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Jang YE, Park JB, Kang P, Ji SH, Kim EH, Lee JH, Kim HS, Kim JT. Risk factors for chloral hydrate sedation failure in pediatric patients: a retrospective analysis. Korean J Anesthesiol 2024; 77:526-536. [PMID: 38951746 DOI: 10.4097/kja.24125] [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: 02/20/2024] [Accepted: 07/01/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND This study aimed to investigate the risk factors for chloral hydrate sedation failure and complications in a tertiary children's hospital in South Korea. METHODS A retrospective analysis of pediatric procedural sedation with chloral hydrate between January 1, 2021, and March 30, 2022, was performed. The collected data included patient characteristics, sedation history, and procedure. Multivariable regression analysis was performed to identify the risk factors for procedural sedation failure and complications. RESULTS A total of 6,691 procedural sedation were included in the analysis; sedation failure following chloral hydrate (50 mg/kg) occurred in 1,457 patients (21.8%) and was associated with a higher rate of overall complications compared to those with successful sedation (17.5% [225/1457] vs. 6.2% [322/5234]; P < 0.001, odds ratio: 3.236). In the multivariable regression analysis, the following factors were associated with increased risk of sedation failure: general ward or intensive care unit inpatient (compared with outpatient); congenital syndrome; oxygen dependency; history of sedation failure or complications with chloral hydrate; procedure more than 60 min; and magnetic resonance imaging, radiotherapy, or procedures with painful or intense stimuli (all P values < 0.05). Factors contributing to the complications included general ward inpatient, congenital syndromes, congenital heart disease, preterm birth, oxygen dependency, history of complications with chloral hydrate, and current sedation failure with chloral hydrate (all P values < 0.05). CONCLUSIONS To achieve successful sedation with chloral hydrate, the patient's sedation history, risk factors, and the type and duration of the procedure should be considered.
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Affiliation(s)
- Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Pereira EMM, Nascimento TSD, da Costa MG, Slawka E, Júnior CG. Comparison of intranasal dexmedetomidine versus oral midazolam for premedication in pediatric patients: an updated meta-analysis with trial-sequential analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844520. [PMID: 38801889 PMCID: PMC11223073 DOI: 10.1016/j.bjane.2024.844520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/14/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Midazolam is routinely used as preanesthetic medication in pediatric patients. Recently, dexmedetomidine has emerged as an alternative as a premedicant. We aimed to add more evidence about the efficacy and safety of two common routes of administration for pediatric premedication: oral midazolam versus intranasal dexmedetomidine. METHODS We systematically searched Randomized Controlled Trials (RCTs) involving patients ≤ 18 years old undergoing preanesthetic medication and comparing intranasal dexmedetomidine with oral midazolam. Risk Ratio (RR) and Mean Difference (MD) with 95% Confidence Intervals (95% CI) were computed using a random effects model. Trial-sequential analyses were performed to assess inconsistency. RESULTS Sixteen RCTs (1,239 patients) were included. Mean age was 5.5 years old, and most procedures were elective. There was no difference in satisfactory induction or mask acceptance (RR = 1.15, 95% CI 0.97-1.37; p = 0.11). There was a higher incidence of satisfactory separation from parents in the dexmedetomidine group (RR = 1.40; 95% CI 1.13-1.74; p = 0.002). Dexmedetomidine was also associated with a reduction in the incidence of emergence agitation (RR = 0.35; 95% CI 0.14-0.88; p = 0.02). Heart rate and mean arterial pressure were marginally lower in the dexmedetomidine group but without clinical repercussions. CONCLUSION Compared with oral midazolam, intranasal dexmedetomidine demonstrated better separation from parents and lower incidence of emergence agitation in pediatric premedication, without a difference in satisfactory induction. Intranasal dexmedetomidine may be a safe and effective alternative to oral midazolam for premedication in pediatric patients.
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Affiliation(s)
| | | | - Mariana Gaya da Costa
- University Medical Center of Groningen, Department of Anesthesiology, Groningen, The Netherlands.
| | - Eric Slawka
- Universidade Federal do Rio de Janeiro, Departamento de Medicina, Rio de Janeiro, RJ, Brazil
| | - Carlos Galhardo Júnior
- McMaster University & DeGroote Schol of Medicine, Department of Anesthesiology, Hamilton, Canada
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Alsabri MAH, Abdelshafi A, Bostamy Elsnhory A, Selim NS, Elsnhory AB, Albelal D, Akram F, Elshanbary AA. Efficacy and Safety of Dexmedetomidine Compared to Other Needle-Free Pharmacological Sedation Methods in Pediatric Patients Undergoing Imaging Procedures. Pediatr Emerg Care 2024; 40:e233-e239. [PMID: 38713855 DOI: 10.1097/pec.0000000000003169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
BACKGROUND Pediatric patients often require sedation during magnetic resonance imaging (MRI) and computed tomography (CT) to ensure stillness and minimize stress. This meta-analysis compared the effectiveness and safety of 3 sedative agents-dexmedetomidine, midazolam, and chloral hydrate-for pediatric MRI/CT sedation. METHODS Six studies with a total of 633 patients were included in the analysis. Quality assessment revealed varying levels of bias risk. Dexmedetomidine exhibited a significantly higher successful sedation rate compared to midazolam (risk ratio [RR] = 0.43, 95% confidence interval [CI] [0.29-0.64]), but no statistically significant difference compared to chloral hydrate (RR = 0.94, 95% CI [0.60-1.45]). Chloral hydrate also showed a higher successful sedation rate compared to midazolam (RR = 0.46, 95% CI [0.25-0.83]). The onset of sedation time did not significantly differ between the 3 agents. RESULTS The dexmedetomidine group had a significantly higher incidence of bradycardia compared to the chloral hydrate group (RR = 0.17, 95% CI [0.05-0.59]), but no significant difference compared to the midazolam group (RR = 0.29, 95% CI [0.06-1.26]). No statistically significant differences were observed in the incidence of nausea and vomiting between the 3 groups. CONCLUSIONS Dexmedetomidine demonstrates effectiveness in pediatric MRI/CT sedation, offering advantages over midazolam and similar efficacy to chloral hydrate. Careful cardiovascular monitoring is essential during administration, particularly in patients with congenital heart disease. Sublingual and intranasal administration of dexmedetomidine is a viable option with high bioavailability. This meta-analysis contributes valuable insights into refining sedation protocols for pediatric imaging procedures, emphasizing efficacy and safety considerations.
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Kim SH, Moon YJ, Chae MS, Lee YJ, Karm MH, Joo EY, Min JJ, Koo BN, Choi JH, Hwang JY, Yang Y, Kwon MA, Koh HJ, Kim JY, Park SY, Kim H, Chung YH, Kim NY, Choi SU. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol 2024; 77:5-30. [PMID: 37972588 PMCID: PMC10834708 DOI: 10.4097/kja.23745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.
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Affiliation(s)
- Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yea-Ji Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Eun-Young Joo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yeonmi Yang
- Department of Pediatric Dentistry, Jeonbuk National University School of Dentistry, Jeonju, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Hyun Jung Koh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yang-Hoon Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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Wang X, Ma L, Yang X, Zhou Y, Zhang X, Han F. Efficacy of intranasal administration of dexmedetomidine in combination with midazolam for sedation in infant with cleft lip and palate undergoing CT scan: a randomized controlled trial. BMC Anesthesiol 2024; 24:10. [PMID: 38166622 PMCID: PMC10759416 DOI: 10.1186/s12871-023-02397-2] [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: 11/04/2023] [Accepted: 12/25/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND There is a great challenge to sedation for infants with cleft lip and palate undergoing CT scan, because there is the younger age and no consensus on the type, dosage, and route of drug administration. OBJECTIVE This study aimed to evaluate the efficacy of intranasal administration of dexmedetomidine combined with midazolam as a sedative option for infants with cleft lip and palate under imaging procedures. METHODS Infants scheduled for cleft lip and palate repair surgery were randomly assigned to the IND group (intranasal dexmedetomidine 2 µg/kg alone) and the INDM group (intranasal dexmedetomidine 2 µg/kg combined with midazolam 0.05 mg/kg). The primary outcome was the proportion of infants underwent successful computed tomography (CT) scans under intranasal sedation. The secondary outcomes included onset time and duration of sedation, recovery time, Ramsay sedation scale, hemodynamic parameters during sedation, and adverse events. Data analyses involved the unpaired t-test, the repeated-measures analysis of variance test, and the continuity correction χ2 test. RESULTS One hundred five infants were included in the analysis. The proportion of infants underwent successful CT scans under sedation was significantly greater in the INDM group than in the IND group (47 [95.9%] vs. 45 [80.4%], p = 0.016). Additionally, the INDM group had a shorter onset time and a longer duration of sedation statistically (12 [8.5, 17] min vs. 16 [12, 20] min, p = 0.001; 80 [63.6, 92.5] min vs. 68.5 [38, 89] min, p = 0.014, respectively), and their recovery time was significantly longer (43 [30, 59.5] min vs. 31.5 [20.5, 53.5] min, p = 0.006). The difference in Ramsay sedation scale values 20 min after administration was statistically significant between the groups. No statistically significant difference was found between the groups in changes in heart rate and respiratory rate. CONCLUSION Intranasal administration of dexmedetomidine in combination with midazolam resulted in higher sedation success in comparison with sole dexmedetomidine. However, it has a relatively prolonged duration of sedation and recovery time. TRIAL REGISTRATION ChiCTR2100049122, Clinical trial first registration date: 21/07/2021.
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Affiliation(s)
- Xiaodong Wang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Lian Ma
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, Beijing, China
| | - Xudong Yang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Yi Zhou
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Xiang Zhang
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China
| | - Fang Han
- Department of Anesthesiology, Peking University Hospital of Stomatology, NO. 22 Zhongguancun South Avenue, Beijing, 100081, China.
