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Liew J, Winston M. Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service. Prim Dent J 2022; 11:50-57. [PMID: 35383494 DOI: 10.1177/20501684221085846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.1 This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.
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Affiliation(s)
- Jonathan Liew
- Specialty Registrar in Oral Surgery, Edinburgh Dental Institute, Edinburgh UK
| | - Michael Winston
- Tier 2 Specialist in Oral Surgery, Cheshire and Merseyside Primary Care Oral Surgery Service, Liverpool, UK
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Ang TL, Seet E, Goh YC, Ng WK, Koh CJ, Lui HF, Li JW, Oo AM, Lim KBL, Ho KS, Chew MH, Quan WL, Tan DMY, Ng KH, Goh HS, Cheong WK, Tseng P, Ling KL. Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:24-39. [PMID: 35091728 DOI: 10.47102/annals-acadmedsg.2021306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Gurunathan U, Rahman T, Williams Z, Vandeleur A, Sriram S, Harch J, Boggett S, Hill C, Bowyer A, Royse C. Effect of Midazolam in Addition to Propofol and Opiate Sedation on the Quality of Recovery After Colonoscopy: A Randomized Clinical Trial. Anesth Analg 2020; 131:741-750. [PMID: 31922999 DOI: 10.1213/ane.0000000000004620] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is a concern that midazolam, when used as a component of sedation for colonoscopy, may impair cognition and prolong recovery. We aimed to identify whether midazolam produced short- and longer-term effects on multiple dimensions of recovery including cognition. METHODS A 2-center double-blinded, placebo-controlled, parallel-group, randomized, phase IV study with a 1:1 allocation ratio was conducted in adults ≥18 years of age undergoing elective outpatient colonoscopy, with sufficient English language proficiency to complete the Postoperative Quality of Recovery Scale (PostopQRS). Participants were administered either midazolam (0.04 mg·kg) or an equivalent volume of 0.9% saline before sedation with propofol with or without an opiate. The primary outcome was incidence of recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy, which was analyzed using a χ test. Secondary outcomes included recovery in other domains of the PostopQRS over time, time to eye-opening, and hospital stay, and patient and endoscopist satisfaction. All hypotheses were defined before recruitment. RESULTS During September 2015 to June 2018, 406 patients were allocated to either midazolam (n = 201) or placebo (n = 205), with one withdrawn before allocation. There was no significant difference in recovery in the cognitive domain of the PostopQRS on day 3 after colonoscopy (midazolam 86.8% vs placebo 88.7%, odds ratio, 0.838; 95% confidence interval [CI], 0.42-1.683; P= .625). Furthermore, there was no difference in recovery over time in the cognitive domain of the PostopQRS (P = .534). Overall recovery of the PostopQRS increased over time but was not different between groups. Furthermore, there were no differences between groups for nociceptive, emotive, activities-of-daily-living domains of the PostopQRS. Patient and endoscopist satisfaction were high and not different. There were no differences in time to eye-opening (midazolam 9.4 ± 12.8 minutes vs placebo 7.3 ± 0.7 minutes; P = .055), or time to hospital discharge (midazolam 103.4 ± 1.4 minutes vs placebo 98.4 ± 37.0 minutes; P = .516). CONCLUSIONS The addition of midazolam 0.04 mg·kg as adjunct to propofol and opiate sedation for elective colonoscopy did not show evidence of any significant differences in recovery in the cognitive domain of the PostopQRS, overall quality of recovery as measured by the PostopQRS, or emergence and hospital discharge times. The use of midazolam should be determined by the anesthesiologist.
