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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dexmedetomidine as a Short-Use Analgesia for the Immature Nervous System

Pain management in neonates continues to be a challenge. Diverse therapies are available that cause loss of pain sensitivity. However, because of side effects, the search for better options remains open. Dexmedetomidine is a promising drug; it has shown high efficacy with a good safety profile in sedation and analgesia in the immature nervous system. Though dexmedetomidine is already in use for pain control in neonates (including premature neonates) and infants as an adjunct to other anesthetics, the question remains whether it affects the neuronal activity patterning that is critical for development of the immature nervous system. In this study, using the neonatal rat as a model, the pharmacodynamic effects of dexmedetomidine on the nervous and cardiorespiratory systems were studied. Our results showed that dexmedetomidine has pronounced analgesic effects in the neonatal rat pups, and also weakly modified both the immature network patterns of cortical and hippocampal activity and the physiology of sleep cycles. Though the respiration and heart rates were slightly reduced after dexmedetomidine administration, it might be considered as the preferential independent short-term therapy for pain management in the immature and developing brain.

The EC50 of propofol with different doses of dexmedetomidine during gastrointestinal endoscopy: A double-blind, placebo-controlled trial

PURPOSE

The goal of this study was to evaluate the dose-response relationship between dexmedetomidine and propofol in sedating patients and to determine the optimal dosage of dexmedetomidine during gastrointestinal endoscopy.

METHODS

One hundred fifty patients were divided into 5 groups, each receiving a loading dose of dexmedetomidine (0.4, 0.6, 0.8, 1.0 µg/kg) or saline, with propofol for sedation. The median effective concentration (EC50) of propofol was calculated using the modified Dixon up-and-down approach. Adverse effects, vital signs, procedure, and recovery times were recorded.

RESULTS

The EC50 of propofol in groups NS, D0.4, D0.6, D0.8, and D1.0 were 3.02, 2.44, 1.97, 1.85, and 1.83 µg/mL, respectively. Heart rate in the dexmedetomidine groups decreased more than the NS group (P < .001). The mean arterial pressure (MAP) in the NS group experienced a decline compared to groups D0.8 and D1.0 when the plasma concentration and effect-site concentration reached equilibrium. Additionally, the respiratory rate was found to be lower in groups NS, D0.4, D0.6, and D0.8 (P < .05). Recovery time in groups D0.8 and D1.0 was longer than the NS group (P < .05). Bruggemann comfort scales score was higher in group D1.0 (P < .05). No significant difference was found in the incidences of hypotension and bradycardia, and the dose of ephedrine and atropine. Respiratory depression was significantly reduced in groups D0.8 and D1.0 compared to the NS group.

CONCLUSION

A single dose of 0.6 to 0.8 µg/kg of dexmedetomidine should be recommended in combination with propofol for gastrointestinal endoscopy. And the EC50 of propofol is 1.97 to 1.85 µg/mL.

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.

Effect of dexmedetomidine on pulmonary function in obese patients undergoing laparoscopic surgery

OBJECTIVE

This research aimed to ascertain the effect of dexmedetomidine on pulmonary function in obese patients undergoing laparoscopic surgery.

METHODS

Obese patients undergoing laparoscopic surgery under general anesthesia were separated into the control group (group C) and the dexmedetomidine group (group D) (n = 30). Patients in group D were infused with dexmedetomidine (1 μg/kg) intravenously for 10 min and then at a rate of 0.5 mg/kg h until 30 min before the end of the surgery, and those in group C were infused with an equal volume of saline. The surgery time points were divided into: before anesthesia induction (T0), 5 min after intubation (T1), 30 min after pneumoperitoneum (T2), 10 min after pneumoperitoneum release (T3), at the time of extubation (T4), 3 min after extubation (T5), and 24 h after surgery (T6). Arterial blood was collected for blood gas analysis to record arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2). Dynamic lung compliance (Cdyn), oxygenation index (OI), alveolar-arterial oxygen partial pressure difference (A-aDO2), and respiratory index (RI) were calculated. The time of surgery, anesthesia, CO2 pneumoperitoneum, eye-opening, and time from the end of surgery to extubation were recorded. Plasma IL-8 and IL-10 levels were measured from T0 to T6.

RESULTS

The time of surgery, anesthesia, CO2 pneumoperitoneum, eye-opening, and time from the end of surgery to extubation in group D were not statistically significant when compared with those in group C. Versus at the T1 time point, A-aDO2 and RI were higher and Cdyn and OI were lower in both groups at T2 and T3 time points. Versus group C, group D had higher Cdyn and OI and lower A-aDO2 and RI at T2 and T3 time points. Versus at the T0 time point, at each time point from T1 to T6, IL-8 and IL-10 levels were higher in both groups. Versus group C, group D had lower IL-8 and higher IL-10 levels at each time point from T1 to T6.

CONCLUSION

In obese patients undergoing laparoscopic surgery under general anesthesia, the use of dexmedetomidine can improve the lung compliance and OI of the patients, inhibit the inflammatory response of the lungs of the patients and thus have a certain protective effect on the lung function.

Dexmedetomidine attenuates acute stress-impaired learning and memory in mice by maintaining the homeostasis of intestinal flora

Dexmedetomidine (Dex) has been used in surgery to improve patients' postoperative cognitive function. However, the role of Dex in stress-induced anxiety-like behaviors and cognitive impairment is still unclear. In this study, we tested the role of Dex in anxiety-like behavior and cognitive impairment induced by acute restrictive stress and analyzed the alterations of the intestinal flora to explore the possible mechanism. Behavioral and cognitive tests, including open field test, elevated plus-maze test, novel object recognition test, and Barnes maze test, were performed. Intestinal gut Microbe 16S rRNA sequencing was analyzed. We found that intraperitoneal injection of Dex significantly improved acute restrictive stress-induced anxiety-like behavior, recognition, and memory impairment. After habituation in the environment, mice (male, 8 weeks, 18-23 g) were randomly divided into a control group (control, N = 10), dexmedetomidine group (Dex, N = 10), AS with normal saline group (AS + NS, N = 10) and AS with dexmedetomidine group (AS + Dex, N = 10). By the analysis of intestinal flora, we found that acute stress caused intestinal flora disorder in mice. Dex intervention changed the composition of the intestinal flora of acute stress mice, stabilized the ecology of the intestinal flora, and significantly increased the levels of Blautia (A genus of anaerobic bacteria) and Coprobacillus. These findings suggest that Dex attenuates acute stress-impaired learning and memory in mice by maintaining the homeostasis of intestinal flora.

Melatonin vs. dexmedetomidine for sleep induction in children before electroencephalography

Background and objectives

In children requiring electroencephalography (EEG), sleep recording can provide crucial information. As EEG recordings during spontaneous sleep are not always possible, pharmacological sleep-inducing agents are sometimes required. The aim of the study was to evaluate safety and efficacy of melatonin (Mel) and dexmedetomidine (Dex; intranasal and sublingual application) for sleep induction prior to EEG.

