piperidines and Psychomotor-Agitation

Emergence agitation (EA) is an adverse effect after sevoflurane anesthesia in pediatric patients. The effectiveness of prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil in preventing EA is debatable.. A literature search was conducted to identify clinical trials that observed the effect of μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil on preventing EA in pediatric patients under sevoflurane anesthesia. The statistical software RevMan 5.3 was used for meta-analysis. Data from each study were combined using the relative ratio (RR), weighted mean differences, and their associated 95% confidence intervals. I(2) was used to evaluate heterogeneity. Subgroup analysis was conducted to investigate the possible influences of patient age, adenotonsillectomy, premedication, N2 O, propofol, and regional block/local anesthetics on preventing EA with prophylactic administration of μ-opioid agonists. Publication bias was checked using funnel plots and Begg's test.. This meta-analysis showed the inclusion of 19 randomized controlled trials with 1528 patients (857 patients received μ-opioid agonists therapy and 671 patients had placebo). The pooled data indicated that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil significantly decreased the incidence of EA [RR = 0.49 (0.38, 0.64), I(2) = 42%, P = 0.04; RR = 0.57 (0.33, 0.99), I(2) = 37%, P = 0.19; RR = 0.18 (0.08, 0.39), I(2) = 0%, P = 0.98; and RR = 0.56 (0.40, 0.78), I(2) = 6%, P = 0.34, respectively]. All subgroup analyses strengthened the proof for lower incidence of EA under sevoflurane anesthesia after fentanyl administration. A possibility of publication bias was detected in the fentanyl group.. This meta-analysis suggested that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil could significantly decrease the incidence of EA under sevoflurane anesthesia in children compared to placebo. Considering the limitations of the included studies, more clinical studies are required.

Topics: Alfentanil; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Child; Fentanyl; Humans; Methyl Ethers; Piperidines; Psychomotor Agitation; Randomized Controlled Trials as Topic; Remifentanil; Sevoflurane; Sufentanil

Sedation practices in the critical care unit have been trending toward lighter sedation since the start of the new millennium, but patients continue to experience inadequate pain management and excessive sedation. This paper includes a brief examination of the problem of pain management in the ICU; trends in sedation practices, including light sedation and the daily interruption of sedation; and a literature review of analgosedation. While the analgosedation literature is relatively sparse, it offers a promising, patient-centered method for managing the triad of pain, agitation, and delirium, while reducing common complications associated with long-term ventilation. This paper concludes with a recommended method for analgosedation, the nursing implications, and a discussion of limitations and recommendations.

Topics: Analgesics; Communication; Delirium; Humans; Hypnotics and Sedatives; Intensive Care Units; Morphine; Pain Management; Patient Outcome Assessment; Piperidines; Psychomotor Agitation; Remifentanil; Respiration, Artificial

Topics: Anesthesia Recovery Period; Anesthetics, Inhalation; Conscious Sedation; Critical Care; Dexmedetomidine; Drug Administration Schedule; Fentanyl; Humans; Hypnotics and Sedatives; Piperidines; Psychomotor Agitation; Remifentanil; Wakefulness

The first part of the present review describes the current status of elderly people with behavioral and psychological symptoms of dementia (BPSD) in the community and basic viewpoints for differentiating between different forms of dementia. Specifically, it focuses on four points among the data and research related to determining the current status of elderly people with BPSD. We also propose basic concepts for differentiating between the core symptoms of dementia and BPSD, BPSD and delirium, and agitation and delirium. In the second part of the present review, various aspects of the symptom 'agitation' are discussed based on the experience of our home visit medical service for people with dementia by describing two cases. In cases such as Case 1, where the subject was given high doses of antipsychotics, we believe the problem was that the physicians immediately abstracted all of the abnormal behavior in the subject's life as 'agitation', and provided treatment to the subject accordingly. In Case 2, where the subject had dementia with Lewy bodies (DLB), we propose that it is crucial to differentiate clearly between agitation and delirium. Both of these cases show the risks of focusing treatment simply on agitation. When BPSD occurs in a person with dementia, the burden on caregivers increases. At such times, physicians tend to side with the family rather than with the patient. However, medical care is intended to be for the afflicted person, and physicians should base their plans for medical intervention on this principle.

Topics: Aged; Aged, 80 and over; Antipsychotic Agents; Caregivers; Delirium; Dementia; Diagnosis, Differential; Donepezil; Home Care Services; House Calls; Humans; Indans; Lewy Body Disease; Male; Nootropic Agents; Piperidines; Psychomotor Agitation; Tokyo

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are management of Alzheimer's agitation with donepezil; needle-free lidocaine powder for minor painful procedures; psychostimulants in depression; anticoagulation for cancer-related venous thromboembolism; effect of waiting for acute pain treatment on risk of chronic pain; and an update on severe cutaneous reactions associated with medications.

Topics: Alzheimer Disease; Amphetamines; Anesthetics, Local; Anticoagulants; Antidepressive Agents; Depression; Donepezil; Drug Therapy; Drug-Related Side Effects and Adverse Reactions; Humans; Indans; Lidocaine; Nootropic Agents; Pain; Palliative Care; Phlebotomy; Piperidines; Prescription Drugs; Psychomotor Agitation; Randomized Controlled Trials as Topic; Sertraline; Stevens-Johnson Syndrome; Thromboembolism

Akathisa is one of the most common and distressing neuroleptic-induced extrapyramidal side effects. Although it is well recognized in the context of conventional antipsychotic medications, there have been recent concerns raised by clinicians and researchers that this syndrome is overlooked in relation to second-generation or atypical antipsychotics. This review examines the recent literature relevant to second-generation antipsychotic (SGA)-induced akathisia.. Recent studies using large databases clearly indicate that extrapyramidal side effects, in particular akathisia, do occur with the SGAs, although the frequency is not as high as with the conventional antipsychotics. Risk factors include use of high doses, high potency SGAs, or combinations of SGAs with other psychotropic drugs, bipolar depression, palliative care settings, and comorbid substance abuse in psychosis. The dopamine hypothesis remains plausible for understanding the pathophysiology of akathisia. There is emerging evidence that mirtazapine may be useful in the treatment of acute akathisia.. Even though akathisia is less prevalent with SGAs than with the first-generation drugs, it remains clinically important and all clinicians should be conversant with its recognition and management.

Topics: Amisulpride; Antipsychotic Agents; Aripiprazole; Benzodiazepines; Clozapine; Dibenzothiazepines; Humans; Isoxazoles; Olanzapine; Piperazines; Piperidines; Prevalence; Psychomotor Agitation; Psychotic Disorders; Quetiapine Fumarate; Quinolones; Risk Factors; Risperidone; Sulpiride; Thiazoles

Patients with Alzheimer's disease psychosis (ADP) commonly experience concomitant agitation and aggression. We investigated whether a reduction in ADP following pimavanserin treatment conferred a reduction in associated agitation and aggression.. ACP-103-019 was a 12-week, randomized, double-blind, placebo-controlled study that evaluated the efficacy of pimavanserin (34 mg) in reducing psychotic symptoms in patients with ADP. The primary endpoint was change from baseline in Neuropsychiatric Inventory-Nursing Home Version-Psychosis Score (NPI-NH-PS) at week six. A post hoc analysis examined whether there was a greater reduction in agitation and aggression (NPI-NH domain C [agitation/aggression] and Cohen-Mansfield Agitation Inventory-Short Form [CMAI-SF]) in pimavanserin-treated patients who experienced a reduction of hallucinations and delusions (psychosis responders defined as ≥50% reduction from baseline in NPI-NH-PS, week six) when compared with those who did not (nonresponders).. Pimavanserin-treated patients with ≥50% response in psychotic symptoms (n = 44) showed a greater improvement in agitation and aggression symptoms on the NPI-NH domain C (week six, least squares mean [LSM] difference = -3.64, t = -4.69, P < .0001) and the CMAI-SF (week six, LSM difference = -3.71, t = -2.01, P = .0483) than nonresponders (n = 32). Differences between psychosis responders and nonresponders were also observed in patients with more severe agitation and aggression at baseline on the NPI-NH domain C (responders, n = 26; nonresponders, n = 13; week six, LSM difference = -3.03, t = -2.44, P = .019).. Patients with ADP, who show improvement in psychotic symptoms after pimavanserin treatment, also experience an improvement in concomitant agitation and aggression.

