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El-Rouby SH, Crystal YO, Elshafie AM, Wahba NA, El-Tekeya MM. Effectiveness of buccal administration of dexmedetomidine and ketamine combination in paediatric dental sedation: A randomized controlled clinical trial. Int J Paediatr Dent 2024. [PMID: 39011758 DOI: 10.1111/ipd.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Pain and anxiety can be considerable obstacles while treating paediatric dental patients. Moderate sedation is needed to treat uncooperative patients. AIM This study aimed to compare the effectiveness of buccal administration of dexmedetomidine-ketamine combination versus dexmedetomidine. DESIGN Fifty-six uncooperative children were randomly assigned into two groups: Group I received buccal dexmedetomidine (2 μg/kg) and ketamine (2 mg/kg) (DEX-KET), whereas Group II received buccal dexmedetomidine (4 μg/kg) (DEX). The effects of drugs were evaluated based on changes in vital signs, onset and duration of sedation, sedation level, analgesia, ease of treatment and procedural adverse effects. RESULTS There were no significant differences in vital signs or sedation onset between the two groups. DEX-KET group showed shorter recovery time than DEX group (p < .0001). There were no statistically significant differences between both groups regarding sedation level at optimum sedation and during operative procedure (p = .064, p = .069 respectively). The ease of treatment was significantly better in DEX-KET group than in DEX group (p = .048). Procedural side effects and analgesic effects of the sedative drugs were comparable between both groups. CONCLUSION The combination of dexmedetomidine and ketamine delivered buccally provided a better method of delivering care to uncooperative children with more rapid recovery than dexmedetomidine.
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Affiliation(s)
- Sara H El-Rouby
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Yasmi O Crystal
- Department of Pediatric Dentistry, NYU College of Dentistry, New York, New York, USA
| | | | - Nadia A Wahba
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Magda M El-Tekeya
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
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Hebbar K C, Reddy A, Luthra A, Chauhan R, Meena SC, Tripathi M. Comparison of the efficacy of intranasal atomised dexmedetomidine versus intranasal atomised ketamine as a premedication for sedation and anxiolysis in children undergoing spinal dysraphism surgery: A randomized controlled trial. Eur J Anaesthesiol 2024; 41:288-295. [PMID: 38095481 DOI: 10.1097/eja.0000000000001936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Preoperative anxiety leads to adverse clinical outcomes and long-term maladaptive behavioural changes. The role of intranasal atomised dexmedetomidine and atomised ketamine as premedication to produce sedation and anxiolysis in paediatric neurosurgical patients has not been extensively studied. OBJECTIVE To study the efficacy of intranasal atomised dexmedetomidine and intranasal atomised ketamine as premedication in producing sedation and facilitating smooth induction in children undergoing spinal dysraphism surgery. DESIGN A prospective randomised double-blind trial. SETTING A tertiary teaching hospital. PATIENTS Sixty-four children aged 1 to 10 years undergoing spinal dysraphism surgery. METHODS Children were randomised to receive intranasal atomised dexmedetomidine 2.5 μg kg -1 (Group D, n = 32) and intranasal atomised ketamine 5 mg kg -1 (Group K, n = 32) 30 min before surgery. OUTCOMES MEASURED The primary outcome was to compare the level of sedation in both groups using the University of Michigan Sedation Score (UMSS). The secondary outcomes included an assessment of the ease of parental separation, intravenous cannulation and satisfactory mask acceptance along with perioperative vitals (heart rate, blood pressure and oxygen saturation). The incidence of emergence agitation and time to discharge were also noted. RESULTS The degree of sedation was significantly better in Group D as compared to Group K at 20 min (UMSS, 1.55 ± 0.51 versus 1.13 ± 0.34, difference, -0.406; 95% CI, -0.621 to -0.191; P = 0.0001) and 30 min (2.32 ± 0.6 versus 1.94 ± 0.50, difference, -0.374; 95% CI, -0.650 to -0.100; P = 0.007). The ease of parental separation, venous cannulation and mask acceptance ( P = 0.83, 0.418 and 0.100 respectively) were comparable in both groups. The heart rate was lower in group D at 10, 20 and 30 min post-drug administration but was clinically insignificant. The incidence of emergence agitation and time to discharge was also similar with no adverse events reported. CONCLUSION Intranasal atomised dexmedetomidine produces greater sedation as compared to intranasal atomised ketamine with comparable ease of parental separation, venous cannulation and mask acceptance with no adverse effects.
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Affiliation(s)
- Chethan Hebbar K
- From the Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India (CHK, AR, AL, RC, SCM), Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India (MT)
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Liu X, Lang B, Zeng L, Huang L, Chen S, Jia ZJ, Cheng G, Yu Q, Zhang L. Comparison of the effects of ketamine via nebulization versus different pharmacological approaches in pediatric sedation: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2023; 23:375. [PMID: 37974083 PMCID: PMC10652489 DOI: 10.1186/s12871-023-02298-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/27/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Nebulized drug delivery is commonly used in pediatric clinical practice. The growing number of literatures have reported the application of nebulized ketamine in pediatric sedation in recent years. This meta-analysis of randomized controlled trials comparing the efficacy and safety of nebulized ketamine versus different pharmacological approaches was conducted to estimate the effects of this technique in pediatric sedation. METHODS We searched PubMed, Embase, and Cochrane Library from inception to Feb 2023. All randomized controlled trials used nebulized ketamine as presurgical and pre-procedural sedatives in children were included. Sedative effects and various adverse events were considered as the outcomes. RESULTS Ten studies with 727 pediatric patients were enrolled. Compared to nebulized dexmedetomidine, using of ketamine via nebulization showed similar sedation satisfaction (54.79% vs. 60.69%, RR = 0.88, with 95%CI [0.61, 1.27]), success rate of parental separation (57.27% vs. 73.64%, RR = 0.81, with 95%CI [0.61, 1.08]), and mask acceptability (37.27% vs. 52.73%, RR = 0.71, with 95%CI [0.45, 1.10]). However, the using of combination of two medications (nebulized ketamine plus nebulized dexmedetomidine) was associated with better sedative satisfaction (33.82% vs. 68.11%, RR = 0.50, with 95%CI [0.27, 0.92]) and more satisfactory mask acceptance (45.59% vs. 71.01%, RR = 0.69, with 95%CI [0.56, 0.86]). Compared with nebulized ketamine, using of nebulized dexmedetomidine was associated with less incidence of emergence agitation (18.18% vs. 3.33%, RR = 4.98, with 95%CI [1.88, 13.16]). CONCLUSIONS Based on current evidences, compared to nebulized dexmedetomidine, nebulized ketamine provides inconspicuous advantages in pediatric sedation, and it has a relatively high incidence of emergence agitation. Combination of nebulized ketamine and dexmedetomidine might be considered as one preferred option in pediatric sedation as it can provide more satisfactory sedative effects. However, there is insufficient evidence regarding nebulized ketamine versus ketamine administered through other routes and nebulized ketamine versus other sedatives. The overall low or moderate quality of evidence evaluated by the GRADE system also calls for more high-quality studies with larger sample sizes in future. RESEARCH REGISTRATION The protocol of present study was registered with PROSPERO (CRD42023403226).
