Biomedical subjects

R Conradi

Publications and source records attributed to R Conradi.

At least 19 recordsLinked to original sources

PubMed2003

[Ultrasound and local anaesthesia. Part III: ultrasound and neuroaxial local anaesthesia].

The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia. This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques. The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented. We review all presently available data on the prediction of the puncture depth. The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm. Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31. The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels. The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved. The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.

Anesthesia, Epidural↗

PubMed2002

[The visualisation of dura perforation and blood patches with ultrasound].

The postdural puncture headache (PDPH) is a possible complication after spinal or epidural puncture. The therapeutic concept is usually organised step by step, but the epidural blood patch is the most reliable and effective therapy. In earlier studies myelographie, epidurographie and MRT were used, to visualise the localisation of the dural defect and to describe the effects of patching the epidural space. Our working group focused on the utilisation of ultrasound and we decided to use this technique for the visualisation of bloodpatches. With agreement of the local ethics committee we monitored the performance of 4 epidural bloodpatches in pregnant women, who suffered from PDPH. We used a General Electric LQ 400 ultrasonograph with a 7-MHz-probe. To ensure sterile conditions we used sterile ultrasound sleeves and sterile ultrasound gel. In 3 of 4 cases a continuity loss could be represented in the doppel layer signal of the dura. It had the size of the diameter of a Tuohy needle. In one case the defect of the dura was larger than in the preliminary investigations (2,5 - 3 mm). The ultrasonography of the epidural space was performed in the paramedian scan. All patches were placed by using the conventional loss of resistance technique with using online ultrasound support. The epidural puncture and the application of the blood patches were visualised simultaneously in all cases. With the injection of blood a brief expansion of the epidural space was seen. The patients recieved a mean injection volume of 17 ml sterile blood. 10 to 40 seconds after the injection of blood the disconituity of the dura doppel layer signal was no longer provable. Within a short time we could detect the increase of cerebrospinal fluid and the patients headache was treated sucessfully. The clinical use of this diagnostic technique can be found in the simultaneous presentation of the dura leakage and the intervention while performing an epidural bloodpatch. Since these informations are relevant for further clinical practice further investigations are warranted.

Adult↗

PubMed2001

[Ultrasonography and peridural anesthesia. Technical possibilities and limitations of ultrasonic examination of the epidural space].

Epidural anaesthesia (EA) is the most important analgesia technique in obstetrics for delivery. In pregnancy, hormonal adjustments lead to an alteration of tissue consistency, which often causes an early, untimely loss of resistance. Apart from mere inspection and palpation, no useful diagnostic method prior to EA performance has been established yet. In this prospective study, we examined 100 pregnant women, who had been admitted for childbirth and were undergoing epidural block (level L3-L4) for delivery. Sonotopography of the lumbar epidural structures was performed directly before epidural puncture and childbirth. We evaluated the visibility of all anatomical structures and compared all distances measured by ultrasonography and during puncture. The correlation between distances measured by ultrasound and by puncture needle was high (r2 = 0.79). No obvious dependency was found between ultrasonic and puncture angle (r2 = 0.19). The temporal distance from ultrasonic examination and puncture causes unavoidable differences: each deviation between ultrasound and puncture conditions causes a modification of the puncture depth. The patient acceptance of the procedure was very good. Ultrasonography offers the possibility to determine site and direction of epidural puncture and distance of the epidural space to the skin even before the puncture attempt. The ultrasound controlled EA for delivery can easily be inserted into the clinical routine. Ultrasonography can fill an important diagnostic gap in regional anaesthesia.

Adult↗

PubMed2001

Paramedian access to the epidural space: the optimum window for ultrasound imaging.

