Sedation effects of intranasal dexmedetomidine delivered as sprays versus drops on pediatric response to venous cannulation

Paediatric sedation with intranasal dexmedetomidine: Protocol for a systematic review and meta-analysis

INTRODUCTION

Sedation ensures a child remains motionless during a procedure and decreases anxiety. Several pharmacologic regimes exist for paediatric sedation. However, often, intravenous cannulation is required, causing distress for the child. Creating a low-stress environment for children during medical procedures is crucial. Intranasal dexmedetomidine offers a promising alternative by either removing the need for intravenous cannulation or significantly reducing stress and anxiety when cannulation is necessary. We aim to investigate the safety and efficiency of sedating children with intranasal dexmedetomidine.

METHODS AND ANALYSIS

We will systematically search MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), CENTRAL, Clinicaltrials.gov, and the WHO ICTRP portal. We will include all randomized controlled trials (RCT) that investigate the use of intranasal dexmedetomidine compared to alternative sedatives for premedication or sedation of children. Two researchers will independently screen title/abstract and full-text articles for eligibility using Covidence. Our primary outcome is sedation success rate. RCTs that meet the inclusion criteria will form the unit of analysis. Data extracted from each study will be presented in table format (S2 Table). Information on parameters that describe safety and efficiency outcomes will be extracted and analysed. Outcome data will be reported as risk ratios and 95% confidence intervals (CI) for dichotomous outcomes or mean and standardized mean differences with 95% CI for continuous outcomes. The assessment of statistical heterogeneity will be examined using Chi2- and I2-statistics. PROSPERO registration number CRD42024532993.

DISCUSSION

Sedation with intranasal dexmedetomidine is not common practice in all countries, though the medicament has the potential to provide a child-friendly approach to sedation and premedication. Reviews on the area are conflicting, and new RCT studies have been published. Our systematic review aims to comprehensively assess intranasal paediatric sedation, focusing on dexmedetomidine and guiding clinicians in daily decision-making for optimal paediatric sedation.

Intranasal Dexmedetomidine Administration Precipitates Respiratory Failure in Child With Croup and Asthma

Intranasal dexmedetomidine administration in clinically recommended doses has a small but important risk of causing catastrophic respiratory failure in the setting of preexisting severe respiratory workloads.

Pharmacokinetics, pharmacodynamics and bioavailability of dexmedetomidine nasal spray in healthy Chinese adults: A phase I clinical trial

Background

Intranasal administration is a convenient route for drug delivery that can be applied for procedural sedation. However, there is currently limited exploration into fixed dosing regimens. This study was to investigate the pharmacokinetics (PK), pharmacodynamics (PD), bioavailability (BA) and safety of dexmedetomidine after fixed doses of intranasal and intravenous administration in healthy male and female subjects.

Methods

Group A subjects received intranasal or intravenous administration in two periods (12 subjects received intranasal dexmedetomidine (Dex) or the intravenous formulation, and four received the corresponding placebo). Groups B to F underwent single-period dose ascending, receiving only the intranasal Dex formulation or the corresponding placebo (the number of subjects receiving the drug/placebo in groups B to F were 12/2, 12/2, 12/2, 10/2, 10/2, respectively), with doses of 75 μg, 125 μg, 150 μg, 175 μg, and 200 μg, respectively. After administration of each group, blood samples were collected to investigate the plasma concentration of dexmedetomidine, adrenaline and noradrenaline using a HPLC-MS/MS method. Ramsay score, blood pressure and heart rate were collected for safety evaluation. Pharmacokinetic parameters (Cmax, Tmax, AUC0-24h,AUC 0 - ∞ , and t1/2) of dexmedetomidine were calculated.

Results

A total of 82 subjects were randomized. One subject withdrew for personal reasons before administration and the other subjects completed the entire study process. At a dose of 25 μg, the absolute bioavailability was 59%. Across the dose range of 25 to 200 μg, the median Tmax was similar (0.5-1 h), and the mean elimination half-life was comparable (3.09-4.28 h), with exposure (Cmax and AUC0-t) increasing with dose. The pharmacokinetics after intranasal spray administration exhibited linear characteristics, although Cmax was similar in the higher dose groups (175 μg and 200 μg). PD results showed that ideal sedation effects (Ramsay score of 3 or higher in at least 90% of subjects) could be achieved within 30 min following intranasal administration of 75 μg or higher doses. All the subjects were well tolerated without any serious adverse events (SAEs).