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Affiliation(s)
- Usha Gurunathan
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Tony Rahman
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology and University of Sunshine Coast, Queensland, Australia
| | - Zelda Williams
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ann Vandeleur
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sweta Sriram
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Harch
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Stuart Boggett
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cindy Hill
- From the The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Andrea Bowyer
- Department of Anesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Colin Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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Vaessen H, Bruens E, Knape J. Clinical analysis of moderate-to-deep-sedation by nonmedical sedation practitioners in 597 patients undergoing gastrointestinal endoscopy: a retrospective study. Endosc Int Open 2016; 4:E564-71. [PMID: 27227116 PMCID: PMC4874805 DOI: 10.1055/s-0042-103238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/08/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIM The purpose of this study was to evaluate whether moderate-to-deep sedation with propofol and alfentanil can be administered safely by nonmedical sedation practitioners, and the outcomes of this practice in the Netherlands. We retrospectively analyzed the occurrence of sedation-related complications in patients undergoing gastrointestinal endoscopic procedures. PATIENTS AND METHODS In this study, 597 adult patients consecutively underwent upper gastrointestinal endoscopic procedures. The health status of the patients was screened according to a standardized protocol, and the patients were sedated by trained nonmedical sedation practitioners. Their vital signs were continuously monitored and recorded. All patients received oxygen, and the depth of sedation was continuously assessed and recorded. Mild and severe complications were recorded and analyzed. RESULTS All patients recovered uneventfully, and no mortality occurred. Overall, of the 597 sedated patients, 85 had mild and 4 had severe complications. Hypoxemia and upper airway obstruction, which were easily managed by trained nonmedical sedation practitioners, were the most common events. Hypotension was rare. No signs or symptoms suggestive of aspiration were reported. CONCLUSION Moderate-to-deep sedation has been and continues to be a risky medical procedure. Serious complications of propofol/opioid-based sedation, especially respiratory and cardiovascular adverse events, may occur. These complications need to be recognized rapidly and appropriately managed. Our study shows that well-trained nonmedical sedation practitioners can be entrusted to take responsibility for the safe administration of moderate-to-deep sedation.
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Affiliation(s)
- Hermanus Vaessen
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands,Corresponding author H. H. B. (Paul) Vaessen, RNA, PSA Specialist University Medical Centre UtrechtDepartment of Anesthesiology, Intensive Care and Emergency MedicineHeidelberglaan 100Huispostnr.: F02.8113584 CX UtrechtThe Netherlands+ 31-30-7555442
| | - Elisabeth Bruens
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands
| | - Johannes Knape
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, the Netherlands
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Andersen LPH, Werner MU, Rosenkilde MM, Fenger AQ, Petersen MC, Rosenberg J, Gögenur I. Pharmacokinetics of high-dose intravenous melatonin in humans. J Clin Pharmacol 2015; 56:324-9. [PMID: 26184078 DOI: 10.1002/jcph.592] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/10/2015] [Indexed: 11/11/2022]
Abstract
This crossover study investigated the pharmacokinetics and adverse effects of high-dose intravenous melatonin. Volunteers participated in 3 identical study sessions, receiving an intravenous bolus of 10 mg melatonin, 100 mg melatonin, and placebo. Blood samples were collected at baseline and 0, 60, 120, 180, 240, 300, 360, and 420 minutes after the bolus. Quantitative determination of plasma melatonin concentrations was performed using a radioimmunoassay technique. Pharmacokinetic parameters were estimated by a compartmental pharmacokinetic analysis. Adverse effects included assessments of sedation and registration of other symptoms. Sedation, evaluated as simple reaction times, was measured at baseline and 120, 180, 300, and 420 minutes after the bolus. Twelve male volunteers completed the study. Median (IQR) Cmax after the bolus injections of 10 mg and 100 mg of melatonin were 221,500.0 (185,637.5-326,175.0) pg/mL and 1,251,500.0 (864,375.0-1,770,500.0) pg/mL, respectively; mean (SD) t1/2 was 42.3 (5.6) minutes and 46.2 (6.2) minutes; mean (SD) Vd was 1.6 (0.9) L/kg and 2.0 (0.8) L/kg; mean (SD) CL was 0.0253 (0.0096) L/min · kg and 0.0300 (0.0120) L/min · kg; and median (IQR) AUC0- ∞ , 8,997,633.0 (6,071,696.2-11,602,811.9) pg · min/mL and 54,685,979.4 (36,028,638.6-105,779,612.0) pg · min/mL. High-dose intravenous melatonin did not induce sedation, evaluated as simple reaction times. No adverse effects were reported in the study.