STUDY OBJECTIVE: To establish a useful ultrasonic approach to the epidural space so as to optimize pre-puncture diagnostics. DESIGN: Prospective study. SETTING: University clinic. PATIENTS: 60 participants (19 to 34 years of age), 40 healthy volunteers (20 male, 20 female) and 20 parturients. INTERVENTIONS: Ultrasound scanning of the lumbar spine was performed at the L(3)-L(4) vertebral interspace. Three ultrasound planes were employed: the transverse, median, and paramedian longitudinal approaches. MEASUREMENTS: We compared the width of the ultrasound-permeable area in the median and paramedian planes and assessed the visibility of the epidural space and its surrounding structures. MAIN RESULTS: In the paramedian plane, the permeable window was larger (p < 0.001) than in the median approach. The visibility of the ligamentum flavum (p < 0.0001), dura mater (p < 0.0001), and cauda equina (p < 0.0001) was significantly higher. Pulsation of epidural vessels could be observed more frequently (p < 0.0001) in the paramedian plane. CONCLUSIONS: The longitudinal paramedian plane provided information about the epidural space depth in excellent imaging quality. The additional information might be beneficial in epidural anesthesia and in other clinical specialties (e.g., neurosurgery, trauma care).

Adult↗

PubMed2001

Ultrasound control for presumed difficult epidural puncture.

BACKGROUND: The efficacy of epidural anaesthesia depends on the accurate identification of the epidural space (ES). Abnormal anatomical conditions may make the procedure difficult or impossible. The aim of this study was to investigate whether pre-puncture ultrasound examination of the spinal anatomy might be beneficial in expected cases of difficult epidural anaesthesia. METHODS: We used digital ultrasound equipment with a 5-MHz transducer to assess the anatomy of the ES and the posterior parts of the spinal column. We examined 72 parturients with abnormal anatomical conditions who were scheduled for epidural anaesthesia. The women were randomised into two equal groups. In all patients, the standard loss of resistance technique was used. In the ultrasound group, an ultrasound examination of the appropriate spinal region was conducted prior to epidural puncture. ES depth seen on the ultrasound images was compared to the ES depth measured by the needle. We compared the number of puncture attempts with the standard method (control group) to the number of attempts under ultrasound guidance. RESULTS: Ultrasonography significantly improved operating conditions for epidural anaesthesia. The maximum VAS scores and patient acceptance were significantly better. CONCLUSIONS: With ultrasound measurement of the ES depth, the quality of epidural anaesthesia was enhanced.

Adult↗

PubMed2001

The lumbar epidural space in pregnancy: visualization by ultrasonography.

Epidural anaesthesia is an important analgesia technique for obstetric delivery. During pregnancy, however, obesity and oedema frequently obscure anatomical landmarks. Using ultrasonography, we investigated the influence of these changes on spinal and epidural anatomy. We examined 53 pregnant women who were to receive epidural block for vaginal delivery or Caesarean section. The first ultrasound imaging was performed immediately before epidural puncture; the follow-up scan was done 9 months later. The ultrasound scan of the spinal column was performed at the L3/4 interspace in transverse and longitudinal planes, using a Sonoace 6000 ultrasonograph (Kretz, Marl, Germany) equipped with a 5.0-MHz curved array probe. We measured two distances from the skin to the epidural space: the minimum (perpendicular) and the maximum (oblique) needle trajectory. The quality of ultrasonic depiction was analysed by a numerical scoring system. An average weight reduction of 12.5 kg had occurred by the follow-up examination. During pregnancy, the optimum puncture site available on the skin for epidural space cannulation was smaller, the soft-tissue channel between the spinal processes was narrower, and the skin-epidural space distance was greater. The epidural space was narrower and deformed by the tissue changes. The visibility of the ligamentum flavum, of the dura mater and of the epidural space decreased significantly during pregnancy. Nevertheless, ultrasonography offered useful pre-puncture information. Thus far, palpation has been the only available technique to facilitate epidural puncture. Ultrasound imaging enabled us to assess the structures to be perforated. We anticipate that this technique will become valuable clinically.

Adult↗

PubMed1999

Serum bone sialoprotein in patients with primary breast cancer is a prognostic marker for subsequent bone metastasis.

