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Midazolam Premedication in Children: A Pilot Study Comparing Intramuscular and Intranasal Administration
Christy Lam DDS,
 Richard D. Udin DDS,
 Stanley F. Malamed DDS,
 David L. Good DDS, and
 Jane L. Forrest RDH, EdD
Article Category: Research Article
Volume/Issue: Volume 52: Issue 2
Online Publication Date: Jun 01, 2005
DOI: 10.2344/0003-3006(2005)52[56:MPICAP]2.0.CO;2
Page Range: 56 – 61

preoperative sedative agent via the intramuscular, 1 2 intranasal, 3 4 oral, 5 and rectal 6 routes. A relatively slower onset of action is a disadvantage of both the oral and rectal routes of administration. Tolksdorf and Eick 7 found the oral route to be less predictable than the other routes studied, with patients experiencing nausea and vomiting postoperatively. Wilton et al 4 noted that oral midazolam also prolongs the recovery time when compared with other routes. Lejus et al 8 pointed out that although rectal midazolam is an effective premedication, a drawback

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A Survey of Dentist Anesthesiologists on Preoperative Intramuscular Sedation
David B. Guthrie DMD,
 Ralph H. Epstein DDS,
 Martin R. Boorin DMD,
 Andrew R. Sisti BA,
 Jamie L. Romeiser MPH, and
 Elliott Bennett-Guerrero MD
Article Category: Research Article
Volume/Issue: Volume 69: Issue 2
Online Publication Date: Jul 18, 2022
DOI: 10.2344/anpr-69-01-03
Page Range: 17 – 23

General anesthesia induction for children and patients with special needs can be very challenging, as patient anxiety and agitation can cause preoperative disturbances and disrupt clinic schedules. In extreme circumstances, violent or combative behavior poses a physical risk to the patient, their caregivers, and health care personnel. In these situations, preoperative intramuscular (IM) sedation is often used to facilitate safe transfer to the operating room (OR) and intravenous (IV) cannulation, with the primary goal being behavior

Retrospective Comparison of Intramuscular Admixtures of Ketamine and Dexmedetomidine Versus Ketamine and Midazolam for Preoperative Sedation
David B. Guthrie DMD,
 Martin R. Boorin DMD,
 Andrew R. Sisti BA,
 Ralph H. Epstein DDS,
 Jamie L. Romeiser MPH,
 David K. Lam MD, DDS, PhD,
 Tong J. Gan MD, MBA, MHS, and
 Elliott Bennett-Guerrero MD
Article Category: Research Article
Volume/Issue: Volume 68: Issue 1
Online Publication Date: Apr 07, 2021
DOI: 10.2344/anpr-67-04-02
Page Range: 3 – 9

, combative and violent behavior may pose a physical danger to the patient, caretakers, and the anesthesia care team. The use of intramuscular (IM) sedative agents, which does not require patient cooperation, can facilitate an efficient transfer to the OR and induction of GA. Although IM ketamine is effective and commonly used for the management of special need patients, it has numerous undesirable side effects including dysphoria, hypersalivation, hyperreactive airway reflexes, hypertension, tachycardia, muscle hypertonia, hallucinations, increased incidence of

Figure 2.; Management of Anaphylaxis in the Dental Office Anaphylaxis should be recognized at an early stage, epinephrine should be administered intramuscularly, and the patient should be transported immediately to a hospital. *Implement steps 3–5 promptly and simultaneously.1
Takashi Goto
Figure 2.
Figure 2.

Management of Anaphylaxis in the Dental Office

Anaphylaxis should be recognized at an early stage, epinephrine should be administered intramuscularly, and the patient should be transported immediately to a hospital.

*Implement steps 3–5 promptly and simultaneously. 1

Figure 1.; Pharmacokinetic considerations. The concentration of drug at the target tissue is determined by combined influences of absorption, metabolism, distribution, and elimination (excretion). Notice obstacles to bioavailability (serum concentration) following oral and intramuscular administration compared to those following intravenous administration.
Daniel E. Becker
Figure 1.
Figure 1.

Pharmacokinetic considerations. The concentration of drug at the target tissue is determined by combined influences of absorption, metabolism, distribution, and elimination (excretion). Notice obstacles to bioavailability (serum concentration) following oral and intramuscular administration compared to those following intravenous administration.

Figure 1.; Drug absorption. Following oral (PO) or topical administration, a drug requires lipid solubility in order to diffuse through the epithelium to reach the capillaries. When administered by intramuscular (IM) or subcutaneous (SC) injection, lipid solubility is not required to reach the capillaries. Once absorbed following PO administration, a drug must travel through the portal system to liver before reaching systemic circulation (venae cavae). See text for further explanation.
Daniel E. Becker
Figure 1.
Figure 1.