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Affiliation(s)
- Lars P H Andersen
- Department of Surgery D, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark
| | - Mads U Werner
- Multidisciplinary Pain Center 7612, Neuroscience Center, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Mette M Rosenkilde
- Department of Neuroscience and Pharmacology, University of Copenhagen, DK-2100 Copenhagen, Denmark
| | - Andreas Q Fenger
- Department of Surgery D, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark
| | - Marian C Petersen
- Multidisciplinary Pain Center 7612, Neuroscience Center, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Jacob Rosenberg
- Department of Surgery D, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark
| | - Ismail Gögenur
- Department of Surgery, Roskilde and K, ø, ge Hospital, University of Copenhagen, DK-4000 Roskilde, Denmark
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Ettinger KS, Jacob AK, Viozzi CF, Van Ess JM, Fillmore WJ, Arce K. Does Intravenous Midazolam Dose Influence the Duration of Recovery Room Stay Following Outpatient Third Molar Surgery? J Oral Maxillofac Surg 2015; 73:2287-93. [PMID: 26183011 DOI: 10.1016/j.joms.2015.06.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 06/16/2015] [Accepted: 06/19/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the impact of intravenous midazolam dose on the duration of recovery room stay for patients undergoing outpatient third molar surgery. MATERIALS AND METHODS Using a retrospective cohort study design, a sample of patients undergoing outpatient third molar surgery under intravenous sedation at Mayo Clinic from 2010 to 2014 was identified. All patients underwent extraction of all 4 third molars during a single operative procedure and the age range was limited to 14 to 29 years. The primary predictor variable was the total dose of intravenous midazolam administered during sedation. The primary outcome variable was recovery room length of stay (LOS) after completion of surgery. Multiple covariates also abstracted included patient age, gender, American Society of Anesthesiologists (ASA) score, duration of surgical procedure, complexity of surgical procedure, types and dosages of all intravenous medications administered during sedation, and volume of crystalloid fluid administered perioperatively. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary outcome variable. RESULTS The study sample was composed of 2,610 patients. Mean age was 18.3 years (SD, 3.0 yr; range, 14 to 29 yr) and gender distribution was 52% female. Mean dosage of midazolam administered was 4.1 mg (SD, 1.1 mg; range, 0.5 to 10.0 mg). Variables predicting shorter LOS at multivariable analysis included older age (P < .001), male gender (P = .004), and administration of larger crystalloid fluid volumes (P < .001). Variables predicting longer LOS included higher ASA score (P < .001), administration of ketamine (P < .001), and administration of ketorolac (P < .001). The dose of midazolam administered during sedation was not found to be significantly associated with prolonged recovery room LOS in univariable or multivariable settings. CONCLUSION Dosage of intravenous midazolam does not appear to significantly impact the duration of recovery room stay in the prototypical patients undergoing sedation for outpatient third molar surgery.
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Affiliation(s)
- Kyle S Ettinger
- Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN.
| | - Adam K Jacob
- Associate Professor and Consultant, Department of Anesthesiology, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Christopher F Viozzi
- Assistant Professor and Program Chair, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - James M Van Ess
- Assistant Professor and Consultant, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - W Jonathan Fillmore
- Assistant Professor and Consultant, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
| | - Kevin Arce
- Assistant Professor and Program Director, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine, Rochester, MN
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Evident cognitive impairments in seemingly recovered patients after midazolam-based light sedation during diagnostic endoscopy. J Formos Med Assoc 2015; 114:489-97. [DOI: 10.1016/j.jfma.2013.07.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 06/11/2013] [Accepted: 07/31/2013] [Indexed: 12/22/2022] Open
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Mathus-Vliegen EMH, de Jong L, Kos-Foekema HA. Significant and safe shortening of the recovery time after flumazenil-reversed midazolam sedation. Dig Dis Sci 2014; 59:1717-25. [PMID: 24563235 DOI: 10.1007/s10620-014-3061-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/05/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopy under midazolam sedation requires a 2-h recovery facility. AIM To study the potential of shortening patients' stay without jeopardizing patients' safety by the use of the benzodiazepine-antagonist flumazenil in the everyday practice and to investigate the feasibility of a study comparing midazolam with recovery with midazolam-flumazenil and immediate discharge. METHODS Consecutive ambulatory patients referred for endoscopy under midazolam sedation with ASA I or II, escorted by a person, were eligible. Flumazenil was given on arrival in the recovery room. Patients were discharged when adequate Aldrete scores and physical mobility were present. The next day, they were contacted by telephone. RESULTS A total of 1,506 patients participated. They received 5 mg midazolam, while 887 patients also received 50 mcg fentanyl. The median dose of flumazenil was 0.2 mg. Oxygen desaturation (sO2 <92%) occurred in 15% during the procedure without an effect on recovery and discharge times. Patients left the department 65 min after the last midazolam administration. The majority (82.7%) were fully alert during their journey home. At home, 2.7% went to bed, 45.2% took a nap, and 40% undertook activities. Almost every patient (98.8%) liked the shortened recovery time. Three patients had an incident (fainting, fall, and near-fall) without consequences. Based on this low incidence, a non-inferiority comparison of midazolam-flumazenil with midazolam-recovery would require a total of 32,650 patients. CONCLUSIONS Administration of flumazenil resulted in a safe shortening of the recovery period and offers the possibility for substantial savings in time, space, and nurse resources. A non-inferiority comparison will not be practicable.
