Dexmedetomidine and ketamine for sedation during spinal anesthesia in children

Efficacy and safety of ketamine alone and ketamine-dexmedetomidine combination for sedation for brain computed tomography in paediatric patients with head injuries: A retrospective study

OBJECTIVE

To compare the efficacy and safety of ketamine alone with those of ketamine-dexmedetomidine combination for sedation during brain CT in paediatric patients with head injuries.

METHODS

We retrospectively analysed the data of paediatric patients who underwent sedation for brain CT at the ED. We included patients aged 6 months to 6 years with American Society of Anesthesiologists physical status I or II. The sedative protocol involved the administration of intramuscular (IM) ketamine 3 mg/kg (K), ketamine 2 mg/kg with dexmedetomidine 1.5 μg/kg (KD) or ketamine 1.5 mg/kg with dexmedetomidine 1.5 μg/kg (low-KD). The primary and secondary outcomes were sedation failure and adverse events, respectively.

RESULTS

We included 77 patients; among them, 28, 23 and 26 were in the K, KD and low-KD groups, respectively. In multivariable analysis, the combination groups (KD and low-KD groups) were significantly associated with a lower possibility of sedation failure compared to the K group (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.56). Moreover, there were no significant differences in adverse events between the groups, and the sedation-related time variables also did not significantly differ among the three groups.

CONCLUSIONS

Our findings indicated that a combination of IM ketamine-dexmedetomidine provides effective sedation for paediatric patients undergoing brain CT without significant adverse events. Further research is needed to investigate the potential benefits of using lower doses of ketamine in combination.

Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.

Ketamine-dexmedetomidine combination for sedation in pediatric major surgery in a low-income country

Anorectal malformations are one of the most frequent congenital malformations treated by pediatric surgeons. In low-income countries, the surgical and anesthetic management of children in need of these procedures can be challenging. Limited oxygen supply, lack of equipment, especially pediatric, and intensive care units make the use of regional anesthesia appealing. We present a series of four cases of anorectal malformations corrections in Guinea Bissau, in children up to 13 months of age, under regional anesthesia and sedation with ketodex, a mixture of ketamine and dexmedetomidine (in a proportion of 1 mg to 1 μg). No child developed respiratory depression requiring airway intervention or supplemental oxygen, or had hemodynamic instability.

Do Spinal Needle Sizes Affect the Development of Traumatic CSF in Neonatal LP Procedures?

Lumbar puncture (LP) is widely employed to evaluate infectious, neurological and metabolic diseases in the newborn. Neonatal LP is a difficult procedure with 45–54% success rates. Although there are studies examining traumatic LP failure, studies on the effects of needle sizes are limited. This study was intended to investigate the effect of needle sizes on LP traumatization. Term and premature babies who underwent LP in the neonatal intensive care unit between 30 November 2017 and 30 July 2019 were included in the study by retrospective file scanning. LP was performed by a pediatric or neonatal specialist using a 22 Gauge pen (G) or 25 G pen spinal needle in all cases, with all patients being placed in the lateral decubitus position. The primary outcome was to evaluate the effect of needle sizes used in LP on traumatization. The secondary outcome was to evaluate traumatization rates and complications. A statistically significant difference was determined in the rate of traumatized LP and desaturation development between needle sizes and CSF microscopic findings (p = 0.031, p = 0.005, and p = 0.006, respectively). The study data show that 25 G pen-tip spinal needles cause less traumatic LP in neonates than 22 G pen-tip spinal needles.

Material and sedation-analgesia in the neonatal lumbar puncture procedure

INTRODUCTION

Lumbar puncture (LP) is a frequent procedure during the neonatal period. Correctly performing this technique can avoid many of its complications.

OBJECTIVE

To evaluate the LP procedure in neonates in Spanish hospitals, studying the type of material and the sedation-analgesia used.

MATERIAL AND METHODS

Cross-sectional study conducted in Spain gathering data through a survey research distributed by email through the Segurneo-SEN Hospital Network and the Spanish Neonatal Society. Data on the LP technique in neonates were collected.

