Use of midazolam and ketamine as sedation for children undergoing minor operative procedures

Dexmedetomidine - An Alternative to Midazolam in the Treatment of Ketamine-Induced Emergence Delirium: A Systematic Review

PURPOSE

Analyze the effectiveness of dexmedetomidine compared to midazolam for the treatment of ketamine-induced emergence delirium in noncardiac surgical patients.

DESIGN

Systematic review.

METHODS

Guidelines outlined in the Preferred Reporting Items For Systematic Reviews and Meta-analyses (PRISMA)22 were used for this review. PubMed, Cumulative Index To Nursing And Allied Health Literature (CINAHL), MEDLINE, The Cochrane Library, EBSCOhost, National Institute of Health clinical trials, Google Scholar, and gray literature were searched for relevant studies. Only peer-reviewed nonexperimental studies, quasi-experimental studies, and randomized control trials with or without meta-analysis were included. The evidence was assessed using the Johns Hopkins Nursing Evidence-Based Practice guidelines for quality ratings and evidence level.

FINDINGS

Five blinded randomized controlled trials, three quasi-experimental studies, and two retrospective nonexperimental studies comprised of 1,024 subjects were evaluated for this review. Dexmedetomidine was more effective at reducing ketamine-induced delirium in adult patients, although midazolam attenuated the psychomimetic effects of ketamine better in pediatric patients. Furthermore, postanesthesia care unit discharge times were similar between patients treated with dexmedetomidine and midazolam. The studies in this review were categorized as Level I, Level II, or Level III and rated Grade A, implying strong confidence in the actual effects of dexmedetomidine in all outcome measures of the review.

CONCLUSIONS

The current evidence suggests that dexmedetomidine is an effective alternative for alleviating ketamine-induced delirium in noncardiac adult surgical patients. Multiple studies in this review noted improved hemodynamics and reduced postoperative analgesic requirements after administration of dexmedetomidine in conjunction with ketamine.

Predictors for surgical intervention in orbital complications of pediatric rhinosinusitis

OBJECTIVES

Orbital complications are the most common complication of acute rhinosinusitis, especially among pediatric patients. While most cases are treated with antibiotics alone, severe presentation may demand surgical intervention. Our goal was to determine which factors predict the need for surgery and to investigate the role of computerized tomography in the decision process.

METHODS

A retrospective review of all children hospitalized between 2001-2018 with orbital complications of acute rhinosinusitis in a university-affiliated children's hospital.

RESULTS

A total of 156 children were included. Mean age was 7.9 years (1-18 years). Twenty-three children (14.7%) were surgically treated, and the rest were conservatively treated. High fever, ophthalmoplegia and diplopia in association with minimal or no response to conservative treatment were predictive for surgical intervention, as well as higher inflammatory indices. Eighty-nine children (57%) underwent imaging during hospitalization. Presence of a subperiosteal abscess, as well as its size and its location were not found to be predictors for surgery.

CONCLUSION

Clinical and laboratory findings in association with minimal or no response to conservative treatment predict the need for surgical intervention in cases of orbital complications of acute rhinosinusitis. As Computerized Tomography scans can have long-term implications in the pediatric population, caution and patience should be practiced when deciding on the timing of imaging in this population. Thus, close clinical and laboratory monitoring should lead the decision-making process in these cases and imaging should be reserved for when the decision for surgery has been made.

The effect of anesthetic agents for oocyte pick-up on in vitro fertilization outcome: A retrospective study in a tertiary center

OBJECTIVE

General anesthesia is used in most in vitro fertilization (IVF) clinics for oocyte pick-up (OPU), however, there is no consensus on type of anesthetic agent use among clinicians performing OPU. Therefore, we aimed to evaluate the effects of propofol, ketamine, or combination of propofol and ketamine (P + K) for OPU on IVF outcome.

MATERIAL AND METHODS

Three hundred and thirty three women (n = 333) undergoing IVF treatment were retrospectively included and were evaluated in three groups depending on whether they received propofol (n = 217), or ketamine (n = 60), or P + K (n = 56) for anesthesia during OPU.

