The objectives of this study were to assess midazolam and propofol as sedative agents for outpatient gastrointestinal endoscopy, with particular reference to recovery profile, amnesic effects, and haemodynamic state and oxygenation during the procedure. Forty consecutive patients were allocated randomly to two groups. Patients in group I (n = 19) received midazolam 81 (SEM 32) μg kg−1; those in group II (n = 21) received propofol 950 (400) μg kg−1. Both agents were administered as single injections to similar end-points of sedation. Psychomotor function was assessed using the digit symbol substitution test (DSST). Amnesia was measured with a visual memory test and subjective questionnaire. Patients in group I had a lower DSST score than those in group II (P

Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam

The implications for addiction research of recent knowledge about human memory are described. It is important that research using self-reported data understands the limits of such data. The nature of human memory and the selective, constructive processes of remembering provide one set of limits. Abandoning retrospective data entirely is not feasible in addiction research, for it would require the abandonment of current and prospective self-reported data as well, as they are also subject to memory biases. Because of memory distortions, self-reports, even by rigorous questionnaire, are biased narratives rather than incomplete but otherwise accurate evocations of past events. These limits necessitate caution and humility in the interpretation of findings, and cannot be eliminated by any particular set of research methods. There will never be a philosophers' stone which will convert self-reported data into absolutely accurate figures of quantity, frequency and timing. Nor is it straightforward to infer social and psychological causality from the organization and timing of events as remembered.

A digest of memory phenomena for addiction research.

GABA is the major inhibitory neurotransmitter in the central nervous system (CNS). The type A GABA receptor (GABAAR) system is the primary pharmacological target for many drugs used in clinical anesthesia. The α1, β2, and γ2 subunit-containing GABAARs located in the various parts of CNS are thought to be involved in versatile effects caused by inhaled anesthetics and classic benzodiazepines (BZD), both of which are widely used in clinical anesthesiology. During the past decade, the emergence of tonic inhibitory conductance in extrasynaptic GABAARs has coincided with evidence showing that these receptors are highly sensitive to the sedatives and hypnotics used in anesthesia. Anesthetic enhancement of tonic GABAergic inhibition seems to be preferentially increased in regions shown to be important in controlling memory, awareness, and sleep. This review focuses on the physiology of the GABAARs and the pharmacological properties of clinically used BZDs. Although classic BZDs are widely used in anesthesiological practice, there is a constant need for new drugs with more favorable pharmacokinetic and pharmacodynamic effects and fewer side effects. New hypnotics are currently developed, and promising results for one of these, the GABAAR agonist remimazolam, have recently been published.

Enhancement of GABAergic Activity: Neuropharmacological Effects of Benzodiazepines and Therapeutic Use in Anesthesiology

The dental care of people with severe learning disability and challenging behaviour presents many problems. The maintenance of oral health by regular examination, prevention and treatment may be difficult because of the limitations in patient cooperation. In many cases the diagnosis of orofacial pain may need to be discounted as a cause of uncharacteristic and sometimes aggressive behaviour. In such cases the use of general anaesthesia for examination and treatment would seem to be the obvious option but this strategy has limitations. This paper undertakes a focused review of sedation techniques as an alternative to general anaesthesia in the treatment of people with challenging behaviour. The use of novel techniques of sedation combining intravenous with oral or intranasal routes is described with patients treated in a community dental health centre. All patients had previously received treatment using general anaesthesia. The techniques described proved effective and safe for use in the primary care setting.

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Dental treatment for people with challenging behaviour: general anaesthesia or sedation?

Physically and neurologically handicapped pediatric dental patients are often a challenge to treat and may require the use of pharmacological agents for behavior modification. The purpose of this study was to investigate the safety, in terms of vital sign changes and complications, and the effectiveness, in terms of behavioral changes, of two dosages of oral midazolam as a conscious sedative agent for this unique population. Participating in this study were 31 patients of Texas Scottish Rite Hospital for Children, who were uncooperative (as rated on the Frankl scale) at a previous dental appointment. The patients, 3-18 years old, were randomly selected to receive one of the two dosage regimens; Group A received 0.3 mg/kg oral midazolam and Group B received 0.5 mg/kg. Physiologic parameters and behavior were recorded throughout the appointment and overall safety and success were determined. Although clinically insignificant, Group A's pulse rates 20 min into treatment were significantly higher than at baseline or treatment start, and oxygen saturations were lower during treatment than at baseline and start of treatment. Intratreatment systolic and diastolic blood pressures and pulse rates of Group B were significantly higher than the baseline figures; however, these changes were not clinically significant. No clinical or postoperative complications were noted for either dosage. The regimen of 0.3 mg/kg of oral midazolam was successful 75% of the time, and the regimen of 0.5 mg/kg of oral midazolam was successful 60% of the time in providing adequate sedation to allow operative treatment to be safely and efficiently performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of two dosages of oral midazolam as a conscious sedation for physically and neurologically compromised pediatric dental patients.

In a randomized double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either midazolam 15 mg orally followed at 35 min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of sedation was seen after midazolam, while the pattern and duration of postoperative sedation, as measured by standard psychometric tests, indicated slower recovery after midazolam than after diazepam. Ratings by the surgeon indicated superior anxiolysis following midazolam and significantly more patients expressed a preference for oral midazolam sedation. Significant, comparable anterograde amnesia was seen with both treatments. No significant cardiovascular complications occurred with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as midazolam provide safe, effect alternatives to i.v. diazepam for conscious sedation in outpatients undergoing minor surgical procedures.

Comparison of midazolam by mouth and diazepam i.v. in outpatient oral surgery

In a randomized double-blind, parallel groups study, 39 patients underging surgical removal of impacted third molar teeth received either temazepam 40 mg by mouth (as soft gelatin capsules) followed at 35min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of significant anxiolytic activity and psychomotor depression was seen following temazepam, while the pattern and duration of postoperative sedation measured with standard psychometric tests, were similar for both treatments. Ratings by the surgeon and by the patients indicated that sedation following the two treatments was comparable. No significant cardiovascular complications were found with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as temazepam provide safe, effective alternatives to i.v. diazepam for sedation in outpatients undergoing minor surgical procedures.

SEDATION IN OUTPATIENT ORAL SURGERY Comparison of Temazepam by Mouth and Diazepam i.v.

In a randomized, double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either sublingual lormetazepam 2.5 mg (n = 20) in a new cellulose wafer formulation followed at 35 min by i.v. saline; or sublingual placebo followed at 35min by i.v. diazepam 10mg (Diazemuls). Rapid onset of sedation was seen after sublingual lormetazepam, while the course and duration of postoperative sedation, measured using standard psychometric tests, was similar following both treatments. Surgeons′ ratings indicated that sublingual lormetazepam was comparable to i.v. diazepam but patients′ ratings indicated greater satisfaction with and preference for i.v. diazepam. Significant anterograde amnesia was found following both treatments. Both treatments were tolerated well, with no significant cardiovascular complications. These results indicate that sublingual lormetazepam may have a role in anaesthesia as a premedicant and for conscious sedation.

H. Barry

Papers

Comparison of midazolam by mouth and diazepam i.v. in outpatient oral surgery

SEDATION IN OUTPATIENT ORAL SURGERY Comparison of Temazepam by Mouth and Diazepam i.v.

Controlled comparison of a new sublingual lormetazepam formulation and i.v. diazepam in outpatient minor oral surgery