A forecast of relevant pediatric sedation trends

Preoperative Anxiolytic and Sedative Effects of Intranasal Remimazolam and Dexmedetomidine: A Randomized Controlled Clinical Study in Children Undergoing General Surgeries

Purpose

Remimazolam, an ultra-short-acting and fast-metabolized sedative, has only been sporadically investigated in children. This study was performed to determine the beneficial effects of intranasal remimazolam or dexmedetomidine on preoperative anxiety in children undergoing general surgeries.

Patients and Methods

Ninety children were randomly and equally assigned to Group R (intranasal remimazolam 1.5mg kg-1), Group D (intranasal dexmedetomidine 2 mcg kg-1), and Group C (intranasal distilled water). The primary outcomes were the preoperative anxiety scores using the modified Yale preoperative anxiety scale (m-Ypas). The secondary outcomes included the cooperation behaviour of intranasal drug application, preoperative sedation levels, parental separation anxiety scores (PSAS), and mask acceptance scores (MAS).

Results

Group R showed a significant low anxiety at 10 min after intranasal premedication (vs group C, P=0.010; vs group D, P = 0.002) and at anaesthesia induction (vs group C, P = 0.004). Group D showed a significantly low anxiety score only prior to anaesthesia induction (vs group C, P = 0.005). Most children in group R achieved mild sedation at 10 min (vs group C, P < 0.001; vs group D, P < 0.001), with a few progressing to deep sedation afterwards, while group D tended toward deep sedation. Compared to Group C, patients in Group R performed significantly better on the MAS (P = 0.014) and PSAS (P = 0.008). However, remimazolam did cause poor cooperation behavior to the intranasal application due to its mucosal irritation (vs group C, P = 0.001; vs group D, P = 0.010).

Conclusion

Both intranasal remimazolam and dexmedetomidine can effectively alleviate preoperative anxiety in children. While intranasal remimazolam has a rapid onset, it produces only mild sedation and causes substantial nasal irritation.

Trial Registration

NCT04720963, January 22, 2021, ClinicalTrials.Gov.

Pharmacokinetics of remimazolam after intravenous infusion in anaesthetised children

BACKGROUND

The pharmacokinetic properties of the new benzodiazepine remimazolam have been studied only in adults. We investigated the pharmacokinetics of remimazolam after i.v. infusion in anaesthetised paediatric patients.

METHODS

Twenty-four children (2-6 yr, ASA physical status 1-2, BMI 15-18 kg m-2) undergoing general anaesthesia with sevoflurane were enrolled. During surgery, remimazolam was administered as an i.v. infusion over 1 h at 5 mg kg-1 h-1 for 5 min, followed by 1.5 mg kg-1 h-1 for 55 min. Plasma concentrations of remimazolam and its metabolite CNS7054 were determined from arterial blood samples using ultra-high performance liquid chromatography-mass spectrometry. Pharmacokinetic modelling was performed by population analysis.

RESULTS

Pharmacokinetics were best described by a three-compartment model for remimazolam and a two-compartment model for CNS7054 linked by a transit compartment. Remimazolam showed a high clearance of 15.9 (12.9, 18.2) ml kg-1 min-1 (median, Q25, Q75), a small central volume of distribution of 0.11 (0.08, 0.14) L kg-1 and a short terminal half-life of 67 (49, 85) min. The context-sensitive half-time after an infusion of 4 h was 17 (12, 21) min. The metabolite CNS7054 showed a low clearance of 0.89 (0.33, 1.40) ml kg-1 min-1, a small central volume of distribution of 0.011 (0.005, 0.016) L kg-1, and a long terminal half-life of 321 (230, 770) min.

CONCLUSIONS

Remimazolam in children was characterised by a high clearance and short context-sensitive half-time. When normalised to weight, pharmacokinetic properties were similar to those reported for adults.

CLINICAL TRIAL REGISTRATION

ChiCTR2200057629.

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.

Recent advancements in total intravenous anaesthesia and anaesthetic pharmacology

Target-controlled infusion pumps and depth of anaesthesia monitors have made total intravenous anaesthesia (TIVA) easy, safe, and precise. The merits of TIVA were highlighted during the coronavirus disease 2019 (COVID-19) pandemic, confirming its potential further in the post-COVID clinical practice as well. Ciprofol and remimazolam are newer drugs that are being tried with a hope to upgrade the practice of TIVA. While research on safe and effective drugs continues, TIVA is being practised with a combination of drugs and adjuncts to overcome the disadvantages of each and to provide complete and balanced anaesthesia with additional benefits in recovery and pain relief postoperatively. Modulation of TIVA for the special population groups is still under process. Advancement in digital technology with mobile apps has increased the scope of TIVA in day-to-day use. The formulation and update of guidelines can establish a safe and efficient practice of TIVA.