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Zhang G, Xin L, Yin Q. Intranasal dexmedetomidine vs. oral midazolam for premedication in children: a systematic review and meta-analysis. Front Pediatr 2023; 11:1264081. [PMID: 38027288 PMCID: PMC10661234 DOI: 10.3389/fped.2023.1264081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To compare the effects of intranasal dexmedetomidine (Dex) and oral midazolam in the preoperative medication of children by using a method of meta-analysis. Methods Cochrane Library, Pubmed, Embase, and Web of Science were searched from inception to July 2023. Randomized controlled trials (RCTs) of intranasal Dex vs. oral midazolam in pediatric premedication were collected. Stata 15.0 statistical software was used to analyze the collected data. Relative risk (RR) and 95% confidence interval (CI) were used as effect sizes. Results A total of 11 studies with 824 children were included, containing 415 patients in the Dex group and 409 patients in the midazolam group. Compared with the oral midazolam group, the intranasal Dex group had a better preoperative sedation effect at parent-child separation (RR = 1.37, 95% CI: 1.14-1.64) and anesthesia induction (RR = 2.08, 95% CI: 1.03-4.22). In addition, there was no significant difference in the incidence of analgesia remedy (RR = 0.60, 95% CI: 0.36-1.00) the acceptance of anesthesia masks (RR = 0.97, 95% CI: 0.83-1.12), and incidence of adverse events between (RR = 0.25, 95% CI: 0.06-1.13, P = 0.072) between the intranasal Dex and oral midazolam groups. Conclusion Compared with oral midazolam, intranasal Dex has better sedative effects of parent-child separation and anesthesia induction in pediatric premedication, but there was no difference in the incidence of anesthesia remedy, anesthesia mask acceptance, and incidence of adverse events. Therefore, compared with oral midazolam, intranasal Dex is a better choice for premedication in children.
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Affiliation(s)
- Guangxuan Zhang
- Department of Anesthesiology, Hainan Branch, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Sanya, Hainan, China
| | - Li Xin
- Department of Pharmacy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingtang Yin
- Department of Anesthesiology, Haimen District People’s Hospital, Nantong, China
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Nie J, Chen C, Xie J, Ding G. Oral midazolam vs. intranasal dexmedetomidine plus oral midazolam for sedation of pediatric outpatients: a double-blinded randomized controlled trial. BMC Anesthesiol 2023; 23:341. [PMID: 37817075 PMCID: PMC10563331 DOI: 10.1186/s12871-023-02289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Moderate to deep sedation is required for dental treatment of children with dental anxiety. Midazolam is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric sedation. OBJECTIVE The aim of this trial was to compare the sedative efficacy of oral midazolam alone with that of intranasal dexmedetomidine plus oral midazolam during dental treatment of children with dental anxiety. DESIGN In total, 83 children (aged 3-12 years) scheduled to undergo dental sedation were randomized to receive oral midazolam (0.5 mg/kg) and intranasal placebo, or oral midazolam (0.5 mg/kg) plus intranasal dexmedetomidine (2 µg/kg). The primary outcome was the rate of successful sedation for dental treatment. Secondary outcomes were the onset time and adverse events during and after treatment. Data analyses involved descriptive statistics and nonparametric tests. RESULTS The rate of successful sedation was significantly higher in combination group (P = 0.007), although the sedation onset time was significantly longer in combination group (17.5 ± 2.4 min) than in monotherapy group (15.7 ± 1.8) (P = 0.003). No children required medical intervention or oxygen therapy for hemodynamic disturbances, and the incidences of adverse events had no significant difference between groups (P = 0.660). CONCLUSION Combined treatment with oral midazolam (0.5 mg/kg) and intranasal dexmedetomidine (2 µg/kg) is more significantly effective for managing the behavior of non-cooperative children during dental treatment, compared to oral midazolam (0.5 mg/kg) alone. (Chinese Clinical Trial Registry: ChiCTR2100042300) TRIAL REGISTRATION: ChiCTR2100042300, Clinical trial first registration date: 17/01/2021.
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Affiliation(s)
- Juan Nie
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
- Department of Pediatric Dentistry, Sichuan Hospital of Stomatology, Chengdu, 61000, China
| | - Chanchan Chen
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
| | - Jing Xie
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China
| | - Guicong Ding
- Shenzhen Children's Hospital of China Medical University, Shenzhen, 518026, China.
- Department of stomatology, Shenzhen Children's Hospital, China Medical University, Yitian Road 7019, Shenzhen, 518000, P.R. China.
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Kenneally A, Cummins M, Bailey A, Yackey K, Jones L, Carter C, Dugan A, Baum RA. Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department. Pediatr Emerg Care 2023; 39:685-691. [PMID: 36728557 DOI: 10.1097/pec.0000000000002901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES In recent years, dexmedetomidine has gained traction as a treatment for anxiolysis in the emergency department (ED). When used with an atomizer, it may also be given intranasally for anxiolysis. The primary objective was to determine the level of ED provider satisfaction and comfort with intranasal (IN) dexmedetomidine for anxiolysis in pediatric patients with behavioral agitation and/or acute psychosis. The secondary objectives included determining safety, rates of therapy failure, and ED length of stay compared with oral midazolam. The efficacy of IN dexmedetomidine versus oral midazolam in patients with autism spectrum disorder (ASD) was also evaluated. METHODS This was a single-center, prospective study in a pediatric ED from March 1 to December 31, 2021. Patients were included in the study if the ED provider requested IN dexmedetomidine anxiolysis and completed a postadministration survey. Safety and efficacy outcomes were assessed by chart review and compared with patients who received oral midazolam during the same study period. Efficacy was defined as the rate of treatment failure, as the need for procedural termination, progression to procedural sedation, or the requirement of additional medications for anxiolysis. RESULTS Sixty-two patients received IN dexmedetomidine {median dose [interquartile range (IQR)] of 3.05 [2.04-4.00] μg/kg/dose} compared with 58 who received oral midazolam [median (IQR) dose of 0.29 (0.25-0.48) mg/kg/dose). Providers reported high comfort and satisfaction scores, with median (IQR) scores of 90 (75-100) and 88 (60-100) of 100. Twenty-nine percent of patients experienced treatment failure, most commonly because of the need for additional medications. Those who received IN dexmedetomidine had a longer ED length of stay (6.0 vs 4.4 hours, P = 0.010). Among the patients with ASD, those who received IN dexmedetomidine had a lower rate of treatment failure compared with oral midazolam (21.2% vs 66.7%, P = 0.039). CONCLUSIONS This study demonstrates that IN dexmedetomidine has high levels of provider comfort and satisfaction, moderately high success rate, and a promising safety profile. In addition, IN dexmedetomidine may be superior to oral midazolam in patients with ASD for anxiolysis, but additional studies are needed.
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Affiliation(s)
- Allison Kenneally
- From the Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
| | - Megan Cummins
- From the Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
| | - Abby Bailey
- From the Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
| | - Katelyn Yackey
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY
| | - Landon Jones
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY
| | - Craig Carter
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, KY
| | - Adam Dugan
- Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Regan A Baum
- From the Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
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Wabelo ON, Schmartz D, Giancursio M, De Pooter F, Caruso G, Fils JF, Van der Linden P. Prospective, randomized, double-blind, double-dummy, active-controlled, phase 3 clinical trial comparing the safety and efficacy of intranasal dexmedetomidine to oral midazolam as premedication for propofol sedation in pediatric patients undergoing magnetic resonance imaging: the MIDEX MRI trial. Trials 2023; 24:518. [PMID: 37568242 PMCID: PMC10422697 DOI: 10.1186/s13063-023-07529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Children under 6 years who need magnetic resonance imaging usually require sedation to obtain best quality images, but the optimal sedation protocol remains to be determined. In 2018, we showed a 22% interruption in image acquisition during magnetic resonance imaging when performing a propofol-based sedation using a bolus approach. As non-pharmacological premedication is often insufficient to reduce the anxiety of children related to parental separation, pharmacological premedication may be useful to facilitate the induction of anesthesia. In our institution, effective premedication is obtained oral intake of midazolam, though its administration relies on patients' compliance and could also lead to paradoxical reaction. Dexmedetomidine has a safe profile in the pediatric population and can therefore represent an interesting alternative. The primary objective of this trial is to demonstrate the superiority of intranasal dexmedetomidine compared to oral midazolam as premedication in reducing the occurrence of any event requiring temporary or definitive interruption of the examination to allow anesthesiologist intervention in children undergoing magnetic resonance imaging under propofol sedation. METHODS In this single-center, prospective, randomized, double-blind, double-dummy, active comparator-controlled, superiority trial, we planned to include 250 patients, aged 6 months to 6 years, undergoing a scheduled magnetic resonance imaging requiring the presence of an anesthesiologist. After informed consent, the patients will be randomized to receive either oral midazolam or intranasal dexmedetomidine as premedication. The data will be analyzed in intention to treat, using Kolmogorov-Smirnov Z, chi-square, Wilcoxon, and Mann-Whitney U tests. A P-value < 0.05 will be considered statistically significant. DISCUSSION The MIDEX MRI study will assess the efficacy of intranasal dexmedetomidine compared to oral midazolam to improve the quality of a propofol-based sedation prior to magnetic resonance imaging, without negative repercussion on the postoperative period. TRIAL REGISTRATION ClinicalTrial.gov NCT05192629 . Registered on 14 January 2022. Protocol version 2.1.
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Affiliation(s)
- Olivia Nzungu Wabelo
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - Denis Schmartz
- Université Libre de Bruxelles, Brussels, Belgium.