Topics: Aggression; Alzheimer Disease; Double-Blind Method; Humans; Piperidines; Psychomotor Agitation; Psychotic Disorders; Treatment Outcome; Urea

This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence.. This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated.. The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05).. Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

Topics: Adult; Airway Management; Anesthesia Recovery Period; Anesthetics, Intravenous; Cough; Device Removal; Dose-Response Relationship, Drug; Double-Blind Method; Female; Humans; Infusions, Intravenous; Laryngeal Masks; Male; Middle Aged; Piperidines; Postoperative Complications; Psychomotor Agitation; Remifentanil; Vomiting

Postoperative emergency agitation (EA) is a common problem. Dexmedetomidine and remifentanil may be used to prevent this problem. Our primary aim was to compare dexmedetomidine, remifentanil, and placebo with respect to their effectiveness in preventing postoperative EA.. Ninety patients undergoing nasal surgery were randomized into three groups. The dexmedetomidine group (group D, n = 30) received dexmedetomidine infusion at a rate of 0.4 μg kg(-1 ) h(-1); the remifentanil group (group R, n = 30) received remifentanil infusion at a rate of 0.05 μg kg(-1) min(-1) from induction of anesthesia until extubation; and the control group (group S, n = 30) received a volume-matched normal saline infusion as a placebo. Propofol (1.5-2 mg kg(-1)) and fentanyl (1 μg kg(-1)) were used to initiate anesthesia, and desflurane was used to maintain anesthesia. The incidence of agitation, hemodynamic parameters, and recovery characteristics were evaluated during emergence.. The incidence of EA was significantly higher in group S (46.7%) compared with groups R and D (3.3 and 20%, respectively; p < 0.001). The lowest incidence of EA was detected in group R (p = 0.046). Residual sedation in the post-anesthesia care unit (PACU) was similar in all groups (p = 0.947). The incidence of nausea or vomiting was significantly lower in group D than in groups R and S (p = 0.043). Administration of analgesics in the PACU was higher in group R than in groups S and D (p = 0.015).. Anesthetic maintenance with either remifentanil or dexmedetomidine infusion until extubation provided a more smooth and hemodynamically stable emergence, without complications after nasal surgery. While remifentanil was superior to dexmedetomidine with regard to avoiding EA, dexmedetomidine was more effective than remifentanil regarding vomiting and pain.

Topics: Adolescent; Adult; Aged; Airway Extubation; Anesthesia Recovery Period; Anesthesia, General; Dexmedetomidine; Double-Blind Method; Female; Hemodynamics; Humans; Hypnotics and Sedatives; Infusions, Intravenous; Male; Middle Aged; Nasal Surgical Procedures; Piperidines; Psychomotor Agitation; Remifentanil; Young Adult

Patients undergoing orthognathic surgery are at high risk of developing emergence agitation. We hypothesised that a single-dose of dexmedetomidine would reduce emergence agitation in adults with nasotracheal intubation after orthognathic surgery.. Seventy adults (20-45 years old) undergoing orthognathic surgery were randomly assigned to two groups. Patients received intravenous dexmedetomidine 1 μg/kg (dex group) or normal saline (control group) for 10 min at the end of surgery. Remifentanil was infused at 0.02 μg/kg/min during emergence in both groups. The severity of emergence agitation was assessed with the Richmond agitation-sedation scale. Cough, haemodynamic and respiratory profiles, pain, and time to eye opening were evaluated.. The incidence of emergence agitation was not different between dex group and control group (38% vs. 47%, P = 0.45). However, severe cough during emergence was reduced in the dex group (P = 0.04). Tachycardia during emergence and recovery phases was attenuated in the dex group. The verbal numeric rating of pain was lower in the dex group. There were no differences in respiratory rate between the two groups. Time to eye opening was prolonged in the dex group.. The addition of a single dose of dexmedetomidine (1 μg/kg) to low-dose remifentanil infusion did not attenuate emergence agitation in intubated patients after orthognathic surgery compared with low-dose remifentanil infusion alone. However, single-dose dexmedetomidine suppressed coughing, haemodynamic changes, and pain during emergence and recovery phases, without respiratory depression. Delayed awakening might be associated with this treatment.

Topics: Adult; Anesthesia Recovery Period; Anesthesia, General; Cough; Delayed Emergence from Anesthesia; Desflurane; Dexmedetomidine; Double-Blind Method; Drug Synergism; Female; Humans; Intubation, Intratracheal; Isoflurane; Male; Middle Aged; Orthognathic Surgical Procedures; Pain Measurement; Piperidines; Psychomotor Agitation; Remifentanil; Tachycardia; Young Adult

Flexible fibreoptic bronchoscopy is an important tool in the evaluation and management of paediatric respiratory disease. Total intravenous anaesthesia (TIVA) and volatile agent induction and maintenance of anaesthesia (VIMA) are commonly used for these procedures. The aim of this study was to determine which is superior for children undergoing flexible fibreoptic bronchoscopy.The study included two phases. In Phase 1, ED99 of propofol in TIVA and ED99 of sevoflurane in VIMA were first determined. In Phase 2, 50 children aged from one to three years were recruited and randomly assigned to either a TIVA or a VIMA group. An ED99 dose of propofol with remifentanil was administered to the TIVA group and sevoflurane to the VIMA group. Haemodynamic variables, stress hormone responses, anaesthesia profiles, adverse reactions and physicians' levels of satisfaction were compared between the two groups. The ED99 values of propofol in the TIVA group and sevoflurane in the VIMA group were 8.9 µg/ml and 6.8% respectively. Haemodynamic variables and stress hormone levels were higher in the VIMA group than in the TIVA group. Agitation and coughing also occurred less frequently in the TIVA group. In addition, physicians' levels of satisfaction were greater in the TIVA group. Our results suggest that TIVA with propofol plus remifentanil is superior to VIMA using sevoflurane alone for children undergoing flexible fibreoptic bronchoscopy.

