Journal of Dental Anesthesia and Pain Medicine

The Korean Dental Society of Anesthsiology (대한치과마취과학회)
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Comparison of the effects of target-controlled infusion-remifentanil/midazolam and manual fentanyl/midazolam administration on patient parameters in dental procedures

  • Received : 2021.10.04
  • Accepted : 2022.03.16
  • Published : 2022.04.01
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Abstract

Background: Moderate sedation is an integral part of dental care delivery. Target-controlled infusion (TCI) has the potential to improve patient safety and outcome. We compared the effects of using TCI to administer remifentanil/manual bolus midazolam with manual bolus fentanyl/midazolam administration on patient safety parameters, drug administration times, and patient recovery times. Methods: In this retrospective chart review, records of patients who underwent moderate intravenous sedation over 12 months in a private dental clinic were assessed. Patient indicators (pre-, intra-, and post-procedure noninvasive systolic and diastolic blood pressure, respiration, and heart rate) were compared using independent t-test analysis. Patient recovery time, procedure length, and midazolam dosage required were also compared between the two groups. Results: Eighty-five patient charts were included in the final analysis: 47 received TCI-remifentanil/midazolam sedation, and 38 received manual fentanyl/midazolam sedation. Among the physiological parameters, diastolic blood pressure showed slightly higher changes in the fentanyl group (P = 0.049), respiratory rate changes showed higher changes in the fentanyl group (P = 0.032), and the average EtCO2 was slightly higher in the remifentanil group (P = 0.041). There was no significant difference in the minimum SpO2 levels and average procedure length between the fentanyl and remifentanil TCI pump groups (P > 0.05). However, a significant difference was observed in the time required for discharge from the chair (P = 0.048), indicating that patients who received remifentanil required less time for discharge from the chair than those who received fentanyl. The dosage of midazolam used in the fentanyl group was 0.487 mg more than that in the remifentanil group; however, the difference was not significant (P > 0.05). Conclusion: The combination of TCI administered remifentanil combined with manual administered midazolam has the potential to shorten the recovery time and reduce respiration rate changes when compared to manual administration of fentanyl/midazolam. This is possibly due to either the lower midazolam dosage required with TCI remifentanil administration or achieving a stable, steady-state low dose remifentanil concentration for the duration of the procedure.

Keywords

Acknowledgement

Our study team acknowledges many staff members in assisting and contributing to this project: Madison Howey, Jacqueline Green, and all staff from the dental office where this study took place.

