29
FANTASIES DURING SEDATION WITH INTRAVENOUS MIDAZOLAM OR DIAZEPAM JWDUNDEE Emeritus Professor of Anaesthetics, The Queen's University of Belfast Summary
Details are reportedof 41 incidents wherewomenreportedfantasies duringsedation withIV midazolamor diazepam: 27 of them had some sexualelementand 20 were unpleasant experiences. The events occurred in a logical sequence and all were certainof their authenticity. Someled to litigationagainstthe sedationist.Outof25 verifiedreports madeby patientsof incidentsoccurring during sedation, 17did not happenand in 9/13 clear descriptionsthere was some relation between the fantasy and something that reallyhappenedunder sedation.Alloccurredwithwhatare now considered largedosesofthedrugs. Duringor following sedation ladypatients should not be treated or examined withoutthe presence of a responsiblethird person. The use of the injectablebenzodiazepines,diazepamand more recentlymidazolaw, with their sedative, amnesic and relaxing properties have made unpleasant operativeprocedures, particularly those usuallycarried out under local analgesia, more acceptable to many patients. These include oral endoscopy and dental procedures and operations under spinal or epidural analgesia. These drugs also provide good sedationduring ventilatory support and in the intensive care unit. Overalongperiodoftimethesebenzodiazepines haveprovento be, inappropriate doses, among the safest in medicine for short term use. There have however been a fewcasesof whatcanbest be describedas "fantasies" occurringduring sedation: eventsoccuring in a logical sequencewhich are very real to the patient and yet, on the evidenceof two or more independentwitnesses, did not occur. Many of these have had an element of sexual trespass. The subjectaroused interest in December 1984when a dentist was found guilty of sexually assaulting two patients when they were sedated with intravenous benzodiazepines, one with diazepamand one with midazolam. 1 Reports of this in the lay press attracted the attention of the author who was involved in the early evaluation of midazolam and had encountered a not dissimilar incident. An unpremedicated middleagedwomanwhohadneverhada benzodiazepine beforewas sedated with 10mg midazolam for endoscopy andon recoveryshetoldtheattending nurse that she had been sexuallyassualted (oral sex) during the procedure. It was explainedthat this wasphysicallyimpossiblealthoughit was difficultto assure her of this. Somemonthslatera colleague hada similarexperience. A 52 yearold womanhad a cholecystectomy under epidural analgesiawas sedatedwith IV diazepamand on themorning following theoperationsaidshethoughtshehadbeensexually assualted. Thiscouldnothave happenedand the onlypossibleinterference with genitaliawas whena swabwasplacedbetweenher thighsto preventpossibleirritationby surgical spirit. Shewasstillquiteupsetwhenseentwo weekslaterbutwaseventually assured that nothinghad happenedto her.
30
Medico-Legal J oumal 58/J
These incidents happened when the Belfast Department of Anaesthetics was investigating theclinicaluse of midazolam as a sedative-hypnotic, in dentalpractice2 andfor en'doscopy 3 andcarryingoutbothdose-fmding andpharmacokinetic studies. Phannacokinetic studies,whichinvolved frequentbloodsampling, werecarriedout on staffvolunteersin the hospitalintensivecare unit. 4 Nonehadtakenanydrugs or alcoholfor at leasttwo days. A 32year oldlady, weighing approximately 60 kg, was given 10 mg IV and had frequent blood samplingthrough an indwellingcatheter. Vitalsignswerefrequently monitoredandshehada continuous ECGtracing(3chest leads). She requestedthatshe be allowedto drop outof thestudybecauseof dreams and fantasies about which she felt embarrassed as she had helped with previous studies and and knew that she had not been interfered with during the procedure. Although notpressedforexactdetails sheleftnodoubtthattherewasa sexual element in this unpleasantexperience. Aroundthattimethe role of midazolamas an inductionagentwasbeingevaluated using what would now be considered very large doses. We encounteredsix out of 120patients whohadunusual experiences duringtheslowinduction periodbut; these were not mentioned in the published reports 5 - 7 • Theseeventsprompteda followup of a seriesof2l20 endoscopies and900dental operations carried out under local (topical or nerve block) analgesia with either diazepam or midazolam for sedation. The results of these, published in a dental journal 1 producedreportsof similarcasesfrommanydoctorsanddentists,andsome of thesehavebeendescribedelsewhere.8 Thelastpaperevokedmuchmediainterest both from the press 9 and radio in the form of a phone-inprogramme. 10 Theseagain produced more correspondence and the author has now details of 41 incidentsof which many could fall into the class of fantasies. Seven of these have resulted in litigation. Here are reviewed33 of these allegedfantasiesand similar events all of which occurred in women.