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium.
| | - Mario Giancursio
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
| | - Françoise De Pooter
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
| | - Giulia Caruso
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles - Hôpital universitaire des enfants Reine Fabiola, Brussels, Belgium
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Bosch OG, Dornbierer DA, Bavato F, Quednow BB, Landolt HP, Seifritz E. Dexmedetomidine in Psychiatry: Repurposing of its Fast-Acting Anxiolytic, Analgesic and Sleep Modulating Properties. PHARMACOPSYCHIATRY 2023; 56:44-50. [PMID: 36384232 DOI: 10.1055/a-1970-3453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Drug repurposing is a strategy to identify new indications for already approved drugs. A recent successful example in psychiatry is ketamine, an anesthetic drug developed in the 1960s, now approved and clinically used as a fast-acting antidepressant. Here, we describe the potential of dexmedetomidine as a psychopharmacological repurposing candidate. This α2-adrenoceptor agonist is approved in the US and Europe for procedural sedation in intensive care. It has shown fast-acting inhibitory effects on perioperative stress-related pathologies, including psychomotor agitation, hyperalgesia, and neuroinflammatory overdrive, proving potentially useful in clinical psychiatry. We offer an overview of the pharmacological profile and effects of dexmedetomidine with potential utility for the treatment of neuropsychiatric symptoms. Dexmedetomidine exerts fast-acting and robust sedation, anxiolytic, analgesic, sleep-modulating, and anti-inflammatory effects. Moreover, the drug prevents postoperative agitation and delirium, possibly via neuroprotective mechanisms. While evidence in animals and humans supports these properties, larger controlled trials in clinical samples are generally scarce, and systematic studies with psychiatric patients do not exist. In conclusion, dexmedetomidine is a promising candidate for an experimental treatment targeting stress-related pathologies common in neuropsychiatric disorders such as depression, anxiety disorders, and posttraumatic stress disorder. First small proof-of-concept studies and then larger controlled clinical trials are warranted in psychiatric populations to test the feasibility and efficacy of dexmedetomidine in these conditions.
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Affiliation(s)
- Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse, Zurich, Switzerland
| | - Dario A Dornbierer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse, Zurich, Switzerland
- Institute of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse, Zürich
| | - Francesco Bavato
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse, Zurich, Switzerland
| | - Boris B Quednow
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland
| | - Hans-Peter Landolt
- Institute of Pharmacology and Toxicology, University of Zurich, Winterthurerstrasse, Zürich
- Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland
- Sleep & Health Zurich, University Center of Competence, University of Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland
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11
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Jang YE, Joo EY, Lee JH, Kim EH, Kang P, Park JB, Kim HS, Kim JT. Two-center randomized controlled trial comparing oral chloral hydrate and intranasal combination of dexmedetomidine and ketamine for procedural sedation in children: study protocol. Trials 2023; 24:2. [PMID: 36597163 PMCID: PMC9808979 DOI: 10.1186/s13063-022-07033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Oral chloral hydrate is widely used in pediatric sedation. Intranasal dexmedetomidine has been increasingly used for pediatric sedation; however, its improvement is warranted. The combination of dexmedetomidine with ketamine can improve onset and hemodynamic stability while maintaining sedative efficacy. This study aims to determine the efficacy and safety of intranasal combination of dexmedetomidine and ketamine compared to oral chloral hydrate. METHODS This is a prospective, parallel-arm, single-blinded, two-center, superiority randomized controlled trial with 1:1 allocation, designed to compare the effects of intranasal combination of dexmedetomidine and ketamine with those of oral chloral hydrate. We shall enroll 136 patients aged < 7 years old in this study. Prior to the procedure, we shall randomize each patient into the control group (oral chloral hydrate 50 mg/kg) or study group (intranasal dexmedetomidine 2 μg/kg and ketamine 3 mg/kg). The primary outcome will be the rate of achieving an adequate sedation level (6-point Pediatric Sedation State Scale 1, 2, or 3) within 15 min. In addition, we shall measure the sedation time, sedation failure rate, completion of procedure, adverse events, patient acceptance, and physician satisfaction. DISCUSSION This study will provide evidence of the efficacy and safety of the intranasal combination of dexmedetomidine and ketamine in comparison with oral chloral hydrate. TRIAL REGISTRATION ClinicalTrials.gov , NCT04820205. Registered on 19th March 2021.
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Affiliation(s)
- Young-Eun Jang
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Eun-Young Joo
- grid.267370.70000 0004 0533 4667Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Eun-Hee Kim
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Pyoyoon Kang
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Jung-Bin Park
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Hee-Soo Kim
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Jin-Tae Kim
- grid.412484.f0000 0001 0302 820XDepartment of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
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12
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Quan S, Lu Y, Huang Y. Analgesic effect of ropivacaine combined with dexmedetomidine in the postoperative period in children undergoing ultrasound-guided single-shot sacral epidural block: A systematic review and meta-analysis. Front Pediatr 2023; 11:1099699. [PMID: 37063658 PMCID: PMC10090670 DOI: 10.3389/fped.2023.1099699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Objective This study aims to evaluate the efficacy of dexmedetomidine as an adjuvant to ropivacaine in prolonging postoperative analgesia and reducing pain scores in children undergoing surgery. Methods Five online databases were searched for RCTs on postoperative analgesia of pediatric patients undergoing ultrasound-guided single-shot sacral epidural block with dexmedetomidine as an adjuvant to ropivacaine up to January 2, 2023. Pain score and sedation score at 2, 4, 8, 12, and 24 h after the operation, the time of first receiving additional analgesic drugs, and the number of postoperative adverse effects were selected to compare the efficacy and safety of combined treatment with ropivacaine alone for pediatrics. The standard mean difference (SMD) or odds ratio (OR) and the corresponding 95% confidence interval (95%CI) were calculated by using a random-effects model. Results A total of 295 articles were retrieved, but only 20 records were included in this meta-analysis. The results showed that dexmedetomidine combined with ropivacaine for sacral epidural block in children undergoing ultrasound-guided single-shot sacral epidural block had a more prolonged analgesia effect (SMD = 3.47, 95%CI: 2.80, 4.14). There were lower analgesia scores at 2 h(T1), 4 h(T2), 8 h(T3), 12 h(T4), and 24 h(T5) in postoperative period (T1 : SMD = -1.02, 95%CI: -1.31, -0.72; T2 : SMD = -1.02, 95%CI: -1.32, -0.72; T3 : SMD = -0.84, 95%CI: -1.12, -0.56; T4 : SMD = -0.61, 95%CI: -1.03, -0.20; T5 : SMD = -1.03, 95%CI: -1.28, -0.78). And the incidence of adverse effects was similar between the two groups (OR = 0.84, 95%CI: 0.59, 1.18). Conclusions The results of this review and meta-analysis support that dexmedetomidine, as an adjuvant to ropivacaine, can improve postoperative analgesia of surgery and significantly prolong the analgesic time in children, with a similar incidence rate of adverse symptoms when compared with ropivacaine alone.
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Affiliation(s)
- Shoubo Quan
- Department of Anesthesiology, Songshan Lake Central Hospital of Dongguan City, Dongguan, China
| | - Yuexia Lu
- Department of Anesthesiology, Haikou Hospital of Traditional Chinese Medicine, Haikou, China
| | - Yujie Huang
- Department of Anesthesiology, Nantong Haimen District People's Hospital, Nantong, China
- Correspondence: Yujie Huang
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Yarimoglu R, Basaran B, Korkusuz M, Et T, Bilge A, Toprak H, Kumru N. The optimum time for intravenous cannulation after induction with sevoflurane in children premedicated with dexmedetomidine. Acta Anaesthesiol Scand 2023; 67:12-18. [PMID: 36239075 DOI: 10.1111/aas.14156] [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: 07/28/2022] [Revised: 09/15/2022] [Accepted: 10/05/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Inhalation anesthesia is a frequently used method for anesthesia induction, especially in young children. No information is available on the optimum time for safe intravenous cannulation after inhalational induction in children with dexmedetomidine premedication. The purpose of the present study was to determine the optimal time for intravenous cannulation after induction of anesthesia with sevoflurane and nitrous oxide in children premedicated with intranasal dexmedetomidine. METHODS This prospective and observational study was conducted by using the up-down sequential method. Children, who were aged 2-6 years with ASA physical status I, and who underwent inhalation induction for elective surgery were included in the study. Anesthesia was induced with sevoflurane and nitrous oxide after the premedication with intranasal dexmedetomidine (2 mcg/kg). Intravenous cannulation was attempted on the dorsum of the hand by an experienced anesthesiologist 4 min after the loss of the eyelash reflex in the first patient. The procedure was considered successful in patients without any movement, cough, or laryngospasm. The waiting time for cannulation was increased by 15 s if the procedure was not successful in the previous patient, and on the contrary, it was reduced by 15 s if the procedure was successful in the previous patient. The probit test was used in the analysis of up-down sequences. RESULTS In the present study in which a total of 40 patients were included, the effective cannulation time was found to be 14.40 s (95% confidence limits, 1.30-27.82 s) in 50% of the patients, and the effective cannulation time was found as 84.64 s (95% confidence limits, 69.61-218.26 s) in 95% of the patients. CONCLUSIONS In conclusion, we suggest that the appropriate time for cannulation is 85 s (1.45 min) after the loss of eyelash reflex in children sedated with dexmedetomidine and induction with sevoflurane and nitrous oxide-oxygen mixture.
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Affiliation(s)
- Rafet Yarimoglu
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Betul Basaran
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Muhammet Korkusuz
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Tayfun Et
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Aysegul Bilge
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Hatice Toprak
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Nuh Kumru
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
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14
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Pediatric Neuroanesthesia — a Review of the Recent Literature. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00540-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Purpose of Review
Pediatric neuroanesthesia is a growing and still challenging subspecialty. The purpose of this review is to summarize the available knowledge and highlight the most recent findings of the literature on non-traumatic pediatric neuroanesthesia care.
Recent Findings
Several human studies have confirmed the negative effects of early life anesthetic exposure. According to non-human studies, volatile anesthetics and opioids contribute to tumor progression. Tranexamic acid effectively reduces perioperative blood loss; it is used in several different doses without standard guidelines on optimal dosing. The widespread use of neuromonitoring has necessitated the development of anesthetic methods that do not affect neuromuscular transmission.
Summary
Pediatric anesthetic neurotoxicity, management of intraoperative bleeding, and the effect of anesthesia on tumor growth are among the most debated and researched topics in pediatric neuroanesthesia. The lack of evidence and clinical guidelines underlines the need for further large prospective studies in this subspecialty.