RESULTS

Baseline characteristics and duration of anesthesia of each group were comparable except lower motile sperm percentage in the ketamine group compared to the propofol group (p = 0.002). Fertilization rate (FR) was decreased with ketamine compared to propofol (p = 0.013) and P + K (p = 0.008). After adjustment for sperm motility, this negative effect of ketamine on FR persisted. Implantation, clinical pregnancy, take-home baby rates, and oocyte retrieval parameters (number of total retrieved oocyte, metaphase II oocytes, embryo and methaphase II rate, and embryo quality) did not differ between the groups. Extended anesthesia duration (>30 min) was associated with low implantation (p = 0.04) and clinical pregnancy rates (p = 0.02).

CONCLUSION

Ketamine use during OPU can affect FR compared to propofol and P + K. Long durations of anesthesia also seem to decrease implantation and clinical pregnancy rates.

Psychosocial interventions for reduction of distress in children with leukemia during bone marrow aspiration and lumbar puncture

BACKGROUND

Children with cancer undergo many invasive medical procedures that are often painful and highly distressing, including bone marrow aspiration (BMA) and lumbar puncture (LP). Psychosocial interventions have been demonstrated to reduce children's distress resulting from invasive medical procedures. The aim of the study is to assess the efficacy of psychosocial interventions to reduce distress in children with cancer undergoing BMA and LP in a pediatric cancer center in Taiwan.

METHODS

Children with cancer who received treatment between March 2015 and December 2016 at Chang Gung Memorial Hospital, Linkou, Taiwan were eligible for the study. The psychosocial intervention comprised preparation and cognitive behavioral intervention and was provided by a certified child life specialist. The assessment instrument was the revised version of the Observational Scale of Behavioral Distress (OSBD-R). The behavioral distress of patients who underwent psychosocial interventions for BMA and LP was compared with patients without interventions. We also analyzed the difference of behavioral distress in patients' pre- and post-psychosocial intervention for BMA and LP.

RESULTS

Eighteen patients were enrolled into this study. The mean age of diagnosis of leukemia was 6.6 years old (range: 3-11 years). Fifteen patients were diagnosed with acute lymphoblastic leukemia, and 3 were diagnosed with acute myeloid leukemia. The mean of OSBD-R total scores in 7 patients with psychosocial intervention was significantly lower than the mean score in 6 patients without intervention (0.65 vs. 4.81, p = 0.002). Pre- and post-psychosocial intervention for BMA and LP behavioral distress were evaluated for the remaining 5 patients. Consistently, there was a significant reduction of the OSBD-R score following interventions (3.04 vs. 7.81, p = 0.025).

CONCLUSION

Psychosocial interventions provided by a certified child life specialist have a significant potential to reduce children's distress during BMA and LP in pediatric healthcare settings in Taiwan.

Topical Pharyngeal Lidocaine Reduces Respiratory Adverse Events During Upper Gastrointestinal Endoscopies Under Ketamine Sedation in Children

BACKGROUND

Upper gastrointestinal endoscopies (UGEs) performed under ketamine sedation may increase the risk of respiratory adverse events (RAEs) due to pharyngeal stimulation. Topical lidocaine prevents general anesthesia-induced laryngospasm.

OBJECTIVE

Our objective was to determine whether topical lidocaine may reduce the incidence of RAEs induced by pharyngeal stimulation in UGEs performed on children sedated with ketamine.

METHODS

We conducted a single-center prospective study. We included every patient admitted for an elective diagnostic UGE under ketamine sedation who received lidocaine prior to the technique. Patients requiring any other medication were excluded. Our main outcome measure was the number of desaturation episodes. We then compared these results with those obtained in an historic group who did not receive topical lidocaine, in which we registered a total of 54 desaturation episodes.

RESULTS

In total, 88 children (52.3% boys) were included. The median age was 7 years [interquartile range (IQR) 3-11]. The mean duration of the procedure was 6.5 ± 2.4 min, and the median initial ketamine dose was 1.76 mg/kg (IQR 1.56-2.03). The total number of desaturation episodes was 3 (3.4%), and two of these occurred prior to the introduction of the endoscope. This result represents a lower incidence than in previously reported series, and a significant decrease (p < 0.0001) with respect to the 54 RAEs registered in the historic group of 87 children.

CONCLUSIONS

Topical lidocaine premedication significantly reduced the incidence of RAEs in children during UGEs under ketamine sedation. Our findings should be confirmed by a double-blind randomized controlled trial.

Bone marrow aspirations in oncological patients: experience from an in-house standard in paediatrics

BACKGROUND

Nearly all paediatric patients require deep sedation when undergoing bone marrow aspiration (BMA). We analyzed the data from our protocols documented in a standardised procedure for bone marrow puncture over a period of 2 years.

