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ANESTHESIA/FACIAL PAIN

Does Intravenous Midazolam Dose Influence the Duration of Recovery Room Stay Following Outpatient Third Molar Surgery? Kyle S. Ettinger, DDS, MD,* Adam K. Jacob, MD,y Christopher F. Viozzi, DDS, MD,z James M. Van Ess, DDS, MD,x W. Jonathan Fillmore, DMD, MD,k and Kevin Arce, DMD, MD{

Q4

Purpose:

To evaluate the impact of intravenous midazolam dose on the duration of recovery room stay for patients undergoing outpatient third molar surgery.

Materials and Methods:

Using a retrospective cohort study design, a sample of patients undergoing outpatient third molar surgery under intravenous sedation at Mayo Clinic from 2010 to 2014 was identified. All patients underwent extraction of all 4 third molars during a single operative procedure and the age range was limited to 14 to 29 years. The primary predictor variable was the total dose of intravenous midazolam administered during sedation. The primary outcome variable was recovery room length of stay (LOS) after completion of surgery. Multiple covariates also abstracted included patient age, gender, American Society of Anesthesiologists (ASA) score, duration of surgical procedure, complexity of surgical procedure, types and dosages of all intravenous medications administered during sedation, and volume of crystalloid fluid administered perioperatively. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary outcome variable.

Results:

The study sample was composed of 2,610 patients. Mean age was 18.3 years (SD, 3.0 yr; range, 14 to 29 yr) and gender distribution was 52% female. Mean dosage of midazolam administered was 4.1 mg (SD, 1.1 mg; range, 0.5 to 10.0 mg). Variables predicting shorter LOS at multivariable analysis included older age (P < .001), male gender (P = .004), and administration of larger crystalloid fluid volumes (P < .001). Variables predicting longer LOS included higher ASA score (P < .001), administration of ketamine (P < .001), and administration of ketorolac (P < .001). The dose of midazolam administered during sedation was not found to be statistically associated with prolonged recovery room LOS in univariable or multivariable settings.

Conclusion:

Dosage of intravenous midazolam does not appear to materially affect the duration of recovery room LOS in prototypical patients undergoing sedation for outpatient third molar surgery. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-7, 2015

{Assistant Professor and Program Director, Division of Oral and

Received from the Mayo Clinic and Mayo College of Medicine, Rochester, MN.

Maxillofacial Surgery, Department of Surgery.

*Resident, Division of Oral and Maxillofacial Surgery, Department

Address correspondence and reprint requests to Dr Ettinger: Di-

of Surgery. yAssociate

vision of Oral and Maxillofacial Surgery, Department of Surgery, Professor

and

Consultant,

Department

of

Mayo Clinic Rochester, Mail Code: ro_ma_12_12eres, 200 First Street

Anesthesiology. zAssistant Professor and Program Chair, Division of Oral and

SW, Rochester, MN 55905; e-mail: [email protected] Received May 22 2015

Maxillofacial Surgery, Department of Surgery.

Accepted June 19 2015

xAssistant Professor and Consultant, Division of Oral and

Ó 2015 American Association of Oral and Maxillofacial Surgeons

Maxillofacial Surgery, Department of Surgery.

0278-2391/15/00899-X

kAssistant Professor and Consultant, Division of Oral and

http://dx.doi.org/10.1016/j.joms.2015.06.164

Maxillofacial Surgery, Department of Surgery.

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MIDAZOLAM AND DURATION OF RECOVERY