RESULTS

A total of 301 participants were analysed. Most professionals used a trocar needle with a stylet as the first option (89.7%); however, when the LP failed or was blood-stained, 32.2% changed the type of needle. A total of 143 doctors gave their subjective feeling about the type of needle: they only use trocar needles with stylet (41.3%), the technique is easier using scalp-vein needles (32.2%), there is less probability of a blood-stained LP, or failed using scalp-vein needles (7.7%), they choose the type of needle depending on the size of the newborn (10.5%), indifference when using one type or another needle (8.4%). Almost all (99%) of the surveyed doctors used some type of analgesia. The most widely used measures were topical anaesthetics (90.3%) and sucrose (82.2%).

CONCLUSIONS

Currently, the LP procedure in the neonatal period is mainly performed with a trocar needle with a stylet and with the widespread use of different analgesic measures.

Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis

OBJECTIVE

To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication.

METHODS

Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events.

RESULTS

15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia.

CONCLUSIONS

DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.

A review of the clinical applications of ketamine in pediatric oncology

Ketamine is a dissociative anesthetic agent with excellent analgesic properties and a favorable safety profile. The feasibility and efficacy of various routes of administration have been established, including intravenous (IV), intramuscular (IM), oral, intranasal, rectal, and transdermal routes. The advent of newer anesthetic agents has led to a decline in the use of ketamine as an anesthetic, but its utility in short-term sedation and analgesia has expanded. Its value for chronic pain management in children with cancer is being increasingly recognized but requires more evidence. The use of topical ketamine is largely in investigational stages. Medical use of ketamine is, to a great extent, free from significant long-term neurological side effects. The objective of this review is to provide a brief account of the pharmacology of ketamine and primarily focus on the clinical applications of ketamine in pediatric oncology.

Effects on the Upper Airway Morphology with Intravenous Addition of Ketamine after Dexmedetomidine Administration in Normal Children

General anesthesia decreases the tone of upper airway muscles in a dose-dependent fashion, potentially narrowing the pharyngeal airway. We examined the effects of adding ketamine on the airway configuration after dexmedetomidine administration in spontaneously breathing children with normal airways. 25 children presenting for Magnetic Resonance Imaging (MRI) of the brain/spine under general anesthesia were prospectively recruited in the study. Patients were anesthetized with dexmedetomidine bolus (2 mcg over 10 min) followed by dexmedetomidine infusion (2 mcg·kg−1·h) and ketamine and permitted to breathe spontaneously via the native airway. MR-CINE images of the upper airway were obtained with dexmedetomidine infusion alone (baseline) and 5, 10, and 15 min after administering ketamine bolus (2 mg·kg−1) in two anatomical axial planes at the nasopharynx and the retroglossal upper airway. Airway lumen is segmented with a semi-automatic image processing approach using a region-growing algorithm. Outcome measures of cross-sectional area, transverse and anterior-posterior diameters of the airway in axial planes at the level of the epiglottis in the retroglossal airway, and in the superior nasopharynx were evaluated for changes in airway size with sedation. Airway dimensions corresponding to the maximum, mean, and minimum sizes during a respiratory cycle were obtained to compare the temporal changes in the airway size. The dose-response of adding ketamine to dexmedetomidine alone condition on airway dimensions were examined using mixed-effects of covariance models. 22/25 patients based on inclusion/exclusion criteria were included in the final analysis. The changes in airway measures with the addition of ketamine, when compared to the baseline of dexmedetomidine alone, were statistically insignificant. The modest changes in airway dimensions are clinically less impactful and within the accuracy of the semi-automatic airway segmentation approach. The effect sizes were small for most airway measures. The duration of ketamine seems to not affect the airway size. In conclusion, adding ketamine to dexmedetomidine did not significantly reduce upper airway configuration when compared to dexmedetomidine alone.

[Material and sedation-analgesia in the neonatal lumbar puncture procedure]

INTRODUCTION

Lumbar puncture (LP) is a frequent procedure during the neonatal period. Correctly performing this technique can avoid many of its complications.

OBJECTIVE

To evaluate the LP procedure in neonates in Spanish hospitals, studying the type of material and the sedation-analgesia used.