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15
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Hermans K, Ramaekers L, Toelen J, Vanhonsebrouck K, Allegaert K. Intranasal Dexmedetomidine as Sedative for Medical Imaging in Young Children: A Systematic Review to Provide a Roadmap for an Evidence-Guided Clinical Protocol. CHILDREN 2022; 9:children9091310. [PMID: 36138619 PMCID: PMC9498011 DOI: 10.3390/children9091310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/24/2022] [Accepted: 08/27/2022] [Indexed: 11/16/2022]
Abstract
There is an increasing need for effective anxiety and pain reduction during medical imaging procedures in children, addressed by non-pharmacological or pharmacological approaches. Dexmedetomidine is a fairly recently marketed, selective α2-adrenergic agonist that can be administered intranasally. To develop an evidence-guided clinical protocol, we investigated the (side) effects, preconditions and safety aspects following intranasal dexmedetomidine administration in children (1 month–5 years) for procedural sedation during medical imaging. To this end, a systematic search (PubMed, Embase and CINAHL (12/2021)) was performed to identify studies on intranasal dexmedetomidine for procedural sedation for medical imaging (computer tomography and magnetic resonance imaging). Following screening and quality assessment, eight studies were retained. Nasal nebulization was considered the best administration method, dosing varied between 2 and 4 µg/kg (age-dependent) 30–45 min prior to imaging and contraindications or restrictions with respect to oral intake were somewhat consistent across studies. Valid sedation scores and monitoring of vital signs were routinely used to assess sedation and the need for rescue dosing (different approaches), whereas discharge was generally based on Aldrete score (score ≥ 9). Heart rate, blood pressure and saturation were routinely monitored, with commonly observed bradycardia or hypotension (decrease by 20%). Based on these findings, a roadmap for evidence-guided clinical protocol was generated.
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Affiliation(s)
- Kato Hermans
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Levuen, 3000 Leuven, Belgium
| | - Larissa Ramaekers
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Levuen, 3000 Leuven, Belgium
| | - Jaan Toelen
- Child and Youth Institute, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Pediatrics, University Hospitals UZ Leuven, 3000 Leuven, Belgium
| | - Koen Vanhonsebrouck
- Department of Pediatrics, University Hospitals UZ Leuven, 3000 Leuven, Belgium
| | - Karel Allegaert
- Child and Youth Institute, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, 3000 GA Rotterdam, The Netherlands
- Correspondence:
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16
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Abusinna RG, Algharabawy WS, Mowafi MM. Comparative evaluation of intranasal midazolam, dexmedetomidine, ketamine for their sedative effect and to facilitate venous cannulation in pediatric patients: A prospective randomized study. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2033074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Rasha Gamal Abusinna
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Sayed Algharabawy
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Marwa Mostafa Mowafi
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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17
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Sedation with Intranasal Dexmedetomidine in the Pediatric Population for Auditory Brainstem Response Testing: Review of the Existing Literature. Healthcare (Basel) 2022; 10:healthcare10020287. [PMID: 35206901 PMCID: PMC8872591 DOI: 10.3390/healthcare10020287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Intranasal dexmedetomidine (IN DEX) is a relatively new sedative agent with supporting evidence on its efficacy and safety, which can be used for procedural sedation in children, and could have a major role in auditory brainstem response testing, especially in the case of non-cooperative children. The goal of this systematic review is to assess the role of IN DEX in ABR testing, evaluating the reported protocol, potential, and limits. Methods: We performed a comprehensive search strategy on PubMed, Scopus, and Google Scholar, including studies in English on the pediatric population, without time restrictions. Results: Six articles, published between 2016 and 2021, were included in the systematic review. Sedation effectiveness was high across the studies, except for one study; 3 μg/kg was the dosing most often used. A comparison group was present in three studies, with oral chloral hydrate as the drug of comparison. Adverse effects were rarely reported. Conclusion: This systematic review showed how IN DEX can represent an adequate sedative for children undergoing ABR testing; larger and more rigorous trials are warranted in order to recommend its systematic utilization.
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Zhang Q, Shen F, Wei Q, Liu H, Li B, Zhang Q, Zhang Y. Development and Validation of a Risk Nomogram Model for Perioperative Respiratory Adverse Events in Children Undergoing Airway Surgery: An Observational Prospective Cohort Study. Risk Manag Healthc Policy 2022; 15:1-12. [PMID: 35023976 PMCID: PMC8747787 DOI: 10.2147/rmhp.s347401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose The aim of this study was to explore the associated risk factors of perioperative respiratory adverse events (PRAEs) in children undergoing airway surgery and establish and validate a nomogram prediction model for PRAEs. Patients and Methods This study involved 709 children undergoing airway surgery between November 2020 and July 2021, aged ≤18 years in the affiliated hospital of Xuzhou Medical University. They were divided into training (70%; n = 496) and validation (30%; n = 213) cohorts. The least absolute shrinkage and selection operator (LASSO) was used to develop a risk nomogram model. Concordance index values, calibration plot, decision curve analysis, and the area under the curve (AUC) were examined. Results PRAEs were found in 226 of 496 patients (45.6%) and 88 of 213 patients (41.3%) in the training and validation cohorts, respectively. The perioperative risk factors associated with PRAEs were age, obesity, degree of upper respiratory tract infection, premedication, and passive smoking. The risk nomogram model showed good discrimination power, and the AUC generated to predict survival in the training cohort was 0.760 (95% confidence interval, 0.695–0.875). In the validation cohort, the AUC of survival predictions was 0.802 (95% confidence interval, 0.797–0.895). Calibration plots and decision curve analysis showed good model performance in both datasets. The sensitivity and specificity of the risk nomogram model were calculated, and the result showed the sensitivity of 69.5% and 64.8% and specificity of 73.3% and 81.6% for the training and validation cohorts, respectively. Conclusion The present study showed the proposed nomogram achieved an optimal prediction of PRAEs in patients undergoing airway surgery, which can provide a certain reference value for predicting the high-risk population of perioperative respiratory adverse events and can lead to reasonable preventive and treatment measures.
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Affiliation(s)
- Qin Zhang
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Fangming Shen
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Qingfeng Wei
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine; Huzhou Central Hospital, Huzhou City, Zhejiang Province, People's Republic of China
| | - Bo Li
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Qian Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Yueying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
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Kumar K, Ali S, Sabhaney V, Trottier E, Drendel A, Bhatt M, Boisvert L, Poonai N. Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada. CAN J EMERG MED 2022; 24:75-83. [PMID: 34746980 DOI: 10.1007/s43678-021-00210-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers' practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption. METHODS We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics. RESULTS The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%). CONCLUSIONS Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.
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Affiliation(s)
- Kriti Kumar
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Vikram Sabhaney
- Department of Pediatrics, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Evelyne Trottier
- Département d'Urgence Pédiatrique, CHU Sainte-Justine, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Amy Drendel
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Leslie Boisvert
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 800 Commissioners Road East, London, ON, N6A 2V5, Canada.
- Division of Pediatric Emergency Medicine, Children's Health Research Institute, London Health Sciences Centre, London, ON, Canada.
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Gernhold C, Kundtner N, Steinmair M, Henkel M, Oswald J, Haid B. Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit. CHILDREN-BASEL 2021; 8:children8050424. [PMID: 34065386 PMCID: PMC8160837 DOI: 10.3390/children8050424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022]
Abstract
Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.
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Affiliation(s)
- Christa Gernhold
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
- Correspondence:
| | - Nina Kundtner
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Martin Steinmair
- Department of Nuclear Medicine, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria;
| | - Martin Henkel
- Department of Paediatrics, Hospital of the Sisters of Charity Seilerstätte 4, 4020 Linz, Austria;
| | - Josef Oswald
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Bernhard Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
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Yu LS, Xie WP, Liu JF, Wang J, Cao H, Wang ZC, Chen Q. A comparison of the outcomes of dexmedetomidine and remifentanil with sufentanil-based general anesthesia in pediatric patients for the transthoracic device closure of ventricular septal defects. J Cardiothorac Surg 2021; 16:111. [PMID: 33892771 PMCID: PMC8063160 DOI: 10.1186/s13019-021-01498-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
Objective To compare the safety and efficacy of dexmedetomidine and remifentanil with sufentanil-based general anesthesia for the transthoracic device closure of ventricular septal defects (VSDs) in pediatric patients. Methods A retrospective analysis was performed on 60 children undergoing the transthoracic device closure of VSDs from January 2019 to June 2020. The patients were divided into two groups based on different anesthesia strategies, including 30 cases in group R (dexmedetomidine- and remifentanil-based general anesthesia) and 30 cases in group S (sufentanil-based general anesthesia). Results There was no significant difference in preoperative clinical information, hemodynamics before induction and after extubation, postoperative pain scores, or length of hospital stay between the two groups. However, the hemodynamic data of group R were significantly lower than those of group S at the time points of anesthesia induction, skin incision, thoracotomy, incision closure, and extubation. The amount of intravenous patient-controlled analgesia (PCA), the duration of mechanical ventilation, and the length of the intensive care unit (ICU) stay in group R were significantly less than those in group S. Conclusion Dexmedetomidine combined with remifentanil-based general anesthesia for the transthoracic device closure of VSDs in pediatric patients is safe and effective.
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Affiliation(s)
- Ling-Shan Yu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Wen-Peng Xie
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Jian-Feng Liu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Jing Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Zeng-Chun Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China. .,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China. .,Fujian Children's Hospital, Fuzhou, China. .,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China.
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China. .,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China. .,Fujian Children's Hospital, Fuzhou, China. .,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China.
