Use Of Intranasal Midazolam Research Articles

Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review.

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

INTRANASAL MIDAZOLAM FOR THE TREATMENT OF SEIZURES IN CHILDREN IN RURAL INDIA

Background: About 5% of healthy children experience at least one convulsive episode in their lifetime with onset during childhood in more than half the cases. The current evidence suggests that prolonged seizures are best stopped with early treatment. Objective: The objective of the study was to assess the role of intranasal administration of midazolam for seizure cessation at home by caregiver in semi-urban and rural settings. Materials and Methods: A total of 50 children in the age group of 6 months–14 years were included in the study, who previously had a history of convulsions and were on regular follow-up. The study was conducted over a period of 6 months. The parents were instructed to give intranasal midazolam (INM) if seizure activity lasted for more than 3 minutes and the need of giving it 2nd time if the seizure was not aborted and to bring the child to nearest pediatrics emergency set up for the further management. Results: The subjects were divided into three groups according to age: Group A consisted of children between 6 months and 4 years, Group B of 4 and 9 years, and Group C had 9 and 14 years old children. Average duration of aborting seizures before INM use was 16.22 min and after its use was 4.66 min. Seizures were aborted in 45 children within 10 min. Conclusion: INM is safe and efficacious in aborting seizures at home in semi-urban and rural settings.

The effectiveness of topical lidocaine in relieving pain related to intranasal midazolam sedation: a randomized, placebo-controlled clinical trial.

Intranasal midazolam (INM) is an increasingly popular agent for sedation in the emergency department and outside the hospital in physician, imaging, and dental offices, to facilitate diagnostic and minor surgical procedures and avoid the need for an operating room and general anesthesia. The use of INM has been commonly associated with a burning sensation of the nasal mucosa. Despite its significance, this subject has received little adequate research focus. The objective of the current study was to evaluate the effectiveness of topical lidocaine in relieving pain related to INM administration. This was a blinded, randomized placebo-controlled trial. Sixty-three uncooperative children undergoing dental treatment, aged 4 to 11 years, were randomly assigned to one of three groups to receive the drug nasally via a precalibrated spray as per the following assignments: group A received 0.5 mg/kg midazolam, group B received lidocaine 2% prior to 0.5 mg/kg midazolam, and group C received saline 0.9% (placebo), 0.5 mg/kg. Children were asked to record the degree of pain using the Wong-Baker faces scale. Parental acceptance was also rated. Topical lidocaine prior to INM administration reduced the burning sensation in the nasal mucosa and improved the drug acceptance. The median score of pain was 8, 1, and 4 in groups A, B, and C, respectively. The differences among the three groups were statistically significant (P > .05). The children's acceptance and parents' future acceptance regarding the intranasal drug administration was significantly higher in group B. INM administration results in burning sensation in the nasal mucosa with high levels of pain. Using topical lidocaine 2% counteracted the burning sensation and achieved a higher acceptance rate and lower pain scores.

Impact of prescribing intranasal midazolam as rescue medication for domiciliary management of acute seizure among children with epilepsy

Prescription pattern of rescue medication like intranasal midazolam (INM) for domiciliary management of seizure is highly variable. The present cross-sectional study was designed to determine the impact of the use of INM on healthcare utilization by those who used INM when compared with those who are not on any rescue medications in a resource-constraint setting. Children with epilepsy aged 1–14 years who have used INM to abort seizure at home (INM group) were compared with those who have not used INM (control group). The baseline demographic and seizure characteristics including the severity of epilepsy were comparable between the INM group (n = 50) and controls (n = 50). The INM group had significantly better knowledge of the correct method of administration when compared with controls [43 (86%) vs. 17 (34%); p < 0.01]. Seizures were aborted in 36 (72%) users in the INM group; of the rest of 14 children, 4 (8%) used it for the second time. The median Interquartile range (IQR) time taken to abort the seizure was 2.5 (1.0, 5.2) min. The need for intensive care admissions was comparable between the INM group and control group, although the number of emergency visits was significantly higher in the former [2.9 vs. 1.4, p = 0.04]. Despite comparable severity of epilepsy and better knowledge of its correct use, children who were prescribed INM required more hospital emergency visits. This study with a limited sample size prompts us to introspect the practice of INM for children with epilepsy.

Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children

PurposeProcedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED. ObjectiveTo evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores. MethodsA prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction. Results112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale. ConclusionOur data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.

Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.

Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.

Implementation of Intranasal Midazolam for Prolonged Seizures in a Child Neurology Practice.