MATERIAL AND METHODS

Cross-sectional study conducted in Spain gathering data through a survey research distributed by email through the Segurneo-SEN Hospital Network and the Spanish Neonatal Society. Data on the LP technique in neonates were collected.

RESULTS

A total of 301 participants were analysed. Most professionals used a trocar needle with a stylet as the first option (89.7%); however, when the LP failed or was blood-stained, 32.2% changed the type of needle. A total of 143 doctors gave their subjective feeling about the type of needle: they only use trocar needles with stylet (41.3%), the technique is easier using scalp-vein needles (32.2%), there is less probability of a blood-stained LP, or failed using scalp-vein needles (7.7%), they choose the type of needle depending on the size of the new-born (10.5%), indifference when using one type or another needle (8.4%). Almost all (99%) of the surveyed doctors used some type of analgesia. The most widely used measures were topical anaesthetics (90.3%) and sucrose (82.2%).

CONCLUSIONS

Currently, the LP procedure in the neonatal period is mainly performed with a trocar needle with a stylet and with the widespread use of different analgesic measures.

Addition of dexmedetomidine, tramadol and neostigmine to lidocaine 1.5% increasing the duration of postoperative analgesia in the lower abdominal pain surgery among children: A double-blinded randomized clinical study

Pain is a common complication after surgery. Insufficient control of postoperative pain has adverse effects on the physiological, metabolic and psychological state of the child. The use of local analgesics and anesthetics alone cannot produce complete anesthesia and intraoperative comfort. The addition of adjuvant drugs is commonly used to improve the quality of the block. Therefore, adding new supplements may increase the duration of analgesia. The aim of this study was to compare the addition of dexmedetomidine, tramadol and neostigmine to lidocaine 1.5% in increasing the duration of postoperative analgesia in the lower abdominal pain surgery in children aged 2–8 years. This double-blind randomized clinical trial was conducted on children candidate for lower abdominal surgery. The 96 patients were randomly divided into 3 groups including dexmedetomidine, neostigmine, and tramadol. For all children, 3 mg of midazolam was administered orally before entering the operating room. The patients underwent general anesthesia with 2 μg/kg fentanyl, 0.03 mg/kg midazolam, 0.5 mg/kg atracurium and 5–6 mg/kg thiopental. After determining the hiatus membrane, 2 mL syringes containing air and distilled water (each of which 1 mL) slowly entered the space. After eliminating caudal resistance, 1.5% lidocaine was injected at dose of 0.5 mL/kg. A total of 96 patients were enrolled in this study. The results revealed that pain scores in the dexmedetomidine group in recovery, 2, 6 and 12 hours after surgery were less than the other two groups. Furthermore, the tramadol group showed a lower score in comparison with the neostigmine group and the duration of analgesia in the dexmedetomidine group was more than the other two groups. In addition, the mean of analgesic at 24 hours after operation in the dexmedetomidine group was lower as compared to the other two groups, indicating the effect of dexmedetomidine as an adjuvant in increasing the duration of analgesia and reducing postoperative pain in patients along with lidocaine 1.5%. All three drugs (neostigmine, tramadol and dexmedetomidine drugs), along with other local anesthetic, increased the duration of analgesia and decreased postoperative pain in children. The effect of dexmedetomidine was greater than the other two drugs. The study was approved by the Ethics Committee of Arak University of Medical Sciences, Iran (approved No. IR.ARAKMU.REC.1396.112) on October 28, 2017, and registered at Iranian Registry of Clinical Trials (registration No. IRCT20141209020258N83) on August 29, 2018.

Intranasal dexmedetomidine and intravenous ketamine for procedural sedation in a child with alpha-mannosidosis: a magic bullet?

Background

Procedural sedation is increasingly needed in pediatrics. Although different drugs or drugs association are available, which is the safest and most efficient has yet to be defined, especially in syndromic children with increased sedation-related risk factors.

Case report

we report the case of a five-year-old child affected by alpha-mannosidosis who required procedural sedation for an MRI scan and a lumbar puncture. We administered intranasal dexmedetomidine (4 μg/kg) 45 min before intravenous cannulation, followed by one bolus of ketamine (1 mg/kg) for each procedure. The patient maintained spontaneous breathing and no desaturation or any complication occurred.

