Oral benzodiazepines and conscious sedation: A review

Comparision of Vital Surgical Parameters, after Administration of Midazolam and Dexmedetomidine for Conscious Sedation in Minor Oral Surgery

Aim:

The aim of this study is to compare the efficacy between midazolam and dexmedetomidine in relation to vital parameters, sedation score, pain score, cognitive judgment, and postoperative amnesia to the event in conscious sedation for minor oral surgical procedure.

Materials and Methods:

A sample size of 30 patients were selected in each group: Group M (midazolam) and Group D (dexmedetomidine).

Results:

The mean heart rate (HR) and systolic and diastolic blood pressure measurements were significantly higher in Group M after the 20^th min when compared to Group D. The visual analog scale (VAS) scores of pain were not statistically significant between the two groups during the procedure, but at the time of discharge, statistically significant VAS scores were found between the two groups. Nine (30%) patients in Group D and 21 (70%) patients in Group M showed cognitive judgment impairment with the Stroop Color and Word Test at the 30^th min.

Conclusion:

The dexmedetomidine group of patients had reduced blood pressure and HR. No significant differences were noted in oxygen saturation or in respiratory rate between the two drugs. Patients had better sedation, analgesia, lesser cognitive impairment, and amnesia in the dexmedetomidine group.

Comparison of Bite Force After Administration of Midazolam and Dexmedetomidine for Conscious Sedation in Minor Oral Surgery

Aim:

The aim of this study was to compare the bite force and sedation score in moderate/conscious sedation for minor oral surgical procedure.

Materials and Methods:

A sample size of 30 was selected in each group (group M [midazolam] and group D [dexmedetomidine]).

Results:

Dexmedetomidine group had a statistically significant sedation score than midazolam. A statistically significant increase in the bite force was observed in both midazolam and dexmedetomidine groups, but there was no significant difference between the two groups.

Conclusion:

Dexmedetomidine and midazolam significantly increased the bite force because of the loss of proprioceptive function of periodontal ligament, but there was no significant difference between the drugs regarding bite force.

Enhanced GABAergic actions resulting from the coapplication of the steroid 3α-hydroxy-5α-pregnane-11,20-dione (alfaxalone) with propofol or diazepam

Many GABAergic drugs are in clinical use as anesthetics, sedatives, or anxiolytics. We have investigated the actions of the combinations of the neuroactive steroid 3α-hydroxy-5α-pregnane-11,20-dione (alfaxalone) with the intravenous anesthetic propofol or the benzodiazepine diazepam. The goal of the study was to determine whether coapplication of alfaxalone reduces the effective doses and concentrations of propofol and diazepam. Behavioral effects of alfaxalone, propofol, diazepam, and the combinations of the drugs were evaluated during a 30-min activity test in mice. Functional effects of the individual drugs and drug combinations were tested by measuring the decay times of spontaneous inhibitory postsynaptic currents in rat hippocampal neurons, and peak current responses from heterologously expressed concatemeric α1β2γ2L GABA_A receptors. Co-administration of alfaxalone increased the sedative actions of propofol and diazepam in mice. The combination of alfaxalone with propofol or diazepam increased the decay times of sIPSCs and shifted the concentration-response relationships for GABA-activated receptors to lower transmitter concentrations. We infer that alfaxalone acts as a co-agonist to enhance the GABAergic effects of propofol and diazepam. We propose that co-administration of alfaxalone, and possibly other neuroactive steroids, can be employed to reduce dosage requirements for propofol and diazepam.

Relative potency and effectiveness of flunitrazepam, ethanol, and beta-CCE for disrupting the acquisition and retention of response sequences in rats

Despite the knowledge that gamma-aminobutyric acid(A) modulators can affect learning and memory, their capacity for disrupting each of these complex processes is rarely compared, and often mistakenly assumed to occur with identical potency. For these reasons, the effects of flunitrazepam (0.056-3.2 mg/kg), ethanol (0.25-1.5 g/kg), and ethyl-beta-carboline-3-carboxylate (beta-CCE; 1-17.8 mg/kg) were compared in groups of rats responding under baselines that assessed learning and memory separately. The first baseline was a multiple schedule of repeated acquisition and performance of tandem response sequences, whereas the second baseline was a retention or memory procedure where a tandem response sequence was acquired and then retested after a 30-min delay. Under both procedures, responding was maintained under a second-order fixed-ratio-2 schedule of food reinforcement, and incorrect responding (errors) produced a 5-s timeout. With regard to the effects of the three drugs on sequence acquisition (learning), all three drugs dose dependently decreased the overall response rate and increased the percentage of errors. Both flunitrazepam and beta-CCE affected accuracy more potently than response rate, whereas ethanol was equipotent in affecting these two dependent measures. With regard to the effects of these drugs on sequence retention (memory), both flunitrazepam and ethanol dose dependently decreased retention at doses that had little or no effect on sequence acquisition under the multiple schedule, whereas beta-CCE decreased retention and sequence acquisition similarly at the doses tested. Together, these data show that drugs with differing capacities for altering the function of gamma-aminobutyric acid(A) receptors differ in their capacity for disrupting the acquisition and retention of response sequences and that positive modulation of this receptor complex may be more predictive of disruptions in memory than disruptions in learning.