Methods

In this prospective randomized study, 156 consecutive patients aged 1-19 years were enrolled and randomized by draw into melatonin group (Mel; n = 54; dose: 0.1 mg/kg), dexmedetomidine (Dex) sublingual group (DexL; n = 51; dose: 3 mcg/kg) or dexmedetomidine intranasal group (DexN; n = 51; dose: 3 mcg/kg). We compared the groups in several parameters regarding efficacy and safety and also carried out a separate analysis for a subgroup of patients with complex behavioral problems.

Results

Sleep was achieved in 93.6% of participants after the first application of the drug and in 99.4% after the application of another if needed. Mel was effective as the first drug in 83.3% and Dex in 99.0% (p < 0.001); in the subgroup of patients with complex developmental problems Mel was effective in 73.4% and Dex in 100% (p < 0.001). The patients fell asleep faster after intranasal application of Dex than after sublingual application (p = 0.006). None of the patients had respiratory depression, bradycardia, desaturation, or hypotension.

Conclusions

Mel and Dex are both safe for sleep induction prior to EEG recording in children. Dex is more effective compared to Mel in inducing sleep, also in the subgroup of children with complex behavioral problems.

Clinical Trial Registration

Dexmedetomidine and Melatonin for Sleep Induction for EEG in Children, NCT04665453.

General Anesthesia Exposure in Infancy and Childhood: A 10-year Bibliometric Analysis

PURPOSE

Heated discussions have divided health care providers and policymakers on the risks versus benefits of general anesthesia in pediatric populations. We conducted this study to provide a comprehensive bibliometric analysis of general anesthesia in this specific population over the past decade.

DESIGN

We summarized and quantitatively analyzed the studies related to general anesthesia in children and infants over the past decade.

METHODS

Using the Web of Science Core Collection as the data source, we analyzed the literature using CiteSpace software, focusing on authors, countries, institutions, keywords, and references to identify hotspots and predict research trends.

FINDINGS

A total of 2,364 publications on pediatric anesthesia were included in the analysis. The number of related publications and citations steadily increased from 2013 to 2022. The United States was the leading country in terms of output, and University of Toronto was the primary contributing institution. Co-citation analysis revealed that over the past decade research has mainly focused on the long-term adverse effects of general anesthesia on neurodevelopment and acute perioperative crisis events. Keyword analysis identified infant sedation and drug selection and compatibility as promising areas for development. In addition, improving the quality of perioperative anesthesia will be a major research focus in the future.

CONCLUSIONS

Recent research in pediatric anesthesia has focused on mitigating the adverse effects of general anesthesia in infants and young children and studying the pharmacological compatibility of anesthetics. Our study results would assist researchers and clinicians in understanding the current research status and optimizing clinical practice in this field.

Anaesthesia and brain development: a review of propofol-induced neurotoxicity in pediatric populations

With the advancement of medical technology, there are increasing opportunities for new-borns, infants, and pregnant women to be exposed to general anaesthesia. Propofol is commonly used for the induction of anaesthesia, maintenance of general intravenous anaesthesia and sedation of intensive-care children. Many previous studies have found that propofol has organ-protective effects, but growing evidence suggests that propofol interferes with brain development, affecting learning and cognitive function. The purpose of this review is to summarize the latest progress in understanding the neurotoxicity of propofol. Evidence from case studies and clinical studies suggests that propofol has neurotoxicity on the developing brain. We classify the findings on propofol-induced neurotoxicity based on its damage mechanism. We end by summarizing the current protective strategies against propofol neurotoxicity. Fully understanding the neurotoxic mechanisms of propofol can help us use it at a reasonable dosage, reduce its side effects, and increase patient safety.

Application of Dexmedetomidine in Epidural Labor Analgesia: A Systematic Review and Meta-Analysis on Randomized Controlled Trials

OBJECTIVES

To summarize and appraise the use of dexmedetomidine in epidural labor analgesia, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted the literature search about the RCTs of epidural labor analgesia with or without dexmedetomidine from inception until November 1, 2022, in the following databases: PubMed, Cochrane Library, and Embase. The primary outcome was visual analog scale (VAS) within 2 hours after epidural intubation. The secondary outcomes included the duration of the first and second labor stages, Apgar score, umbilical blood pH, dosage of analgesics, and side effects.

RESULTS

Eight RCTs including 846 parturients were included. The VAS score of the dexmedetomidine group was significantly lower than that of the control group at the time of 15 minutes (mean difference [MD] -1.41, 95% confidence interval [CI] -2.23, -0.59), 30 minutes (MD -1.02, 95% CI -1.70, -0.33), 60 minutes (MD -0.90, 95% CI -1.36, -0.44), and 90 minutes (MD -0.70, 95% CI -1.16, -0.23). The incidence of pruritus in the dexmedetomidine group was lower than that of the control group （MD 0.28, 95% CI 0.11, 0.74), but the incidence of maternal bradycardia was higher (MD 6.41, 95% CI 1.64, 25.04). There were no significant difference in other outcomes.

DISCUSSION

Dexmedetomidine combined with local anesthetic for epidural labor analgesia can improve the VAS score of parturients. Except for the increased incidence of maternal bradycardia, it seems to be safe for the parturients and fetuses.

Effect of wound infiltration of dexmedetomidine in lumbar spine surgery on postoperative wound pain: A meta-analysis

In a meta-study, we evaluated the effectiveness and security of the combination of topical anaesthetic and dexmedetomidine in the treatment of postoperative pain in patients with lumbar disease. Four databases were systematically searched for possible related articles. Only English-language research was taken into account on the Internet. Furthermore, we only took into account the studies that were published prior to 2023. Only those that fulfilled the eligibility criteria were considered: (1) in adults who were about to undergo spine operation, (2) dexmedetomidine combined with local anaesthesia, (3) Visual Analog Scale scores at 4 and 24 h after the event and (4) this was a randomized or nonrandomized, controlled study. The meta-analysis was carried out with Revman 5.3 software. A ROBINS-I-based instrument was used to evaluate controlled studies. All trials were synthesized by computing the end results with either a fixed or a random effect model, which was dependent on statistical diversity. Five trials showed a marked reduction in wound pain at 4 h after the operation in patients who were treated with dexmedetomidine for lumbar spinal surgery (MD, -0.81; 95% CI, -1.24, -0.35; p = 0.0005). In the case of lumbar spinal operations, the addition of dexmedetomidine to the postoperative treatment resulted in a marked reduction in the pain at 24 h post-operation (MD, -0.64; 95% CI, -0.79, -0.48; p < 0.0001). The quality of the data we evaluated was 'moderate' to 'good'; thus, we have limited confidence in the impact estimation, and the actual impact might be significantly different from what we had expected. Additional studies should concentrate on practices that are well known to cause severe postoperative pain, especially for cases where the improvement of pain management may lead to substantial clinical benefits in terms of reduction of morbidity or cost-effectiveness in terms of quicker healing and release.

