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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by SandyWeb on May 7, 2007, at 21:19:06
Hi all. I just had some dental extractions done myself today, but it was just an out-patient situation where I needed a driver to take me home.
I have a question: I was given IV of both Fentanyl (15 ml) and Versed (200 ml). The oral surgeon had to keep checking on me to see if the Versed was working, and it wasn't. So then he increased it to 200 ml. I was still conscious, but was told to close my eyes. It only hurt about 3 times during the surgery, but they kept telling me I was doing real good when I'd start to groan.
Anyways, afterwards he told the nurse Recovery Room nurse to log the 15 ml and the 200 ml. She looked up at him and said in a shocked voice, "200?!". And he shook his head up and down with an amazed look on his face. Was that dose way off the charts? I had told him that I had an anxiety disorder, but maybe he didn't realize that I'd need an inordinate amount of Versed?? I really don't know. Does anyone know the usual dose? It was only a surgery that lasted half an hour.
God bless,
Sandy
Posted by Phillipa on May 7, 2007, at 21:35:22
In reply to Fentanyl AND Versed, posted by SandyWeb on May 7, 2007, at 21:19:06
Sandy wow 5mg of versed puts me in la la land and I also have an anxiety disorder. I'm going to google the dose range as this seems way to high. Thankfully you're still with us. Love Phillipa
Posted by Phillipa on May 7, 2007, at 21:45:15
In reply to Re: Fentanyl AND Versed » SandyWeb, posted by Phillipa on May 7, 2007, at 21:35:22
Sandy here is part of an article on the versed. Love Phillipa
Intravenously
Sedation/anxiolysis/amnesia for procedures (See INDICATIONS AND USAGE): Narcotic premedication results in less variability in patient response and a reduction in dosage of midazolam. For peroral procedures, the use of an appropriate topical anesthetic is recommended. For bronchoscopic procedures, the use of narcotic premedication is recommended.
Midazolam HCl 1 mg/mL formulation is recommended for sedation/anxiolysis/amnesia for procedures to facilitate slower injection. Both the 1 mg/mL and the 5 mg/mL formulations may be diluted with 0.9% sodium chloride or 5% dextrose in water. When used for sedation/anxiolysis/amnesia for a procedure, dosage must be individualized and titrated. Midazolam should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. Individual response will vary with age, physical status and concomitant medications, but may also vary independent of these factors. (See WARNINGS concerning cardiac/respiratory arrest/airway obstruction/hypoventilation.)
1. Healthy Adults Below the Age of 60: Titrate slowly to the desired effect, e.g., the initiation of slurred speech. Some patients may respond to as little as 1 mg. No more than 2.5 mg should be given over a period of at least 2 minutes. Wait an additional 2 or more minutes to fully evaluate the sedative effect. If further titration is necessary, continue to titrate, using small increments, to the appropriate level of sedation. Wait an additional 2 or more minutes after each increment to fully evaluate the sedative effect. A total dose greater than 5 mg is not usually necessary to reach the desired endpoint.
If narcotic premedication or other CNS depressants are used, patients will require approximately 30% less midazolam than unpremedicated patients.
2. Patients Age 60 or Older, and Debilitated or Chronically Ill Patients: Because the danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients and those with chronic disease states or decreased pulmonary reserve, and because the peak effect may take longer in these patients, increments should be smaller and the rate of injection slower.
Titrate slowly to the desired effect, e.g., the initiation of slurred speech. Some patients may respond to as little as 1 mg. No more than 1.5 mg should be given over a period of no less than 2 minutes. Wait an additional 2 or more minutes to fully evaluate the sedative effect. If additional titration is necessary, it should be given at a rate of no more than 1 mg over a period of 2 minutes, waiting an additional 2 or more minutes each time to fully evaluate the sedative effect. Total doses greater than 3.5 mg are not usually necessary.
If concomitant CNS depressant premedications are used in these patients, they will require at least 50% less midazolam than healthy young unpremedicated patients.
3. Maintenance Dose: Additional doses to maintain the desired level of sedation may be given in increments of 25% of the dose used to first reach the sedative endpoint, but again only by slow titration, especially in the elderly and chronically ill or debilitated patient. These additional doses should be given only after a thorough clinical evaluation clearly indicates the need for additional sedation.
Induction of Anesthesia: For induction of general anesthesia, before administration of other anesthetic agents.