Bone sialoprotein (BSP) is a noncoflagenous bone matrix protein that is important for both mineralization and cell-cell interactions. Tissue studies in primary breast cancers have shown that immunohistochemical expression of BSP is associated with a high incidence of bone metastases in the course of the disease. We used a RIA to investigate the importance of serum BSP as a marker for subsequent bone metastases. Between 1994 and 1996, preoperative blood samples were collected from 388 consecutive patients with nonmetastatic breast cancer and from 30 control patients with benign breast disease. Serum BSP concentrations were measured in a blinded fashion by RIA. The cutoff for elevated serum BSP values was 24 ng/ml, ie., two SDs above the normal mean value. Serum BSP was correlated with the risk of metastasis and analyzed with regard to its prognostic value. After a median follow-up period of only 20 months, 28 patients had developed metastases. Fourteen patients had bone metastases only, 9 visceral metastases only, and 5 a combination of osseous and visceral metastases. Of the 19 women with skeletal metastases, 17 had preoperative serum BSP values in excess of 24 ng/ml (median BSP values: 48.3 ng/ml for isolated metastatic bone disease, 30.6 ng/ml for combined metastases), whereas none of the women with visceral metastases only had elevated serum BSP concentrations (median BSP value: 12.3 ng/ml). The median serum BSP value in the control group (benign breast disease) was 8.8 ng/ml serum BSP; levels correlated with the size of the primary tumor, but not with any other prognostic factors. Using a multivariate regression analysis, serum BSP was found to be the most important independent prognostic factor for the development of skeletal metastasis (P < 0.001; relative risk, 94); its specificity was 96.7%, and its sensitivity was 89.5%. Our study shows that patients with preoperatively elevated serum BSP levels are at high risk of subsequent bone metastases in the first years after primary surgery. The mechanism of BSP in the pathogenesis of skeletal metastases is unclear. Because BSP contains an integrin recognition sequence, its expression in tumor cells may facilitate their adhesion to the bone surface. However, it is possible that a proportion of circulation BSP is derived from normal or tumor-induced bone turnover. Breast cancer patients with elevated serum BSP levels may benefit from osteoprotective adjuvant therapy with bisphosphonates.

Adult↗

PubMed1999

[Pre-eclampsia and anesthesia].

The management of anaesthesia in patients suffering preeclampsia has to be selected individually. There is a high rate of caesarean sections in patients with preeclampsia. Intubation anaesthesia or regional anaesthesia are commonly used methods and can be considered comparable and equally useful. In our opinion, the application of regional anaesthesia should be preferred, if the initial criteria, such as normal neurologic status and blood coagulation, are fulfilled. We believe in a considerable reduction of vital risks when using regional anaesthesia. Our aim was to figure out the risk-factors of preeclampsia and preterm maturity regarding anaesthesia management. Preeclampsia is a severe illness in pregnancy with a frequency of 5-10%. In 1997, we experienced 73 patients with praeeclampsia according to the definition of ISSPH. Mode of delivery was conventional in 10 patients, 2 patients had a vacuum extraction and 61 patients needed a caesarean section. The rate of epidural anesthesia for delivery was 51%. We used epidural anaesthesia in 6 spontaneous deliveries, in 2 vacuum extractions and in 30 caesarean sections. There were no problems with epidural anaesthesia and the outcome of mother and child was also considered to be excellent. We suggest to use regional anesthesia techniques whenever possible.

Anesthesia, Conduction↗

PubMed1996

[Addition of ethanol to the distension medium in surgical hysteroscopy as screening to prevent "fluid overload". A prospective randomized comparative study of ablative versus non-ablative surgical hysteroscopy and different ethanol concentration].