Conclusion

intranasal dexmedetomidine and intravenous ketamine could be a feasible option for MRI and lumbar puncture in children with alpha-mannosidosis needing 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.

Safety and efficacy of ketamine-dexmedetomidine versus ketamine-propofol combinations for sedation in patients after coronary artery bypass graft surgery

Background and Aims:

Prolonged mechanical ventilation after cardiac surgery is associated with serious complications that increase morbidity and mortality. The present study was designed to compare ketamine-propofol (KP) and ketamine-dexmedetomidine (KD) combinations for sedation and analgesia in patients after coronary artery bypass graft (CABG) surgery as regards hemodynamics, total fentanyl dose, time of weaning from mechanical ventilation, time of extubation, and any adverse outcome.

Materials and Methods:

Seventy post-CABG patients were sedated using ketamine 1 mg/kg IV then 0.25 mg/kg/h infusion combined with either dexmedetomidine or propofol to maintain Ramsay sedation score ≥4 during assisted ventilation. Group KP received ketamine + propofol 1 mg/kg bolus followed by 25–50 μg/kg/min. Group KD received ketamine + dexmedetomidine 1.0 μg/kg over 20 min and then 0.2–0.7 μg/kg/h. Total dose of fentanyl in the first 24 h, time of weaning, time of extubation, mean arterial blood pressure, heart rate, and Intensive Care Unit (ICU) stay time were recorded.

Statistics:

Sample size of 35 patients was calculated for 90% power, α = 0.05, β = 0.1, and anticipated effect size = 0.40 using sample size software (G*Power version 3.00.10, Germany). Analytic statistics was performed on IBM compatible computer using SPSS version 11.5 (IBM, New York, United States) software package under Windows XP operating system. All results presented in the form of mean ± standard deviation. Data compared using unpaired Student's t-test, P < 0.05 was considered as statistically significant.

Results:

Group KD showed a significant decrease in mean time of weaning and extubation in group KD in comparison with group KP (374.05 ± 20.25 min vs. 445.23 ± 21.7 min, respectively, P < 0.001) (432.4 ± 19.4 min and 504 ± 28.7 min, respectively, P < 0.0001). Fentanyl consumption showed a significant decrease in group KD in comparison with group KP (41.94 ± 20.43 μg and 152.8 ± 51.2 μg, respectively, with P < 0.0001). There were insignificant difference between both groups as regards hemodynamic stability and length of ICU stay.

Conclusion:

Using KD combination for sedation, post-CABG surgery provided short duration of mechanical ventilation with less fentanyl dose requirement in comparison with KP with insignificant difference in both groups as regards hemodynamic stability and length of the ICU stay.

Dexmedetomidine as a Supplement to Spinal Anesthesia Block: A Case Report of Three Infants

We report a novel use for dexmedetomidine as a supplemental intravenous or intranasal sedative for spinal anesthesia in infants. The children were 1, 2, and 9 months old having either inguinal hernia repair or circumcision. None of them experienced clinically relevant hemodynamic changes or apnea. Pain scores were zero throughout the postoperative period.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

Dexmedetomidine-ketamine combination and caudal block for superficial lower abdominal and genital surgery in children

BACKGROUND

The use of dexmedetomidine-ketamine combination to perform different diagnostic and surgical pediatric procedures has increased. The optimal ketamine dose to combine with dexmedetomidine has not been determined. The goal of this study was to determine the ED50 and ED95 of ketamine, which in combination with, dexmedetomidine (1 μg · kg(-1)) provides an adequate anesthetic effect to perform a caudal block and then the ensuing superficial lower abdominal or genital surgery.

MATERIAL AND METHODS

Twenty-five patients, aged 1-8 years, scheduled for superficial lower abdominal or genital surgery, were studied. All patients received an intravenous dose of dexmedetomidine 1 μg · kg(-1) and a random dose of ketamine from 1 mg · kg(-1) to 2 mg · kg(-1). After ketamine administration, a caudal block was performed and then surgery was initiated. Hemodynamics, respiratory variables, sedation level, and postoperative complications were recorded. The ED50 and ED95 of ketamine were calculated using logistic regression analysis.

