Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging

Intranasal dexmedetomidine for sedation in ABR testing in children: No pain, big gain!

OBJECTIVES

Obtaining perfect immobility or sleep in children undergoing ABR auditory brainstem response) testing can be challenging. We examined the effectiveness and safety of intranasal dexmedetomidine for sedation of children undergoing ABR testing.

MATERIAL AND METHODS

We included prospectively all patients aged from 1 to 15 years for whom sedation for ABR testing was required, between July 2018 and November 2021. We administered an initial dose of 2.5 μg/kg intranasal dexmedetomidine with a repeat dose of 1 μg/kg if needed 30 min later. Collected data included success rate of sedation, sedation onset and recovery times and incidence of side effects.

RESULTS

ABR testing was undertaken successfully in 57 of the 59 patients, giving a total success rate of 96,6 %. (95 % confidence interval 88.5 %-99.1 %). The median time to onset of sleep was 32 ± 18.3 min. The median duration of sedation recovery time was 48 ± 24.7 min. We recorded the adverse effects. Thirty-one patients experienced bradycardia and 28 patients experienced hypotension, all of which resolved without intervention.

CONCLUSION

Intranasal dexmedetomidine is an effective, safe, simple of use and noninvasive method for sedation in children. It could have a major role in auditory brainstem response testing, specially in the case of non-cooperative children.

REGISTRATION NUMBER OF THE TRIAL

NCT03530371.

Combination of Intranasal Dexmedetomidine and Midazolam for Sedation in Pediatric Magnetic Resonance Imaging: A Retrospective Observational Study

BACKGROUND

Intranasal dexmedetomidine associated with midazolam has been used for pediatric magnetic resonance imaging studies because immobility is a fundamental requirement for correct execution. Many studies have shown dexmedetomidine to be a good option for non-operating room sedation. However, identifying the optimal dose remains a key challenge, especially for pediatric patients.

METHODS

All medical records of 139 pediatric patients who underwent sedation for magnetic resonance imaging studies between September 2021 and November 2022 at the University Hospital of Salerno, Italy, were retrospectively reviewed about success rate and adverse events. Our protocol required dosing 30 minutes before the procedure. Patients weighing up to 40 kg received intranasal dexmedetomidine (3 μg/kg) with intranasal midazolam (0.2 mg/kg). Those weighing more than 40 kg received intranasal dexmedetomidine (2 μg/kg) with midazolam orally (0.3 mg/kg; maximum dose, 15 mg).

RESULTS

A total of 139 pediatric patients, with age range between 2 months and 16 years, median (95% confidence interval) of 3 (3-5) years, and weight range between 4 and 70 kg, median (95% confidence interval) of 19 (15-24) kg, were reviewed.The procedure was satisfactorily completed in 93.5% (130 patients) ( P < 0.01). Only 9 (6.5%) patients completed the procedure with general anesthesia; there are hot adverse events.

CONCLUSIONS

Our experience with association of intranasal dexmedetomidine and midazolam has a high success rate, with high effectiveness and safety.

Combined sedation in pediatric magnetic resonance imaging: determination of median effective dose of intranasal dexmedetomidine combined with oral midazolam

BACKGROUND

The exact median effective dose (ED50) of intranasal dexmedetomidine combined with oral midazolam sedation for magnetic resonance imaging (MRI) examination in children remains unknow and the aim of this study was to determine the ED50 of their combination.

METHODS

This is a prospective dose-finding study. A total of 53 children aged from 2 months to 6 years scheduled for MRI examination from February 2023 to April 2023 were randomly divided into group D (to determine the ED50 of intranasal dexmedetomidine) and group M (to determine the ED50 of oral midazolam). The dosage of dexmedetomidine and midazolam was adjusted according to the modified Dixon's up-and-down method, and the ED50 was calculated with a probit regression approach.

RESULTS

The ED50 of intranasal dexmedetomidine when combined with 0.5 mg∙kg- 1 oral midazolam was 0.39 µg∙kg- 1 [95% confidence interval (CI) 0.30 to 0.46 µg∙kg- 1] while the ED50 of oral midazolam was 0.17 mg∙kg- 1 (95% CI 0.01 to 0.29 mg∙kg- 1) when combined with 1 µg∙kg- 1 intranasal dexmedetomidine. The sedation onset time of children with successful sedation in group D was longer than in group M (30.0[25.0, 38.0]vs 19.5[15.0, 35.0] min, P < 0.05). No other adverse effects were observed in the day and 24 h after medication except one dysphoria.

CONCLUSION

This drug combination sedation regimen appears suitable for children scheduled for MRI examinations, offering a more precise approach to guide the clinical use of sedative drugs in children.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR2300068611(24/02/2023).

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/.

Retrospective comparison between MRI examinations during radiographer-administered intranasal sedation or general anesthesia

INTRODUCTION

In order for young children to be able to undergo a Magnetic Resonance Imaging (MRI) examination, general anesthesia is often required. The aim of this study was to compare the image quality, times, and costs of the examinations of infant brains performed with MRI either during sedation with dexmedetomidine administered by radiographers or anesthesia with propofol administered by anesthesia staff.

METHODS

This study was a quantitative retrospective study of 27 consecutive standard brain examinations performed under sedation or anesthesia, involving 15 children under sedation and 12 under anesthesia. The age of the children was from 0.5 to five years old. The image quality was evaluated by three radiologists experienced in pediatric MRI examinations. Information such as examination time and the expense of the examination was also collected.

RESULTS

There was no statistically significant difference in the general image quality, but one image series was assessed to have significantly better image quality under sedation than under anesthesia, but all images had very high quality. However, it emerged that children under anesthesia were at the hospital on average 55 min longer and the scanner room was occupied 20 min longer on average. The anesthesia examinations were three times more expensive.

CONCLUSION

This study demonstrated equivalent image quality between sedation and anesthesia. In addition, sedation was less time-consuming and had a lower price, partly because no extra anesthetic staff were required. The use of intranasal sedation offers a possibility to expand the competence area for radiographers.

IMPLICATIONS FOR PRACTICE

If radiographers learn to perform intranasal sedation, examinations can be performed in less time, at a third of the staff costs while maintaining image quality.

Intranasal Dexmedetomidine With Intravenous Midazolam: A Safe and Effective Alternative in the Paediatric MRI Sedation

Background and aims MRI sedation in paediatrics includes challenges like respiratory depression, maintaining haemodynamic stability and use of neuroprotective drugs, since MRI is performed in remote places outside the operating room with a lack of support staff and nonavailability of choice of medications and equipments. The primary aim was to use a combination of the drugs to encounter the above challenges and look for its efficacy. The secondary aim of the study was to determine the rate of successful completion of MRI in children using a combination of intranasal dexmedetomidine and intravenous midazolam - without the need for rescue sedatives. Methods This is an observational study involving 60 children in the age group between two months and six years undergoing an MRI. Children belonging to the American Society of Anesthesiology (ASA) 1 and 2 were given intranasal dexmedetomidine 3µg/kg, time to onset of sedation was noted and injection of midazolam 0.1 mg/kg was given intravenously. MRI was started once the child was asleep. Children who woke up during the MRI were supplemented with inj. propofol 0.5-1mg/kg and were documented. Results The median time duration for MRI was 38.7 min and the onset of sedation after intranasal dexmedetomidine was 18.7 min. The scan was successfully completed with a combination of intranasal dexmedetomidine and intravenous midazolam in 86.7% and only 13.3% of the children woke up either at the start or in between the scan and required the addition of propofol. Conclusion Drugs used for sedation during MRI should not cause respiratory depression and be safe for the developing brain. The above study has shown that a combination of intranasal dexmedetomidine and intravenous midazolam is effective and safe in performing MRIs in paediatrics.

Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department

OBJECTIVES

In recent years, dexmedetomidine has gained traction as a treatment for anxiolysis in the emergency department (ED). When used with an atomizer, it may also be given intranasally for anxiolysis. The primary objective was to determine the level of ED provider satisfaction and comfort with intranasal (IN) dexmedetomidine for anxiolysis in pediatric patients with behavioral agitation and/or acute psychosis. The secondary objectives included determining safety, rates of therapy failure, and ED length of stay compared with oral midazolam. The efficacy of IN dexmedetomidine versus oral midazolam in patients with autism spectrum disorder (ASD) was also evaluated.

METHODS

This was a single-center, prospective study in a pediatric ED from March 1 to December 31, 2021. Patients were included in the study if the ED provider requested IN dexmedetomidine anxiolysis and completed a postadministration survey. Safety and efficacy outcomes were assessed by chart review and compared with patients who received oral midazolam during the same study period. Efficacy was defined as the rate of treatment failure, as the need for procedural termination, progression to procedural sedation, or the requirement of additional medications for anxiolysis.

RESULTS

Sixty-two patients received IN dexmedetomidine {median dose [interquartile range (IQR)] of 3.05 [2.04-4.00] μg/kg/dose} compared with 58 who received oral midazolam [median (IQR) dose of 0.29 (0.25-0.48) mg/kg/dose). Providers reported high comfort and satisfaction scores, with median (IQR) scores of 90 (75-100) and 88 (60-100) of 100. Twenty-nine percent of patients experienced treatment failure, most commonly because of the need for additional medications. Those who received IN dexmedetomidine had a longer ED length of stay (6.0 vs 4.4 hours, P = 0.010). Among the patients with ASD, those who received IN dexmedetomidine had a lower rate of treatment failure compared with oral midazolam (21.2% vs 66.7%, P = 0.039).

CONCLUSIONS

This study demonstrates that IN dexmedetomidine has high levels of provider comfort and satisfaction, moderately high success rate, and a promising safety profile. In addition, IN dexmedetomidine may be superior to oral midazolam in patients with ASD for anxiolysis, but additional studies are needed.

Prospective, randomized, double-blind, double-dummy, active-controlled, phase 3 clinical trial comparing the safety and efficacy of intranasal dexmedetomidine to oral midazolam as premedication for propofol sedation in pediatric patients undergoing magnetic resonance imaging: the MIDEX MRI trial

BACKGROUND

Children under 6 years who need magnetic resonance imaging usually require sedation to obtain best quality images, but the optimal sedation protocol remains to be determined. In 2018, we showed a 22% interruption in image acquisition during magnetic resonance imaging when performing a propofol-based sedation using a bolus approach. As non-pharmacological premedication is often insufficient to reduce the anxiety of children related to parental separation, pharmacological premedication may be useful to facilitate the induction of anesthesia. In our institution, effective premedication is obtained oral intake of midazolam, though its administration relies on patients' compliance and could also lead to paradoxical reaction. Dexmedetomidine has a safe profile in the pediatric population and can therefore represent an interesting alternative. The primary objective of this trial is to demonstrate the superiority of intranasal dexmedetomidine compared to oral midazolam as premedication in reducing the occurrence of any event requiring temporary or definitive interruption of the examination to allow anesthesiologist intervention in children undergoing magnetic resonance imaging under propofol sedation.

METHODS

In this single-center, prospective, randomized, double-blind, double-dummy, active comparator-controlled, superiority trial, we planned to include 250 patients, aged 6 months to 6 years, undergoing a scheduled magnetic resonance imaging requiring the presence of an anesthesiologist. After informed consent, the patients will be randomized to receive either oral midazolam or intranasal dexmedetomidine as premedication. The data will be analyzed in intention to treat, using Kolmogorov-Smirnov Z, chi-square, Wilcoxon, and Mann-Whitney U tests. A P-value < 0.05 will be considered statistically significant.

DISCUSSION

The MIDEX MRI study will assess the efficacy of intranasal dexmedetomidine compared to oral midazolam to improve the quality of a propofol-based sedation prior to magnetic resonance imaging, without negative repercussion on the postoperative period.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05192629 . Registered on 14 January 2022. Protocol version 2.1.

Intranasal dexmedetomidine for transthoracic echocardiography in infants with shunt-dependent single ventricle heart disease

OBJECTIVES

We investigated the efficacy and complication profile of intranasal dexmedetomidine for transthoracic echocardiography sedation in patients with single ventricle physiology and shunt-dependent pulmonary blood flow during the high-risk interstage period.

METHODS

A single-centre, retrospective review identified interstage infants who received dexmedetomidine for echocardiography sedation. Baseline and procedural vitals were reported. Significant adverse events related to sedation were defined as an escalation in care or need for any additional/increased inotropic support to maintain pre-procedural haemodynamics. Minor adverse events were defined as changes from baseline haemodynamics that resolved without intervention. To assess whether sedation was adequate, echocardiogram reports were reviewed for completeness.

RESULTS

From September to December 2020, five interstage patients (age 29-69 days) were sedated with 3 mcg/kg intranasal dexmedetomidine. The median sedation onset time and duration time was 24 minutes (range 12-43 minutes) and 60 minutes (range 33-60 minutes), respectively. Sedation was deemed adequate in all patients as complete echocardiograms were accomplished without a rescue dose. When compared to baseline, three (60%) patients had a >10% reduction in heart rate, one (20%) patient had a >10% reduction in oxygen saturations, and one (20%) patient had a >30% decrease in blood pressure. Amongst all patients, no significant complications occurred and haemodynamic changes from baseline did not result in need for intervention or interruption of study.

CONCLUSIONS

Intranasal dexmedetomidine may be a reasonable option for echocardiography sedation in infants with shunt-dependent single ventricle heart disease, and further investigation is warranted to ensure efficacy and safety in an outpatient setting.

Intranasal Dexmedetomidine for Pain Management in Older Patients: A Cross-Over, Randomized, Double-Blinded, Active-Controlled Trial

BACKGROUND

Daily care procedures provoke breakthrough pain and anxiety in palliative situations. Dexmedetomidine may be an alternative to opioids during nursing procedures for older patients.

OBJECTIVE

We aimed to compare the efficacy of intranasal dexmedetomidine with subcutaneous opioids on the intensity of pain and anxiety during comfort management procedures.

METHODS

We conducted a randomized, active-controlled, double-blind, crossover trial (NCT03151863). Patients aged ≥ 65 years were randomized to receive, 45 min before nursing care, either intranasal dexmedetomidine together with subcutaneous placebo or intranasal placebo together with a subcutaneous opioid. Each of these two interventions were administered in a cross-over design and spaced out over a 24- or 48-h period. The primary outcome was the number of patients with an Elderly Caring Pain Assessment score > 5. Secondary outcomes included pain, sedation score, and vital signs.

RESULTS

Because of difficult recruitment, the trial was interrupted after the inclusion of 24 patients. Three patients withdrew after randomization, leaving 21 patients undergoing 42 complete sessions for descriptive analyses. Of the 21 patients, 12 (57.1%) were women, and their median age was 84 years, interquartile range (75-87 years). Nine (42.9%) patients presented an Elderly Caring Pain Assessment score > 5 when receiving subcutaneous opioids, and seven (33.3%) with intranasal dexmedetomidine. Hypoxemia occurred in a single patient receiving subcutaneous opioids. No episode of bradycardia was observed.

CONCLUSIONS

Intranasal dexmedetomidine is feasible in elderly patients and may be an alternative to opioids to ensure comfort during nursing care. Future studies are needed to confirm the efficacy and safety of this procedure.

The use of dexmedetomidine in the emergency department: A systematic review

BACKGROUND

Dexmedetomidine (DEX), a centrally acting alpha-2 agonist, is increasingly used for sedation in multiple clinical settings. Evidence from the intensive care unit and operative settings suggests DEX may have significant advantages over traditional GABAergic sedatives such as benzodiazepines. There has been limited research on the use of DEX in the emergency department (ED).