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Fan L, Lim Y, Wong GS, Taylor R. Factors affecting successful use of intranasal dexmedetomidine: a cohort study from a national paediatrics tertiary centre. Transl Pediatr 2021; 10:765-772. [PMID: 34012826 PMCID: PMC8107840 DOI: 10.21037/tp-20-358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Use of intranasal (IN) dexmedetomidine for procedural sedation has been reported in recent years. Good patient selection is important to ensure high success rates. We aimed to identify factors that influence the successful use of IN dexmedetomidine in non-invasive investigations. METHODS All paediatric patients who received IN dexmedetomidine for investigations between 01 July 2019 to 01 July 2020 were included. Baseline demographics, time to reach adequate sedation level, duration of sedation, dose, indications for sedation and need for rescue sedatives were recorded. Procedures were classified into "long" or "short" according to completion time. Successful sedation was defined by completion of investigations by IN dexmedetomidine alone. RESULTS Of 105 patients included, median age was 20.0 months, and median weight 11.0 kg. Magnetic resonance imaging (56, 53.3%) was the most common indication. Sixty (57.1%) were successfully sedated using IN dexmedetomidine alone. Automated auditory brainstem response, computerised tomography and mercaptoacetyltriglycine-3 renogram scans had the highest success rate (83.3%, 83.3%, and 100% respectively). On multivariate analysis, short procedures had an adjusted odds ratio of 5.30 (95% CI: 1.69-16.61; P=0.004) compared to long procedures. CONCLUSIONS IN dexmedetomidine is effective for procedural sedation for paediatric patients. The most important predictor for sedation success was indication of sedation and duration of procedures.
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Affiliation(s)
- Lijia Fan
- Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Gloria Songmei Wong
- Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Ryan Taylor
- Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
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Evaluation of Intranasal Dexmedetomidine as a Procedural Sedative for Ophthalmic Examination of Children With Glaucoma. J Glaucoma 2021; 29:1043-1049. [PMID: 32740502 DOI: 10.1097/ijg.0000000000001607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PRECIS This study evaluated 2 doses of intranasal dexmedetomidine (IND) (3.0 and 3.5 µg/kg) as a procedural sedative for postoperative examination of children with glaucoma. A dose of 3.5 µg/kg was more efficacious and obviated the need for repeated general anesthesia. PURPOSE This study was carried out to determine the safety and effective dose of IND as a procedural sedative for postoperative follow-up examinations after glaucoma surgery in children in place of repeated examination under anesthesia. MATERIALS AND METHODS In this prospective randomized double-blinded interventional study, consecutive children aged 6 months to 6 years were randomized to receive 3.0 and 3.5 µg/kg IND using a mucosal atomizer device in the preoperative area of the operating room, under continuous monitoring of vital signs. Intranasal midazolam 0.25 mg/kg was used as a rescue agent in case of inadequate sedation, and general anesthesia was administered in case of persistent failure. All infants underwent a complete anterior and posterior segment evaluation including intraocular pressure and corneal diameter measurements. RESULTS A total of 30 and 31 children aged 23.9±15.0 and 19.2±10.1 months, respectively, received 3.0 and 3.5 µg/kg IND. Adequate sedation was possible in 18 of 30 (60%) children receiving 3.0 µg/kg and 24 of 31 (77.4%) receiving 3.5 µg/kg IND alone (P=0.17). In combination with midazolam, successful sedations were 86.6% versus 100%, respectively (P=0.052). One patient in the 3.5 µg/kg group had ventricular arrhythmia, reversed with dextrose-saline infusion and injection glycopyrrolate. CONCLUSIONS IND appears to be a safe and effective procedural sedative for postoperative follow-up examinations of pediatric glaucoma patients at doses of 3 and 3.5 µg/kg. The dose of 3.5 µg/kg was successful in more children.
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Azizkhani R, Heydari F, Ghazavi M, Riahinezhad M, Habibzadeh M, Bigdeli A, Golshani K, Majidinejad S, Mohammadbeigi A. Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging. J Pediatr Neurosci 2020; 15:245-251. [PMID: 33531939 PMCID: PMC7847110 DOI: 10.4103/jpn.jpn_107_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/04/2019] [Accepted: 05/24/2020] [Indexed: 11/04/2022] Open
Abstract
Background: Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging. Materials and Methods: A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID (n = 81) with dose of 0.3 mg.kg and DEX (n = 81) with dose of 3 μg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by t test and chi-square test. Results: Decreasing in MBP and HR was higher in DEX group than MID group (P < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, P = 0.001) was lower in DEX group. Parents (P < 0.001) and physician (P < 0.001) satisfaction score was higher in DEX group than the MID group. Conclusion: Using 3 μg/kg intranasal DEX for sedation of 1–6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.
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Affiliation(s)
- Reza Azizkhani
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farhad Heydari
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Maryam Riahinezhad
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Bigdeli
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keihan Golshani
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeid Majidinejad
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abolfazl Mohammadbeigi
- Neuroscience Research Center, Department of Epidemiology and Biostatistics, Qom University of Medical Sciences, Qom, Iran
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Chen H, Wang B, Li Q, Zhou J, Li R, Zhang Y. Intravesical dexmedetomidine instillation reduces postoperative catheter-related bladder discomfort in male patients under general anesthesia: a randomized controlled study. BMC Anesthesiol 2020; 20:267. [PMID: 33092527 PMCID: PMC7583202 DOI: 10.1186/s12871-020-01189-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Background The catheter-related bladder discomfort (CRBD) of male patients is a common clinical problem, albeit lacking effective solutions. The present study aimed to investigate whether intravesical dexmedetomidine instillation alleviates the postoperative urinary discomfort in male patients with catheter under general anesthesia. Methods This single-blinded, prospective, randomized study included a total of 167 male patients American Society of Anesthesiologists (ASA) physical status I-II scheduled for surgery under general anesthesia were allocated to two groups: 84 in the dexmedetomidine group and 83 in the control group. Dexmedetomidine group patients received intravesical instillation of the drug 0.5 μg/kg and normal saline 20 mL, while the control group received intravesical instillation of 20 mL normal saline. The catheter was clamped for 30 min after intravesical instillation for all patients. CRBD scores and urethra pain numerical rating scale (NRS) scores were measured at admittance to post-anesthesia care unit (PACU) (T0), intravesical instillation (T1), 30 min (T2), 60 min (T3), 2 h (T4) after intravesical instillation, discharged from PACU (T5), and 6 h (T6) and 24 h (T7) after the operation. Patient satisfaction at discharge from PACU and 24 h post-operation were compared between the two groups. Results CRBD scores and urethra pain NRS scores after 30 min of intravesical dexmedetomidine instillation to 24 h post-operation were significantly lower than the control group (p < 0.001), and patient satisfaction was higher at discharge from PACU and 24 h post-operation (p < 0.001). No differences were detected in Steward score out of PACU (p = 0.213) and from the time of the end of operation to fully awake (p = 0.417). Conclusion Intravesical dexmedetomidine instillation reduces postoperative urinary discomfort and urethra pain and improves satisfaction in male patients under general anesthesia. Trial registration Chinese Clinical Trial Registry (No. ChiCTR1800016429), date of registration 1st June 2018.
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Affiliation(s)
- Hong Chen
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Bin Wang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Qin Li
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Juan Zhou
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Rui Li
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Ye Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China.
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Tervonen M, Pokka T, Kallio M, Peltoniemi O. Systematic review and meta-analysis found that intranasal dexmedetomidine was a safe and effective sedative drug during paediatric procedural sedation. Acta Paediatr 2020; 109:2008-2016. [PMID: 32400892 DOI: 10.1111/apa.15348] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022]
Abstract
AIM This systematic review and meta-analysis evaluated the effectiveness of intranasal dexmedetomidine as a sole sedative during paediatric procedural sedation outside the operating room. METHODS Relevant literature identified by PubMed, Scopus, ClinicalTrials.gov, ScienceDirect and Cochrane Library up to 31 December 2019 was systematically reviewed. Randomised controlled trials that compared intranasal dexmedetomidine with another sedative or placebo during paediatric procedural sedation were included. Trials that studied intranasal dexmedetomidine as a premedication before anaesthesia were excluded. The primary outcome was the success of the planned procedure. RESULTS We analysed seven randomised controlled trials of 730 patients: four trials with 570 patients compared dexmedetomidine with chloral hydrate and three trials with 160 patients compared dexmedetomidine with midazolam. The incidence of successfully completing the procedure did not differ between dexmedetomidine and chloral hydrate, but dexmedetomidine had a higher success rate than midazolam. The incidence of hypotension, bradycardia or respiratory complications did not differ between the sedatives used. Nausea and vomiting were more common in children treated with chloral hydrate than in those treated with other sedatives. CONCLUSION Intranasal dexmedetomidine was a safe and effective sedative for minor paediatric procedures.
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Affiliation(s)
- Miikka Tervonen
- Department of Children and Adolescents Oulu University Hospital Oulu Finland
- PEDEGO Research Unit and Medical Research Center Oulu University of Oulu Oulu Finland
| | - Tytti Pokka
- Department of Children and Adolescents Oulu University Hospital Oulu Finland
- PEDEGO Research Unit and Medical Research Center Oulu University of Oulu Oulu Finland
| | - Merja Kallio
- Department of Children and Adolescents Oulu University Hospital Oulu Finland
- PEDEGO Research Unit and Medical Research Center Oulu University of Oulu Oulu Finland
| | - Outi Peltoniemi
- Department of Children and Adolescents Oulu University Hospital Oulu Finland
- PEDEGO Research Unit and Medical Research Center Oulu University of Oulu Oulu Finland
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Dexmedetomidine: What's New for Pediatrics? A Narrative Review. J Clin Med 2020; 9:jcm9092724. [PMID: 32846947 PMCID: PMC7565844 DOI: 10.3390/jcm9092724] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Over the past few years, despite the lack of approved pediatric labelling, dexmedetomidine’s (DEX) use has become more prevalent in pediatric clinical practice as well as in research trials. Its respiratory-sparing effects and bioavailability by various routes are only some of the valued features of DEX. In recent years the potential organ-protective effects of DEX, with the possibility for preserving neurocognitive function, has put it in the forefront of clinical and bench research. This comprehensive review focused on the pediatric literature but presents relevant, supporting adult and animal studies in order to detail the recent growing body of literature around the pharmacology, end-organ effects, organ-protective effects, alternative routes of administration, synergetic effects, and clinical applications, with considerations for the future.
