Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation 4/2/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence

Article title: Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation

Author(s): Primosch, Robert DDS. Fara Bender, DDS
Journal: Journal of Dentistry for Children
Year. Volume (number). Page #’s: 2001, July-August, 233-238
Major topic: Different ways to admin. Midazolam in the pediatric dental office
Overview of method of research: Retrospective chart study of 222 charts, containing 257 sedations. The children ranged from 15-82 months old. Children were either given intranasal or oral Midazolam, assessed pre-op, intra-op, and post op.

Findings: Midazolam (MD) is a benzodiazepine that possesses hypnotic, anticonvulsant, muscle relaxant, ante grade amnesia, and anxiolytic activity. It has been used in both medicine and dentistry for years. MD can be administered via IV, IM, and submucosal, intranasal, oral, and rectal routes, with each having it’s own advantages and limitations. IV administration is the best, however this can be quite hard to achieve due to lack of patient compliance. IV, IM and submucosal are painful to the child, and rectal is….well it’s rectal. Who wants to do that? Not this guy. Therefore the nasal and oral methods are the more commonly used delivery systems in dentistry. This article basically breaks down which route is better, intranasal or oral, and if preoperative behavior can be correlated with intra-operative behavior. Both have their pros and cons. Intranasal is easily administered (.18-.4 mg/kg), fast acting (10 minutes), and was associated with shorter treatment time than oral. Admin. However, 97% of the children who had the intranasal route were frightened, and described the experience of taking the MD as “horrible”. Also, children receiving intranasal MD were more combative, leading to more children being papoosed.
For oral admin, it’s easy to administer (.25-.75 mg/kg, mixed w/ 15mg ibuprofen or 1.5mg/kg vistaril), is relatively fast acting (20-30 min), and is usually better tolerated than the intranasal route. A con of oral admin is that it has an extremely bitter taste of the solution, even when mixed with other liquids.
The study found that compliance to oral drug admin did not correlate with cooperative behavior during treatment. This could be due to the psychotropic effects of MD, altering the child’s ability to cooperate, thus resulting in undesirable behavior. MD can cause dis-inhibition, eliminating or reducing the child’s ability to cope. Overall, behavior improved from pre-operative to intraoperative.

Key points/Summary: There were definite differences between each of the two methods of delivery. However, the are a number of variables that must be taken into account, including treatment history of the child, treatment style of the operator just to name a few. More research is needed to determine the predictive value of various parameters affecting pediatric sedation behavior management during dental treatment.

Assessment of Article: Some pertinent information that we all need to be aware of and think of when deciding whether to use MD, and which way to admin. it. Unfortunately, I found the article poorly organized, constantly contradicting itself, and non-committal.

Resident: Roberts
Date: 4/2/10
Article title: Adverse events and outcomes of conscious sedation for pediatric patients; study of an oral sedation regimen
Author: Leelataweedwud, pattarawadee, et al.
Journal: Jada
Volume: 132 month: November
Year: 2001
Method and Materials:
In a five year retrospective study, the authors examined 195 records of conscious sedation performed in 111 healthy children aged 24 months to 48 months. The author analyzed age, sex, weight, methods of drug delivery, waiting time after administration, adverse events, and sedation outcomes. The sedation regimen used was a cocktail of chloral hydrate (50mg/kg), meperidine (1.5mg/kg), hydroxizine pamoate (25mg) and supplemental oxygen.

Results: All of the following categories were compared in a table to satisfactory sedations, unsatisfactory sedations, and aborted cases to find any correlations if possible. Satisfactory defined as treatment completed without difficulty. Unsatisfactory defined as completed with difficulty or treatment not completed – due to disruptive behavior. Aborted – not attempted.

Age S: 24-80 months ( avg. 48mo w/sd of 13), U: 27 - 66 months (avg. 44 +-11),
A: 33-84 months (avg. 46+- 15)

Sex S: (M -77 F - 64), U: (M-21 F-23), A: (M-2 F-8)

Weight in kg S: 11-34 (avg. 17 +-3), U: 10 – 20 (avg16+-2), A: 10-23 (avg16+-3)

methods of drug delivery according to pt compliance
- all meds drunk 174/195 S: 131 (75%), U: 36 (21%), A: 7 (4%)
- meds delivered by syringe 21/195 S: 10 (48%), U: 8 (38%), A: 3 (14%)

waiting time after administration in min. S: 30 – 115 (avg. 61+-11), U: 30-75 (avg. 58+-11),
A: 35-65 (avg. 49+-12)

treatment time duration in min. S: 65+-22, U: 64+-24, A: N/A

adverse events S: 6 (100%), U: 0 (0%), A: 0 (0%)

apnea - defined as no visual signs of breathing, no audible signs from a precordial stethoscope Out of the 195 cases reviewed, only one case was recorded.

vomiting – defined as vomiting after the administration of the drug and before discharge requirements are met. Only 1 case incident was recorded in the study

desaturation – defined as an Spo2 reading from a pulse oximeter that fell below below95% while the patient was quiet and still. Only one incident was recorded.

prolonged sedation – defined as prolonged sedation time after all dental treatment is finished in which more than 30 minutes or more of recovery time is necessary to achieve discharge criteria recommended by the AAPD’s guidelines. A total of 3 incidents were found.

Conclusions
The described regimen of Chloral hydrate, meperidine, hydroxizine, and supplemental oxygen yielded a 72% overall success rate, while 23 percent of cases were unsuccessful, and 5 percent were aborted. Compliance with taking the full amount of oral sedation and waiting time prior to treatment (of around 60 min) were the most important factors for predicting success. Age, sex, and duration of treatment seamed to be less reliable predictors for success. Only 3% of cases resulted in adverse events occurring.

Assessment: I thought the author did a great job of reviewing the history of OCS cases performed. Though the conclusion was simple and precise he also had a lot of good information covered throughout his article pertaining to these drugs and this regimen. So for those of you that are interested in reading more, I would say go for it.