Conclusion

Dexmedetomidine nasal spray was well tolerated and achieved satisfactory sedation in the dose range of 25-200 μg in Chinese healthy male and female subjects.

Clinical Trial Registration

http://www.chinadrugtrials.org.cn/, identifier CTR20201650.

A randomized clinical trial of intranasal dexmedetomidine versus inhaled nitrous oxide for procedural sedation and analgesia in children

BACKGROUND

Procedural sedation and analgesia is an important part of pediatric emergency care, safe and clinically useful alternatives for adequate management are necessary. The objective of this clinical trial was to evaluate the non-inferiority of intranasal dexmedetomidine to nitrous oxide with respect to analgesia for a painful procedure in children 3-15 years of age.

METHODS

This prospective, equally randomized, open-label, non-inferiority trial was conducted at a Pediatric Emergency Department. Previously healthy children 3-15 years of age, with an extremity fracture or luxation or a burn and requiring procedural sedation and analgesia were eligible. Patients were randomized to receive either intranasal dexmedetomidine or inhaled nitrous oxide. The primary outcome measure was highest pain level during the procedure, assessed with Face, Legs, Activity, Cry, Consolability scale (FLACC). Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables) were used for statistical analysis.

RESULTS

The highest FLACC was median 4 (IQR 3-6) with intranasal dexmedetomidine and median 4 (IQR 2-6) with nitrous oxide. The median of the difference between samples from each group for FLACC was 0 with 95%CI (0-1), thus intranasal dexmedetomidine was not inferior to nitrous oxide with respect to the level of pain during the procedure. The same method for procedural sedation and analgesia would be accepted by 52/74 (82.5%) children and 65/74 (91.5%) parents in the intranasal dexmedetomidine group respectively 59/74 (88.1%) versus 70/74 (94.6%) with nitrous oxide. No serious adverse events were reported.

CONCLUSIONS

The results of this trial support that intranasal dexmedetomidine is not inferior to 50% nitrous oxide in providing analgesia for a painful procedure in children 3-15 years of age and can be considered as an alternative to 50% nitrous oxide for procedural sedation and analgesia.

TRIAL REGISTRATION

EudraCT 201,600,377,317, April 20, 2017. https://eudract.ema.europa.eu/ .

Comparison of intranasal dexmedetomidine and ketamine for paediatric premedication: A randomized study

INTRODUCTION AND OBJECTIVES

Paediatric patients are given premedication in order to decrease preoperative anxiety, allow smooth induction, and prevent postoperative psychological insult and behavioural changes. A child friendly method of administration is desirable. We compared intranasal administration of dexmedetomidine and ketamine in the operating room environment, to evaluate the Faces, Legs, Activity, Cry and Consolability (FLACC) score at the time of establishing intravenous access for induction of general anaesthesia.

METHODS

This prospective, double-blind, randomized controlled trial was conducted at a tertiary care center. One hundred patients, 2-10 years of age, ASA physical status 1 & 2, scheduled for general anaesthesia were enrolled. Patient's presedation behaviour was assessed by the modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF). Patients in Group D received Dexmedetomidine 1 mcg/kg intranasally, and patients in Group K received Ketamine 5 mg/kg intranasally. After 45 min, patients were transferred to the operating table where intravenous cannulation was carried out and the response to needle insertion was assessed by FLACC scale. Vital signs, including the pulse-oximetry, heart rate and respiratory rate were monitored. Side effects such as nausea, vomiting, and agitation were also recorded.

RESULTS

A significantly higher FLACC score was seen in Group D as compared to Group K (p = 0.001). The mean heart rate between two groups was found to be significantly (p = 0.001) lower in Group D compared to Group K. However, the proportion of adverse events was 8% in patients who received ketamine.

CONCLUSIONS

Intranasal ketamine in a dose of 5 mg/kg is clinically more effective as premedication in children aged 2-10 years in comparison with intranasal dexmedetomidine in a dose of 1 mcg/kg.

Safety and efficacy of a novel dexmedetomidine nasal spray for pre-anesthetic sedation in children: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Off-label intranasal administration of injectable dexmedetomidine has been widely applied in the pediatric sedation setting. However, the development of an improved drug delivery system that is easy to use is needed. We developed a novel dexmedetomidine nasal spray that can be administered directly without dilution or configuration for pediatric pre-anesthetic sedation. This nasal spray has a fixed dose and is stable during storage. To the best of our knowledge, this is the first licensed nasal spray preparation of dexmedetomidine worldwide.