Topics: Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Biomarkers; Blood Glucose; Bronchoscopy; Child, Preschool; Cough; Epinephrine; Female; Fiber Optic Technology; Hemodynamics; Humans; Hydrocortisone; Infant; Male; Methyl Ethers; Norepinephrine; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane; Stress, Physiological; Treatment Outcome

Sevoflurane is an ideal agent for anesthesia since its respiratory irritant effect is minimal during mask induction. Emergence agitation (EA) is a common problem after anesthesia with sevoflurane. In this study it was aimed to compare the effects of dexmedetomidine and remifentanyl on emergence agitation after sevoflurane anesthesia in adults undergoing septoplasty operation.. This prospective, randomized, double-blind study was conducted in Yenimahalle State Hospital after obtaining local Ethics Committee approval and patient's written informed consent. The patients were randomized into dexmedetomidine and remifentanyl groups. Hemodynamic parameters including heart rat, Mean arterial pressure, and sPO2 were recorded. The patients were followed for 1 hour at the recovery room. Categorical data was analyzed using c2 test. Hemodynamic data was evaluated using unpaired t test for intergroup and paired t-test for within group comparisons. Data not normally distributed was compared using Mann Whitney U test. p < 0.05 was considered statistically significant.. Demographic data were similar in both groups (p > 0.05). Riker score was similar in both groups. VAS score was also not significantly different between both groups at the recovery room.. Our study demonstrated that Dexmedotimidine and Remifentanyl had equal effectiveness in reducing emergence agitation in patients undergoing septoplasty under Sevoflurane anesthesia.

Topics: Adult; Aged; Anesthetics, Inhalation; Dexmedetomidine; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Middle Aged; Nasal Septum; Piperidines; Prospective Studies; Psychomotor Agitation; Remifentanil; Sevoflurane; Young Adult

Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA.. Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2-3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit.. The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25-10.25) vs. 11 (7.75-14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025].. The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Topics: Adenoidectomy; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Child, Preschool; Delirium; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Piperidines; Postoperative Complications; Psychomotor Agitation; Remifentanil; Sevoflurane; Tonsillectomy

Sevoflurane is widely used for paediatric anaesthesia. However, many cases of emergence agitation after sevoflurane anaesthesia have been reported and pain was suggested as a major contributing factor. The purpose of this study was to evaluate the effect of sub-Tenon lidocaine injection on emergence agitation in children receiving sevoflurane or propofol-remifentanil anaesthesia.. We enrolled 260 children, aged 4-10 years, who were scheduled for strabismus surgery, and randomized them to one of four groups: group SS, SL, BS, and BL. Anaesthesia was maintained with sevoflurane (SS, SL) or propofol-remifentanil infusion (BS, BL). At the end of surgery, the surgeon injected into the sub-Tenon space 1 ml of isotonic saline (SS, BS) or 2% lidocaine (SL, BL). Emergence behaviour was assessed in the post-anaesthesia care unit using a 5-point scoring scale (score 1, asleep; 2, awake and calm; 3, irritable or consolable crying; 4, inconsolable crying; and 5, severe restlessness). We defined a score of 4 or 5 as emergence agitation. The incidence of emergence agitation was analysed using χ² and Fisher's exact test.. The incidence of emergence agitation in group SL and BL was significantly lower compared to group SS and BS, respectively (P = 0.011, 0.019). The lidocaine-injected group showed significantly lower occurrence of emergence agitation (10.4%) than isotonic saline-injected group (27.2%; P = 0.001). Emergence agitation was significantly higher following sevoflurane (25.0%) than balanced anaesthesia (13.1%; P = 0.023).. The frequency of emergence agitation is significantly reduced by sub-Tenon lidocaine injection regardless of the modality of anaesthesia used.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Child; Child, Preschool; Female; Follow-Up Studies; Humans; Incidence; Lidocaine; Male; Methyl Ethers; Ophthalmologic Surgical Procedures; Pain, Postoperative; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane; Strabismus

Behavioural and psychological symptoms (BPSD) are frequent in people with Alzheimer's disease and cause considerable stress to patients and their carers. Antipsychotics have been widely used as a first-line treatment, resulting in an estimated 1,800 excess strokes and 1,600 excess deaths in the UK alone. Safe and effective alternatives are urgently needed. Based upon preliminary evidence from clinical trials, aromatherapy with melissa oil may be such an alternative, but initial studies have been modest in size, and adequate blinding has been problematic. Our objective was to assess the efficacy of melissa aromatherapy in the treatment of agitation in people with Alzheimer's disease in an adequately powered and robustly blinded randomized controlled trial comparing it with donepezil, an anticholinesterase drug used with some benefit to treat BPSD.. The study was a double-blind parallel-group placebo-controlled randomized trial across 3 specialist old age psychiatry centres in England. Participants had probable or possible Alzheimer's disease, were resident in a care home, had clinically significant agitation (defined as a score of 39 or above on the Cohen Mansfield Agitation Inventory) and were free of antipsychotics and/or anticholinesterase for at least 2 weeks. Participants were allocated to 1 of 3 groups: placebo medication and active aromatherapy; active medication and placebo aromatherapy or placebo of both.. The primary outcome measure was reduction in agitation as assessed by the Pittsburgh Agitation Scale (PAS) at 4 weeks. This is an observational scale, and raters were required to wear nose clips to ensure that full blinding was maintained. The PAS, Neuropsychiatric Inventory (NPI; another measure of BPSD) and other outcome measures were completed at baseline, 4-week and 12-week follow-ups. 114 participants were randomized, of whom 94 completed the week 4 assessment and 81 completed the week 12 assessment. Aromatherapy and donepezil were well tolerated. There were no significant differences between aromatherapy, donepezil and placebo at week 4 and week 12, but importantly there were substantial improvements in all 3 groups with an 18% improvement in the PAS and a 37% improvement in the NPI over 12 weeks.. When assessed using a rigorous design which ensures blinding of treatment arms, there is no evidence that melissa aromatherapy is superior to placebo or donepezil, in the treatment of agitation in people with Alzheimer's disease. However, the sizeable improvement in the placebo group emphasizes the potential non-specific benefits of touch and interaction in the treatment of agitation in people with Alzheimer's disease.

Topics: Aged; Aged, 80 and over; Alzheimer Disease; Aromatherapy; Cholinesterase Inhibitors; Data Interpretation, Statistical; Donepezil; Double-Blind Method; Female; Humans; Indans; Male; Melissa; Middle Aged; Nootropic Agents; Patient Compliance; Piperidines; Plant Oils; Psychomotor Agitation; Quality of Life; Sample Size; Treatment Outcome

Early recovery of patients following sedation/analgesia and anesthesia is important in ambulatory practice. The aim of this study was to assess whether modafinil, used for the treatment of narcolepsy, improves recovery following sedation/analgesia.. Patients scheduled for extracorporeal shock wave lithotripsy were randomly assigned to one of four groups. Two groups received a combination of fentanyl/midazolam with either modafinil or placebo. The remaining groups received remifentanil/propofol with either modafinil or placebo. Modafinil 200 mg was administered to the treatment group patients 1 h before sedation/analgesia. Groups were compared using the digital symbol substitution test (DSST), trail making test (TMT), observer scale of sedation and analgesia (OAA/S) and Aldrete score. Verbal rating scale (VRS) scores for secondary outcome variables e.g. energy, tiredness and dizziness were also recorded before and after treatment.. Sixty-seven patients successfully completed the study. Groups received similar doses of sedation and analgesic drugs. No statistically significant difference was found for DSST between groups. No significant adverse effects occurred in relation to modafinil. No statistically significant difference between groups was identified for TMT, OAA/S and Aldrete scores. The mean VRS score for tiredness was lesser in the modafinil/fentanyl/midazolam group [1.3 (2.0)] compared with the placebo group [3.8 (2.5)], P=0.02. Such a difference was not found between the remifentanil/propofol groups [placebo 2.6 (2.2) vs. modafinil 3.1(2.7)], p>0.05. Dizziness was greater in the modafinil/remifentanil/propofol group 1.7 (2.0) vs. placebo 0.0 (0.5), p<0.05.. Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve recovery in terms of objective measures of patient psychomotor skills.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia; Anesthesia Recovery Period; Anesthetics, Inhalation; Appetite; Benzhydryl Compounds; Central Nervous System Stimulants; Deep Sedation; Dizziness; Fatigue; Fentanyl; Humans; Lithotripsy; Midazolam; Middle Aged; Modafinil; Nausea; Neuropsychological Tests; Pain; Piperidines; Placebos; Propofol; Psychomotor Agitation; Psychomotor Performance; Relaxation; Remifentanil; Sleep Stages; Young Adult

