Intranasal Remifentanil as an Adjunct to Oral Midazolam Sedation in Pediatric Dental Patients

Abstract

Oral midazolam (MID) sedation is often used for pediatric dental procedures, however the quality of procedural sedation is variable and maybe inadequate for successful procedure completion. Intranasal (IN) sedative administration can be a useful adjunct as it has a more rapid onset and can be repeated as needed. MID can also be given IN however it burns and often results in crying. Routinely we use adjunct IN sufentanil, but due to a prolonged drug shortage and unavailability (> 1 year) we decided to assess the efficacy and safety of IN remifentanil (REMI), an ultra short acting synthetic opiate. There are only a few papers on IN REMI use. One report of 150 children given IN REMI as an adjunct to intubation did not find any problems and the kinetics appeared to demonstrate a fast onset of IN REMI and a rapid elimination as expected.Methods: We performed at retrospective chart and QA database review of this novel sedation technique. Children scheduled for elective moderate dental sedation procedures were given 0.7mg/kg oral midazolam. Since the shortage of Sufentanil we started using REMI in June 2012. We gave 2 to 4 doses (2mcg/kg) of IN REMI (Maximum REMI dose used was 40 mcg). The first dose was given in the PREAN area 25 minutes after the MID dose. The next dose was given when the child was in the dental chair and monitoring applied in the operatory. Any subsequent doses were given at a minimum of 5 minute intervals at the request of the dentist performing the procedure. All patients were monitored with pulse oximetry, HR and NIBP. The quality of sedation, airway complications and discharge times were assessed as part of our QA process. The IN REMI was prepared each day at a 100 mcg/ml concentration (in NS) and administered using a MAD atomizer device. The volume for each spray was about 0.3-0.4ml. The right nares were used first and then the alternate nares were used for any repeat dosing.Results: Data was collected on 74 children. The mean age was 5.5 years (Range 2 -13) and the mean weight was 22.3kg (Range 12-68). The mean MID dose was 12.6.mg, 51% were female. The median number of dental procedures performed on each child was 3 (range 1-9). The mean total dose of REMI given was 94 mcg. The median number of REMI doses given was 3 (range 2-4). The depth of sedation was assessed using the RASS score. The median RASS score at: MID dosing, Entry into the Operatory, During the Procedure, and arrival in the PACU were: 0, -1, -1, and 1, respectively. The mean procedure duration was 30 minutes. And the mean discharge time was 50 minutes. The median dental assessment score was 5.0. All procedures were completely successfully. There were 2 airway complications noted. Two patients had a desaturation to 90, this was treated with supplemental oxygen in 1 child (2 REMI doses) and no treatment was required in the other (3 REMI doses). There were no episodes of apnea, airway obstruction, or bradycardia. Conclusion:The REMI appeared to be an effective adjunct to oral MID. Due to its short half life, repeat dosing of the RE...