Drug-Facilitated Robbery or Sexual Assault

Amnesia following sedative-hypnotic drug exposure is discussed. Anterograde amnesia clearly occurs with many benzodiazepines. Several drugs are assessed: benzodiazepines and two hypnotics in particular that are structurally unrelated to the benzodiazepines but share some of their properties: zolpidem and zopiclone. The amnesic effects of these drugs are described, memory process, biology of memory, and memory process impairment documented. With these drugs anterograde amnesia has been demonstrated to be dose dependent. This effect is associated with hypnotic drugs, however, the receptors are different. As regards forensic medicine, a significant and specific type of amnesia should be considered: amnesia automatism or amnesic complex automatism. Also, several cases observed in our laboratory are presented to demonstrate the impact of amnesia.

Drug interactions in dentistry

BACKGROUND

The hepatic and intestinal cytochrome, or CY, P450 enzyme system is responsible for the biotransformation of a multitude of drugs. Certain medications used in dentistry can act as substrates, inducers or inhibitors of this system.

METHODS

The authors conducted a MEDLINE search of articles appearing between 1976 and the present using the keywords "drug interactions" and "cytochrome P450," and reviewed reports involving dental therapeutic agents using PubMed links from an Indiana University CYP450 drug interaction table on the World Wide Web.

RESULTS

The antibiotics erythromycin and clarithromycin are potent inhibitors of CYP3A4 and can increase blood levels and toxicity of CYP3A4 substrates. Likewise, quinolone antibiotics such as ciprofloxacin inhibit the metabolism of CYP1A2 substrates. Other dental therapeutic agents are substrates for CYP2C9 (celecoxib, ibuprofen and naproxen), CYP2D6 (codeine and tramadol), CYP3A4 (methylprednisolone) and CYP2E1 (acetaminophen). Because codeine and tramadol are prodrugs, inhibition of their metabolism can lead to a diminution of their analgesic effects. While inducers of acetaminophen metabolism, including alcohol, theoretically can increase the proportion of it that is biotransformed into a potentially hepatotoxic metabolite, recent research suggests that concomitant alcohol intake does not increase the hepatotoxic potential of therapeutic doses of acetaminophen.

CONCLUSIONS

A number of clinically significant drug interactions can arise with dental therapeutic agents that act as substrates or inhibitors of the CYP450 system. Clinical Implications. As polypharmacy continues to increase, the likelihood of adverse drug interactions in dentistry will increase as well. Ensuring that patients' medical histories are up to date and acquiring knowledge of the various substrates, inducers and inhibitors of the CYP450 system will help practitioners avoid potentially serious adverse drug interactions.

A randomized, placebo-controlled study of outpatient premedication for bone marrow biopsy in adults with lymphoma

The outpatient bone marrow biopsy and aspiration (BMBA) procedure performed with local anesthetic is often poorly tolerated in adults. This prospective, randomized, placebo-controlled, double-blind trial was designed to determine whether oral (p.o.) lorazepam and hydromorphone reduces pain and anxiety during BMBA. Eligible patients had lymphoma, had no prior BMBA, and were > or = 18 years old. Since patients had bilateral BMBA, each served as their own control. Patients were stratified by anxiety level using the Spielberger Trait Anxiety Scale and randomized to: A) placebo for the first BMBA and 2 mg lorazepam and 2 mg hydromorphone p.o. for the contralateral BMBA, or B) placebo for both BMBAS. Changes in pain and anxiety experienced between the first and second BMBA were measured by the Visual Analogue Scale (VAS) and the Spielberger State Anxiety Scale at the time of the BMBA and 24 hours later. Twenty-seven patients were enrolled and 25 were evaluable; there were 17 males and eight females. The median age was 57 years (range, 28-79 years). Overall, BMBA was reported as painful in both arms, with a median VAS pain score after the second BMBA of 3.9 (scale, 0-10) for arm A and 5.8 for arm B (P = 0.21). There was no difference in the change in pain, anxiety, or recalled anxiety between treatment arms (all P values > 0.05). The difference in the change in recalled pain was of borderline significance (P = 0.07) and consistent with benzodiazepine-induced anterograde amnesia.