The aim of the present study was to assess the effect of remifentanil on the incidence of emergence agitation in preschool-aged children undergoing adenotonsillectomy with sevoflurane anaesthesia. Sixty children, aged three to seven years, American Society of Anesthesiologists physical status I or II, were randomised into either group S (sevoflurane alone, n=30) or group R (sevoflurane plus remifentanil, n=30). Anaesthesia was induced with an intravenous bolus injection of fentanyl 3 microg/kg and propofol 2.5 mg/kg. Endotracheal intubation was facilitated by vecuronium 0.1 mg/kg. All patients were ventilated with 50% nitrous oxide and 1.5 to 2.5% sevoflurane in oxygen. End-tidal CO2 was maintained at 35 +/- 4 mmHg. Group S received no other medication while group R received remifentanil 1 microg/kg/minute intraoperatively. Mean blood pressure, heart rate, pulse oximetry, eye-opening time and extubation time were recorded in the operating room. In recovery, emergence agitation was assessed using the Pediatric Anesthesia Emergence Delirium scale with a score > or =10 taken as indicating agitation. Emergence agitation occurred in 20 of the 30 patients in group S and seven of the 30 patients in group R (P < 0.01). In preschool-aged children undergoing adenotonsillectomy with sevoflurane general anaesthesia, after propofol and fentanyl induction, intraoperative remifentanil decreased the incidence of emergence agitation.

Topics: Adenoids; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child, Preschool; Female; Fentanyl; Humans; Male; Methyl Ethers; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane; Tonsillectomy

The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge.. Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane-remifentanil maintenance may experience this type of agitation.. In 120 un-premedicated children aged 1-7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward.. There were significantly more agitated children in the ketamine-group when compared to the midazolam-group or to the propofol-group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam-fentanyl [5 (2-15)] and propofol-fentanyl [6 (3-15)] versus ketamine-fentanyl [10 (3-20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups.. Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane anesthesia was both effective on decreasing the incidence and severity of emergence agitation in children undergoing cataract extraction without significant delaying recovery time and discharge. The effect of midazolam was clearer than that seen with propofol.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Dissociative; Anesthetics, Inhalation; Anesthetics, Intravenous; Cataract Extraction; Child; Child, Preschool; Delirium; Double-Blind Method; Female; Fentanyl; Humans; Hypnotics and Sedatives; Infant; Ketamine; Male; Methyl Ethers; Midazolam; Pain Measurement; Piperidines; Postoperative Complications; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane

Compare duration of mechanical ventilation (MV), weaning time, ICU-LOS (ICU-LOS), efficacy and safety of remifentanil-based regimen with conventional sedation and analgesia.. Centre randomised, open-label, crossover, 'real-life' study.. 15 Dutch hospitals.. Adult medical and post-surgical ICU patients with anticipated short-term (2-3 days) MV.. Patient cohorts were randomised to remifentanil-based regimen (n = 96) with propofol as required, for a maximum of 10 days, or to conventional regimens (n = 109) of propofol, midazolam or lorazepam combined with fentanyl or morphine.. Outcomes were weaning time, duration of MV, ICU-LOS, sedation- and analgesia levels, intensivist/ICU nurse satisfaction, adverse events, mean arterial pressure, heart rate. Median duration of ventilation (MV) was 5.1 days with conventional treatment versus 3.9 days with remifentanil (NS). The remifentanil-based regimen reduced median weaning time by 18.9 h (P = 0.0001). Median ICU-LOS was 7.9 days versus 5.9 days, respectively (NS). However, the treatment effects on duration of MV and ICU stay were time-dependent: patients were almost twice as likely to be extubated (P = 0.018) and discharged from the ICU (P = 0.05) on day 1-3. Propofol doses were reduced by 20% (P = 0.05). Remifentanil also improved sedation-agitation scores (P < 0.0001) and intensivist/ICU nurse satisfaction (P < 0.0001). All other outcomes were comparable.. In patients with an expected short-term duration of MV, remifentanil significantly improves sedation and agitation levels and reduces weaning time. This contributes to a shorter duration of MV and ICU-LOS.

Topics: Cross-Over Studies; Female; Humans; Hypnotics and Sedatives; Male; Middle Aged; Netherlands; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Respiration, Artificial; Respiratory Insufficiency; Ventilator Weaning

Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses.. In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued.. Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 +/- 0.011 microg x kg(-1) x min(-1)) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates.. Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube.

Topics: Adolescent; Adult; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Blood Pressure; Cough; Double-Blind Method; Drug Administration Schedule; Female; Heart Rate; Humans; Hypotension; Infusions, Intravenous; Intubation, Intratracheal; Male; Middle Aged; Nose; Piperidines; Prospective Studies; Psychomotor Agitation; Remifentanil; Severity of Illness Index; Tachycardia; Time Factors; Treatment Outcome; Young Adult

The aim of this study was to compare the effects of sevoflurane vs. sevoflurane and remifentanil on cough and agitation during emergence and recovery after fiberoptic bronchoscopy.. Children between 2 and 6 years of age undergoing fiberoptic bronchoscopy were enrolled. All patients were premedicated with oral midazolam. Patients were randomly assigned to either group S (sevoflurane alone, n = 25) or group SR (sevoflurane with remifetanil, n = 25). Anaesthesia was induced and maintained with sevoflurane in all patients. Group SR received remifentanil at a bolus dose of 1 microg/kg over 2 min followed by a maintenance infusion of 0.15 microg/kg/min. In addition to routine anaesthesia documentation, agitation scores and cough scores were recorded every 5 min during emergence and recovery.. Duration of the procedure, anaesthesia and emergence phases was similar in both groups (P > 0.05). Time until recovery was significantly shorter in group SR than in group S (7.0 +/- 5.5 min and 13.0 +/- 3.5 min, respectively; P = 0.001). Cough scores were not significantly different between the two groups during emergence and recovery (Kruskal-Wallis ANOVA test, P > 0.05). However, the mean agitation score at 5 min in group SR was significantly higher than that in group S (Kruskal-Wallis ANOVA test, P < 0.01). One case of hypoxaemia from thoracic rigidity occurred in a patient in group SR.. The addition of remifentanil significantly shortened recovery time in children undergoing fiberoptic bronchoscopy under sevoflurane anaesthesia. In the recovery period, remifentanil did not decrease cough, and increased agitation.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Bronchoalveolar Lavage; Bronchoscopy; Child; Child, Preschool; Cough; Female; Fiber Optic Technology; Humans; Male; Methyl Ethers; Piperidines; Psychomotor Agitation; Remifentanil; Sevoflurane; Time Factors; Treatment Outcome

Good practice guidelines state that a psychological intervention should usually precede pharmacotherapy, but there are no data evaluating the feasibility of psychological interventions used in this way.. At the first stage of a randomized blinded placebo-controlled trial, 318 patients with Alzheimer disease (AD) with clinically significant agitated behavior were treated in an open design with a psychological intervention (brief psychosocial therapy [BPST]) for 4 weeks, preceding randomization to pharmacotherapy. The therapy involved social interaction, personalized music, or removal of environmental triggers.. Overall, 318 patients with AD completed BPST with an improvement of 5.6 points on the total Cohen-Mansfield Agitation Inventory (CMAI; mean [SD], 63.3 [16.0] to 57.7 [18.4], t = 4.8, df = 317, p < 0.0001). Therapy worksheets were completed in six of the eight centers, with the key elements of the intervention delivered according to the manual for >95% of patients. More detailed evaluation of outcome was completed for the 198 patients with AD from these centers, who experienced a mean improvement of 6.6 points on the total CMAI (mean [SD], 62.2 [14.3] to 55.6 [15.8], t = 6.5, df = 197, p < 0.0001). Overall, 43% of participants achieved a 30% improvement in their level of agitation.. The specific attributable benefits of BPST cannot be determined from an open trial. However, the BPST therapy was feasible and was successfully delivered according to an operationalized manual. The encouraging outcome indicates the need for a randomized controlled trial of BPST.