METHODS

We performed a systematic review of the medical literature to identify all published evidence regarding the use of DEX in the ED. We included randomized and nonrandomized studies and studies reporting any use of DEX in the ED, even when it was not the primary focus of the study. Two authors reviewed studies for inclusion, and a single author assessed studies for quality and risk of bias and abstracted data.

RESULTS

We identified 35 studies meeting inclusion criteria, including 11 randomized controlled trials, 13 cohort and other nonrandomized studies, and 11 case reports and case series. Significant heterogeneity in interventions, comparators, indications, and outcomes precluded data pooling and meta-analysis. We found modest evidence that DEX was efficacious in facilitating medical imaging and mixed and limited evidence regarding its efficacy for procedural sedation and sedation of nonintubated medical and psychiatric patients. Our results suggested that DEX is associated with bradycardia and hypotension, which are generally transient and infrequently require medical intervention.

CONCLUSIONS

A limited body of generally poor- to moderate-quality evidence suggests that the use of DEX may be efficacious in certain clinical scenarios in the ED and that DEX use in the ED is likely safe. Further high-quality research into DEX use in the ED setting is needed, with a particular focus on clear and consistent selection of indications, identification of clear and clinically relevant primary outcomes, and careful assessment of the clinical implications of the hemodynamic effects of DEX therapy.

Intranasal dexmedetomidine sedation for paediatric MRI by radiology personnel: A retrospective observational study

BACKGROUND

MRI often requires sedation or anaesthesia to ensure good image quality in paediatric patients. Access to paediatric anaesthesia services is, however, a limiting factor for effective paediatric MRI service, and alternative sedation methods are, therefore, warranted.

OBJECTIVE

To investigate the efficacy and safety of an intranasal dexmedetomidine sedation program for paediatric MRI, without immediate presence of anaesthesia personnel.

DESIGN

Single institution retrospective observational study.

SETTING

Tertiary care paediatric hospital.

PATIENTS

Children 0 to 12 years, ASA risk class 1 or 2 with heart rate within age-appropriate limit.

INTERVENTION

Radiology personnel administered an initial dose of intranasal dexmedetomidine of 4 μg kg -1 followed by a second dose of 2 μg kg -1 to the patients if needed. Recordings of image quality, critical events, heart rate, pulse oximetry saturation and noninvasive blood pressure before and after dexmedetomidine administration were made.

MAIN OUTCOME MEASURES

Changes in haemodynamic and respiratory data before vs. after intranasal dexmedetomidine were analysed for changes, and the incidence of critical events was evaluated as well as rate of successful MRI scans.

RESULTS

One thousand and ninety-one MRIs under intranasal dexmedetomidine sedation were included (mean age 34 months, 95% confidence interval (CI), 33 to 36, 599 male individuals). A success rate of 93% (95% CI, 91 to 94%) was found. No major critical events were recorded, total incidence of minor issues was 0.2% (95% CI, 0 to 0.7%). Five children had a heart rate under a preset minimal limit after dexmedetomidine (0.4%; 95% CI, 0.1 to 0.9%). Significant decreases in heart rate and mean arterial pressure, within acceptable limits not requiring intervention, was seen after dexmedetomidine administration.

CONCLUSION

Intranasal dexmedetomidine sedation without immediate presence of anaesthesia personnel appears to be well tolerated and associated with minimal interference on MRI image quality.

TRIAL REGISTRATION

clinicaltrials.org NCT05163704, retrospectively registered.

Nasal drip of dexmedetomidine for optimal sedation during PICC insertion in pediatric burn care

BACKGROUND

For peripherally inserted central catheter (PICC) inserting, tranquil cooperation of children for an extended period is often required. Therefore, sedation is routinely induced clinically prior to PICC inserting. Chloral hydrate is a commonly used sedative for children. However, its clinical acceptance has remained low. And the sedation effect is non-satisfactory. Previous studies have confirmed the safety and effectiveness of intravenous/oral dosing or nasal dripping for sedation during the examinations of electrocardiography and computed tomography. Yet few studies have assessed the sedating efficacy of dexmedetomidine nasal drops for PICC inserting.

METHODS

From a cohort of 40 hospitalized patients scheduled for PICC inserting, 15 children employing a novel sedative mode of dexmedetomidine nasal drops at a dose of 2 ug/kg were assigned into group A while group B included another 25 children sedated routinely via an enema of 10% chloral hydrate at a dose of 0.5 mL/kg. The Ramsay's scoring criteria were utilized for assessing the status of sedation. Two groups were observed with regards to success rate of sedation, onset time of sedation and occurrences of adverse reactions.

RESULTS

Statistical inter-group differences existed in success rate and onset time of sedation. The success rate of group A was higher than that of group B (93.3% vs 64.0%, X2 = 4.302, P = .038 < 0.05). Group A had a faster onset of sedation than group B (14.86 ± 2.57 vs 19.06 ± 3.40 minutes, t = 3.781, P = .001 < 0.05). No inter-group difference of statistical significance existed in occurrence of adverse reactions (P = 1.000 > 0.05). Logistic regression analysis showed that the success rate of sedation in group A was higher than that in group B, and the difference was statistically significant (P = .036 < 0.05).

CONCLUSIONS

For sedating burn children, nasal dripping of dexmedetomidine is both safe and effective during PICC inserting. Without any obvious adverse reaction, it may relieve sufferings and enhance acceptance.

Nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children: a single centre audit

The purpose of this study is to audit the efficacy and safety of intranasal dexmedetomidine sedation for non-invasive procedural sedation in children provided by nurses of the procedural sedation (PROSA) team in the University Hospitals Leuven. Efficacy (successful sedation as sole sedative) and safety (cardiorespiratory monitoring, saturation) were assessed. In this audit, prospectively recorded data were extracted from the medical files in 772 patients between 4 weeks to 18 years old, who underwent sedation with intranasal dexmedetomidine (2-4 µg/kg) by the nurse-driven PROSA team, following pre-screening on risk factors. Ninety-one percent of the patients were successfully sedated (single dose, monotherapy), 60 patients (7.8%) needed an additional intervention during sedation, 37 (4.8%) needed an extra dose of intranasal dexmedetomidine, and 14 (1.8%) received an additional other sedative. Successful sedation rates were higher in younger children, and medical imaging was the most common indication. Sedation failed in 12 (1.6%) patients, with 10 of them failed to fall asleep. Adverse events were limited in number (n = 13, 1.7%) and severity: 4 patients had a low heart rate (one received atropine), one had an irregular heart rate, and 7 desaturation events were described. Hypotension was treated with normal saline in one case.

CONCLUSIONS

In this nurse-driven PROSA setting, intranasal dexmedetomidine is effective and safe for non-invasive procedural sedation in an a priori low risk group of paediatric patients.

WHAT IS KNOWN

• Procedural sedation outside the operating theatre or intensive care units is increasingly used, including sedation performed by non-anaesthesiologists or nurses. This resulted in the development of procedural sedation and analgesia (PROSA) teams. • Off-label use of intranasal dexmedetomidine in children is increasing, with a limited number of audits on this practice, its safety and efficacy.

WHAT IS NEW

• In an audit on 772 procedures, nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children within a structured framework was safe and effective. • Imaging (CT, MRI) was the most common procedural indication in our study, but also nuclear imaging techniques were included.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

Procedural sedation in children for fractionated radiation treatment: Intranasal dexmedetomidine versus oral midazolam and ketamine

BACKGROUND AND AIMS

Sedation in paediatric cancer for fractionated radiation treatment (RT) is unique as the child has to be still for accurate delivery of RT, monitoring of the child is from a remote location and sedation is repeated for multiple sessions of RT. The present study was undertaken to compare the efficacy of intranasal dexmedetomidine with oral midazolam and ketamine combination for repeated sedation during fractionated RT in paediatric oncology.

