[Oral ketamine-midazolam premedication of uncooperative patients in major outpatient surgery]

Clinical Uses of Ketamine in Children: A Narrative Review

Ketamine is a phencyclidine derivative that acts as a noncompetitive N-methyl-D-aspartate as well as a glutamate receptor antagonist. It also has other minor mechanisms that contribute to its extensive drug profile. Ketamine is a bronchodilator and maintains normal airway reflexes and, thus, permits spontaneous respiration. This, coupled with the fact that it produces potent analgesia, makes it highly suitable for children.

Despite its many merits, the drug’s side effects, along with its cultural image of being a drug of abuse, a drug used in veterinary medicine, or a “date-rape drug” have sullied its reputation within the armamentarium of medicine. Even though it is widely used in developing countries, its use in Western nations has diminished. We have strived to explore the various clinical uses of ketamine in children through this article. In addition, the article also highlights how some of the fears associated with using the drug are unfounded and provides ways by which the drug’s side effects can be prevented and managed.

Comparison between dexmedetomidine and esketamine in pediatric dentistry surgery

BACKGROUND

Dexmedetomidine (D) and esketamine (K) are used for the sedation of pediatric dental surgery. This study was designed to compare the effect of intranasal D and K in producing moderate sedation for uncooperative pediatric dental patients.

METHODS

This prospective single-center cohort study was conducted at the Maternal and Child Health Hospital of Hubei Province after approval of the Medical Ethics Committee. One hundred and fifty American Society of Anesthesiologists (ASA) grade I and II patients aged 3-10 years who were uncooperative and could not be managed by conventional behavior management techniques were included in this study. Patients were classified into four groups. Group K was administered with esketamine (0.5 mg/kg), and group D was given D1 (1 µg/kg), D2 (1.5 µg/kg), or D3 (2.0 µg/kg) intranasally. The outcome measurements included the sedation level, changes in vital signs, sedation onset and recovery times, analgesia, behavior, and overall success.

RESULTS

The sedation onset time was significantly shorter for K and D3 compared with D1 and D2. The recovery time was fastest in group D1. The overall success rate was highest in group D3, followed by the D2, D1, and K groups; however, the difference between them was not significant. The intra-and postoperative pain scores in the D3 and K groups were significantly lower than those in the D1 group.

CONCLUSIONS

Intranasal D and K are effective in producing moderate sedation for uncooperative pediatric dental patients.

Anesthetic Management of an Adult Patient With Down Syndrome for Thoracic Surgery

The anesthetic management of adult patient with Down syndrome (DS) can be challenging due to poor patient cooperation, age-related comorbidities, and a possible difficult airway. Thoracic anesthesia requires an advanced airway management; thus, treatment of DS patients can be particularly demanding. An accurate preoperative assessment is paramount in order to plan a well-designed perioperative strategy in advance. This report describes the anesthetic management of an adult patient affected by DS who underwent pleural decortication for pleural empyema.

Comparison of Intranasal Dexmedetomidine and Oral Ketamine Versus Intranasal Midazolam Premedication for Children Undergoing Dental Rehabilitation

Background

Dental rehabilitation surgery is associated with significant fear and anxiety with subsequent psychological disturbances. Midazolam has been used frequently as a premedication. However, it may be associated with side effects. Dexmedetomidine and ketamine combination has been suggested as an effective premedication in improving preoperative sedation and analgesia.

Objectives

This study compared the effects of combined intranasal dexmedetomidine and oral ketamine versus intranasal midazolam on anxiolysis and postoperative analgesia.

Methods

Seventy-six children (aged two to six years) undergoing dental rehabilitation under general anesthesia were assigned randomly to one of the two groups (n = 38 each) receiving either intranasal dexmedetomidine at 2 µg/kg and oral ketamine at 3 mg/kg (Group DK) or intranasal midazolam at 0.2 mg/kg (group M) 30 minutes prior to the anesthesia induction. The sedation levels and parental separation state were evaluated. Time to recovery, postoperative rescue analgesia, and postoperative adverse effects were assessed.

Results

Seventy-six children completed the study. Patients in group DK had significantly lower sedation scores than those in group M after 20 and 30 min (P < 0.05). The rate of satisfactory separation showed no statistically significant difference between the two groups 30 minutes after the administration of premedication (P = 0.926). A significantly higher number of patients in group M required rescue analgesic (42%) compared to those in group DK (16%) (P = 0.012).

Conclusions

Premedication with intranasal dexmedetomidine 2 µg/kg and oral ketamine 3 mg/kg is a rapid and effective alternative in children undergoing dental rehabilitation when compared to intranasal midazolam 0.2 mg/kg.