Background
Midazolam is commonly administered orally or intranasally to reduce preoperative anxiety in children undergoing tympanostomy. Prior studies suggest differences in recovery exist between the two routes, but their impact on post-anesthesia care unit (PACU) length of stay remains unclear.
Methods
We conducted a retrospective chart review of pediatric patients aged 6 months to 10 years undergoing tympanostomy at Nemours Children’s Hospital, Central Florida, between November 2023 and November 2024. Patients were grouped by midazolam route (intranasal 0.2 mg/kg IV formulation vs. oral 0.5 mg/kg syrup). The primary outcome was PACU length of stay, defined as time from PACU arrival to discharge based on standard hospital criteria. Predictors of administration route were evaluated using univariate logistic regression, and PACU length of stay was analyzed using age-adjusted ANCOVA with backward stepwise variable selection.
Results
A total of 463 patients were included: 322 received oral midazolam and 141 received intranasal midazolam. In unadjusted analysis, intranasal midazolam was associated with a shorter PACU stay (mean 39.7 vs. 42.9 min, p = 0.02). However, patients receiving intranasal midazolam were significantly younger (31.5 vs. 37.8 months, p < 0.001). After adjustment for age, age emerged as the only independent predictor of PACU length of stay, and the association between administration route and PACU duration was attenuated and no longer significant (p = 0.15).
Conclusions
Age, rather than route of midazolam administration, primarily explained differences in PACU discharge readiness among children undergoing tympanostomy. Previously reported differences in recovery time between oral and intranasal midazolam may reflect age-related confounding rather than a true effect of route. Future prospective, age-stratified studies are needed to clarify this relationship and refine pediatric sedation practices.