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Affiliation(s)
- Elisabeth M H Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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Rye DB, Bliwise DL, Parker K, Trotti LM, Saini P, Fairley J, Freeman A, Garcia PS, Owens MJ, Ritchie JC, Jenkins A. Modulation of vigilance in the primary hypersomnias by endogenous enhancement of GABAA receptors. Sci Transl Med 2013; 4:161ra151. [PMID: 23175709 DOI: 10.1126/scitranslmed.3004685] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The biology underlying excessive daytime sleepiness (hypersomnolence) is incompletely understood. After excluding known causes of sleepiness in 32 hypersomnolent patients, we showed that, in the presence of 10 μM γ-aminobutyric acid (GABA), cerebrospinal fluid (CSF) from these subjects stimulated GABA(A) receptor function in vitro by 84.0 ± 40.7% (SD) relative to the 35.8 ± 7.5% (SD) stimulation obtained with CSF from control subjects (Student's t test, t = 6.47, P < 0.0001); CSF alone had no effect on GABA(A) signaling. The bioactive CSF component had a mass of 500 to 3000 daltons and was neutralized by trypsin. Enhancement was greater for α2 subunit- versus α1 subunit-containing GABA(A) receptors and negligible for α4 subunit-containing ones. CSF samples from hypersomnolent patients also modestly enhanced benzodiazepine (BZD)-insensitive GABA(A) receptors and did not competitively displace BZDs from human brain tissue. Flumazenil--a drug that is generally believed to antagonize the sedative-hypnotic actions of BZDs only at the classical BZD-binding domain in GABA(A) receptors and to lack intrinsic activity--nevertheless reversed enhancement of GABA(A) signaling by hypersomnolent CSF in vitro. Furthermore, flumazenil normalized vigilance in seven hypersomnolent patients. We conclude that a naturally occurring substance in CSF augments inhibitory GABA signaling, thus revealing a new pathophysiology associated with excessive daytime sleepiness.
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Affiliation(s)
- David B Rye
- Department of Neurology, Program in Sleep, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Geerts H, Roberts P, Spiros A. A quantitative system pharmacology computer model for cognitive deficits in schizophrenia. CPT Pharmacometrics Syst Pharmacol 2013; 2:e36. [PMID: 23887686 PMCID: PMC3636495 DOI: 10.1038/psp.2013.12] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/08/2013] [Indexed: 01/29/2023] Open
Abstract
Although the positive symptoms of schizophrenia are reasonably well-controlled by current antipsychotics, cognitive impairment remains largely unaddressed. The Matrics initiative lays out a regulatory path forward and a number of targets have been tested in the clinic, so far without much success. To address this translational disconnect, we have developed a mechanism-based humanized computer model of a relevant key cortical brain network with schizophrenia pathology involved with the maintenance aspect of working memory (WM). The model is calibrated using published clinical experiments on N-back WM tests. We further simulate the opposite effect of γ-aminobutyric acid (GABA) modulators lorazepam and flumazenil and of a published augmentation trial of clozapine with risperidone, illustrating the introduction of new targets and the capacity of predicting the effects of polypharmacy. This humanized approach allows for early prospective and quantitative assessment of cognitive outcome in a central nervous system (CNS) research and development project, thereby hopefully increasing the success rate of clinical trials.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e36; doi:10.1038/psp.2013.12; advance online publication 3 April 2013.