METHODS

Our standard included the documentation of personal data as well as vital parameters. In addition, we documented all medications administered, potential complications and required intervention measures, as necessary.

RESULTS

A total of 107 protocols were available for the evaluation. Our standard covered the usage of midazolam and S‑ketamine and resulted in complications in just 9 patients, which could be remedied using simple measures. For both active substances, the dosage necessary to reach sufficient deep analgosedation was significantly higher for patients under 24 months of age.

CONCLUSIONS

Our standard for BMA provides a practical and feasible procedure. In addition to good examination conditions, our standard also helps ensure the safety of our patients.

Respiratory adverse events during upper digestive endoscopies in children under ketamine sedation

BACKGROUND

There is no evidence of the need for oxygen supplementation during upper digestive endoscopies under ketamine sedation in children, and the latest recommendations specifically state that it is not mandatory for the procedure. The aim of our study is to assess the incidence of respiratory adverse events during upper digestive endoscopies in children under Ketamine sedation when performed without oxygen supplementation, in accordance with the latest recommendations.

METHODS

Eighty-eight children undergoing ketamine sedation for programmed upper digestive endoscopy at our Pediatric Intensive Care Unit were included. Patients needing other sedative agents different from ketamine were excluded. No patients received previous oxygen therapy. Suction equipment, oxygen, a bag-valve-mask, and age-appropriate equipment for advanced airway management were immediately available. The primary outcome measure was the incidence of desaturation episodes (i.e. FiO<inf>2</inf> below 90% requiring an intervention).

RESULTS

Fifty-five patients (62.5%) presented a desaturation episode during the procedure. Most desaturation episodes occurred during the endoscope introduction (78.2%), and 5 episodes were previous to the endoscope introduction (minute 0). Around sixty percent of patients (58.9%) required oxygen therapy and four patients required bag-mask ventilation. Once oxygen therapy was initiated, 34 patients (70.5%) required it during the complete procedure or part of it.

CONCLUSIONS

Desaturation episodes occur frequently early on in the procedure. Our data suggest that the role of oxygen supplementation prior to, and during upper digestive endoscopies under ketamine sedation in children should be thoroughly assessed for future recommendations.

The Efficacy and Safety of Procedural Sedoanalgesia with Midazolam and Ketamine in Pediatric Hematology

OBJECTIVE

The aim of this study is to investigate the efficacy and safety of sedoanalgesia performed outside the operating room by pediatricians trained in advanced airway management and life support.

MATERIALS AND METHODS

Midazolam and ketamine were administered consecutively by intravenous route under cardiorespiratory monitoring for painful procedures of pediatric hematology.

RESULTS

A total of 115 patients had 237 sedoanalgesia sessions. Sedation time was 24.02±23.37 s and sedation success was 92.5% (Ramsay scores of ≥5). Patient satisfaction was high. The recovery time was 28.81±14.4 min. Although statistically significant (p<0.01) increases in systolic and diastolic blood pressure, heart rate, and respiratory rate were observed without clinical importance, they improved without any intervention. No severe adverse events were observed.

CONCLUSION

Sedoanalgesia with intravenous midazolam and ketamine for pediatric hematology and oncology patients' painful minor invasive procedures performed in an optimally equipped setting outside the operating room by pediatricians trained and certificated in advanced airway management and life support is effective and safe.

The use of basic parameters for monitoring the haemodynamic effects of midazolam and ketamine as opposed to propofol during cardiac catheterization

OBJECTIVE

Our aim is to compare the haemodynamic and adverse effects of propofol versus the mixture of midazolam and ketamine as used in sedation for cardiac catheterization in children.

METHODS

In a prospective randomized trial, we divided patients needing sedation into 72 receiving a mixture of midazolam and ketamine and 42 receiving propofol. Their ages ranged from 6 months to 12 years, and 1 year to 16 years, respectively. We collected data relative to heart rate, mean arterial pressure, respiratory rate, peripheral saturations of oxygen, and adverse effects. We assessed cyanotic patients to establish any relationship between the haemodynamic data and peripheral arterial saturations of oxygen.

