Part 1 – Clinical Dentistry of Implants
Chapter 1- Drugs used in implant treatments
Professor of Department of Anesthesiology, School of Dental Medicine, Tsurumi University
Haruhisa Fukayama
I.

Tranquilizers

The general perception of the use of tranquilizers may be for its use in psychological disorders, but in thefield of dentistry, it is an agent that is administered as a preanesthetic or for sedative purposes, as will bementioned in this book (Refer to The Fundamentals chapter, p. 123-126 for details). Preanesthetics are
the sedative agents that are taken before inducing a general sedative to reduce the anxiety of patients,
restrain respiratory secretion, prevent adverse reflects, and also to prevent the fall in analgesia levels
and body metabolism. Anxiety and nervousness is often felt by the patient prior to surgery, therefore
administration of pharmaceutical agents that are mentioned below should be considered. It is important
to note that the effects of these agents can induce strong signs of drowsiness and dizziness – which thepatient should be informed at consultation since these are required to be taken an hour prior to surgery.
Additionally, these agents are known for their anticonvulsant effects, therefore are also administered for
hyperventilation syndromes, local anesthetic poisoning, and for epileptic fits. If administering via theintravenous route, respiratory control must be taken into account.
A. Benzodiazepines
1. Diazepam
This has been used as both via the intravenous or as preanesthetics for a long time, and is known for its
safe usage. Common brand names such as Cercine®, Horizon® are induced as intravenous sedation 0.2 to
0.4 mg/kg via the intravenous route. The downside of this is that angialgia or vasculitis (the pain or
inflammation felt in the veins from the administration of the drug) can also be induced. As
preanesthetics, 2 to 10 mg should be administered.
2. Midazolam
It is used as an intravenous sedation agent that has become increasingly administered due to its shorter
duration of action compared to diazepam. Dormicum®, 0.05 to 0.075 mg/kg is commonly administeredintravenously. The simplest method is to dilute the ampoule formulations made as 10 mg in 2ml (i.e.
5mg/ml) using distilled water for injections, or biological saline to 1mg/ml (5 time dilution) or 0.5mg/ml(10 times dilution).
3. Flunitrazepam
The duration of action is longer than that of diazepam, and is often used for a relatively long term
treatment. Doses of 0.01 to 0.015 mg/kg of Rohypnol®, or Silece® are injected gently into the veins. As
with the midazolam, it is easier to administer by dilution. Its tablet forms have been used for sleep
inducers, and if 1mg of this are often administered as preanesthetics, to reduce any anxiety, or
nervousness felt by the patients.
4. Traizolam

Halcion® is administered as a sleep inducing agent. This option is considered if sleeplessness, due toanxiety can be expected on the day before surgery.
5. Alprazolam
To ease anxiety or tension felt by the patient, with the brand name of Solanax®. Best effects can be
expected with administration of 0.4 mg (one tab) two hours before surgery.
6. Lorazepam
Conditions of anxiety can be eliminated with agents such as Wypax®, and are often used aspreanesthetics. Also prescribed for panic disorder, a dose of 1-3 mg is administered per day for thiscondition.
B. Barbiturates derivatives
There are a number of types for this group, thiopental, thiamilal (short action), pentobarbital (shortaction), amobarbital (medium action), and phenobarbital (long action) and are further divided by theirduration of action. Rapid acting, and short acting agents are applied as intravenous sedation or
intravenous analgesia in preparation for the induction of general anesthesia, and the medium, and longacting agents are used as preanesthetics or anticovulsant agents.
When administering these agents for intravenous sedation, the dose should be determined with a close
watch of patient conditions, alongside this, monitoring their blood pressure, heart rate, and respiratory
conditions are strongly recommended. In particular, any restraints can be detected readily by pulse
oxymetry, SpO2.
II. Sedatives (Table 1-1-1)
Essentially, the signal of pain is a warning sign that should not be ignored but the source of the warning
should be investigated. In implant surgery, the large source of pain is usually caused by the surgicalinvasion, therefore analgesic agents for pain control are taken in order to prevent any physiologicaleffects that could result from a large pain.
Narcotic analgesic
Sodium salicylate
Antipyretic analgesic

Salicylic acid derivative

Methyl salicylate
Acetylsalicylic acid

Anilines
Table 1-1-1 Classification of analgesics
A.