For answering the question at which hysteroscopical procedures an intraoperative screening method is necessary to avoid a fluid overload and whether a beginning fluid absorption can be diagnosed early by adding ethanol to the distension medium, a prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentrations was performed (n = 120). Purisole (a mannit/sorbit solution) was used a distension medium. The measuring parameters (breath alcohol, amount of absorbed fluid, haematocrit and haemoglobin values, central venous pressure, heart frequency) were intraoperatively determined at 5-minute intervals. The results of the study show that with those hysteroscopical procedures during which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation). Intraoperative screening is not necessary due to the low absorbing amounts. With hysteroscopical procedures such as resection of myoma, endometrium ablation and septum resection, however, an addition of ethanol of 2% to the distension medium has proved useful, because with this method absorption amounts of 400 ml and more can be detected by positive values of breath alcohol. As the result of a further absorption of fluid, delayed in time compared to the first positive value of breath alcohol, there is an increase in central venous pressure and hyponatraemia. Intraoperative ethanol monitoring is a non-invasive procedure which can be performed during ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.

Adult↗

PubMed1996

[Etomidate versus propofol for anesthesia in ambulatory cardioversion].

OBJECTIVE: This study compared the two short-acting intravenous anaesthetic agents, etomidate in lipid emulsion and propofol, for anaesthesia during elective outpatient cardioversion. METHODS: After institutional approval and informed consent, 40 patients (ASA II/III) scheduled for cardioversion were studied. Patients with a left ventricular ejection fraction < 30% were excluded. The anti-arrhythmic medication was not discontinued, and no patient was given pharmacological premedication. Anaesthesia was induced either with etomidate (in lipid emulsion) 0.25 mg/kg or propofol 1.5 mg/kg. Both agents were administered over 30 seconds. Subsequent increments were given until the patients no longer followed verbal commands and the lid reflex was absent. Patients were allowed to breathe 40% oxygen via face mask. Artificial ventilation was performed if a patient became apnoeic for more than 20 seconds. The blood pressure was monitored continuously with the Finapres noninvasive blood pressure monitor, and the heart rate was recorded simultaneously. All data were collected electronically. The duration of anaesthesia was taken as the period from the start of induction until the opening of the eyes on command. For assessment of recovery from anaesthesia, patients were asked to perform a series of psychomotor tests. RESULTS: The two groups were similar in their demographic and haemodynamic baseline data. In both groups, a significant decrease in blood pressure occurred 120 seconds after anaesthesia induction, which was due to the performance of the cardioversion. Five minutes after induction, the blood pressure returned to baseline in the etomidate group, while it remained below baseline in the propofol group. Propofol caused a significant decrease in heart rate. Significantly more patients needed artificial ventilation after propofol administration because of apnoea. Involuntary muscle movements occurred only in patients receiving etomidate. The immediate emergence from anaesthesia was faster after propofol. However, 15 minutes after awakening there was no difference in psychomotor skills between the two groups. No residual psychomotor impairment was evident 60 minutes after anaesthesia in any patient. All patients were discharged four hours after the cardioversion. CONCLUSIONS: Because the recovery characteristics were similar in both groups, the occurrence of side effects may be a major factor when choosing between etomidate and propofol for outpatient cardioversion.

Adult↗

PubMed1996

[Effect of resorption of Purisole (mannitol/sorbitol solution) as a distention medium in hysteroscopic operations on cardiovascular and laboratory parameters and energy metabolism--a prospective non-randomized observational study].

This paper reports on an open explorative study on the absorption of the electrolytfree distension medium Purisole (Mannitol-Sorbitol solution) during hysteroscopic procedures and its effects on laboratory and cardiovascular parameters. Intra- and postoperative levels of mannitol and sorbitol in urine were also measured to determine elimination of both components. The study population consisted of 84 patients aged 22-62 years. 54 women underwent ablative (resection of submucous fibroids, endometrial ablation, septum resection), 30 patients non-ablative operative hysteroscopic procedures (synechiolysis, hysteroscopic proximal tubal catheterisation). The duration of operations was between 23-48 minutes. Ethanol was added to the Purisole solution for determination of resorption. In 57 cases 1% ethanol in Purisole was used as irrigating fluid. In 27 cases 2% ethanol was added to the distension fluid. A median slight encrease of central venous pressure was noted during the procedures. 18 women had an intraoperative hyponatriaemia (only 4 patients < 130 mmmol/1). For the 15 patients, in which ethanol absorption was noted, fluid resorption was calculated on the basis of blood alcohol concentration (median 850 ml). Resorption was below the determination threshold in the other 69 women. Urine examination showed intra- and postoperatively increased concentrations of sorbitol and mannitol. Fluid overload and intraoperative cardiovascular complications did not occur in our patients.

