Average Dose Of Midazolam Research Articles

Effectiveness and safety of dentist-led conscious sedation using fentanyl with midazolam in dentistry: a five-year retrospective service evaluation.

Background Fentanyl provides systemic analgesia and enhances the sedative effect of benzodiazepines. When midazolam-only sedation is ineffective, fentanyl can be considered as an adjunct, but this advanced sedation technique requires additional training. Studies reporting on the safety and effectiveness of dentist-led conscious sedation using fentanyl and midazolam are lacking.Aims To review the indication of use, safety and effectiveness of fentanyl and midazolam sedation at The Royal London Dental Hospital since its introduction into the service.Method Retrospective data collection of sedation cases from October 2016 to October 2021 was carried out.Results Of the 109 cases included, the majority of patients who had fentanyl (90.8%) had a history of unsuccessful sedation with midazolam. A lower average dose of midazolam was administered when fentanyl was used; the difference was statistically significant (p <0.0001). A higher proportion of patients who had fentanyl and midazolam presented with lower Ellis scores (better operating condition) compared to midazolam-only sedation. No adverse incidents were recorded.Conclusion In this evaluation, the synergistic effects of fentanyl and midazolam resulted in enhanced sedation, anxiolysis and intraoperative conditions. This service evaluation showed some encouraging data regarding the potential safety profile and effectiveness of fentanyl in dental sedation when used by experienced clinicians; however, larger scale studies are required to validate this.

Service evaluation of an intravenous sedation service within a hospital paediatric dentistry unit: ten-year results.

Background An intravenous sedation (IVS) service was established in 2008 for young people aged 12 years or over, within the paediatric dentistry department at the Eastman Dental Hospital in London. The aim of this study was to carry out a service evaluation and assess the case mix and success rate of this service over the last ten years.Materials and methods A retrospective service evaluation was carried out, including all patients attending the IVS clinic between April 2009 and March 2019.Results A total of 457 patients attended over 525 appointments. The mean age was 14. The success rate was over 98%. The average dose of midazolam was 4 mg and dosage ranged from 1.5-10 mg.Conclusion This IVS service has been established successfully and offers patients an alternative to general anaesthetic. This consequently reduced the general anaesthetic waiting list by 10%.

The use and safety of intramuscular midazolam during in-office botulinum toxin injections in pediatric patients.

Pediatric outpatient procedures can be traumatic experiences for patients. This retrospective study, evaluates intramuscular midazolam as a safe option for anxiolysis during spasticity management injections. We performed a retrospective chart review of 72 patients from a Tertiary Pediatric Hospital Outpatient Clinic. One hundred and twenty injections were administered over two years by a single practitioner. Comorbidities included asthma, sleep apnea, chronic obstructive disease, and epilepsy. Duration of sedation, safety of midazolam as determined through the use of the REACT (Respiration, Energy, Alertness, Circulation, Temperature) score, and frequency of side effects (prolonged sedation, breakthrough crying, medication reversal, and emergent evaluation) were recorded. A student's t test evaluated the relationship between the above comorbidities and duration of sedation. The average duration of sedation was 29 minutes (95% CI 26.51-31.35) with an average dose of midazolam of 0.20mg/kg (95% CI 0.9-0.21). None of the subjects required medication reversal or emergent evaluation. 39% of the patients had prolonged sedation (> 30 minutes after medication administration), 22% had breakthrough crying, and 0% had respiratory events requiring oxygen, intubation or an emergency evaluation. No statistical significance found between the comorbidities and duration of sedation. Intramuscular midazolam is a possible effective anxiolytic medication strategy for outpatient pediatric injections. Additional studies are needed to ensure its safety and efficacy.

Ketamine to treat super-refractory status epilepticus.

To test ketamine infusion efficacy in the treatment of super-refractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM). We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not. Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio 1.39, 95% confidence interval 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure. Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure. This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.