METHODS

Ninety children aged between 3-6 years, planned for 21 fractions of RT, were randomised to receive intranasal dexmedetomidine 2 μg/kg (group D) or oral midazolam 0.2 mg/kg and ketamine 5 mg/kg (group MK). The 21 sessions of fractionated radiotherapy were divided into three subgroups of seven consecutive exposures 1-7, 8-14 and 15-21 for comparison. The primary endpoint was to determine the incidence of successful sedation. The sedation score achieved, time to satisfactory sedation and discharge, rescue ketamine required, and side effects were secondary endpoints.

RESULTS

The incidence of successful sedation in the three successive RT subgroups; sessions: 1-7, 8-14 and 15-21, was 82%, 75.6% and 66.7% in group D, as compared to 40%, 24.4% and 13.3% in group MK, respectively. (P < 0.001). A decrease in successful sedation was noted in the successive subgroups. Time to successful sedation and discharge was earlier in group D in comparison to MK (P = 0.000). More patients in group MK required rescue ketamine (P = 000).

CONCLUSION

Intranasal dexmedetomidine produces more satisfactory sedation as compared to oral ketamine with midazolam for fractionated RT.

Intranasal Dexmedetomidine as Sedative for Medical Imaging in Young Children: A Systematic Review to Provide a Roadmap for an Evidence-Guided Clinical Protocol

There is an increasing need for effective anxiety and pain reduction during medical imaging procedures in children, addressed by non-pharmacological or pharmacological approaches. Dexmedetomidine is a fairly recently marketed, selective α2-adrenergic agonist that can be administered intranasally. To develop an evidence-guided clinical protocol, we investigated the (side) effects, preconditions and safety aspects following intranasal dexmedetomidine administration in children (1 month–5 years) for procedural sedation during medical imaging. To this end, a systematic search (PubMed, Embase and CINAHL (12/2021)) was performed to identify studies on intranasal dexmedetomidine for procedural sedation for medical imaging (computer tomography and magnetic resonance imaging). Following screening and quality assessment, eight studies were retained. Nasal nebulization was considered the best administration method, dosing varied between 2 and 4 µg/kg (age-dependent) 30–45 min prior to imaging and contraindications or restrictions with respect to oral intake were somewhat consistent across studies. Valid sedation scores and monitoring of vital signs were routinely used to assess sedation and the need for rescue dosing (different approaches), whereas discharge was generally based on Aldrete score (score ≥ 9). Heart rate, blood pressure and saturation were routinely monitored, with commonly observed bradycardia or hypotension (decrease by 20%). Based on these findings, a roadmap for evidence-guided clinical protocol was generated.

Recovery characteristics and parental satisfaction in pediatric procedural sedation

BACKGROUND

Despite being a standard of care for children undergoing stressful procedures, little data exist on parental perception of pediatric sedation.

AIMS

This study aimed to investigate recovery characteristics and parental satisfaction for pediatric sedations performed with four widely used sedative regimens.

METHODS

A prospective observational study was conducted at the Institute for Maternal and Child Health of Trieste, Italy, enrolling children undergoing procedural sedation with one of the following pharmacological regimens: propofol, propofol + midazolam, ketamine + propofol, and dexmedetomidine + midazolam. A questionnaire was used to assess the occurrence of symptoms upon recovery from sedation and the following day, and the caregivers' satisfaction for both the recovery pattern and the overall sedation experience, according to a numerical rating scale (0-10). Answers were collected through a telephone survey. The primary outcome was the difference in the quality of the recovery as perceived by caregivers; the secondary and tertiary outcomes were the perceived quality of the overall sedation experience and the frequency of sedation-related adverse events, respectively.

RESULTS

Data from 655 patients, 149 receiving propofol, 245 propofol + midazolam, 134 ketamine + propofol, and 127 dexmedetomidine + midazolam, were analyzed. The level of parents' satisfaction for both the recovery and the sedation experience was overall high and increased with the patients' age in all the pharmacological groups (Spearman's rank correlation, ρ .083, p = .033, and ρ .087, p = .026, respectively), with no statistically significant differences between groups when adjusting for age. The occurrence of irritability, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress at any moment negatively affected parental satisfaction.

CONCLUSIONS

In this study, caregivers' satisfaction with pediatric sedation was high, regardless of the regimen used. Lower parental satisfaction was associated with younger age, irritability after sedation, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress.

Efficacy and safety of intranasal dexmedetomidine versus oral chloral hydrate as sedatives for pediatric patients: a systematic review and meta-analysis

This study was designed to review published literature to determine the efficacy and safety of intranasal dexmedetomidine versus oral chloral hydrate (CH) for sedation in pediatric patients based on qualified studies. We searched the PubMed, Cochrane, and Embase databases for qualified studies published before March 2021. For each study, we analyzed the relative risk or weighted mean difference combined with a 95% CI. Fourteen studies including 3749 pediatric patients were included in this meta-analysis. Compared with oral CH, intranasal dexmedetomidine significantly increased the success rate of sedation and decreased the duration and latency of sedation, time of recovery from sedation, and total sedation time. Compared with oral CH, intranasal dexmedetomidine significantly decreased the incidence of adverse events, including vomiting, but increased the incidence of bradycardia. In conclusion, intranasal dexmedetomidine provides better sedation than oral CH for pediatric patients with good safety; however, the incidence of bradycardia is increased.

Intranasal Dexmedetomidine increases the successful sedation of children with autism for out-patient auditory brainstem response hearing tests

INTRODUCTION

The auditory brainstem response (ABR) hearing test can be challenging in children with autism spectrum disorder (ASD) due to the inherent behavioral challenges associated with this condition. To attempt to increase our success in sedating ASD patients, we added the use of intranasal Dexmedetomidine (Dexmed) to be used alone or with oral Chloral Hydrate (CH) in an ambulatory care setting, with monitoring by a specialist nurse.

OBJECTIVES

To determine the success and safety of a protocol for ABR testing performed under sedation with intranasal Dexmed and oral chloral hydrate in ASD patients. To compare the success rate, the occurrence of adverse events and time needed to initiate ABR between Dexmed-CH protocol and previous CH-alone protocol in ASD patients.

METHODS

Retrospective review. ASD patients in Dexmed-CH sedation protocol were age- and sex-matched to ASD patients who underwent CH-alone sedation protocol, for comparison.

RESULTS

74 ABR records in ASD children were included, 37 patients using Dex-CH protocol and 37 patients using CH-alone protocol. In the Dexmed-CH protocol group, Dexmed was used in 2 different ways: alone as a first choice in patients who refused to swallow CH (9/37), or combined with CH as a rescue (28/37). Under this sedation protocol, 89% of the attempted ABRs were completed successfully with no major adverse effects. In comparison, in ASD patients sedated using the protocol of CH-alone, the success rate significantly lower (69% vs. 89%). The time needed to initiate the test was not significantly different.

CONCLUSION

The use of intranasal Dexmed by itself or in combination with CH was a safe and reliable method of performing sedated ABR in ASD patients. Modifying our previous oral CH protocol to include intranasal Dexmed, substantially improved our success rate of sedation in ASD patients in an ambulatory setting. This study may be of significant value to centers worldwide exploring alternatives to general anesthesia for ABR testing in ASD patients.

The Safety and Efficacy Evaluation of Dexmedetomidine for Procedural Sedation and Postoperative Behaviors in Pediatric Populations: A Systematic Review and Meta-analysis

BACKGROUND

This study systematically evaluated the safety and efficacy of dexmedetomidine for procedural sedation and postoperative behaviors in a pediatric population as well as whether the results met the information required to draw conclusions.