Narcotic analgesics

As morphine as a classic example, narcotics are a group of agents that are effective for pain relief. Others
include, codeine, pentazocine, fentanyl and used for various effects. However, the uses of these agentsrequire strict management, therefore are not used in implant surgery.
B.

Antipyretic analgesics

1.

Salicylic acid derivatives

Well known as the non-sterioidal anti-inflammatory drugs (NSAIDs), there are sodium salicylic acid,methyl salicylate, acetyl salicylate, and the typical uses involve agents such as aspirin, and acetyl
salicylate as ethenzamide. They also have antipyretic actions which are effective in the reduction oftemperature under high temperatures, but have no effect under normal conditions. However its analgesic
effect is less than that of the narcotics, and is not effective for visceral pains. The main side-effects include
those of the digestive tract such as nausea, vomiting, and can result in stomach ulcers.
2.

Aniline derivatives

Acetoaminophen (Calonal®) as a typical example, it has antipyretic effect, but no anti-inflammatory
actions. Contrary to NSAIDs, it has the advantage of hardly having side-effects to the digestive systems.
III. Anti-inflammatories (Table 1-1-2)
Inflammation, with pain have been regarded as physiological defense mechanism, and five symptoms,
redness, pyrexia, inflammation, swelling, and dysfunctions have been advocated from the past.
Anti-inflammatory agents are often administered to prevent these symptoms becoming extreme.
Steroidal anti-inflammatory drugs
Nonspecificanti-inflammatory
drugs

Nonsteroidal anti-inflammatory
drugs

Acidic non-steroidal anti-inflammatory drugs
Non-acidic non-steroidal anti-inflammatory
drugs

Oxygen-inflammatory drugs
Specificanti-inflammatory
drugs
Table 1-1-2 Classification of anti-inflammatory drugs
A. Non-typical anti-inflammatories
1. Steroidal anti-inflammatories
Glucocorticoids within the steroid hormone family have strong anti-inflammatory effect, andhydrocortisone, prednisolone, triamcinolone, dexamethasone are present. It is often administeredsystemically against serious allergic reactions in those with autoimmune disorders and cases ofanaphylactic shock. Triamcinolone and dexamethasone can be administered intraorally as ointments.
Although an effective agent as anti-inflammatory agents, its effectiveness can lead to serious withdrawal
symptoms such as, muscle and joint pain, nausea and vomiting, and hypotension, and side-effects suchas osteoporosis, diabetes, aggravation of infection, and stomach ulcers. Therefore a long-term
administration should be done with extreme caution.
2. Non-steroidal anti-inflammatories
NSAIDs, as mentioned above, also have analgesic and antipyretic effects, therefore are effective in thefield of dental surgery for the infectious anti-inflammatory effect, postoperative inflammatory control, forpain, and non-infectious anti-inflammatory.
a. Acidic non-steroidal anti-inflammatories

Typically used as the main substituent of aspirin, mefanamic acid, indomethacin, diclofenac sodium,ibuprofen, Loxoprofen sodium, Ampiroxicam are also included in this category. Side-effects that may
arise are, gastrointestinal effects, sensitivity, renal/ hepatic failure, blood dyscrasia or hematologic
disorder, and disorder of the central nervous system. The most common amongst these are thoseaffecting the gastrointestinal tract, which can progress onto stomach or duodenal ulcer.
b. Non-acidic non-steroidal anti-inflammatories
3.

Enzymatic anti-inflammatories

Enzymatic agents such as serratiopeptidase, pronase, lysozyme chloride, streptokinase do not haveanalgesic or antipyretic effects. However, they are applied for effects such as, vascular permeability,
restrain formation of oedema or granulation tissues, and promote mucus discharge and migration of thesite of inflammation.
B.

Typical anti-inflammatories

These involve antirheumatic drugs for chronic arthritis conditions and immunosuppressants fortreatment of gout are in this category. Therefore are not used in implant surgery.
IV. Chemotherapy (Antibacterials) (Table 1-1-3)
The term, chemotherapy are used mainly for treatment of malignant tumour, or infection. As implant
treatment does not deal with malignant tumour conditions, we will only mention the drugs for infections.
The term antibiotics used to describe any substance produced by a microorganism that was effective ininhibiting the growth of another in high dilution were included in the term, however, with the advances inmedicinal chemistry, the term antibacterial is used as a synonymous term that also encompasses
chemically synthesized materials.
The interior of oral cavity acts as an optimum environment for growth of microorganisms, therefore in
implant surgery, an intraoperative use of antibacterials are common.
There are no antibacterial agents that are effective for a whole spectrum of microbes and are specific tothe effective agents. This is called the antibacterial spectrum. Therefore it is essential to select the agents
having established the causative agents.
A.