596 ICU Sedation Practices for Mechanically Ventilated Burn Patients Following Guideline Implementation

Abstract Introduction Our American Burn Association verified regional burn center has approximately 700 admissions for burn injury per year, 200 of which are admitted to the burn intensive care unit (BICU). Sedation practices during acute burn resuscitations remain variable. In order to standardize our sedation practices, we developed a Background Pain and Anxiety Decision Tree for Mechanically Intubated Adults in March 2017. Concern over hypotension led to the removal of propofol as the sedative of choice. The new protocol made midazolam the primary choice and recommended the use of adjunct analgesics, including acetaminophen, for background pain. It uses the Richmond Agitation Sedation Scale (RASS) to determine whether patients were oversedated (RASS&amp;lt; 0) or anxious (RASS &amp;gt;1+). Methods We conducted a single center retrospective chart review on intubated patients admitted to the BICU from November 2017 through November 2018. Data collection focused primarily on sedation practices during this time to determine whether our protocol had the desired effects. Highest and lowest RASS were collected, and the difference between the two (delta RASS) was used to determine changes in patient agitation and sedation. Results Thirty three adult patients requiring mechanical ventilation were admitted to the BICU between November 2017 and November 2018. Of these patients, 21 (66%) received propofol on hospital day one, and 12 (38%) received propofol on hospital day two. Eleven patients received both propofol and midazolam on hospital day one. Of these patients, the average propofol dose was 511 micrograms per day and the average midazolam dose was 13.3mg per day (p=0.02). Eighteen (56%) and twenty five (78%) patients received acetaminophen on hospital days one and two, respectively. Twenty four patients had a RASS recorded during their first hospital day. The average highest RASS recorded was 1.3 and the average lowest recorded RASS was -3.2. Patients who received both propofol and midazolam had a higher peak RASS (2.4) and a lower minimum RASS (3.4), creating a larger delta RASS for this group. Conclusions Despite eliminating propofol from our sedation guidelines, its use remains the predominant mode of sedation for burn patients throughout the first forty eight hours of hospitalization. There is also room for improvement for administration of non-opioid analgesics, including acetaminophen. Finally, our ventilated patients tend to be more oversedated than undersedated, and a combination of midazolam and propofol creates the largest swings in patients’ sedation and agitation status. Applicability of Research to Practice Changing sedation and pain management practices in the ICU is a multifactorial process that requires more than ICU guideline implementation. The use of two sedatives during the first hospital day can result in larger swings in RASS as opposed to use of a single agent.

Fentanyl Waste Was Reduced by Conservation Measures While Maintaining Patient Comfort During Moderate Sedation Endoscopy Procedures

Injectable fentanyl is widely used as part of moderate sedation for endoscopic procedures. In the setting of a national injectable fentanyl shortage, conservation measures were enacted in 4/2018 at our academic medical center, which performs over 14,000 moderate sedation endoscopy cases per year. We aimed to evaluate the impact of conservation measures on overall fentanyl use, fentanyl waste, and patient procedural tolerance. Conservation measures were implemented in the setting of increased awareness of fentanyl shortage (6 weeks after first hospital wide notifications). The measures consisted of: 1) education over a 1-week period on dose contained within each fentanyl ampule and change in recommended dose escalation strategy near threshold (100 mcg) and 2) nursing medication preparation protocol change to avoid anticipatory medication pre-draw. Data on procedural type, patient demographics, administered medication doses for fentanyl, midazolam, patient tolerance of procedure were retrospectively queried from our endoscopy reporting database for 6 months before and after implementation of above measures. Fentanyl waste data was queried for the same period from Omnicell® medication cabinet logs. Primary outcomes were average fentanyl dose administered, average fentanyl waste, and patient tolerance of procedure as documented by the provider. Statistical analyses were performed using Student’s t-test for continuous variables and Chi-squared test for categorical variables. 14,682 moderate sedation endoscopy cases (9,305 colonoscopies, 4,382 upper endoscopies, and 995 other) were performed in the 12-month period surrounding conservation measure implementation (7,393 pre, 7,289 post). A small but significant reduction in average fentanyl dose (106.9 mcg/case pre, 100.8 mcg/case post, p<0.0001) and a sizeable difference in average fentanyl waste (63.9 mcg/case pre, 48.9 mcg/case post, p<0.0001) (Figure 1) was observed after implementation of conservation measures without significant change in patient tolerance during endoscopy (“tolerated procedure well” 94.9% pre, 94.5% post, p = 0.4294). Total fentanyl ampules wasted in the 6 months pre and post-implementation decreased by 653 (5,680 to 5,027). Additionally, average midazolam dose also decreased during the same period (4.21 mg/case pre, 4.09 mg/case post, p<0.0001). Conscientious care in endoscopy using a low-cost, education/policy-based intervention in the setting of a fentanyl shortage is feasible with significant benefits. Conservation measures were highly effective in reducing fentanyl use and waste for moderate sedation endoscopic procedures without impacting patient experience.

