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Paradoxical reactions in children associated with midazolam use during endoscopy
M Massanari1, J Novitsky, L J Reinstein
1Department of Pediatrics, College of Medicine, University of South Florida, USA.
Insights
Paradoxical behavioral reactions occurred in 1.4% of pediatric patients receiving midazolam and meperidine during endoscopy. Prompt flumazenil administration effectively resolved these adverse events.
Area of Science:
- Pediatric Anesthesiology
- Clinical Pharmacology
- Behavioral Medicine
Background:
- Midazolam and meperidine are commonly used sedatives for pediatric endoscopic procedures.
- Paradoxical behavioral reactions are a potential adverse effect of sedative medications.
- Monitoring for behavioral changes is crucial in pediatric sedation.
Purpose of the Study:
- To investigate the incidence and characteristics of paradoxical behavioral reactions in children receiving midazolam and meperidine.
- To evaluate the efficacy of flumazenil in managing these reactions.
- To assess the role of meperidine alone in causing similar reactions.
Main Methods:
- A retrospective analysis of 2,617 children undergoing endoscopic procedures with midazolam and meperidine.
- Systematic monitoring for adverse behavioral events post-administration.
- Documentation of reaction onset, symptoms, and response to flumazenil treatment.
- Comparison of outcomes in patients receiving only meperidine.
Main Results:
- Thirty-six children (1.4%) experienced paradoxical reactions, including inconsolable crying, combativeness, and agitation.
- Reactions typically occurred within 17 minutes of midazolam administration.
- Flumazenil treatment resolved reactions within a mean of 14 minutes.
- No similar reactions were observed in three patients who received only meperidine.
Conclusions:
- Paradoxical behavioral reactions are an uncommon but significant adverse event associated with midazolam and meperidine in pediatric endoscopy.
- Flumazenil is an effective antidote for these reactions, rapidly reversing symptoms.
- The findings suggest midazolam is a primary contributor to these specific behavioral reactions.
Abstract:
All 2,617 children who received midazolam and meperidine for a variety of endoscopic procedures were monitored for the development of adverse behavioral problems. Thirty-six (1.4%) of the children (ages 1-17 years) experienced a paradoxical behavioral reaction, which consisted of inconsolable crying, combativeness, disorientation, dysphoria, tachycardia, agitation, and restlessness. The reaction occurred at a mean of 17 minutes after the administration of midazolam. Following treatment with flumazenil, the reaction dissipated within a mean of 14 minutes. Three of the 36 patients underwent additional endoscopic procedures utilizing only meperidine. No similar reaction was observed in these patients. Awareness of the reaction and prompt administration of flumazenil decreased the duration of the reaction.