RESULTS

Demographic data, including age, gender, and weight, was not statistically different between the groups. In those receiving midazolam and ketamine, mean systemic arterial pressures before, and 30 minutes after, sedation were 64.3, with standard deviation of 9.8, and 62.5, with standard deviation of 10.2, millimetre of mercury (p equals to 0.237). Heart rates were 131.3, with standard deviation of 13.5, and 109.2, with standard deviation of 17.3 beats per minute, (p less than 0.001) whereas in those given propofol the comparable values were 71.2, with standard deviation of 14.4, and 53.6 with standard deviation of 9.7 millimetres of mercury (p less than 0.001), and 115.2, with standard deviation of 13.6, and 100.5 with standard deviation of 20.1 beats per minute (p less than 0.01), respectively. Mean systemic arterial pressures in the subgroups of cyanotic patients before and 30 minutes after sedation were 74.8, with standard deviation of 14.6, and 72.7, with standard deviation of 12.4 millimetres of mercury for those receiving midazolam and ketamine (p equals to 0.544), and heart rates were 119.3, with standard deviation of 12.2, and 104.6 with standard deviation of 16.1 beats per minute (p equals to 0.001). In those given propofol, the comparable values were 71.1 with deviation of 15.5 and 53.9 with deviation of 9.2 millimetres of mercury (p equals to 0.001), and 126.7 with deviation of 20.8 and 107.2 with deviation of 13.5 beats per minute (p equals to 0.001), respectively.

CONCLUSIONS

In cyanotic children, propofol used as a sedative agent during cardiac catheterization causes a decrease in mean arterial pressure and arterial desaturation. Ketamine produces more stable haemodynamic data in children with congenitally malformed hearts.

The role of a low-dose ketamine-midazolam regimen in the management of severe painful crisis in patients with sickle cell disease

CONTEXT

Acute pain is one of the main causes of hospital admission in sickle cell disease, with variable intensity and unpredictable onset and duration.

OBJECTIVES

We studied the role of a low-dose intravenous (IV) ketamine-midazolam combination in the management of severe painful sickle cell crisis.

METHODS

A retrospective analysis was performed with data from nine adult patients who were admitted to the intensive care unit with severe painful sickle cell crises not responding to high doses of IV morphine and other adjuvant analgesics. A ketamine-midazolam regimen was added to the ongoing opioids as an initial bolus of ketamine 0.25mg/kg, followed by infusion of 0.2-0.25mg/kg/h. A midazolam bolus of 1mg followed by infusion of 0.5-1mg/h was added to reduce ketamine emergence reactions. Reduction in morphine daily requirements and improvement in pain scores were the determinants of ketamine-midazolam effect. The t-tests were used for statistical analysis.

RESULTS

Nine patients were assessed, with mean age of 27±11 years. Morphine requirement was significantly lower after adding the IV ketamine-midazolam regimen. The mean±SD IV morphine requirement (milligram/day) in the pre-ketamine day (D0) was 145.6±16.5, and it was 112±12.2 on Day 1 (D1) of ketamine treatment (P=0.007). The Numeric Rating Scale scores on D0 ranged from eight to ten (mean 9.1), but improved to range from five to seven (mean 5.7) on D1. There was a significant improvement in pain scores after adding ketamine-midazolam regimen (P=0.01).

CONCLUSION

Low-dose ketamine-midazolam IV infusion might be effective in reducing pain and opioid requirements in patients with sickle cell disease with severe painful crisis. Further controlled studies are required to prove this effect.

Intramuscular midazolam for pediatric sedation in the emergency department: a short communication on clinical safety and effectiveness

Background:

Procedural sedation in children continues to be a problem in the emergency department (ED). Midazolam is the first water-soluble benzodiazepine and it has been widely used for procedural sedation in pediatric patients.

Objectives:

The aim of this study was evaluation of clinical safety and effectiveness of intramuscular Midazolam for pediatric sedation in the ED setting.

Materials and Methods:

We performed a self-controlled clinical trial on 30 children who referred to the Baqiyatallah Hospital ED between 2009 and 2010. They received intramuscular Midazolam 0.3 mg/kg for procedural sedation and then they were followed for sedative effectiveness and safety. Vital signs and O2 saturation were also observed. The findings were compared using SPSS ver. 16 software.

Results:

The mean age was 5.50 ± 2.70 years, the mean weight was 19.50 ± 6.63 kilograms and 16 patients (53.3%) were females. The most common adverse effect was euphoria (66.66%) and vertigo (6.7%); 27.7% did not show any side effects. There was an overall complication rate of 72.3%. The vital signs including heart rate, respiratory rate, systolic and diastolic blood pressure and O2 saturation decreased significantly during sedation (P value < 0.05).