OBJECTIVE

To evaluate the safety and efficacy evaluation of dexmedetomidine for procedural sedation and postoperative behaviors in a pediatric population.

METHODS

PubMed, Cochrane library, Web of Science and Ovid MEDLINE were searched to obtain randomized controlled trials (RCTs) comparing dexmedetomidine with control medicine and comparing different doses of dexmedetomidine.

RESULTS

There were a total of 16 RCTs for a total of 3240 patients. Dexmedetomidine slowed down the heart rate (HR; mean difference: -13.27; 95% CI: -16.41 to 10.14; P < 0.001) and reduced postoperative delirium (risk ratio [RR]: 0.31; 95% CI: 0.20-0.50; P < 0.001), the number of pain patients (RR: 0.48; 95% CI: 0.30-0.75; P = 0.002), and desaturation (RR: 0.34; 95% CI: 0.13-0.89; P = 0.03) compared with the control group. The limitation was that it was difficult to determine the range of low- and high-dose dexmedetomidine.

CONCLUSION AND RELEVANCE

Dexmedetomidine slowed down intraoperative HR within the normal range, which might reduce myocardial oxygen consumption. It reduced postoperative pain and postoperative complications: delirium and desaturation. Dexmedetomidine showed no dose-dependent increase in the procedural sedation time of pediatric patients. Clinically, dexmedetomidine can improve pediatric procedural sedation and postoperative behavior, and it can be considered as a related medicine for safety in pediatric surgery.

Comparison of dexmedetomidine with chloral hydrate as sedatives for pediatric patients: A systematic review and meta-analysis

BACKGROUND

Dexmedetomidine (Dex) and chloral hydrate (CH) are the most frequently used sedative agents in pediatric patients. We aimed to systematically review the literature comparing the efficacy and safety of Dex and CH for sedation in pediatric patients.

METHODS

Seven electronic databases and 3 clinical trial registry platforms were searched for articles published prior to October 2019. Randomized controlled trials (RCTs) evaluating the efficacy and safety of Dex versus CH for sedation in children were examined by 2 reviewers. The extracted information included the success rate of sedation, sedation latency, sedation duration, sedation recovery time, and adverse events. Moreover, the extracted data included 5 subgroups: the effects of 1, 1.5, 2, 2.5, and 3 μg/kg doses of Dex were compared with the effect of CH on the success rate of sedation. We also formed separate subgroups for different types of adverse events (incidence of vomiting, hypotension, bradycardia, etc). The outcomes were analyzed by Review Manager 5.3 software and are expressed as relative risks (RR) or the mean difference (MD) with the 95% confidence interval (CI). Heterogeneity was assessed with I-squared (I) statistics.

RESULTS

A total of 15 RCTs involving 2128 children with Dex versus CH for sedation were included in the meta-analysis. The dose range of Dex ranged from 1 to 3 μg/kg. Compared with CH, the Dex group had a significantly higher success rate of sedation (RR = 1.14, 95% CI [1.05, 1.25], I = 79%, P = .003). Additionally, subgroup analysis revealed that there was no significant difference in the success rate of sedation between the CH group and the 1, 1.5, 2.5, and 3 μg/kg Dex groups; only the 2 μg/kg Dex group had a significantly higher success rate than the CH group (RR = 1.15, 95% CI [1.03, 1.29], I = 80%, P = .02). There was no significant difference in the number of subjects who required 2 doses or the duration of sedation between the CH and Dex groups. Furthermore, compared with the Dex group, the CH group had a significantly longer sedation latency (MD = -3.54, 95% CI [-5.94, -1.15], I = 95%, P = .004), sedation recovery time (MD = -30.08, 95% CI [-46.77, -13.39], I = 99%, P = .0004), and total time from sedative administration to discharge (MD = -12.73, 95% CI [-15.48, -9.97], I = 0%, P < .05), as well as a higher number of adverse events in total (RR = 0.25, 95% CI [0.11, 0.61], I = 89%, P = .002). Moreover, the subgroup analysis of adverse events revealed that CH was associated with higher risks of vomiting (RR = 0.07, 95% CI [0.03, 0.17], I = 0%, P < .0001), crying or resisting (RR = 0.22, 95% CI [0.07, 0.71], I = 60%, P = .01), and cough (RR = 0.15, 95% CI [0.05, 0.44], I = 0%, P = .0006); there was no significant difference in the risk of hypotension, supplemental oxygen, or respiratory events between CH and Dex. However, Dex was associated with a higher risk of bradycardia (RR = 4.08, 95% CI [1.63, 10.21], I = 0%, P = .003).

CONCLUSIONS

Dex is an appropriate effective alternative to CH for sedation in pediatrics. However, considering the possibility of bradycardia, Dex should be used with caution.

[Comparison of ED50 of intranasal dexmedetomidine sedation in children with acyanotic congenital heart disease before and after cardiac surgery]

OBJECTIVE

To compare the median effective dose (ED50) of intranasal dexmedetomidine for procedural sedation in uncooperative pediatric patients with acyanotic congenital heart disease before and after cardiac surgery.

METHODS

We prospectively recruited 47 children (22 in preoperative group and 25 in postoperative group) who needed sedation for transthoracic echocardiography (TTE). A modified up-and-down sequential study design was employed to determine dexmedetomidine dose for each patient with a starting dose of 2 μg/kg in both groups; dexmedetomidine doses for subsequent subjects were determined according to the responses from the previous subject using the up-and-down method at a 0.25 μg/kg interval. The ED95 was determined using probit regression. The onset time, examination time, wake-up time and adverse effects were measured, and the safety was evaluated in terms of changes in vital signs every 5 min.

RESULTS

The ED50 value of intranasal dexmedetomidine for sedation was 1.84 μg/kg (95% CI: 1.68-2.00 μg/kg) in children with congenital heart disease before cardiac surgery, and 3.38 μg/kg (95% CI: 3.21-3.54 μg/kg) after the surgery. No significant difference was found between the two groups in the demographic variables, onset time, examination time, wake-up time, or adverse effects.

CONCLUSIONS

In children with acyanotic congenital heart disease, the ED50 of intranasal dexmedetomidine for TTE sedation increases to 3.38 μg/ kg after cardiac surgery from the preoperative value of 1.84 μg/kg.

Pharmacokinetics and Sedative Effects of Intranasal Dexmedetomidine in Ambulatory Pediatric Patients

BACKGROUND

Our aim was to characterize the pharmacokinetics and sedative effects of intranasally (IN) administered dexmedetomidine used as an adjuvant in pediatric patients scheduled for magnetic resonance imaging (MRI) requiring sedation.

METHODS

This was an open-label, single-period study without randomization. Pediatric patients from 5 months to 11 years of age scheduled for MRI and receiving IN dexmedetomidine for premedication as part of their care were included in this clinical trial. Single doses of 2-3 µg·kg of dexmedetomidine were applied IN approximately 1 hour before MRI. Five or 6 venous blood samples were collected over 4 hours for dexmedetomidine concentration analysis. Sedation was monitored with Comfort-B scores, and vital signs were recorded. Pharmacokinetic variables were calculated with noncompartmental methods and compared between 3 age groups (between 1 and 24 months, from 24 months to 6 years, and over 6-11 years).

RESULTS

We evaluated 187 consecutive patients for suitability, of which 132 were excluded. Remaining 55 patients were recruited, of which 5 were excluded before the analysis. Data from 50 patients were analyzed. The average (standard deviation [SD]) dose-corrected peak plasma concentration (Cmax) was 0.011 liter (0.0051), and the median (interquartile range [IQR]) time to reach peak concentration (tmax) was 37 minutes (30-45 minutes). There was negative correlation with Cmax versus age (r = -0.58; 95% confidence interval [CI], -0.74 to -0.37; P < .001), but not with tmax (r = -0.14; 95% CI, 0.14-0.39; P = .35). Dose-corrected areas under the concentration-time curve were negatively correlated with age (r = -0.53; 95% CI, 0.70 to -0.29; P < .001). Median (IQR) maximal reduction in Comfort-B sedation scores was 8 (6-9), which was achieved 45 minutes (40-48 minutes) after dosing. Median (IQR) decrease in heart rate was 15% (9%-23%) from the baseline.