Incidents Of the events summarised in table 1, 6 were of a non-sexual nature and 7 of the remaining 26 werenotconsidered unpleasant: noneof these7 resultedina complaint againstthe sedationist.In 27 of these cases the "incident" occurred 5-6 years ago, the dates of the others are not known. Therewerea further8 reportsoffantasiesor hallucinations in men.Details ofthese were scantyandonly one wasan actualcomplaint.This wasbecausethe patientwas not warned of the possibilityof its occurrence. These are not consideredfurther. Endoscopy The event which led to this study has already been described. A series of about 600 patients were questionedabout similar events and 2 recalled definite sexualexperiences whenunderthe influence of midazolam. A further2 haddistressingexperiencesof a non-sexualnature. The dosesusedat this time were 10-15mg. In a differentseriesof200 patientsof bothsexgiveneitherdiazepam or midazolam followedby pentazocineabout20 appeareddistressedfollowing the procedureand 2 describedhallucinationsof a non-sexualnature. This study was stoppedbecause of a high incidence of vomiting. Dental Procedures Becauseof their source, theseare less welldocumented thanthe
Fantasies During Sedation with Intravenous Midazolam or Diazepam
31
Table 1 Details of 33 "incidents" in women.
Dental Procedures (16) 3 spontaneous reports of sexual indecency 7 "events" leading to litigation 4 spontaneous reports 3 elicited by police enquiries 3 reported during radio phone-in 2 sexual connotations : pleasurable 1 non-sexual "pleasant trip" 3 reported following newspaper article 2 disturbing sexual acts I non-sexual Oral Endoscopy (7) 3 with a sexual connotation I spontaneous complaint 2 elicited on questioning 2 spontaneous reports: non-sexual 2 hallucinogenic experiences after midazolam-pentazocine Induction ofAnaesthesia (6) All had a sexual element, some pleasant. None complained of assult. Others (4) All spontaneous complaints with a sexual element. I local anaesthesia and light sedation 1 removing of dressing I sedation in intensive care unit 1 volunteer in pharmacokinetic studies
above cases. The most dramatic event was a woman who claimed that the dentist had asked her to squeeze his penis while 2 others thought the operator could have had oral sex with her. None of these events happened.
Induction ofAnaesthesia In the evaluation of the role ofmidazolam for the induction of anaesthesia doses of0.3 to 0.5 mg kg? were given to 200 unpremedicated women scheduled for minor gynaecological operations. Many of the younger patients had not lost consciousness by 5 minutes and 6 of these had fantasies with a sexual connotation. Some spoke ofthese at the time and some on return of consciousness. All these were considered to be pleasurable "I wouldn't mind having that drug again" . Others Details of the volunteer in the pharmacokinetic study and one operation case have been described. The other operation was removal of a dressing under sedation with a complaint of a "wandering hand". The sedated patient in the intensive care unit complained her breasts were regularly fondled.