Conclusions:

Midazolam is an effective and relatively safe sedative for pediatric patients in the ED. The patient should be observed closely and monitored for psychological and hemodynamic side effects.

Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature

Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?

OBJECTIVE

Ketamine has become the drug most favoured by emergency physicians for sedation of children in the ED. Some emergency physicians do not use ketamine for paediatric procedural sedation (PPS) because of concern about emergence delirium on recovery. The present study set out to determine the true incidence and nature of this phenomenon.

METHODS

Prospective data relating to any emergence agitation, crying, hallucinations, dreams, altered perceptions, delirium and necessary interventions were recorded in consecutive cases of ketamine PPS from March 2002 to June 2007, and analysed. Standard inclusion and exclusion criteria for the use of ketamine were followed.

RESULTS

A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure.

CONCLUSION

The belief that ketamine, in the doses used for ED PPS, causes frequent emergence delirium is flawed. A pleasant emergence phenomenon is common, but is not distressing for the child, and has no long-term (up to 30 days) negative sequelae. Rarely, there is anxiety or distress on awakening from ketamine sedation, which settles spontaneously. This should not deter emergency physicians from using ketamine for PPS.

Serious adverse events during procedural sedation with ketamine

OBJECTIVES

Compare the frequency of respiratory adverse events between patients who received intramuscular (IM) versus intravenous ketamine.

METHODS

Case control study from 1997 to 2005 at a large urban pediatric emergency department. Adverse events were defined as apnea, hypoxemia (oximetry <93%), hypoventilation, laryngospasm, and other upper airway obstruction. Serious adverse events were defined by the level of intervention and included those cases that required positive pressure ventilation, insertion of oral or nasal airway, or endotracheal intubation. Minor adverse events were respiratory events requiring minimal intervention (stimulation, supplemental O2, airway repositioning). Controls (2:1) were selected by the next chronological patient in the data set who received ketamine but had no respiratory adverse event.

RESULTS

Four thousand two hundred fifty-two patients received ketamine; 102 cases (2.4%) had respiratory adverse events, including 38 patients with severe adverse events (0.9%). Interventions for the cases included supplemental O2 (59/102, 58%), airway repositioning (36/102, 35%), continuous positive airway pressure (7/102, 7%), positive pressure ventilation (33/102, 32%), nasal airway (2/102, 2%), oral airway (1/102, 1%), stimulation (11/102, 11%), and intubation (1/102, 1%). Overall, 33% of all subjects received IM ketamine including 47% of cases and 27% of controls. Intramuscular IM ketamine was associated with increased likelihood of adverse events (odds ratio [OR] 2.1, 95% CI, 1.3-3). Twenty (69%) of the 29 patients with laryngospasm received IM ketamine (OR, 5.2; 95% CI, 2.3-11.9) and 20 (53%) of the 38 patients who had severe events were administered IM (OR, 2.4; 95% CI, 1.2-4.9). Use of pre-sedation morphine or combined administration with midazolam and/or atropine was not associated with adverse events. Specific procedures were not associated with increased adverse events.

CONCLUSIONS

Respiratory adverse events with ketamine are uncommon. Serious events, like laryngospasm, are rare but occur more commonly with IM administration. This increased risk associated with IM administration should be considered in the sedation plan.

Can analysis of the bispectral index prove helpful when monitoring titration of doses of midazolam and ketamine for sedation during paediatric cardiac catheterization

OBJECTIVE

We investigated the use of the bispectral index for monitoring sedation during cardiac catheterization. The scores for the bispectral index may not reflect correct values in children, but may be helpful during titration of sedatives such as midazolam and ketamine.

METHODS

We conducted a prospective randomized clinical trial in 126 patients scheduled for cardiac catheterization in a teaching hospital. They ranged in age from 4 months to 15 years. In 66 patients, sedation was performed without use of the bispectral index, while the index was used in the other 60 patients. The data collected included heart rate, mean arterial pressure, respiratory rate, saturation of oxygen, amount of sedatives, awakening time and adverse effects. We subdivided the patients into age-related groups for each parameter.