Drug absorption. Following oral (PO) or topical administration, a drug requires lipid solubility in order to diffuse through the epithelium to reach the capillaries. When administered by intramuscular (IM) or subcutaneous (SC) injection, lipid solubility is not required to reach the capillaries. Once absorbed following PO administration, a drug must travel through the portal system to liver before reaching systemic circulation (venae cavae). See text for further explanation.

Figure 2.; Time-concentration curves for meperidine. This graph illustrates time-concentration curves for identical doses of meperidine following 3 routes of administration. Following intravenous (IV) administration the concentration drops rapidly during the first 30 minutes due to distribution. The decline then becomes more gradual as drug is eliminated. Following intramuscular (IM) and oral (PO) administration the serum level rises gradually as drug is absorbed and distributed simultaneously. The peak is lower than that following IV administration as initial drug absorbed undergoes distribution and possible elimination before final amounts are absorbed. Compared to IM administration, the time until peak concentration following a PO dose is longer due to slower absorption, and the peak is lower due to more factors hindering bioavailability, eg, first-pass metabolism. Notice that once the processes of absorption and distribution are completed, elimination of drug occurs at an identical rate regardless of the route by which it was administered; elimination T1/2 is identical (adapted from Stambaugh et al2).
Daniel E. Becker
Figure 2.
Figure 2.

Time-concentration curves for meperidine. This graph illustrates time-concentration curves for identical doses of meperidine following 3 routes of administration. Following intravenous (IV) administration the concentration drops rapidly during the first 30 minutes due to distribution. The decline then becomes more gradual as drug is eliminated. Following intramuscular (IM) and oral (PO) administration the serum level rises gradually as drug is absorbed and distributed simultaneously. The peak is lower than that following IV administration as initial drug absorbed undergoes distribution and possible elimination before final amounts are absorbed. Compared to IM administration, the time until peak concentration following a PO dose is longer due to slower absorption, and the peak is lower due to more factors hindering bioavailability, eg, first-pass metabolism. Notice that once the processes of absorption and distribution are completed, elimination of drug occurs at an identical rate regardless of the route by which it was administered; elimination T1/2 is identical (adapted from Stambaugh et al2).

Management of Anaphylaxis in Dental Practice
Takashi Goto DDS, PhD
Article Category: Other
Volume/Issue: Volume 70: Issue 2
Online Publication Date: Jun 28, 2023
DOI: 10.2344/anpr-70-02-16
Page Range: 93 – 105

be placed in the supine position, and epinephrine should be administered intramuscularly, ideally in the vastus lateralis (outer thigh), at an early stage. If necessary, the patient should be given high-flow supplemental oxygen via a face mask, IV access should be established using large-bore catheters (ideally 14–16 gauge), and a transfusion of 0.9% saline (5–10 mL/kg for an adult and 10 mL/kg for a child in the first 5–10 min) should be initiated. In addition to these measures, cardiopulmonary resuscitation should be performed if indicated. Preparations should be

The Fallacy of a Lifesaving Sublingual Injection of Flumazenil
Joel M Weaver DDS, PhD
Article Category: Editorial
Volume/Issue: Volume 58: Issue 1
Online Publication Date: Jan 01, 2011
DOI: 10.2344/0003-3006-58.1.1
Page Range: 1 – 2

positive‐pressure ventilation. If 0.2 mg of flumazenil given intravenously does not adequately reverse even conscious sedation in most people, much less in unconscious overdosed patients, to recommend that a single small dose injected by the much slower and much less researched sublingual route is not only unscientific but also unsafe. Although it is reasonable to suspect that flumazenil would eventually work by sublingual or intramuscular injection if enough drug is injected, a sufficient amount of flumazenil may not be absorbed quickly enough to save a patient from

Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist
Daniel A. Haas
Article Category: Other
Volume/Issue: Volume 53: Issue 1
Online Publication Date: Jan 01, 2006
DOI: 10.2344/0003-3006(2006)53[20:MOMEIT]2.0.CO;2
Page Range: 20 – 24

of cardiac arrest, but in the dental office setting, it may not be as likely to be given, since intravenous access may not be available. Its administration intramuscularly is not as likely to be very effective in this latter emergency, where adequate oxygenation and early defibrillation is most important for the cardiac arrest dysrhythmias with the relatively best prognoses, namely ventricular fibrillation or pulseless ventricular tachycardia. As a drug, epinephrine has a very rapid onset and short duration of action, usually 5 to 10 minutes when given