32
Medico-LegalJoumaI58/1
Authenticity In 18non-litigationreports relatedto someact of sexualindecencythe
details havebeenverifiedbytheauthor,bytalking to eitherthecomplainant or a close confidant. On consideringthe circumstances 15of these couldnot have happened: in 13 others were present all the time, while 2 were physicallyimpossible. To these onecouldadd 7 eventsconsideredauthenticbythecourtswhichruledthat 5 actually happened. This givesa total of 25 incidentsreportedby patientsof whichat least 17 could not have happened. In some instancesit has been possibleto see some connectionbetweenthe act of sexual indecency and some events which actually happened during the period of sedation. 8 Table 2 is basedon the 13 non-litigation caseswherethepatientwasupset by an "event whichdid nothappen',. Thiswouldsuggestsomealteredinterpretation of fact due to the benzodiazepine. Table 2 A possible association between thecomplaint andaneventoccurring during benzodiazepinesedation. No. stimulus 2 Dental sucker 2 Oral endoscopy 1 Tight bra 1 Swab between legs 1 Venepuncture: squeeze fist 1 Leaning over patient 1 Leaning over patient
Complaint Oral sex Oral sex Fondling breasts Sexual assualt Induced masturbation Fondling breasts "Wandering hand"
Frequency and dosage It is impossible to estimate the frequency of these fantasies as not every case is
reported. In the previous survey) there was a clear correlationbetweendosageand frequency of complaints. No sequelae were reportedafter 1425 smalldosesof either drug (0.07-0.10 mgkg-) midazolam or equivalent doseofdiazepam). Theincidence with high doses was 9·: 720 and excludingthe anaesthesiainductionthis was about in 200. Comment Sexualoffencescanbe feignedmore easilyand plausiblythanotheroffences, II but on close questioningof the 15of thesepatients whowere not assaulted, it wasclear that their experienceswere very vividand the sequenceof eventswasorderly. They were not' 'malicious" in their intentand therewereno suggestions of blackmail. All were intelligent andsurprisedwhenthetrue natureof theirexperience wasexplained to them. It is worthy of notethat in a recent litigationcase the Crown prosecutor grouped together 1spontaneous reportand3 elicitedcomplaints whenthe policevisitedthose patients who were known to have been given the drug by the same dentist. It is dangerous to speculate on this without knowing the exact questions asked, but it would seem that a comparison of the Crown's alleged incidence of 4 in 12 administrations withthe infrequent incidence of reportedcases,showsa lackofbasic
Fantasies During Sedation with Intravenous Midazolam or Diazepam
33
knowledge of epidemiological research which was not challenged in court. Many of the cases occurred early in the clinical use of sedative techniques with midazolam, when doses were often much higher than presently employed. This may have been a contributing factor. Now that the possibility of such occurrences is known and care should be taken to ensure that sedated women are never left without an intelligent and mature chaperone. This should be mandatory in all cases because of the vulnerability of the single-handed male operator/sedationist, whether endoscopist, dentist or any other. Endoscopists are particularly prone to take this risk. With these precautions it would be expected that further incidents leading to litigation would be uncommon. Nevertheless it is important to put on record that these fantasies do occur, albeit infrequently. These occur not only with benzodiazepines as they have been reported after nitrous oxide-oxygen. 12 More recently there has been a report of a similar event in the postoperative period following infusion ofpropofol and fentanyl, when midazolam was given as premedication;" The relative role of the three sedatives used in this technique is not clear, but it is important to ensure the presence of a third person when visiting such patients after operation.
Acknowledgements Details ofsome ofthese patients and part oftable 2 have appeared in SAAD (Society for the Advancement of Anaesthesia in Dentistry) Digest and are reproduced by permission. Update Earlier this year a dentist was convicted on two out of four charges of sexual assault on female patients who had been given benzodiazepines. Subsequently, another dentist with seven charges of sexual assault against him was acquitted on the direction of the judge. Ed MU
References 1. 2. 3.
4. 5.
6. 7.