Advantages of ketamine in pediatric anesthesia

Although ketamine is primarily used for induction and maintenance of general anesthesia, it also presents sedative, amnestic, anesthetics, analgesic, antihyperalgesia, neuroprotective, anti-inflammatory, immunomodulant, and antidepressant effects. Its unique pharmacodynamics and pharmacokinetic properties allow the use of ketamine in various clinical settings including sedation, ambulatory anesthesia, and intensive care practices. It has also adopted to manage acute and chronic pain management. Clinically, ketamine produces dissociative sedation, analgesia, and amnesia while maintaining laryngeal reflexes, with respiratory and cardiovascular stability. Notably, it does not cause respiratory depression, maintaining both the hypercapnic reflex and the residual functional capacity with a moderate bronchodilation effect. In the pediatric population, ketamine can be administered through practically all routes, making it an advantageous drug for the sedation required setting such as placement of difficult vascular access and in uncooperative and oppositional children. Consequently, ketamine is indicated in prehospital induction of anesthesia, induction of anesthesia in potentially hemodynamic unstable patients, and in patients at risk of bronchospasm. Even more, ketamine does not increase intracranial pressure, and it can be safely used also in patients with traumatic brain injuries. This article is aimed to provide a brief and practical summary of the role of ketamine in the pediatric field.

Analgosedation for diagnostic and interventional procedures: a countrywide survey of pediatric centers in Germany

Background

As more and more diagnostic and interventional options are becoming available for use in pediatric patients, techniques of procedural sedation analgesia (PSA) are being administered in considerably growing numbers as well.

Aims

The objective of this research effort was to conduct the first countrywide survey on the status quo of sedation analgesia as delivered to children and adolescents in Germany.

Methods

We dispatched letters to all pediatric hospital settings in Germany (n = 305), including a questionnaire that had been developed with existing guidelines taken into account. Its items were designed to elucidate the current practice of PSA throughout these pediatric centers regarding (a) organizational structures and (b) standards of medication and staffing.

Results

A total of 138 centers returned the questionnaire, hence the response rate was 45.2%. Numerous centers had implemented adequate structures and staffing standards. Deficits were nevertheless identified, most notably in terms of on-location equipment and staff provided to deliver sedations. Essential items of equipment were not provided in up to 26.8% of centers. Adequate staffing was not provided in up to 44.2% of centers, depending on the diagnostic or interventional procedures for which the PSA was delivered. The most widely used sedative agents were midazolam, ketamine/esketamine, and propofol.

Conclusions

Adequate care structures for the management of procedural sedation analgesia have been implemented by many pediatric centers in Germany. On the downside, these findings also reveal deficits that will take efforts to be eliminated.

Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches

Objective

To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA).

Study Design

Case series with chart review.

Setting

Tertiary pediatric hospital.

Subjects and Methods

Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment.

Results

A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001).

Conclusion

CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Prolonged sedation in critically ill children: is dexmedetomidine a safe option for younger age? An off-label experience

BACKGROUND

Dexmedetomidine (DEX) is an alpha-2-adrenergic agonist, recently approved by Italian-Medicines-Agency for difficult sedation in pediatrics, but few data exist regarding prolonged infusions in critically-ill children, especially in younger ages. Aim of our study was to evaluate DEX use and safety for prolonged sedation in Pediatric Intensive Care Units (PICUs).

METHODS

Patients receiving DEX for ≥24 hours were retrospectively evaluated to analyze DEX indications, dosages, use of analgesics or sedatives, adverse events (AEs), withdrawal syndrome or delirium.

