In short - yes, lots of references (can supply if you like, by private
e-mail).
However, it carries few advantages over oral - works in 5-10 rather than
10-15 minutes, but burns a bit in the nose.
As far as giving in GP surgery is concerned, the problem with midazolam is
the highly variable individual response.
This means it does nothing for some patients, and makes others quite flat -
especially if you tried giving a second dose because the first didn't seem
enough. On top of that, some kids just go a bit bananas (opposite reaction
from that desired!), so it's really quite unpredictable.
Safety-wise, it's dangerous to assume it's innocuous just because it's not
IV. Therefore you need full paeds resuscitation facilities available (and
pulse oximeter), and need to be happy with your own expertise in paeds
resuscitation and that of your nurse, to provide one-to-one observation for
half an hour or so.
So the practicalities of all this in a busy GP surgery are likely to
significantly dampen your enthusiasm for a solution to the difficult
problem of doing procedures on anxious children. I wish there was an easy
answer.
And us doctors are quick to jump at pharmacological solutions, when a bit
of patience, reassurance and explanation (along with a supportive nurse) go
a long way!
Ketamine is more airway-protective than midazolam, but the practicalities
remain the same.
Sorry if all that sounds a bit negative - the same applies to many A&E's,
not just GP surgeries.
Ffion Davies
Consultant A&E/paeds A&E
Royal London
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