Dundee J. W. Do fantasies occur with intravenous benzodiazepines? SAAD Digest 1986; 6: 72-75. McGimpsey J.G., Kawar P., Gamble J.A.S., Browne E.S., Dundee J.W. Midazolam in dentistry. BrDentJ 1983; 155: 47-50. Kawar P., Porter K. G., Hunter E.K., McLaughlin J., Dundee J. W., Brophy T. a 'R. Midazolam for upper gastrointestinal endoscopy. Ann Roy Coll Surg Eng11984; 66: 283-285. Dundee I.W., Samuel La., Toner W., Howard P.I. Midazolam. A watersoluble benzodiazepine. Studies in volunteers. Anaesthesia 1980; 35: 454-458. Gamble J .A.S., Kawar P., Dundee J. W., Moore J., Briggs L.P. Evaluation of midazolam as an intravenous introduction agent. Anaesthesia 1981; 36: 868-873. Dundee J.W., Halliday N.J., Loughran P.C., Harper K.W. The influence of age on the onset of anaesthesia with midazolam. Anaesthesia 1985; 40: 441-443. Halliday N.J., Dundee J.W., Collier P.S., Loughran P.C., Harper H.W. Influence of plasma proteins on the onset of hypnotic action of intravenous midazolam. Anaesthesia 1985; 40: 767-771.
34
Afedico-LegaIJournaI58/1
8.
Dundee J. W. Further data on sexual fantasies during benzodiazepine sedation. SAAD Digest 1989; 7: 171-172. Newton T. The sexual side-effect of the dentist's drug. The Independent 26 September 1989; p 13. Dundee J.W., Phone-in. London Broadcasting Company 2 October 1989. Brahams D. Benzodiazepine sedation and allegations of sexual assult. Lancet 1989; 1: 1339-1340. JastakJ.T., Malamed S.F. Nitrous oxide sedation and sexual phenomena. J AmerDentAss 1980; 101: 38-40. Schaefer H. G., Marsch S.C. U. An unusual emergence after total intravenous anaesthesia. Anaesthesia 1989; 44: 928-929.
9. 10. 11. 12. 13.
FANTASIES DURING SEDATION WITH INTRAVENOUS MIDAZOLAM OR DIAZEPAM JWDUNDEE Emeritus Professor of Anaesthetics, The Queen's University of Belfast Summary
Details are reportedof 41 incidents wherewomenreportedfantasies duringsedation withIV midazolamor diazepam: 27 of them had some sexualelementand 20 were unpleasant experiences. The events occurred in a logical sequence and all were certainof their authenticity. Someled to litigationagainstthe sedationist.Outof25 verifiedreports madeby patientsof incidentsoccurring during sedation, 17did not happenand in 9/13 clear descriptionsthere was some relation between the fantasy and something that reallyhappenedunder sedation.Alloccurredwithwhatare now considered largedosesofthedrugs. Duringor following sedation ladypatients should not be treated or examined withoutthe presence of a responsiblethird person. The use of the injectablebenzodiazepines,diazepamand more recentlymidazolaw, with their sedative, amnesic and relaxing properties have made unpleasant operativeprocedures, particularly those usuallycarried out under local analgesia, more acceptable to many patients. These include oral endoscopy and dental procedures and operations under spinal or epidural analgesia. These drugs also provide good sedationduring ventilatory support and in the intensive care unit. Overalongperiodoftimethesebenzodiazepines haveprovento be, inappropriate doses, among the safest in medicine for short term use. There have however been a fewcasesof whatcanbest be describedas "fantasies" occurringduring sedation: eventsoccuring in a logical sequencewhich are very real to the patient and yet, on the evidenceof two or more independentwitnesses, did not occur. Many of these have had an element of sexual trespass. The subjectaroused interest in December 1984when a dentist was found guilty of sexually assaulting two patients when they were sedated with intravenous benzodiazepines, one with diazepamand one with midazolam. 1 Reports of this in the lay press attracted the attention of the author who was involved in the early evaluation of midazolam and had encountered a not dissimilar incident. An unpremedicated middleagedwomanwhohadneverhada benzodiazepine beforewas sedated with 10mg midazolam for endoscopy andon recoveryshetoldtheattending nurse that she had been sexuallyassualted (oral sex) during the procedure. It was explainedthat this wasphysicallyimpossiblealthoughit was difficultto assure her of this. Somemonthslatera colleague hada similarexperience. A 52 yearold womanhad a cholecystectomy under epidural analgesiawas sedatedwith IV diazepamand on themorning following theoperationsaidshethoughtshehadbeensexually assualted. Thiscouldnothave happenedand the onlypossibleinterference with genitaliawas whena swabwasplacedbetweenher thighsto preventpossibleirritationby surgical spirit. Shewasstillquiteupsetwhenseentwo weekslaterbutwaseventually assured that nothinghad happenedto her.
