Association between midazolam premedication and deep sedation following general anesthesia in pediatric patients: a retrospective cohort study.

PURPOSE: We examined if midazolam premedication via oral (PO) vs. intravenous (IV) route in pediatric patients was associated with risk for deep sedation in the postanesthesia care unit.

METHODS

Medical records from May 2018 to December 2023 of patients aged 2-17 years premedicated with midazolam were reviewed and stratified according to administration route. Sedation level was classified using the Richmond Agitation-Sedation Scale: deeply sedated (≤ - 4) or not (≥ - 3). Inverse probability of treatment weighting (IPTW) analysis was performed to assess whether midazolam administration route was associated with postoperative deep sedation.

RESULTS

Among 5245 pediatric patients, 608 (11.6%) experienced deep sedation. In unadjusted analyses, deep sedation occurred more frequently with PO than IV midazolam (13.7% vs. 5.3%, P < 0.001). After IPTW adjustment, this association remained significant (13.3% vs. 6.6%; OR 2.17, 95% CI 1.35-3.48; P = 0.001). The incidence of deep sedation decreased with increasing age and surgical duration. In IPTW-adjusted analyses, route-related differences were significant in patients aged 2-5 years (17.0% vs. 7.3%, P = 0.013) and 6-11 years (12.3% vs. 6.2%, P = 0.018), but not in adolescents (P = 0.632). Deep sedation rates were higher after procedures lasting ≤ 1 h (20.0% vs. 7.6%, P = 0.018), but not for longer procedures. No sedation-related adverse events were observed.

CONCLUSIONS

Oral midazolam is a key driver of postoperative deep sedation in premedicated patients aged 2-11, especially following shorter procedures likely due to limited drug elimination time. Notably, deep sedation was not linked to adverse outcomes.