Rectal Midazolam Research Articles

A review of a diazepam nasal spray for the treatment of acute seizure clusters and prolonged seizures

Introduction Some people with epilepsy experience acute repetitive seizures (ARS), also termed seizure clusters, which have a negative impact on patient and caregiver quality of life, emotional wellbeing, daily function, and may pose risk of injury or death. In addition, these events increase healthcare utilization in emergency departments and hospitals, which might be avoided with use of an at-home rescue medication. Intranasal formulations of benzodiazepines used as rescue medications provide a means of delivering rescue medication that is socially acceptable and more easily administered than rectal drug. Areas covered This article provides a review of intranasal diazepam covering development, pharmacokinetics, dosing, safety, adverse effects, and efficacy. The authors compare it with rectal diazepam and intranasal midazolam. Expert opinion Intranasal rescue drugs are a valuable treatment modality for seizure clusters and prolonged seizures that are effective and well-tolerated with potential to enhance patient quality of life, reduce the incidence of seizure-related injury, and lessen the need for hospital visits. The literature does not provide evidence comparing the various rescue agents, and head-to-head comparison studies are needed. An inhaled benzodiazepine as a seizure rescue drug is currently undergoing clinical trials.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Anesthetic management of a child with catecholaminergic polymorphic ventricular tachycardia undergoing insertion of implantable cardioverter defibrillator : a case report

BackgroundCatecholaminergic polymorphic ventricular tachycardia (CPVT) is a fatal cardiac ion channelopathy that causes sudden unexpected death in the young.Case presentationThe patient was a 3-year-old girl with CPVT. Insertion of an implantable cardioverter defibrillator (ICD) using epicardial pacing was scheduled. After premedication of rectal midazolam was given, general anesthesia was induced with midazolam, fentanyl, and rocuronium, and maintained with midazolam, fentanyl, remifentanil, and rocuronium. The operation was performed without any complications. Dexmedetomidine and fentanyl were continuously infused after the operation until she was extubated in the morning of postoperative day 1. Fatal arrhythmia due to perioperative stress did not occur.ConclusionsWe report the anesthetic management of a child with CPVT who underwent insertion of an ICD. CPVT-induced fatal arrhythmia did not occur perioperatively by carefully avoiding perioperative stress with premedication and post-operative sedation.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Rektal Midazolam Sedasyonunun Çocuklarda Sistometrik Parametrelere Etkisi

Rektal Midazolam Sedasyonunun Çocuklarda Sistometrik Parametrelere Etkisi

Effect of Sedation with Midazolam and Time to Discharge among Pediatric Dental Patients.

The aim of this study was to examine the recovery time of children who underwent conscious sedation with oral or rectal midazolam. The medical files in the Department of Pediatric Dentistry of all the children who underwent conscious sedation with midazolam between 3/2013-4/2016 were examined. The total duration of sedation and time to discharge were calculated. Descriptions of the children's behavior before and during sedation were compared. The files of 120 children were retrieved. They included 64 girls, mean (± standard deviation) age 5.7 ± 2.67 years and 56 boys, mean age 4.9 ±1.06 years. The mean weight for the entire cohort was 18.7 ± 5.2 kg. Eighty-one children (67.5%) received oral sedation and 39 (32.5%) received rectal sedation. The mean total duration of sedation was 105 ± 26 min, and the mean time to discharge after treatment was 55:17 ± 22:30 min. A hundred and seven children exhibited positive behavior before undergoing sedation, but the behavior deteriorated during sedation in 36 cases. The time to discharge post-midazolam sedation correlated to the child's age and weight and total amount of administered midazolam. Sedation negatively affected behavior in 43.6% of the cases.

Evaluation of the effects of sedation administered via three different routes on the procedure, child and parent satisfaction during cystometry.