30
Medico-Legal J oumal 58/J
These incidents happened when the Belfast Department of Anaesthetics was investigating theclinicaluse of midazolam as a sedative-hypnotic, in dentalpractice2 andfor en'doscopy 3 andcarryingoutbothdose-fmding andpharmacokinetic studies. Phannacokinetic studies,whichinvolved frequentbloodsampling, werecarriedout on staffvolunteersin the hospitalintensivecare unit. 4 Nonehadtakenanydrugs or alcoholfor at leasttwo days. A 32year oldlady, weighing approximately 60 kg, was given 10 mg IV and had frequent blood samplingthrough an indwellingcatheter. Vitalsignswerefrequently monitoredandshehada continuous ECGtracing(3chest leads). She requestedthatshe be allowedto drop outof thestudybecauseof dreams and fantasies about which she felt embarrassed as she had helped with previous studies and and knew that she had not been interfered with during the procedure. Although notpressedforexactdetails sheleftnodoubtthattherewasa sexual element in this unpleasantexperience. Aroundthattimethe role of midazolamas an inductionagentwasbeingevaluated using what would now be considered very large doses. We encounteredsix out of 120patients whohadunusual experiences duringtheslowinduction periodbut; these were not mentioned in the published reports 5 - 7 • Theseeventsprompteda followup of a seriesof2l20 endoscopies and900dental operations carried out under local (topical or nerve block) analgesia with either diazepam or midazolam for sedation. The results of these, published in a dental journal 1 producedreportsof similarcasesfrommanydoctorsanddentists,andsome of thesehavebeendescribedelsewhere.8 Thelastpaperevokedmuchmediainterest both from the press 9 and radio in the form of a phone-inprogramme. 10 Theseagain produced more correspondence and the author has now details of 41 incidentsof which many could fall into the class of fantasies. Seven of these have resulted in litigation. Here are reviewed33 of these allegedfantasiesand similar events all of which occurred in women.
Incidents Of the events summarised in table 1, 6 were of a non-sexual nature and 7 of the remaining 26 werenotconsidered unpleasant: noneof these7 resultedina complaint againstthe sedationist.In 27 of these cases the "incident" occurred 5-6 years ago, the dates of the others are not known. Therewerea further8 reportsoffantasiesor hallucinations in men.Details ofthese were scantyandonly one wasan actualcomplaint.This wasbecausethe patientwas not warned of the possibilityof its occurrence. These are not consideredfurther. Endoscopy The event which led to this study has already been described. A series of about 600 patients were questionedabout similar events and 2 recalled definite sexualexperiences whenunderthe influence of midazolam. A further2 haddistressingexperiencesof a non-sexualnature. The dosesusedat this time were 10-15mg. In a differentseriesof200 patientsof bothsexgiveneitherdiazepam or midazolam followedby pentazocineabout20 appeareddistressedfollowing the procedureand 2 describedhallucinationsof a non-sexualnature. This study was stoppedbecause of a high incidence of vomiting. Dental Procedures Becauseof their source, theseare less welldocumented thanthe
Fantasies During Sedation with Intravenous Midazolam or Diazepam
31
Table 1 Details of 33 "incidents" in women.