Low-dose midazolam infusion for oculoplastic surgery under local anesthesia

PURPOSE

Oculoplastic surgery with infiltration of local anaesthesia at the operative site performed as a day-case procedure is both efficient and cost-effective. Patients considered unsuitable for this because of fear or apprehension may, however, benefit from per-operative conscious sedation. We sought to study the efficacy and safety of this using midazolam, a water-soluble benzodiazepine.

METHOD

We have performed a controlled clinical trial comparing the effect of a low-dose intravenous infusion of midazolam (0.2 mg/ml of normal saline at a rate of 1 mg/h) with saline placebo on 48 subjects undergoing oculoplastic surgery with local anaesthesia. Patients were given pre- and post-operative questionnaires assessing, amongst other factors, anxiety levels, pain, degree of reported amnesia and psychomotor recovery.

RESULTS

Using the low-dose midazolam infusion no adverse cardiorespiratory reactions occurred. Patients receiving midazolam reported remembering significantly less about their operation than controls (p = 0.04) and showed significantly lower state-anxiety after their operation than before (p < 0.02). This change was not noted in the placebo group. There was no significant difference in the psychomotor performance of patients given midazolam compared with controls 2 h after surgery.

CONCLUSIONS

A low-dose continuous infusion of midazolam can be used to safely provide effective anxiolysis and conscious sedation with good psychomotor recovery during oculoplastic procedures in a day-case setting.

A randomized clinical trial of triazolam in 3- to 5-year-olds

Triazolam has shown promise as a sedative agent for use in pediatric dentistry. However, the efficacy of triazolam has not been previously examined in a placebo-controlled study. The present clinical trial used a two-group, randomized, double-blind study design to compare the efficacy of oral triazolam with that of a placebo. The primary hypothesis tested was that triazolam would reduce negative behaviors of pediatric dental patients compared with a placebo. A secondary hypothesis was that triazolam would increase the efficiency of dental treatment by reducing the need for time-consuming behavior management by the pediatric dentist. The subjects were 54 3- to 5-year-old children, randomly assigned to the drug and placebo groups. The active drug, 0.03 mg/kg triazolam (Halcion), or lactose placebo was given orally 30 min before dental treatment. Behavior management techniques commonly used in pediatric dentistry were used during dental treatment. A single pediatric dentist provided all of the dental treatment. The procedure included an inferior block anesthesia and careful attention to anesthesia effectiveness. All sessions were video-taped and the tapes coded for child and dentist behaviors by an independent observer. There were no statistically significant differences between the groups with respect to completion of dental treatment. There were no significant differences found in either the total time or the percent of time that the subjects exhibited disruptive movements, verbal or non-verbal distress. The total use of time in the dental chair was slightly higher in the placebo than in the drug group due to more time spent preparing the child. Contrary to preliminary reports in the literature, this investigation found little or no improvement in child behavior when triazolam was used as a sedative compared with a placebo. However, triazolam did shorten the length of dental treatment, primarily by reducing dentist time in preparing the child for the dental procedure (e.g., establishing rapport and shaping behavior).

Death related to midazolam overdose during endoscopic retrograde cholangiopancreatography

We report a midazolam-related death that occurred during endoscopic retrograde cholangiopancreatography (ERCP). The acute intoxication due to midazolam overdose was confirmed by high-pressure liquid chromatography (HPLC) analysis of the blood samples taken from the patient in the intensive care unit (2.8 microg/ml) and postmortem (2.4 microg/ml). The case strongly emphasizes the necessity of the precautions that should be taken when midazolam is intravenously administered.

Adverse drug interactions in dental practice: interactions involving antibiotics. Part II of a series

BACKGROUND

The prudent use of antibiotics is an integral part of dental practice. While these agents generally are considered safe in the dental setting, their use can result in interactions that can lead to serious morbidity in dental patients.

METHODS

The faculty of a symposium entitled "Adverse Drug Interactions in Dentistry: Separating the Myths From the Facts" did an extensive literature review on drug interactions. Through this, they were able to establish a significance rating of alleged adverse drug interactions as they relate to dentistry, based on their scientific documentation and severity of effect. The author of this article focused on antibiotics.