Topics: Aged; Aged, 80 and over; Alzheimer Disease; Cholinesterase Inhibitors; Donepezil; Female; Homes for the Aged; Humans; Indans; Male; Middle Aged; Neuropsychological Tests; Nursing Homes; Piperidines; Psychomotor Agitation; Psychotherapy; Treatment Outcome

To assess the efficacy and tolerability of quetiapine for agitation or psychosis in patients with dementia and parkinsonism.. Multicenter randomized, double-blind, placebo-controlled parallel groups clinical trial involving 40 patients with dementia with Lewy bodies (n = 23), Parkinson disease (PD) with dementia (n = 9), or Alzheimer disease with parkinsonian features (n = 8). The main outcome measure for efficacy was change in the Brief Psychiatric Rating Scale (BPRS) from baseline to 10 weeks of therapy. For tolerability it was change in the Unified PD Rating Scale (UPDRS) motor section over the same time period. The trial was confounded by the need for a design change and incomplete recruitment.. No significant differences in the primary or secondary outcome measures of efficacy were observed. An unexpectedly large placebo effect, inadequate dosage (mean 120 mg/day), and inadequate power may have contributed to lack of demonstrable benefit. Quetiapine was generally well-tolerated and did not worsen parkinsonism, but was associated with a trend toward a decline on a measure of daily functioning.. Quetiapine was well-tolerated and did not worsen parkinsonism. Although conclusions about efficacy may be limited, the drug in the dosages used did not show demonstrable benefit for treating agitation or psychosis in patients with dementia and parkinsonism. These findings are in keeping with prior studies reporting limited efficacy of various medications for reducing behavioral problems in demented patients.

Topics: Activities of Daily Living; Aged; Aged, 80 and over; Alzheimer Disease; Antiparkinson Agents; Antipsychotic Agents; Cholinesterase Inhibitors; Confounding Factors, Epidemiologic; Dementia; Dibenzothiazepines; Donepezil; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Indans; Lewy Body Disease; Male; Neuropsychological Tests; Parkinson Disease; Patient Selection; Piperidines; Placebo Effect; Psychomotor Agitation; Psychotic Disorders; Quetiapine Fumarate; Research Design; Severity of Illness Index; Treatment Failure

Agitation is a common and distressing symptom in patients with Alzheimer's disease. Cholinesterase inhibitors improve cognitive outcomes in such patients, but the benefits of these drugs for behavioral disturbances are unclear.. We randomly assigned 272 patients with Alzheimer's disease who had clinically significant agitation and no response to a brief psychosocial treatment program to receive 10 mg of donepezil per day (128 patients) or placebo (131 patients) for 12 weeks. The primary outcome was a change in the score on the Cohen-Mansfield Agitation Inventory (CMAI) (on a scale of 29 to 203, with higher scores indicating more agitation) at 12 weeks.. There was no significant difference between the effects of donepezil and those of placebo on the basis of the change in CMAI scores from baseline to 12 weeks (estimated mean difference in change [the value for donepezil minus that for placebo], -0.06; 95% confidence interval [CI], -4.35 to 4.22). Twenty-two of 108 patients (20.4%) in the placebo group and 22 of 113 (19.5%) in the donepezil group had a reduction of 30% or greater in the CMAI score (the value for donepezil minus that for placebo, -0.9 percentage point; 95% CI, -11.4 to 9.6). There were also no significant differences between the placebo and donepezil groups in scores for the Neuropsychiatric Inventory, the Neuropsychiatric Inventory Caregiver Distress Scale, or the Clinician's Global Impression of Change.. In this 12-week trial, donepezil was not more effective than placebo in treating agitation in patients with Alzheimer's disease. (ClinicalTrials.gov number, NCT00142324 [ClinicalTrials.gov].).

Topics: Aged; Aged, 80 and over; Alzheimer Disease; Cholinesterase Inhibitors; Donepezil; Double-Blind Method; Female; Humans; Indans; Male; Piperidines; Psychomotor Agitation; Psychotherapy; Social Support; Treatment Failure

This prospective randomized study, deals with neurosedation in dental treatment of 200 disabled patients and unable to cooperate, subdivided in 4 groups of 50 male only patients, with age ranging from 28 to 59 (39+/-11), ASA I-III.. The pharmaceuticals used were Midazolam (group MID) Propofol (group Prop) and Remifentanil. Midazolam and Propofol were used following a bolus-infusion sequence, both separately and in combination among themselves (MID\\PROP group), or with an opioid, Remifentanil (MID\\PROP\\REMI group). ECG, heart rate , non invasive blood pressure (NIBP), SaO(2), EtCO(2) during the procedure were monitored. Induction time, duration of the sedation, recovery time and discharge were reported.. The statistical analysis demonstrated the superiority of the PROP group for induction time in minute (3.1+/-0.5) in comparison with the MID group (10.6+/-2.1), the MID\\PROP group (4.3+/-1.3) and MID\\PROP\\REMI (3.7+/-1.2). The recovery and discharge times have confirmed the superiority of the MID\\PROP\\REMI group in comparison with the other 3 groups.. This combination proved best at leveraging the synergistic characteristics of each single pharmaceutical and minimizing the collateral effects of each individually.

Topics: Adult; Conscious Sedation; Dental Anxiety; Dental Implantation; Disabled Persons; Drug Synergism; Drug Therapy, Combination; Hemodynamics; Humans; Hypnotics and Sedatives; Infusions, Intravenous; Injections, Intravenous; Jaw Cysts; Male; Mandibular Diseases; Midazolam; Middle Aged; Oral Hygiene; Piperidines; Propofol; Prospective Studies; Psychomotor Agitation; Remifentanil; Root Canal Therapy; Tooth Extraction; Treatment Outcome

To investigate the behavioral effects of memantine in moderate to severe Alzheimer disease (AD).. The authors conducted a hypothesis-generating, exploratory analysis of a 24-week, double-blind, placebo-controlled trial comparing memantine (20 mg/day) with placebo in subjects with moderate to severe AD on stable donepezil treatment. They employed the Neuropsychiatric Inventory (NPI; 12-item), administered at baseline, week 12, and week 24, to assess the effects of memantine on behavior. Global, cognitive, and functional measures were collected and relationships between these assessments and changes in behavior were determined. The intent-to-treat population was examined using last-observation-carried-forward and observed-cases approaches.. Patients treated with memantine had significantly lower NPI total scores than patients treated with placebo. Analyses of the 12 NPI domains revealed significant effects in favor of memantine on agitation/aggression, eating/appetite, and irritability/lability. Of patients who exhibited agitation/aggression at baseline, those treated with memantine showed significant reduction of symptoms compared with placebo-treated patients. Memantine-treated patients without agitation/aggression at baseline evidenced significantly less emergence of this symptom compared with similar patients receiving placebo. Caregivers of patients receiving memantine registered significantly less agitation-related distress. There were significant relationships between the NPI and the global rating scale and performance of activities of daily living, but not between changes in the NPI and cognition.. Treatment with memantine reduced agitation/aggression, irritability, and appetite/eating disturbances. Memantine reduced agitation/aggression in patients who were agitated at baseline and delayed its emergence in those who were free of agitation at baseline.