PurposeIn this study, we retrospectively investigated case reports with and without midazolam administration via oral, intranasal and rectal before cystometry procedure. We aimed to compare the data to evaluate the effects of sedation before cystometry on the pediatric patients and parents’ satisfaction.MethodsA total of 124 ASA I-II pediatric cases aged 5–14 years were retrospectively investigated from the hospital records. One of the three administration routes was chosen; oral midazolam at a dose of 0.5 mg/kg and nasal or rectal midazolam at a dose of 0.3 mg/kg (maximum 15 mg). Heart rate, blood pressure, oxygen saturation, the Wisconsin Hospital of Children Sedation Scale (CHWSS) score and the Groningen Distress Rating Scale (GDRS) score were recorded. Cystometry measurement values, diagnoses of the cases and procedure durations were recorded from the urodynamic laboratory records.Results80 female, 44 male cases were evaluated. The CHWSS score at the 10th and 20th minutes after the drug administeration was higher in the oral group than the others (p = 0.001). The duration between the administration of the drug and the start of the procedure was shorter in the nasal group (p = 0.01). Parents satisfaction for sedation was 77 % when comparison of the cystometry with and without sedation. Comparison of the cystometry results with or without sedation no significant difference was found between all parameters (p > 0.01).ConclusionWe believe that sedation with midazolam administered through all three routes is a safe, effective and convenient option during cystometry, especially in the young age group.

Effect of Premedication on Hemodynamics and Bispectral Index in Pediatric Dental Rehabilitation

Objective: The aim of this study was to evaluate the effects of rectal midazolam premedication on hemodynamic parameters and BIS values in children undergoing general anesthesia (GA) for dental rehabilitation. Study Design: Records of 30 children aged 2 to 7 years were retrieved and divided into 2 groups. Group 1 received midazolam 0.3mg/kg body weight rectally, and group 2 involved children who did not receive any presedative (control). Mean arterial blood pressure (MAP), heart rate (HR), oxygen saturation (SpO 2 ), and BIS were evaluated (1) before laryngoscopy; (2) 1 min; (3) 5 min; (4) 10 min after nasotracheal intubation; (5) at the time of extubation; and (6) at the time of recovery. Paired t-test was performed to analyze all data. p 0.05), but increased significantly in control group 1 min after intubation (p 0.05). The BIS records of the midazolam group were slightly lower than the control group in general, but this difference was insignificant (p>0.05). Conclusion: Midazolam premedication prior to GA induction resulted with lower MAP and HR than the control group immediately after intubation whereas it did not alter BIS values remarkably at all time intervals.

Comparative pharmacokinetics and bioavailability of intranasal and rectal midazolam formulations relative to buccal administration in rabbits

The rectal and intranasal formulations under current development demonstrated comparative potential for administering midazolam in treating seizures in a medical emergency service.

The Effects of Single-Dose Rectal Midazolam Application on Postoperative Recovery, Sedation, and Analgesia in Children Given Caudal Anesthesia Plus Bupivacaine

Background. This study aimed to compare the effects of rectal midazolam addition after applying bupivacaine and caudal anesthesia on postoperative analgesia time, the need for additional analgesics, postoperative recovery, and sedation and to find out its adverse effects in children having lower abdominal surgery. Methods. 40 children between 2 and 10 years of ASA I-II were randomized, and they received caudal anesthesia under general anesthesia. Patients underwent the application of caudal block in addition to saline and 1 mL/kg bupivacaine 0.25%. In the postoperative period, Group C (n = 20) was given 5 mL saline, and Group M (n = 20) was given 0.30 mg/kg rectal midazolam diluted with 5 mL saline. Sedation scale and postoperative pain scale (CHIPPS) of the patients were evaluated. The patients were observed for their analgesic need, first analgesic time, and adverse effects for 24 hours. Results. Demographic and hemodynamic data of the two groups did not differ. Postoperative sedation scores in both groups were significantly lower compared with the preoperative period. There was no significant difference between the groups in terms of sedation and sufficient analgesia. Conclusions. We conclude that caudal anesthesia provided sufficient analgesia in peroperative and postoperative periods, and rectal midazolam addition did not create any differences. This trial is registered with ClinicalTrials.gov NCT02127489.