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Affiliation(s)
- H Geerts
- In Silico Biosciences, Berwyn, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Roberts
- In Silico Biosciences, Berwyn, Pennsylvania, USA
- OHSUPortland, Oregon, USA
| | - A Spiros
- In Silico Biosciences, Berwyn, Pennsylvania, USA
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Wilson KE, Thorpe RJ, McCabe JF, Girdler NM. Complications Associated with Intravenous Midazolam Sedation in Anxious Dental Patients. ACTA ACUST UNITED AC 2011; 18:161-6. [DOI: 10.1308/135576111797512801] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aim This prospective study was designed to establish the nature, frequency and sequelae of complications arising in patients receiving dental treatment under intravenous midazolam sedation. Methods All patients attending the Sedation Department at Newcastle Dental Hospital for intravenous sedation over a six-month period were audited. A standardised data-collection pro forma was designed in order to collect data relating to the patient, the sedation episode, the dental treatment and any complications arising. The published standard used in this study states that the incidence of complications should be no more than 8%. Results Four hundred and one patients were included. The mean dose of midazolam administered was 7.6 mg with a mean titration rate of 0.9 mg/min. Complications were reported in 12 patients (3%), 11 of which were minor and one moderate. All complications were managed successfully within the department with no lasting sequelae. Treatment was completed in 382 (95.7%) patients, with failure to complete treatment in 17 (4.3%) patients due to disinhibition (1), poor cooperation (10), and the sedation wearing off (6). Conclusion The standard was met because complications arising were infrequent (3%) and predominantly minor in nature. Complications were managed conservatively and effectively, with all patients being discharged home the same day with no lasting sequelae. The study demonstrates that intravenous midazolam provides a safe sedation technique, suitable for adult dental patients in primary care, when administered by trained personnel on carefully selected patients and in accordance with nationally agreed protocols and guidelines.
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Affiliation(s)
- Katherine E Wilson
- Department of Sedation
- School of Dental Sciences, Newcastle upon Tyne, UK
| | | | - John F McCabe
- Dental Material Science
- School of Dental Sciences, Newcastle upon Tyne, UK
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Henthorn KM, Dickinson C. The use of flumazenil after midazolam-induced conscious sedation. Br Dent J 2010; 209:E18. [DOI: 10.1038/sj.bdj.2010.1132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2010] [Indexed: 11/09/2022]
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Hosey MT, Asbury AJ, Bowman AW, Millar K, Martin K, Musiello T, Welbury R. The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction. Br Dent J 2009; 207:E2; discussion 32-3. [PMID: 19574992 DOI: 10.1038/sj.bdj.2009.570] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2008] [Indexed: 11/09/2022]
Abstract
BACKGROUND The project aims were to evaluate the benefit of transmucosal midazolam 0.2 mg/kg pre-medication on anxiety, induction behaviour and psychological morbidity in children undergoing general anaesthesia (GA) extractions. METHOD One hundred and seventy-nine children aged 5-10 years (mean 6.53 years) participated in this randomised, double blind, placebo-controlled trial. Ninety children had midazolam placed in the buccal pouch. Dental anxiety was recorded preoperatively and 48 hours later using a child reported MCDAS-FIS scale. Behaviour at anaesthetic induction was recorded and psychological morbidity was scored by the parent using the Rutter Scale preoperatively and again one week later. Subsequent dental attendance was recorded at one, three and six months after GA. RESULTS While levels of dental anxiety did not reduce overall, the most anxious patients demonstrated a reduction in anxiety after receiving midazolam premedication (p = 0.01). Neither induction behaviour nor psychological morbidity improved. Irrespective of group, parents reported less hyperactive (p = 0.002) and more pro-social behaviour (p = 0.002) after the procedure; older children improved most (p = 0.048). Post-GA dental attendance was poor and unaffected by premedication. CONCLUSION 0.2 mg/kg buccal midazolam provided some evidence for reducing anxiety in the most dentally anxious patients. However, induction behaviour, psychological morbidity and subsequent dental attendance were not found to alter.
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Affiliation(s)
- M T Hosey
- Paediatric Dentistry, Kings College London Dental Institute, London, UK.