Topics: Activities of Daily Living; Aged; Aged, 80 and over; Alzheimer Disease; Antiparkinson Agents; Behavioral Symptoms; Donepezil; Double-Blind Method; Female; Humans; Indans; Male; Memantine; Mental Status Schedule; Middle Aged; Neuropsychological Tests; Nootropic Agents; Outcome Assessment, Health Care; Piperidines; Prospective Studies; Psychomotor Agitation; Severity of Illness Index; Time Factors

This open label, multicentre study was conducted to assess the times to offset of the pharmacodynamic effects and the safety of remifentanil in patients with varying degrees of renal impairment requiring intensive care.. A total of 40 patients, who were aged 18 years or older and had normal/mildly impaired renal function (estimated creatinine clearance >/= 50 ml/min; n = 10) or moderate/severe renal impairment (estimated creatinine clearance <50 ml/min; n = 30), were entered into the study. Remifentanil was infused for up to 72 hours (initial rate 6-9 microgram/kg per hour), with propofol administered if required, to achieve a target Sedation-Agitation Scale score of 2-4, with no or mild pain.. There was no evidence of increased offset time with increased duration of exposure to remifentanil in either group. The time to offset of the effects of remifentanil (at 8, 24, 48 and 72 hours during scheduled down-titrations of the infusion) were more variable and were statistically significantly longer in the moderate/severe group than in the normal/mild group at 24 hours and 72 hours. These observed differences were not clinically significant (the difference in mean offset at 72 hours was only 16.5 min). Propofol consumption was lower with the remifentanil based technique than with hypnotic based sedative techniques. There were no statistically significant differences between the renal function groups in the incidence of adverse events, and no deaths were attributable to remifentanil use.. Remifentanil was well tolerated, and the offset of pharmacodynamic effects was not prolonged either as a result of renal dysfunction or prolonged infusion up to 72 hours.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Conscious Sedation; Drug Therapy, Combination; Female; Humans; Hypnotics and Sedatives; Infusions, Intravenous; Intensive Care Units; Male; Middle Aged; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Renal Insufficiency; Safety; Severity of Illness Index; Time Factors

No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques.. This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).. Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour.. This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.

Topics: Age Factors; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child Behavior; Child, Preschool; Delirium; Female; Humans; Isoflurane; Pain, Postoperative; Piperidines; Prospective Studies; Psychiatric Status Rating Scales; Psychomotor Agitation; Random Allocation; Remifentanil

Akathisia is a frequent and distressing side effect of antipsychotic medication. Little is known about its pathophysiology. Treatment trials of serotonin antagonists in Parkinson's disease and neuroleptic-induced Parkinsonism have been disappointing, with the possible exception of akathisia which has been reported to respond favorably to ritanserin. We report first results of a single-blind trial of ritanserin in the treatment of neuroleptic-induced akathisia. Ten patients received a mean dose of 13.5 mg/day (SD +/- 5.8) ritanserin for 2 to 4 days. Treatment response was assessed by the Hillside Akathisia Scale (HAS). HAS baseline ratings were 16.4 (+/- 6). After 3 days of treatment, these values dropped to 7.4 (+/- 5.2). This amelioration was statistically significant (p = .0069 matched-pairs signed rank test). Two patients did not respond. These results, although preliminary in nature, are encouraging and warrant further studies.

Topics: Administration, Oral; Adult; Akathisia, Drug-Induced; Antipsychotic Agents; Female; Humans; Male; Piperidines; Psychomotor Agitation; Ritanserin; Serotonin Antagonists

Mutations of the. We investigated the behavior of mice with a conventional or conditional deletion of. Conventional heterozygous

Topics: Animals; Anxiety; Autism Spectrum Disorder; Dioxoles; Gamma Rhythm; Haploinsufficiency; Male; Membrane Transport Modulators; Memory; Mice; Mice, Inbred C57BL; NAV1.2 Voltage-Gated Sodium Channel; Phenotype; Piperidines; Prefrontal Cortex; Psychomotor Agitation; Social Behavior

Pain is considered as being one cause of post-operative emergence agitation (EA) from sevoflurane anaesthesia. The purpose of this study was to investigate the pure effect of post-operative pain on EA after sevoflurane anaesthesia in preschool children undergoing excision of scalp nevi.. Forty-four children, 1-7 years old, undergoing scalp nevus excision were enrolled. Patients were randomly assigned to two groups: the remifentanil group received single intravenous injection of short-acting synthetic opioid, remifentanil 1 μg/kg just before the scalp incision, and the block group received scalp nerve block with 0.25% ropivacaine after intubation. The end-tidal sevoflurane concentration was maintained around 1.5 vol% unless the mean arterial pressure is out of ±20% range of preoperative values during surgery in both groups. Watcha behaviour scale for EA and face, legs, activity, cry, consolability (FLACC) scale scores for pain were recorded post-operatively.. There was no difference in end-tidal sevoflurane concentration between the two groups during surgery and the emergence period. Agitation incidence and scores were not different between the two groups during the recovery period. FLACC scale was significantly lower in the block group than in the remifentanil group at post-anaesthesia care unit (PACU) arrival, at 10 and 20 min after PACU arrival, respectively.. The scalp nerve block decreased the early post-operative pain after paediatric nevus excision, but it did not decrease the incidence of EA with sevoflurane anaesthesia.

Topics: Amides; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Child; Child Behavior; Child, Preschool; Emergence Delirium; Female; Humans; Infant; Male; Methyl Ethers; Nerve Block; Nevus; Pain, Postoperative; Piperidines; Prospective Studies; Psychomotor Agitation; Remifentanil; Ropivacaine; Scalp; Sevoflurane; Single-Blind Method

Emergence agitation (EA) is a common phenomenon in preschool children during emergence from general anesthesia. This study evaluated the safety and efficacy of dezocine for emergence agitation in preschool children anesthetized with sevoflurane-remifentanil.. A total of 100 preschool children, scheduled for elective laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia were randomized into two groups: Group C (n = 50) received Ringer's lactate 10 mL and Group D received Ringer's lactate 10 mL containing dezocine 0.1 mg/kg, postoperatively.. Incidence of EA, defined as a score ≥ 3 on Aono's four point scale or Pediatric Anesthesia Emergence Delirium (PAED) score ≥ 10 in the PACU (10% vs. 76%) and the percentage of patients with severe EA (PAED score ≥ 13) (12% vs. 76%) were significantly lower in Group D compared to Group C (P < 0.05). Mean Children and Infants Postoperative Pain Scale (CHIPPS) score was significantly lower in Group D compared to Group C (1.2 ± 0.5 vs. 5.2 ± 0.6; P < 0.05). Patients need for fentanyl (18% vs. 4%) or propofol rescue (20% vs. 0) was significantly greater in Group C compared to Group D. No significant differences in other relative aspects after surgery between groups.. Administration of dezocine 0.1 mg/kg decreased the incidence and severity of EA in preschool children that had undergone laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia.. A single dose of dezocine suppresses emergence agitation in preschool children anesthetized with sevoflurane-remifentanil effectively: A double-blind, prospective, randomized, controlled study, Chinese Clinical Trial Registry (ID: ChiCTR-IOR-16010033), retrospectively registered on November 21, 2016.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Bridged Bicyclo Compounds, Heterocyclic; Child, Preschool; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Piperidines; Postoperative Complications; Prospective Studies; Psychomotor Agitation; Remifentanil; Sevoflurane; Tetrahydronaphthalenes