Adult↗

PubMed1995

[Is co-administration of ethanol to the distension medium in surgical hysteroscopy a screening method to prevent fluid overload? A prospective randomized comparative study of ablative versus non-ablative hysteroscopy and various ethanol concentrations].

OBJECTIVE: Is it possible to diagnose early a beginning fluid absorption during operative hysteroscopy by adding ethanol to the distension medium? METHODS: A prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentration was performed. Purisole (a mannitol/sorbitol solution) was used as distension medium. RESULTS: The results of the study show that at those hysteroscopical procedures at which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation) an intraoperative screening is not necessary due to the low absorbing amounts. At the hysteroscopical procedures as the resection of myoma, endometriumablation and septumresection, however, an addition of ethanol of 2% to the distension medium has proved to be useful, because with this method absorbing amounts from 400 mls can be established by positive values of breath alcohol. As the result of a further absorption of fluid, but delayed in time compared to the first positive value of breath alcohol, there is an increase of the central venous pressure and a hyponatraemia. CONCLUSION: The intraoperative ethanol-monitoring is a non-invasive procedure which can be performed at ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.

Adult↗

PubMed1995

[Hysteroscopic endometrium ablation in "high-risk" situations and in hemorrhagic diathesis].

A hysteroscopic endometrial ablation (HEA) under maximal anesthesiologic surveillance was performed on 34 high-risk patients (group I: chronic anticoagulant therapy n = 26; group II: endogenous coagulopathy n = 8) with therapy resistant meno-metrorrhagia to avoid a hysterectomy (HE). Total amenorrhea, or a least hypomenorrhea respectively cyclic spotting could be attained primarily in 22 patients (group I: 19; group II: 3), after a repeat procedure in further 6 patients (4 in group I, 2 in group II). Subjective evaluation of surgical results (overall 22 patients primarily satisfied, 6 secondarily) also differed between the two subgroups (group I: p < 0.01 primarily satisfied; p < 0.05 secondarily satisfied vs. p < 0.05 and p < 0.01 in group II). A HE had to be performed on two patients due to extensive adenomyosis uteri interna (group II). The significantly better results in the anticoagulation group were probably due to the basic illness. Larger groups will, however, be necessary before any conclusions from this difference can be drawn. No surgical or anesthesiological complications occurred. There also were no major postoperative complications (1 endomyometritis, 2 cervical stenoses). Endometrial ablation was found to be a valuable treatment alternative for this specific group of patients with severe coagulopathy, thrombo-embolic or thrombotic disease.

Adult↗

PubMed1994

[Hysteroscopic endometrium ablation to avoid hysterectomy in "high risk" patients].

Hysteroscopic endometrial ablation under maximal anaesthesiological surveillance was performed in 34 high-risk patients to avoid hysterectomy. It was a collective of patients with heavy thrombo-embolic or thrombotic disease, either under permanent anticoagulation due to residual disease or multiple endoprosthetic treatment, or with endogenous coagulopathy. In all these women, hysterectomy was either a relative or an absolute contraindication. In 22 patients, treatment resulted in complete amenorrhoea or at least hypomenorrhoea (without menometrorrhagia) respectively cyclic spotting. In 6 further patients, amenorrhoea was achieved after a repeat procedure. Endometrial ablation was thus successful in 28 of 34 cases. In these patients, hysterectomy with the risk of major or even lethal complications, could thus be avoided. Hysterectomy, however, had to be performed in 2 women with extensive adenomyosis uteri interna. Within two respectively three years after endometrial ablation, two other patients died from causes unrelated to the surgical intervention (cardiac infarction, cerebral haemorrhage). Follow-up ranged from 1 to 5 years. Hysteroscopic endometrial ablation proved an effective therapeutic option in this selected group of patients. Other indications require further study.