Role of Music for Conscious Sedation During Invasive Cardiac Catheterization

Patients undergoing invasive cardiac catheterization (ICC) can experience anxiety and pain. A common practice in the United States is to administer benzodiazepines and opioids for conscious sedation to relieve these symptoms. Music may reduce anxiety and pain perception. We sought to evaluate the role of music in lieu of pharmacotherapy for conscious sedation during elective ICC. A retrospective data analysis was performed on patients who underwent ICC and received music therapy ± intravenous sedation/analgesics based on patient's preference compared with control patients who were offered and received intravenous sedation/analgesics based on patient's preference. A total of 161 patients were analyzed, 49 in the music arm, and 112 in the control arm. Baseline characteristics were similar in the 2 groups except that the rate of drug addiction, back pain, post-traumatic stress disorder, and hearing loss were higher in the control group when compared with the music arm. 42 (86%) of the patients in the music group and 29 (26%) of the control group received no sedation or analgesia in the periprocedural period. The average dose of midazolam (0.7 mg vs 0.1 mg, p <0.0001) and fentanyl (39.5 mcg vs 3 mcg, p <0.0001) was higher in the control than the music arm, respectively. 42 (86%) of patients receiving music therapy believed music was helpful in reducing their stress/anxiety levels. In conclusion, music may serve as adjunctive/alternative intervention to pharmacotherapy in relieving anxiety and stress for patients undergoing elective ICC.

Comparison of fasting and non‐fasting patients receiving intravenous (IV) sedation

AbstractAimIn 2015 the Intercollegiate Advisory Committee for Sedation in Dentistry published a national standard for the provision of conscious sedation in dentistry. This document highlighted the need for justification of the decision not to fast patients prior to administration of IV sedation. The aim of this case control study was to compare a fasting (F) and non‐fasting (NF) group of patients undergoing oral surgery procedures under IV sedation, and to assess for sedation related complications in both groups.Material and methodsA total of 228 patients were analysed, with 114 patients in each group.ResultsMean age was 33 years for the F group and 30.2 years for the NF group. The average midazolam dose was 5.11 mg for the F group and 5.72 for the NF group (pa = 0.03). The mean recovery time was: 38.53 min for the F group and 36.57 min for the NF group (pa = 0.14). Extra measures required included: supplemental oxygen for 5 patients in the F group and 6 patients in the NF group, Oral glucose was given during the recovery period to 6 patients in the F group. 1 patient in the F group was unable to be cannulated.ConclusionsPracticing minimal to moderate sedation in ASA 1 and 2 non‐fasting patients is safe and in our study appears to give less complications than the fasting patients.