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Abstract
Dexmedetomidine is an α2 adrenoreceptor agonist that may be administered by the intranasal route as a sole sedative agent in children. It is odourless, colourless and tasteless and is formulated in a concentration of 100µg.ml-1. We performed a review of published randomised controlled trials in order to determine the efficacy of intranasal dexmedetomidine for sedation in children. Fourteen trials were eligible for inclusion in the review and contained a total of 1809 patients ranging in age from one month to 14 years. Intranasal dexmedetomidine was administered in a dose range of 1-4µg.kg-1 and was compared with various other sedatives. Dexmedetomidine was administered by either drops or a mucosal atomiser device. The procedures ranged from non-painful examinations such as magnetic resonance imaging scans and transthoracic echocardiography to painful procedures such as dentistry and venous cannulation. Administration of 2µg.kg-1 appears to be the optimal dose.
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Affiliation(s)
- J Lewis
- KCL School of Medicine, London, UK
| | - C R Bailey
- Department of Anaesthetics, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
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Suvvari P, Mishra S, Bhatnagar S, Garg R, Bharati SJ, Gupta N, Kumar V, Khan M. Comparison of Intranasal Dexmedetomidine Versus Intranasal Ketamine as Premedication for Level of Sedation in Children Undergoing Radiation Therapy: A Prospective, Randomised, Double-Blind Study. Turk J Anaesthesiol Reanim 2020; 48:215-222. [PMID: 32551449 PMCID: PMC7279870 DOI: 10.5152/tjar.2019.45087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/26/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Radiation therapy is indicated in many solid tumours in children. Absolute immobility is required to precisely position children for optimal delivery of radiation energy to the target tissues, improve success rate and reduce the damage to nearby normal tissues. Intranasal (IN) administration of drugs is well tolerated, effective and fast acting. The primary aim of the present study was to evaluate the effectiveness of IN ketamine and dexmedetomidine for providing sedation in children before shifting to the radiotherapy suite. The secondary objective was to assess the requirement of propofol dosage in these patients. METHODS A total of 243 children aged between 1 and 5 years scheduled to undergo external beam radiotherapy were randomised to receive 5 mg kg-1 ketamine (group K, n=80), 2.5 μg kg-1 dexmedetomidine (group D, n=85) or 0.5 ml of saline (group S, n=78) in each nostril. After 45 min, sedation score was measured according to the modified Ramsay score (MRS) at the time of shifting for radiation. Time to awakening and time to discharge after the procedure were also noted. RESULTS A significantly higher proportion of children in group D (84.7%) achieved an MRS score ≥3 as compared to group K (36.2%) and group S (3.84%). The total propofol dose (mg kg-1) required was significantly less in group D (p<0.01). The patients in group D required more time to awakening, but this difference was not clinically significant. CONCLUSION The present study demonstrated that IN dexmedetomidine is superior to IN ketamine to provide procedural sedation for radiotherapy in children.
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Affiliation(s)
- Praneeth Suvvari
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - M.A. Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Dexmedetomidine versus other sedatives for non-painful pediatric examinations: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020; 62:109736. [DOI: 10.1016/j.jclinane.2020.109736] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/20/2019] [Accepted: 01/25/2020] [Indexed: 01/04/2023]
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The Role of Precedex in Post-Operative Pain Management Following Craniosynostosis Repair. J Craniofac Surg 2020; 31:e569-e572. [PMID: 32433135 DOI: 10.1097/scs.0000000000006547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The application of dexmedetomidine (precedex) in pediatric settings has increased due to its superior safety and efficacy profile and it has been specifically suggested as an adjunct to IV acetaminophen and a substitute for morphine in craniosynostosis repair. However, reports of its use in pediatrics, let alone in craniosynostosis repair, remain limited and to date there are no studies addressing its use after craniosynostosis repair in children. This study is an IRB-approved retrospective case review of the use of dexmedetomidine following pediatric craniosynostosis repair as a postoperative analgesic/sedative agent at one institution.
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Wang FH, Zhang J, Xiao M, Wu F, Liu L, Zhou XH. [Sedative effect of intranasal midazolam in neonates undergoing magnetic resonance imaging: a prospective single-blind randomized controlled study]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:441-445. [PMID: 32434638 PMCID: PMC7389410 DOI: 10.7499/j.issn.1008-8830.1911147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To compare intranasal midazolam and intramuscular phenobarbital sodium for their sedative effect in neonates undergoing magnetic resonance imaging (MRI). METHODS A total of 70 neonates who underwent cranial MRI from September 2017 to March 2019 were randomized into an observation group and a control group, with 35 cases in each group. The observation group received intranasal drops of midazolam (0.3 mg/kg), and the control group received intramuscular injection of phenobarbital sodium (10 mg/kg). The sedation status of the neonates was evaluated using the Ramsay Sedation Scale. Meanwhile, the two groups were compared for the success rate of MRI procedure and incidence of adverse reactions. RESULTS In the observation group, the sedation score was the highest at 20 minutes post administration, then was gradually decreasing, and decreased to the lowest level at 70 minutes post administration. In the control group, the sedation score was the lowest at 10 minutes post administration, then was gradually increasing, and increased to the highest level at 40 minutes and 50 minutes post administration, followed by a gradual decrease. Comparison of the sedation score at each time period suggested that the sedation score was significantly higher in the observation group than in the control group within 40 minutes post administration (P<0.05), while there were no significant differences between the two groups in the sedation score after 40 minutes post administration (P>0.05). The success rate of MRI procedure was significantly higher in the observation group than in the control group (89% vs 69%, P<0.05). There was no significant difference between the two groups in the incidence of adverse reactions (P>0.05). CONCLUSIONS Intranasal midazolam is superior to intramuscular phenobarbital sodium in the sedative effect in neonates undergoing MRI, with the benefits of being fast, convenient, safe, and effective.
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Affiliation(s)
- Fang-Hui Wang
- Department of Neonatology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
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Lang B, Zhang L, Zhang W, Lin Y, Fu Y, Chen S. A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis. CNS Neurosci Ther 2020; 26:862-875. [PMID: 32347647 PMCID: PMC7366749 DOI: 10.1111/cns.13377] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 02/05/2023] Open
Abstract
Background The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions. Methods PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences. Results We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups. Conclusions Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.
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Affiliation(s)
- Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wensheng Zhang
- Laboratory of Anesthesia and Critical Care Medicine, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yunzhu Lin
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuzhi Fu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shouming Chen
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
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Comparison of Intranasal Dexmedetomidine and Oral Midazolam for Premedication in Pediatric Dental Patients under General Anesthesia: A Randomised Clinical Trial. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5142913. [PMID: 32382556 PMCID: PMC7196136 DOI: 10.1155/2020/5142913] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 12/26/2022]
Abstract
The aim of this study was to compare the effects of preoperative intranasal dexmedetomidine and oral midazolam on preoperative sedation and postoperative agitation in pediatric dentistry. A total of 60 children (ASA grade I, aged 3-6 years) scheduled for elective pediatric dental treatment were randomly divided into the dexmedetomidine (DEX) and midazolam (MID) groups. Ramsay sedation score, parental separation anxiety scale, mask acceptance scale, pediatric anesthesia emergence delirium scale, and hemodynamic parameters were recorded. The Ramsay sedation scale and hemodynamic parameters of the children were observed and recorded immediately before administration and 10, 20, and 30 min after administration. A satisfactory mask acceptance scale rate was 93.33% in both MID and DEX groups, and there was no significant difference between the two groups (p > 0.05). The proportions of children that "successfully separated from their parents" were 93.33% (MID) and 96.67% (DEX). No significant difference was found between the two groups (p > 0.05). The incidence of agitation was 20% in the MID group and 0% in the DEX group, and the difference was statistically significant (p < 0.05). Intranasal dexmedetomidine and oral midazolam provided satisfactory sedation. No significant difference between the two groups was found in terms of parental separation anxiety and mask acceptance (p > 0.05). The incidence of postoperative pediatrics emergence delirium was significantly lower in the DEX group (p < 0.05).
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Cheng X, Chen Z, Zhang L, Xu P, Qin F, Jiao X, Wang Y, Lin M, Zeng L, Huang L, Yu D. Efficacy and Safety of Midazolam Oral Solution for Sedative Hypnosis and Anti-anxiety in Children: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:225. [PMID: 32256348 PMCID: PMC7093581 DOI: 10.3389/fphar.2020.00225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Midazolam is recommended by health guidelines for sedation and hypnosis in children. Oral solution is a suitable dosage form for children. But there is no conclusive evidence for sedative-hypnosis and antianxiety effects by midazolam oral solution in children. Methods: Relevant studies were identified through searching PubMed, Embase, Cochrane Library, CINAHL, International Pharmaceuticals, four Chinese electronic databases, and relevant lists. Two reviewers independently selected trials, assessed trial quality, and extracted the data. Results: Eighty-nine randomized controlled trials (RCTs) comparing midazolam oral solution with placebo or blank (n = 33), dexmedetomidine (n = 15), ketamine (n = 11), different midazolam doses (n = 10), midazolam injection (n = 8), chloral hydrate (n = 7), diazepam (n = 5), N2O (n = 5), triclofos (n = 4), butorphanol (n = 2), fentanyl (n = 2), hydroxyzine (n = 1), and thiopental (n = 1) were identified. Meta-analysis showed no significant difference in the success rate and duration of sedation and hypnosis between midazolam oral and injectable solution (P > 0.05). The success rate of sedation and hypnosis of midazolam was higher than that of ketamine [risk ratio (RR) = 1.32, 95% CI (1.07, 1.62), I 2 = 0%, P < 0.01]. No significant difference was found in the success rate of sedation and hypnosis, mask acceptance, and parental separation between midazolam oral solution and dexmedetomidine (P > 0.05), and the result of one cohort study was consistent. The results of RCTs and a prospective cohort study showed that the incidence of adverse drug reactions (ADR) was 19.57% (189/966). Incidence of adverse reactions between dose groups of (0.25, 0.5] and (0.5, 1.0] mg/kg was similar [Pf (95% CI) = 0.10 (0.04, 0.24) and Pf (95% CI) = 0.09 (0.02, 0.39), respectively], higher than that of the dose group of (0, 0.25] mg/kg [Pf (95% CI) = 0.01 (0.00, 0.19)]. Conclusions: Available evidence suggests that midazolam oral solution is as good as midazolam injection and dexmedetomidine and is better than ketamine. Based on efficacy and safety results, an oral midazolam solution dose of 0.5-1 mg/kg is recommended for children.
