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On Feb.8, G. Allen Finley wrote:
Maintenance infusions of midazolam with epidural or intravenous analgesics
have specific problems and concerns, but they are NOT THE SAME as the bolus
use of respiratory depressant drug combinations for acute sedation. The
AAP sedation guidelines were never intended to cover postoperative pain
management and should not be interpreted as condemnation or support of such
practices.
 
At least one anesthesiologist and the JCAHO appear to disagree with your
view (Cote, see Pediatrics 94;281,1994).  While it is true that there
are differences between maintenance infusions and i.v. boluses given for
certain procedures, serious complications from either method may occur.
 
Quoting the JCAHO:
 
        "patients with the same health status and condition receive a comparable level of quality of surgical and anesthesia care throughout the hospital"
 
and     "when any patient, in any setting, received for any purpose, by any
route... sedation (with or without analgesia)for which there is reasonable
expectation that in the manner used, the sedation/analgesia will result in
the loss of protective reflexes..."
 
If AAP guidelines were not intended to apply to infusions of benzodiazepines
or opioids in children, why are some practitioners interpreting non-paren-
teral administration as included under these guidelines?  Are you proposing
that children receiving, say 0.5 mg/kg of oral midazolam, would require
continuous pulse oximetry and not children receiving continuous infusions
of the same agent?
 
To me, the issue is not where or who is administering the sedative, but
the likelihood of loss of protective reflexes - given the clinical condition
of the patient, the medication, dosage, and route of administration.
 
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Thomas E. Terndrup, M.D., F.A.C.E.P.
Department of Emergency Medicine
S.U.N.Y. Health Science Center at Syracuse
750 E. Adams St.
Syracuse, N.Y.  13210
/Fax# (315) 464-6229     /E-mail [log in to unmask]
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