Currently, evidence supports the use of intranasal midazolam as an effective, and in many cases, preferable treatment option for prolonged seizures in children. Despite this knowledge, intranasal midazolam is not routinely found as a standard of care. The goal of this project was to implement the use of intranasal midazolam as a rescue medication for prolonged seizures within a child neurology practice and, in doing so, create a model for implementation that would be replicable for other practice sites. This project focused on the development of a process to make intranasal midazolam available as a treatment option and then the creation of an educational intervention for providers within a child neurology practice. Provider surveys analyzed provider attitudes toward intranasal midazolam and its frequency of use. Because of this project, a dramatic increase in the prescribing of intranasal midazolam was observed within a child neurology practice.

Intranasal dexmedetomidine versus midazolam in preoperative sedation for noncomplex pediatric congenital cardiac surgeries

Background & objectives Preoperative anxiety can be reduced pharmacologically. Midazolam is a benzodiazepine potent sedative, hypnotic, anaesthetic agent with strong anticonvulsant properties but does not have analgesic properties. The administration of intranasal lidocaine prior to the use of intranasal midazolam has been reported to be beneficial in reducing the burning sensation from intranasal midazolam. Dexmedetomidine, the newest sedative, is a highly selective α2 adrenergic agonist. Materials and methods Sixty children, aged between 3–12 years. The children were divided into two groups of 30 each. Thirty minutes before induction, Group-D (n=30) received intranasal Dexmedetomidine and Group M+L received intranasal midazolam preceeded by single puff on intranasal lidocaine spray 1% in each nostril. Results Children who were premedicated with intranasal dexmedetomidine had lower sedation (MOAA/S Scale) scores, and easier child-parent separation than children who received intranasal midazolam. In addition to lower BIS measurements at the OR, after face mask application and after IV cannulation. Conclusion Intranasal Dexmedetomidine can be used effectively and safely as a preanaesthetic medication in children undergoing repair of non-complex congenital cardiac defects.

Intranasal midazolam for anxiolysis in closed reduction of nasal fractures in children

ObjectivesNasal fractures can result in obstruction of the nasal airflow and cosmetic deformities, and are treated either with observation, closed reduction, or a delayed rhinoplasty. In the pediatric patient, closed reduction is challenging due to anxiety and poor patient cooperation. Here, we describe the unique topical use of intranasal midazolam for anxiolysis in two pediatric patients at the time of closed reduction of nasal fractures, which has not been previously described. MethodsRetrospective case series. ResultsIn this case series, intranasal midazolam was used in two pediatric patients with isolated nasal fractures during closed reduction for anxiolysis in the Emergency department at a single academic medical institution between 2012 and 2013. There were no adverse outcomes and anxiolysis was achieved in both patients. ConclusionsIntranasal midazolam can provide effective anxiolysis for pediatric patients during closed reduction of nasal fractures.

The Use of Intranasal Midazolam in a Special Care Dentistry Department: Technique and Cases

Intranasal (IN) administered midazolam has allowed patients who require conscious sedation but struggle to tolerate cannulation another option by which they can receive dental treatment. Studies have demonstrated that a mean bioavailability (F) of more than 73% can be achieved with IN-administered midazolam. This is due to the high vascularity within the nose. These studies have also demonstrated that peak plasma concentrations can be reached within 10 minutes. This signifies a fast onset of action. The standard bolus dose of IN midazolam is 10mg; this bolus can be reduced or increased depending on the patient's age and susceptibility to benzodiazepines. The bolus can also be repeated if adequate sedation is not reached. A protocol for administering IN midazolam is outlined and two cases are discussed.

Alternative for pre-anesthetic sedation and for surgical procedures in children: use of intranasal midazolam

Alternative for pre-anesthetic sedation and for surgical procedures in children: use of intranasal midazolam

865 Intranasal Midazolam and Ketamine for Gastric Aspirates in Children Evaluated for Suspected Tuberculosis

Background and AimsTo confirm the diagnosis of pulmonary tuberculosis in children sequential gastric lavages are recommended. Limitations of gastric lavage include the need for an overnight fast, repeated specimens, and...