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Affiliation(s)
- Xiao Cheng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Zhe Chen
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, 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, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Peipei Xu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Fang Qin
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Xuefeng Jiao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yiyi Wang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Mao Lin
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, 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, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, 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, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Dan Yu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Sun M, Liu H, Yu Q, Liu Y, Zhang J, Lei Y, Zhao QY, Li SY, Tu SF, Wei GH. A Comparison of Intranasal Dexmedetomidine and Dexmedetomidine-Ketamine Combination Sedation for Transthoracic Echocardiography in Pediatric Patients With Congenital Heart Disease: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020; 34:1550-1555. [PMID: 32127283 DOI: 10.1053/j.jvca.2019.12.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the effects of intranasal dexmedetomidine (DEX) and DEX-ketamine (KET) on hemodynamics and sedation quality in children with congenital heart disease. DESIGN A randomized controlled, double-blind, prospective trial. SETTING A tertiary care teaching hospital. PARTICIPANTS The study comprised 60 children undergoing transthoracic echocardiography (TTE). INTERVENTIONS Patients were randomly allocated into the DEX group (group D [n = 30]) or the DEX-KET group (group D-K [n = 30]). Group D received 2 μg/kg of intranasal DEX; group D-K received 2 μg/kg of DEX and 1 mg/kg of KET intranasally. MEASUREMENTS AND MAIN RESULTS The primary outcome was the change in hemodynamics, measured using mean arterial pressure (MAP) and heart rate (HR). Secondary outcomes were onset time, wake-up time, and discharge time. No differences were found in mean arterial pressure or heart rate. The onset time was significantly shorter in group D-K than in group D (9.6 ± 2.9 minutes v 14.3 ± 3.4 minutes; p = 0.031). The wake-up time was longer in group D-K than in group D (52 ± 14.7 minutes v 39.6 ± 12.1 minutes; p = 0.017). The discharge time was longer in group D-K than in group D (61.33 ± 11.59 minutes v 48.17 ± 8.86 minutes; p < 0.001). No differences in hemodynamics were found between the 2 groups. Intranasal DEX was found to be as effective for TTE sedation as intranasal DEX-KET, with longer onset time and shorter recovery and discharge times. CONCLUSION No differences in hemodynamics were found between the 2 groups. Intranasal DEX was found to be as effective for TTE sedation as is intranasal DEX-KET, with longer onset time and shorter recovery and discharge times.
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Affiliation(s)
- Mang Sun
- Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Hui Liu
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qing Yu
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Yang Liu
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Jing Zhang
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Yao Lei
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qing-Yan Zhao
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Shang-Yingying Li
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Sheng-Fen Tu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Guang-Hui Wei
- Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Poonai N, Spohn J, Vandermeer B, Ali S, Bhatt M, Hendrikx S, Trottier ED, Sabhaney V, Shah A, Joubert G, Hartling L. Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic Review. Pediatrics 2020; 145:peds.2019-1623. [PMID: 31862730 DOI: 10.1542/peds.2019-1623] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. OBJECTIVE To explore the effectiveness of IND for procedural distress in children. DATA SOURCES We performed electronic searches of Medline (1946-2019), Embase (1980-2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981-2019), and Cochrane Central Register. STUDY SELECTION We included randomized trials of IND for procedures in children. DATA EXTRACTION Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation. RESULTS Among 19 trials (N = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures. LIMITATIONS The adequacy of sedation was subjective, which possibly led to biased outcome reporting. CONCLUSIONS Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; .,Division of Emergency Medicine and.,Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | | | - Ben Vandermeer
- Department of Pediatrics and Alberta Research Centre for Health Evidence
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, and.,Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Shawn Hendrikx
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Evelyne D Trottier
- Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montréal, Québec, Canada; and
| | - Vikram Sabhaney
- BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Gary Joubert
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.,Division of Emergency Medicine and
| | - Lisa Hartling
- Department of Pediatrics and Alberta Research Centre for Health Evidence
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Nozawa M, Mishina H, Tsuji S, Takayama JI. Low plasma D-dimer predicts absence of intracranial injury and skull fracture. Pediatr Int 2020; 62:22-28. [PMID: 31758836 DOI: 10.1111/ped.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/02/2019] [Accepted: 10/02/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intracranial injury (ICI) is a leading cause of morbidity in children; however, the use of computed tomography (CT) to evaluate ICI has significant risks in children. A recent study suggests D-dimer is associated with ICI. We surveyed the performance of plasma D-dimer in ruling out ICI or skull fracture (SF) in children with head trauma. METHODS In a cross-sectional study in the Emergency Department (ED) at the National Center for Child Health and Development in Tokyo, Japan we reviewed the medical records of all children age 0-16 years brought to the ED with head trauma from January 2010 to July 2013, who underwent CT based on established clinical criteria and had plasma D-dimer measured. We evaluated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of plasma D-dimer, using abnormal findings on CT (ICI, SF) as the criterion standard. We repeated analysis after stratification by age (<2 years, ≥2 years). RESULTS Among 364 eligible children (112 children <2 year of age), abnormal findings on CT were demonstrated in 33.8% (123/364). With the cut-off set at 0.5 μg/mL, sensitivity was 100.0% (95% confidence interval [CI]: 95.6-100.0%), specificity 34.0% (95%CI: 28.1-40.4%), PPV 43.6% (95%CI: 37.7-49.6%), NPV 100.0% (95%CI: 93.5-100%). After stratification by age (<2 years and ≥2 years), sensitivity (100.0% and 100.0%) and NPV (100.0% and 100.0%) remained high in both age groups. CONCLUSIONS Low plasma D-dimer (≤0.5 μg/mL) is useful to limit the use of CT in children by excluding traumatic ICI or SF.
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Affiliation(s)
- Masahiro Nozawa
- Emergency Service and Transport Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Hiroki Mishina
- Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Satoshi Tsuji
- Emergency Service and Transport Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - John I Takayama
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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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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40
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Sathyamoorthy M, Hamilton TB, Wilson G, Talluri R, Fawad L, Adamiak B, Wallace C, Borissova I, Heard C. Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam. Acta Anaesthesiol Scand 2019; 63:1162-1168. [PMID: 31318038 DOI: 10.1111/aas.13425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 01/21/2019] [Accepted: 06/15/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children. METHODS This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age >5 years and weight >20 kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5 mg/kg (max 15 mg) or intranasal dexmedetomidine at a dose of 2 mcg/kg (max 100 mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug. RESULTS The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P = .03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P = 1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure. CONCLUSIONS Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.
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Affiliation(s)
| | - Thomas B. Hamilton
- Department of Anesthesiology University of Mississippi Medical Center Jackson Mississippi
| | - Gerri Wilson
- Department of Anesthesiology University of Mississippi Medical Center Jackson Mississippi
| | - Rajesh Talluri
- Department of Data Science University of Mississippi Medical Center Jackson Mississippi
| | - Lubna Fawad
- Department of Dentistry, Pediatric Dentistry University of Mississippi Medical Center Jackson Mississippi
| | - Brittany Adamiak
- Department of Dentistry, Pediatric Dentistry University of Mississippi Medical Center Jackson Mississippi
| | - Cayce Wallace
- Department of Dentistry, Pediatric Dentistry University of Mississippi Medical Center Jackson Mississippi
| | - Irina Borissova
- Department of Anesthesiology University of Mississippi Medical Center Jackson Mississippi
| | - Christopher Heard
- Department of Anesthesiology Women and Children's Hospital of Buffalo Buffalo New York
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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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Liu H, Sun M, Zhang J, Tian Q, Yu Q, Liu Y, Yang F, Li S, Tu S. Determination of the 90% effective dose of intranasal dexmedetomidine for sedation during electroencephalography in children. Acta Anaesthesiol Scand 2019; 63:847-852. [PMID: 30982953 DOI: 10.1111/aas.13372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/09/2019] [Accepted: 03/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The intranasal route of dexmedetomidine (DEX) administration is becoming increasingly popular for providing adequate sedation during short examinations in infants and children. However, data on the 90% effective dose (ED90) of intranasal DEX are rare in children under 3 years old. METHODS This is a double-blind trial using a biased coin design up-and-down sequential method (BCD-UDM). Fifty-three children aged under 3 years old requiring DEX for EEG were included in our study. The first patient received 2.5 μg kg-1 DEX, and the dose of DEX administered to the subsequent patient was determined by the response of the previous patient. The patient responses were recorded and analysed to calculate the ED90 by isotonic regression. The 95% confidence interval (CI) was estimated using a bootstrapping method. RESULTS Fifty-three patients were included in our study, of which 45 patients were successfully sedated, and the 8 instances of failed sedation were rescued using sevoflurane inhalation, allowing the completion of the procedure. The 90% effective dose of DEX was calculated to be 3.28 µg kg-1 , and the 95% CI was 2.74 ~ 3.39 µg kg-1 . No significant adverse events occurred in any of the patients. CONCLUSION The 90% effective dose of intranasal DEX sedation for EEG was 3.28 μg kg-1 in children under 3 years old.
