deep sedation has been recommended during endoscopic submucosal dissection (ESD). However, it is often accompanied by adverse events such as respiratory depression or aspiration pneumonia. This study investigated the respiratory complications and ESD outcomes of two sedation protocols: moderate sedation with analgesic supplementation (MSAS) and analgesia targeted light sedation (ATLS).. The clinical data of 293 patients who underwent ESD between May and December 2012 were reviewed. During the first 4 months, 155 patients were managed by moderate sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 2-3] with the MSAS protocol. During the latter period, 138 patients were managed using the ATLS protocol (MOAA/S at 4-5). For both protocols, propofol and remifentanil were infused for sedation and pain control, respectively.. The ATLS protocol required less propofol [22.9 (sd 17.3) vs 88.1 (44.0) µg kg(-1) min(-1), P<0.001] and more remifentanil [6.8 (sd 3.1) vs 4.9 (3.0) µg kg(-1) hr(-1), P<0.001] than the MSAS protocol. The desaturation events during the procedure occurred significantly less often (2.2 vs 12.9%, P=0.001) and recovery was significantly faster [19.7 (sd 4.8) vs 27.9 (16.0) min, P<0.001] with the ATLS protocol than with the MSAS protocol. The incidence of aspiration pneumonia with the ATLS protocol was 1.4% compared with 5.2% with the MSAS protocol (P=0.109). There were no differences in outcomes and complications of ESD.. The ATLS protocol reduced the incidence of desaturation events without affecting ESD performance compared with the MSAS protocol. There was also a trend towards a low incidence of aspiration pneumonia with the ATLS protocol.

Topics: Adult; Aged; Aged, 80 and over; Analgesia; Anesthesia; Anesthesia Recovery Period; Conscious Sedation; Endoscopy; Female; Gastric Mucosa; Humans; Hypnotics and Sedatives; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Propofol; Remifentanil; Retrospective Studies

Topics: Aged, 80 and over; Androstanols; Anesthesia, Intravenous; Anesthetics, Intravenous; Carcinoma, Squamous Cell; Delayed Emergence from Anesthesia; Dermatomyositis; Disease Susceptibility; Female; Humans; Intraoperative Complications; Neuromuscular Nondepolarizing Agents; Parathyroid Neoplasms; Parathyroidectomy; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication; Propofol; Remifentanil; Risk; Rocuronium

Laryngotracheo-esophageal cleft is a rare congenital anomaly that results from complete or partial failure of the development of the tracheoesophageal septum. The presenting symptoms include stridor, respiratory distress, and coughing or cyanotic episodes with feeding. There are four classifications for laryngeal clefts; the severity depends on the type present. We discuss the anesthesia management of a neonate with a Type IV cleft who presented for an emergency gastric division to prevent pulmonary aspiration and later returned for final repair of the defect.

Topics: Anesthesia; Anesthetics, Inhalation; Anesthetics, Intravenous; Cardiopulmonary Bypass; Esophagus; Female; Gastrostomy; Humans; Infant, Newborn; Intubation, Intratracheal; Isoflurane; Larynx; Neuromuscular Nondepolarizing Agents; Pancuronium; Piperidines; Pneumonia, Aspiration; Rare Diseases; Remifentanil; Severity of Illness Index; Tracheostomy; Treatment Outcome; Vecuronium Bromide