Individual response to the drug is variable, particularly when a narcotic premedication is not used. The dosage should be titrated to the desired effect according to the patients age and clinical status.
When midazolam is used before other intravenous agents for induction of anesthesia, the initial dose of each agent may be significantly reduced, at times to as low as 25% of the usual initial dose of the individual agents.
Unpremedicated Patients
In the absence of premedication, an average adult under the age of 55 years will usually require an initial dose of 0.3 to 0.35 mg/kg for induction, administered over 20 to 30 seconds and allowing 2 minutes for effect. If needed to complete induction, increments of approximately 25% of the patient's initial dose may be used; induction may instead be completed with inhalational anesthetics. In resistant cases, up to 0.6 mg/kg total dose may be used for induction, but such larger doses may prolong recovery.
Unpremedicated patients over the age of 55 years usually require less midazolam for induction; an initial dose of 0.3 mg/kg is recommended. Unpremedicated patients with severe systemic disease or other debilitation usually require less midazolam for induction. An initial dose of 0.2 to 0.25 mg/kg will usually suffice; in some cases, as little as 0.15 mg/kg may suffice.
Premedicated Patients
When the patient has received sedative or narcotic premedication, particularly narcotic premedication, the range of recommended doses is 0.15 to 0.35 mg/kg.
In average adults below the age of 55 years, a dose of 0.25 mg/kg, administered over 20 to 30 seconds and allowing 2 minutes for effect, will usually suffice.
The initial dose of 0.2 mg/kg is recommended for good risk (ASA I & II) surgical patients over the age of 55 years.
In some patients with severe systemic disease or debilitation, as little as 0.15 mg/kg may suffice.
Narcotic premedication frequently used during clinical trials included fentanyl (1.5 to 2 mcg/kg IV, administered 5 minutes before induction), morphine (dosage individualized, up to 0.15 mg/kg IM), and meperidine (dosage individualized, up to 1 mg/kg IM). Sedative premedications were hydroxyzine pamoate (100 mg orally) and sodium secobarbital (200 mg orally). Except for intravenous fentanyl, administered 5 minutes before induction, all other premedications should be administered approximately 1 hour prior to the time anticipated for midazolam induction.
Injectable midazolam HCl can also be used during maintenance of anesthesia, for surgical procedures, as a component of balanced anesthesia. Effective narcotic premedication is especially recommended in such cases. Incremental injections of approximately 25% of the induction dose should be given in response to signs of lightening of anesthesia and repeated as necessary.
Continuous Infusion
For continuous infusion, midazolam 5 mg/mL formulation is recommended diluted to a concentration of 0.5 mg/mL with 0.9% sodium chloride or 5% dextrose in water.
Usual Adult Dose
If a loading dose is necessary to rapidly initiate sedation, 0.01 to 0.05 mg/kg (approximately 0.5 to 4 mg for a typical adult) may be given slowly or infused over several minutes. This dose may be repeated at 10 to 15 minute intervals until adequate sedation is achieved. For maintenance of sedation, the usual initial infusion rate is 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr). Higher loading or maintenance infusion rates may occasionally be required in some patients.
The lowest recommended doses should be used in patients with residual effects from anesthetic drugs, or in those concurrently receiving other sedatives or opioids.
Individual response to midazolam is variable. The infusion rate should be titrated to the desired level of sedation, taking into account the patient's age, clinical status and current medications. In general, midazolam should be infused at the lowest rate that produces the desired level of sedation. Assessment of sedation should be performed at regular intervals and the midazolam infusion rate adjusted up or down by 25% to 50% of the initial infusion rate so as to assure adequate titration of sedation level. Larger adjustments or even a small incremental dose may be necessary if rapid changes in the level of sedation are indicated. In addition, the infusion rate should be decreased by 10% to 25% every few hours to find the minimum effective infusion rate. Finding the minimum effective infusion rate decreases the potential accumulation of midazolam and provides for the most rapid recovery once the infusion is terminated. Patients who exhibit agitation, hypertension or tachycardia in response to noxious stimulation, but who are otherwise adequately sedated, may benefit from concurrent administration of an opioid analgesic. Addition of an opioid will generally reduce the minimum effective midazolam infusion rate.