β-lactam antibiotics

1. Penicillins
Natural penicillin was the first antibiotic that was discovered, but because of its overuse, resistances
have been developed in a significant number of organisms, therefore are no longer common.
Semi-synthetic, narrow spectrum antibiotics including methicillins and oxacillins are effective for Gram
positive bacteria, in contrast, the broad spectrum antibiotics, ampicillin, amoxicillin, bacampicillin are
effective also for Gram negative bacteria. Additionally, sulbenicillin, piperacillin, and carbenicillin are
effective against Pseudomonas aeruginosa.
2. Cephalosporins
This class is divided into four groups depending on their “generations” or period of discovery. First
generations include cephaclor and cephalexim and show effectiveness against broad spectrum ofmicroorganisms including, gram positive coccus, and Klebsiella pneumoniae. Second generation agents
such as cefaloxime and cefotiam are more effective against the gram negative bacteria than the first
generation agents. Cefoxitam and cefixime are the third generation agents, and cover a broader
spectrum of efficacy against gram negative bacteria than the second generation. The fourth generationthat involve, cefpirome and cefepime are effective against Staphylococcus aureus and P. aeruginosa on
top of the other bacteria.

Penicillin
Cefem
β - Lactam antibiotics

Carbapenem
Penem
Monobactam

Aminoglycoside antibiotic
Macrolide antibiotic
Tetracyclines
Pyridon carboxylic acidsynthetic (Quinolone) antibacterial agent
Table 1-1-4 Chemotherapy drugs (antibiotics)
3. Carbapenems, penems, monobactams
The three types, Imipenem, Panipenem, Meropenem are under carbapenems, which have a broad
spectrum of activity, against gram positive, gram negative, as well as anaerobic bacteria.
Penems show a strong activity against gram positive and negative agents, excluding P. aeruginosa.
Monobactams are effective against gram negative agents including P. aeruginosa, as well as theinfluenza viruses.
B. Aminoglycoside
Included in this group are kanamycin, amikamycin, tobramycin, gentamycin, and arbekacin. These
display activity against gram positive and negative bacteria as well as Mycobacterium tuberculosis and P.

aeruginosa. Arbekacin, amongst these, is also effective against methicillin-resistant Staphylococcus
aureus (MRSA).
C. Macrolides
This group of agents is effective against broad spectrum of microorganisms such as, gram negative
bacteria including staphylococci, or gram positives such as gonococci, spirochete, mycoplasma, rickettsia,
and chlamydia. Erythromycin, roxithromycin, chlarithromycin, telithromycin, azithromycin androkitamycin are in this group. In comparison to the other agents, the absorption from the digestinal tract
is much better, therefore are often orally administered.
D. Tetracyclines

Effective against the gram negative and positive bacteria, mycoplasma, rickttsia, chlamydia. The agentsinclude, chlortetracycline, tetracycline, methacycline, doxycycline, and minocycline. Although commonly
administered orally, it is in the form as ointments, lozenges, or as a local filling agent in some settings.
E. Synthetic pyridonecarboxylic acid (Quinolone)
These include, ciprofloxacin, ofloxacin, and levofloxacin, and are referred to as third generation newquinolone. Its use has become more common due to its low frequencies of side-effects occuring. The
agents are readily absorbed from the digestive tract, therefore are often administered as oral medicines.
If the above chemotherapeutic agents (anti-bacterials) are administered repetitively, or if theadministered dose or the administration period is insufficient, the microorganisms can gain resistanceagainst the agents, therefore reducing the pharmacological effect or become ineffective. This is referred toas ‘antibiotics resistance’, and the microorganisms, ‘antibiotic resistant bacteria’. Furthermore, if the
microorganism becomes resistant to one kind of agent, these can also be resistant to the agents of thesame types, which are referred to as cross-resistance. The resistance and cross-resistance have become amajor problem in Japan in the recent years; therefore, more careful considerations should be given in
administration of these agents.
As the main side-effects of chemotherapeutic agents, the disorder of organs including bone marrow, liver,kidneys digestive tracts, sensory organs, nervous systems, and allergies, and skin diseases are common.
In particular, the liver or kidney failures, and serious allergic reactions like anaphylaxic shock that arise
as a result of long-term administration have to be taken into consideration when choosing the agents.
V. Anticoagulants
This group can be divided into systemic and local agents. Under usual implant surgery, the local
anticoagulants are most commonly administered. Though, systemic anticoagulant can be adopted in
extremely rare cases of unexpected bleeding.
A.