RESULTS

Most of the reported drug interactions discussed in this article are well-documented by clinical studies. It is particularly important that dentists be aware of the potentially serious and life-threatening interactions of the antibiotics erythromycin, clarithromycin and metronidazole, and of the antifungal agents ketoconazole and itraconazole, with a host of other drugs whose metabolism is impaired by these antimicrobial agents. In contrast, the alleged ability of commonly employed antibiotics to reduce the effectiveness of oral contraceptive agents is not adequately supported by clinical research. It still is recommended, however, that clinicians discuss this possible interaction with their patients, as it might represent a relatively rare event that cannot be discerned in clinical trials.

CONCLUSIONS

Potentially serious adverse drug interactions can occur between antimicrobial agents used in dental practice and other drugs patients are taking for a variety of medical conditions.

CLINICAL IMPLICATIONS

It is important that dentists stay abreast of potential drug interactions involving antibiotics to avoid serious morbidity among their patients.

Conscious sedation for in vitro fertilization

OBJECTIVE

To review the principles and practice of the use of conscious sedation for IVF.

DESIGN

The pertinent literature was reviewed and recommendations are provided.

RESULT(S)

Conscious sedation appears to be the most commonly used method of pain relief for transvaginal retrieval of oocytes. Conscious sedation does not require the presence of an anesthesiologist and can be done in freestanding clinics. Agents commonly used include opioids in combination with benzodiazepines. This combination minimizes pain, decreases anxiety, and provides sedation and some amnesia. Adjuvants such as promethazine and hydroxyzine can also be used but often are not needed. Conscious sedation is well tolerated by patients and does not require highly specialized equipment. However, there are specific safeguards that should be followed. Only a few toxicity studies have been performed, but they are reassuring because they have not found significant effects on fertilization or cleavage.

CONCLUSION(S)

Conscious sedation appears to be a safe and cost-effective method of providing analgesia and anesthesia for transvaginal retrieval of oocytes.

Effects of oral diazepam on intravenous access in same day surgery patients

STUDY OBJECTIVE

To determine the effects of 5 mg oral diazepam on vein quality, patient anxiety, and intravenous (i.v.) access.

DESIGN

Prospective, randomized, double-blind, placebo controlled study.

SETTING

Preoperative holding area of a large university hospital.

PATIENTS

202 adult ASA physical status I, II, and III patients scheduled for elective outpatient surgery.

INTERVENTIONS

Patients were randomized to receive either 5 mg oral diazepam or placebo, 30 minutes prior to i.v. access.

MEASUREMENTS AND MAIN RESULTS

Vein quality and patient anxiety were assessed prior to, and 30 minutes following, premedication (just prior to venipuncture) using a 5 point ordinal scale and 10 cm visual analog scale, respectively. The number of attempts at venous access and the gauge of the catheter used were also recorded. Baseline patient anxiety was similar between the two groups and both showed a significant improvement in patient anxiety at 30 minutes following drug administration. The diazepam group, however, had a significantly greater reduction in anxiety scores (p < 0.05). There were no differences in baseline vein quality between the two groups; however, the quality of the vein was subjectively improved following diazepam administration. The mean number of attempts at i.v. access between the diazepam group (1.26 +/- 0.56) and the placebo group (1.32 +/- 0.65) was not significantly different. However, the ability to place larger gauge catheters was significantly enhanced in the diazepam group.

CONCLUSIONS

The administration of 5 mg oral diazepam prior to the establishment of i.v. access improved vein quality and decreased patient anxiety. This technique may be a useful method for i.v. catheter placement, particularly when large gauge catheters are required, or when difficult i.v. access is anticipated.

Amnestic and anxiolytic effects of alprazolam in oral surgery patients

PURPOSE

This study was designed to identify a dose of alprazolam that would reduce anxiety associated with oral surgery without causing accompanying memory impairment.

PATIENTS AND METHODS

Thirty-six subjects in experiment 1 and 48 subjects in experiment 2 were pretested on a computerized memory battery to establish baseline performance. Subjects were then randomly assigned to receive placebo, 0.25 mg, or 0.75 mg oral alprazolam (experiment 1) or placebo, 0.25 mg, 0.50 mg, or 0.75 mg oral alprazolam (experiment 2). Forty-five minutes after the double-blind administration of alprazolam, subjects were given a second memory battery. The memory batteries tested story recall and recognition and word recall and recognition. Subjects in experiment 2 subsequently underwent oral surgery for the removal of one to four molars. The subjects completed anxiety questionnaires both before and after surgery.