RESULTS

The demographic data were not statistically different. Monitoring with the bispectral index in those aged from 1 to 3 years revealed use of lower doses of midazolam, at 2.09 mg per kg per hr, with standard deviation of 0.36, and similarly lowers doses of ketamine, at 2.07 mg per kg per hr, with standard deviation of 0.22, the values in those not monitored being 2.93, with standard deviation of 0.45, and 2.96 with standard deviation of 0.51 respectively, these difference being statistically significant (p = 0.001 and p = 0.04, respectively). In those aged from 3 to 6 years of age, dosage of midazolam was 2.09, with deviation of 0.36, and of ketamine 1.78, with deviation of 0.27, following use of the bispectral index, compared to 2.89 with deviation of 0.28, and 2.62 with deviation of 0.69 respectively, when the bispectral index was not used, these again being significant differences (p = 0.033 and p = 0.04). The requirements for respiratory support and adverse effects were also significantly lower when using the bispectral index (p less than 0.05). No significant difference was found regarding dosages at the ages of 4 months to 1 year, and 6 to 15 years. The awakening time, however, was shorter with use of the index in those aged from 1 to 6 years.

CONCLUSIONS

When using the bispectral index for monitoring sedation during catheterization in children, we noted decreased need for doses of midazolam and ketamine, a lower need for respiratory support and less adverse effects.

Is intravenous conscious sedation for surgical orthodontics in children a viable alternative to general anaesthesia? – a case review

AIM

The aim of this case review was to describe the use of local anaesthesia (LA) and intravenous conscious sedation (IVCS) as a safe and effective means of managing patients requiring surgical orthodontic procedures as an alternative to general anaesthesia (GA) in children between the age of 11 and 15 years.

MAIN OUTCOME MEASURES

1) Whether treatment was completed, partially completed or not completed; 2) assessment of physiological parameters to verify safety profile of the technique.

METHODS

Records were reviewed retrospectively for all patients included in the series undergoing planned surgical orthodontic procedures between January 2001 and January 2004 under IVCS. All patients had been pre-assessed and deemed to be of sufficient mental and physical maturity to be treated with IVCS. Written informed consent was gained from patients and their parents/guardians with full discussion of the alternative pain and anxiety control methods available including GA. All cases were undertaken by experienced SAS grade surgeons assisted by two dental nurses holding the certificate in dental sedation nursing and their recovery was supervised by registered general nurses. Patients were clinically monitored throughout together with continuous pulse oximetry and intermittent recording of non invasive blood pressure and pulse at 10-15 minute intervals. Patients were reviewed post operatively and any complications or comments noted.

RESULTS

Over a three year period a total of 107 patients underwent surgical procedures to aid orthodontic treatment, 28 (26%) under IVCS and 79 (74%) under GA. Twenty-five out of 28 patients in the IVCS group successfully completed all of their planned treatment.

CONCLUSIONS

Based on this case series, IVCS would appear to offer a safe and effective alternative to GA for this group of patients providing they are selected and managed by an appropriately trained team in a suitable setting. Further prospective evidence is needed if IVCS is to be recommended for general dental treatment in patients under the age of 16 years.

Pharmacokinetic and Pharmacodynamic Characteristics of??Medications Used for Moderate Sedation

The ability to deliver safe and effective moderate sedation is crucial to the ability to perform invasive procedures. Sedative drugs should have a quick onset of action, provide rapid and clear-headed recovery, and be easy to administer and monitor. A number of drugs have been demonstrated to provide effective sedation for outpatient procedures but since each agent has its own limitations, a thorough knowledge of the available drugs is required to choose the appropriate drug, dose and/or combination regimen for individual patients. Midazolam, propofol, ketamine and sevoflurane are the most frequently used agents, and all have a quick onset of action and rapid recovery. The primary drawback of midazolam is the potential for accumulation of the drug, which can result in prolonged sedation and a hangover effect. The anaesthetics propofol and sevoflurane have recently been used for sedation in procedures of short duration. Although effective, these agents require monitored anaesthesia care. Ketamine is an effective agent, particularly in children, but there is concern regarding emergence reactions. AQUAVAN injection (fospropofol disodium), a phosphorylated prodrug of propofol, is an investigational agent possessing a unique and distinct pharmacokinetic and pharmacodynamic profile. Compared with propofol emulsion, AQUAVAN is associated with a slightly longer time to peak effect and a more prolonged pharmacodynamic effect. Advances in the delivery of sedation, including the development of new sedative agents, have the potential to further improve the provision of moderate sedation for a variety of invasive procedures.