Systemic anticoagulants

1.

Vitamin K

Vitamin K is involved in the synthesis of coagulation factors, and agents such as phytonadione (K1) andmenatetronone (K2) are used in case of deficiency, however, it not an emergency.
2.

Blood products

Applied in the cases of inherent shortage of coagulation factors. For example, in the case of haemophilia A,
Factor VIII preparations, or for haemophilia B, Factor IX preparations or platelet concentratepreparations are administered.
3.

Antifibrolytic agentsThe agents for this are known as anti-plasmin drugs, and the examples include, epsilon-aminoacaproic
acid, Tranexamic acid as typical agents in use.
4.

Capillary stabilizer

Adrenochrome preparations including carbazochrome, ascorbic acid (vitamin C), flavonoids are used.

B.

Local anticoagulants

1.

Thrombin

It can be applied topically for controlling bleeding from capillaries and small venules. Thrombin is one ofthe physiological coagulation factors. As it requires fibrinogen for coagulation to occur, in the patients
suffering from hypofibrinogenemia, application of this agent is ineffective.
2.

Absorbable gelatin sponge

This can absorb a large volume of blood for a physical antihemorrhagic effect by forming a mesh byeffervescence of the gelatin solution. In addition, as this activates the platelets, rapid blood coagulation
can be expected. There are no irritative, impairing or antigenic effects to the tissues, and are absorbed
within a month.
3.

Oxidized cellulose

By expansion mechanisms, the flexible and absorbable fibres act to absorb large volumes of blood. It canbe applied to the bleeding site, for an antihemorrhagic effect. It has been reported that it is absorbed
within one to three weeks, but due to its acidity, processes such as osteogenesis and wound healing can bedelayed.
4.

Astringents

Aluminum chloride preparations are effective for small scale bleeding by acting astringently in the bloodvessels.
5.

Adrenaline

It has a strong constricting effect on the peripheral blood vessels therefore are often included in the local
anesthetics as antihemorrhagic, or to stop bleeding in a large area, the diluted solution is used to soak thegauze for application.
Vitamin K
Systemic hemostatic agent

Blood products
Antifibrolytic agent
Capillary stabilizer
Thrombin
Gelatin sponge

Local hemostatic agent

Oxycellulose
Astringent drug
Adrenalin

Table 1-1-4 Haemostatic agents
VI. Mouthwash
A. Fluoride rinsing agent
Either rinse once a day with 0.05% sodium fluoride solution, or once a week or once every two weeks witha 0.2% solution for prevention of tooth decay.
B. Azulene sodium sulfonate, povidone iodine, benzethonium chloride

Used for all types of stomatitis. Consider diluting the agent if any symptom of pain arises.
VII.

Local anesthetics

Local anesthesia is imperative for implant treatment. As mentioned previously, a number of local
anesthetics contain adrenaline or felypressin as vasoconstricting agents, therefore it should be noted of
the systemic effect of these agents.
A. Surface anesthetics
1.

LidocaineThis is a commonly administered amide local anesthetics in the field of dentistry. As the surface
anesthetics agents are supplied in the forms of jelly (2%), viscous (2%), or as spray (8%). Although there
are no applications to the oral cavity, tapes that contain 60% lidocaine are also formulated. These are alladministered to relive the pain from injecting infiltration or conduction anesthesia.
2.

Benzocaine (ethylamino benzoate)This agent is used as 5 to 10 % formulation for surface anesthetics due to its low water solubility.
3.

Tetracaine

A small sponge is soaked in the 6% solution, and surface anesthesia is expected when applied to themucosal membrane.
B. Infiltration, conduction anesthesia
1.

LidocaineThis is the standard amide local anesthetics. As infiltration and conduction anesthesia, typically, 2%
lidocaine solution, with roughly 1/80,000 adrenaline as an adjunct for vasoconstriction is used. Widely
applied in the field of dentistry for its rapid infiltration, it is supplied as a glass tube that is referred to as
cartilage, to enable application with high pressure. Lidocaine inhibits irritatability to the myocardium,
therefore are also used as antiarrhythmic agent.
2.

