Paradoxical Reactions to Benzodiazepines in Intravenous Sedation: CASE DESCRIPTIONS

In: Main

14 Dec 2009

Case 1

A 65-kg, 19-year-old African-American female presented in 1999. The patient had no significant medical or surgical history. Removal of symptomatic mandibular third molars was recommended. The patient was apprehensive regarding the extractions and requested sedation for the extraction of teeth nos. 1, 16, 17, and 32. The following week, the patient presented with her mother for the procedure and was visibly anxious. After standard monitoring was established, an intravenous catheter was introduced in the patient’s left arm. The patient’s blood pressure was 135/65 and pulse was 95 beats per minute before administration of sedation. Two milligrams of midazolam and 50 |mg of fentanyl were administered through the intravenous line. Midazolam was titrated to achieve a mild to moderately deep se dation. A total amount of 5 mg of midazolam was given during about 7 minutes. The patient appeared comfortable, and the procedure was started during titration. After the first maxillary and mandibular extractions, the patient started crying and did not follow commands. The procedure was stopped. The patient continued to weep for about 5 minutes. During that time, the vital signs remained stable. Even with calm reassurance, the patient remained inconsolable while not complaining of any pain or discomfort. Flumazenil (0.2 mg) was administered to the patient intravenously. Approximately 10 minutes after receiving the dosage of flumazenil (25 minutes after the first administration of midazolam), the patient became communicative. She had no recollection of the events. The remaining third molars were extracted a few days later under local anesthesia without any complications.

Case 2

A 72-kg, 21-year-old African-American female presented in 2000. The patient’s medical history was significant for an obstetrics/gynecology procedure, which was performed under intravenous sedation a few months earlier. The patient requested to be sedated for the extraction of a symptomatic left mandibular third molar because she was very anxious. The following day, the patient presented with her boyfriend and was extremely nervous. After standard monitoring was established, an intravenous catheter was introduced in the patient’s left arm. The patient’s was 145/90 and pulse was 105 beats per minute before administration of medications. Two milligrams of midazolam and 50 |xg of fentanyl were administered intravenously. Midazolam was titrated to achieve a moderately deep sedation. A total amount of 7 mg of midazolam was given during about 10 minutes. The anxiety of the patient appeared to be relieved, and the procedure was started during titration. After the local anesthetic was administered, the patient became very combative and would not follow commands. The procedure was terminated and approximately 3 minutes after this combative episode, the patient started crying and was very apprehensive. During that time, the vital signs remained stable. Even with reassurance, the patient remained out of verbal contact despite the fact that she was not complaining of any pain or discomfort. Two doses of flumazenil of 0.2 mg each were given intravenously 1 minute apart. Five minutes after administration of the flumazenil (approximately 35 minutes after the first administration of midazolam), the patient began to calm and became verbose. She had no recollection of the event. The extraction was completed a few minutes later under local anesthesia without further complications. canadian pharmacy generic viagra


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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.

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