RESULTS

The ED50 and ED95 of ketamine to perform a caudal block were 1.53 (1.29-1.76) mg · kg(-1) and 2.25 (1.63-2.88) mg · kg(-1), respectively. The ED50 and ED95 of ketamine to perform a caudal block and to complete the entire procedure were 1.76 (1.57-1.95) mg · kg(-1), and 2.21 (1.77-2.64) mg · kg(-1), respectively. Three patients presented mild, self-limited, intraoperative bradycardia.

CONCLUSIONS

These results suggest that adding ketamine 2 mg · kg(-1) to dexmedetomidine 1 μg · kg(-1) should produce an effective anesthetic level to perform a caudal block and the ensuing superficial lower abdominal or genital surgery in children.

Dexmedetomidine premedication in relevance to ketamine anesthesia: A prospective study

Background:

Ketamine-induced hemodynamic pressor response and psychomimetic effects should be attenuated by appropriate premedication. The present study was designed to evaluate the clinical efficacy and safety of dexmedetomidine premedication for balancing the ketamine-induced hemodynamic pressor response and psychomimetic effects.

Materials and Methods:

A total of 80 normotensive adult consented patients of ASA grade I and II of both genders, aged 21 to 55 years, who met the inclusion criteria for elective surgery under ketamine anesthesia were randomized for this prospective blind study and divided into two treatment groups of 40 patients each. Group I patients received premedication of midazolam and Group II patients received premedication of dexmedetomidine. Anesthetic and surgical techniques were standardized. Both groups were assessed for changes in heart rate and systolic blood pressure intraoperatively and psychomimetic effects with behavioral changes postoperatively.

Results:

Preoperatively, all patients were awake. Intraoperatively, the heart rate was 116.6±4.2 in group I versus 76.8±5.8 in group II (P value 0.0004) and systolic blood pressure was 153.07±16.05 in group I versus 139.17±19.9 in group II (P value 0.001). Post-anesthetic psychomimetic responses were not statistically significant between groups.

Conclusion:

The dexmedetomidine premedication effectively attenuated the ketamine induced hemodynamic pressor response and post-anesthetic delirium effects.

Dexmedetomidine and fentanyl combination for procedural sedation in a case of Duchenne muscular dystrophy

Duchenne muscular dystrophy, an X-linked disorder characterized by progressive muscle weakness, is the most common muscular dystrophy among children leading to death before the end of third decade. Anesthesia in such patients pose a great challenge due to various complications associated with it. The dreaded metabolic and clinical complications occur due to various inhalational anesthetics and succinylcholine in this subset of patients. We are reporting a child with diagnosed Duchenne muscular dystrophy who underwent excision of dentigerous cyst in oral cavity under procedural sedation with combination of dexmedetomidine and fentanyl and thus administration of general anesthesia was avoided.

Developmental neurotoxicity of ketamine in pediatric clinical use

Ketamine is widely used as an anesthetic, analgesic, and sedative in pediatric clinical practice and it is also listed as an illicit drug by most countries. Recent in vivo and in vitro animal studies have confirmed that ketamine can induce neuronal cell death in the immature brain, resulting from widespread neuronal apoptosis. These effects can disturb normal development further altering the structure and functions of the brain. Our recent studies further indicate that ketamine can alter neurogenesis from neural stem progenitor cells in the developing brain. Taken together, these findings identify a novel complication associated with ketamine use in premature infants, term newborns, and pregnant women. Recent data on the developmental neurotoxicity of ketamine are reviewed with proposed future directions for evaluating the safety of ketamine in these patient populations.

Comparison of effects of dexmedetomidine-ketamine and dexmedetomidine-midazolam combinations in transurethral procedures

OBJECTIVE

To compare the effects of dexmedetomidine-ketamine and dexmedetomidine-midazolam combinations on the recovery time, hemodynamic and respiratory variables, and side effects in patients undergoing transurethral procedures.

