Safety of adjunct pre-emptive intravenous tramadol with midazolam sedation for third molar surgery

Efficacy and cost analysis of intravenous conscious sedation for long oral surgery procedures

The aim of this study was to determine what is considered a long oral surgery and conduct a cost-effective analysis of sedative agents used for intravenous sedation (IVS) and sedation protocols for such procedures. Pubmed and Google Scholar databases were used to identify human studies employing IVS for extractions and implant-related surgeries, between 2003 and July/2023. Sedation protocols and procedure lengths were documented. Sedative satisfaction, operator satisfaction, and sedation assessment were also recorded. Cost estimation was based on The British National Formulary (BNF). To assess bias, the Cochrane Risk of Bias tools were employed. This review identified 29 randomised control trials (RCT), six cohorts, 14 case-series, and one case-control study. The study defined long procedures with an average duration of 31.33 minutes for extractions and 79.37 minutes for implant-related surgeries. Sedative agents identified were midazolam, dexmedetomidine, propofol, and remimazolam. Cost analysis revealed midazolam as the most cost-effective option (<10 pence per procedure per patient) and propofol the most expensive option (approximately £46.39). Bias analysis indicated varying degrees of bias in the included studies. Due to diverse outcome reporting, a comparative network approach was employed and revealed benefits of using dexmedetomidine, propofol, and remimazolam over midazolam. Midazolam, dexmedetomidine, propofol, and remimazolam demonstrated safety and efficacy as sedative agents for conscious IVS in extended procedures like extractions or implant-related surgeries. While midazolam is the most cost-effective option, dexmedetomidine, propofol, and remimazolam offer subjective and clinical benefits. The relatively higher cost of propofol may impede its widespread use. Dexmedetomidine and remimazolam stand out as closely priced options, necessitating further clinical investigations for comparative efficacy assessment.

Can Remimazolam Be a New Sedative Option for Outpatients Undergoing Ambulatory Oral and Maxillofacial Surgery?

PURPOSE

Midazolam is a classic sedative drug. The sedative effect of remimazolam has not been demonstrated in ambulatory oral and maxillofacial surgery (OMS). This study aimed to measure whether remimazolam can achieve the same sedation effects compared with midazolam, but with a faster recovery and fewer adverse reactions in outpatients undergoing ambulatory OMS.

MATERIALS AND METHODS

This was a prospective, randomized, controlled, single-center study of 40 patients who underwent ambulatory OMS at Peking University Hospital of Stomatology, Beijing, China, between April 2021 and June 2021. The patients were randomly divided into a midazolam group (Group M) and a remimazolam group (Group R). The success rate of sedation, which was defined as completion of the operation with no rescue sedative medication, was the primary outcome. In this study, bispectral index and modified observer's assessment of alertness/sedation value, intraoperative adverse events, time to discharge, and the number of additional doses of sedative were compared. Descriptive, comparative analyses were conducted.

RESULTS

Forty patients were eligible for this study, and the final sample size was 40 (including 25 males, average age was 29). The success rate of sedation in Group R was statistically significantly higher than that in Group M (Group R vs Group M: 95% [19/20] vs 70% [14/20], P = .037, 95% confidence interval [CI]: 0.681 to 0.913). The median number of additional doses of the medications per 5 minutes in Group R was lower than that in Group M (0.51 [0.19, 0.71] vs 0.82 [0.51, 1.25], P = .006, 95% CI: 0.013 to 0.583). Group R showed a higher bispectral index number (93.9 ± 4.6 vs 86.6 ± 7.2, P = .001, 95% CI: 3.451 to 11.149) at the end of the surgery and a higher modified observer's assessment of alertness/sedation score (4.70 ± 0.47 vs 4.05 ± 0.68, P = .001, 95% CI: 0.273 to 1.027) after 5 minutes at the recovery room compared with Group M.

CONCLUSIONS

The success rate of remimazolam is higher than that of midazolam. The use of remimazolam is effective for sedation of patients undergoing ambulatory OMS.

Pre-emptive analgesic efficacy of injected ketorolac in comparison to other agents for third molar surgical removal: a systematic review

This study aimed to evaluate and compare the pre-emptive analgesic efficacy of injected ketorolac to that of other agents for impacted third molar surgical removal in a healthy population.

PubMed, Ovid SP, Cochrane databases were filtered from 1980 to July 2020 for potential papers using relevant MeSH terms and pre-specified inclusion and exclusion criteria independently by reviewers. Studies that compared pre-emptive intramuscular or intravenous administration of ketorolac to other agents were evaluated. The outcomes sought were self-reported postoperative pain (patient-perceived pain), median duration for rescue analgesic medication, total number of analgesics consumed in the recovery period, and global assessment (overall patient satisfaction) after the recovery period.

Six studies were included in the final evaluation. The outcome of pain perception and the number of analgesics taken were significantly lower in the ketorolac group (intramuscular or intravenous) in most of the studies (n=5) than in the group of other drugs. The mean time for rescue analgesia intake was higher for the ketorolac group, and global assessment scores were also better in the ketorolac group.

Although the included studies show significantly better outcomes such as postoperative pain, median time taken for rescue medication, total number of analgesics taken, and overall patient satisfaction with injected ketorolac group in comparison to injected diclofenac, dexamethasone, and tramadol, definitive conclusions cannot be made regarding the superiority of injected Ketorolac as a pre-emptive agent. A greater number of randomized control trials with a proper protocol are needed to make definitive conclusions.