Dexmedetomidine at Home for Intractable Dystonia and Insomnia in Children With Special Needs: A Case Series

BACKGROUND

We know that syndromic conditions and severe chronic diseases can be associated with symptoms that may interfere with sleep, significantly impacting the life quality of children and caregivers. Drugs commonly used in treating insomnia, such as melatonin, benzodiazepines, niaprazine, and antihistamines, are often either ineffective or associated with adverse effects, requiring new therapeutic perspectives. Dexmedetomidine is a selective alpha-2 agonist with hypnotic and anxiolytic effects, which, by stimulating alpha-2 adrenergic receptors in the locus coeruleus, induces sleep comparable to stages 2-3 of the non-REM phase without substantially affecting the respiratory drive during sedation. Its use has already been extensively described in pediatric intensive care or procedural sedation literature. In 2018, the Italian Medicines Agency (Agenzia Italiana Del Farmaco AIFA) authorized the off-label use of dexmedetomidine outside of intensive care in Children undergoing palliative treatment to control distressing symptoms related to pathology and refractory sleep disorders, and the literature reported cases of children who received dexmedetomidine at home.

OBJECTIVE

Our study aims to describe the home use of dexmedetomidine in children with insomnia or intractable dystonic states.

MEASURES

We conducted a retrospective analysis through a questionnaire addressed to 12 Italian pediatric palliative care centers regarding the home use of dexmedetomidine in sleep disorders and intractable dystonic states.

INTERVENTION

We collected a case series of 9 children treated with dexmedetomidine at home, 8 via intranasal and 1 via intravenous route. All children received the first drug administration in the hospital or hospice during a dedicated admission, under close monitoring of vital signs parameters for 72 hours (3 days, range 2-7 days). After discharge, the potential side effects of the drug were explained to the patient's families, and, once informed consent was obtained, the home administration of dexmedetomidine continued, with follow-up by the palliative care team. At home, dexmedetomidine was administered for 3000 days (minimum 1 month, maximum 36 months). The first patient was treated for 1095 days, from 2019 to 2021 (discontinued due to underlying condition-related death).

OUTCOMES

All patients observed a persistent benefit from the treatment on symptoms, and none of them discontinued dexmedetomidine administration due to drug-related adverse effects or perceived lack of therapeutic efficacy.

CONCLUSIONS

Therefore, its use at home may represent a promising therapeutic approach for intractable sleep disorders or dystonic states in pediatric palliative care children. Further studies are needed to confirm our results.

Hypotensive Events in Pediatric Patients Receiving Dexmedetomidine for MRI

PURPOSE

Dexmedetomidine, the preferred pediatric sedating agent for magnetic resonance imaging (MRI), has the side effect of hypotension. Newer recommendations for reporting adverse events in pediatric procedural sedation include using a two-pronged definition. Our aim was to describe the incidence of hypotension in patients undergoing sedated MRI and to identify demographic and clinical factors associated with hypotension, applying a two-pronged definition, where a numerical threshold/clinical criterion must be met as well as at least one clinical intervention performed.

DESIGN

An observational cohort study.

METHODS

Medical record data were extracted for outpatients less than 18 years of age sedated primarily with dexmedetomidine for MRI in a single center for over a seven-year period. Patients who received propofol as an adjunct were also included. Hypotension was defined using a two-pronged approach, as a 20% reduction in systolic blood pressure from baseline lasting ≥10 minutes, coupled with a fluid bolus. Analysis included descriptive statistics, t tests and logistic regression using discrete-time survival analysis.

FINDINGS

Of the 1,590 patient encounters, 90 (5.7%) experienced hypotension. Males were significantly more likely to have hypotension. Patients with hypotension had overall longer appointment times, including longer sedation times and recovery time. Greater blood pressure (BP) variability in the preceding 20 minutes also increased the risk of hypotension.

CONCLUSIONS

Our lower incidence of hypotension is likely related to the two-pronged intervention-based definition used, as it likely more accurately reflects clinically meaningful hypotension. To our knowledge, this is the first study using this approach with this population. Research further examining the relationship between prolonged sedation, blood pressure variability, gender, hypotension, and recovery time is needed. Understanding these relationships will help interdisciplinary teams, including nurses in pediatric procedural areas, to reduce the incidence of hypotension, potentially maximize patient safety, and optimize throughput.

Comparison of oxygen reserve index according to the remimazolam or dexmedetomidine for intraoperative sedation under regional anesthesia-A single-blind randomized controlled trial

Introduction

We aimed to evaluate the difference in intraoperative oxygen reserve index (ORi) between the sedatives remimazolam (RMMZ) and dexmedetomidine (DEX).

Methods

Seventy-eight adult patients scheduled for sedation under regional anesthesia were randomly assigned to either the DEX (n = 39) or RMMZ (n = 39) group. The primary outcome was the difference in perioperative ORi between the groups. The secondary outcomes included respiratory depression, hypo- or hypertension, heart rate (HR), blood pressure, respiratory rate and postoperative outcomes. Additionally, the number of patients who experienced a decrease in intraoperative ORi to < 50% and the associated factors were analyzed.

Results

The ORi was significantly higher in the RMMZ group at 15 min after sedation maintenance. There were no significant differences in respiratory depression between the two groups. The intraoperative HR was significantly higher in the RMMZ group after the induction of sedation, 15 min after sedation maintenance, and at the end of surgery. No other results were significantly different between the two groups. The incidence of a decrease in intraoperative ORi to < 50% was significantly higher in the DEX group. Factors associated with a decrease in the intraoperative ORi to < 50% were diabetes mellitus, low baseline peripheral oxygen saturation (SpO2), and DEX use. In the receiver operating characteristic curve analysis for a decrease in the intraoperative ORi to < 50%, the cutoff baseline SpO2 was 97%.

Conclusion

RMMZ is recommended as a sedative for patients with a low baseline SpO2 and intraoperative bradycardia. Further studies should be conducted to establish the criteria for a significant ORi reduction.

Impact of Dexmedetomidine Infusion on Opioid and Benzodiazepine Doses in Ventilated Pediatric Patients in the Cardiac Intensive Care Unit

INTRODUCTION

Dexmedetomidine (DEX) is frequently used as an adjunct agent for prolonged sedation in the intensive care unit (ICU), though its effect on concomitant opioids or benzodiazepines infusions is unclear. We explored the impact of DEX on concomitant analgosedation in a cohort of ventilated pediatric patients in a cardiac ICU, with stratification of patients according to duration of ventilation (< 5 versus ≥ 5 days) following DEX initiation.

METHODS

We conducted a retrospective analysis on ventilated patients receiving a DEX infusion ≥ 24 h and at least one other sedative/analgesic infusion (January 2011-June 2021). We evaluated trends of daily doses of opioids and benzodiazepines from 24 h before to 72 h following DEX initiation, stratifying patients based on ventilation duration after DEX initiation (< 5 versus ≥ 5 days).