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Affiliation(s)
- Xiao Liu
- Department of Pharmacy, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China.
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Hirano T, Kimoto Y, Kuratani N, Cavanaugh D, Mason KP. Remimazolam for Pediatric Procedural Sedation: Results of an Institutional Pilot Program. J Clin Med 2023; 12:5937. [PMID: 37762878 PMCID: PMC10532234 DOI: 10.3390/jcm12185937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Remimazolam, an ultra-short-acting benzodiazepine sedative, was first approved in 2020 in Japan as a general anesthetic for adults. However, its utilization in pediatric settings remains unexplored and, to date, is confined to isolated case reports due to a lack of specific pediatric labeling. The primary objective of our study was to evaluate the safety profile of remimazolam when used for procedural sedation in children following dosages established in adult protocols. Additional parameters, including dosage per kg of body weight, duration of the procedure, efficacy (measured as successful completion of the procedure), the necessity for supplemental medications, and changes in physiological parameters, such as the heart rate (HR) and mean arterial blood pressure (MAP), were assessed. Our study encompassed 48 children with an average age of 7.0 years. The objective Tracking and Reporting Outcomes of Procedural Sedation tool indicated no adverse events. In our cohort, propofol and ketamine were used as adjunctive treatments in 8 and 39 patients, respectively, with successful completion of all procedures. Notable hemodynamic variability was observed, with 88.4% of patients experiencing a ≥20% change (increase or decrease) and 62.8% experiencing a ≥30% change in MAP. Additionally, a ≥20% change in HR was observed in 54.3% of patients, and a ≥30% change was observed in 34.8% of patients. Nevertheless, none of the patients required pharmacological intervention to manage these hemodynamic fluctuations. Our findings suggest that remimazolam, when supplemented with propofol or ketamine, could offer a safe and effective pathway for administering procedural sedation in pediatric populations.
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Affiliation(s)
- Tatsuya Hirano
- Department of Anesthesia, National Hospital Organization Saitama Hospital, Wako 351-0102, Japan
| | - Yoshitaka Kimoto
- Department of Anesthesiology, Kurume University School of Medicine, Kurume 830-0011, Japan;
| | - Norifumi Kuratani
- Department of Anesthesia, Saitama Children’s Medical Center, Saitama 330-8777, Japan;
| | - David Cavanaugh
- Boston Biostatistical Consulting, North Reading, MA 01864, USA;
| | - Keira P. Mason
- Department of Anesthesia, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA;
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Dieudonné Rahm N, Zaccaria I, Gil Wey B, Pautex S, Habre W, Elia N. Intranasal Dexmedetomidine for Pain Management in Older Patients: A Cross-Over, Randomized, Double-Blinded, Active-Controlled Trial. Drugs Aging 2023; 40:527-538. [PMID: 37170043 PMCID: PMC10174599 DOI: 10.1007/s40266-023-01027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Daily care procedures provoke breakthrough pain and anxiety in palliative situations. Dexmedetomidine may be an alternative to opioids during nursing procedures for older patients. OBJECTIVE We aimed to compare the efficacy of intranasal dexmedetomidine with subcutaneous opioids on the intensity of pain and anxiety during comfort management procedures. METHODS We conducted a randomized, active-controlled, double-blind, crossover trial (NCT03151863). Patients aged ≥ 65 years were randomized to receive, 45 min before nursing care, either intranasal dexmedetomidine together with subcutaneous placebo or intranasal placebo together with a subcutaneous opioid. Each of these two interventions were administered in a cross-over design and spaced out over a 24- or 48-h period. The primary outcome was the number of patients with an Elderly Caring Pain Assessment score > 5. Secondary outcomes included pain, sedation score, and vital signs. RESULTS Because of difficult recruitment, the trial was interrupted after the inclusion of 24 patients. Three patients withdrew after randomization, leaving 21 patients undergoing 42 complete sessions for descriptive analyses. Of the 21 patients, 12 (57.1%) were women, and their median age was 84 years, interquartile range (75-87 years). Nine (42.9%) patients presented an Elderly Caring Pain Assessment score > 5 when receiving subcutaneous opioids, and seven (33.3%) with intranasal dexmedetomidine. Hypoxemia occurred in a single patient receiving subcutaneous opioids. No episode of bradycardia was observed. CONCLUSIONS Intranasal dexmedetomidine is feasible in elderly patients and may be an alternative to opioids to ensure comfort during nursing care. Future studies are needed to confirm the efficacy and safety of this procedure.
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Affiliation(s)
- Nathalie Dieudonné Rahm
- Division of Palliative Medicine, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Hôpital de Bellerive, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland.
