Delayed Postoperative Agitation in a Child After Preoperative Midazolam

Procedural sedation in pediatric dentistry: a narrative review

Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.

Midazolam exposure in the paediatric intensive care unit predicts acute post-traumatic stress symptoms in children

BACKGROUND

Clinically significant post-traumatic stress symptoms (PTSS) have been reported in up to a quarter of paediatric intensive care unit (PICU) survivors. Ongoing PTSS negatively impacts children's psychological development and physical recovery. However, few data regarding associations between potentially modifiable PICU treatment factors, such as analgosedatives and invasive procedures, and children's PTSS have been reported.

OBJECTIVES

We sought to investigate the medical treatment factors associated with children's PTSS after PICU discharge.

METHODS

A prospective longitudinal cohort study was conducted in two Australian tertiary referral PICUs. Children aged 2-16 y admitted to the PICU between June 2008 and January 2011 for >8 h and <28 d were eligible for participation. Biometric and clinical data were obtained from medical records. Parents reported their child's PTSS using the Trauma Symptom Checklist for Young Children at 1, 3, 6, and 12 months after discharge. Logistic regression was used to assess potential associations between medical treatment and PTSS.

RESULTS

A total of 265 children and their parents participated in the study. In the 12-month period following PICU discharge, 24% of children exhibited clinically elevated PTSS. Median risk of death (Paediatric Index of Mortality 2 [PIM2]) score was significantly higher in the PTSS group (0.31 [IQR 0.14-1.09] v 0.67 [IQR 0.20-1.18]; p = 0.014). Intubation and PICU and hospital length of stay were also significantly associated with PTSS at 1 month, as were midazolam, propofol, and morphine. After controlling for gender, reason for admission, and PIM2 score, only midazolam was significantly and independently associated with PTSS and only at 1 month (adjusted odds ration (aOR) 3.63, 95% CI 1.18, 11.12, p = 0.024). No significant relationship was observed between the use of medications and PTSS after 1 month.

CONCLUSIONS

Elevated PTSS were evident in one quarter (24%) of children during the 12 months after PICU discharge. One month after discharge, elevated PTSS were most likely to occur in children who had received midazolam therapy.

Postoperative expressive aphasia associated with intravenous midazolam administration: a 5-year retrospective case-control study

Objectives

This study aimed to investigate the epidemiology of intravenous midazolam-induced postoperative expressive aphasia (EA).

Methods

The incidence rate, risk ratio, and contributing factors to intravenous midazolam-induced postoperative EA were analyzed retrospectively in 6756 orthopedic patients. A telephone interview was conducted with patients with EA after surgery.

Results

Patients were allocated to either the midazolam group (n = 6178) or no-midazolam group (n = 578). Twelve patients developed EA in the midazolam group, with an incidence of 0.19%, and no patient developed EA in the no-midazolam group. The mean age of EA patients was 70 years, and 92% were women. Among them, 75% received general anesthesia, and the mean dose of midazolam was 1.8 mg. EA was reversed in nine of 12 (75%) patients within 4 minutes of flumazenil administration, and >60 minutes were required to reverse EA in the other three patients (25%).

Conclusion

Intravenous midazolam administration for preoperative sedation caused transient EA in 0.19% of patients, especially elderly women who received general anesthesia, and EA could be reversed by flumazenil.

Emergence delirium with transient associative agnosia and expressive aphasia reversed by flumazenil in a pediatric patient

Multiple factors may contribute to the development of emergence delirium in a child. We present the case of a healthy 12-year-old girl who received preoperative midazolam with the desired anxiolytic effect, underwent a brief general anesthetic, and then exhibited postoperative delirium, consisting of a transient associative agnosia and expressive aphasia. Administration of flumazenil led to immediate and lasting resolution of her symptoms. We hypothesize that γ-aminobutyric acid type A receptor-mediated effects, most likely related to an atypical offset of midazolam, are an important subset of emergence delirium that is amenable to pharmacologic therapy with flumazenil.