Regional Anesthesia for Postoperative Pain Control

Regional Anesthesia for Postoperative Pain Control

Safety of Botulinum Toxin A in Children and Adolescents with Cerebral Palsy in a Pragmatic Setting

This retrospective study aimed to examine the safety of botulinum toxin A (BoNT-A) treatment in a paediatric multidisciplinary cerebral palsy clinic. In a sample of 454 patients who had 1515 BoNT-A sessions, data on adverse events were available in 356 patients and 1382 sessions; 51 non-fatal adverse events were reported (3.3% of the total injections number, 8.7% of the patients). On five occasions, the adverse reactions observed in GMFCS V children were attributed to the sedation used (rectal midazolam plus pethidine; buccal midazolam) and resulted in prolongation of hospitalization. Of the reactions attributed to the toxin, 23 involved an excessive reduction of the muscle tone either of the injected limb(s) or generalized; others included local pain, restlessness, lethargy with pallor, disturbance in swallowing and speech production, seizures, strabismus, excessive sweating, constipation, vomiting, a flu-like syndrome and emerging hypertonus in adjacent muscles. Their incidence was associated with GMFCS level and with the presence of epilepsy (Odds ratio (OR) = 2.74 − p = 0.016 and OR = 2.35 − p = 0.046, respectively) but not with BoNT-A dose (either total or per kilogram). In conclusion, treatment with BoNT-A was safe; adverse reactions were mostly mild even for severely affected patients. Their appearance did not necessitate major changes in our practice.

Oral Gabapentin Versus Rectal Diclofenac for Postoperative Analgesia

Dear Editor, I read with interest the article by Mogadam et al. (1) in which the authors have compared the analgesic efficacy of gabapentin and diclofenac in patients undergoing tonsillectomy. They concluded that both gabapentin and diclofenac reduced postoperative pain and opioid consumption without side effects. Four additional points deserve commentary and clarification. Gabapentin is being increasingly used as a multimodal perioperative drug because of its ability to produce analgesia, anxiolysis and sedation. Pre-treatment with gabapentin has been shown to allay preoperative anxiety (2). In this study, patients received atropine and alfentanyl as premedication. It would benefit the readers to know if patients who received gabapentin preoperatively displayed greater anxiolysis compared with those who received placebo or rectal diclofenac. Gabapentin 800 mg administered 1 - 2 h preoperatively attenuates the increase in blood pressure in the first 10 min following laryngoscopy and intubation (3). Was there any significant difference in hemodynamic parameters between the three groups during laryngoscopy and intubation or during the intraoperative period? Gabapentin decreases analgesic consumption and opioid related adverse effects; however, this is at the expense of increased sedation and dizziness (4). Somnolence is a side effect observed in 15.2% of patients (5). It would be interesting to know whether there was any difference in the degree of sedation in their patients during the postoperative period. Also, was there any significant difference in intraoperative isoflurane requirement within the three groups? Diclofenac rectal suppository is absorbed in 30 - 60 min and achieves T max after 50 min of insertion. It offers a simple means to administer the drug, equalling the analgesic efficacy of the oral preparation (6). It bypasses the enteric system thus eliminating several gastrointestinal adverse effects of the drug. While Taj et al. (7) found that all children in their study accepted rectally administered drug, Tolksdorf et al. (8) found that oral midazolam was better accepted than rectal midazolam. Did the authors find the rectal administration of diclofenac during the preoperative period to be acceptable to patients or would the patients have preferred the oral route of premedication?

Feasibility of nasal epithelial brushing for the study of airway epithelial functions in CF infants

Background For a better understanding of the early stages of cystic fibrosis (CF), it is of major interest to study respiratory epithelial cells obtained as early as possible. Although bronchoalveolar lavage has been proposed for this purpose, nasal brushing, which is a much less invasive technique, has seldom been used in CF infants. The aim of the present study was to examine in a few infants the feasibility of a nasal brushing technique for studies of airway epithelial functions in very young CF infants. Methods In 5 CF (median age 12, range 1–18 months) and 10 control infants (median age 5, range 1–17 months), a nasal brushing was performed by means of a soft sterile cytology brush, after premedication with oral paracetamol (15 mg/kg body weight) and rectal midazolam (0.2 mg/kg body weight). Samples were used for microbiological, cytological and functional studies. Results The procedure was well tolerated. Number of cells collected was similar in CF and non-CF patients (CF: median 230 × 10 3, range 42 × 10 3–900 × 10 3; non-CF: median 340 × 10 3, range 140 × 10 3–900 × 10 3). Median number of viable cells was 67% (range 31–84%). Freshly obtained samples were successfully used for studies of ciliary beating frequency and cAMP-dependent chloride efflux. In 7 out of 17 cell cultures, confluence was obtained (CF: 2 out of 7; non-CF: 5 out of 10). The feasibility of studying protein release and mRNA expression of IL-8, IL-6 and TNF-α, under basal conditions and after stimulation by Pseudomonas aeruginosa, was demonstrated. Conclusions By means of a simple nasal brushing technique easily performed and well tolerated, it is feasible, in infants, to harvest respiratory cells in sufficient amounts to study the airway epithelium using a broad range of techniques including cell culture.

Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children

Behavioral disturbance in children following sevoflurane anesthesia is a relatively frequent event. The aim of this study was to evaluate whether a higher dose of preoperatively administered rectal midazolam compared with a lower would alleviate this phenomenon. Furthermore the impact of these two doses of midazolam on sedation at induction of anesthesia was compared. A total of 115 children presenting for minor surgery under anesthesia were included in the study. The children were randomized to receive rectally either 1 mg.kg(-1) midazolam (group H) or 0.5 mg.kg(-1) midazolam (group L). General anesthesia was induced with propofol or sevoflurane and maintained with 1.5% sevoflurane in the inspiratory limb. Prior to the start of surgery a regional block was performed to ensure adequate pain relief. Behavior on emergence was assessed using a three point scale. In case of severe agitation propofol was administered IV. The children in group H were significantly better sedated preoperatively (P < 0.01). There was no significant difference in emergence behavior: 42.1% of children in group H compared with 36.2% of children in group L exhibited severe agitation requiring sedation with propofol (P = 0.37). However, regardless of the preoperative dose of midazolam more children under the age of 36 months (61.4%) were severely distressed at emergence compared with older children (16.7%) (P < 0.01). A higher dose of 1 mg.kg(-1) rectal midazolam results in much better sedated children on induction of anesthesia than 0.5 mg.kg(-1). This, however, does not result in a reduced incidence of emergence delirium after sevoflurane anesthesia. Regardless of the premedication negative behavioral changes occur more frequently in children younger than 3 years of age.

Agitation and changes of Bispectral IndexTM and electroencephalographic-derived variables during sevoflurane induction in children: clonidine premedication reduces agitation compared with midazolam

This double-blind randomized study was undertaken to assess agitation, Bispectral Index (BIS) and EEG changes during induction of anaesthesia with sevoflurane in children premedicated with midazolam or clonidine. Children were allocated randomly to receive rectal midazolam 0.4 mg kg(-1) (n=20) or oral clonidine 4 microg kg(-1) (n=20) as premedication. Rapid induction of anaesthesia was achieved with inhalation of sevoflurane 8% in nitrous oxide 50%-oxygen 50%. After tracheal intubation, the children's lungs were mechanically ventilated and the inspired sevoflurane concentration was adjusted to achieve an end-tidal fraction of 2.5%. The EEG and BIS were recorded during induction until 10 min after tracheal intubation. The EEG was analysed using spectral analysis at five points: baseline, loss of eyelash reflex, 15 s before the nadir of the BIS (BIS(nadir)), when both pupils returned to the central position (immediately before intubation), and 10 min after intubation. Agitation was observed in 12 midazolam-treated and five clonidine-treated patients (P=0.05). At baseline, EEG rhythms were slower in the clonidine group. Induction of anaesthesia was associated with similar EEG changes in the two groups, with an increase in total spectral power and a shift towards low frequencies; these changes were maximal around the end of the second minute of induction (BIS(nadir)). When the pupils had returned to the central position, fast EEG rhythms increased and BIS was higher than BIS(nadir) (P<0.05). In both groups, agitation was associated with an increase in slow EEG rhythms at BIS(nadir). Compared with midazolam, clonidine premedication reduced agitation during sevoflurane induction. During induction with sevoflurane 8% (oxygen 50%-nitrous oxide 50%), the nadir of the BIS occurred at the end of the second minute of inhalation. Agitation was associated with a more pronounced slowing of the EEG rhythms at BIS(nadir) compared with inductions in which no agitation was observed. The BIS may not follow the depth of anaesthesia during sevoflurane induction in children.

Efficacy and safety of rectal thiopental, intramuscular cocktail and rectal midazolam for sedation in children undergoing neuroimaging.