OBJECTIVE

To evaluate the pre-anesthetic sedation efficacy and safety of the novel dexmedetomidine nasal spray in children.

METHODS

The study was conducted at 11 sites in China between 24 November 2021 and 20 May 2022 and was registered in ClinicalTrials.gov (NCT05111431, first registration date: 20/10/2021). Subjects (n = 159) between 2 and 6 years old who were to undergo elective surgery were randomized to the dexmedetomidine group (n = 107) or the placebo group (n = 52) in a 2:1 ratio. The dosage was 30 µg or 50 µg based on the stratified body weight. The primary outcome measure was the proportion of subjects who achieved the desired child-parent separation and Ramsay scale ≥ 3 within 45 min of administration. Safety was monitored via the assessments of adverse events, blood pressure, heart rate, respiratory rate and blood oxygen saturation.

RESULTS

The proportion of subjects achieving desired parental separation and Ramsay scale ≥ 3 within 45 min was significantly higher in the dexmedetomidine group (94.4%) vs the placebo group (32.0%) (P < 0.0001). As compared with placebo, dexmedetomidine treatment led to more subjects achieving Ramsay scale ≥ 3 or UMSS ≥ 2, and shorter time to reach desired parental separation, Ramsay scale ≥ 3 and UMSS ≥ 2 (all P < 0.0001). Adverse events were reported in 90.7% and 84.0% of subjects in the dexmedetomidine and placebo groups, respectively, and all the events were mild or moderate in severity.

CONCLUSIONS

This novel dexmedetomidine nasal spray presented effective pre-anesthetic sedation in children with a tolerable safety profile.

Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists

BACKGROUND

Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries.

METHODS

A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices.

RESULTS

One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting.

CONCLUSION

This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.

Comparison of the efficacy of intranasal atomised dexmedetomidine versus intranasal atomised ketamine as a premedication for sedation and anxiolysis in children undergoing spinal dysraphism surgery: A randomized controlled trial

BACKGROUND

Preoperative anxiety leads to adverse clinical outcomes and long-term maladaptive behavioural changes. The role of intranasal atomised dexmedetomidine and atomised ketamine as premedication to produce sedation and anxiolysis in paediatric neurosurgical patients has not been extensively studied.

OBJECTIVE

To study the efficacy of intranasal atomised dexmedetomidine and intranasal atomised ketamine as premedication in producing sedation and facilitating smooth induction in children undergoing spinal dysraphism surgery.

DESIGN

A prospective randomised double-blind trial.

SETTING

A tertiary teaching hospital.

PATIENTS

Sixty-four children aged 1 to 10 years undergoing spinal dysraphism surgery.

METHODS

Children were randomised to receive intranasal atomised dexmedetomidine 2.5 μg kg -1 (Group D, n  = 32) and intranasal atomised ketamine 5 mg kg -1 (Group K, n  = 32) 30 min before surgery.

OUTCOMES MEASURED

The primary outcome was to compare the level of sedation in both groups using the University of Michigan Sedation Score (UMSS). The secondary outcomes included an assessment of the ease of parental separation, intravenous cannulation and satisfactory mask acceptance along with perioperative vitals (heart rate, blood pressure and oxygen saturation). The incidence of emergence agitation and time to discharge were also noted.

RESULTS

The degree of sedation was significantly better in Group D as compared to Group K at 20 min (UMSS, 1.55 ± 0.51 versus 1.13 ± 0.34, difference, -0.406; 95% CI, -0.621 to -0.191; P  = 0.0001) and 30 min (2.32 ± 0.6 versus 1.94 ± 0.50, difference, -0.374; 95% CI, -0.650 to -0.100; P  = 0.007). The ease of parental separation, venous cannulation and mask acceptance ( P  = 0.83, 0.418 and 0.100 respectively) were comparable in both groups. The heart rate was lower in group D at 10, 20 and 30 min post-drug administration but was clinically insignificant. The incidence of emergence agitation and time to discharge was also similar with no adverse events reported.

CONCLUSION

Intranasal atomised dexmedetomidine produces greater sedation as compared to intranasal atomised ketamine with comparable ease of parental separation, venous cannulation and mask acceptance with no adverse effects.

A randomized double-blind trial of intranasal dexmedetomidine versus intranasal esketamine for procedural sedation and analgesia in young children

BACKGROUND

Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine.