References

  1. Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the american society of anesthesiologists task force on moderate procedural sedation and analgesia, the american association of oral and maxillofacial surgeons, american college of radiology, american dental association, american society of dentist anesthesiologists, and society of interventional radiology. Anesthesiology 2018; 128:437-79. https://doi.org/10.1097/ALN.0000000000002043
  2. Del Gaudio A, Ciritella P, Perrotta F, Puopolo M, Lauta E, Mastronardi P, et al. Remifentanil vs fentanyl with a target controlled propofol infusion in patients undergoing craniotomy for supratentorial lesions. Minerva Anestesiol 2006; 72: 309-19.
  3. Benzoni T, Cascella M. Procedural sedation.2020 Jul 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-PMID: 31869149.
  4. Kapur A, Kapur V. Conscious sedation in dentistry. Ann Maxillofac Surg 2018: 8: 320-3. https://doi.org/10.4103/ams.ams_191_18
  5. Finder RL, Moore PA. Benzodiazepines for intravenous conscious sedation: agonists and antagonists. Compendium 1993; 14: 972. 974, 976-80.
  6. Averley PA, Girdler NM, Bond S, Steen N, Steele J. A randomized controlled trial of pediatric conscious sedation for dental treatment using intravenous midazolam combined with inhaled nitrous oxide or nitrous oxide/sevoflurane. Anaesthesia 2004; 59: 844-52. https://doi.org/10.1111/j.1365-2044.2004.03805.x
  7. Prabhudev AM, Chogtu B, Magazine R. Comparison of midazolam with fentanyl-midazolam combination during flexible bronchoscopy: a randomized, double-blind, placebo-controlled study. Indian J Pharmacol 2017; 49: 304-11. https://doi.org/10.4103/ijp.IJP_683_16
  8. Ryan PM, Kienstra AJ, Cosgrove P, Vezzetti R, Wilkinson M. Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department. Am J Emerg Med 2019; 37: 237-40. https://doi.org/10.1016/j.ajem.2018.05.036
  9. Lee B, Park JD, Choi YH, Han YJ, Suh DI. Efficacy and safety of fentanyl in combination with midazolam in children on mechanical ventilation. J Korean Med Sci 2019; 34: e21. https://doi.org/10.3346/jkms.2019.34.e21
  10. Lobb D, Clarke A, Lai H. Administration order of midazolam/fentanyl for moderate dental sedation. J Dent Anesth Pain Med 2018; 18: 47-56. https://doi.org/10.17245/jdapm.2018.18.1.47
  11. Galeotti A, Garret Bernardin A, D'Anto V, Ferrazzano GF, Gentile T, Viarani V, et al. Inhalation conscious sedation with nitrous oxide and oxygen as an alternative to general anesthesia in precooperative, fearful, and disabled pediatric dental patients: a large survey on 688 working sessions. Biomed Res Int 2016: 7289310.
  12. Lacombe GF, Leake JL, Clokie CM, Haas DA. Comparison of remifentanil with fentanyl for deep sedation in oral surgery. J Oral Maxillofac Surg 2006; 64: 215-22. https://doi.org/10.1016/j.joms.2005.10.026
  13. Gurbet A, Goren S, Sahin S, Uckunkaya N, Korfali G. Comparison of analgesic effects of morphine, fentanyl, and remifentanil with intravenous patient-controlled analgesia after cardiac surgery. J Cardiothorac Vasc Anesth 2004; 18: 755-8. https://doi.org/10.1053/j.jvca.2004.08.014
  14. Abad A. Sistema de Infusion. In: Aguilera L, Abad A, editors. Anestesia total intravenosa. Principios basicos. Madrid: SA delitografia; 2009. p. 87-102.
  15. Mu J, Jiang T, Xu XB, Yuen VM, Irwin MG. Comparison of target-controlled infusion and manual infusion for propofol anesthesia in children. Br J Anaesth 2018; 120: 1049-55. https://doi.org/10.1016/j.bja.2017.11.102
  16. Salinas Salmeron KS, Kim HJ, Seo KS. Effects site concentrations of propofol using target-controlled infusion in dental treatment under deep sedation among different intellectual disability types. J Dent Anesth Pain Med 2019; 19: 217-26. https://doi.org/10.17245/jdapm.2019.19.4.217
  17. Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status - historical perspectives and modern developments. Anaesthesia 2019; 74: 373-9. https://doi.org/10.1111/anae.14569
  18. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974; 2(5920): 656-9. https://doi.org/10.1136/bmj.2.5920.656
  19. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg 1970; 49: 924-34.