- Medical Faculty, University of Geneva, Geneva, Switzerland.
| | - Isabelle Zaccaria
- Unit for Anaesthesiological Investigations, Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
| | - Béatrice Gil Wey
- Unit for Anaesthesiological Investigations, Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
| | - Sophie Pautex
- Division of Palliative Medicine, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Hôpital de Bellerive, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
- Medical Faculty, University of Geneva, Geneva, Switzerland
| | - Walid Habre
- Medical Faculty, University of Geneva, Geneva, Switzerland
- Unit for Anaesthesiological Investigations, Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
| | - Nadia Elia
- Medical Faculty, University of Geneva, Geneva, Switzerland
- Unit for Anaesthesiological Investigations, Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
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Dharamkhele SA, Singh S, Honwad M, Gollapalli VK, Gupta N, Saurav. Comparative evaluation of nebulized ketamine and its combination with dexmedetomidine as premedication for paediatric patients undergoing surgeries under general anaesthesia. Med J Armed Forces India 2022; 78:S213-S218. [PMID: 36147408 PMCID: PMC9485766 DOI: 10.1016/j.mjafi.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 11/15/2020] [Indexed: 10/22/2022] Open
Abstract
Background Various drugs have been endorsed but no standardised premedication protocol exists for paediatric patients. Nebulised form of drug not only results in better patient acceptability but also has improved clinical effectiveness. The present study delineates and evaluates the efficacy and safety of nebulised ketamine and combination of nebulised dexmedetomidine and ketamine for premedication in paediatric patients. Methods Prospective randomised controlled study was planned in patients, 3-10 years of age, undergoing surgeries. Patients received either nebulised ketamine (2 mg/kg) (group X, n = 23) or dexmedetomidine 1 μg/kg plus ketamine (1 mg/kg) (group Y; n = 24), 30 min before shifting inside the operation theatre. The sedation level, haemodynamic response and ill-effects were recorded for 30 min. Results The baseline haemodynamic (HR, MAP, RR and SpO2) parameters were normal and comparable in both the groups. There was no significant variation noticed in terms of HR, MAP, RR and SpO2% in either of the groups at 15 min (p < 0.15, p < 0.20, p < 0.85, p < 0.46) and 30 min (p < 0.21, p < 0.97, p < 0.75, p < 0.61) respectively, after receiving premedication. The level of sedation in group Y (score of 4 or less) was found to be better than that achieved by group X patients (p < 0.001). Face mask acceptance was satisfactory in group Y (score of 2 or less) as compared to group X patients (p < 0.001). The parental separation was comparable in both groups (p = 0.46). Conclusion Nebulisation is a satisfactory method of premedication for children. A combination of nebulised ketamine with a dose of 1 mg/kg and dexmedetomidine with a dose of 1 μg/kg is capable of producing a satisfactory level of sedation in a more effective manner than sedation induced by nebulised ketamine alone (2 mg/kg).
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Affiliation(s)
- Shital A. Dharamkhele
- Assistant Professor (Anaesthesiology), Dr Panjabrao Deshmukh Memorial Medical College, Amravati, India
| | - Shalendra Singh
- Associate Professor, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, India
| | - M.S. Honwad
- Professor, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, India
| | | | - Nipun Gupta
- Assistant Professor, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, India
| | - Saurav
- Assistant Professor, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, India
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Ali RM, Mahmoud NMY. The effect of nebulized dexmedetomidine as sedative premedication in pediatrics undergoing cochlear implantation. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2079901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Rania M Ali
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Noura M. Youssri Mahmoud
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Singariya G, Malhotra N, Kamal M, Jaju R, Aggarwal S, Bihani P. Comparison of nebulized dexmedetomidine and ketamine for premedication in pediatric patients undergoing hernia repair surgery: a randomized comparative trial. Anesth Pain Med (Seoul) 2022; 17:173-181. [PMID: 35378572 PMCID: PMC9091671 DOI: 10.17085/apm.21081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Allaying anxiety and providing calm children in the operating room is a challenging task for anesthesiologists. This study was designed to compare the use of nebulized dexmedetomidine and ketamine for premedication in pediatric patients under general anesthesia. Methods Seventy patients, aged 2 to 8 years of both sexes, with American Society of Anesthesiologists physical status I/II scheduled for hernia repair surgery under general anesthesia, were randomized to two equal groups using a computer-generated random number table. Patients in group D received dexmedetomidine (2 µg/kg), and patients in group K received ketamine (2 mg/kg) by a jet nebulizer before the induction of anesthesia. The study's primary objective was comparing the level of sedation, which was achieved at 30 min after a study drug administration using the Ramsay sedation scale, between the two groups. The secondary objectives were the two-group comparison of parental separation anxiety scale, acceptance of the mask, hemodynamic variables, recovery time, incidence of emergence agitation, and adverse events. Results The median Ramsay sedation scale at 30 min was 3 (1–4) in group D and 3 (1–3) in group K (P = 0.002). Patients in group D had a more acceptable parental separation anxiety scale (P = 0.001) and a satisfactory mask acceptance scale (P = 0.042). Conclusions Nebulized dexmedetomidine (2 µg/kg) provided better sedation along with smooth parental separation and satisfactory mask acceptance during induction of anesthesia with a similar emergence agitation profile and adverse reactions compared to nebulized ketamine in pediatric patients.
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Affiliation(s)
- Geeta Singariya
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
- Corresponding Author Geeta Singariya, M.D. Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur 123, Vaishali Avenue, Jhanwar Road, Jodhpur 342008, Rajasthan, India E-mail: Tel: 91-0291-2705705, Fax: 91-0291-2434376
| | - Namita Malhotra
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
| | - Manoj Kamal
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Rishabh Jaju
- Department of Anesthesiology & Critical Care, Andaman Nicobar Island Institute of Medical Sciences, Port Blair, India
| | - Shruti Aggarwal
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
| | - Pooja Bihani
- Department of Anesthesiology & Critical Care, Dr S N Medical College, Jodhpur, India
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Cai YH, Wang CY, Li Y, Chen J, Li J, Wu J, Liu HC. Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries. Front Pharmacol 2021; 12:648699. [PMID: 34975463 PMCID: PMC8714926 DOI: 10.3389/fphar.2021.648699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 11/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction. Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg−1, Group D with intranasal dexmedetomidine 2 μg kg−1, and Group M + D with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time. Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001). Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1 had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.