METHODS

This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1-3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents' satisfaction, and physician's assessment. Comparisons were done using Mann-Whitney U test (continuous variables) and Fisher's test (categorical variables).

RESULTS

Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0-3) with intranasal dexmedetomidine and 5 (2-6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were "very satisfied" with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial.

CONCLUSIONS

This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1-3 years with minor injuries.

TRIAL REGISTRATION

Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/.

The prescription design and key properties of nasal gel for CNS drug delivery: A review

Central nervous system (CNS) diseases are among the major health problems. However, blood-brain barrier (BBB) makes traditional oral and intravenous delivery of CNS drugs inefficient. The unique direct connection between the nose and the brain makes nasal administration a great potential advantage in CNS drugs delivery. However, nasal mucociliary clearance (NMCC) limits the development of drug delivery systems. Appropriate nasal gel viscosity alleviates NMCC to a certain extent, gels based on gellan gum, chitosan, carbomer, cellulose and poloxamer have been widely reported. However, nasal gel formulation design and key properties for alleviating NMCC have not been clearly discussed. This article summarizes gel formulations of different polymers in existing nasal gel systems, and attempts to provide a basis for researchers to conduct in-depth research on the key characteristics of gel matrix against NMCC.

Intranasal dexmedetomidine improves postoperative sleep quality in older patients with chronic insomnia: a randomized double-blind controlled trial

Objective: This study was determined to investigate the impact of intranasal dexmedetomidine (DEX) on postoperative sleep quality in older patients (age over 65) with chronic insomnia during their hospitalization after surgery. Design: A randomized double-blind controlled trial was conducted to compare the effects of intranasal dexmedetomidine spray with a placebo group. Setting and Participants: The study was carried out at Xiangya Hospital, Central South University. 110 participants with chronic insomnia were analyzed. Methods: This trial enrolled older patients who underwent total hip/knee arthroplasty and randomized them to receive intranasal dexmedetomidine (2.0 μg/kg) or saline daily at around 9 p.m. after surgery until discharge. The primary outcomes were subjective sleep quality assessed with the Leeds Sleep Evaluation Questionnaire (LSEQ). The secondary outcomes included the objective sleep quality measured with the Acti-graph, the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI). The other outcomes included the incidence of delirium, levels of inflammatory factors, visual analog scale (VAS) pain scores, postoperative opioid consumption, and treatment-related adverse events. Results: 174 patients were screened for eligibility, and 110 were recruited and analyzed. The DEX group had significantly higher scores on both the LSEQ-Getting to sleep and LSEQ-Quality of Sleep at each time point compared to the placebo (p < 0.0001), The least squares (LS) mean difference in LSEQ-GTS score at T0 between placebo group and DEX group was 2 (95% CI, -1-6), p = 0.4071 and at T5 was -14 (95% CI, -17 to -10), p < 0.0001; The LS mean difference in the LSEQ-QOS score at T0 was -1 (95% CI, -4 to 1), p = 0.4821 and at T5 was -16 (95% CI, -21 to -10), p < 0.0001. The DEX group exhibited significant improvement in Total Sleep Time (TST), Sleep Onset Latency (SOL), and Sleep Efficiency (SE), at each time point after treatment compared to the placebo group (p < 0.0001). The PSQI and ISI scores in the DEX group were reduced after treatment (p < 0.001). No significant adverse events were reported with the use of dexmedetomidine. Conclusion and Implications: This study demonstrates that intranasal administration of dexmedetomidine improves postoperative sleep quality in older patients with chronic insomnia who undergo surgery, without increasing the incidence of adverse effects. Clinical Trial Registration: http://www.chictr.org.cn/, identifier ChiCTR2200057133.

Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study

STUDY OBJECTIVE

To determine the optimal sedative dose of intranasal dexmedetomidine for children undergoing laceration repair.

METHODS

This dose-ranging study employing the Bayesian Continual Reassessment Method enrolled children aged 0 to 10 years with a single laceration (<5 cm), requiring single-layer closure, who received topical anesthetic. Children were administered 1, 2, 3, or 4 mcg/kg intranasal dexmedetomidine. The primary outcome was the proportion with adequate sedation (Pediatric Sedation State Scale score of 2 or 3 for ≥90% of the time from sterile preparation to tying of the last suture). Secondary outcomes included the Observational Scale of Behavior Distress-Revised (range: 0 [no distress] to 23.5 [maximal distress]), postprocedure length of stay, and adverse events.