  20. Fenn NE 3rd, Plake KS. Opioid and benzodiazepine weaning in pediatric patients: review of current literature. Pharmacotherapy 2017; 37: 1458-68. https://doi.org/10.1002/phar.2026
  21. Eleveld DJ, Colin P, Absalom AR, Struys MMRF. Target-controlled-infusion models for remifentanil dosing consistent with approved recommendations. Br J Anaesth 2020; 125: 483-91. https://doi.org/10.1016/j.bja.2020.05.051
  22. Hannam JA, Borrat X, Troconiz IF, Valencia JF, Jensen EW, Pedroso A, et al. Modeling respiratory depression induced by remifentanil and propofol during sedation and analgesia using a continuous noninvasive measurement of pCO2. J Pharmacol Exp Ther 2016; 356: 563-73. https://doi.org/10.1124/jpet.115.226977
  23. Hsieh ML, Lu YT, Lin CC, Lee CP. Comparison of the target-controlled infusion and the manual infusion of propofol anesthesia during electroconvulsive therapy: an open-label randomized controlled trial. BMC Psychiatry. 2021; 21: 71. https://doi.org/10.1186/s12888-021-03069-6
  24. Beers R, Camporesi E. Remifentanil update: clinical science and utility. CNS Drugs 2004; 18: 1085-104. https://doi.org/10.2165/00023210-200418150-00004
  25. Pattinson KT. Opioids and the control of respiration. Br J Anaesth 2008; 100: 747-58. https://doi.org/10.1093/bja/aen094
  26. Southerland JH, Brown LR. Conscious intravenous sedation in dentistry: a review of current therapy. Dent Clin North Am 2016; 60: 309-46. https://doi.org/10.1016/j.cden.2015.11.009
  27. Dahan A, Nieuwenhuijs D, Olofsen E, Sarton E, Romberg R, Teppema L. Response surface modeling of alfentanil-sevoflurane interaction on cardiorespiratory control and bispectral index. Anesthesiology 2001; 94: 982-91. https://doi.org/10.1097/00000542-200106000-00011
  28. Nieuwenhuijs DJ, Olofsen E, Romberg RR, Sarton E, Ward D, Engbers F, et al. Response surface modeling of remifentanil-propofol interaction on cardiorespiratory control and bispectral index. Anesthesiology 2003; 98: 312-22. https://doi.org/10.1097/00000542-200302000-00008
  29. Egan TD, Westphal M, Minto CF, Schnider TW. Moving from dose to concentration: as easy as TCI! Br J Anaesth 2020; 125: 847-9. https://doi.org/10.1016/j.bja.2020.08.033
  30. Egan TD. An intellectual framework for drug administration methods in anesthesia: three practice domains. Anesth Analg 2018; 127: 817-9. https://doi.org/10.1213/ane.0000000000003601
  31. Egan TD. Target-controlled drug delivery: progress toward an intravenous "vaporizer" and automated anesthetic administration. Anesthesiology 2003; 99: 1214-9. https://doi.org/10.1097/00000542-200311000-00031
  32. Hill R, Santhakumar R, Dewey W, Kelly E, Henderson G. Fentanyl depression of respiration: comparison with heroin and morphine. Br J Pharmacol 2020; 177: 254-66. https://doi.org/10.1111/bph.14860
  33. Sridharan K, Sivaramakrishnan G. Comparison of fentanyl, remifentanil, sufentanil and alfentanil in combination with propofol for general anesthesia: a systematic review and meta-analysis of randomized controlled trials. Curr Clin Pharmacol 2019; 14: 116-24. https://doi.org/10.2174/1567201816666190313160438
  34. Bilgin H, Basagan Mogol E, Bekar A, Iscimen R, Korfali G. A comparison of effects of alfentanil, fentanyl, and remifentanil on hemodynamic and respiratory parameters during stereotactic brain biopsy. J Neurosurg Anesthesiol 2006; 18: 179-84. https://doi.org/10.1097/01.ana.0000210998.10410.2e
  35. Drummond GB, Lafferty B. Oxygen saturation decreases acutely when opioids are given during anesthesia. Br J Anaesth 2010; 104: 661-3 https://doi.org/10.1093/bja/aeq076
  36. Maurtua MA, Pursell A, Damron K, Sonal P. Remifentanil: pharmacokinetics, pharmacodynamics, and current clinical applications. Clin Med Rev Case Rep 2020; 7: 304.
  37. Barends CRM, Driesens MK, van Amsterdam K, Struys MMRF, Absalom AR. Moderate-to-deep sedation using target-controlled infusions of propofol and remifentanil: adverse events and risk factors: a retrospective cohort study of 2937 procedures. Anesth Analg 2020; 131: 1173-83. https://doi.org/10.1213/ane.0000000000004593
  38. Tylleskar I, Skulberg AK, Skarra S, Nilsen T, Dale O. Pharmacodynamics and arteriovenous difference of intravenous naloxone in healthy volunteers exposed to remifentanil. Eur J Clin Pharmacol 2018; 74: 1547-53. https://doi.org/10.1007/s00228-018-2545-y