Is fentanyl key to treating difficult-to-sedate patients?

Adding fentanyl to midazolam for conscious sedation may improve dental operating conditions for patients, specifically those who could not be sedated with a single drug in the past, according to a study published on June 7 in the British Dental Journal.

Though fentanyl may reduce the amount of midazolam needed for sedation, and patients experienced no adverse events, larger studies are needed to validate the safety of this technique, the authors wrote.

“The fentanyl-midazolam multi-drug advanced sedation technique is a useful one to have in the armamentarium of sedation techniques offered when single-drug sedation has failed or where additional pain relief is deemed beneficial for surgical procedures,” wrote co-author, Xin Hui Yeo of Bart's Health National Health Service Trust in the U.K.

Fentanyl, a synthetic opioid, provides systemic analgesia and improves the sedation of benzodiazepines, like midazolam. Though fentanyl can be used as an adjunct when midazolam-only conscious sedation fails, the combination of the two drugs requires that clinicians receive additional training. However, studies showing the safety and effectiveness of this technique are limited, according to the study.

To evaluate the advanced sedation technique of fentanyl combined with midazolam in a dental outpatient setting, the authors conducted a retrospective data collection of cases from October 2016 to October 2021. Of the 109 cases included in the evaluation, almost 91% of patients who were given fentanyl had a history of unsuccessful sedation with midazolam. Of the patients, 25 patients had special needs and 84 had dental phobia or fear, the authors wrote.

About 93% of patients who didn’t receive fentanyl recorded worse operating conditions, like more uninvited movement, anxiety, and poor cooperation. Those who received both midazolam and fentanyl showed improved cooperation, and 87% recorded better operating conditions, including full cooperation, the authors wrote.

When fentanyl was used, a lower average dose of midazolam was administered. The difference in dosage was clinically relevant and statistically significant (t [108] = 9.609; p < 0.0001), and the difference in the average dose of midazolam use with and without fentanyl was 2.95 mg with a 95% confidence interval of 2.34-3.55 mg, they wrote. Additionally, nearly 95% of patients who previously could not be sedated with benzodiazepines proceeded to have dental treatment completed successfully using the fentanyl and midazolam sedation technique, the authors wrote.

Nevertheless, a limitation of the study was its small sample size, they wrote. Therefore, larger and longer-term studies should be conducted in different dental settings to provide evidence that could support rigorous sedation regulations.

“In this evaluation, the synergistic effects of fentanyl and midazolam resulted in enhanced sedation, anxiolysis and intraoperative conditions,” Yeo and colleague Zahra Shehabi wrote.