Adult↗

PubMed1992

Lack of accumulation of midazolam in plasma and lipoprotein fractions during intravenous lipid infusions in patients on artificial respiration.

Severely ill patients often require total parenteral nutrition including intravenous lipid emulsions concurrently administered with lipophilic drugs. Therefore we investigated whether therapeutic application of a mixed medium chain/long chain triglyceride infusion affects the disposition of midazolam necessary for sedation in patients on artificial respiration. The concentrations of midazolam were measured in unfractionated plasma, and in lipoprotein fractions isolated from ex vivo blood samples, including determination of triglycerides and cholesterol; the albumin level was also analysed. Midazolam in the VLDL fraction was only 0.246 microgram.ml-1, whereas the total plasma concentration averaged 1.101 micrograms.ml-1, and the midazolam content of the LDL plus HDL fractions amounted to 1.771 micrograms.ml-1. Albumin in these lipoprotein fractions was just as unequally distributed. A lipid infusion resulted in a significant elevation of total triglycerides from 157 to 221 mg.dl-1 and VLDL-triglycerides from 77 to 155 mg.dl-1. The triglyceride content of the LDL plus HDL fraction rose from 102 to 139 mg.dl-1. At the same time the midazolam concentration in unfractionated plasma and in the VLDL and the LDL + HDL fractions decreased to 0.899 microgram.ml-1, 0.130 micrograms.ml-1, and 1.265 micrograms.ml-1, respectively. Cholesterol and albumin concentrations were not affected. The data show for the first time that a significant increase in plasma triglycerides during an intravenous lipid infusion does not result in accumulation of midazolam in lipoproteins, probably because albumin binding of the drug is very strong. The lack of midazolam trapping is important with respect to the safety of concurrent use of lipophilic drugs and intravenous lipid infusions.

Adult↗

PubMed1990

The determination of total and unbound midazolam in human plasma. A comparison of high performance liquid chromatography, gas chromatography and gas chromatography/mass spectrometry.

Midazolam concentrations in patients' plasma was determined after extraction with high performance liquid chromatography (HPLC), gas chromatography (GC) and gas chromatography/mass spectrometry (GC/MS). GC was selected for routine plasma assays in terms of selectivity, simplicity, precision, accuracy and sensitivity (0.02 microgram/mL); HPLC analysis was less sensitive (0.1 microgram/mL) than GC; GC/MS was used for analysis validation. Plasma protein binding of midazolam was determined by GC in patients' plasma after in vitro incubation with midazolam, ultrafiltration and extraction; 5% of the drug was unbound to plasma proteins. Midazolam distribution in lipoprotein fractions separated by ultracentrifugation of plasma obtained from patients on prolonged midazolam treatment was also assayed by GC.

Blood Proteins↗

PubMed1977

[Congenital tracheal stenosis due to pulmonary artery sling (author's transl)].

Congenital stridor was observed in a newborn due to left pulmonary artery sling. Clinical signs and the course of the disease were determined by an extreme tracheal stenosis. In newborns and infants with apneic episodes, inspiratory and expiratory wheezing and cyanosis a pulmonary sling should be considered. Unilateral hyperexpansion of the lung and an anterior indentation of the esophagus are helpful diagnostic signs. Surgical treatment for pulmonary sling is possible but remains unsatisfactory. Patients with associated tracheobronchial stenosis show a high over-all mortality rate.

Autopsy↗

PubMed1977

[A special technique of neurolept analgesia for thermocoagulation of the gasserian ganglion (author's transl)].

A special technique of neurolept analgesia for electrocoagulation of the gasserian ganglion is described which has been used since 1974. Induction is by means of Fentanyl and Valium. The dosis is sufficiently low for the patient to remain responsive and co-operative but practically painfree. The actual thermocoagulation is performed in intravenous methohexital sodium anaesthesia. The dosis is kept so low that the patient wakes up within 2--3 minutes and is able to inform the surgeon of the success or failure of the operation. If no relief from pain has been obtained a further 20 mg of methohexital are injected and the operation is repeated.

Diazepam↗