Midazolam fentanyl

A 61-year-old woman undergoing mitral valve surgery received fentanyl, midazolam, nitrous oxide, and propofol infusion 3 mg/kg/hour during a 5-hour anesthetic. She developed lactic acidosis soon after the completion of surgery and required reintubation and ventilation. The peak lactate concentration, which occurred 1 day later, was 14.3 mmol/1. There was also mild disturbance of liver function. She eventually recovered. 

In 113 patients undergoing general anesthesia, intravenous midazolam 15 mg slowed recovery of the twitch height after vecuronium and atracurium compared with diazepam. The recovery index was not altered (162). However, in another study in 20 patients, midazolam 0.3 mg/kg did not affect the duration of blockade, recovery time, intensity of fasciculations, or adequacy of relaxation for tracheal intubation produced by suxamethonium 1 mg/kg, nor the duration of blockade and adequacy of relaxation for tracheal intubation produced by pancuronium 0.025 mg/kg in incremental doses until 99% depression of muscle-twitch tension was obtained (161). Furthermore, in 60 patients undergoing maintenance anesthesia randomly assigned to one of six regimens (etomidate, fentanyl, midazolam, propofol, thiopental plus nitrous oxide, or isoflurane plus nitrous oxide), midazolam did not alter rocuronium dosage requirements (165). 

Olkkola KT, Tammisto T. Quantifying the interaction of rocuronium (Org 9426) with etomidate, fentanyl, midazolam, propofol, thiopental, and isoflurane using closed-loop... 

Observational studies Several studies have reported better recovery with a combination of remifentanil + midazolam compared with combinations of fentanyl +midazolam and... 

McQueen A, Wright RO, Kido MM, Kaye E, Krauss B. Procedural sedation and analgesia outcomes in children after discharge from the emergency department ketamine versus fentanyl/midazolam. Aim Emerg Med 2009 54(2) 191-97.el-4. 

Drugs, DIOS Amphetamines, fentanyls, midazolam. Huikko et al. (2003), Kebarle and Tang... 

Recovery is sufficiently rapid with most intravenous drugs to permit their use for short ambulatory (outpatient) surgical procedures. In the case of propofol, recovery times are similar to those seen with sevoflurane and desflurane. Although most intravenous anesthetics lack antinociceptive (analgesic) properties, their potency is adequate for short superficial surgical procedures when combined with nitrous oxide or local anesthetics, or both. Adjunctive use of potent opioids (eg, fentanyl, sufentanil or remifentanil see Chapter 31) contributes to improved cardiovascular stability, enhanced sedation, and perioperative analgesia. However, opioid compounds also enhance the ventilatory depressant effects of the intravenous agents and increase postoperative emesis. Benzodiazepines (eg, midazolam, diazepam) have a slower onset and slower recovery than the barbiturates or propofol and are rarely used for induction of anesthesia. However, preanesthetic administration of benzodiazepines (eg, midazolam) can be used to provide anxiolysis, sedation, and amnesia when used as part of an inhalational, intravenous, or balanced anesthetic technique. 

Tamura M, Nakamura K, Kitamura R, et al. Oral premedication with fentanyl may be a safe and effective alternative to oral midazolam. Eur J Anaesthesiol. 2003 20 482M86. 

Induce and maintain anesthesia using a mixture of fentanyl/ fluanisone with midazolam (Hypnorm/Hypnovel see Note 4). The dosage for these agents is 0.25 mL of each active ingredient plus 0.5 mL of water given IP at a rate of 0.1 mL per mouse. 

Several drugs are used intravenously, alone or in combination with other drugs, to achieve an anesthetic state (as components of balanced anesthesia) or to sedate patients in intensive care units who must be mechanically ventilated. These drugs include the following (1) barbiturates (thiopental, methohexital) (2) benzodiazepines (midazolam, diazepam) (3) opioid analgesics (morphine, fentanyl, sufentanil, alfentanil, remifentanil) (4) propofol (5) ketamine and (6) miscellaneous drugs (droperidol, etomidate, dexmedetomidine). Figure 25-2 shows the structures of... 

