Ketamine-propofol (ketofol) in procedural sedation: a narrative review

Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

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.

Sexual hallucinations during conscious sedation for dentistry - an update of the phenomenon

Background Sexual hallucinations have been suggested as an infrequent side effect during sedation and cases can result in sexual assault allegations. The aim of this article is to review the literature on this rare side effect during sedation.Methods Publications were chosen using inclusion criteria: hallucinations and/or alleged sexual assaults and/or paradoxical reactions to either sedation or anaesthesia, that were of a sexual nature. Non-English language papers were excluded. Studies were analysed for: methodological quality, sedative agent, dose, population, treatment undertaken and outcome of the hallucination.Results Twenty-eight publications were reviewed. There was literature discussing sexual hallucinations to midazolam (13 studies), propofol (12 studies) and nitrous oxide (three studies). This side effect to sedative agents has a low incidence and can depend on factors like the sedation agent, dosage and type of procedure undertaken.Conclusions Current literature suggests that on rare occasions, sedation may induce sexual hallucinations and higher dosages are more likely to be implicated. In an occurrence of this side effect, presence of a third party and record-keeping is essential. Thorough patient assessment, appropriate clinician training and adhering to national dental sedation guidelines will help maintain the excellent safety record of UK dental sedation.

Can intravenous conscious sedation with midazolam be effective at facilitating surgical dentistry in adolescent orthodontic patients? A service evaluation

Background Surgical dentistry during orthodontic care often occurs in adolescence and may involve surgical removal or exposure of teeth. The invasive nature of treatment, combined with dental anxiety, means care can often be provided under general anaesthesia (GA). Best-practice guidelines however endorse conscious sedation as an alternative, where appropriate. Although a limited number of studies have shown safe and effective use of intravenous conscious sedation (IVCS) with midazolam in this cohort, robust evidence to support routine use is lacking. Aim To assess whether IVCS with midazolam can effectively facilitate surgical dentistry in adolescent orthodontic patients in primary care.Method A retrospective service evaluation was undertaken reviewing clinical records of adolescents (aged 12-15 years) undergoing surgical exposure and/or surgical removal of teeth under IVCS with midazolam.Results A total of 174 adolescents (mean age 14.2 years) attended for treatment between 2009 and 2015. Of these adolescents, 98.9% (N = 172) allowed cannulation, with all surgical dentistry completed during a single visit. Midazolam dose ranged from 2-7 mg with 79.1% of patients having good or excellent cooperation and three minor adverse events occurring.Conclusion This service evaluation shows IVCS with midazolam can effectively facilitate surgical orthodontics in carefully selected adolescents. There is however a distinct need to further explore potential for this technique to provide a viable alternative to GA.

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery

Background

Anxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique.

Methods

The medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients.

Results

In total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications.

Conclusions

Our results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae.

Reported side effects of intravenous midazolam sedation when used in paediatric dentistry: a review

BACKGROUND

Intravenous (IV) midazolam may be of value as an alternative paediatric dental sedation technique, but there is some apprehension concerning its routine use due to a lack of evidence regarding its safety and side effects.

AIM

To review all available literature reporting the side effects of IV midazolam in children undergoing dental procedures.

DESIGN

Both randomised controlled trials (RCT) and non-randomised studies were reviewed. Reported side effects were categorised as either significant or minor, and the percentage prevalence of significant or minor side effects per episode of treatment was calculated.

RESULTS

Five RCTs were included, in which no significant side events were reported; however, minor side effects were recorded (n = 33, 19.5%), with paradoxical reaction being the most common (n = 11, 6.5%). Six non-randomised studies were included, in which no significant side effects were reported; however, minor side effects were reported (n = 118, 16.8%) with paradoxical reaction being the most common (n = 89, 12.7%).

CONCLUSIONS

Although no significant side effects were recorded, of the minor side effects reported paradoxical reaction was the most common. Due to inconsistency in side effect reporting, the authors suggest the application of a standardised adverse event reporting tool for future studies of sedation in paediatric dentistry.

Conscious sedation procedures using intravenous midazolam for dental care in patients with different cognitive profiles: a prospective study of effectiveness and safety

The use of midazolam for dental care in patients with intellectual disability is poorly documented. This study aimed to evaluate the effectiveness and safety of conscious sedation procedures using intravenous midazolam in adults and children with intellectual disability (ID) compared to dentally anxious patients (DA). Ninety-eight patients with ID and 44 patients with DA programmed for intravenous midazolam participated in the study over 187 and 133 sessions, respectively. Evaluation criteria were success of dental treatment, cooperation level (modified Venham scale), and occurrence of adverse effects. The mean intravenous dose administered was 8.8±4.9 mg and 9.8±4.1 mg in ID and DA sessions respectively (t-test, NS). 50% N₂O/O₂ was administered during cannulation in 51% of ID sessions and 61% of DA sessions (NS, Fisher exact test). Oral or rectal midazolam premedication was administered for cannulation in 31% of ID sessions and 3% of DA sessions (p<0,001, Fisher exact test). Dental treatment was successful in 9 out of 10 sessions for both groups. Minor adverse effects occurred in 16.6% and 6.8% of ID and DA sessions respectively (p = 0.01, Fisher exact test). Patients with ID were more often very disturbed during cannulation (25.4% ID vs. 3.9% DA sessions) and were less often relaxed after induction (58.9% ID vs. 90.3% DA) and during dental treatment (39.5% ID vs. 59.7% DA) (p<0.001, Fisher exact test) than patients with DA. When midazolam sedation was repeated, cooperation improved for both groups. Conscious sedation procedures using intravenous midazolam, with or without premedication and/or inhalation sedation (50% N₂O/O₂), were shown to be safe and effective in patients with intellectual disability when administered by dentists.