RESULTS

After excluding 1146 patients receiving DEX only, 1073 patients were included [median age 234 days (interquartile range 90, 879)]. DEX was associated with an opioid infusion in 99% of patients and a benzodiazepine infusion in 62%. Among patients ventilated for < 5 days (N = 761), opioids increased in the first 24 h following DEX initiation [+ 1.12 mg/kg/day (95% CI 0.96, 1.23), P < 0.001], then decreased [- 0.90 mg/kg/day (95% CI - 0.89, - 0.71), P < 0.001]; benzodiazepines slowly decreased [- 0.20 mg/kg/day (95% CI - 0.21, - 0.19), P < 0.001]. Among patients ventilated for ≥ 5 days (N = 312), opioid administration doubled [+ 2.09 mg/kg/day (95% CI 1.82, 2.36), P < 0.001] in the first 24 h, then diminished minimally [- 0.18 mg/kg/day (95% CI - 0.32, - 0.04), P = 0.015] without returning to baseline; benzodiazepine administration decreased minimally [- 0.03 mg/kg/day (95% CI - 0.05, - 0.01), P = 0.010]. Similar trends were confirmed when adjusting for age, gender, surgical complexity, recent major invasive procedures, duration of mechanical ventilation before DEX initiation, extubation within 72 h following DEX initiation, mean hourly DEX dose, and use of neuromuscular blocking infusion.

CONCLUSION

While in patients ventilated < 5 days opioids initially increased and then quickly decreased in the 72 h following DEX initiation, among patients ventilated ≥ 5 days opioids doubled, then decreased only minimally; benzodiazepines decreased minimally in both groups, although more slowly in the long-ventilation cohort. These findings may inform decision-making on timing of DEX initiation in ventilated patients already being treated with opioid or benzodiazepine infusions.

Postoperative agitation or delirium in paediatric patients. What we know and how to avoid it

Emergence delirium or postoperative agitation is the name given to the state of altered consciousness that occurs after surgery and especially affects pediatric patients. Its incidence is not negligible, reaching 80% of cases in certain studies. It is frequently confused with other clinical entities, for which reason a scale has been validated to facilitate its diagnosis. Risk factors include age under 5 years, the presence of pain after surgery and especially intense preoperative anxiety. Pediatric emergence delirium presents as an adverse event after surgery and influences patient safety by significantly increasing patient comorbidity. It is essential to recognize the entity, as well as its risk factors, in order to apply effective preventive measures to reduce its incidence and intensity when it occurs.

GPR30 agonist G1 combined with hypothermia alleviates cognitive impairment and anxiety-like behavior after subarachnoid hemorrhage in rats

INTRODUCTION

This study aimed to investigate the treatment effect of G protein-coupled receptor 30 (GPR30) agonist G1 combined with hypothermia (HT) on cognitive impairment and anxiety-like behavior after subarachnoid hemorrhage (SAH) in rats.

METHODS

Fifty male rats were randomly assigned to one of five groups: Sham group, SAH group, SAH + G1 group, SAH + HT group, and SAH + G1 + HT group. The SAH rat model was established by modified endovascular puncture in all groups except the Sham group. Neurological function after the operation was assessed by Garcia scoring. The degree of rat cerebral edema was determined using dry-wet weighing method on the 28th day after operation. Moreover, the behavioral test was performed on rats on the 4th and 28th days after operation.

RESULTS

Compared with Sham group, the Garcia score of each SAH rat model group decreased significantly on the first day and thereafter increased gradually. However, the recovery rate of each treatment group was higher than the SAH group (no treatment), and the Garcia score of SAH + G1 + HT group was much higher than the SAH group on the seventh day after operation. In addition, each treatment group could obviously reduce the cerebral edema degree of SAH rats, among which rats in SAH + G1 + HT group had lower cerebral edema degree than SAH + G1 group and SAH + HT group. Behavioral test results showed that the combination of GPR30 agonist G1 and HT markedly improved the learning and memory ability of SAH rats, alleviated their anxiety- and emotion-related behavior, and enhanced their social interaction.

CONCLUSION

GPR30 agonist G1 combined with HT reduces cognitive impairment and anxiety-like behavior in rats with SAH.

Future Directions in Optimizing Anesthesia to Reduce Perioperative Acute Kidney Injury

BACKGROUND

Perioperative acute kidney injury (AKI) is common in surgical patients and is associated with high morbidity and mortality. There are currently few options for AKI prevention and treatment. Due to its complex pathophysiology, there is no efficient medication therapy to stop the onset of the injury or repair the damage already done. Certain anesthetics, however, have been demonstrated to affect the risk of perioperative AKI in some studies. The impact of anesthetics on renal function is particularly important as it is closely related to the prognosis of patients. Some anesthetics can induce anti-inflammatory, anti-necrotic, and anti-apoptotic effects. Propofol, sevoflurane, and dexmedetomidine are a few examples of anesthetics that have protective association with AKI in the perioperative period.

SUMMARY

In this study, we reviewed the clinical characteristics, risk factors, and pathogenesis of AKI. Subsequently, the protective effects of various anesthetic agents against perioperative AKI and the latest research are introduced.

KEY MESSAGE

This work demonstrates that a thorough understanding of the reciprocal effects of anesthetic drugs and AKI is crucial for safe perioperative care and prognosis of patients. However, more complete mechanisms and pathophysiological processes still need to be further studied.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience

BACKGROUND

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA.

METHODS

In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA.

RESULTS

Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year.

CONCLUSIONS

These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

BACKGROUND

Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.

RESULTS

A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).

CONCLUSION

DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Perineural dexmedetomidine in femoral nerve blocks increases the duration of postoperative analgesia for anterolateral thigh flap donor sites in patients with oral cancer

Although the duration of analgesia provided by a single-shot nerve block is limited, perineural dexmedetomidine significantly enhances nerve blocks during extremity surgery. This study aimed to investigate the role of dexmedetomidine added to ropivacaine in femoral nerve blocks for postoperative analgesia of the anterolateral thigh (ALT) flap donor site in patients with oral cancer. Fifty-two participants scheduled for maxillofacial tumor resection and reconstruction using an anterolateral thigh flap were randomly allocated to either the Ropi group (femoral nerve block with ropivacaine) or the Ropi + Dex group (femoral nerve block with ropivacaine plus dexmedetomidine). The primary outcome was the duration of the sensory block, while the secondary outcomes were 24 h postoperative sufentanil use, number of patients using rescue analgesics, vital signs, postoperative pain score, incidence of agitation, and presence of adverse effects. Dexmedetomidine plus ropivacaine significantly prolonged the duration of sensory block compared with ropivacaine alone (10.4 ± 0.9 h vs 14.0 ± 1.3 h; P < 0.001). Age was positively correlated with increased duration of sensory block (r = 0.300; P = 0.033). Postoperative pain scores at the donor sites were lower in the Ropi + Dex group than in the Ropi group, at 12 h after surgery (P < 0.001). Although there were no statistically significant differences in the incidence of bradycardia between the two groups, four patients treated with dexmedetomidine experienced episodes of bradycardia. Perineural dexmedetomidine prolonged the duration of femoral nerve block and reduced postoperative pain scores at the ALT flap donor sites in patients with oral cancer.

The preventive effect of dexmedetomidine on anesthesia complications in strabismus surgery: a systematic review and meta-analysis

OBJECTIVE

Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.

METHODS

Literature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.

RESULTS

A total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).

CONCLUSION

Among patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.

