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A4204
October 27, 2015
1:00:00 PM - 3:00:00 PM
Room Hall B2-Area D
Postoperative Outcomes After Varying Oral Midazolam Doses: A Retrospective Chart Review
Laura S. Gonzalez, M.D., Shelly B. Borden, M.D., John M. Reynen, M.D., Lana M. Volz, M.D., Bridget L. Muldowney, M.D.
University of Wisconsin, Madison, Wisconsin , United States
Disclosures: L.S. Gonzalez: None. S.B. Borden: None. J.M. Reynen: None. L.M. Volz: None. B.L. Muldowney: None.
Introduction: Perioperative anxiety is common in children. Beyond the immediate distress on the patient and caregivers, perioperative anxiety has been associated with increased postoperative pain1 and maladaptive or regressive behaviors in the weeks after surgery.2 Premedication with anxiolytics such as midazolam is a common strategy to decrease anxiety; however benzodiazepines may have adverse effects such as prolonged sedation or paradoxical agitation. We conducted a retrospective chart review to investigate the effects of midazolam on postoperative care in pediatric patients undergoing tonsillectomy and adenoidectomy.

Methods: Following IRB approval we performed a retrospective chart review of 888 patients age 0-12 undergoing tonsillectomy with or without adenoidectomy from 1/1/2010 to 12/31/2012. We excluded patients who received an intraoperative opioid other than morphine or hydromorphone. Data regarding demographics, preoperative acetaminophen, total opioid dose (calculated as total morphine equivalent), incidence of postoperative nausea or vomiting, PACU time, and total postoperative time were recorded. Frequency data were analyzed with chi-square test; mean data were analyzed with a t-test. Pre-operative midazolam dose was categorized as greater than 0.3mg/kg, equal to or less than 0.3 mg/kg, and none, and analyzed with ANOVA and chi-square test.

Results: Of the 797 patients included, 299 (37.5%) received preoperative midazolam; of these, 80 (25.7%) received ≤ 0.3mg/kg and 219 (73.2%) received >0.3 mg/kg. Patients who received midazolam preoperatively were more likely to receive a preoperative dose of acetaminophen. Patients who received a dose of ≤ 0.3 mg/kg midazolam received the least amount of opioid (0.105 morphine equivalents), followed by patients who did not receive midazolam (0.127); patients who received > 0.3 mg/kg midazolam had the highest morphine equivalent dose (0.134). PACU stay was 19 minutes shorter in patients who did not receive midazolam (p <0.001). Midazolam premedication was associated with a decreased incidence of postoperative nausea and vomiting (9.8% in those who received midazolam versus 17.3% in those who did not, p = 0.005).

Discussion: Midazolam is commonly given to children to relieve perioperative anxiety, which in previous studies been shown to contribute to increased pain, worse post-operative recovery, and behavioral disturbance up to 2 months after surgery.2 However, there are adverse effects associated with midazolam use, including prolonged sedation and paradoxical agitation. Previous studies have demonstrated that the anxiolytic effects of midazolam are inferior to dexmedetomidine in reducing anxiety levels at mask induction and reduced need for rescue analgesia.3 Non-pharmacologic strategies to control perioperative anxiety, such as tablet-based interactive distraction devices, have also been shown more effective at decreasing anxiety, emergence delirium, and postoperative length of stay in pediatric patients.4 While not designed to evaluate efficacy of midazolam compared to other interventions, our study raises concerns about routine use of midazolam for perioperative anxiolysis in children undergoing tonsillectomy. Midazolam had no opiate sparing effects, as the group receiving the highest midazolam dose required the most opioid, despite being more likely to receive preoperative acetaminophen. In addition, midazolam use at any dose was associated with a longer PACU stay and longer total postoperative stay, which has cost implication. Routine use of preoperative midazolam may not be of benefit in all patients, especially given the existence of other modalities to alleviate anxiety.

References

1. Esteve R, et al. J Pain. 2014;15:157-68.

2. Kain, ZN, et al. Anesthesiology. 1999;90:758-65.

3. Sun, Y, et al. Paediatr Anaesth. 2014;24:863-74.

4. Seiden, SC, et al. Paediatr Anaesth. 2014;24:1217-23.

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