RESULTS

We enrolled 55 children (35/55 [64%] males; median [interquartile range {IQR}] age 4 [2, 6] years). At 1, 2, 3, and 4 mcg/kg intranasal dexmedetomidine, respectively, the proportion of participants "adequately" sedated was 1/3 (33%), 2/9 (22%), 13/21 (62%), and 12/21 (57%); the posterior mean (95% equitailed credible intervals) for the probability of adequate sedation was 0.38 (0.04, 0.82), 0.25 (0.05, 0.54), 0.61 (0.41, 0.80), and 0.57 (0.36, 0.76); the median (IQR) Observational Scale of Behavior Distress-Revised scores during suturing was 2.7 (0.3, 3), 0 (0, 3.8), 0.6 (0, 5), and 0 (0, 3.7); the median (IQR) postprocedure length of stay was 67 (60, 78), 76 (60, 100), 89 (76, 109), and 113 (76, 150) minutes. There was 1 adverse event, a decrease in oxygen saturation at 4 mcg/kg, which resolved with head repositioning.

CONCLUSION

Despite limitations, such as our limited sample size and subjectivity in Pediatric Sedation State Scale scoring, sedation efficacy for 3 and 4 mcg/kg were similarly based on equitailed credible intervals suggesting either could be considered optimal.

Two-center randomized controlled trial comparing oral chloral hydrate and intranasal combination of dexmedetomidine and ketamine for procedural sedation in children: study protocol

BACKGROUND

Oral chloral hydrate is widely used in pediatric sedation. Intranasal dexmedetomidine has been increasingly used for pediatric sedation; however, its improvement is warranted. The combination of dexmedetomidine with ketamine can improve onset and hemodynamic stability while maintaining sedative efficacy. This study aims to determine the efficacy and safety of intranasal combination of dexmedetomidine and ketamine compared to oral chloral hydrate.

METHODS

This is a prospective, parallel-arm, single-blinded, two-center, superiority randomized controlled trial with 1:1 allocation, designed to compare the effects of intranasal combination of dexmedetomidine and ketamine with those of oral chloral hydrate. We shall enroll 136 patients aged < 7 years old in this study. Prior to the procedure, we shall randomize each patient into the control group (oral chloral hydrate 50 mg/kg) or study group (intranasal dexmedetomidine 2 μg/kg and ketamine 3 mg/kg). The primary outcome will be the rate of achieving an adequate sedation level (6-point Pediatric Sedation State Scale 1, 2, or 3) within 15 min. In addition, we shall measure the sedation time, sedation failure rate, completion of procedure, adverse events, patient acceptance, and physician satisfaction.

DISCUSSION

This study will provide evidence of the efficacy and safety of the intranasal combination of dexmedetomidine and ketamine in comparison with oral chloral hydrate.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04820205. Registered on 19th March 2021.

Atomised intranasal dexmedetomidine versus oral melatonin in prevention of emergence delirium in children undergoing ophthalmic surgery with sevoflurane: A randomised double-blind study

BACKGROUND

Melatonin and dexmedetomidine have both been used as a premedication to decrease emergence delirium in children. The effectiveness of oral melatonin, compared with atomised intranasal dexmedetomidine, in this role is not well studied.

OBJECTIVE

To study the efficacy of pre-operative atomised intranasal dexmedetomidine versus oral melatonin in children scheduled for ophthalmic surgery under sevoflurane.

DESIGN

A prospective, randomised, double-blind trial.

SETTING

Ophthalmic surgery in a university teaching hospital, April 2021 to October 2021.

PATIENTS

A total of 120 children undergoing ophthalmic surgery with sevoflurane anaesthesia.

INTERVENTION

Children were randomised to receive pre-operative intranasal dexmedetomidine 2 μg/kg via an atomiser device (dexmedetomidine group) or oral melatonin 0.5 mg kg -1 (melatonin group), 45 min before surgery.

OUTCOMES MEASURED

The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included pre-operative sedation, quality of inhalational induction, postoperative sedation and pain.