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Affiliation(s)
- Yu-Hang Cai
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Cheng-Yu Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yang Li
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jia Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jun Li
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzheng Wu
- Department of Anesthesiology, Cincinnati Children’s Hospital, Cincinnati, OH, United States
- Correspondence: Junzheng Wu, ; Hua-Cheng Liu,
| | - Hua-Cheng Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- Correspondence: Junzheng Wu, ; Hua-Cheng Liu,
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10
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Yuan YJ, Zhou P, Xia F, Zhang XB, He SS, Guo DY, Xing YH, Zhao HW. Intranasal dexmedetomidine combined with local anesthesia for conscious sedation during breast lumpectomy: A prospective randomized trial. Oncol Lett 2020; 20:77. [PMID: 32863910 PMCID: PMC7436885 DOI: 10.3892/ol.2020.11938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022] Open
Abstract
Breast lumpectomy is usually performed under general or local anesthesia. To the best of our knowledge, whether conscious sedation with intranasal dexmedetomidine and local anesthesia is an effective anesthetic technique has not been studied. Thus, the present study aimed to investigate the effectiveness of conscious sedation with intranasal dexmedetomidine combined with local anesthesia in breast lumpectomy, and to identify its optimal dose. A prospective randomized, double-blinded, placebo-controlled, single-center study was designed, and patients undergoing breast lumpectomies were recruited based on the inclusion and exclusion criteria. All patients were randomly allocated to four groups: i) Local anesthesia with 0.9% intranasal saline (placebo); local anesthesia with ii) 1 µg.kg−1; iii) 1.5 µg.kg−1; or iv) 2 µg.kg−1 intranasal dexmedetomidine. The sedation status, pain relief, vital signs, adverse events, and satisfaction of patient and surgeon were recorded. Patients in the three dexmedetomidine groups were significantly more sedated and experienced less pain compared with the placebo group 45 min after intranasal dexmedetomidine administration and during 30 min in the post-anesthesia care unit. Patients in the 1.5 µg.kg−1 group were more sedated compared with the 1 µg.kg−1 group (without reaching statistical significance), whereas the 1.5 µg.kg−1 group exhibited a similar level of sedation 45 min after intranasal dexmedetomidine administration compared with the 2 µg.kg−1 group. In addition, patients in the 1 and 1.5 µg.kg−1 group experienced no adverse hemodynamic effects. Patient and surgeon satisfaction were greater in the 1.5 µg.kg−1 group compared with the 1 and 2 µg.kg−1 groups. Taken together, the results of the present study suggested that conscious sedation with intranasal dexmedetomidine and local anesthesia may be an effective anesthetic for breast lumpectomy surgery, and that the optimal dose for intranasal dexmedetomidine administration may be 1.5 µg.kg−1, as it resulted in good sedation and patient satisfaction without adverse effects.
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Affiliation(s)
- Ya-Jing Yuan
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Peng Zhou
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Fei Xia
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Xiao-Bei Zhang
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Shan-Shan He
- Department of Breast Reconstruction, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Dong-Yong Guo
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Yu-Hong Xing
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Hong-Wei Zhao
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
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11
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Mondardini MC, Amigoni A, Cortellazzi P, Di Palma A, Navarra C, Picardo SG, Puzzutiello R, Rinaldi L, Vitale F, Zito Marinosci G, Conti G. Intranasal dexmedetomidine in pediatrics: update of current knowledge. Minerva Anestesiol 2019; 85. [DOI: 10.23736/s0375-9393.19.13820-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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12
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Trevisan M, Romano S, Barbi E, Bruno I, Murru FM, Cozzi G. Intranasal dexmedetomidine and intravenous ketamine for procedural sedation in a child with alpha-mannosidosis: a magic bullet? Ital J Pediatr 2019; 45:119. [PMID: 31481093 PMCID: PMC6720406 DOI: 10.1186/s13052-019-0711-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/22/2019] [Indexed: 02/04/2023] Open
Abstract
Background Procedural sedation is increasingly needed in pediatrics. Although different drugs or drugs association are available, which is the safest and most efficient has yet to be defined, especially in syndromic children with increased sedation-related risk factors. Case report we report the case of a five-year-old child affected by alpha-mannosidosis who required procedural sedation for an MRI scan and a lumbar puncture. We administered intranasal dexmedetomidine (4 μg/kg) 45 min before intravenous cannulation, followed by one bolus of ketamine (1 mg/kg) for each procedure. The patient maintained spontaneous breathing and no desaturation or any complication occurred. Conclusion intranasal dexmedetomidine and intravenous ketamine could be a feasible option for MRI and lumbar puncture in children with alpha-mannosidosis needing sedation.
