Nursing Pharmacology Chapter 12:  Anxiolytics and Sedative-Hypnotics

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Preoperative Medication: Sedative Hypnotics and Other Agents and Issues

Benzodiazepines

  • Overview:

    • Most commonly used sedative/anxiolytic

    • Anxiolytic effectiveness is observed at dosages which do not result in cardiopulmonary depression or excessive sedation

    • Certain benzodiazepines also exhibit significant anterograde amnesia (amnesia subsequent to drug administration).  

      •  Examples of these benzodiazepines include midazolam (Versed) and lorazepam (Ativan).

      •  These agents may also cause, on predictably, some degree of retrograde amnesia as well.

    • Benzodiazepines may also be used the night before schedule surgery in management of pre-surgical insomnia-- examples include lorazepam (Ativan), temazepam (Restoril), & triazolam (Halcion)

    • Sometimes benzodiazepines used pre-surgically can result in prolonged and excessive sedation.  Patients receiving lorazepam (Ativan) at high dosages (total dose > 4 mg orally at 5 ug/kg) may be most susceptible to this excessive sedation.  

      • A benzodiazepine antagonist, flumazenil (Romazicon) may be used to reverse benzodiazepine effects.

    • Intramuscular injection of diazepam (Valium) may be painful because diazepam (Valium) is dissolved in the irritating solvent propylene glycol; intramuscular injections of midazolam (Versed) does not cause local irritation since the chemical characteristics of midazolam (Versed) do not require the use of propylene glycol as a solvent (an aqueous solvent is used).

  • Adverse Effects: benzodiazepines

    • Major adverse effects

      • Respiratory depression

      • Reduction in cognitive & motor function

    •  Inpatient considerations:

      • If cognitive function need not be immediately returned to normal following procedure, lorazepam (Ativan) (oral) may be appropriate the morning of surgery

    •  Outpatient considerations:

      • Diazepam (Valium) (oral)

      • Midazolam (Versed) (IV), particularly appropriate

    • Factors/conditions which increase likelihood of preoperative excessive sedation associated with the use of benzodiazepines and other sedative hypnotics:

      • Infancy, advanced age (elderly patients), chronic debilitating disease or malnutrition, pregnancy, renal dysfunction, hepatic dysfunction, pulmonary dysfunction, adrenal insufficiency, myasthenia gravis, myotonia, sickle cell disease, acute drug/ethanol intoxication5.

  • "The arrows point to multiple papilloma growths on the larynx caused by a viral infection. Permission to reproduce photo courtesy of the University of Pittsburgh Voice Center.

  • (Ed. note: This is a photograph that shows how laryngeal papillomatosis--RRP of the larynx--does not invariably present with a traditional cauliflower-appearance.)"

 

Papillomatosis

  • From On-Line Airway Atlas 2000, John Sherry, II, M.D 1999,2000

Epiglottis (with Abscess)

  • From On-Line Airway Atlas 2000, John Sherry, II, M.D 1999,2000

 

 

References

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