METHODS

Sixty patients scheduled for elective outpatient transurethral procedure were randomized into 2 groups. In the group K, a ketamine-dexmedetomidine combination was administered, and in the group M, midazolam-dexmedetomidine was administered, to provide sedation/analgesia. Pain and sedation levels were assessed using visual analog score (VAS) and Ramsey Sedation Scale, respectively. The recovery time was assessed with the scale of Aldrete. Time was measured and recorded to the moment at which patient responses brought the Aldrete score to 10 points. Time to eye opening and length of stay in the recovery room were recorded.

RESULTS

Group M showed significantly lower mean arterial pressure (MAP) values at 5 and 10 minutes during the procedure when compared with group K (P = .02 and P = .01, respectively). Visual analogue scale scores were greater in group M than in group K at 5 and 10 minutes for the transurethral procedure (P = .039 and P = .028, respectively). Sedation scores were similar between groups during the procedure. Time to eye opening and length of recovery room stay were shorter (P < .001 and P < .001, respectively), and Aldrete scores were greater in group K than group M.

CONCLUSION

Both combinations provided satisfactory sedation levels, but the dexmedetomidine-ketamine combination provided better analgesia and hemodynamic stability, with less nausea and vomiting and shorter recovery time, than the dexmedetomidine-midazolam combination.

Dexmedetomidine-ketamine sedation during upper gastrointestinal endoscopy and biopsy in a patient with Duchenne muscular dystrophy and egg allergy

Sedation during invasive procedures provides appropriate humanitarian care as well as facilitating the completion of procedure. Although generally safe and effective, adverse effects may occur especially in patients with co-morbid diseases. In many cases, given its rapid onset and offset, propofol is chosen to provide sedation during various invasive procedures. We present a nine-year-old, 45 kg child with Duchenne muscular dystrophy (DMD) who presented for esophagogastroduodenoscopy (EGD). Given the egg allergy, which was a relative contraindication to the use of propofol, and the potential risk of malignant hyperthermia due to DMD, a combination of dexmedetomidine and ketamine was used for procedural sedation. Dexmedetomidine was administered as a loading dose of 1 μg/kg along with a single bolus dose of ketamine (1 mg/kg). This was followed by a dexmedetomidine infusion at 0.5 μg/kg/hour. The patient tolerated the procedure well and was discharged to home. Previous reports regarding the use of dexmedetomidine and ketamine for procedural sedation are reviewed and the potential efficacy of this combination is discussed.

Dexmedetomidine reduces emergence agitation after tonsillectomy in children by sevoflurane anesthesia: a case-control study

OBJECTIVE

To evaluate the efficacy and safety of dexmedetomidine for emergence agitation after tonsillectomy in children.

METHODS

120 ASA physical status I and II children, aged 5-14 years, undergoing anesthesia for tonsillectomy, were randomly divided into 3 groups: Placebo group, the low dexmedetomidine concentration group and the high dexmedetomidine concentration group. Before the entrance of the operating room (OR), all of the children received intravenous injection 40 μg kg(-1) midazolam to reduce anxiety at first, and then dexmedetomidine was given intravenously at an initial loading dose of 0.5 μg kg(-1) or 1 μg/kg over a 10-min period via a computer controlled infusion pump followed by a maintenance infusion of 0.2 μg kg(-1)h(-1) or 0.4 μg kg(-1)h(-1)over the surgery. The heart rate, SpO(2) and mean arterial blood pressure were recorded for each patient in both operation room and PACU. The designated time points: at the start of the anesthetic induction, at the discontinuation of inhalational agents, at first opening of eyes, at time to remove endotracheal tube were recorded. After patient arrival at the PACU, VAS score, RSS, the occurrence of emergence agitation were recorded every 5 min for the first 30 min and every 10 min for the next 30 min after endotracheal tube was removed.

RESULTS

There was significant difference in the incidence of emergence agitation between Placebo group and the high concentration group when endotracheal tube was removed (P<0.05). There was significant difference in the VAS pain scores and in the RSS between three groups at the time of extubation, as well as 5 min and 10 min after extubation (P<0.05).