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14
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Sedation for middle ear surgery: prospective clinical trial comparing propofol and midazolam. Open Med (Wars) 2008. [DOI: 10.2478/s11536-008-0069-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AbstractDuring middle-ear-surgery under local anaesthesia (MES-LA), patients report hearing noises, feeling anxious, and experiencing earache. In a prospective randomized clinical trial, we compared propofol and midazolam for sedation in 68 patients scheduled for MES-LA. The starting dose of propofol was 1 to 1.5 mg per kilogram intravenously, followed by 1 to 2 mg per kilogram per hour given by infusion. The starting dose of midazolam was 0.02 to 0.05 mg per kilogram intravenously, followed by 0.01 to 0.02 mg per kilogram intravenously. Metamizol and fentanyl were added when required. Sedation was titrated to a Ramsay score of 3 to 4 and a bispectral index value of 70 to 80. Patients were assessed for vital parameters and sedation and pain scores. In the recovery room, readiness for discharge and satisfaction of both patient and surgeon with the procedure were assessed. The group receiving propofol had a significantly lower heart rate, shorter duration of sedation, and earlier readiness for discharge (p<0.05). There were no significant differences in other parameters evaluated. Seventy-nine per cent of patients in the group receiving propofol and 91.1% receiving midazolam would choose the same method of anaesthesia and sedation for any further MES-LA. Our results suggest that, compared to midazolam, propofol is more suitable for sedation in patients undergoing MES-LA. However, appropriate patient selection, adequate preparation, and careful monitoring are mandatory.
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Mundt JC, Geralts DS, Moore HK. Dial "T" for Testing: Technological Flexibility in Neuropsychological Assessment. Telemed J E Health 2006; 12:317-23. [PMID: 16796499 DOI: 10.1089/tmj.2006.12.317] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Computer-automated neuropsychological testing can be conducted over the telephone via interactive voice response (IVR) technology by adapting cognitive measures traditionally administered by a clinician or in paper-and-pencil formats. By utilizing automated telephone interviews in neuropsychological research, time and money can be saved, and patients can be assessed remotely. This paper reviews the use of IVR to assess neuropsychological functioning in six studies that examined alcohol impairment of mental and physical functioning, cognitive and psychomotor recovery after surgery, and impairment resulting from central nervous system disease. Future directions for expanding application of cognitive performance assessment via IVR are discussed.
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Affiliation(s)
- James C Mundt
- Healthcare Technology Systems, Inc., Madison, Wisconsin 53717, USA.
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Girdler NM, Lyne JP, Wallace R, Neave N, Scholey A, Wesnes KA, Herman C. A randomised, controlled trial of cognitive and psychomotor recovery from midazolam sedation following reversal with oral flumazenil. Anaesthesia 2002; 57:868-76. [PMID: 12190751 DOI: 10.1046/j.1365-2044.2002.02785.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Flumazenil is traditionally administered intravenously to reverse the adverse effects of over sedation with benzodiazepines. The aim of this study was to test postoperative cognitive and psychomotor recovery from midazolam conscious sedation, following reversal with orally administered flumazenil. It was hypothesised that when administered by the oral route, flumazenil may enhance recovery over a prolonged period, thus increasing safety. Eighteen patients requiring intravenous midazolam sedation for dental treatment completed a randomised, double-blind, crossover trial. Following treatment the patients' sedation was reversed using either flumazenil or saline (as placebo), administered orally, on alternate appointments. Assessment of mood and cognitive function were undertaken using ClinPhone.cdr(R), a highly sensitive and specific computerised battery of cognitive tests administered by telephone prior to sedation and every hour for seven hours post reversal. Results indicate that within 20 min of administration, oral flumazenil is capable of partially reversing some cognitive and psychomotor impairments but the attentional and stimulus discrimination effects of midazolam sedation still remain.
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Affiliation(s)
- N M Girdler
- Senior Lecturer and Honorary Consultant in Sedation, General Dental Practitioner and Clinical Assistant, SHO in Dental Sedation, University of Newcastle Dental Hospital and School, Richardson Road, Newcastle-upon-Tyne NE2 4AZ, UK
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Sedation reversal with flumazenil? Br Dent J 2002. [DOI: 10.1038/sj.bdj.4801367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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