Pediatric Patients
UNLIKE ADULT PATIENTS, PEDIATRIC PATIENTS GENERALLY RECEIVE INCREMENTS OF MIDAZOLAM ON A MG/KG BASIS. As a group, pediatric patients generally require higher dosages of midazolam (mg/kg) than do adults. Younger (less than six years) pediatric patients may require higher dosages (mg/kg) than older pediatric patients and may require close monitoring (see tables below). In obese PEDIATRIC PATIENTS, the dose should be calculated based on ideal body weight. When midazolam is given in conjunction with opioids or other sedatives, the potential for respiratory depression, airway obstruction or hypoventilation is increased. For appropriate patient monitoring, see BOX WARNING, WARNINGS, Monitoring subsection of DOSAGE AND ADMINISTRATION. The health care practitioner who uses this medication in pediatric patients should be aware of and follow accepted professional guidelines for pediatric sedation appropriate to their situation.
OBSERVER'S ASSESSMENT OF ALERTNESS/SEDATION (OAA/S)
Assessment Categories
Responsiveness Speech Facial Expression Eyes Composite Score
Responds readily to name spoken in normal tone normal normal clear; no ptosis 5 (alert)
Lethargic response to name spoken in normal tone mild slowing or thickening mild relaxation glazed or mild ptosis (less than half the eye) 4
Responds only after name is called loudly and/or repeatedly slurring or prominent slowing marked relaxation (slack jaw) glazed and marked ptosis (half the eye or more) 3
Responds only after mild prodding or shaking few recognizable words 2
Does not respond to mild prodding or shaking 1 (deep sleep)
Posted by Phillipa on May 7, 2007, at 21:52:36
In reply to Re: Fentanyl AND Versed, posted by Phillipa on May 7, 2007, at 21:45:15
Sandy sorry about the pediatric doses and the wide gaps just learning to do this type of posting. And I thought I had a high tolerance!!!!!Love Phillipa
Posted by Quintal on May 7, 2007, at 22:17:45
In reply to Fentanyl AND Versed, posted by SandyWeb on May 7, 2007, at 21:19:06
It seems unlikely you got 200mg Versed, much more probable was that you got 200*micrograms* of Fentanyl and 15mg midazolam?
--------------------------------------------------
>Endoscopy: 3-5 mg (rarely 10mg) IV, often paired with short acting opioids in moderate dosage. For example, 50mg pethidine or equivalent dosage of fentanyl (50-200 micrograms).
http://en.wikipedia.org/wiki/Versed
-------------------------------------------------->Anyways, afterwards he told the nurse Recovery Room nurse to log the 15 ml and the 200 ml.
When they're measured in millilitres you only have the unit volume, not the concentration of the solution so it's impossible to say for sure how many mg/micrograms of each drug you actually got.
Q
Posted by Phillipa on May 7, 2007, at 22:46:28
In reply to Re: Fentanyl AND Versed » SandyWeb, posted by Quintal on May 7, 2007, at 22:17:45
Q so why was the doc shaking his head? Love Phillipa ps I would ask for a copy of the record as it's a patient's right to have a copy.
Posted by SandyWeb on May 8, 2007, at 9:39:22
In reply to Re: Fentanyl AND Versed » Quintal, posted by Phillipa on May 7, 2007, at 22:46:28
Hi guys,
No, the 200 was actually for Versed because he had a student with him and told him it was Versed, and then wanted the student to tell him what type of med it was and it's method of action. Eeks....students didn't know and was told to come back and tell him the next day. Lol. Same as for the Fentanyl...told the student what it was and stated it was a narcotic...what was its method of action? Again, 3rd year student didn't know. Eeks!
After the dose of Versed, they all left me by myself in the room to get sleepy. Well, I didn't. I was looking at my x-ray, all the lovely instruments, twiddling my thumbs basically. The door was open, and they kept walking back and forth every few minutes to check on me. Finally they all came in at once and started setting up (oxygen for my nose, etc). I said, "Wait! Don't start anything yet. I'm not sedated!" And the oral surgeon said, "oh no, we wouldn't do that." Then he injected quite a full syringe into my IV, and I still wasn't sleepy but they kept getting prepared. Then the nurse closed my eyes, and in went the freezing. I was conscious the whole time, but it wasn't that bad...except for three times when it hurt kind-of bad....which I let them know. When he said it was done, I opened my eyes right up, was walked over to recovery, and probably only stayed for about 15 minutes or so because I was fully alert (other than a little dizzy).
