Oral Midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/02/2010
Article title: Oral Midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study
Author(s): Nathan JE, Vargas KG.
Journal: Pediatric Dentistry Volume 24, Number 2
Month, Year: March/April 2002
Major topic: Midazolam and meperedine oral sedation
Type of Article: Retrospective Research article.
Purpose: this study evaluated the effects of different dosages of midazolam used alone or in combination with meperedine to manage difficult pediatric patients. The goal was to increase the time of sedation in the office while maintaining a safe conscious sedation state. This regimen has the potential of providing the amnesic and sedative qualities of midazolam with the analgesic and additive effect of the sedation of meperedine.
Overview of method of research: Patient sedation records of 120 moderately to severely apprehensive/ uncooperative patients, ages 24-48 months were reviewed. All patients received pre-treatment ratings for anxiety and cooperation potential which determined the dosage and type of medication used during the sedation. The author classified medication regimens as preventive doses to manage mild to moderate apprehension to management medication to manage more severe types of anxiety or negative behavior. The 120 patients were divided into 6 groups: Group 1 had 0.7mg/kg of midazolam, Group 2, 1.0mg/kg of midazolam, Group 3 had 0.7mg midazolam and 1.0mg/kg meperedine, Group 4 had 0.7mg of midazolam and 1.5mg/kg of meperedine, Group 5 had 1.0mg/kg of midazolam and 1.0mg/kg of meperedine, and Group 6 had 1 mg/kg of midazolam and 1.5mg/kg of meperedine. Success of sedation was determined by a sedation record assessment instrument developed by Nathan which rated sedation effectiveness in terms of rendering quality care to a patient with minimal or no interfering movement. Excellent or optimal sedation was defined as treatment permitted without restraint where patient remained responsive to verbal stimulation before, during and after sedation and was returned to the parent in full levels of responsiveness. Acceptable sedation was defined as occasional or persistent somnolence requiring mild physical stimulation to arouse, completed most of the treatment objectives, and minimal or limited restraint due to non-intentional interfering movements. Inadequate sedation and over-sedation are self explanatory. Mean heart rate was recorded at one minute intervals prior to and during the application of local anesthetic and cavity prep. Of further interest in this study was the effect of dosage on working time of sedation and also parental satisfaction with the sedation and post-operative recovery.
Findings: There was a statistical difference in ages between Group I and II and Group V and VI. No statistical difference was found between Groups II through VI with adequate sedation achieved in 80-100% of cases while Group I had excellent/adequate sedation in 40% of cases. Group V had the best results with 100% of patients receiving excellent/ adequate sedation. Heart rate changes were significant in Groups V and VI only during cavity preparation. In terms of safety, there were no episodes of persistent deeper sedation, but transient episodes of oxygen desaturation occurred in Groups II, III, and V and VI. Differences were noted in length of time before discharge in Groups IV, V, and VI with extended time needed for discharge in these groups. Working time was significantly better for Groups IV, V, and VI with Group I being ultra short. Parental assessment showed that most parents in all groups expressed approval and willingness to consider sedation again. The author noted that the addition of meperedine doubled the working time from 8±5 to 18±9 minutes.The author further noted that restraint was intentionally not used in order to better ascertain the effectiveness of the sedation. Restraint may mask the ability of the child to respond to noxious stimuli and therefore by eliminating restraint, we are removing a potential variable from this study.
Conclusion: In patients receiving only oral midazolam, the higher dose of 1.0mg/kg was significantly more effective. Adding meperedine seemed to improve the efficacy and duration of midazolam. Higher doses of the combination of midazolam and meperedine may increase the risk of deeper sedation and prolonged recovery.
Assessment of article: Good article but study was done retrospectively