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Affiliation(s)
- Matteo Trevisan
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Sara Romano
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.,Department of Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Irene Bruno
- Department of Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Flora Maria Murru
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy. Via dell'Istria 65/1, 34131, Trieste, Italy
| | - Giorgio Cozzi
- Pediatric Emergency Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - Trieste, Italy. Via dell'Istria 65/1, 34131, Trieste, Italy
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13
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Oriby ME. Comparison of Intranasal Dexmedetomidine and Oral Ketamine Versus Intranasal Midazolam Premedication for Children Undergoing Dental Rehabilitation. Anesth Pain Med 2019; 9:e85227. [PMID: 30881910 PMCID: PMC6412317 DOI: 10.5812/aapm.85227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Background Dental rehabilitation surgery is associated with significant fear and anxiety with subsequent psychological disturbances. Midazolam has been used frequently as a premedication. However, it may be associated with side effects. Dexmedetomidine and ketamine combination has been suggested as an effective premedication in improving preoperative sedation and analgesia. Objectives This study compared the effects of combined intranasal dexmedetomidine and oral ketamine versus intranasal midazolam on anxiolysis and postoperative analgesia. Methods Seventy-six children (aged two to six years) undergoing dental rehabilitation under general anesthesia were assigned randomly to one of the two groups (n = 38 each) receiving either intranasal dexmedetomidine at 2 µg/kg and oral ketamine at 3 mg/kg (Group DK) or intranasal midazolam at 0.2 mg/kg (group M) 30 minutes prior to the anesthesia induction. The sedation levels and parental separation state were evaluated. Time to recovery, postoperative rescue analgesia, and postoperative adverse effects were assessed. Results Seventy-six children completed the study. Patients in group DK had significantly lower sedation scores than those in group M after 20 and 30 min (P < 0.05). The rate of satisfactory separation showed no statistically significant difference between the two groups 30 minutes after the administration of premedication (P = 0.926). A significantly higher number of patients in group M required rescue analgesic (42%) compared to those in group DK (16%) (P = 0.012). Conclusions Premedication with intranasal dexmedetomidine 2 µg/kg and oral ketamine 3 mg/kg is a rapid and effective alternative in children undergoing dental rehabilitation when compared to intranasal midazolam 0.2 mg/kg.
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Affiliation(s)
- Mohamed E Oriby
- Department of Anesthesia and Surgical Intensive Care, Tanta University, Tanta, Egypt
- Anesthesia Department, Magrabi Center, Doha, Qatar
- Corresponding Author: Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Doha, Qatar. PO Box: 23293, Tel: +974-33059056,
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14
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Jaikaria A, Thakur S, Singhal P, Chauhan D, Jayam C, Syal K. A Comparison of Oral Midazolam-ketamine, Dexmedetomidine-fentanyl, and Dexmedetomidine-ketamine Combinations as Sedative Agents in Pediatric Dentistry: A Triple-Blinded Randomized Controlled Trial. Contemp Clin Dent 2018; 9:S197-S203. [PMID: 30294144 PMCID: PMC6169282 DOI: 10.4103/ccd.ccd_818_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: It is common to encounter a patient who is anxious to the magnitude that precludes the possibility of provision of dental treatment. This study aims to evaluate and compare the sedative effect of oral combinations of midazolam-ketamine (MK), dexmedetomidine-fentanyl (DF), and dexmedetomidine-ketamine (DK) in a group of uncooperative children requiring dental treatment. Methodology: This was a prospective, randomized, triple-blind study where 36 children who were 3–9 year old with American Society of Anesthesiologists –I status and presenting early childhood caries were randomly assigned to: Group A – 0.3 mg/kg of M and 5 mg/kg K, Group B – 2 ug/kg of D with 3 ug/kg of F, and Group C – 2ug/kg of D with 5 mg/kg of K in 1 mL honey. Patients' blood pressure, heart rate, and oxygen saturation were recorded from the start of the procedure till discharge. Patients' behavior, sedation status, and wake-up behavior were evaluated with Modified Observer Assessment of Alertness and Sedation Scale and ease of treatment completion by Houpt scale. Results: Hemodynamic changes were statistically insignificant in all three groups. 72.8% of patients in Group A and 58.3% of patients in Group B were successfully sedated during treatment. Behavior improvement was seen in all three groups during treatment with statistically insignificant difference in behavior scores produced by Group C. Ease of treatment completion was moderately better with Group A. Conclusion: Oral DK has a comparable sedative property with oral MK combination. Oral DF promises to be a potential sedative agent for children due to its successful anxiolysis.
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Affiliation(s)
- Astha Jaikaria
- Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| | - Seema Thakur
- Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| | - Parul Singhal
- Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| | - Deepak Chauhan
- Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| | - Cheranjeevi Jayam
- Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
| | - Kartik Syal
- Department of Anesthesiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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15
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Qiao H, Xie Z, Jia J. Pediatric premedication: a double-blind randomized trial of dexmedetomidine or ketamine alone versus a combination of dexmedetomidine and ketamine. BMC Anesthesiol 2017; 17:158. [PMID: 29187151 PMCID: PMC5708105 DOI: 10.1186/s12871-017-0454-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/21/2017] [Indexed: 12/20/2022] Open
Abstract
Background Preoperative anxiety is common in pediatric patients. When dexmedetomidine is used alone for sedation as premedication, children tend to awaken when separated from their parents, and body movements occur during invasive procedures. We tested the hypothesis that the combination of dexmedetomidine and ketamine may be a useful premedication to alleviate preoperative anxiety and improve cooperation during intravenous cannulation in pediatric patients, while producing minimal adverse events. Methods A total of 135 children, aged 2–5 years and American Society of Anesthesiologists status I–II, scheduled for eye surgery were randomly allocated to receive intranasal dexmedetomidine 2.5 μg/kg (group D), oral ketamine 3 mg/kg and intranasal dexmedetomidine 2 μg/kg (group DK), or oral ketamine 6 mg/kg (group K) 30 min before surgery. Sedation state was evaluated every 10 min after premedication and emotional state was assessed during separation from their parents and peripheral intravenous cannulation. Adverse events were recorded for 24 h postoperatively. The primary endpoint was the rate of successful intravenous cannulation. Results The rate of successful venous cannulation was 47% with dexmedetomidine alone, 68% with ketamine alone, and 80% with combined premedication (P = 0.006). The rate of satisfactory separation from parents was not different among groups. The incidence of adverse events was higher in group K compared with the other two groups (postoperative vomiting, P = 0.0041; respiratory-related complications during the perioperative period, P = 0.0032; and postoperative psychological/psychiatric adverse events, P = 0.0152). Conclusion The combination of intranasal dexmedetomidine 2 μg/kg and oral ketamine 3 mg/kg produces satisfactory separation from parents and more successful venous cannulation, allowing children to smoothly accept induction of general anesthesia. Trial registration Chinese Clinical Trial Register (Unique identifier: ChiCTR-TRC-14004475, Date of registration: 2 April 2014).