Sedation with orally administered midazolam in elderly dental patients with major neurocognitive disorder

The aim of this study was to evaluate acceptance of treatment after oral sedation with midazolam in dental patients with major neurocognitive disorder. Midazolam is commonly used as premedication in paediatric dentistry, oral surgery and people suffering from dental fear. Little is known about its use in other patient groups. Dental and sedation records of 61 patients (64% women) sedated with midazolam were examined retrospectively. All records came from patients with major neurocognitive disorder who had been referred to a special dental care unit in Sweden due to uncooperative behaviour and sedated with orally administered midazolam between 2006 and 2011. Data concerning dose, degree of acceptance of dental treatment (four-point scale) and number of possible interacting drugs were collected from dental records. On average, the participants were 80years old (range: 62-93) and used 3.4 possible interacting drugs. The average midazolam dose was 0.11mg/kg body weight, which is in line with the regional medical guidelines for sedation. Twenty-seven participants (44%) had no cooperation problems when sedated, twenty-six (43%) were treated with minor adaptations, five had poor cooperation, and three were not possible to treat. No statistically significant differences were found for degree of acceptance of treatment and dose or number of possible interacting drugs. Antiepileptics were used by 13% (n=7) with good or quite good acceptance compared to 37% (n=3) among those with poor or no acceptance. Unfavourable side effects were rare; one participant became hyperactive and one drowsier than expected. Sedation with orally administered midazolam seems to be effective and safe in dental treatment of uncooperative persons with major neurocognitive disorder.

Adverse Drug Reaction with Midazolam Use in Emergency Department

Midazolam is one of the most commonly used drugs for sedation in Emergency Department (ED). This was a retrospective study conducted on 380 patients from December 2012 to May 2014 in ED of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). The objective was to elicit the frequency of side effects and correlation to various factors i.e. socio-demography, co-morbidities, age groups and underlying illnesses. Out of 380 patients, 35 patients experienced side effects (20 patients with midazolam alone, 15 patients with combination of drugs). The average age was 42 years and the average dose of midazolam was 3.5mg. The most common other drug combined was fentanyl. The overall complication rate for midazolam was 5.3%. The most common side effect recorded was excessive somnolence (1.6%). Other side effects included local skin reactions (1.1%), vomiting (0.8%), headache (0.8%) and hypotension (0.5%). There was no significant association between the socio-demographic factors and drugs combination with the side effects of midazolam on patients. It was concluded that midazolam was a safe drug due to absence of any life-threatening side effects. There are possibilities that most side effects recorded could be caused by other comfounding factors e.g. underlying injuries or disease and combination with other drugs.

The Effects of Ketamine on Cognitive Function in Elderly Patients Undergoing Ophthalmic Surgery

Acute postoperative cognitive dysfunction is characterized by neurocognitive dysfunction and confusion. In this study, we compared the cognitive status of a geriatric population undergoing ophthalmic surgery, as assessed by the Short Portable Mental Status Questionnaire (SPMSQ) before and after ketamine administration. Eighty patients were enrolled and randomly assigned in a double-blind study to receive either ketamine (0.3 mg/kg dose) or physiologic solution (control group). Sixty-five (control, n = 32; ketamine, n = 33) patients completed the trial. Cognitive performance was assessed with an abbreviated version of the SPMSQ. Measurements of analgesia, sedation, intraocular pressure, and hemodynamic variables were recorded. With respect to cognitive performance, the baseline evaluation was similar for the control and ketamine groups. Postoperative evaluation showed an improvement only in the ketamine group. No increase in intraocular pressure or a secondary nystagmus was observed. The average dose of midazolam was higher in the control group, but the difference was not clinically significant. After surgery, analgesic behavior was better in the ketamine group than in the control group. There were no differences between groups in the sedation scale or in hemodynamic variables. The administration of 0.3 mg/kg ketamine during ophthalmic surgery in geriatric patients changed their cognitive status as assessed by the SPMSQ, decreased the required dose of anesthetics, and produced no increase in intraocular pressure or in hemodynamic variables. However, because the evaluation only analyzed the immediate effects of the administered drug, further research will be required to examine the impact of ketamine on the postoperative cognitive performance of geriatric patients before the drug can be formally recommended for this purpose.

Patient comfort and quality in colonoscopy.