RESULTS

Forty-seven patients (median 0.7years) from nine PICUs were enrolled. Main indications were adjuvant for drugs sparing (59.6%) and for analgosedation weaning (36.2%). Median infusion duration was 82.0 hours (IQR 62.2-126.0), with dosages between 0.4 (IQR 0.2-0.5) and 0.8 mcg/kg/h (IQR 0.6-1.2). Fifty-nine-percent of patients received other sedatives, 83% other analgesics. Twenty-one-percent presented withdrawal syndrome, 4.2% delirium, none of them DEX-related. Forty-six-percent experienced a potentially-DEX-related AE. AEs were all hemodynamic, 14.9% requiring intervention but none DEX interruption. The median minimum and maximum dosages were significantly higher in patients with AEs (0.5 vs. 0.3,P=0.001; 1.0 vs. 0.7,P<0.001), without correlations with the infusion duration. AEs rate was higher in patients receiving benzodiazepines (P=0.020) or more than one analgesic (P=0.003) and in those presenting withdrawal syndrome (P<0.001).

CONCLUSIONS

DEX was confirmed as useful and relatively safe drug for prolonged sedation in critically-ill children, particularly in younger ages. Main AEs were cardiovascular, reversible, related with higher doses, with the concomitant use of benzodiazepines or multiple sedation drugs and with the presence of withdrawal syndrome.

Different effects of propofol and dexmedetomidine sedation on electroencephalogram patterns: Wakefulness, moderate sedation, deep sedation and recovery

Sedation induces changes in electroencephalography (EEG) dynamics. However, the distinct EEG dynamic characteristics at comparable sedation levels have not been well studied, resulting in potential interpretation errors in EEG monitoring during sedation. We aimed to analyze the EEG dynamics of dexmedetomidine and propofol at comparable sedation levels and to explore EEG changes with increased sedation levels for each agent. We measured the Bispectral Index (BIS) and 20-channel EEG under dexmedetomidine and propofol sedation from wakefulness, moderate sedation, and deep sedation to recovery in healthy volunteers (n = 10) in a randomized, 2-day, crossover study. Observer's Assessment of Alertness and Sedation (OAA/S) score was used to assess sedation levels. Despite similar changes in increased delta oscillations, multiple differences in the EEG spatiotemporal dynamics were observed between these two agents. During moderate sedation, both dexmedetomidine and propofol induced increased spindle power; however, dexmedetomidine decreased the global alpha/beta/gamma power, whereas propofol decreased the alpha power in the occipital area and increased the global spindle/beta/gamma power. During deep sedation, dexmedetomidine was associated with increased fronto-central spindle power and decreased global alpha/beta/gamma power, but propofol was associated with increased theta/alpha/spindle/beta power, which was maximized in the frontal area. The transition of topographic alpha/spindle/beta power distribution from moderate sedation to deep sedation completely differed between these two agents. Our study demonstrated that there was a distinct hierarchy of EEG changes with increased sedation depths by propofol and dexmedetomidine. Differences in EEG dynamics at the same sedation level might account for differences in the BIS value and reflect the different sedation mechanisms. EEG-based clinical sedation monitoring should consider the effect of drug types on EEG dynamics.

Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members

BACKGROUND

Children with autism spectrum disorder are challenging to sedate because of communication, sensory, and behavioral challenges.

AIMS

The aim of this survey was to determine how procedural sedation is provided to children with autism spectrum disorders and whether sedation programs have specialized protocols for procedural sedation of these children.

METHODS

We surveyed physician Medical Directors of sedation programs who are members of the Society for Pediatric Sedation, asking about practice characteristics and resource utilization during procedural sedation of children with autism spectrum disorders.

RESULTS

Of 58 directors, 47 (81%) responded. Of the programs surveyed, 53% were either a large university medical center and 40% were a freestanding children's hospital. Only (12/47, 25.5%) of the programs used an individualized autism coping plan. To accomplish procedural sedation in this study cohort, 36% of the programs used additional nurses, whereas a child life specialist was used in 55% of the programs surveyed. Only 28% of the centers allotted additional time to accommodate children with autism spectrum disorders. Distraction methods were used in 80% whereas restrains were used in 45% programs for were used most commonly for i.v. catheter placement. Propofol was the preferred agent for 70% of programs for imaging, while propofol + fentanyl was used by 66% of programs for painful procedures. Although 57% of directors reported that their program staff was extremely comfortable providing procedural sedation for children with autism spectrum disorder, 79% of the directors wanted more education about behavioral management strategies for procedural sedation of these children.

CONCLUSION

Among the Society for Pediatric Sedation programs, significant institutional variation exists on the delivery of procedural sedation to children with autism spectrum disorders. A better understanding of resources required, standardization of behavioral management strategies and pharmacologic approaches, and protocol development may help optimize care to this vulnerable population.

Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers

Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.