Changing Trends in Conscious Sedation at Pediatric Dental Offices: A Bibliometric Analysis

The uncooperative behavior of children in the dental office has increased the demand for pharmacological behavior management techniques. Moderate sedation is more effective by providing analgesia and anxiolysis, thereby aiding in carrying out the most comfortable, efficient, and high-quality dental services. There is a need to understand the various aspects such as the choice of drug, method of drug administration, safety, and efficacy. Bibliometrics can reveal significant shifts in research and publication trends. Therefore, this study aimed to perform a bibliometric analysis of the literature on evolving trends in conscious sedation at pediatric dental offices. The bibliometric research used RStudio 2021.09.0+351 for Windows (RStudio, Boston, MA), package "bibliometrix," and VOS viewer software (Centre for Science and Technology Studies, Leiden University, The Netherlands. https://www.vosviewer.com). Elsevier's Scopus database (www.scopus.com) provided the literary data for this study, which were exported in BibTex format. The articles were independently categorized according to the following aspects: (a) annual scholarly output; (b) leading countries or regions; (c) leading journals; (d) productive authors; (e) citations; (f) study design; and (g) distribution of topics. The findings considered 1996 through 2022 and used journals, books, articles, and other sources, totaling 1064 papers, with an average of 10.7 per year. According to the findings, the United States, the United Kingdom, and India were principally leading the field of conscious sedation research. In total, 2433 authors were found through the search. The study identified the nations that are currently researching the topics such as midazolam and nitrous-oxide; this paves the way for future partnerships to strengthen the evidence generated in other topic areas using novel sedatives and exploring the different routes of drug administration, thereby benefiting the scientific community by identifying knowledge gaps and experts in this area of research.

Perioperative management and drug selection for sedated/anesthetized patients undergoing MRI examination: A review

In recent years, magnetic resonance imaging (MRI) technology has become an indispensable imaging tool owing to significant improvements in MRI that have opened up new diagnostic perspectives. Due to the closed environment, long imaging time, and need to remain still during the examination process, the examiner may cannot cooperate with the completion of the examination of the procedure, which increases the need for deep sedation or anesthesia. Achieving this can sometimes be challenging, especially in the special nontraditional environment of MRI equipment (unfamiliar and narrow spaces, away from patients, strong magnetic fields) and in special populations requiring sedation/anesthesia during examinations, which pose certain challenges for the perioperative anesthesia management of MRI. A simple "checklist" is necessary because it allows the anesthesiologist to become familiar with the particular environment and human and material resources as quickly as possible. For the choice of sedative/anesthetic, the traditional drugs, such as midazolam and ketamine, are still used due to the ease of administration despite their low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, propofol, with high effectiveness and rapid recovery, and sevoflurane, which is mild and nonirritating, are preferred for sedation/anesthesia in children and adults undergoing MRI. Therefore, familiarity with the perioperative management of patient sedation and general anesthesia and drug selection in the MRI environment is critical for successful surgical completion and for the safe and rapid discharge of MRI patients receiving sedation/anesthesia.

Dexmedetomidine improves lung compliance in patients undergoing lateral decubitus position of shoulder arthroscopy: A randomized controlled trial

BACKGROUND

The improvement of oxygenation and pulmonary mechanics in patients under general anesthesia can be achieved by dexmedetomidine (DEX) infusion. However, its role in patients undergoing lateral supine shoulder arthroscopy has not been thoroughly studied. This study aimed to evaluate the effect of DEX on lung compliance in patients undergoing shoulder arthroscopic surgery in a lateral decubitus position.

METHODS

The patients who underwent lateral recumbent shoulder arthroscopy under general anesthesia were randomly divided into the DEX group (group D) and the control group (group N). At the start of the trial, group D was given 0.5 μg/kg/hours continuous pumping until 30 minutes before the end of anesthesia; Group N was injected with normal saline at the same volume. The patients were recorded at each time point after intubation: supine position for 5 minutes (T0), lateral position for 5 minutes (T1), lateral position for 1 hour (T2), lateral position for 2 hours (T3), airway peak pressure, platform pressure, dynamic lung compliance, and static lung compliance, etc.

RESULTS

At the end of the drug infusion, the DEX group showed significant improved pulmonary mechanics and higher lung compliance than the control group. Compared with group N, group D's heart rate and mean arterial pressure were lower at all time points; there was no statistical difference in Tidal volume and Pressure end-tidal carbon dioxide data at each time point in Group D.

CONCLUSION

DEX can improve lung compliance and reduce airway pressure and platform pressure of patients undergoing shoulder arthroscopy in the lateral position under general anesthesia.

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.

Propofol-Induced Developmental Neurotoxicity: From Mechanisms to Therapeutic Strategies

Propofol is the most commonly used intravenous general anesthetic in clinical anesthesia, and it is also widely used in general anesthesia for pregnant women and infants. Some clinical and preclinical studies have found that propofol causes damage to the immature nervous system, which may lead to neurodevelopmental disorders and cognitive dysfunction in infants and children. However, its potential molecular mechanism has not been fully elucidated. Recent in vivo and in vitro studies have found that some exogenous drugs and interventions can effectively alleviate propofol-induced neurotoxicity. In this review, we focus on the relevant preclinical studies and summarize the latest findings on the potential mechanisms and therapeutic strategies of propofol-induced developmental neurotoxicity.

Evaluation of the Relationship between Baseline Autonomic Tone and Haemodynamic Effects of Dexmedetomidine

Dexmedetomidine, a central α-2 agonist, is used for procedural sedation and for conscious sedation influences on heart rate and blood pressure. Authors verified whether it is possible to predict bradycardia and hypotension with the use of heart rate variability (HRV) analysis for an autonomic nervous system (ANS) activity assessment. The study included adult patients of both sexes with an ASA score of I or II scheduled for ophthalmic surgery to be performed under sedation. The loading dose of dexmedetomidine was followed by a 15 min infusion of the maintenance dose. The frequency domain heart rate variability parameters from the 5-min Holter electrocardiogram recordings before dexmedetomidine administration were used for the analysis. The statistical analysis also included pre-drug heart rate and blood pressure as well as patient age and sex. The data from 62 patients were analysed. There was no relationship between the decrease in heart rate (42% of cases) and initial HRV parameters, haemodynamic parameters or sex and age of patients. In multivariate analysis, the only risk factor for a decrease in mean arterial pressure (MAP) > 15% from the pre-drug value (39% of cases) was the systolic blood pressure before dexmedetomidine administration as well as for a >15% decrease in MAP sustained at more than one consecutive time point (27% of cases). The initial condition of the ANS did not correlate with the incidence of bradycardia or hypotension; HRV analysis was not helpful in predicting the abovementioned side effects of dexmedetomidine.