To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy. All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson's correlation coefficient was used to identify relationships between performance indicators. A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r = -0.61, P < 0.005), and with poor patient experience (r = -0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r = -0.59, P < 0.01). CIR was positively correlated with PDR (r = 0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r = 0.64, P < 0.01). The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.

Randomised clinical trial: a ‘nudge’ strategy to modify endoscopic sedation practice

In behavioural economics, a 'nudge' describes configuration of a choice to encourage a certain action without taking away freedom of choice. To determine the impact of a 'nudge' strategy - prefilling either 3mL or 5mL syringes with midazolam - on endoscopic sedation practice. Consecutive patients undergoing sedation for EGD or colonoscopy were enrolled. On alternate weeks, midazolam was prefilled in either 3mL or 5mL syringes. Preprocedure sedation was administered by the endoscopist to achieve moderate conscious sedation; dosages were at the discretion of the endoscopist. Meperidine was not prefilled. Overall, 120 patients received sedation for EGD [59 (5mL), 61 (3mL)] and 86 patients were sedated for colonoscopy [38 (5mL), 48 (3mL)]. For EGDs, average midazolam dose was significantly higher in the 5-mL group (5.2mg) vs. 3-mL group (3.3mg), (P<0.0001); for colonoscopies, average midazolam dose was also significantly higher in the 5-mL group (5.1mg) vs. 3-mL group (3.3mg), (P<0.0001). There was no significant difference in mean meperidine dose (42.1mg vs. 42.8mg, P=0.9) administered to both colonoscopy groups. No adverse sedation-related events occurred; no patient required reversal of sedation. These findings demonstrate that 'nudge' strategies may hold promise in modifying endoscopic sedation practice. Further research is required to explore the utility of 'nudges' in impacting other aspects of endoscopic practice.

BIS monitoring during midazolam and midazolam-ketamine conscious intravenous sedation for oral surgery.

The purpose of this study was to determine whether the bispectral index scale (BIS) would provide added benefit to established methods of monitoring conscious sedation with midazolam (M group) or midazolam supplemented with ketamine (MK group). BIS was prospectively and blindly examined in 22 patients receiving outpatient oral surgery with conscious sedation supplemented with local anesthesia. The average midazolam dose in the midazolam group over the treatment period was 0.01 mg/kg/h, and the average midazolam plus ketamine dose was 0.01 and 0.05 mg/kg/h, respectively. Mean BIS values throughout the sedation study period were 90 for the midazolam group and 94 for the midazolam plus ketamine group. The addition of ketamine did not lower BIS. BIS values did not alter significantly over time except for an expected transient drop after the midazolam bolus induction. BIS levels remained close to baseline levels, suggesting that BIS would not provided any additional benefit to currently established methods of monitoring patient consciousness during conscious sedation for oral surgery.

Intravenous sedation for the closed reduction of fractures in children.

The safety and efficacy of intravenous sedation with both a narcotic and a benzodiazepine were evaluated in 104 consecutive children who had closed reduction of a fracture. Six patients had a subsequent additional reduction with intravenous sedation, so the study involved a total of 110 procedures. The average dose of meperidine was 1.47 milligrams per kilogram of body weight, and the average dose of midazolam was 0.11 milligram per kilogram of body weight. The interval between induction of the sedation and performance of the procedure averaged ten minutes, and the total duration of the procedure averaged thirty-nine minutes. There were no episodes of apnea or cardiorespiratory complications. Ninety-six (92 percent) of the initial 104 reductions were successful. Only four patients subsequently needed general anesthesia for a repeat closed reduction. The physician's satisfaction with the method of sedation was good or excellent for 103 (94 per cent) of the 110 procedures. Eighty-one (93 per cent) of eighty-seven patients who were able to respond had no memory of the reduction. A telephone survey conducted after the procedure revealed that eighty-four (98 per cent) of eighty-six parents who responded were satisfied with the method of sedation. Intravenous sedation with a narcotic and a benzodiazepine proved to be a safe and effective method of anesthesia for the closed reduction of fractures in children in our series. Careful monitoring of the patient after sedation is imperative.