CONCLUSIONS

Dexmedetomidine appears to be safe and effective to reduce the incidence of early emergence agitation in children after tonsillectomy. Initial loading dose of 1.0 μg kg(-1) followed by a maintenance infusion of 0.4 μg kg(-1)h(-1) is better choice for children received tonsillectomy.

Dexmedetomidine and ketamine: an effective alternative for procedural sedation?

OBJECTIVES

Although generally effective for sedation during noninvasive procedures, dexmedetomidine as the sole agent has not been uniformly successful for invasive procedures. To overcome some of the pitfalls with dexmedetomidine as the sole agent, there are an increasing number of reports regarding its combination with ketamine. This article provides a descriptive account of the reports from the literature regarding the use of a combination of dexmedetomidine and ketamine for procedural sedation.

DATA SOURCE

A computerized bibliographic search of the literature regarding dexmedetomidine and ketamine for procedural sedation.

MEASUREMENTS AND MAIN RESULTS

The literature contains four reports with cohorts of more than ten patients with a total of 122 patients. Two of these studies were prospective randomized trials. Additionally, there are eight single case reports or small case series (six patients or less) with an additional 21 pediatric patients. When used together, dexmedetomidine may prevent the tachycardia, hypertension, salivation, and emergence phenomena from ketamine, whereas ketamine may prevent the bradycardia and hypotension, which has been reported with dexmedetomidine. An additional benefit is that the addition of ketamine to initiate the sedation process speeds the onset of sedation, thereby eliminating the slow onset time when dexmedetomidine is the sole agent. Although various regimens have been reported in the literature, the most effective regimen appears to be the use of a bolus dose of both agents, dexmedetomidine (1 µg/kg) and ketamine (1-2 mg/kg), to initiate sedation. This can then be followed by a dexmedetomidine infusion (1-2 µg/kg/hr) with supplemental bolus doses of ketamine (0.5-1 mg/kg) as needed.

CONCLUSIONS

The available literature except for one trial is favorable regarding the utility of a combination of ketamine and dexmedetomidine for procedural sedation. Future studies with direct comparisons to other regimens appear warranted for both invasive and noninvasive procedures.

Dexmedetomidine-Ketamine Sedation in a Child With a Mediastinal Mass

Sedation during invasive procedures provides appropriate humanitarian care as well as facilitates the completion of procedures. Although generally safe and effective, adverse effects may occur especially in patients with comorbid diseases. One particularly challenging situation is the child with an anterior mediastinal mass who requires sedation during performance of a biopsy to obtain a tissue diagnosis. When there is evidence of airway compromise, it is generally accepted that the maintenance of spontaneous ventilation is necessary as complete airway obstruction may occur, if positive pressure ventilation is chosen. We present the use of a dexmedetomidine–ketamine combination for procedural sedation in a three-year-old child who presented with a large mediastinal mass and respiratory compromise. Previous reports regarding the use of dexmedetomidine and ketamine for procedural sedation are reviewed and the potential efficacy of this combination is discussed.

Dexmedetomidine-ketamine sedation during bone marrow aspirate and biopsy in a patient with duchenne muscular dystrophy

Sedation during invasive procedures not only provides appropriate humanitarian care for patients, but also facilitates the completion of invasive procedures. Although generally safe and effective, adverse effects may occur especially in patients with co-morbid diseases. We present the successful use of a combination of dexmedetomidine and ketamine to provide sedation and analgesia in a 21-year-old patient with Duchenne muscular dystrophy (DMD) undergoing bone marrow aspiration and biopsy. Co-morbidities included both depressed myocardial function and impaired respiratory function. Dexmedetomidine was administered as a loading dose of 1 μg/kg over 5 min followed by an infusion of 1 μg/kg/h. Ketamine (20 mg) was administered along with the dexmedetomidine loading dose. An additional 10 mg of ketamine was administered to treat the pain experienced during the placement of the local anesthetic agent prior to the procedure. No clinically significant hemodynamic or respiratory changes were noted. The patient tolerated the procedure well and was discharged home. A review of previously published reports of dexmedetomidine and ketamine for procedural sedation are reviewed.