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Affiliation(s)
- Hui Qiao
- Department of Anesthesiology, The Eye, Ear, Nose and Throat Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, China
| | - Zhi Xie
- Department of Anesthesiology, Shanghai Deji Hospital, Qingdao University, Shanghai, China
| | - Jie Jia
- Department of Anesthesiology, The Eye, Ear, Nose and Throat Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, China.
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16
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Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate. Paediatr Drugs 2017; 19:107-111. [PMID: 28275979 DOI: 10.1007/s40272-017-0217-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.
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17
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Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med 2017; 70:203-211. [PMID: 28366351 DOI: 10.1016/j.annemergmed.2017.02.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/10/2017] [Accepted: 02/15/2017] [Indexed: 11/15/2022]
Abstract
The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.
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Affiliation(s)
- Megan A Rech
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL; Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL.
| | - Brian Barbas
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
| | - Whitney Chaney
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
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18
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Fett J, Hackbarth R, Boville BM, Olivero AD, Davis AT, Winters JW. Comparative Effectiveness of Intranasal Dexmedetomidine-Midazolam versus Oral Chloral Hydrate Targeting Moderate Sedation during Pediatric Transthoracic Echocardiograms. J Pediatr Intensive Care 2016; 6:182-187. [PMID: 31073445 DOI: 10.1055/s-0036-1597696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022] Open
Abstract
Objective To compare efficacy and safety of two moderate sedation regimens for transthoracic echocardiography (TTE): intranasal dexmedetomidine-midazolam (DM) versus oral chloral hydrate (CH) syrup. Method This was a retrospective cohort of 93 children under 4 years of age receiving moderate sedation with either DM or CH for TTE from January 2011 through December 2014. Measurements and Main Results Forty-nine patients received oral CH and 44 received the intranasal combination of DM. The demographics between groups were similar except the DM patients were slightly older and heavier (each p < 0.05). Failure rate between groups did not reach statistical significance (CH 14.3% vs. DM 6.8%; p = 0.324). Total sedation to discharge time was similar between groups (CH 89.4 minutes vs. DM 89.6 minute; p = 0.97). Cardiopulmonary data did reveal a significantly lower heart rate (101.9 vs. 91.7; p < 0.001) and respiratory rate (23.4 vs. 21.0, p = 0.03) in the DM group, but no difference in blood pressure measurements or echo determined shortening fraction. Conclusion These data support the use of intranasal DM as a safe and efficacious method of moderate sedation for children undergoing TTE.
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Affiliation(s)
- Jordan Fett
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States
| | - Richard Hackbarth
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States.,Division of Critical Care, Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan, United States
| | - Brian M Boville
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States.,Division of Critical Care, Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan, United States
| | - Anthony D Olivero
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States.,Division of Critical Care, Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan, United States
| | - Alan T Davis
- Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan, United States
| | - John W Winters
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States.,Division of Critical Care, Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan, United States
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19
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Wu X, Hang LH, Wang H, Shao DH, Xu YG, Cui W, Chen Z. Intranasally Administered Adjunctive Dexmedetomidine Reduces Perioperative Anesthetic Requirements in General Anesthesia. Yonsei Med J 2016; 57:998-1005. [PMID: 27189297 PMCID: PMC4951480 DOI: 10.3349/ymj.2016.57.4.998] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/08/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Intranasal dexmedetomidine is an effective sedative for premedication and is regularly used to reduce preoperative tension and anxiety in children. This study aimed to assess the effect of intranasally adjunctive dexmedetomidine on perioperative sedative and analgesic requirements in adults. MATERIALS AND METHODS Patients were randomly divided into four groups to receive preoperative administration of saline, intranasal dexmedetomidine 1 μg/kg and 2 μg/kg, and intravenous dexmedetomidine 1 μg/kg, respectively. Propofol and remifentanil were target-controlled infused to maintain intraoperative bispectral index at 45-55 and blood pressure at baseline value±20%. Sufentanil was administered to maintain postoperative visual analogue scale ≤3. Perioperative anesthetics requirements were compared using nonparametric tests. RESULTS Intranasal dexmedetomidine significantly attenuated propofol requirements for anesthesia induction and maintenance in a dose-dependent manner. Patients given intranasal dexmedetomidine 2 μg/kg required less remifentanil for anesthesia maintenance. The first postoperative request for sufentanil analgesia was delayed in patients given intranasal dexmedetomidine 2 μg/kg. The anesthetics-sparing effect of intranasal dexmedetomidine was significantly weaker than intravenous dexmedetomidine at the same dose of 1 μg/kg. The incidences of adverse events, including hemodynamic instability and delayed recovery, were comparable with and without intranasal dexmedetomidine. CONCLUSION Intranasal administration of dexmedetomidine can reduce perioperative anesthetic requirements, and a dose of dexmedetomidine 2 μg/kg produces a better effect in adults. The anesthetics-sparing effect of intranasal dexmedetomidine 1 μg/kg is less than that with the same intravenous dose of dexmedetomidine.
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Affiliation(s)
- Xiang Wu
- Department of Anesthesiology, The Affiliated Hospital of School of Medicine of Ningbo University, Ningbo, Zhejiang, China
| | - Li Hua Hang
- Department of Anesthesiology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Hong Wang
- Department of Anesthesiology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Dong Hua Shao
- Department of Anesthesiology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yi Guo Xu
- Department of Anesthesiology, The Affiliated Hospital of School of Medicine of Ningbo University, Ningbo, Zhejiang, China
| | - Wei Cui
- Department of Anesthesiology, The Affiliated Hospital of School of Medicine of Ningbo University, Ningbo, Zhejiang, China
| | - Zheng Chen
- Department of Anesthesiology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China.
