4.12.1 Intravenous agents
There are many intravenous agents available in the BNF, but for dental purposes the
practical choice is between midazolam, a benzodiazepine that is water soluble and
well tolerated by tissues (important if some midazolam inadvertently becomes
deposited outside rather than inside a vein) and propofol, which leads to rapid
sedation and rapid recovery. Unfortunately, the risk of unintended loss of
consciousness is high with propofol because of the narrow therapeutic range of the
drug that leads quickly to anaesthesia. Therefore, propofol is used only when there is
an anaesthetist present.
4.12.2 Equipment for intravenous sedation
The general surgery set up is the same as for inhalation sedation. A disposable tray
should be prepared with the following:
(1) a 5 ml syringe;
(2) a venflon;
(3) adhesive tape;
(4) a green needle gauge 21;
(5) isopropyl alcohol swab;
(6) a single ampoule of the intravenous sedation drug;
(7) an ampoule of flumazenil (for urgent reversal of benzodiazepine sedation);
(8) a tourniquet.
The technique can be carried out as shown in the following sections.
4.12.3 Intravenous technique
The standard regimen is to use 0.07 mg/kg of midazolam infused slowly until the
signs of satisfactory sedation are reached. This usually entails a loading dose of 2 mg
followed by further increments as appropriate.
The technique requires the insertion of a venflon that is allowed to remain in situ until
the treatment for that visit is complete. This applies to manual infusion by the dental
surgeon, diffusion pump infusion supervised by the dental surgeon, and patient
controlled anaesthesia (PCA). For anxious children this is an almost insuperable
problem as 'the needle' is the cause of their fear. Nevertheless, there appears to be a
group of older children, usually adolescents requiring dento-alveolar surgery, who are
willing to allow the placement of a needle in the dorsum of the hand or the antecubital
fossa for infusion of benzodiazepine drugs.
Intravenous access
The two most common sites of access are the antecubital fossa and the dorsum of the
hand. In children especially, the antecubital fossa carries with it the danger of the
needle causing damage to the vein and surrounding structures if the arm is bent during
sedation. For this reason the dorsum of the hand is the preferred site.
Procedure