Previous reports suggest that complete tolerance to H2 receptor antagonists (H2RAs) in patients with regular H2RA medication may be due to hypergastrinemia-increased histamine synthesis or upregulation of H2 receptors. As proton pump inhibitors (PPIs) have been reported to induce hypergastrinemia (similar to H2RAs), patients receiving long-term medication with PPIs may show tolerance to preanesthetic H2RA. Therefore, we studied the efficacy of an H2RA, roxatidine, in patients receiving long-term PPI medication.. Effects of H2RA in 15 surgical patients receiving a regular PPI for more than 4 weeks (PPI+H2RA group) were compared with those in 30 patients not receiving regular PPIs or H2RAs (None+H2RA group and None+None group, n = 15 each). Oral roxatidine was given to both PPI+H2RA and None+H2RA group patients as an anesthetic premedication, while it was not given to None+None group patients. Gastric volume and pH were measured after induction of anesthesia.. Gastric pH and volume (ml) in the PPI+H2RA group (5.79 +/- 1.61 and 9.1 +/- 16.7, respectively) were both similar to those in the None+H2RA group (5.54 +/- 2.20 and 9.7 +/- 10.8, respectively) but were significantly higher (gastric pH) and lower (volume) than in the None+None group (2.29 +/- 1.84 and 29.3 +/- 22.8, respectively, P < 0.01).. These data suggest that long-term PPI medication may not induce a tolerance to H2RAs.

Topics: Drug Tolerance; Female; Gastric Acid; Gastric Acidity Determination; Histamine H2 Antagonists; Humans; Male; Middle Aged; Piperidines; Pneumonia, Aspiration; Proton Pump Inhibitors; Time Factors

We previously reported that H2-antagonist medication given for longer than 4 wk may produce complete tolerance to preanesthetic H2 antagonist therapy. In this study, we evaluated the efficacy of preanesthetic proton pump inhibitor (PPI; oral rabeprazol) use in patients receiving regular H2-antagonist (oral famotidine) therapy for more than 4 wk. Forty-eight patients with assumed complete tolerance to H2 antagonists undergoing elective surgery were recruited and randomly assigned to receive either a preanesthetic PPI (rabeprazol 20 mg; n = 24) or H2-antagonist (H2 group; roxatidine 75 mg; n = 24) at 9:00 pm on the day before surgery and 2 h before the induction of anesthesia. Volume of gastric contents and pH values were measured after the induction of anesthesia. Gastric pH value in the PPI group (5.38 +/- 2.42) was significantly higher than in the H2 group (3.27 +/- 1.98; P < 0.01). Gastric volume in the PPI group (8.6 +/- 1.5 mL) was significantly smaller than in the H2 group (15.4 +/- 2.8 mL; P < 0.05; cf. PPI). Fourteen patients in the H2 group were at risk of acid aspiration pneumonia (gastric pH <2.5 or volume >25 mL), whereas only four patients in the PPI group (P < 0.05) were at risk. These data suggest that in patients receiving H2-antagonist therapy for longer than 4 wk, prophylaxis for acid aspiration pneumonia should include preanesthetic PPI medication.. We previously reported that more than 4 wk of administration of H2-antagonists may produce a full tolerance to preanesthetic H2-antagonists. The present study suggests that a proton pump inhibitor may be effective for prophylaxis of acid aspiration pneumonia in patients showing the full tolerance to H2 antagonists.

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Adult; Aged; Anti-Ulcer Agents; Benzimidazoles; Drug Tolerance; Famotidine; Female; Gastric Acidity Determination; Gastrins; Histamine H2 Antagonists; Humans; Male; Middle Aged; Omeprazole; Piperidines; Pneumonia, Aspiration; Preanesthetic Medication; Proton Pump Inhibitors; Rabeprazole

Topics: Acetamides; Adolescent; Anesthesia, General; Child; Child, Preschool; Cimetidine; Gastric Acid; Gastric Acidity Determination; Gastric Juice; Histamine H2 Antagonists; Humans; Piperidines; Pneumonia, Aspiration; Pyridines