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20
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Bhat R, Santhosh MCB, Annigeri VM, Rao RP. Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study. Anesth Essays Res 2016; 10:349-55. [PMID: 27212773 PMCID: PMC4864701 DOI: 10.4103/0259-1162.172340] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant. AIMS To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients. SETTINGS AND DESIGN Prospective randomized double-blind study. SUBJECTS AND METHODS After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 μg/kg dexmedetomidine intranasally and in group DK received 1 μg/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale. STATISTICAL ANALYSIS USED Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05. RESULTS Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups. CONCLUSIONS Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.
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Affiliation(s)
- Ravi Bhat
- Department of Anaesthesiology, SDM College of Medical Sciences, Dharwad, Karnataka, India
| | - M C B Santhosh
- Department of Anaesthesiology, SDM College of Medical Sciences, Dharwad, Karnataka, India
| | - Venkatesh M Annigeri
- Department of Paediatric Surgery, SDM College of Medical Sciences, Dharwad, Karnataka, India
| | - Raghavendra P Rao
- Department of Anaesthesiology, SDM College of Medical Sciences, Dharwad, Karnataka, India
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21
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Affiliation(s)
- C. R. Bailey
- Evelina London Children's Hospital; Guy's and St. Thomas' NHS Foundation Trust; London UK
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22
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Zhang W, Wang Z, Song X, Fan Y, Tian H, Li B. Comparison of rescue techniques for failed chloral hydrate sedation for magnetic resonance imaging scans--additional chloral hydrate vs intranasal dexmedetomidine. Paediatr Anaesth 2016; 26:273-9. [PMID: 26714442 DOI: 10.1111/pan.12824] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chloral hydrate, a commonly used sedative in children during noninvasive diagnostic procedures, is associated with side effects like prolonged sedation, paradoxical excitement, delirium, and unpleasant taste. Dexmedetomidine, a highly selective α-2 agonist, has better pharmacokinetic properties than chloral hydrate. We conducted this prospective, double-blind, randomized controlled trial to evaluate efficacy of intranasal dexmedetomidine with that of a second oral dose of chloral hydrate for rescue sedation during magnetic resonance imaging (MRI) studies in infants. METHODS One hundred and fifty infants (age group: 1-6 months), who were not adequately sedated after initial oral dose of 50 mg · kg(-1) chloral hydrate, were randomly divided into three groups with the following protocol for each group. Group C: second oral dose chloral hydrate 25 mg · kg(-1); Group L and Group H: intranasal dexmedetomidine in a dosage of 1 and 2 mcg · kg(-1), respectively. Status of sedation, induction time, time to wake up, vital signs, oxygen saturation, and recovery characteristics were recorded. RESULTS Successful rescue sedation in Groups C, L, and H were achieved in 40 (80%), 47 (94%), and 49 (98%) of infants, respectively, on an intention to treat analysis, and the proportion of infants successfully sedated in Group H was more than that of Group L (P ˂ 0.01). There were no significant differences in sedation induction time; however, the time to wake up was significantly shorter in Group L as compared to that in Group C or H (P < 0.01). No significant adverse hemodynamic or hypoxemic effects were observed in the study. CONCLUSION Intranasal dexmedetomidine induced satisfactory rescue sedation in 1- to 6-month-old infants during MRI study, and appears to cause sedation in a dose-dependent manner.
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Affiliation(s)
- Wenhua Zhang
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
| | - Zixin Wang
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
| | - Yanting Fan
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
| | - Hang Tian
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
| | - Bilian Li
- Department of Anesthesiology, Guangzhou Women & Children's Medical Center, Guangzhou, China
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23
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Baier NM, Mendez SS, Kimm D, Velazquez AE, Schroeder AR. Intranasal dexmedetomidine: an effective sedative agent for electroencephalogram and auditory brain response testing. Paediatr Anaesth 2016; 26:280-5. [PMID: 26814037 DOI: 10.1111/pan.12851] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Dexmedetomidine is an α2 agonist with sedative, anxiolytic, and analgesic properties. The intranasal (IN) route avoids the pain of intravenous (i.v.) catheter placement but limited literature exists on the use of IN dexmedetomidine. This study examines the effectiveness and safety of IN dexmedetomidine for sedation of patients undergoing electroencephalogram (EEG) and auditory brain response (ABR) testing. STUDY DESIGN This was a review of all outpatients sedated with IN dexmedetomidine for EEG or ABR between October 1, 2012 and October 1, 2014. An initial dose of 2.5-3 μg · kg(-1) IN dexmedetomidine was given with a repeat dose of 1-1.5 μg · kg(-1) IN if needed 30 min later. Prospectively entered patient information was extracted from a quality assurance database and additional information gathered via retrospective chart review. RESULTS Intranasal dexmedetomidine was used in 169 patients (EEG = 117, ABR = 52). First-dose success rates were 90.4% for ABR and 87.2% for EEG. Total success rates (with one or two doses of IN dexmedetomidine) were 100% for ABR and 99.1% for EEG. The median time to onset of sleep was 25 min (IQR, 20-32 min). The median duration of sedation was 107 min (IQR, 90-131 min). Adverse events included: 18 patients (10.7%) with hypotension which resolved without intervention, six patients with oxygen desaturation <90%, two of whom received supplemental oxygen, and one patient with an underlying upper airway abnormality who was treated with continuous positive airway pressure. CONCLUSIONS IN dexmedetomidine is an effective and noninvasive method of sedating children for EEG and ABR.