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Affiliation(s)
- Hui Liu
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
- Ministry of Education Key Laboratory of Child Development and Critical Disorders Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing China
- Chongqing Key Laboratory of Pediatrics Chongqing China
| | - Mang Sun
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
- Ministry of Education Key Laboratory of Child Development and Critical Disorders Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing China
- Chongqing Key Laboratory of Pediatrics Chongqing China
| | - Jing Zhang
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
- Ministry of Education Key Laboratory of Child Development and Critical Disorders Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing China
- Chongqing Key Laboratory of Pediatrics Chongqing China
| | - Qin Tian
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
| | - Qing Yu
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
- Ministry of Education Key Laboratory of Child Development and Critical Disorders Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing China
- Chongqing Key Laboratory of Pediatrics Chongqing China
| | - Yang Liu
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
- Ministry of Education Key Laboratory of Child Development and Critical Disorders Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing China
- Chongqing Key Laboratory of Pediatrics Chongqing China
| | - Fei Yang
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
| | - Shangyingying Li
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
| | - Shengfen Tu
- Department of Anesthesiology Children's Hospital of Chongqing Medical University Chongqing China
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Yang F, Liu Y, Yu Q, Li S, Zhang J, Sun M, Liu L, Lei Y, Tian Q, Liu H, Tu S. Analysis of 17 948 pediatric patients undergoing procedural sedation with a combination of intranasal dexmedetomidine and ketamine. Paediatr Anaesth 2019; 29:85-91. [PMID: 30484930 DOI: 10.1111/pan.13526] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 09/21/2018] [Accepted: 10/10/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intranasal procedural sedation using dexmedetomidine is well described in the literature. The combination of intranasal dexmedetomidine and ketamine is a novel approach for which there are little data on the rate of successful sedation or adverse events. OBJECTIVES The aim of this study is to evaluate the rate of successful sedation and adverse events of intranasal procedural sedation using a combination of dexmedetomidine and ketamine for diagnostic examination in children. METHODS This was a retrospective study and data were collected after ethics approval. A total of 17 948 pediatric patients (7718 females, 10 230 males) in a tertiary hospital in China were evaluated. Patients received a combination of 2 μg kg-1 of dexmedetomidine and 1 mg kg-1 of ketamine intranasally for procedural sedation. The level of sedation and recovery was assessed by the Modified Observer Assessment of Alertness/Sedation scale and the Modified Aldrete Score. RESULTS The rate of intranasal sedation success was 93% (16691/17948), intranasal sedation rescue was 1.8% (322/17948), and intranasal sedation failure was 5.2% (935/17948). Sedation success was defined as successful completed the diagnostic examination and obtained adequate diagnostic-quality images and reports. Intranasal sedation success, rescue and failure were respectively defined as sedation success with intranasal a single dose, additional bolus dose and the need for intravenous (IV) medications/inhalation agents. Median sedation time was 62 min (interquartile range: 55-70 min), median time for onset of sedation was 15 min (interquartile range: 15-20 min), and median sedation recovery time was 45 min (interquartile range: 38-53 min). Incidence of adverse events was low (0.58%; 105/17948), with major and minor adverse event being reported in 0.02% (4/17948) and 0.56% (101/17948) patients, respectively. Postoperative nausea and vomiting was the most common (0.3%; 53/17948) minor adverse event. CONCLUSION Procedural sedation using a combination of intranasal dexmedetomidine and ketamine is associated with acceptable effectiveness and low rates of adverse events.
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Affiliation(s)
- Fei Yang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yang Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qing Yu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shangyingying Li
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Jin Zhang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Mang Sun
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Lu Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yao Lei
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Qing Tian
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Hui Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Shengfen Tu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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Abstract
Administration of sedation and/or anaesthesia to patients undergoing painful or uncomfortable procedures at off-site locations is referred to as non-operating room anaesthesia (NORA). Sedating/anaesthetising children in an unfamiliar environment, with the lack of support staff, nonavailability of choice of medication and equipment is often challenging. Studies have shown an increased risk of airway-related adverse events, complications, and even death outside the operating room locations. It is crucial to be familiar with the anatomical and physiological variations in children, well versed with the difficult airway algorithm and call for help early. The most common event in NORA claims was inadequate oxygenation/ventilation, which are preventable with vigilant monitoring. English language articles were searched in Pubmed, Google Scholar, and Academic using 'sedation in children', 'remote location anaesthesia', 'peadiatric sedation', and 'nonoperating room anaesthesia' as the mesh words. Full text of the relevant articles was obtained and this review article was synthesised. The article outlines various safety guidelines, sedation techniques, drugs used for sedation, environmental concerns, procedure-specific risks, and complications associated with NORA in children.
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Affiliation(s)
- Subrahmanyam Maddirala
- Department of Anaesthesiology, Rainbow Children's Hospital, Hyderabad, Telangana, India.,Director, Axon Anaesthesia Associates Pvt. Ltd., Hyderabad, Telangana, India
| | - Annu Theagrajan
- Department of Anaesthesiology, Rainbow Children's Hospital, Hyderabad, Telangana, India
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Abdel-Ghaffar H, Kamal S, El Sherif F, Mohamed S. Comparison of nebulised dexmedetomidine, ketamine, or midazolam for premedication in preschool children undergoing bone marrow biopsy. Br J Anaesth 2018; 121:445-452. [DOI: 10.1016/j.bja.2018.03.039] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/16/2018] [Accepted: 05/20/2018] [Indexed: 11/25/2022] Open
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Pasichow KP, Frizzola M, Miller EG. Palliative Sedation with Oral Medicines in an Infant with Generalized Severe Junctional Epidermolysis Bullosa. J Palliat Med 2018; 21:1048-1052. [PMID: 29775550 DOI: 10.1089/jpm.2018.0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Generalized severe junctional epidermolysis bullosa is a rare mechanobullous skin disorder that is uniformly fatal. We present the case of an infant who received palliative pain management and ultimately proportionate palliative sedation. However, because of the extent of the patient's skin disease, we were unable to provide palliative medication through parenteral routes. We discuss the provision of enteral palliative sedation, including the pharmacology, and creative use of medications to achieve sufficient palliation in this difficult and unique situation.
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Affiliation(s)
| | - Meg Frizzola
- 2 Division of Palliative Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children , Wilmington, Delaware.,3 Division of Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children , Wilmington, Delaware
| | - Elissa G Miller
- 2 Division of Palliative Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children , Wilmington, Delaware
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Miller JL, Capino AC, Thomas A, Couloures K, Johnson PN. Sedation and Analgesia Using Medications Delivered via the Extravascular Route in Children Undergoing Laceration Repair. J Pediatr Pharmacol Ther 2018; 23:72-83. [PMID: 29720907 DOI: 10.5863/1551-6776-23.2.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the method of delivery, dosage regimens, and outcomes of sedatives and analgesics administered via the extravascular route for laceration repair in children. METHODS Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords "child," "midazolam," "ketamine," dexmedetomidine," "fentanyl," "nitrous oxide" (N2O), and "laceration repair." Articles evaluating the use of extravascular sedation in children for laceration repair published in the English language between 1946 and June 2017 were included. Two authors independently screened each article for inclusion. Reports were excluded if they did not contain sufficient details on dosage regimen and outcomes. RESULTS A total of 16 reports representing 953 children receiving sedatives and analgesics via the extravascular route were included for analyses. A statistical analysis was not performed because of heterogeneity in dosing and types of analyses conducted. Midazolam and N2O were the most common agents, with oral (PO) midazolam being the most common agent. Other agents that have supporting data were intranasal (IN) dexmedetomidine, IN ketamine, IN midazolam, PO diazepam, PO ketamine, transmucosal (TM) midazolam, and TM fentanyl. CONCLUSIONS Most of the agents administered through the extravascular route were efficacious. Selection of the agents should be based on perceived need for analgesia versus sedation, patient accessibility, and adverse drug events. Future research is needed to determine the optimal agent and route for laceration repair.
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Yu Q, Liu Y, Sun M, Zhang J, Zhao Y, Liu F, Li S, Tu S. Median effective dose of intranasal dexmedetomidine sedation for transthoracic echocardiography in pediatric patients with noncyanotic congenital heart disease: An up-and-down sequential allocation trial. Paediatr Anaesth 2017; 27:1108-1114. [PMID: 28940686 DOI: 10.1111/pan.13235] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intranasal dexmedetomidine can provide adequate sedation during short procedures. However, previous literature investigating the single-dose use of intranasal dexmedetomidine for sedation during transthoracic echocardiography in younger children is scarce, and the effects of age on sedation with intranasal dexmedetomidine remain controversial. OBJECTIVE This study was to determine the 50% effective dose and estimate the 95% effective dose of single-dose intranasal dexmedetomidine to induce sedation in pediatric patients with noncyanotic congenital heart disease, and also determine the effect of age on the dose required for sedation. METHODS Patients were stratified into three age groups of 1-6 months, 7-12 months, and 13-36 months. Intranasal dexmedetomidine started at a dose of 2 μg kg-1 on the first patient. The dose of dexmedetomidine for each subsequent patient was determined by the previous patient's response using Dixon's up-and-down method with an interval of 0.25 μg kg-1 . Sedation scale and recovery were assessed by the Modified Observer Assessment of Alertness and Sedation Scale and Modified Aldrete Recovery Score. The 50% effective dose was determined by Dixon's up-and-down method. In addition, both 50% effective dose and 95% effective dose were obtained using a probit regression approach. Other variables included sedation onset time, echocardiography time, wake-up time, discharge time, heart rate, blood pressure, oxygen saturation, respiratory rate, and adverse events such as vomiting, regurgitation, and apnea. RESULTS The study population was comprised of 70 patients. The 50% effective dose (95% confidence interval) and the 95% effective dose (95% confidence interval) of intranasal dexmedetomidine for sedation were 1.8 (1.58-2.00) μg kg-1 and 2.2 (1.92-5.62) μg kg-1 in patients aged 1-6 months, 1.8 (1.61-1.95) μg kg-1 and 2.1 (1.90-2.85) μg kg-1 in patients aged 7-12 months, 2.2 (1.92-2.37) μg kg-1 and 2.7 (2.34-6.88) μg kg-1 in patients aged 13-36 months, respectively. The 50% effective dose in age group 13-36 months was higher than those of age group 1-6 months (P = .042) and 7-12 months (P = .043). There were no differences in sedation onset time, echocardiography time, wake-up time, and discharge time between groups. None of the patients experienced oxyhemoglobin desaturation, hypotension, or bradycardia during the procedure. No significant adverse events occurred. CONCLUSION Single-dose of intranasal dexmedetomidine was an effective agent for patients under the age of 3 years requiring sedation for transthoracic echocardiography. The 50% effective dose of intranasal dexmedetomidine for transthoracic echocardiography sedation in children aged 13-36 months was higher than in children <13 months.
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Affiliation(s)
- Qing Yu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yang Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Mang Sun
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jing Zhang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yan Zhao
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Fengzhi Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Shangyingying Li
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Shengfen Tu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
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