James A. Roelofse

A double-blind randomized comparison of midazolam alone and midazolam combined with ketamine for sedation of pediatric dental patients

PURPOSE The safety and efficacy of a new sedation technique for children having dental procedures under local anesthesia were evaluated. MATERIALS AND METHODS One hundred children between the ages of 2 and 7 years who required sedation for dental procedures were administered either a combination of midazolam (0.35 mg/kg) and ketamine (5 mg/kg) or midazolam alone (1 mg/kg) rectally 30 minutes before removal to the dental chair. Pulse rate, respiratory rate, arterial pressure, oxygen saturation, adverse reactions, postoperative recovery, and behavior were recorded. RESULTS Satisfactory sedation and anxiolysis were achieved with both drugs used in the study. When evaluating postoperative recovery, statistically significantly more children receiving midazolam alone were fully awake on admission to the recovery room and 30 minutes later. Results of physiologic monitoring, behavioral ratings, and adverse effects are reported. Excessive salivation occurred in 26% of children receiving the combination of drugs, compared with 14% receiving midazolam alone. Seven (14%) of the children receiving the combination of drugs hallucinated, compared with 21 (42%) receiving midazolam alone. Both drug groups had reliably good anxiolysis and sedation without loss of respiratory drive or protective airway reflexes. CONCLUSION The use of a combination of midazolam and ketamine or midazolam alone is a safe, effective, and practical approach to managing children for minor dental procedures under local anesthesia. With this technique, advanced airway management proficiency is recommended.

Preanesthetic medication with rectal midazolam in children undergoing dental extractions

Three different dosages (0.25, 0.35, and 0.45 mg/kg) of rectally administered midazolam were compared with each other and with placebo for preanesthetic medication in children undergoing dental extractions. Eighty patients between the ages of 2 and 10 years were randomly allocated into four groups in this double-blind study. The results from this trial show that 30 minutes after rectal administration of all doses of midazolam, good anxiolysis, sedation, and cooperation were obtained in most patients. A high prevalence (23%) of disinhibition reactions was observed, particularly in the 0.45 mg/kg group. For this reason, 0.25 or 0.35 mg/kg appears to be the dose of choice when rectal midazolam is used for premedication in children.

Rectal ketamine and midazolam for premedication in pediatric dentistry

Rectally administered midazolam (0.30 mg/kg) and ketamine (5 mg/kg) were compared for preanesthetic medication in children undergoing dental extractions. Sixty patients between the ages 2 and 9 years were randomly allocated to three groups in this double-blind study. In one group of patients who received ketamine rectally, intravenous midazolam (0.05 mg/kg) also was administered immediately after induction of anesthesia. The results from this trial show that 30 minutes after rectal administration of the two drugs, good anxiolysis, sedation, and cooperation were obtained in most patients. Although midazolam appeared to be marginally more efficacious than ketamine in the majority of assessments made and seemed to have less adverse effects, no statistically significant differences could be shown. Ketamine showed a slight decrease and midazolam a slight increase in average blood pressures after premedication. These blood pressure differences were, however, considered to be of little clinical importance.

Disinhibitory reactions to benzodiazepines: A review

This article reviews some of the important aspects of benzodiazepine-induced disinhibitory reactions. Although reactions of this type are relatively rare, they may sometimes manifest themselves in aggressive behavior accompanied by suicidal or homicidal tendencies. It appears that these reactions occur more commonly in younger patients, although the elderly (above 65 years) may also be at risk. Many mechanisms have been postulated, but none truly explain how these reactions arise. The concept that central cholinergic mechanisms may play a role, however, remains attractive and stems primarily from physostigmines ability to successfully reverse this type of reaction. The potential role of the benzodiazepine antagonists, eg, flumazenil, in reversing disinhibitory reactions is also discussed. Apart from patients who previously exhibited poor impulse control, there are no reliable indicators for recognizing potential candidates for this type of reaction. To minimize the occurrence of disinhibitory reactions, some guidelines, which include the avoidance of certain drug combinations, the use of low doses of benzodiazepines, slow incremental intravenous administration, and good rapport with patients, are presented.