To report a case of fatal aspiration pneumonia in a patient shortly after initiation of rivastigmine and discontinuation of donepezil, with no washout period between therapies.. An 83-year-old white man presented to the emergency department in respiratory distress (O2 saturation 70%; RR 44 breaths/min) secondary to aspiration. He had started rivastigmine 1.5 mg twice daily that same day. The patient had been previously treated with donepezil 10 mg/d, and there was no washout period. He was intubated due to worsening respiratory status and was transferred to the cardiac care unit. He then became hypotensive and required dopamine and fluid support. Brief bronchoscopy revealed food particles in the lower airways and bile-stained secretions. Intubation was notable for the large amount of secretions. The patient died approximately 27 hours after presentation to the emergency department. Blood and sputum cultures were subsequently positive for Haemophilus influenzae.. Cholinesterase (ChE) inhibitors approved for treatment of Alzheimer disease are associated with nausea and vomiting in a sizable percentage of patients, ranging from 5% to 31% in clinical trials. Most of these adverse events occur during the initiation/titration phase of therapy. An additive risk of adverse events may be expected with coadministration of ChE inhibitors or cholinergic agents or, potentially, with an inadequate washout period between such agents. Review of MEDLINE (1966-July 2002) and International Pharmaceutical Abstracts (1970-July 2002) failed to identify any previous reports of aspiration with rivastigmine or donepezil.. A washout period should be considered when switching between ChE inhibitors to minimize the risk of vomiting and aspiration.

Topics: Aged; Aged, 80 and over; Carbamates; Cholinesterase Inhibitors; Donepezil; Drug Administration Schedule; Fatal Outcome; Humans; Indans; Male; Phenylcarbamates; Piperidines; Pneumonia, Aspiration; Rivastigmine

Gastro-oesophageal reflux (GOR) has been implicated in such clinical phenomena as aspiration pneumonia, bronchospasm or wheezing, apnea, stridor, and hoarseness. Various tests have been used as an aid to diagnosing patients with chronic respiratory disease where GOR is a causal factor. Different forms of conservative treatment have been tried for GOR, including cisapride. Several studies have evaluated its effect on the pH profile and respiratory symptoms in patients with chronic respiratory disease and have demonstrated improvement of nocturnal wheezing, cough, and irritability. Our experience with cisapride is positive in children with GOR. Patients refractory to medical treatment have been surgically treated with good results.

Topics: Anti-Ulcer Agents; Asthma; Child; Child, Preschool; Chronic Disease; Cisapride; Gastroesophageal Reflux; Humans; Infant; Piperidines; Pneumonia, Aspiration; Respiratory Sounds; Respiratory Tract Diseases

The risk of aspiration during tube feedings has been reduced but not abolished by percutaneous endoscopic gastrostomy (PEG). This open study was planned to evaluate whether cisapride may play some role in preventing aspiration in long-term enteral feeding via PEG. A group of 29 patients, unable to swallow because of head and neck cancer (14 cases) or neurological disorders (15 cases) entered the study; 7 neurological patients, fed via nasogastric tube before PEG placement, had suffered from aspiration pneumonia during nasogastric feeding. All patients underwent PEG, and 10 mg cisapride was routinely given via PEG before each administration of enteral feeding and 6 h after its initiation when the feeding was continued for 12 h or more. Only 1 minor complication was observed during the acute hospital setting (ileus, spontaneously resolving after 36 h). After hospital discharge, the patients were followed for a total of 4935 days of feeding (range 47-508 days, mean time per patient: 170 days) and assessed weekly for the development of complications. No episode of probable/possible aspiration pneumonia was observed during the follow-up. Two neurological patients with involuntary movements had rupture of the feeding tube, which was replaced without complications. These results support the hypothesis that cisapride might play some role in the prevention of aspiration in patients fed via PEG, and justify the planning of some controlled, double-blind trials to verify such a hypothesis.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cisapride; Deglutition Disorders; Enteral Nutrition; Female; Follow-Up Studies; Gastroscopy; Gastrostomy; Head and Neck Neoplasms; Humans; Intubation, Gastrointestinal; Male; Middle Aged; Nervous System Diseases; Pilot Projects; Piperidines; Pneumonia, Aspiration; Serotonin Antagonists; Survival Rate

Topics: Adolescent; Adult; Aged; Anesthesia, General; Child; Female; Histamine H2 Antagonists; Humans; Male; Maternal-Fetal Exchange; Middle Aged; Piperidines; Placenta; Pneumonia, Aspiration; Pregnancy; Premedication