Prilocaine (propitocaine)This has low lipid-solubility therefore is an amide anesthesia that has less or equal efficacy as lidocaine,
but are slower onset of action. 3% concentration solution is often used. However, its toxicity is lower thanlidocaine, and does not have problems of accumulation. Dosages of over 600 mg can induce
methohemoglobinemia (a condition in which the haemoglobins are converted into methohaemoglobinsthat has inferior oxygen carrying abilities). Typically, the cartilage formulations containing felypressin as
adjuct vasoconstrictors are distributed.
3.

Mepivacaine

This has similar anesthesic effect, onset time, and duration of action to lidocaine. However, in contrast to
the vasodilatation action of lidocaine, it has a slight vasoconstriction effect, dental cartilages without thevasoconmstrictor adjuncts are in supply. With no systemic vasoconstricting effect and no additives, it isregarded as a safe agent with that is suitable for induction to a low scale treatment where a rapid
infiltration is required.
VIII.

Disinfectants(Table 1-1-5)

A. Oxidizing agent
Both Oxydol (3% hydrogen peroxide containing solution) and potassium permanganate (0.2 to 1%
solution) act as mechanical cleaner or disinfectants by the generation of oxygen bubbles.
B. Halogen containing compounds
1. Chlorine, chloride compounds
Sodium hypochlorite are effective against bacteria, P. aeruginosa, fungi, and viruses, and areadministered as 0.01 to 0.5% disinfectant to the fingers, skin and in the surgical areas, and as 3 to 10%
for treatment of root canal (dental antiformin, hypochlorite, Neocleaner). In addition to the antibacterial
action, the sodium hydroxide can dissolve the tissues, therefore special care must be taken to inhibit any
leaking out of the root canal.
There are two forms for chlorhexidins, chlorhexidine chloride, and chlorhexidine gluconate that are
effective against gram positive and negative, but have no activity against bacterial spores or viruses.
Chlorhexidine chloride, often in the form of lozenges, are used to prevent infection of intraoral wounds.
Meanwhile, the chlorhexidine gluconate are often used as 0.1 to 0.5% concentrations for disinfection of
fingers, skin, surgical areas, and disinfectants of apparatuses. 1% solutions had frequently been usedpreviously, however due to reports of shock symptoms when applied to the mucosal membrane, the usesof higher concentrations have been forbidden.
2. Iodine, iodide compounds
There are: iodine tincture, iodine glycerin, iodine iodoform, povidone iodine as the different forms.
Ethanol （Ethyl alcohol)

Alcohols

Isopropyl alcohol (Isopropanol)
Formaldehyde

Aldehydes

Paraformaldehyde
Glutaraldehyde (Glutaral)
PhenolPhenolCresolParachlorophenol
Cationicsurfactants

Surfactant(Surface-active agent)

Anionic surfactants
Amphoteric surfactants
Nonionic surfactant

Organic dye

Acrinol
Methylrosanilinium chloride

Table 1-1-5 Disinfectants
C. Alcohols
There are ethanol (ethyl alcohol) and isopropyl alcohol (isopropanol) which are effective for Gram positive
and negative bacteria and HIV, but not for spores and virus. 70% ethanol or 50 to 70% isopropyl solutions

are used to disinfect the finger tips, skin, surgical area, and medical apparatus.
D. Aldehydes
There are formaldehyde, paraformaldehyde and glutaraldehyde (glutaral), which have bacteriocidal
activity whereby the proteins of the microorganisms are denatured. Formaldehyde has a strong stimulant
action, therefore are included in the formulations for the drugs used in disinfection of the root canal, pulp
capping, and root canal obturation. When paraformaldehyde is applied onto the dental pulp, it can
produce aldehyde gas, therefore require a disinfection that is continuous and one that is highly permeable.
Glutaraldehyde is effective for spores, virus, and fungi, but due to its irritating nature on the skin, its
application to the biological body is avoided. Instead, these are used to sterilize the apparatus. It shows
effectiveness especially for those suspected of being infected with Hepatits B virus or HIV.
E. Phenols
There are phenol, cresol, para-chlorophenol under this group. Due to its irritative nature, phenols are nolonger used as the disinfectant on the finger tips, and skin, but are used in combination with volatile oil(camphor) for the disinfection of the cavity, root canal or as analgesics, sedation of the dental pulp. Cresol
is used as formocresol in a formulation with liquid soap, or with formalin for the disinfecting agent of thefinger tips and skin, or for root canal, respectively. para-chlorophenol is used in a formulation with
camphor for infected root canal.
F.