To investigate the effects of remifentanil and dexmedetomidine on recovery period after oral and maxillofacial surgery.. Sixty cases undergoing oral and maxillofacial surgery were randomly divided into 3 groups, including remifentanil group (group R), dexmedetomidine group (group D) and normal saline group (group C). Ten minutes before the end of surgery, the patients were given target control infusion of remifentanil at effect-site concentration of 1.5 ng/mL in group R or dexmedetomidine 0.5 μg/kg in group D or normal saline in group C, respectively. The haemodynamic parameters, Ramsay scales, coughing, agitation were recorded. Extubation time and incidence of adverse events were observed as well. Statistical analysis was performed using SPSS20.0 software package.. The mean arterial pressure and heart rate at the time of extubation were significantly lower in group D and group R than those in group C (P<0.05). The Ramsay scores were significantly better in group D and group R than in group C at the time point of 5 minutes and 10 minutes after extubation , and the score in group D was better than in group R at the same time (P<0.05). The incidences of coughing and agitation were significantly lower in group D and group R than in group C (P<0.05). There was no significant difference in extubation time.. Dexmedetomidine and remifentanil can reduce the haemodynamic responsiveness, coughing and agitation during the recovery period of oral and maxillofacial surgery without extending the extubation time. Dexmedetomidine can provide longer sedation time than TCI of remifentanil.

Topics: Airway Extubation; Analgesics, Non-Narcotic; Anesthesia Recovery Period; Cough; Dexmedetomidine; Heart Rate; Humans; Piperidines; Psychomotor Agitation; Remifentanil; Surgery, Oral

Over the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse.. During a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified.. This is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.

Topics: Academic Medical Centers; Adult; Combined Modality Therapy; Cyclohexenes; Designer Drugs; Drug Users; Emergency Service, Hospital; Fatal Outcome; Female; Humans; Illicit Drugs; Male; Middle Aged; Multiple Organ Failure; Neurotoxicity Syndromes; Piperidines; Psychomotor Agitation; Psychotropic Drugs; Rhabdomyolysis; Toxicokinetics; Treatment Outcome; Treatment Refusal

Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80 % of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium.. Within the framework of this study the question arose whether the barbiturate methohexital could be associated with a lower incidence of delirium in comparison to midazolam or propofol in analgosedated and ventilated ICU patients.. This was a prospective nonrandomized observational cohort study in a mixed medical surgical intensive care unit. Patients ventilated within 72 h after admittance were consecutively allocated to either propofol/remifentanil versus methohexital/remifentanil (expected ventilation duration ≤ 7 days) or midazolam/fentanyl versus methohexital/fentanyl (expected ventilation duration > 7 days) by the attending senior consultant anesthetist at the time of admission and/or intubation. Primary endpoint was delirium at any time during the ICU stay. Delirium was checked every 8 h by ICU nurses using the intensive care delirium screening checklist (ICDSC), with delirium defined as ICDSC ≥ 4 points. Before evaluation of the ICDSC the Richmond agitation sedation scale (RASS) score and the visual analogue scale for pain (VAS target ≤ 4) were measured. To assure reliable evaluation of the ICDSC, the RASS score of the patient at the time of evaluation had to be ≥ - 2. Assuming an incidence of delirium in the midazolam group of 70 % and in the methohexital group of 35 %, 16 patients were needed each in the midazolam/fentanyl and the methohexital/fentanyl cohorts (p = 0.05, β = 0.1). Assuming an incidence of delirium in the propofol group of 50 % and in the methohexital group again of 35 %, 94 patients were needed in the propofol/remifentanil and methohexital/remifentanil groups, respectively (p = 0.05, β = 0.1).. A total of 222 patients were evaluated, 34 in the methohexital vs. midazolam group and 188 in the methohexital vs. propofol group. Out of 16 patients sedated with midazolam, 15 developed delirium (94 %) in contrast to only 5 out of 18 patients sedated with methohexital (28 %). Thus compared to midazolam the sedation with methohexital reduced the incidence of delirium by 66 % (p < 0.001) corresponding to a number needed to treat (NNT) of 1.5. Out of 94 patients in the propofol/remifentanil group, 64 developed delirium (68 %) in contrast to only 23 out of 94 in the methohexital/remifentanil group (24 %). Thus compared to propofol the sedation with methohexital reduced the incidence of delirium by 44 % (p < 0.001), corresponding to an NNT of 2.5.. Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50 % in ventilated ICU patients.

Topics: Aged; Analgesics, Opioid; Anesthetics, Intravenous; Checklist; Cohort Studies; Critical Care; Delirium; Drug Therapy, Combination; Female; Humans; Hypnotics and Sedatives; Male; Methohexital; Middle Aged; Piperidines; Propofol; Prospective Studies; Psychomotor Agitation; Remifentanil; Respiration, Artificial

Topics: Apathy; Behavioral Symptoms; Delusions; Donepezil; Follow-Up Studies; Frontotemporal Dementia; Humans; Indans; Irritable Mood; Nootropic Agents; Pilot Projects; Piperidines; Psychomotor Agitation; Risk Assessment

Diphenylpyraline hydrochloride (DPP) is an internationally available antihistamine that produces therapeutic antiallergic effects by binding to histamine H₁ receptors. The complete neuropharmacological and behavioral profile of DPP, however, remains uncharacterized. Here we describe studies that suggest DPP may fit the profile of a potential agonist replacement medication for cocaine addiction. Aside from producing the desired histamine reducing effects, many antihistamines can also elicit psychomotor activation and reward, both of which are associated with increased dopamine concentrations in the nucleus accumbens (NAc). The primary aim of this study was to investigate the potential ability of DPP to inhibit the dopamine transporter, thereby leading to elevated dopamine concentrations in the NAc in a manner similar to cocaine and other psychostimulants. The psychomotor activating and rewarding effects of DPP were also investigated. For comparative purposes cocaine, a known dopamine transporter inhibitor, psychostimulant and drug of abuse, was used as a positive control. As predicted, both cocaine (15 mg/kg) and an equimolar dose of DPP (14 mg/kg) significantly inhibited dopamine uptake in the NAc in vivo and produced locomotor activation, although the time-course of pharmacological effects of the two drugs was different. In comparison to cocaine, DPP showed a prolonged effect on dopamine uptake and locomotion. Furthermore, cocaine, but not DPP, produced significant conditioned place preference, a measure of drug reward. The finding that DPP functions as a potent dopamine uptake inhibitor without producing significant rewarding effects suggests that DPP merits further study as a potential candidate as an agonist pharmacotherapy for cocaine addiction.