Cardiac dysrhythmias associated with intravenous lorazepam, diazepam, and midazolam during oral surgery

The incidence and nature of cardiac dysrhythmias occurring during intravenous sedation with lorazepam, diazepam, and midazolam for oral surgery were studied. Sixty American Society of Anesthesiologists (ASA) I patients of both sexes between the ages 17 and 32 years were randomly allocated to three groups. Groups received either intravenous lorazepam (.05 mg/kg), diazepam (.25 mg/kg), or midazolam (.1 mg/kg) prior to the oral surgical procedure. Electrocardiograms were made before medication and thereafter throughout the entire procedure. Of the 60 patients studied, 16 (26.7%) exhibited dysrhythmias during the surgical procedure. If sinus dysrhythmias were excluded as a cause of abnormal rhythms, only six patients (10%) exhibited dysrhythmias during surgery. No atrial or ventricular premature beats were recorded for the lorazepam group. In the diazepam group five of the patients (25%) exhibited dysrhythmias; 15% were mainly unifocal ventricular premature beats. Only one patient in the midazolam group exhibited unifocal ventricular premature beats.

Comparison of various physiologic and psychomotor parameters in patients sedated with intravenous lorazepam, diazepam, or midazolam during oral surgery

Intravenously administered lorazepam (0.05 mg/kg), diazepam (0.25 mg/kg), and midazolam (0.1 mg/kg) were compared for sedation during oral surgery under local anesthesia. Sixty patients were randomly allocated into three groups in this double-blind, parallel study. The results from this trial show that all three drugs provide satisfactory sedation. Average mean arterial pressures, however, decreased significantly with midazolam and diazepam. Statistically significantly higher heart rates during the entire procedure were also found for lorazepam when compared with diazepam and midazolam. At the postblock stage, the midazolam group had respiratory rates that were significantly higher than those of the other two drug groups. Patients in the diazepam and midazolam groups took significantly longer to complete the pegboard test at the preblock stage than those in the lorzepam group. At 1, 1.5, and 2 hours after arrival in the recovery room, an inversion of groups took place, with the lorazepam group taking significantly longer for their tests than the other two groups. Significantly more improvement in anxiety levels was found at 10 minutes postdrug for the patients who had received diazepam and this tended to remain so on arrival in the recovery room. When compared with the other two groups, significantly more patients in the lorazepam group reported giddiness/dizziness and significantly more in the diazepam group reported pain on injection.

Intravenous midazolam in oral surgery

Intravenously administered midazolam (0.1 mg/kg) was compared with placebo in a randomized study in 50 patients undergoing oral surgical procedures under local anaesthesia. The results obtained from this study showed that midazolam when compared to placebo had slight cardiovascular and respiratory depressant effects, diminished anxiety and caused amnesia. It also provided better operating conditions and possibly stimulated appetite.

Paradoxical reactions to rectal midazolam as premedication in children

Eighty healthy children, between the ages of 2 and 7 years, who were to undergo oral surgical procedures under general anaesthesia, were allocated randomly to 4 groups. Three groups received rectal midazolam, and the other group a placebo (saline) as premedication 30 min prior to induction of anaesthesia. Group A children received midazolam 0.25 mg/kg, Group B 0.35 mg/kg and Group C 0.45 mg/kg. No statistically significant difference was found between the treatment groups as to the effect on systolic- (p = 0.6920) and diastolic (p = 0.8701) blood pressures, respiration (p = 0.0505) and pulse (p = 0.6192) rates at either pre- or post-sedation levels. However, the results indicate that levels of anxiolysis and sedation were significantly associated with midazolam dosage (p less than 0.0001).

Comparison of rectal midazolam and diazepam for premedication in pediatric dental patients

Rectally administered midazolam (0.35 mg/kg) and diazepam (0.70 mg/kg) were compared with each other and with placebo for preanesthetic medication in children undergoing dental extractions. All rectal medications were very well accepted, but mask acceptance, improvement in anxiety, and sedation were best in the midazolam group. Improvement in anxiety and sedation were significantly better in the two drug groups than in those patients who had received placebo. Thirty minutes after rectal administration of midazolam, patients showed a decrease in both systolic and diastolic blood pressure and heart rate. Although these decreases differed significantly from the premedication values, they were probably of little clinical importance. Only minor adverse effects were observed in this study. Overall rectally administered midazolam appeared to be somewhat more efficacious than diazepam.

Comparison of sublingual lorazepam with intramuscular diazepam as sedatives during oral surgery

Sublingual lorazepam (2 to 3 mg) was compared with intramuscular diazepam (0.25 mg/kg) and placebo for sedation during oral surgery under local anesthesia. Sixty patients were randomly allocated into three groups in this double-blind, parallel study. The results from this trial show that sublingually administered lorazepam provided good sedation and anxiolysis. More side-effects, such as giddiness, dizziness, and ptosis, as well as profound and prolonged psychomotor impairment, were, however, found in the lorazepam group than in those patients who had received intramuscular diazepam (0.25 mg/kg) or placebo.