This study was designed to investigate the overall usefulness of rectal thiopental, rectal midazolam and i.m. modified cocktail (meperidine-chlorpromazine hydrochloride-feniramin maleat) in 70 children undergoing computed tomography (CT) and magnetic resonance imaging (MRI). The dosage of thiopental was 50 mg per kg for infants under 6 months of age, 35 mg per kg between six and 12 months, and 25 mg per kg for older children. The maximal dose did not exceed 700 mg in this study. The dosage of midazolam was 1 mg per kg for all children. A modified cocktail was described as a formulation including 11 mg/mL of meperidine, 2.8 mg/mL of chlorpromazine and 2.8 mg/mL of pheniramine maleat. The dosage of modified cocktail was 0.1 mL per kg for all children. The mean induction time for the i.m. cocktail was significantly longer than that for rectal thiopental (P < 0.001). The mean duration of deep sedation was 60.79 +/- 27.00 min with rectal thiopental and 58.74 +/- 39.70 min with i.m. cocktail (P > 0.05). Although the mean duration of sleep for rectal thiopental and i.m. cocktail was similar, the mean discharge duration for i.m. cocktail was significantly longer than that for rectal thiopental (P < 0.05). Children sedated with the cocktail therapy also required a longer period of observation in the department. Significant decreases in heart rate, systolic blood pressure and oxygen saturation occurred in three groups (P < 0.001). Significant decreases in body temperature occurred after rectal thiopental and i.m. cocktail therapy (P < 0.01). The effect of rectal midazolam was minimal. Rectal thiopental may be the drug of choice for pediatric sedation because it has a more rapid onset and offset of action. It is also safe and effective at the dosage studied in children undergoing MRI. Rectal midazolam also may be used in children undergoing CT imaging because of minimal side-effects.

Oral versus rectal midazolam as a pre‐anaesthetic sedative in children receiving dental treatment under general anaesthesia

Dental treatment in children who are too young or too apprehensive to cooperate is often performed under sedation. In Sweden, the tradition has been to administer sedatives rectally in small children, but oral liquid sedation is now increasingly used. Aim: To compare the sedative effects of oral and rectal administration of midazolam in children undergoing dental treatment under general anaesthesia and to assess acceptance of sedative administration, acceptance of application of the facemask, and amnesia. Methods: Fifty children aged 2–7 y were randomly allocated to receive either liquid oral or rectal sedation, with 25 children in each group. Results: The sedative effect of rectal administration was higher, but not statistically significantly, than that of oral administration (p= 0.07). No significant differences in acceptance of sedative administration, acceptance of mask application or amnesia were found between the groups. Conclusion: Both the oral and the rectal routes can in most cases be appropriate. However, the better sedative effect of rectal administration of midazolam makes it a more favourable route in pre‐cooperative and non‐compliant children.

Reevaluation of Rectal Ketamine Premedication in Children: Comparison with Rectal Midazolam

Reevaluation of Rectal Ketamine Premedication in Children: Comparison with Rectal Midazolam

Sedation of pediatric patients for minor laceration repair: Effect on length of emergency department stay and patient charges

Sedating children can facilitate minor laceration repair by minimizing physical and psychic discomfort. However, some clinicians are reluctant to use sedation, in part because of concern about increased patient charges and fear that the emergency department (ED) stay will be prolonged. The purpose of this study was to determine the extent to which sedative use during the repair of simple facial lacerations in children increased the length of ED stay and patient charges. This was a retrospective cohort study of 152 children with small, simple, facial lacerations. Patients with complex lacerations and those requiring specialty consultation were excluded. Patients, at the discretion of the treating physician, received either intramuscular ketamine (n = 14), intranasal or rectal midazolam (n = 38), or no sedation (n = 100). Length of ED stay and the total patient charges were analyzed. Groups were equal with respect to age, sex, and length of the wound. The mean patient time in the ED, from placement in examination room to discharge, was significantly longer for those given ketamine (149+/-37 minutes) and midazolam (98+/-31 minutes) compared with those given no sedation (82+/-28 minutes). Patient charges were also higher in those given ketamine ($695+/-172) or midazolam ($498+/-153) compared with those receiving no sedation ($390+/-86). The results of this study demonstrate that sedation with ketamine or midazolam increases the length of ED stay compared with using no sedation. However, the increased lengths of stay were modest, particularly for midazolam. Fear of prolonged recovery time should not dissuade clinicians from using either sedative for minor procedures. The patient charges are considerably higher with both midazolam and ketamine, but they may not reflect the actual cost of patient care.