CONCLUSIONS

Dexmedetomidine is relatively rapidly absorbed after IN administration and provides clinically meaningful but short-lasting sedation in pediatric patients.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium

OBJECTIVE

The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature.

MATERIALS AND METHODS

The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed.

RESULTS

A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed.

CONCLUSIONS

This report from the PSRC shows that IN DEX in combination with midazolam is an effective medication regimen for children who require an MRI with sedation.

The 95% effective dose of intranasal dexmedetomidine sedation for pulmonary function testing in children aged 1-3 years: A biased coin design up-and-down sequential method

STUDY OBJECTIVE

Intranasal dexmedetomidine (DEX) can provide adequate sedation during short examinations in children. However, we found no data regarding the 95% effective dose (ED₉₅) of intranasal DEX for children's pulmonary function testing (PFT).

DESIGN

Prospective study and a biased coin design up-and-down sequential method.

SETTING

Sedation center of Children's Hospital of Chongqing Medical University.

PATIENTS

Children aged 1-3 years undergoing pulmonary function testing.

INTERVENTION

The dose of DEX for each subsequent patient was determined by the response of the previous patient with the biased coin design up-and-down sequential method with an interval of 0.25 μg∙kg^-1.

MEASUREMENTS

Children aged 1-3 years who received pulmonary function testing were involved in this dose-finding trial. Intranasal DEX started at a dose of 2 μg∙kg^-1 on the first patient. The dose of DEX for each subsequent patient was determined by the response of the previous patient with the biased coin design up-and-down sequential method with an interval of 0.25 μg∙kg^-1. The sedation was assessed by the Modified Observer Assessment of Alertness and Sedation (MOAA/S) scale, and recovery was assessed by the modified Aldrete recovery score. The ED₉₅ was calculated using isotonic regression. Other variables, including the sedation onset time, examination time, wake-up time, blood pressure (BP), heart rate (HR), respiratory rate (RR), and oxyhaemoglobin desaturation (SpO₂), were recorded. Adverse events such as hypotension, bradycardia, respiration depression, oxyhaemoglobin desaturation, regurgitation and vomiting were recorded.

MAIN RESULTS

A total of 68 children were enrolled for the study; 62 children had successful sedation, and 6 had failed sedation. The ED₉₅ of intranasal DEX was estimated to be 2.64 μg∙kg^-1 [95% confidence interval (CI), 2.49-2.87 μg∙kg^-1]. The sedation onset time for all patients was 15.0 (12.3-19.0) min. The sedation onset time of successful sedation patients was 15.0 (12.0-19.0) min, the sedation onset time of failed sedation patients was 16.0 (15.0-27.8) min, the examination time was 8 (7-10) min, and the wake-up time was 40 (35-43) min. There were no adverse events during the whole procedure.

CONCLUSION

The ED₉₅ of intranasal DEX sedation in children aged 1-3 years undergoing PFT was 2.64 μg∙kg^-1.

Sedatives used in children to obtain head CT in the emergency department

OBJECTIVES

Children in the emergency department who require computerized tomography (CT) of the head often are given sedative medications to facilitate completion of the study with adequate imaging. A prior study found the two most common medications used to obtain head CT in children were pentobarbital and chloral hydrate; however, these medications have become less popular. We hypothesized that there was variability in medication choice amongst providers in the emergency department and there has been a change in the preferred sedatives used in the last decade.

METHODS

We conducted a retrospective multicenter cross-sectional study of children 0-18 years old who received a medication with sedative properties and underwent head CT while in the emergency department from 2007 to 2018, using the Pediatric Health Information System (PHIS) database. The primary outcome measure was the frequency of administration of drugs within an individual sedative class.

RESULTS

We analyzed 24,418 patient encounters, of whom 53% received an opioid and 41% received a benzodiazepine. There were statistically significant decreases in the use of barbiturates, chloral hydrate, anti-emetic sedatives, and opioids, while increases in barbiturate combination drugs, benzodiazepines and dexmedetomidine were observed over the study period. The majority of medications were administered parenterally.

CONCLUSION

There is wide variability in sedatives used in children to obtain head CT and the preferred drugs have shifted over the last decade.

A Comparison of Intranasal Dexmedetomidine and Dexmedetomidine-Ketamine Combination Sedation for Transthoracic Echocardiography in Pediatric Patients With Congenital Heart Disease: A Randomized Controlled Trial

OBJECTIVES

To compare the effects of intranasal dexmedetomidine (DEX) and DEX-ketamine (KET) on hemodynamics and sedation quality in children with congenital heart disease.

DESIGN

A randomized controlled, double-blind, prospective trial.

SETTING

A tertiary care teaching hospital.

PARTICIPANTS

The study comprised 60 children undergoing transthoracic echocardiography (TTE).

INTERVENTIONS

Patients were randomly allocated into the DEX group (group D [n = 30]) or the DEX-KET group (group D-K [n = 30]). Group D received 2 μg/kg of intranasal DEX; group D-K received 2 μg/kg of DEX and 1 mg/kg of KET intranasally.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the change in hemodynamics, measured using mean arterial pressure (MAP) and heart rate (HR). Secondary outcomes were onset time, wake-up time, and discharge time. No differences were found in mean arterial pressure or heart rate. The onset time was significantly shorter in group D-K than in group D (9.6 ± 2.9 minutes v 14.3 ± 3.4 minutes; p = 0.031). The wake-up time was longer in group D-K than in group D (52 ± 14.7 minutes v 39.6 ± 12.1 minutes; p = 0.017). The discharge time was longer in group D-K than in group D (61.33 ± 11.59 minutes v 48.17 ± 8.86 minutes; p < 0.001). No differences in hemodynamics were found between the 2 groups. Intranasal DEX was found to be as effective for TTE sedation as intranasal DEX-KET, with longer onset time and shorter recovery and discharge times.

CONCLUSION

No differences in hemodynamics were found between the 2 groups. Intranasal DEX was found to be as effective for TTE sedation as is intranasal DEX-KET, with longer onset time and shorter recovery and discharge times.

Determination of the 90% effective dose of intranasal dexmedetomidine for sedation during electroencephalography in children

BACKGROUND

The intranasal route of dexmedetomidine (DEX) administration is becoming increasingly popular for providing adequate sedation during short examinations in infants and children. However, data on the 90% effective dose (ED90) of intranasal DEX are rare in children under 3 years old.

METHODS

This is a double-blind trial using a biased coin design up-and-down sequential method (BCD-UDM). Fifty-three children aged under 3 years old requiring DEX for EEG were included in our study. The first patient received 2.5 μg kg^-1 DEX, and the dose of DEX administered to the subsequent patient was determined by the response of the previous patient. The patient responses were recorded and analysed to calculate the ED90 by isotonic regression. The 95% confidence interval (CI) was estimated using a bootstrapping method.

RESULTS

Fifty-three patients were included in our study, of which 45 patients were successfully sedated, and the 8 instances of failed sedation were rescued using sevoflurane inhalation, allowing the completion of the procedure. The 90% effective dose of DEX was calculated to be 3.28 µg kg^-1 , and the 95% CI was 2.74 ~ 3.39 µg kg^-1 . No significant adverse events occurred in any of the patients.

CONCLUSION

The 90% effective dose of intranasal DEX sedation for EEG was 3.28 μg kg^-1 in children under 3 years old.

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.