A comprehensive overview of clinical research on dexmedetomidine in the past 2 decades: A bibliometric analysis

Introduction: Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist with sedative, analgesic, anxiolytic, and opioid-sparing properties. A large number of dexmedetomidine-related publications have sprung out in the last 2 decades. However, no bibliometric analysis for clinical research on dexmedetomidine has been published to analyze hot spots, trends, and frontiers in this field. Methods: The clinical articles and reviews related to dexmedetomidine, published from 2002 to 2021 in the Web of Science Core Collection, were retrieved on 19 May 2022, using relevant search terms. VOSviewer and CiteSpace were used to conduct this bibliometric study. Results: The results showed that a total of 2,299 publications were retrieved from 656 academic journals with 48,549 co-cited references by 2,335 institutions from 65 countries/regions. The United States had the most publications among all the countries (n = 870, 37.8%) and the Harvard University contributed the most among all institutions (n = 57, 2.48%). The most productive academic journal on dexmedetomidine was Pediatric Anesthesia and the first co-cited journal was Anesthesiology. Mika Scheinin is the most productive author and Pratik P Pandharipande is the most co-cited author. Co-cited reference analysis and keyword analysis illustrated hot spots in the dexmedetomidine field including pharmacokinetics and pharmacodynamics, intensive care unit sedation and outcome, pain management and nerve block, and premedication and use in children. The effect of dexmedetomidine sedation on the outcomes of critically ill patients, the analgesic effect of dexmedetomidine, and its organ protective property are the frontiers in future research. Conclusion: This bibliometric analysis provided us with concise information about the development trend and provided an important reference for researchers to guide future research.

Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis

The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Nociception associated with pain/distress in young children sedated for dental treatment: a clinical study with objective and subjective measures

PURPOSE

To evaluate the association between children's pain/distress levels and patient characteristics (age, sex, history of dental pain), sedation type (level of sedation, sedative regimen), nociception and pain intensity reported by the parents in sedated children undergoing minimally invasive dental treatment.

METHODS

This clinical study evaluated secondary outcomes of an RCT that evaluated the efficacy of dexmedetomidine sedation with or without ketamine. Only children who had nociception levels recorded using the Analgesia Nociception Index (ANI) were included (0-100; 0 = highest nociception). FLACC scale (Face, Legs, Activity, Cry and Consolability) was used to assess children's pain/distress (0-10; 0 = no pain/distress). Parental proxy report of the child's pain intensity during the treatment was performed using the Visual Analogue Scale (VAS; 0-100; 0 = no pain). The association between ANI, children's age and sex, dental pain history, sedation level, sedative regimen, and VAS with the FLACC was verified using the generalised estimation equation analysis (alpha 0.05).

RESULTS

Participants were 31 children (51.6% boys) and their parents (90.3% mothers). Median FLACC was 3.3 (25th-75th percentiles 1.7-8.2), ANI 80.9 (74.7-85.8), and VAS 10 (1-23). FLACC associated with ANI (OR 0.96; 95% CI 0.93-0.99; p = 0.02), moderate sedation (0.13; 0.03-0.50; p = 0.003), and VAS (1.05; 1.01-1.10; p = 0.01).

CONCLUSION

Pain/distress was generally low and more prominent with minimal (versus moderate) sedation and higher nociception.

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.

Application of laryngeal mask airway anesthesia with preserved spontaneous breathing in children undergoing video-assisted thoracic surgery

Purpose

To investigate the feasibility and safety of non-intubated general anesthesia with spontaneous breathing combined with paravertebral nerve blocks (PVNB) in young children undergoing video-assisted thoracic surgery (VATS) and to determine its significance for rapid recovery after pediatric thoracic surgery.

Methods

The data of 46 children aged 6-36 months with an American Society of Anesthesiologists status of I-II who underwent elective VATS under general anesthesia were retrospectively analyzed. Of these patients, 25 underwent non-intubated general anesthesia with spontaneous breathing combined with PVNB (non-intubation group), and 21 received conventional intubated general anesthesia combined with local infiltration anesthesia (intubation group). The following perioperative parameters were compared between the two groups: heart rate (HR), mean arterial pressure, saturation of pulse oximetry (SpO₂), partial pressure end-tidal carbon dioxide, time from the completion of the operation to extubation or removing laryngeal masks, time to first feeding after the operation, length of postoperative in-hospital stay, incidence of postoperative complications, and hospitalization expenses.

Results

The operations were completed successfully in both groups. When the non-intubation group was compared with the intubation group, the minimal SpO₂ level during the surgery was higher (93% vs. 88%, P < 0.001), which might indicate better oxygenation. There was no significant difference of the duration of surgery and intraoperative blood loss between two groups. Compared to the intubation group, the duration of anesthesia (P = 0.027), time from the completion of the operation to extubation (P < 0.001), time to the first feeding after surgery (P < 0.001), and length of postoperative in-hospital stay (P < 0.001) were significantly reduced in the non-intubation group. The incidence of postoperative complications was not significantly different.

Conclusions

Non-intubated general anesthesia with spontaneous breathing combined with PVNB is safe and feasible in young children undergoing VATS and can promote rapid recovery in young children undergoing thoracoscopic surgery.

Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis

BACKGROUND

Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0-8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques.

METHODS

Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0-8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events.

RESULTS

Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91-0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92-0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14-0.65); for oral pentobarbital 99% (95% CI: 0.90-1.00); for rectal thiopental 92% (95% CI: 0.85-0.96); for oral melatonin 75% (95% CI: 0.54-0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38-0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78-0.99); and for inhaled sevoflurane 98% (95% CI: 0.97-0.99).

CONCLUSIONS

We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease

BACKGROUND

Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children.

METHODS

Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg.

RESULTS

A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg.

CONCLUSIONS

Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

The optimum time for intravenous cannulation after induction with sevoflurane in children premedicated with dexmedetomidine

BACKGROUND

Inhalation anesthesia is a frequently used method for anesthesia induction, especially in young children. No information is available on the optimum time for safe intravenous cannulation after inhalational induction in children with dexmedetomidine premedication. The purpose of the present study was to determine the optimal time for intravenous cannulation after induction of anesthesia with sevoflurane and nitrous oxide in children premedicated with intranasal dexmedetomidine.

METHODS

This prospective and observational study was conducted by using the up-down sequential method. Children, who were aged 2-6 years with ASA physical status I, and who underwent inhalation induction for elective surgery were included in the study. Anesthesia was induced with sevoflurane and nitrous oxide after the premedication with intranasal dexmedetomidine (2 mcg/kg). Intravenous cannulation was attempted on the dorsum of the hand by an experienced anesthesiologist 4 min after the loss of the eyelash reflex in the first patient. The procedure was considered successful in patients without any movement, cough, or laryngospasm. The waiting time for cannulation was increased by 15 s if the procedure was not successful in the previous patient, and on the contrary, it was reduced by 15 s if the procedure was successful in the previous patient. The probit test was used in the analysis of up-down sequences.

RESULTS

In the present study in which a total of 40 patients were included, the effective cannulation time was found to be 14.40 s (95% confidence limits, 1.30-27.82 s) in 50% of the patients, and the effective cannulation time was found as 84.64 s (95% confidence limits, 69.61-218.26 s) in 95% of the patients.

CONCLUSIONS

In conclusion, we suggest that the appropriate time for cannulation is 85 s (1.45 min) after the loss of eyelash reflex in children sedated with dexmedetomidine and induction with sevoflurane and nitrous oxide-oxygen mixture.

A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center

Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table. A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention. To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.

Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”

This supplementary material was provided by the authors to give readers additional information and resources to replicate their work.