I said "ml" in my message because I was just thinking liquids was millilitres. But it WAS 15 of Fentaanyl and 200 of Versed (which shocked BOTH the surgeon and the nurse. I asked if that was a lot, and he shook his head "yes" as he left the room).
Anyways, that's my story. I had told him beforehand that I had an anxiety disorder, but maybe he didn't realize how bad it was until the normal doses weren't working! Lol.
God bless,
Sandy
Posted by SandyWeb on May 8, 2007, at 11:08:38
In reply to Re: Fentanyl AND Versed, posted by Phillipa on May 7, 2007, at 21:45:15
Posted by SandyWeb on May 8, 2007, at 11:34:09
In reply to Re: Fentanyl AND Versed » SandyWeb, posted by Quintal on May 7, 2007, at 22:17:45
I don't know how much this helps, but the lethal dose (50%) orally (not IV) in animals is 825 mg per kg.
Plus there's another type IV drug to counter an OD of IV Versed, so I'm sure they were ready with that. At least I HOPE so.....unless they left that up to the student!! Eeks! Lol.
God bless,
Sandy
Posted by Quintal on May 8, 2007, at 12:12:37
In reply to Re: Fentanyl AND Versed » Quintal, posted by Phillipa on May 7, 2007, at 22:46:28
I don't know why the doc was shaking his head, I wasn't there. But in any case even 15mg of Versed is still a huge dose when combined with 200micrograms of fentanyl. It's entirely possible they were both surprised by those doses Sandy needed.
Q
Posted by Quintal on May 8, 2007, at 12:24:48
In reply to Re: Fentanyl AND Versed, posted by SandyWeb on May 8, 2007, at 9:39:22
Hi Sandy,
I still think it's most likely the 200ml (assuming it was a 1 microgram/ml solution) was of fentanyl. That's within the recommended dosage range for that drug. 15mg of Versed is still extremely high, half again the normal maximum used in this procedure, but much closer to the usual dose range than 200mg.
15 micrograms of fentanyl would be well below the minimum dose used in surgical procedures and it doesn't really make sense that they'd give you 20 times the maximum dose of Versed while giving you a subtherapeutic dose of fentanyl. I'm not being rude, but it would be entirely normal for your recall to be muddled about events that happened while under the influence of Versed. Is this not a more likely scenario?
Q
Posted by madeline on May 8, 2007, at 12:46:48
In reply to Re: Fentanyl AND Versed, posted by SandyWeb on May 8, 2007, at 9:39:22
Well, I don't know what dose you actually ended up getting, but if they said it was a lot, then it probably was.
However, a lot of things can influence how you react and metabolize narcotics & benzos, including whether or not you have taken them before, if you drink alcohol, or in what mental state you went into the procedure.
I wouldn't worry too much about how much it took to get you sedated, just that they were finally able to moderately do so.
maddie
Posted by SandyWeb on May 8, 2007, at 19:32:27
In reply to Re: Fentanyl AND Versed » SandyWeb, posted by Quintal on May 8, 2007, at 12:24:48
Well, I can't say which was which definately, but all I know is that the dose of 200 shocked the nurse and gave an amazed expression to the surgeon's face....along with telling me that it was a lot. But I think the narcotic (fentanyl) was the first one given at 15 simply because it took so long to get me sedated that the narcotic effects started running out and I was getting more pain as they kept working in my mouth. They also gave me oxygen, so maybe that was because of so much sedative??
Anyways, the 200 dose was the shocker to the professionals. It was one of the two. Lol.
God bless,
Sandy
Posted by SandyWeb on May 8, 2007, at 19:36:50
In reply to Re: Fentanyl AND Versed » SandyWeb, posted by madeline on May 8, 2007, at 12:46:48
I regularly take clonazepam, but I had that in my records and they knew it. I don't drink alcohol. And my state of mind was, "Let's just get this over with." Lol. I've had teeth pulled before, and I just wanted to get sedated and get on with the healing. I wasn't anxious until they all piled back into the room, ready to start, and I wasn't sedated yet!! Lol. But then the doc gave me a mega dose, the nurse closed my eyes, they froze my mouth, and I was relaxed enough to let them begin....although it HURT at times, but I think that was because the narcotic was running out because they had to waste so much time waiting on me. Oh well. It's all over now. And no problems. Yeah!
God bless,
Sandy
This is the end of the thread.
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