Analysis of 17 948 pediatric patients undergoing procedural sedation with a combination of intranasal dexmedetomidine and ketamine

BACKGROUND

Intranasal procedural sedation using dexmedetomidine is well described in the literature. The combination of intranasal dexmedetomidine and ketamine is a novel approach for which there are little data on the rate of successful sedation or adverse events.

OBJECTIVES

The aim of this study is to evaluate the rate of successful sedation and adverse events of intranasal procedural sedation using a combination of dexmedetomidine and ketamine for diagnostic examination in children.

METHODS

This was a retrospective study and data were collected after ethics approval. A total of 17 948 pediatric patients (7718 females, 10 230 males) in a tertiary hospital in China were evaluated. Patients received a combination of 2 μg kg^-1 of dexmedetomidine and 1 mg kg^-1 of ketamine intranasally for procedural sedation. The level of sedation and recovery was assessed by the Modified Observer Assessment of Alertness/Sedation scale and the Modified Aldrete Score.

RESULTS

The rate of intranasal sedation success was 93% (16691/17948), intranasal sedation rescue was 1.8% (322/17948), and intranasal sedation failure was 5.2% (935/17948). Sedation success was defined as successful completed the diagnostic examination and obtained adequate diagnostic-quality images and reports. Intranasal sedation success, rescue and failure were respectively defined as sedation success with intranasal a single dose, additional bolus dose and the need for intravenous (IV) medications/inhalation agents. Median sedation time was 62 min (interquartile range: 55-70 min), median time for onset of sedation was 15 min (interquartile range: 15-20 min), and median sedation recovery time was 45 min (interquartile range: 38-53 min). Incidence of adverse events was low (0.58%; 105/17948), with major and minor adverse event being reported in 0.02% (4/17948) and 0.56% (101/17948) patients, respectively. Postoperative nausea and vomiting was the most common (0.3%; 53/17948) minor adverse event.

CONCLUSION

Procedural sedation using a combination of intranasal dexmedetomidine and ketamine is associated with acceptable effectiveness and low rates of adverse events.

Sedation effects of intranasal dexmedetomidine combined with ketamine and risk factors for sedation failure in young children during transthoracic echocardiography

BACKGROUND

Sedation is often required for young children during transthoracic echocardiography. Dexmedetomidine and ketamine are two sedatives that are commonly used in children for procedural sedation, but they have some disadvantages when they are used alone.

AIMS

The aim of this retrospective study was to analyze the effects and safety of intranasal sedation with a combination of dexmedetomidine and ketamine during transthoracic echocardiography in young children and to analyze risk factors for sedation failure.

METHODS

After IRB approval, we retrospectively evaluated data on patients who underwent echocardiography between May 2016 and August 2017 utilizing a combination of dexmedetomidine 2 μg/kg and ketamine 1 mg/kg. We collected information including heart rate, pulse oxygen saturation, sedation onset time, exam time, recovery time, and adverse reactions. Stepwise logistic regression analyses were performed to analyze the risk factors for sedation failure.

RESULTS

Sedation was successful in 2212 patients (96%) and took effect in 15.7 (IQR: 10-23) min, while sedation failed in 92 patients. Cyanotic heart disease, history of sedation failure, history of congenital heart disease surgery, and fever were independent risk factors for sedation failure. Most of the patients in this study had an American Society of Anesthesiologists (ASA) grade of II to III, but no severe adverse reactions were observed.

CONCLUSION

Intranasal sedation with a combination of dexmedetomidine and ketamine is effective and appears to have an acceptable safety profile for young children during transthoracic echocardiography.

A randomized controlled trial of oral chloral hydrate vs intranasal dexmedetomidine plus buccal midazolam for auditory brainstem response testing in children

BACKGROUND

Moderate to deep sedation is required for an auditory brainstem response test when high-intensity stimulation is used. Chloral hydrate is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric non-painful procedural sedations.

OBJECTIVE

The aim of this study was to compare the sedation success rate after oral chloral hydrate at 50 mg kg^-1 and intranasal dexmedetomidine at 3 μg kg^-1 plus buccal midazolam at 0.1 mg kg^-1 for an auditory brainstem response test.

METHODS

Children who required an auditory brainstem response test were recruited and randomly assigned to receive oral chloral hydrate at 50 mg kg^-1 and intranasal placebo, or intranasal dexmedetomidine at 3 μg kg^-1 with buccal midazolam 0.1 mg kg^-1 . The primary outcome was the rate of successful sedation for auditory brainstem response tests.

RESULTS

Fifty-seven out of 82 (69.5%) were successfully sedated after chloral hydrate, while 70 out of 78 (89.7%) children were successfully sedated with dexmedetomidine plus midazolam combination, with the odd ratio (95% CI) for successful sedation between dexmedetomidine plus midazolam combination and chloral hydrate estimated to be 3.84 (1.61-9.16), P = 0.002. Dexmedetomidine plus midazolam was associated with quicker onset with median onset time 15 (IQR 11.0-19.8) for dexmedetomidine plus midazolam and 20 (IQR 15.0-27.0) for chloral hydrate respectively, with difference between median (95% CI) of 5 [3-8], P < 0.0001). The behavior observed during drug administration of intranasal dexmedetomidine and buccal midazolam was better that of the children who had oral chloral hydrate. No children required oxygen therapy or medical intervention for hemodynamic disturbances in this study and the incidence of hypotension and bradycardia was similar.

CONCLUSION

Intranasal dexmedetomidine plus buccal midazolam was associated with higher sedation success with deeper level of sedation, with similar discharge time and adverse event rate when compared to chloral hydrate.

Sedation With a Combination of Dexmedetomidine and Midazolam for Pediatric Dental Surgery

Intravenous sedation (IVS) is commonly used to complete dental treatment for uncooperative pediatric patients. Propofol (PRO) is widely used for IVS because of its short context sensitive half-time and amnestic effect. However, administering PRO to patients who have a history of egg anaphylaxis is still somewhat controversial. The evidence that supports the potential risks for allergic reactions following PRO use in patients with egg allergies is limited with some anesthesiologists recommending against its use in these patients. Alternative drug regimens for procedural sedation in this population are therefore desirable. Dexmedetomidine (DEX), a selective α-2 agonist, has antianxiety and sedative properties and has been widely used not only for procedural sedation with mild inhibitory effects on respiration but also during minor surgeries for its analgesic effect. In this paper, we describe the successful administration of a combination of DEX and low-dose midazolam (MDZ) for sedation in an uncooperative pediatric patient. Both DEX and MDZ have been reported as safe and useful sedatives for dental treatment, and their combination may provide a helpful option for IVS of pediatric patients for whom PRO is not preferred.

Clinical Pharmacokinetics and Pharmacodynamics of Dexmedetomidine

Dexmedetomidine is an α₂-adrenoceptor agonist with sedative, anxiolytic, sympatholytic, and analgesic-sparing effects, and minimal depression of respiratory function. It is potent and highly selective for α₂-receptors with an α₂:α₁ ratio of 1620:1. Hemodynamic effects, which include transient hypertension, bradycardia, and hypotension, result from the drug’s peripheral vasoconstrictive and sympatholytic properties. Dexmedetomidine exerts its hypnotic action through activation of central pre- and postsynaptic α₂-receptors in the locus coeruleus, thereby inducting a state of unconsciousness similar to natural sleep, with the unique aspect that patients remain easily rousable and cooperative. Dexmedetomidine is rapidly distributed and is mainly hepatically metabolized into inactive metabolites by glucuronidation and hydroxylation. A high inter-individual variability in dexmedetomidine pharmacokinetics has been described, especially in the intensive care unit population. In recent years, multiple pharmacokinetic non-compartmental analyses as well as population pharmacokinetic studies have been performed. Body size, hepatic impairment, and presumably plasma albumin and cardiac output have a significant impact on dexmedetomidine pharmacokinetics. Results regarding other covariates remain inconclusive and warrant further research. Although initially approved for intravenous use for up to 24 h in the adult intensive care unit population only, applications of dexmedetomidine in clinical practice have been widened over the past few years. Procedural sedation with dexmedetomidine was additionally approved by the US Food and Drug Administration in 2003 and dexmedetomidine has appeared useful in multiple off-label applications such as pediatric sedation, intranasal or buccal administration, and use as an adjuvant to local analgesia techniques.