RESULTS

The incidence of emergence delirium was lower in the dexmedetomidine group than in the melatonin group (17 versus 37%, relative risk 0.45, 95% CI: 0.24 to 0.88; P  = 0.01). Children in the dexmedetomidine group were more sedated following premedication and in the postanaesthesia care unit ( P  < 0.05). Postoperative pain scores were lower in the dexmedetomidine group than in the melatonin group: 0 [0 to 3] versus 2.5 [0-4], ( P  = 0.01). The requirement for and dose of rescue fentanyl analgesia postoperatively was comparable between the two groups.

CONCLUSION

Atomised intranasal dexmedetomidine significantly reduced emergence delirium in paediatric opthalmic procedures under sevoflurane anaesthesia compared to oral melatonin.

TRIAL REGISTRATION

Clinical Trials Registry of India CTRI/2021/03/032388 ( www.ctri.nic.in ).

Recent Advances in the Clinical Value and Potential of Dexmedetomidine

Dexmedetomidine, a highly selective α2-adrenoceptor agonist, has sedative, anxiolytic, analgesic, sympatholytic, and opioid-sparing properties and induces a unique sedative response which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Recent studies indicate several emerging clinical applications via different routes. We review recent data on dexmedetomidine studies, particularly exploring the varying routes of administration, experimental implications, clinical effects, and comparative advantages over other drugs. A search was conducted on the PubMed and Web of Science libraries for recent studies using different combinations of the words “dexmedetomidine”, “route of administration”, and pharmacological effect. The current routes, pharmacological effects, and application categories of dexmedetomidine are presented. It functions by stimulating pre- and post-synaptic α2-adrenoreceptors within the central nervous system, leading to hyperpolarization of noradrenergic neurons, induction of an inhibitory feedback loop, and reduction of norepinephrine secretion, causing a sympatholytic effect, in addition to its anti-inflammation, sleep induction, bowel recovery, and sore throat reduction effects. Compared with similar α2-adrenoceptor agonists, dexmedetomidine has both pharmacodynamics advantage of a significantly greater α2:α1-adrenoceptor affinity ratio and a pharmacokinetic advantage of having a significantly shorter elimination half-life. In its clinical application, dexmedetomidine has been reported to present a significant number of benefits including safe sedation for various surgical interventions, improvement of intraoperative and postoperative analgesia, sedation for compromised airways without respiratory depression, nephroprotection and stability of hypotensive hemodynamics, reduction of postoperative nausea and vomiting and postoperative shivering incidence, and decrease of intraoperative blood loss. Although the clinical application of dexmedetomidine is promising, it is still limited and further research is required to enhance understanding of its pharmacological properties, patient selection, dosage, and adverse effects.

The Sedative Effects of Inhaled Nebulized Dexmedetomidine on Children: A Systematic Review and Meta-Analysis

BACKGROUND

Children that need surgery and medical examinations are often uncooperative, and preoperative sedation is necessary. We aimed to assess the safety and efficacy of inhaled nebulized dexmedetomidine in children for sedation that underwent medical examinations or surgery.

METHODS

We systematically searched PubMed, Web of science, Embase, and Cochrane library, for randomized controlled trials of Intranasal dexmedetomidine using a spray or a mucosal atomization device in children undergoing examination or elective surgery. We included all studies that analyzed the sedation efficiency of intranasal dexmedetomidine in children.

RESULTS

Ten studies with 1,233pediatric patients were included. Compared to other sedation treatments, inhaled nebulized dexmedetomidine showed similar sedation satisfaction [risk ratio RR: 1.02; 95% confidence interval (CI): 0.87-1.18; P = 0.83; I² = 72%]. there was also no statistical difference in the success rate of separation from parents (RR: 0.96; 95% CI: 0.82-1.12; P = 0.58; I² = 67%), and mask acceptability (RR: 1; 95% CI: 0.83-1.20; P = 0.99; I² = 35%). But it is worth mentioning that nebulized dexmedetomidine combined with ketamine provided better sedation satisfaction (RR: 0.69; 95% CI: 0.49-0.96; I² = 49%) and more satisfactory separation from parents (RR: 0.85; 95% CI: 0.74-0.97; I² = 0%). Moreover, nebulized dexmedetomidine reduced the occurrences of nausea and vomiting (RR: 0.28; 95% CI: 0.15-0.51; P < 0.01; I² = 10%) and emergence agitation (RR: 0.30; 95% CI: 0.18-0.49; P < 0.01; I² = 0%). There are no hypotension or arrhythmia reported that required intervention in all articles.

CONCLUSION

Compared to other premedication treatments, inhaled nebulized dexmedetomidine provided equivalent sedation satisfaction for the examination or preoperative sedation of children, but it reduced the occurrences of emergence agitation and postoperative nausea and vomiting.

Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada

OBJECTIVES

Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption.

METHODS

We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics.

RESULTS

The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%).

CONCLUSIONS

Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

Intranasal Dexmedetomidine for the Treatment of Pre-operative Anxiety and Insomnia: A Prospective, Randomized, Controlled, and Clinical Trial

BACKGROUND AND OBJECTIVE

Several patients with pre-operative anxiety and insomnia refuse to take sleeping pills because of the side effects of sleeping pills. This study aimed to evaluate the applicability of intranasal dexmedetomidine (DEX) in the treatment of pre-operative anxiety and insomnia.

METHODS

A total of 72 patients with insomnia and anxiety were randomly divided into two groups of intranasal DEX (n = 36) and intranasal normal saline (NS, n = 36). The primary outcomes included patients' time to fall asleep, total sleep time, insomnia severity index (ISI) after treatment, and satisfaction with the treatment effect. The secondary outcomes were mean arterial pressure (MAP), oxygen saturation (SPO₂), heart rate (HR), Narcotrend index (NI) in the first 2 h of treatment, and the incidence of adverse events within 12 h after treatment.

RESULTS

The time to fall asleep (22.08 ± 3.95 min) and total sleep time (400.06 ± 28.84 min) in the DEX group were significantly different from those in the NS group [time to fall asleep, 89.31 ± 54.56 min; total sleep time (295.19 ± 73.51 min; P < 0.001)]. ISI after treatment in the DEX group was lower than that in the NS group (P < 0.001). Satisfaction with the treatment effect was better in the DEX group than that in the NS group (P < 0.001). The general vital signs in the two groups were stable during the treatment. The drowsiness rate in the NS group was higher than that in the DEX group (P < 0.001).

CONCLUSION

Intranasal DEX can significantly improve pre-operative anxiety and insomnia.

CLINICAL TRIAL REGISTRATION

This study was registered on Chinese Clinical Trial Registry (http://www.chictr.org.cn/searchproj.aspx, ChiCTR2100044747).

Systematic review and meta-analysis found that intranasal dexmedetomidine was a safe and effective sedative drug during paediatric procedural sedation

AIM

This systematic review and meta-analysis evaluated the effectiveness of intranasal dexmedetomidine as a sole sedative during paediatric procedural sedation outside the operating room.

METHODS

Relevant literature identified by PubMed, Scopus, ClinicalTrials.gov, ScienceDirect and Cochrane Library up to 31 December 2019 was systematically reviewed. Randomised controlled trials that compared intranasal dexmedetomidine with another sedative or placebo during paediatric procedural sedation were included. Trials that studied intranasal dexmedetomidine as a premedication before anaesthesia were excluded. The primary outcome was the success of the planned procedure.

RESULTS

We analysed seven randomised controlled trials of 730 patients: four trials with 570 patients compared dexmedetomidine with chloral hydrate and three trials with 160 patients compared dexmedetomidine with midazolam. The incidence of successfully completing the procedure did not differ between dexmedetomidine and chloral hydrate, but dexmedetomidine had a higher success rate than midazolam. The incidence of hypotension, bradycardia or respiratory complications did not differ between the sedatives used. Nausea and vomiting were more common in children treated with chloral hydrate than in those treated with other sedatives.

CONCLUSION

Intranasal dexmedetomidine was a safe and effective sedative for minor paediatric procedures.

Intranasal dexmedetomidine for sedation in children; a review

Dexmedetomidine is an α2 adrenoreceptor agonist that may be administered by the intranasal route as a sole sedative agent in children. It is odourless, colourless and tasteless and is formulated in a concentration of 100µg.ml^-1. We performed a review of published randomised controlled trials in order to determine the efficacy of intranasal dexmedetomidine for sedation in children. Fourteen trials were eligible for inclusion in the review and contained a total of 1809 patients ranging in age from one month to 14 years. Intranasal dexmedetomidine was administered in a dose range of 1-4µg.kg^-1 and was compared with various other sedatives. Dexmedetomidine was administered by either drops or a mucosal atomiser device. The procedures ranged from non-painful examinations such as magnetic resonance imaging scans and transthoracic echocardiography to painful procedures such as dentistry and venous cannulation. Administration of 2µg.kg^-1 appears to be the optimal dose.

Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic Review

CONTEXT

Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children.