Sedation methods for transthoracic echocardiography in children with Trisomy 21-a retrospective study

BACKGROUND

Many children with Trisomy 21 have neurologic or behavioral problems that make it difficult for them to remain still during noninvasive imaging studies, such as transthoracic echocardiograms (TTEcho). Recently, intranasal dexmedetomidine sedation has been introduced for this purpose. However, dexmedetomidine has been associated with bradycardia. Children with Trisomy 21 have been reported to have a higher risk of bradycardia and airway obstruction with sedation or anesthesia compared to children without Trisomy 21.

OBJECTIVE

Our aim was to quantify the incidence of age-defined bradycardia and other adverse effects in patients with Trisomy 21 under sedation for TTEcho using a variety of sedation and anesthesia techniques available and utilized at our institution in this challenging patient population, including intranasal dexmedetomidine, oral pentobarbital, general anesthesia with propofol, and general anesthesia with sevoflurane. Our primary hypothesis was that intranasal dexmedetomidine sedation would result in a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens.

METHODS

This is a retrospective, observational study of 147 consecutive patients with Trisomy 21 who were sedated or anesthetized for transthoracic echocardiography. Efficacy of sedation was defined as no need for rescue sedation or conversion to an alternate technique. Lowest and highest heart rate, systolic blood pressure, oxygen saturation, and PR interval from formal electrocardiograms were extracted from the electronic medical record. These data were compared to age-defined normal values to determine adverse events.

RESULTS

Four methods of sedation or anesthesia were utilized to perform sedated transthoracic echocardiography: general anesthesia with sevoflurane by mask, general anesthesia with sevoflurane induction followed by intravenous propofol maintenance, oral pentobarbital, and intranasal dexmedetomidine. Intranasal dexmedetomidine 2.5 mcg·kg^-1 was an effective sedative as a single dose for TTEcho in 37 of 41 (90%) cases. Oral pentobarbital 5 mg·kg^-1 as a single dose for young children with Trisomy 21 was effective in 55 of 75 (73%) cases. Intranasal dexmedetomidine sedation was not associated with a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens, when compared to oral pentobarbital for patients under 2 years of age and general anesthesia for children 3 years and older. The two general anesthesia groups showed lowest heart rates of 66.9 ± 15.9 min^-1 for sevoflurane and 69.0 ± 11.5 min^-1 for sevoflurane-propofol. Hypotension was present in all groups ranging between an incidence of 56% in the sevoflurane group to 11% in the oral pentobarbital group. Oxygen saturation and clinically significant desaturation occurred in 14% of the oral pentobarbital group.

CONCLUSION

Intranasal dexmedetomidine sedation was not associated with a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens.

Effect of anesthesia on intraocular pressure measurement in children

Measurement of the intraocular pressure (IOP) is central to the diagnosis and management of pediatric glaucoma. An examination under anesthesia is often necessary in pediatric patients. Different agents used for sedation or general anesthesia have varied effects on IOP. Hemodynamic factors, methods of airway management, tonometry technique, and body positioning can all affect IOP measurements. The most accurate technique is one that reflects the awake IOP. We review factors affecting IOP measurements in the pediatric population and provide recommendations on the most accurate means to measure IOP under anesthesia based on the present literature.

Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies

Anesthetics that permit surgical procedures and stressful interventions have been found to cause structural brain abnormalities and functional impairment in immature animals, generating extensive concerns among clinicians, parents, and government regulators regarding the safe use of these drugs in young children. Critically important questions remain, such as the exact age at which the developing brain is most vulnerable to the effects of anesthetic exposure, whether a particular age exists beyond which anesthetics are devoid of long-term effects on the brain, and whether any specific exposure duration exists that does not lead to deleterious effects. Accordingly, the present analysis attempts to put the growing body of animal studies, which we identified to include >440 laboratory studies to date, into a translational context, by integrating the preclinical data on brain structure and function with clinical results attained from human neurocognitive studies, which currently exceed 30 studies. Our analysis demonstrated no clear exposure duration threshold below which no structural injury or subsequent cognitive abnormalities occurred. Animal data did not clearly identify a specific age beyond which anesthetic exposure did not cause any structural or functional abnormalities. Several potential mitigating strategies were found, however, no general anesthetic was identified that consistently lacked neurodegenerative properties and could be recommended over other anesthetics. It therefore is imperative, to expand efforts to devise safer anesthetic techniques and mitigating strategies, even before long-term alterations in brain development are unequivocally confirmed to occur in millions of young children undergoing anesthesia every year.