The administration of midazolam for outpatient ambulatory surgery has become an increasingly popular practice within different clinical settings.1-3 This is perhaps nowhere more apparent than in oral and maxillofacial surgery (OMS), where the use of midazolam as a sedative anxiolytic is commonplace. Midazolam has several pharmacokinetic and physiologic advantages that make it an ideal agent for outpatient surgery.4,5 Intravenous (IV) midazolam has a rapid onset of effect, short duration of action, minimal impact on cardiac function, minimal effect on respiratory depression, and it produces anterograde amnesia— which is often desirable for preventing recall of distressing stimuli experienced during surgery.4-7 Transient postoperative cognitive impairment caused by midazolam has been well described in the literature and this remains a relevant concern in any ambulatory care setting.6,8,9 Recently, some evidence has suggested that IV midazolam might be associated with prolonged recovery time when administered for outpatient anesthesia for various oral surgical procedures.10,11 In addition, unpublished data from the Department of Anesthesiology at the Mayo Clinic (Rochester, MN) have identified midazolam administration as an independent risk factor for prolonged stay in the postanesthesia care unit after general anesthesia for different surgical procedures, including OMS. The extremely robust outpatient sedation practice at the authors’ institution provided a unique opportunity to evaluate the effects of midazolam on a very large number of patients undergoing IV sedation for outpatient third molar surgery. Therefore, the purpose of this study was to evaluate the impact of IV midazolam dose on the duration of recovery room length of stay (LOS) after outpatient IV sedation for third molar surgery. The authors hypothesized that patients receiving higher doses of midazolam would experience prolonged recovery room LOSs owing to greater degrees of postoperative cognitive impairment and longer times required to meet dismissal criteria. The aim of the study was to characterize the recovery room LOS for patients undergoing outpatient third molar surgery under IV sedation at a single institution and to correlate LOS with the dose of midazolam administered during the procedure. A secondary aim of the study was to identify additional demographic, anesthetic, and intraoperative features predicting longer recovery room LOSs within this same population.

Materials and Methods STUDY DESIGN AND SAMPLE

To address the research purpose, the authors designed and implemented a retrospective cohort study. A sample of patients was derived from a population of

Table 1. SURGICAL COMPLEXITY SCORE POINT VALUES BY CURRENT DENTAL TERMINOLOGY CODE

Code D7140 D7210 D7220 D7230 D7240

Descriptor Extraction of erupted tooth or exposed root* Surgical extraction of an erupted toothy Extraction of soft tissue impacted toothz Extraction of partially bony impacted toothx Extraction of complete bony impacted toothk

Point Value Assigned 0 1 2 3 4

* Elevation with or without forceps removal. y Extraction requires elevation of mucoperiosteal flap with or without removal of bone with or without sectioning of the tooth. z Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. x Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. k Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Ettinger et al. Midazolam and Duration of Recovery. J Oral Maxillofac Surg 2015.

patients undergoing outpatient third molar surgery under IV sedation at the Mayo Clinic (Rochester, MN) from 2010 through 2014. Inclusion criteria for the study included an age of at least 14 years and no older than 29 years, administration of midazolam as a component of IV sedation, adequate documentation of recovery room LOS in the electronic anesthesia record, and extraction of all 4 third molars under a single operative procedure. Exclusion criteria for the study include an age younger than 14 years or older than 29 years at the time of surgery, lack of midazolam administration during IV sedation, inadequate documentation of recovery room LOS in the anesthesia record, extraction of fewer than 4 third molars at the time of surgery, and the performance of any ancillary procedure in addition to third molar extraction under the same sedation (eg, endosseous implant placement, extraction of additional teeth, etc). Approval from the Mayo Clinic institutional review board was obtained for completion of this study. STUDY VARIABLES

The primary predictor variable for the study was the total dose of IV midazolam administered during sedation. The primary outcome variable was the recovery room LOS documented in the electronic anesthesia record. Multiple covariates also were abstracted, including

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ETTINGER ET AL

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Table 2. SUMMARY OF ABSTRACTED FEATURES FOR ALL PATIENTS UNDER STUDY (N = 2,610)

Feature Age (yr), mean (SD; range) 18.3 (3.0; 14-29) Complexity score, mean (SD; 11.6 (3.5; 4-16) range) Duration of surgery (minutes; 30 (12; 5-121) n = 2,579), mean (SD; range)* IV fluids (n = 2,592), mean (SD; 429 (221; 0-1,609) range)* Propofol (mg), mean (SD; 101 (80; 0-920) range) Midazolam (mg), mean (SD; 4.1 (1.1; 0.5-10.0) range) Age (yr), n (%) 14-16 691 (26) 17 545 (21) 18-19 759 (29) 20-29 615 (24) Gender, n (%) Women 1,364 (52) Men 1,246 (48) ASA score, n (%) I 2,121 (81) II 484 (19) III 5 (

Does Intravenous Midazolam Dose Influence the Duration of Recovery Room Stay Following Outpatient Third Molar Surgery?

To evaluate the impact of intravenous midazolam dose on the duration of recovery room stay for patients undergoing outpatient third molar surgery...
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