Hello Jeff and All.
Regarding your questions and comments:
"I thought that the drug had a variable effect with occasional paradoxical
excitement and the disadvantage of a prolonged action."
Not in my experience - when used with adequate dose, it works almost all of
the time. I have never seen paradoxical reaction with chloral hydrate like I
have with midazolam. The effect is not inordinately prolonged - 45 minutes to
an hour usually.
"I also thought that the absorption of rectal midazolam is very variable
producing inconsistent results with occasional paradoxical excitement."
Absorption is variable BUT there is a larger margin for error compared to
using IV route which is the reason why I use 0.5-0.7 mg/kg. When using the
rectal route, if it is put into a lump of stool - well...the little enteric
buggers are happy but there will be little effect on the patient. As we know,
one problem with midazolam is the not uncommon situation of paradoxical
"Why not use pentobarbital IM (or IV) for all cases if it is consistently
effective? Is there not a small (but significant) risk of severe
respiratory respiratory depression associated with the use of larger
doses of IM pentobarbital (5mg/kg)? When do you think that it is safer
to titrate small IV doses of pentobarbital under controlled observation
(compared to a single dose IM)? "
I use higher dose IM (5 mg/kg) when a child is agiatted or in the middle of
an awake cycle. If it is 11:30 at night, I use 2-3 mg/kg IM because a child
will want to go to sleep with a little encouragement/persuasion. IV is the
safest and most accurate route to titrate drugs which I reserve for the more
complicated or unstable patients. Who wants to put an IV in a cute, chubby 2
year old unless they have to?
<<How does pentobaribital compare to
propofol IV or methohexital IV or midazolam IV, and what dose range
would you recommend for these other agents?>>
Propofol is IV only and has the fastest onset and offset. Methohexital is
pretty darn fast. Pentobarbital is nice because you don't have to stand there
by the bedside and titrate it because its pharmacokinetics and decreased
lipid solubility allow it to have slower onset and offset IV/IM/PO. Quickest
onset on offset would be IV.
<<Also, I thought that IM midazolam was well absorbed and nearly as
consistently effective as IV midazolam - is that correct?>>
Midazolam is a drug that needs to be titrated IV for effective deep sedation.
IM midazolam is really used only for seizures and is given in high enough
doses (i.e. slam dunk doses) to assure a likely ED 50 but also puts it
closer to the LD50 (dose that would cause death in 50%). This is different
than using lower doses and titrating for procedures (higher risk/benefit
BTW - 6 year old yesterday - fell off father's shoulders 12 hours earlier, 2
episodes of vomiting and headache upon awakening, with a scalp hematoma.
Watching TV and GCS 15 but not interested in eating with minimal headache.
CT - occipital skull fracture but clean parenchyma and no bleed.
Have a good day.
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