Use of Intranasal Dexmedetomidine as a Solo Sedative for MRI of Infants

BACKGROUND

Dexmedetomidine, a selective α-2 receptor agonist, can be delivered via the intranasal (IN) route and be used for procedural sedation. The drug's favorable hemodynamic profile and relative ease of application make it a promising agent for sedation during radiologic procedures, although there are few studies on its efficacy for MRI studies.

METHODS

A retrospective chart review was performed between June 2014 and December 2016. Outpatients between 1 and 12 months of age who received 4 μg/kg of IN dexmedetomidine for MRI were included in the analysis. Our aim with this study was to determine the rate of successful completion of the sedation procedure without the need for a rescue drug (other than repeat IN dexmedetomidine).

RESULTS

A total of 52 subjects were included in our study. Median (interquartile range) patient age was 7 (5-8) months. Median (interquartile range) procedure length was 40 (35-50) minutes. Overall success rate (including first dose and any rescue dose IN) of dexmedetomidine was 96.2%. None of the patients had significant adverse effects related to dexmedetomidine.

CONCLUSIONS

IN dexmedetomidine is an effective solo sedative agent for MRI in infants.

Median effective dose of intranasal dexmedetomidine sedation for transthoracic echocardiography in pediatric patients with noncyanotic congenital heart disease: An up-and-down sequential allocation trial

BACKGROUND

Intranasal dexmedetomidine can provide adequate sedation during short procedures. However, previous literature investigating the single-dose use of intranasal dexmedetomidine for sedation during transthoracic echocardiography in younger children is scarce, and the effects of age on sedation with intranasal dexmedetomidine remain controversial.

OBJECTIVE

This study was to determine the 50% effective dose and estimate the 95% effective dose of single-dose intranasal dexmedetomidine to induce sedation in pediatric patients with noncyanotic congenital heart disease, and also determine the effect of age on the dose required for sedation.

METHODS

Patients were stratified into three age groups of 1-6 months, 7-12 months, and 13-36 months. Intranasal dexmedetomidine started at a dose of 2 μg kg^-1 on the first patient. The dose of dexmedetomidine for each subsequent patient was determined by the previous patient's response using Dixon's up-and-down method with an interval of 0.25 μg kg^-1 . Sedation scale and recovery were assessed by the Modified Observer Assessment of Alertness and Sedation Scale and Modified Aldrete Recovery Score. The 50% effective dose was determined by Dixon's up-and-down method. In addition, both 50% effective dose and 95% effective dose were obtained using a probit regression approach. Other variables included sedation onset time, echocardiography time, wake-up time, discharge time, heart rate, blood pressure, oxygen saturation, respiratory rate, and adverse events such as vomiting, regurgitation, and apnea.

RESULTS

The study population was comprised of 70 patients. The 50% effective dose (95% confidence interval) and the 95% effective dose (95% confidence interval) of intranasal dexmedetomidine for sedation were 1.8 (1.58-2.00) μg kg^-1 and 2.2 (1.92-5.62) μg kg^-1 in patients aged 1-6 months, 1.8 (1.61-1.95) μg kg^-1 and 2.1 (1.90-2.85) μg kg^-1 in patients aged 7-12 months, 2.2 (1.92-2.37) μg kg^-1 and 2.7 (2.34-6.88) μg kg^-1 in patients aged 13-36 months, respectively. The 50% effective dose in age group 13-36 months was higher than those of age group 1-6 months (P = .042) and 7-12 months (P = .043). There were no differences in sedation onset time, echocardiography time, wake-up time, and discharge time between groups. None of the patients experienced oxyhemoglobin desaturation, hypotension, or bradycardia during the procedure. No significant adverse events occurred.

CONCLUSION

Single-dose of intranasal dexmedetomidine was an effective agent for patients under the age of 3 years requiring sedation for transthoracic echocardiography. The 50% effective dose of intranasal dexmedetomidine for transthoracic echocardiography sedation in children aged 13-36 months was higher than in children <13 months.

Sedation and analgesia for procedures in the pediatric emergency room

OBJECTIVE

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

DATA SOURCES

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

DATA SYNTHESIS

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

CONCLUSIONS

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

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.

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.

Effect of intranasal dexmedetomidine on emergence agitation after sevoflurane anesthesia in children undergoing tonsillectomy and/or adenoidectomy

BACKGROUND

Emergence agitation (EA) after sevoflurane anesthesia is common in children during recovery from general anesthesia and may result in postoperative complications. This study investigated safety and effectiveness of intranasal dexmedetomidine in reducing the incidence and severity of EA.

METHODS

This prospective, randomized double-blinded controlled trial included 86 patients scheduled for the tonsillectomy and/or adenoidectomy under general anesthesia with sevoflurane. They were randomly allocated into two groups. Group D received intranasal dexmedetomidine at 1 μg/kg, and Group C received intranasal saline 0.9% after the induction of general anesthesia. Four-point agitation scale and Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain assessment were measured at six time points (after extubation, leaving the operating room, on arrival to postanesthesia care unit [PACU], 10, 20, and 30 min after arrival in PACU). Extubation, emergence, and discharge times were recorded in addition to any adverse effects.

RESULTS

There was a significant difference in the incidence of EA between Groups D and C (6.98% and 58%, respectively, with P = 0.001). The median four-point agitation scales and the median scores of FLACC pain scales of Group D were significantly lower than those of Group C at the all six time points with P < 0.05. Extubation, emergence, and discharge times were comparable in both groups, and none of the subjects reported any adverse effects.

CONCLUSION

This study demonstrates that a 1 μg/kg dose of intranasal dexmedetomidine administered after the induction of anesthesia reduces post-sevoflurane incidence and severity of EA in children undergone tonsillectomy and/or adenoidectomy with no adverse effects and smooth recovery profile.

Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study

BACKGROUND

Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation.

AIMS

The aim of this trial was to compare the effectiveness of oral midazolam and intranasal dexmedetomidine as sole premedicants in children for carrying out both IV cannulation as well as CT scanning, without the need for additional IV sedatives.

METHODS

Fifty-nine children, aged 1-6 years, scheduled to undergo CT imaging under sedation were randomized to receive either 0.5 mg·kg^-1 oral midazolam (group M) or 2.5 mcg·kg^-1 intranasal dexmedetomidine (group D). After 20-30 min, intravenous cannulation was performed and response to its placement was graded using the Groningen Distress Rating Scale (GDRS). After cannulation, children were transferred on the CT table, and assessed using the Ramsay sedation score (RSS). CT imaging was performed without any further sedative if the RSS was ≥4. If there was movement or decrease in sedation depth (RSS ≤ 3), ketamine 1 mg·kg^-1 IV was given as an initial dose, followed by subsequent doses of 0.5 mg·kg^-1 IV if required.

RESULTS

A Significantly higher proportion of children in group D (67%) achieved RSS ≥ 4 as compared to group M (24%) (P-0.002). The risk ratio (95% CI) was 2.76 (1.38-5.52). Significantly lower GDRS scores were noted in group D (1(1-2)) as compared to group M (2(1-2)) at the time of venipuncture (P = 0.04).

CONCLUSION

In the doses and time intervals used in our study, intranasal dexmedetomidine (2.5 μg·kg^-1 ) was found to be superior to oral midazolam (0.5 mg·kg^-1 ) for producing satisfactory sedation for CT imaging.