The justifications given for the use of flumazenil following midazolam-induced conscious sedation are shown in Figure 2. The total number of patients given midazolam for dental treatment over the audit period in the Department of Sedation and Special Care Dentistry was 453.Ī total of 32 proformas were completed detailing the use of flumazenil following midazolam-induced conscious sedation during this period, this was equivalent to 7% of the sedation treatment episodes.Īll of the completed proformas provided the required information regarding the time of midazolam administration, details of why flumazenil was administered, details of amount and method of flumazenil administration and time of administration all but one of the proformas gave the time of discharge from the department. It outlined clear actions, which apply to all organisations in the NHS and independent sector, to minimise risks of overdosing and subsequent harm from midazolam in adults. The purpose of the RRR was to alert healthcare staff involved in prescribing, administration or supply of injectable midazolam for use in adult conscious sedation to the risk of overdose or harm. Detailed analysis of the fatalities data showed that patients who had received flumazenil died two days sooner than those who had not received it. The NCEPOD advisors judged that the sedation given was inappropriate in 14% of these cases, usually because an overdose of benzodiazepine had been administered. 2 This report reviewed 1,818 inpatient deaths within 30 days of interventional gastrointestinal endoscopy in hospitals in England, Wales and Northern Ireland. In addition, and of particular concern, was evidence elicited from the 2004 National Confidential Enquiry into Patient Outcome and Death (NCEPOD). It also reported that the use of flumazenil as an antidote to midazolam overdose is widespread and that, although useful to reverse the effects of over-sedation, it is not without risk. Errors were reported to have occurred because of lack of training in the use of midazolam, problems in titration and dosing (including use of part-ampoules and vials of higher strength) for individual patients. The report concluded that the NPSA had identified serious problems in the current use of midazolam for conscious sedation in adults. Pt recovered consciousness shortly afterwards.' 1 Dentist went for advice from Day Surgery Unit while Dental Nurse managed SPO2 drop by managing airway. SATS initially normal (brought back from waiting room to surgery). Pt woke for about 40 minutes then re-sedated. Flumazenil given at 1420 – flumazenil has a shorter half-life than midazolam. One of the dental-related incidents was documented in the report:ĭuring IVS procedure pt re-sedated. Of the 1,529 reports only two were attributed to dentistry. Of the 498 incidents, three patients died, 48 incidents resulted in moderate harm to patient and the remaining 447 caused low or no harm to the patients. The report documented 498 incidents of adult patients being given midazolam during the period from November 2004 to November 2008. The National Patient Safety Agency (NPSA)'s rapid response report (RRR), Reducing risk of overdose with midazolam injection in adults, 1 reviewed 1,529 medication-related patient safety incident reports received by the Reporting and Learning System (RLS) where the words midazolam or flumazenil (or related terms) were contained in the report. Each case should be individually considered, justified and documented within the patient's clinical record. The audit has highlighted distinct indications for the post-operative use of flumazenil in specifically selected cases. No cases required flumazenil for the emergency treatment of respiratory depression.Ĭonclusions The results of the audit confirmed the safe and appropriate use of midazolam for conscious sedation within the Department of Sedation and Special Care Dentistry at Guy's Hospital and demonstrated that flumazenil use was low and in accordance with current best practice. Results Four hundred and fifty-three patients were sedated with midazolam. Method All clinical staff completed the data capture proforma when flumazenil was administered to a patient after sedation with midazolam. Subjects Patients sedated with midazolam for dental treatment. Objective To investigate the use of flumazenil after midazolam-induced conscious sedation.ĭesign and setting A prospective audit was carried out in the Department of Sedation and Special Care Dentistry at Guy's Hospital, King's College, London, 2009.

Versed antidote