OBJECTIVE

To explore the effectiveness of IND for procedural distress in children.

DATA SOURCES

We performed electronic searches of Medline (1946-2019), Embase (1980-2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981-2019), and Cochrane Central Register.

STUDY SELECTION

We included randomized trials of IND for procedures in children.

DATA EXTRACTION

Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation.

RESULTS

Among 19 trials (N = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures.

LIMITATIONS

The adequacy of sedation was subjective, which possibly led to biased outcome reporting.

CONCLUSIONS

Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.

Comparison of the sedative effects of medetomidine administered intranasally, by atomization or drops, and intramuscular injection in dogs

OBJECTIVE

To compare the sedative effects of intranasal atomization (IN_A) of medetomidine with intranasal drops (IN_D) and intramuscular (IM) injection in healthy dogs.

STUDY DESIGN

Prospective, blinded, randomized study.

ANIMALS

A group of 18 mixed-breed shelter-owned dogs weighing 27 ± 4.3 kg (mean ± standard deviation).

METHODS

The dogs were randomly assigned to equal groups of six dogs for administration of medetomidine (40 μg kg^-1) by IN_A, IN_D and IM routes. Ease of administration was evaluated using a resistance scale. Composite sedation score (CSS), heart rate (HR) and respiratory frequency (f_R) were measured immediately before (T0, baseline) and after drug administration at time points 15, 45, 75 and 120 minutes. The time of onset of sedation was recorded. Ease of administration and onset of sedation were analysed by the Kruskal-Wallis and post hoc Dunn's tests. Repeated measures analysis of anova and least significant difference tests were used to analyse CSS, HR and f_R over time. Tukey's post hoc test was used for time point comparisons among groups. Significance was set at p < 0.05.

RESULTS

No differences were detected among groups for ease of administration (p = 0.346). CSS increased in all groups from baseline values. Onset of sedation in IM was 6.3 ± 2.0 minutes, in IN_A was 7.2 ± 2.5 minutes and in IN_D was 20.7 ± 5.4 minutes. CSS in IN_D was lower than in the other groups at T15 and lower than in IN_A at T45. CSS was not different between IM and IN_A. HR and f_R decreased in all groups compared with respective baseline values. HR in IN_D was lower than in IM at T45-T120.

CONCLUSIONS AND CLINICAL RELEVANCE

IN_A medetomidine (40 μg kg^-1) can be an alternative and noninvasive route to IM injections for sedating healthy dogs. IN_D resulted in a slow onset of sedation.

The pearls of pediatric sedation: polish the old and embrace the new

Over the past decade, as the complexity and breadth of pediatric procedures increases, the actual choices of approved sedatives have remained relatively stagnant. Since the introduction of midazolam, there has not been a sedative approved for pediatric labelling until December 2018. This December, the European approval of ADV6209 (Ozalin) for pediatric usage marked the newest addition to the pediatric sedative armamentarium in over a decade. This review is timely and significant because it will provide a balanced evaluation of the most common sedatives in use today, the most recent sedative to be approved and, most importantly, a critical look at the literature supporting the latest approaches to the most commonly performed procedures.

Premedication for Endotracheal Intubation in the Neonate

Endotracheal intubation, a common procedure in neonatal intensive care, results in distress and disturbs physiologic homeostasis in the newborn. Analgesics, sedatives, vagolytics, and/or muscle relaxants have the potential to blunt these adverse effects, reduce the duration of the procedure, and minimize the number of attempts necessary to intubate the neonate. The medical care team must understand efficacy, safety, and pharmacokinetic data for individual medications to select the optimal cocktail for each clinical situation. Although many units utilize morphine for analgesia, remifentanil has a superior pharmacokinetic profile and efficacy data. Because of hypotensive effects in preterm neonates, sedation with midazolam should be restricted to near-term and term neonates. A vagolytic, generally atropine, blunts bradycardia induced by vagal stimulation. A muscle relaxant improves procedural success when utilized by experienced practitioners; succinylcholine has an optimal pharmacokinetic profile, but potentially concerning adverse effects; rocuronium may be the agent of choice based on more robust safety data despite a relatively prolonged duration of action. In the absence of an absolute contraindication, neonates should receive analgesia with consideration of sedation, a vagolytic, and a muscle relaxant before endotracheal intubation. Neonatal units must develop protocols for premedication and optimize logistics to ensure safe and timely administration of appropriate agents.