Dexmedetomidine reduces emergence agitation after tonsillectomy in children by sevoflurane anesthesia: a case-control study

OBJECTIVE

To evaluate the efficacy and safety of dexmedetomidine for emergence agitation after tonsillectomy in children.

METHODS

120 ASA physical status I and II children, aged 5-14 years, undergoing anesthesia for tonsillectomy, were randomly divided into 3 groups: Placebo group, the low dexmedetomidine concentration group and the high dexmedetomidine concentration group. Before the entrance of the operating room (OR), all of the children received intravenous injection 40 μg kg(-1) midazolam to reduce anxiety at first, and then dexmedetomidine was given intravenously at an initial loading dose of 0.5 μg kg(-1) or 1 μg/kg over a 10-min period via a computer controlled infusion pump followed by a maintenance infusion of 0.2 μg kg(-1)h(-1) or 0.4 μg kg(-1)h(-1)over the surgery. The heart rate, SpO(2) and mean arterial blood pressure were recorded for each patient in both operation room and PACU. The designated time points: at the start of the anesthetic induction, at the discontinuation of inhalational agents, at first opening of eyes, at time to remove endotracheal tube were recorded. After patient arrival at the PACU, VAS score, RSS, the occurrence of emergence agitation were recorded every 5 min for the first 30 min and every 10 min for the next 30 min after endotracheal tube was removed.

RESULTS

There was significant difference in the incidence of emergence agitation between Placebo group and the high concentration group when endotracheal tube was removed (P<0.05). There was significant difference in the VAS pain scores and in the RSS between three groups at the time of extubation, as well as 5 min and 10 min after extubation (P<0.05).

CONCLUSIONS

Dexmedetomidine appears to be safe and effective to reduce the incidence of early emergence agitation in children after tonsillectomy. Initial loading dose of 1.0 μg kg(-1) followed by a maintenance infusion of 0.4 μg kg(-1)h(-1) is better choice for children received tonsillectomy.

Premedication with melatonin vs midazolam in anxious children

AIM

Failure of dental treatment caused by anxiety is a common problem in children. Oral midazolam has been the most commonly used premedication for pediatric patient but the use of midazolam may be associated with paradoxical reactions in children. Melatonin may induce a natural sleepiness and improve sedation. We have investigated premedication with melatonin compared with midazolam in children under nitrous oxide/oxygen (N(2)O/O(2)) sedation for dental treatment.

METHODS

In a randomized study, 60 children received either 3 mg of melatonin [Melatonina (3 mg(R)) 60 min before the procedure (n = 15); group I], 0.5 mg.kg(-1) melatonin 60 min before the procedure (n = 15; group II), 0.75 mg.kg(-1) midazolam [Dormicum (15 mg/3 ml (R)) 15 min before the procedure (n = 15); group III] or 3 ml of 0.09 NaCl 15 min (n = 7) or 60 min before the procedure (n = 8; group IV) orally. The children were sedated with 40/60% N(2)O/O(2) inhalation. The heart rate and O(2) saturation were monitored during the treatment period. The level of sedation was assessed according to the Ramsay Sedation Scale. The children's sedation success during dental treatment was classified. The sedation success and other sedation-related events recorded. Comparisons among the four groups were made using one-way anova or Kruskal-Wallis test, and if any significant differences were noted, the Tukey's HSD or Mann-Whitney U-test were used for intergroup comparisons. All differences were considered significant at P < 0.05.

RESULTS

The evaluation of sedation success was as follows: group I: satisfactory (n = 1), average satisfactory (n = 4), and unsatisfactory (n = 10); group II: satisfactory (n = 2), average satisfactory (n = 3), and unsatisfactory (n = 10); group III: satisfactory (n = 9), average satisfactory (n = 6); and group IV: satisfactory (n = 1), average satisfactory (n = 3), and unsatisfactory (n = 11).

CONCLUSION

In these doses and clinical conditions, melatonin was similar to that of placebo and did not contribute to N(2)O/O(2) sedation of anxious children.