RESULTS

The 0.75-mg and 0.50-mg doses, but not the 0.25-mg dose, impaired word recall. The 0.75-mg dose also impaired story recall and recognition. The proportion of subjects reporting moderate to high anxiety during oral surgery decreased with increasing doses of alprazolam. Multiple regression indicated that the 0.75-mg alprazolam dose significantly decreased anxiety during oral surgery. The 0.25-mg and 0.50-mg doses also tended to reduce anxiety, but beta values for these doses did not reach significance.

CONCLUSIONS

These findings indicate that alprazolam produces memory impairment at the dosages necessary to produce clinically significant anxiolysis during oral surgery.

Premedication with midazolam is more effective by the sublingual than oral route

PURPOSE

This study compared the sedative effects of sublingual tablet midazolam (Roche Dormicum 7.5 mg) with the oral route as premedication.

METHODS

One hundred ASA physical status I and II gynaecological patients were randomly selected to receive a 7.5 mg tablet of midazolam either sublingually or orally as premedication about one hour before elective surgery. There were 50 patients in each group. The degree of sedation was assessed according to the Ramsay scale initially and then at 20, 30, 45 and 60 min intervals by a second observer blinded to the route of administration. The time for complete drug dissolution was studied in the sublingual group by the inspection of tablet residue under the tongue every five minutes for 20 min, then the patients were interviewed regarding their acceptance of taste.

RESULTS

The sedation scores in the sublingual group were higher than in the oral group at 30 and 60 min after drug administration. (P = 0.0054 and P = 0.008) Seventy-two percent of the sublingual group had complete drug dissolution within 10 min and 64% of the patients in the sublingual group found the tablet acceptable with regard to its taste.

CONCLUSION

Midazolam 7.5 mg sublingual is a more effective pre-anaesthetic sedative than by the oral route.

A review of pharmacotherapeutics for prosthetic dentistry: Part II

STATEMENT OF PROBLEM

Successful preoperative and postoperative care often depends on systemically administered drugs. The competent and successful practitioner must therefore have a strong background in basic pharmacology, be knowledgeable of pharmacotherapeutics, and keep abreast of the latest advances in medicinal agents.

PURPOSE

The purpose of this article is to review pharmacologic properties of prototype and new drugs that are primarily used to allay anxiety and pain or reduce inflammation and infection. This information should enable clinicians to improve clinical outcomes and make a more knowledgeable assessment and comparison of standard drugs with recently released drugs.

Periodontal implications: anxiety

1. Monitoring significantly improves patient outcomes. 2. Observing and communicating with the patient is the most important means of monitoring the patient's status during sedation. 3. Monitoring of ventilations along with the assessment of oxygen saturation via a pulse oximeter is significant in preventing hypoxemia. 4. The use of supplemental oxygen is recommended. 5. Monitoring of blood pressure and pulse is highly recommended for assessing hemodynamic status. 6. Use of electrocardiograms is recommended for the patients with cardiovascular disorders.

Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alternatives to general anesthesia for dental treatment of uncooperative children

The trial included 24 children (aged 2-7 yr) referred for dental treatment under general anesthesia, since conventional behavioral management methods had failed to achieve treatment acceptance. As an alternative, they received, on two separate occasions with "identical" dental treatment, conscious sedation by rectal administration of either midazolam (0.3 mg/kg body weight (bwt)) or midazolam (0.3 mg/kg bwt) plus ketamine (1.0 mg/kg bwt). This allowed a double-blind, crossover design. The aims were to assess conscious sedation, combined with local anesthesia, as an alternative to general anesthesia, and further to evaluate the effects obtained by addition of a low dose of ketamine to rectally administered midazolam. The feasibility of dental treatment was rated as excellent or good for 16 of the 24 children when premedicated with midazolam, and for 18 of the 24 children when ketamine was added to midazolam. At least some treatment could be given to all children. Verbal contact was maintained with all children throughout both treatment sessions. The children were significantly less anxious when they arrived for the second session. Amnesia and drowsiness were significantly increased when ketamine was added to midazolam. The combination also tended to be more efficient in relief of anxiety and prevention of pain, but there were large variations in the children's responses to the drugs. Midazolam significantly reduced the blood oxygen level, but not with ketamine added. For most children, both regimens proved to be appropriate as alternatives to general anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)