Dental Procedures (16) 3 spontaneous reports of sexual indecency 7 "events" leading to litigation 4 spontaneous reports 3 elicited by police enquiries 3 reported during radio phone-in 2 sexual connotations : pleasurable 1 non-sexual "pleasant trip" 3 reported following newspaper article 2 disturbing sexual acts I non-sexual Oral Endoscopy (7) 3 with a sexual connotation I spontaneous complaint 2 elicited on questioning 2 spontaneous reports: non-sexual 2 hallucinogenic experiences after midazolam-pentazocine Induction ofAnaesthesia (6) All had a sexual element, some pleasant. None complained of assult. Others (4) All spontaneous complaints with a sexual element. I local anaesthesia and light sedation 1 removing of dressing I sedation in intensive care unit 1 volunteer in pharmacokinetic studies
above cases. The most dramatic event was a woman who claimed that the dentist had asked her to squeeze his penis while 2 others thought the operator could have had oral sex with her. None of these events happened.
Induction ofAnaesthesia In the evaluation of the role ofmidazolam for the induction of anaesthesia doses of0.3 to 0.5 mg kg? were given to 200 unpremedicated women scheduled for minor gynaecological operations. Many of the younger patients had not lost consciousness by 5 minutes and 6 of these had fantasies with a sexual connotation. Some spoke ofthese at the time and some on return of consciousness. All these were considered to be pleasurable "I wouldn't mind having that drug again" . Others Details of the volunteer in the pharmacokinetic study and one operation case have been described. The other operation was removal of a dressing under sedation with a complaint of a "wandering hand". The sedated patient in the intensive care unit complained her breasts were regularly fondled.
32
Medico-LegalJoumaI58/1
Authenticity In 18non-litigationreports relatedto someact of sexualindecencythe
details havebeenverifiedbytheauthor,bytalking to eitherthecomplainant or a close confidant. On consideringthe circumstances 15of these couldnot have happened: in 13 others were present all the time, while 2 were physicallyimpossible. To these onecouldadd 7 eventsconsideredauthenticbythecourtswhichruledthat 5 actually happened. This givesa total of 25 incidentsreportedby patientsof whichat least 17 could not have happened. In some instancesit has been possibleto see some connectionbetweenthe act of sexual indecency and some events which actually happened during the period of sedation. 8 Table 2 is basedon the 13 non-litigation caseswherethepatientwasupset by an "event whichdid nothappen',. Thiswouldsuggestsomealteredinterpretation of fact due to the benzodiazepine. Table 2 A possible association between thecomplaint andaneventoccurring during benzodiazepinesedation. No. stimulus 2 Dental sucker 2 Oral endoscopy 1 Tight bra 1 Swab between legs 1 Venepuncture: squeeze fist 1 Leaning over patient 1 Leaning over patient
Complaint Oral sex Oral sex Fondling breasts Sexual assualt Induced masturbation Fondling breasts "Wandering hand"
Frequency and dosage It is impossible to estimate the frequency of these fantasies as not every case is
reported. In the previous survey) there was a clear correlationbetweendosageand frequency of complaints. No sequelae were reportedafter 1425 smalldosesof either drug (0.07-0.10 mgkg-) midazolam or equivalent doseofdiazepam). Theincidence with high doses was 9·: 720 and excludingthe anaesthesiainductionthis was about in 200. Comment Sexualoffencescanbe feignedmore easilyand plausiblythanotheroffences, II but on close questioningof the 15of thesepatients whowere not assaulted, it wasclear that their experienceswere very vividand the sequenceof eventswasorderly. They were not' 'malicious" in their intentand therewereno suggestions of blackmail. All were intelligent andsurprisedwhenthetrue natureof theirexperience wasexplained to them. It is worthy of notethat in a recent litigationcase the Crown prosecutor grouped together 1spontaneous reportand3 elicitedcomplaints whenthe policevisitedthose patients who were known to have been given the drug by the same dentist. It is dangerous to speculate on this without knowing the exact questions asked, but it would seem that a comparison of the Crown's alleged incidence of 4 in 12 administrations withthe infrequent incidence of reportedcases,showsa lackofbasic