The use of intranasal midazolam in the treatment of paediatric dental patients

We wish to congratulate Gilchrist et al. for their recent publication [1]. We agree on the efficacy and safety of midazolam in children having procedures who may otherwise have required a general anaesthetic. However in recent recommendations [2], intranasal midazolam administration in patients under the age of 12 years, is classified in the category of ‘alternative techniques’. It is important to appreciate then, that the apparent simplicity of intranasal sedation belies the potential for undesirable effects so that monitoring, discharge and supervision requirements should be the same as those for intravenous sedation [2-4]. This technique must be limited to skilled hospital personnel and it must be stressed that premature discharge to an unmonitored setting remains the weakest link in this setting [3, 4]. Indeed, the use of sedation is still a limited practice among European dentists: in Italy sedation is provided mainly by anaesthetists (94%), seldom by dentists (6%) [5]. Education is largely theoretical, and practice on patients is lacking in the majority of the European Dental Schools [6]. If the teacher of dental anaesthesia is an anaesthetist, they must be able to transfer specialist professional skills and competences to dentists, who, in turn, will gain greater autonomy. Without this autonomy, the dental profession will remain subject to the anaesthetist’s will and, consequently, deep sedation/general anaesthesia techniques will be preferred to conscious sedation techniques. This situation increases risks for patients and the expenditure for dental care, with the teaching of inappropriate competencies leading to individuals considering they are able to practice in areas that they have not been truly appropriately taught [7]. This situation has arisen in Europe, but we have the opportunity to change it, with a greater autonomy for the dentists. It is necessary to establish a clear definition of objectives, competences and limits for the modern dentist, in order to get a common professional profile and legal framework, produced by European Union Authorities [8-10]. It is impossible currently to say which is the most effective sedation technique for anxious children [11] and this absence of evidence to support current practice is indeed alarming. However, we must remember that the cornerstone of management in dentistry remains an empathic approach to the patient supported by behaviour management techniques.

Atomized Intranasal Midazolam Use for Minor Procedures in the Pediatric Emergency Department

Procedural sedation is increasingly more common in pediatric emergency departments. We report our experience with intranasal midazolam (INM) using a unique atomization delivery device, specifically the efficacy and safety of this method of sedation. We performed a retrospective chart review of children who received INM sedation in the emergency department from April 1, 2005, through June 30, 2005. All children aged 1 to 60 months who received INM as the initial means of sedation were eligible for the study. Patients were excluded if they were older than 60 months. There were 205 patients who received INM for sedation and who met the study criteria. The mean age was 31.3 +/- 13.2 months (range, 1.5-60 months). The mean and median initial INM dose was 0.4 mg/kg (range, 0.3-0.8 mg/kg). Laceration repair was the most common procedure necessitating sedation (89%). The median degree-of-sedation score achieved was 2.0 (anxiolysis). Eleven patients (5.4%; 95% CI, 3%-9%) required an additional sedative to complete the procedure. Ten of the 11 patients received ketamine as the adjunctive sedative, and 1 patient required additional INM. The average time of last oral intake to start of sedation was 3.5 hours (range, 0.5-10.0 hours). Thirty six patients (18%) were NPO for 2 hours or less. There was 1 adverse event (0.5%; 95% CI, 0%-3%). This was a minor desaturation episode following ketamine administration requiring brief blow by oxygen. There were no adverse events (0%; 95% CI, 0%-2%) in patients who received INM alone. We conclude that atomized INM is effective in providing anxiolysis to children undergoing minor procedures in the pediatric emergency department. We are encouraged that no adverse events occurred with the use of INM alone despite relatively short fasting times.

The use of intranasal midazolam in the treatment of paediatric dental patients*

The aim of this study was to assess the use of intranasal midazolam in paediatric dental patients requiring extractions or simple surgical procedures who may otherwise have required a general anaesthetic. Twenty children aged between 2-9 years who required simple surgical procedures were given 0.25 mg.kg(-1) midazolam, administered using a MAD (Mucosal Atomization Device; Wolfe Tory Medical Inc., Salt Lake City, UT, USA). Compliance with the full dose was achieved in 14 patients, 13 of whom completed the treatment. One of two patients who allowed only partial administration completed the treatment and three patients did not comply. The mean time to starting treatment was 13 min (range 6-25 min) and patients were discharged after a mean of 46 min (range 25-67 min). Physiological parameters remained stable throughout with no clinically significant episodes of desaturation. One patient vomited at home postoperatively. Midazolam in a dose of 0.25 mg.kg(-1) administered intranasally provided adequate anxiolysis for the majority of children, allowing them to complete their treatment.