Adjunctive use of potent opioids (eg, fentanyl and related compounds) contributes cardiovascular stability, enhanced sedation, and profound analgesia. Other intravenous agents such as the benzodiazepines (eg, midazolam, diazepam) have slower onset and recovery features and are rarely used for induction of anesthesia. However, preanesthetic administration of benzodiazepines can be used to provide a basal level of sedation and amnesia when used in conjunction with other anesthetic agents. 

During all valvuloplasty interventions antibiotics (e.g., cefuroxime, I, 5 g, i.v.) are administered. Patients allergic to penicillin should receive vancomycin I g intravenously. Most physicians perform transcatheter valvuloplasty in the fasting state under mild sedation, Substances that are frequently used are meperidine, promethazine, and chlorpromazine, given intramuscularly or intermittent doses of midazolam (0.05 to 0.1 mg/kg, i.v.) and/or fentanyl (0.5 to 1.0 Lig/kg, i.v.). Some operators also apply ketamine or general anesthesia for all interventional cases. 

Drugs metabolized by CYP that interact with cimetidine include, but are not limited to, the following lidocaine, quinidine, midazolam, triazolam, nifedipine, verapamil, and fentanyl (4). In each instance, inhibition of CYP by cimetidine results in reduced metabolic clearance and increases in serum concentrations of the other drug, which can lead to the expected toxicity and adverse experiences characteristic of the other drug. 

In a double-bhnd, randomized, placebo-controlled study during coronary angiography in 90 patients, midazolam with or without fentanyl and local anesthesia provided better hemodynamic stability than placebo (11). 

Midazolam depresses both cardiovascular and respiratory function, especially in elderly patients (20). As little as 0.01 mg/kg can obtund the response to hypoxia and hypercapnia (21). The simultaneous use of opiates (such as fentanyl) commonly produces hypoxia (22). 

In a 40-month-old boy a withdrawal syndrome with neurological symptoms was accompanied by thrombocytosis, which peaked at 1230 x 109/1 (45). Recovery from the withdrawal syndrome was accompanied by normalization of the platelet count. The relevance of this change in platelet count was not clear. The boy had also been given fentanyl, and the authors suggested that the combination of midazolam with fentanyl should be used with caution. 

Several adverse effects have been reported with the combined use of fentanyl and midazolam, including chest wall rigidity, making ventilation with a bag and mask impossible (SEDA-16, 79). In neonates, hypotension can occur (SEDA-16, 80), and respiratory arrest in a child and sudden cardiac arrest have been reported (SEDA-16, 80). However, in one study there were no cardiac electrophy-siological effects of midazolam combined with fentanyl in subjects undergoing cardiac electrophysiological studies (SEDA-18, 80). 

Pachulski RT, Adkins DC, Mirza H. Conscious sedation with intermittent midazolam and fentanyl in electrophysiology procedures. J Interv Cardiol 2001 14(2) 143-6. 

Baris S, Karakaya D, Aykent R, Kirdar K, Sagkan O, Tur A. Comparison of midazolam with or without fentanyl for conscious sedation and hemodynamics in coronary angiography. Can J Cardiol 2001 17(3) 277-81. 

Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA, Stanley TH. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990 73(5) 826-30. 

Ducharme MP, Munzenberger P. Severe withdrawal syndrome possibly associated with cessation of a midazolam and fentanyl infusion. Pharmacotherapy 1995 15(5) 665-8. 

Hypotension has occurred in neonates given midazolam and fentanyl... 

Sometimes preanesthesia agents are used before cataract surgery. These agents help to relieve anxiety and to produce sedation and, in some cases, short-term amnesia. Oral or intravenous diazepam (Valium) or midazolam (Versed) or intravenous fentanyl citrate (Sublimaze) are commonly used for preoperative sedation. 

Sedation in critical care units is used to reduce patient anxiety and improve tolerance to tracheal tubes and mechanical ventilation. Whenever possible, patients are sedated only to a level that allows them to open their eyes to verbal command oversedation is harmful. Commonly used drugs include propofol and midazolam, and opioids such as fentanyl, alfentanil, or morphine. 

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