Fantasies During Sedation with Intravenous Midazolam or Diazepam
33
knowledge of epidemiological research which was not challenged in court. Many of the cases occurred early in the clinical use of sedative techniques with midazolam, when doses were often much higher than presently employed. This may have been a contributing factor. Now that the possibility of such occurrences is known and care should be taken to ensure that sedated women are never left without an intelligent and mature chaperone. This should be mandatory in all cases because of the vulnerability of the single-handed male operator/sedationist, whether endoscopist, dentist or any other. Endoscopists are particularly prone to take this risk. With these precautions it would be expected that further incidents leading to litigation would be uncommon. Nevertheless it is important to put on record that these fantasies do occur, albeit infrequently. These occur not only with benzodiazepines as they have been reported after nitrous oxide-oxygen. 12 More recently there has been a report of a similar event in the postoperative period following infusion ofpropofol and fentanyl, when midazolam was given as premedication;" The relative role of the three sedatives used in this technique is not clear, but it is important to ensure the presence of a third person when visiting such patients after operation.
Acknowledgements Details ofsome ofthese patients and part oftable 2 have appeared in SAAD (Society for the Advancement of Anaesthesia in Dentistry) Digest and are reproduced by permission. Update Earlier this year a dentist was convicted on two out of four charges of sexual assault on female patients who had been given benzodiazepines. Subsequently, another dentist with seven charges of sexual assault against him was acquitted on the direction of the judge. Ed MU
References 1. 2. 3.
4. 5.
6. 7.
Dundee J. W. Do fantasies occur with intravenous benzodiazepines? SAAD Digest 1986; 6: 72-75. McGimpsey J.G., Kawar P., Gamble J.A.S., Browne E.S., Dundee J.W. Midazolam in dentistry. BrDentJ 1983; 155: 47-50. Kawar P., Porter K. G., Hunter E.K., McLaughlin J., Dundee J. W., Brophy T. a 'R. Midazolam for upper gastrointestinal endoscopy. Ann Roy Coll Surg Eng11984; 66: 283-285. Dundee I.W., Samuel La., Toner W., Howard P.I. Midazolam. A watersoluble benzodiazepine. Studies in volunteers. Anaesthesia 1980; 35: 454-458. Gamble J .A.S., Kawar P., Dundee J. W., Moore J., Briggs L.P. Evaluation of midazolam as an intravenous introduction agent. Anaesthesia 1981; 36: 868-873. Dundee J.W., Halliday N.J., Loughran P.C., Harper K.W. The influence of age on the onset of anaesthesia with midazolam. Anaesthesia 1985; 40: 441-443. Halliday N.J., Dundee J.W., Collier P.S., Loughran P.C., Harper H.W. Influence of plasma proteins on the onset of hypnotic action of intravenous midazolam. Anaesthesia 1985; 40: 767-771.
34
Afedico-LegaIJournaI58/1
8.
Dundee J. W. Further data on sexual fantasies during benzodiazepine sedation. SAAD Digest 1989; 7: 171-172. Newton T. The sexual side-effect of the dentist's drug. The Independent 26 September 1989; p 13. Dundee J.W., Phone-in. London Broadcasting Company 2 October 1989. Brahams D. Benzodiazepine sedation and allegations of sexual assult. Lancet 1989; 1: 1339-1340. JastakJ.T., Malamed S.F. Nitrous oxide sedation and sexual phenomena. J AmerDentAss 1980; 101: 38-40. Schaefer H. G., Marsch S.C. U. An unusual emergence after total intravenous anaesthesia. Anaesthesia 1989; 44: 928-929.
9. 10. 11. 12. 13.