Community use of intranasal midazolam for managing prolonged seizures

Background Until a few years ago, rectal diazepam (RD) was the only option available to parents and carers managing prolonged seizures. However, its use in the community was limited due to the requirement for privacy, and because education staff in South Australia are not permitted to carry out invasive procedures.Method Following a literature review, a seizure management training package was developed to enhance the implementation of a trial treatment protocol for the administration of intranasal midazolam (INM). Parents, carers and education staff were later surveyed about their experiences and perceptions.Results Intranasal midazolam was administered to 131 people (51 children and 80 adults), with 96.9% control of seizures, and only one minor adverse event. Parents expressed a preference for INM over RD because of the shorter time it took to take effect and wear off, and the ability to administer it in public if necessary.Conclusion Intranasal midazolam is a safe and practical alternative to rectal diazepam for managing prolonged seizures in the community.

Is intranasal midazolam an effective rescue medication in adolescents and adults with severe epilepsy?

The aim of this study was to determine whether intranasal midazolam is a safe and effective rescue medication in adolescent and adult patients with severe epilepsy. This field trial was designed to test the feasibility of the use of intranasal midazolam as an alternative to rectal diazepam in a cohort of patients with severe epilepsy who require rescue medication as part of their treatment. A dose of intranasal midazolam (5 mg if the patient weighed less than 50 kg and 10 mg if the patient weighed over 50 kilograms) was prescribed for those who had previously responded to other rescue medication. Midazolam was prescribed buccally if excessive head movement accompanied seizures. The protocol reverted to the usual rescue medication if there was no response to midazolam within 10 minutes. Vital signs were monitored for half an hour following the administration of the treatment. Twenty-two patients received 84 treatment episodes and 79 of these were considered clinically effective. Five treatment failures were recorded, three due to poor technique in delivering the midazolam. Two patients were successfully retried on midazolam and a third is awaiting a retrial of this drug. The two other treatment failures received the drug buccally. In the first patient the clinical opinion was that this was possibly a psychogenic non-epileptic seizure. The other patient responded initially, but within an hour had another seizure requiring further rescue treatment. No significant adverse effects were reported. Our study shows that intranasal midazolam, when used appropriately, is an effective treatment in those who require rescue treatment. There are clear advantages in the use of midazolam over diazepam in the treatment of acute seizures. These include the favourable pharmacokinetic and pharmacodynamic properties of midazolam as well as the potential of a more acceptable and dignified administration route.

Midazolam via the intranasal route: An effective rescue medication for severe epilepsy in adults with a learning disability

People with a learning disability are often disadvantaged due to the nature of their disability. Up to a third are likely to have concomitant epilepsy which adds to the health loss experienced by this group. It is important to manage their epilepsy in such a way as to limit the debilitating effects of both the illness and the medication. Rectal diazepam remains the gold standard rescue medication for prolonged, recurrent seizures or seizures associated with hypoxia. Some of the drawbacks are highlighted in this paper and we go on to explore a novel means of treating these seizures. Midazolam, via the intranasal route, has been used extensively in children, mostly as a sedative but also in the treatment of epilepsy. We present two cases, both are adults with a learning disability, who have benefited significantly from the use of intranasal midazolam. Ongoing research into the safe use of this form of treatment, training of staff and carers and the impact on the individual is being conducted.

New routes in pediatric sedation: a research-based protocol for intranasal midazolam.

The quality assurance and improvement committee on a general pediatric unit identified a problem with sedation for neuroradiologic studies. Twenty-three percent of children (n = 63) failed to sedate with one dose of chloral hydrate, resulting in delays or cancellations. For children receiving a second dose of chloral hydrate, average time to study completion was 97 minutes, and 70 percent of the children (n = 10) were successfully sedated. A protocol was developed for the use of intranasal midazolam as the follow-up agent. Evaluation on a pilot unit revealed that the average time to test completion decreased to 55 minutes and that the success rate was 82 percent (n = 11). The nursing staff prefer the use of intranasal midazolam as the follow-up agent because of its quicker sedation and decreased duration of action.

Complication of Intranasal Midazolum

The recent article by Theroux et al on the use of intranasal midazolam was interesting. The purpose of this letter is to share our experience regarding a complication associated with the use of this drug. The need for an ideal sedative for pediatric patients undergoing diagnostic and short surgical procedures is well established. In the past 5 years, the literature is replete with reports on the efficacy, ease of administration, and tolerance of intranasal midazolam. Currently, our group is also evaluating the efficacy of intranasal midazolam in pediatric patients (aged 2 to 12 years) undergoing upper endoscopy. Soon after beginning enrollment, however, it became apparent that intranasal midazolam causes intense burning, irritation, and lacrimation on instillation into the nares.