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>On Feb.8, I wrote (rather late at night):
>>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.
 
and Tom Terndrup replied:
>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.
...
>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
...
>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.
_____________________________________________________________________________
 
I think that is exactly my point. Naturally a patient receiving continuous
combined benzodiazepine and opioid infusion should have pulse oximetry _in
most cases_ (particularly for acute postoperative use). I have seen very
successful and very prolonged use of high-dose combined infusion at home in
palliative care, without any monitoring.
 
The question is the risk of respiratory supression and loss of reflexes, as
you say, and I believe that is a greater risk with acute administration (by
whatever route) with rapidly changing levels of stimulation than it is in a
patient with stable pain levels on a continuous infusion. Thus, for example,
I would want pulse oximetry for the patient you referred to in your original
post (postop with painful spasms), but I would not insist on constant
attendance by a physician and V/S every 5 - 15 minutes, which would be
appropriate for sedation for a procedure.
 
There is no recipe that will guarantee safety and efficacy with a specific drug
or drug regime in all patients.
 
   /|
  /_|llen..
 /  | /~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\
    | |  G. Allen Finley MD FRCPC        <[log in to unmask]>  |
      |     Medical Director, Pain/Palliative Care Program     |
      |  IWK Children's Hospital, Halifax NS  B3J 3G9  CANADA  |
      ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~