The safety and efficacy of esketamine in comparison to dexmedetomidine during drug-induced sleep endoscopy in children with obstructive sleep apnea hypopnea syndrome: A randomized, controlled and prospective clinical trial

Background and Purpose: Data and high-quality studies of anesthetic methods for children with obstructive sleep apnea hypopnea syndrome (OSAHS) who undergo drug-induced sleep endoscopy (DISE) are limited. Research on pediatric DISE using esketamine has never been reported before. To test the safety and efficacy of esketamine during DISE in children with OSAHS, we compare esketamine (Group K) with dexmedetomidine (Group D) in this study. Methods: 100 children with ASA Ⅰ∼Ⅱ grade, prepared for an elective adenotonsillectomy under general anesthesia, were enrolled in this study and randomized into two groups. Midazolam 0.1 mg/kg was administered intravenously for both groups. In Group D a 1 μg/kg bolus of dexmedetomidine was given over 10 min followed by the infusion rate 1 μg/kg/hr to the end of DISE. Group K received a 1.0 mg/kg IV bolus of esketamine over 10 s followed by the infusion rate 1 mg/kg/hr to the end of DISE. Results: Group K had a higher percentage of success than Group D (p = 0.008). The onset time of Group K was shorter than that of Group D (p = 0.000). The University of Michigan Sedation Scale (UMSS) score of Group K was higher than that of Group D (p = 0.005). The risk of adverse effects (AEs) was lower in Group K (p = 0.000). In Group D, systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) all decreased, while in Group K, SBP, DBP, and HR hardly changed. Conclusion: Esketamine in comparison to dexmedetomidine provides more effective and safer depth of anesthesia for OSAHS pediatric DISE by ensuring short onset time, deep sedation, and few AEs. Clinical Trial Registration: ClincalTrials.gov, identifier NCT04877639.

Neuraxial block anesthetic technique in a patient with SCN8A encephalopathy: case report

Mutations in SCN8A gene lead to changes in sodium channels in the brain, which are correlated with severe epileptic syndrome. Due to the rarity, there are few studies that support anesthesia in that population. The present study aims to report alternatives to inhalation anesthesia at epileptic encephalopathy. CASE REPORT: Male, 4 years old, with SCN8A encephalopathy with surgical indication of orchidopexy. Neuroaxis block was performed and dexmedetomidine was used as a pre-anesthetic and sedation. The anestheticsurgical act was uneventful. CONCLUSION: The association of neuraxial block and dexmedetomidine proved to be a viable alternative for surgery in patients with SCN8A encephalopathy.

Moderate sedation with dexmedetomidine-remifentanil is safer than deep sedation with propofol-remifentanil for endobronchial ultrasound while providing comparable quality: a randomized double-blind trial

OBJECTIVE

We compared dexmedetomidine-remifentanil vs. propofol-remifentanil in terms of safety and quality during sedation for Endobronchial ultrasonography (EBUS).

METHODS

A randomized, double-blind trial. Outpatients undergoing EBUS randomly received 1 μg/kg/hour dexmedetomidine or a target concentration of 2.5 μg/mL propofol, both combined with remifentanil initially targeted at 1.5 ng/mL and subsequently titrated. Additional sedatives were restricted. The primary outcome was the need for airway rescue interventions to treat oxygen desaturation.

RESULTS

Twenty-eight patients received dexmedetomidine-remifentanil and 27 received propofol-remifentanil. Airway rescue interventions were fewer in the dexmedetomidine group vs. the propofol one (23 vs. 76% patients, relative risk 3.21 (95% CI 1.55-6.64, P < 0.002)). Desaturation in the dexmedetomidine group was always resolved by increasing nasal oxygen flow, whereas additional interventions were needed in 60% of patients receiving propofol. Hypotension was more frequent in the propofol group, while hypertension, bradycardia and coughing were similar in both. Bronchoscopists' and patients' satisfaction were similar, although in the dexmedetomidine group two patients needed additional sedatives and two patients would not repeat the sedation technique.

CONCLUSION

Moderate sedation with dexmedetomidine-remifentanil for EBUS is safer than deep sedation with propofol-remifentanil but it would occasionally need additional sedatives to ensure patient satisfaction.

Inhibition of stress and spontaneous respiration: Efficacy and safety of monitored anesthesia care by target-controlled infusion remifentanil in combination with dexmedetomidine in fibreoptic bronchoscopy for patients with severe tracheal stenosis

Objective

This study aimed to determine the effective concentration of target-controlled infusion (TCI) of remifentanil used to inhibit stress during the treatment of severe tracheal stenosis with fibreoptic bronchoscopy and to evaluate the monitored anesthesia care (MAC) by remifentanil.

Materials and methods

60 patients with severe tracheal stenosis who underwent fibreoptic bronchoscopy was performed. Dexmedetomidine was initially administered at a bolus dose (0.8 mcg/kg), followed by a 0.5 mcg/(kg⋅h) continuous infusion. Remifentanil was administered by TCI. The effective concentration (EC) of remifentanil was titrated by the improved sequential method, and 30 patients were included. The EC95 of remifentanil was set as the plasma target concentration to evaluate the safety of the MAC, and another 30 patients were included.

Results

The half effective effect-chamber concentration of remifentanil (EC50) was 2.243 ng/ml, and the EC95 was 2.710 ng/ml. Among the 30 patients who received an EC95 of remifentanil as the target concentration, one patient was remedied by injecting propofol, the score of Ramsay sedation was three. The incidence of subclinical hypoxemia (SPO2 of 90-95%) was 30%, the incidence of moderate hypoxemia (SPO2 of 75-89%, ≤60 s) was 20 and 86.7% of patients with oxygen saturation was less than 95% returned to normal by awakening. The satisfaction score of the operator was nine, the satisfaction score of the anesthesiologist was eight, the satisfaction score of the patients was 10, the rate of patient willingness to re-accept the procedure was 93.3% and the circulation was stable during the operation.

Conclusion

MAC using TCI of remifentanil with continuous pumping dexmedetomidine can effectively inhibit the stress response to fibreoptic bronchoscopy in patients with severe tracheal stenosis while maintaining spontaneous breathing. Under the anesthesia management of an experienced anesthesiologist, it provides a reference to tracheoscopic anesthesia of autonomous breathing.

Clinical trial registration

[http://www.chictr.org.cn/], identifier [ChiCTR 2100043380].

The comparison of ketamine-dexmedetomidine (ketadex) and ketamine-propofol (ketofol) for procedural sedation in pediatric patients: A meta-analysis of randomized controlled trials

Introduction

The combination of different agents used for procedural sedation allows a greater range of desirable effects while minimizing side effects. The ketamine-dexmedetomidine combination (ketadex) and ketamine-propofol combination (ketofol) are successful examples. The purpose of this meta-analysis was to compare the safety and efficacy of ketadex with ketofol used for procedural sedation in pediatric patients.

Methods

We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from inception to June 2022. Studies were independently evaluated for inclusion criteria and exclusion criteria by two reviewers. Outcome measures for safety comparison were the incidence of hypotension, bradycardia, respiratory depression, nausea, vomiting, and agitation; Outcome measure for efficacy comparison was clinicians' satisfaction. In addition, we compared the recovery time of ketadex and ketofol.