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Affiliation(s)
- Nicole M Baier
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Suzanne S Mendez
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Danielle Kimm
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Amanda E Velazquez
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alan R Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
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Ye W, Hu Z, Jin X, Wang P. Effects of dexmedetomidine for retrobulbar anesthesia in orbital ball implants after enucleation surgery. Indian J Ophthalmol 2015; 63:704-9. [PMID: 26632125 PMCID: PMC4705705 DOI: 10.4103/0301-4738.170981] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Dexmedetomidine (DEX) can prolong the duration of local anesthetics, but the use of retrobulbar DEX has not been fully elucidated. This study was designed to determine the effects of adding DEX to lidocaine-bupivacaine for retrobulbar block in orbital ball implants after enucleation surgery. Materials and Methods: A total of 200 patients of both sexes aged 30–60 years of American Society of Anesthesiologists I and II, scheduled for orbital ball implants after enucleation surgery, were enrolled for the study. Patients were randomly assigned into one of the two groups: Control (n = 100) received lidocaine-bupivacaine retrobulbar block, DEX (n = 100) received lidocaine-bupivacaine plus 1 ug/kg DEX retrobulbar block. Hemodynamic data, duration of motor and sensory blocks, pain by visual analog scale, bispectral index (BIS), side effects, consumption of dezocine as a rescue analgesic, patient and surgeon satisfaction were recorded. Results: Duration of analgesia was prolonged in the DEX, compared with the control group ([258.35 ± 66.82 min] as [130.75 ± 29.52 min], [P < 0.05]). The median number of postoperative analgesic requests per patient during the first 24 h was decreased in the DEX group (P < 0.05). In the first 24 postoperative hours, DEX group consumed significantly less dezocine (P < 0.05). BIS values and mean arterial pressure remained lower in the DEX group, but within the safe range (P < 0.05). The side effect profile was similar between the two groups. Patients and surgeon satisfaction were higher in the DEX group (P < 0.05). Demographic characteristics were comparable in both groups (P > 0.05). Conclusion: Retrobulbar DEX reduces consumption of rescue analgesic, prolonged the duration of retrobulbar block, improved postoperative pain, provided better sedation effects, and increased patient and surgeon satisfaction after orbital ball implants after enucleation surgery.
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Affiliation(s)
| | - Zhiyong Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou; Department of Anesthesiology, The Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Zanaty OM, El Metainy SA. A Comparative Evaluation of Nebulized Dexmedetomidine, Nebulized Ketamine, and Their Combination as Premedication for Outpatient Pediatric Dental Surgery. Anesth Analg 2015; 121:167-171. [DOI: 10.1213/ane.0000000000000728] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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26
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Peng K, Wu SR, Ji FH, Li J. Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis. Clinics (Sao Paulo) 2014; 69:777-86. [PMID: 25518037 PMCID: PMC4255070 DOI: 10.6061/clinics/2014(11)12] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/14/2014] [Indexed: 11/26/2022] Open
Abstract
Premedication is important in pediatric anesthesia. This meta-analysis aimed to investigate the role of dexmedetomidine as a premedicant for pediatric patients. A systematic literature search was conducted to identify randomized controlled trials comparing dexmedetomidine premedication with midazolam or ketamine premedication or placebo in children. Two reviewers independently performed the study selection, quality assessment and data extraction. The original data were pooled for the meta-analysis with Review Manager 5. The main parameters investigated included satisfactory separation from parents, satisfactory mask induction, postoperative rescue analgesia, emergence agitation and postoperative nausea and vomiting. Thirteen randomized controlled trials involving 1190 patients were included. When compared with midazolam, premedication with dexmedetomidine resulted in an increase in satisfactory separation from parents (RD = 0.18, 95% CI: 0.06 to 0.30, p = 0.003) and a decrease in the use of postoperative rescue analgesia (RD = -0.19, 95% CI: -0.29 to -0.09, p = 0.0003). Children treated with dexmedetomidine had a lower heart rate before induction. The incidence of satisfactory mask induction, emergence agitation and PONV did not differ between the groups. Dexmedetomidine was superior in providing satisfactory intravenous cannulation compared to placebo. This meta-analysis suggests that dexmedetomidine is superior to midazolam premedication because it resulted in enhanced preoperative sedation and decreased postoperative pain. Additional studies are needed to evaluate the dosing schemes and long-term outcomes of dexmedetomidine premedication in pediatric anesthesia.
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Affiliation(s)
- Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shao-ru Wu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Li
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
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Linares Segovia B, García Cuevas M, Ramírez Casillas I, Guerrero Romero J, Botello Buenrostro I, Monroy Torres R, Ramírez Gómez X. Pre-anaesthetic medication with intranasal dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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28
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Linares Segovia B, García Cuevas M, Ramírez Casillas I, Guerrero Romero J, Botello Buenrostro I, Monroy Torres R, Ramírez Gómez X. Medicación preanestésica con dexmedetomidina intranasal y midazolam oral como ansiolítico. Un ensayo clínico. An Pediatr (Barc) 2014; 81:226-31. [DOI: 10.1016/j.anpedi.2013.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/12/2013] [Accepted: 12/16/2013] [Indexed: 11/26/2022] Open
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Abstract
Preoperative anxiolysis is important for children scheduled for surgery. The nature of the anxiety depends on several factors, including age, temperament, past hospitalizations, and socioeconomic and ethnic backgrounds. A panoply of interventions effect anxiolysis, including parental presence, distraction, and premedication, although no single strategy is effective for all ages. Emergence delirium (ED) occurs after the use of sevoflurane and desflurane in preschool-aged children in the recovery room. Symptoms usually last approximately 15 minutes and resolve spontaneously. The Pediatric Anesthesia Emergence Delirium scale is used to diagnose ED and evaluate therapeutic interventions for ED such as propofol and opioids.
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Affiliation(s)
- Richard J Banchs
- Department of Anesthesiology (MC515), University of Illinois Medical Center, Children's Hospital University of Illinois, 1740 West Taylor Street, Suite 3200 West, Chicago, IL 60612-7239, USA
| | - Jerrold Lerman
- Department of Anesthesia, Women and Children's Hospital of Buffalo, SUNY at Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA; Department of Anesthesia, Strong Medical Center, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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