Adverse Events in Procedural Sedation for the Dental Chair: Analysis of 800 Patients Managed with the Association Midazolam or Fentanyl - Abstract
Purpose: This study evaluated the adverse events [AEs] rates of sedation with midazolam and fentanyl in ambulatory patients undergoing oral surgery.
Methods: 844 consecutive patients aged 8-95 years, ASA class 1-4, undergoing oral surgery [multiple surgical extractions, wisdom teeths extractions, difficult conservative care, sinus lift, bone grafts] were sedated with small dosages of midazolam and fentanyl under full monitoring (ECG, NIBP [non invasive blood pressure], SaO2, et CO2] with the aim to maintain conscious sedation (CS) [Ramsay scale score 3-4]. AEs included episodes [number and/or duration] of hypertension, hypotension, tachycardia, bradycardia, hypercapnia, desaturation, sleepiness. AEs were correlated to demographic and study variables with a multivariate analysis.
Results: Patients were premedicated with various drugs before the induction of CS. Surgery lasted a mean of 118 +/- 55 min:mean midazolam and fentanyl dosage were 0.048 +/- 0.029 mg/kg and 0.79 +/- 0.60 microgr/kg respectively. Per cent of cases [%] occurrence of AEs was : desaturation [SaO2<90] 17.7% ,duration 2.5 +/- 8 min: hypertension [diastolic BP > 95 mmHg or BP >25% basal ] 17.9, hypotension[ systolic or diastolic <25% of basal ] 3.7, bradycardia 4 [ hr<50 or <25% of basal], tachycardia 0.6 [>25% of basal], hypercapnia 38.4 [etCO2 >40 mmHg], sleepiness 21 [Ramsay 5][duration 4.3 +/- 11 min]. All surgeries were completed and patients sent home with a responsible adult within 2 hours.
Hypertension hypotension, tachycardia occurrences were associated with ASA, age, dosages of midazolam .Bradycardia was associated with age. Desaturation cases,duration and episodes were linked to the drugs used [midazolam and fentanyl]. Sleepiness was accompanied by desaturation and hypotension and little influenced by drugs dosages.
Discussion: Aes were frequent but of relatively minor intensity and all responded to the approriate therapy. Titration of sedatives and analgesics was kept to a minimun compatible with the condition of the patient and the extent of surgery.
Safety in the dentist office can be maintained with the careful monitoring of the vital signs under this drug regimen [midazolam and fentanyl] assuring the maintenance of conscious sedation.Any derangement from the normal physiology must be timely and properly treated.