Results

Nine studies were included in this meta-analysis. Compared with ketofol, ketadex sedation in pediatric patients had lower risk of respiratory depression (RR: 0.51, 95% CI: 0.34–0.76, P = 0.0009). However, ketadex displayed significant effect on recovery time (MD: 8.38 min, 95% CI: 7.55–9.22 min, P < 0.00001). Ketadex had similar incidence of hypotension (RR: 0.95, 95% CI: 0.33–2.67, P = 0.92) and bradycardia (RR: 1.80, 95% CI: 0.64–5.06, P = 0.26) compared to those with ketofol. Clinicians' satisfaction rate of ketadex and ketofol were both high (RR: 0.93, 95% CI: 0.69–1.25, P = 0.62). Also, no significant difference was observed between ketadex and ketofol on the incidence of nausea, vomiting, and agitation.

Conclusions

Both ketadex and ketofol can provide effective sedation and maintain stable hemodynamics. In consideration of good safety profile in respiratory problems, we suggest ketadex is a better option for procedural sedation in pediatric patients.

Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial

Background

Low-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children.

Methods

Seventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation-Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events.

Results

Statistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44-6.2) vs. 6.25 (4.21-7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75-21) and 22.5 (22-24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay.

Conclusion

Low-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay.

The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease

OBJECTIVE

After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery.

METHODS

This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects.

RESULTS

A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases.

CONCLUSIONS

In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

Innate immunity and immunotherapy for hemorrhagic shock

Hemorrhagic shock (HS) is a shock result of hypovolemic injury, in which the innate immune response plays a central role in the pathophysiology ofthe severe complications and organ injury in surviving patients. During the development of HS, innate immunity acts as the first line of defense, mediating a rapid response to pathogens or danger signals through pattern recognition receptors. The early and exaggerated activation of innate immunity, which is widespread in patients with HS, results in systemic inflammation, cytokine storm, and excessive activation of complement factors and innate immune cells, comprised of type II innate lymphoid cells, CD4⁺ T cells, natural killer cells, eosinophils, basophils, macrophages, neutrophils, and dendritic cells. Recently, compelling evidence focusing on the innate immune regulation in preclinical and clinical studies promises new treatment avenues to reverse or minimize HS-induced tissue injury, organ dysfunction, and ultimately mortality. In this review, we first discuss the innate immune response involved in HS injury, and then systematically detail the cutting-edge therapeutic strategies in the past decade regarding the innate immune regulation in this field; these strategies include the use of mesenchymal stem cells, exosomes, genetic approaches, antibody therapy, small molecule inhibitors, natural medicine, mesenteric lymph drainage, vagus nerve stimulation, hormones, glycoproteins, and others. We also reviewed the available clinical studies on immune regulation for treating HS and assessed the potential of immune regulation concerning a translation from basic research to clinical practice. Combining therapeutic strategies with an improved understanding of how the innate immune system responds to HS could help to identify and develop targeted therapeutic modalities that mitigate severe organ dysfunction, improve patient outcomes, and reduce mortality due to HS injury.

The effect of ultra-fast track cardiac anaesthesia in infants and toddlers: a randomised trial

BACKGROUND

The usefulness of ultra-fast track cardiac anaesthesia may give great benefits to patients; however, its usefulness has not been completely evaluated in infants and toddlers, who are generally considered the most difficult group for ultra-fast track cardiac anaesthesia.

METHOD

A total of 130 children were allocated randomly into to a ultra-fast track cardiac anaesthesia group (Group D) or a conventional anaesthesia group (Group C) (each n = 65). In Group D, dexmedetomidine was administrated at a dosage of 1 µg/kg/hour after induction. The patient- controlled intravenous analgesia was dexmedetomidine and sufentanil. In Group C, patients were infused with of the same volume of normal saline, and sufentanil alone for patient-controlled intravenous analgesia. The dosages of sufentanil, extubation time, haemodynamic parameters, postoperative hospitalisation conditions, pain and sedation scores, blood gas analysis, and inotropic scores were all recorded.

RESULTS

The dosage of sufentanil (1.49 ± 0.05 vs. 3.81 ± 0.04 µg, p < 0.001) and extubation time (2.63 ± 0.52 vs. 436.60 ± 22.19 minutes, p < 0.001) in Group D were all significantly lower than those in Group C. Moreover, cardiac intensive care unit stay time, total hospital stay, hospitalisation costs, postoperative lactate levels, and inotropic scores were also significantly lower in Group D.

CONCLUSIONS

Using of ultra-fast track cardiac anaesthesia in infants and toddlers is effective, it not only reduce the perioperative requirement for opioids and shorten the extubation time but also decreases the inotrope requirement and provide a better postoperative condition for young children.

Preoperative sedation in children with congenital heart disease: 50% and 95% effective doses, hemodynamic effects, and safety of intranasal dexmedetomidine

STUDY OBJECTIVE

To determine the 50% and 95% effective doses (ED50 and ED95, respectively), hemodynamic effects, and safety of intranasal dexmedetomidine for preoperative sedation in pediatric patients with congenital heart disease (CHD) with a left-to-right shunt.

DESIGN

Double-blind sequential allocation trial.

SETTING

Pediatric preoperative waiting area.

PATIENTS

86 pediatric patients ASA physical status II-III scheduled for cardiac surgery, aged1-month to 6-years-old with left-to-right type CHD.

INTERVENTIONS

Children were divided into three groups according to age: infants (1 month-1 year), toddlers (1-3 years), and preschoolers (3-6 years). The first patient in all groups received intranasal dexmedetomidine (2 μg/kg), using the up-and-down Dixon method, and the and the next patient's dose was dependent on the previous patient's response.

MEASUREMENTS

Assessment using the Modified Observer's Assessment of Alertness/Sedation Scale and the Mask Acceptance Scale was performed before and every 5 min after treatment. Pulse oxygen saturation and heart rate were recorded at baseline, at 10-min intervals, and after admission to the operating room. Systolic pulmonary artery pressure was measured before anesthesia induction.

MAIN RESULTS

The respective ED₅₀ (95% confidence interval [CI]) and ED₉₅ (95% CI) values for preoperative sedation using intranasally administered dexmedetomidine were 3.1 (2.8-3.3) and 3.5 (3.3-4.0) μg/kg for infants; 3.4 (3.2-3.6) and 3.9 (3.7-4.4) μg/kg for toddlers; and 2.4 (2.2-2.6) and 2.9 (2.6-3.3) μg/kg for preschoolers. ED₅₀ was lower for preschoolers than for toddlers (p < 0.001) and infants (p = 0.044). No obvious difference in ED50 was found between infants and toddlers. There was no significant difference in sedation onset time among the groups, and no adverse events were observed during sedation in all patients.

CONCLUSIONS

Intranasal dexmedetomidine can be safety used for preoperative sedation in children with CHD and is effective for sedation when dosed appropriately. Trial registrationclinicaltrials.gov (ChiCTR2100047472); registered 20 June 2021.