Surfactants

There are cationic, anionic, or non-ionic surfactant types. Cationic agents include general soap anddetergents, with its strength to lie in the washing power, with no effectiveness as a disinfecting agent. On
the contrary, the anionic agents, also known as invert soap, where washing power is weak, but with ahigh disinfecting strength. It is particularly effective for Gram positive and Gram negative bacteria.
These are not irritating to the biological body, with no metallic corroding properties, therefore are applied
to the finger tips and apparatus as disinfection agents. Benzalkonium chloride or benzethonium chloride
is applied as 0.05 to 0.1 % disinfectant solution to the finger tips and skin, or as 0.01 to 0.025%
disinfectant solution to the wounds.
G. Organic dyes
There are acrinol and methylrosanilinium chloride. Acrinol displays efficacy for streptococci, andstaphylococci but are inactive against spores and virus. This is applied as a 0.02 to 0.2 % solution for thedisinfection of the skin and mucosa of the wounded region or festering wounds. The latter agent displays
bacteriocidal activity against Gram positive bacteria with 0.1 to 0.2 % solution.
IX. Emergency medicines
Among the patients undergoing implant treatment, there are elderly or have concomitant systemic
diseases. During the invasive implant surgery, these patients are predisposed with the unforeseen
circumstances therefore are required to act promptly with a suitable solution to the problem. In otherwords, in the case of an emergency treatment, an accurate diagnosis, and timely treatment are necessary.

The administrations of the pharmaceutical agents below should also be considered. As these drugs aremostly administered via the intravenous route, practices of securing a vein are desired.
A. Atropine sulphate
It is a parasympathetic neuroleptic agent, and show efficacy for bradycardia and decreased bloodpressure. The common abnormal condition arising in dental treatments including implant surgery is theneurogenic shock. This is thought to be due to the tensing of the parasympathetic nerves, therefore theadministration of this agent is apt for the prevention of this condition. 0.5 mg of this is administered,intravenously, and increased as required.
B. Adrenaline
This is a classic sympathomimetic agent that show higher efficacy for the substantial decrease in bloodpressure, or anaphylactic shock. The 1mg/ml ampule is diluted ten times, then 0.1 mg (i.e. 1 ml) is
gradually administered intravenously. The hypodermic injection of 0.3 mg is effective against
anaphylactic shock. A pre-filled syringe that can readily be used for anaphylactic shock can be purchased.
C. Tranquilizers
Diazepam or midazolam are infused, intravenously as a psycho-sedation for cases of hyperventilation
syndrome. The benzodiazepams also show effectiveness for convulsion which is a toxicity symptom fromlocal anesthetics. The overdose can lead to respiratory suppression and arrest therefore care must be
taken when administering.
D. Calcium channel blocker
As antihypertensive drugs, Nicardipine hydrochloride and nifedipine, which are effective for emergency
procedures, are adopted for the abrupt rise in blood pressure during the treatment. Principally, it isadministered via intravenous route, but orally formulated nifedipine for internal use can be administered
via the sublingual route. The overdose can cause abrupt decrease in blood pressure overdose, therefore
care must be taken at the time of administration.
E. Nitrous acid
Used as a coronary vasodilator. It can be applied by the intravenous infusion for the acute exacerbation ofischemic heart disease, or by appending a patch containing active ingredients to the chest.
X. Others
A. Propofol
It is applied widely as an intravenous anesthesic agent, it is also used in implant surgery as an
intravenous sedation methods. Amongst the intravenous sedatives, it has the advantage of being simple
to manipulate the doses due to its fast induction, and prompt awakening. It is often induced via infusion
pumps or syringe pumps. The introducing dose is 0.3 to 1 mg/kg which is rapidly administered, and thenthe maintenance dose for sedation is infused at the rate of 2 to 3 mg/kg/h. A rapid administration cancause vascular pain (angialgia). Due to the drug property, the overdose can lead to respiratorysuppression or arrest, and decreased blood pressure, particularly in the elderly, therefore monitoring thepatient’s respiration and circulation is essential if used. In addition, oxygen pumps should be prepared forprompt inhalation.

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