Topics: Animals; Behavior, Animal; Benztropine; Central Nervous System Stimulants; Cocaine; Cocaine-Related Disorders; Dopamine Uptake Inhibitors; Exploratory Behavior; Histamine H1 Antagonists; Illicit Drugs; Kinetics; Male; Mice; Mice, Inbred C57BL; Motor Activity; Nucleus Accumbens; Piperidines; Psychomotor Agitation; Reward; Spatial Behavior

The aim of this study was to evaluate the recovery complications following the use of 2 anesthetic protocols in orthognathic surgery, namely, propofol with remifentanil and isoflurane with remifentanil. Sixty-two patients with American Society of Anesthesiologists physical status I were selected. All underwent bimaxillary orthognathic surgery. Propofol with remifentanil was used as an anesthesia in group 1 (n = 32), and isoflurane with remifentanil was used in the patients in group 2 (n = 30). Early recovery complications consisting of pain, postoperative nausea and vomiting (PONV), shivering, and agitation were evaluated and documented. The length of the operation and duration of recovery were documented for all patients. Analysis of the data demonstrated no relationship between age and recovery time (P > 0.05). Analysis of data with χ(2) and independent t-tests did not show any difference between the 2 groups with regard to pain, agitation, PONV, and shivering (P > 0.05). Logistic regression was used to evaluate the effect of the operation time on recovery complications. The analysis showed that pain and PONV were significantly higher in those who experienced a longer operation time. With increasing operation time longer than 165 minutes, 64% of patients experienced pain, and 89% of them had PONV. General anesthesia can be provided via intravenously administered medications and/or inhaled volatile anesthetics. No significant difference in early recovery time was found in patients when either isoflurane or propofol was used to maintain the anesthesia. However, the length of the operation played a major role in increasing early recovery complications.

Topics: Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Chi-Square Distribution; Female; Humans; Isoflurane; Logistic Models; Male; Orthognathic Surgery; Pain Measurement; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Psychomotor Agitation; Remifentanil; Shivering; Statistics, Nonparametric; Young Adult

Topics: Aged; Antipsychotic Agents; Delirium; Humans; Male; Piperazines; Piperidines; Pneumonia; Psychiatric Status Rating Scales; Psychomotor Agitation; Risperidone

Topics: Alzheimer Disease; Humans; Indans; Piperidines; Psychomotor Agitation; Randomized Controlled Trials as Topic

Topics: Akathisia, Drug-Induced; Antipsychotic Agents; Aripiprazole; Basal Ganglia Diseases; Dopamine Agonists; Dopamine Antagonists; Dose-Response Relationship, Drug; Humans; Piperazines; Piperidines; Positron-Emission Tomography; Psychomotor Agitation; Quinolones; Receptor, Serotonin, 5-HT1A; Receptors, Dopamine D2; Schizophrenia; Serotonin 5-HT1 Receptor Agonists; Urea

Delirium and agitation are commonly encountered after administration of electroconvulsive therapy (ECT). Management is generally fairly straightforward, although some patients may have a severe, prolonged, or refractory course. We recently cared for a 65-year-old man who consistently developed severe and very prolonged post-ECT delirium that did not respond to typical pharmacological agents; the duration of delirium was dramatically shortened by the addition of donepezil. Cholinesterase inhibitors may have a place in mitigating severe and prolonged post-ECT delirium.

Topics: Aged; Cholinesterase Inhibitors; Delirium; Depressive Disorder, Major; Donepezil; Electroconvulsive Therapy; Humans; Indans; Male; Piperidines; Psychomotor Agitation

Topics: Aged; Alzheimer Disease; Antipsychotic Agents; Cholinesterase Inhibitors; Donepezil; Humans; Indans; Patient Selection; Piperidines; Psychomotor Agitation; Psychotherapy; Social Support; Treatment Failure

To describe the assessment and treatment of an elderly woman with parkinsonism, progressive memory and cognitive deficits, and visual hallucinations.. The patient presented with a 10-year history of hand tremors, an 8-year history of short-term memory problems, and a 3-4-year history of visual hallucinations. Treatment with donepezil and rivastigmine (successively) did not produce the desired benefits. Then she was started on galantamine 4 mg b.i.d. (escalated to 8 mg b.i.d.).. The patient's social interaction improved and cognitive decline appeared to be stabilized; hallucinations and agitation were also better controlled.. By current criteria, this subject would be labeled as having Parkinson's disease with dementia, although she exhibited the core features of dementia with Lewy body disease. As suggested in previous studies, cholinesterase inhibitors may be effective in treating psychotic symptoms; however, all currently available agents may not be equally effective.

Topics: Aged; Aged, 80 and over; Carbamates; Cognition Disorders; Donepezil; Drug Resistance; Female; Galantamine; Hallucinations; Humans; Indans; Lewy Body Disease; Neuroprotective Agents; Nootropic Agents; Phenylcarbamates; Piperidines; Psychomotor Agitation; Rivastigmine; Social Behavior

A new diaryl-methylene piperidine derivative, 2, displayed an atypical antipsychotic profile both in vitro and in vivo. The main pharmacological characteristics of this compound appears to reside in a more potent antagonism of the 5-HT2 serotonergic receptor than of the D2 dopaminergic receptor. This confirms that molecules displaying a D2/5-HT2 binding ratio < 1 possess clozapine-like antipsychotic activity.

Topics: Animals; Antipsychotic Agents; Disease Models, Animal; Dose-Response Relationship, Drug; Drug Evaluation, Preclinical; Mice; Piperidines; Protein Binding; Psychomotor Agitation; Psychotic Disorders; Receptors, Dopamine D2; Receptors, Serotonin; Serotonin Antagonists

We report two patients who developed Pisa syndrome after treatment with cholinesterase inhibitors--cognition-enhancing novel agents for patients with Alzheimer's disease. Cholinergic excess could be another factor in Pisa syndrome, especially in cholinergically-imbalanced Alzheimer's disease.

Topics: Aged; Alzheimer Disease; Carbamates; Cholinesterase Inhibitors; Donepezil; Dopamine Antagonists; Dystonia; Female; Humans; Indans; Memory Disorders; Middle Aged; Neuroprotective Agents; Nootropic Agents; Phenylcarbamates; Piperidines; Posture; Psychomotor Agitation; Risperidone; Rivastigmine; Syndrome

Sundowning, manifested as a recurring increase in restlessness and agitation in the evening, is described in a 71-year-old man with clinically diagnosed dementia with Lewy bodies. An objective measure of activity using the activity electronic monitoring technique indicated a marked increase in activity level during the evening compared to earlier in the day. After treatment with donepezil, a cholinesterase inhibitor, ratings of behavioural symptoms improved. In addition, there was a marked reduction in evening activity and an increase in daytime activity. Cognition and parkinsonism also improved. Possible explanations for this finding are discussed.

Topics: Aged; Cholinesterase Inhibitors; Circadian Rhythm; Donepezil; Humans; Indans; Lewy Body Disease; Male; Piperidines; Psychomotor Agitation; Treatment Outcome

Topics: Akathisia, Drug-Induced; Child, Preschool; Diazepam; Female; Humans; Medication Errors; Piperidines; Psychomotor Agitation

Topics: Bipolar Disorder; Butyrophenones; Hallucinations; Humans; Hypnotics and Sedatives; Intellectual Disability; Mental Disorders; Paranoid Disorders; Paresis; Parkinsonian Disorders; Piperidines; Psychomotor Agitation; Psychotic Disorders; Schizophrenia

Topics: Aged; Anxiety; Anxiety Disorders; Disease; Humans; Piperidines; Psychomotor Agitation; Reserpine

Topics: Electroencephalography; Humans; Pentylenetetrazole; Piperidines; Psychomotor Agitation