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El-Rouby SH, Crystal YO, Elshafie AM, Wahba NA, El-Tekeya MM. Effectiveness of buccal administration of dexmedetomidine and ketamine combination in paediatric dental sedation: A randomized controlled clinical trial. Int J Paediatr Dent 2024. [PMID: 39011758 DOI: 10.1111/ipd.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Pain and anxiety can be considerable obstacles while treating paediatric dental patients. Moderate sedation is needed to treat uncooperative patients. AIM This study aimed to compare the effectiveness of buccal administration of dexmedetomidine-ketamine combination versus dexmedetomidine. DESIGN Fifty-six uncooperative children were randomly assigned into two groups: Group I received buccal dexmedetomidine (2 μg/kg) and ketamine (2 mg/kg) (DEX-KET), whereas Group II received buccal dexmedetomidine (4 μg/kg) (DEX). The effects of drugs were evaluated based on changes in vital signs, onset and duration of sedation, sedation level, analgesia, ease of treatment and procedural adverse effects. RESULTS There were no significant differences in vital signs or sedation onset between the two groups. DEX-KET group showed shorter recovery time than DEX group (p < .0001). There were no statistically significant differences between both groups regarding sedation level at optimum sedation and during operative procedure (p = .064, p = .069 respectively). The ease of treatment was significantly better in DEX-KET group than in DEX group (p = .048). Procedural side effects and analgesic effects of the sedative drugs were comparable between both groups. CONCLUSION The combination of dexmedetomidine and ketamine delivered buccally provided a better method of delivering care to uncooperative children with more rapid recovery than dexmedetomidine.
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Affiliation(s)
- Sara H El-Rouby
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Yasmi O Crystal
- Department of Pediatric Dentistry, NYU College of Dentistry, New York, New York, USA
| | | | - Nadia A Wahba
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Magda M El-Tekeya
- Pediatric Dentistry and Dental Public Health Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
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2
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Feng H, Hu X, Lin Y, Xiao J, Dai C, Hu Z, Feng H, Qin J, Chen L. Dexmedetomidine attenuates acute stress-impaired learning and memory in mice by maintaining the homeostasis of intestinal flora. Eur J Med Res 2024; 29:271. [PMID: 38711117 DOI: 10.1186/s40001-024-01832-5] [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: 01/07/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024] Open
Abstract
Dexmedetomidine (Dex) has been used in surgery to improve patients' postoperative cognitive function. However, the role of Dex in stress-induced anxiety-like behaviors and cognitive impairment is still unclear. In this study, we tested the role of Dex in anxiety-like behavior and cognitive impairment induced by acute restrictive stress and analyzed the alterations of the intestinal flora to explore the possible mechanism. Behavioral and cognitive tests, including open field test, elevated plus-maze test, novel object recognition test, and Barnes maze test, were performed. Intestinal gut Microbe 16S rRNA sequencing was analyzed. We found that intraperitoneal injection of Dex significantly improved acute restrictive stress-induced anxiety-like behavior, recognition, and memory impairment. After habituation in the environment, mice (male, 8 weeks, 18-23 g) were randomly divided into a control group (control, N = 10), dexmedetomidine group (Dex, N = 10), AS with normal saline group (AS + NS, N = 10) and AS with dexmedetomidine group (AS + Dex, N = 10). By the analysis of intestinal flora, we found that acute stress caused intestinal flora disorder in mice. Dex intervention changed the composition of the intestinal flora of acute stress mice, stabilized the ecology of the intestinal flora, and significantly increased the levels of Blautia (A genus of anaerobic bacteria) and Coprobacillus. These findings suggest that Dex attenuates acute stress-impaired learning and memory in mice by maintaining the homeostasis of intestinal flora.
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Affiliation(s)
- Hao Feng
- Department of Dermatology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, 410000, People's Republic of China
| | - Xing Hu
- Department of Dermatology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, 410000, People's Republic of China
| | - Yizi Lin
- Department of Radiology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325200, People's Republic of China
| | - Jingni Xiao
- Department of Nephrology, Hengyang Medical School, University of South China Affiliated Changsha Central Hospital, No. 161 Shaoshan South Road, Changsha, Hunan, 410004, People's Republic of China
| | - Chao Dai
- Department of Nephrology, Hengyang Medical School, University of South China Affiliated Changsha Central Hospital, No. 161 Shaoshan South Road, Changsha, Hunan, 410004, People's Republic of China
| | - Zhaolan Hu
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, 139 Ren-Min Central Road, Changsha City, Hunan, 410011, People's Republic of China
| | - Hao Feng
- State Key Laboratory of Developmental Biology of Freshwater Fish, College of Life Science, Hunan Normal University, Changsha, 410081, People's Republic of China
| | - Jiao Qin
- Department of Nephrology, Hengyang Medical School, University of South China Affiliated Changsha Central Hospital, No. 161 Shaoshan South Road, Changsha, Hunan, 410004, People's Republic of China.
| | - Li Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Wenzhou Medical University, No.108 Wansong Road, Wenzhou, Zhejiang, 325200, People's Republic of China.
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Esmaillian M, Kouhestani S, Azizkhani R, Heydari F, Safavi MR. Dexmedetomidine versus propofol: An effective combination with ketamine for adult procedural sedation: A randomized clinical trial. Am J Emerg Med 2023; 73:95-101. [PMID: 37639920 DOI: 10.1016/j.ajem.2023.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/11/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Recently, drug combination protocols have been preferred over single drugs in procedural sedation and analgesia (PSA). This study aimed to compare the effectiveness and hemodynamic profile of ketamine-dexmedetomidine (ketodex) and ketofol as drug combinations with ketamine as a single medication for PSA in the emergency department (ED). METHODS This prospective, randomized, double-blind clinical trial was performed among adult patients (≥18 years) requiring PSA for a painful procedure in the ED. 135 patients were enrolled and assigned into three equal groups to receive either ketodex, ketofol, or ketamine. Additional ketamine was used as a rescue agent for inadequate sedation in three groups. Oxygen saturation, heart rate, and blood pressure were recorded from baseline until 120 min after induction of PSA. Adverse events, hemodynamic variables, induction, and recovery time were recorded and compared between groups. RESULTS The mean age of the patients was 38.16 ± 19.09 years and no differences were observed between the three groups in terms of demographic variables, pain scores, and procedures between the three groups. Respiratory events had similar incidences between the three groups. The O2 reduction was less in the Ketodex group in comparison with Ketofol and Ketamine groups (1.9%, 6.5%, and 3.8%, P = 0.015). No patient needed endotracheal intubation. Changes in mean arterial pressure from the baseline in Ketamine and Ketofol groups compared to Ketodex was higher (difference was 12.9 mmHg [95% CI, 9.5 to 20.3] and 8.6 mmHg [95% CI, 3.4 to 13.7]. Tachycardia in the Ketamine group had a significantly higher incidence. The recovery time was statistically shorter in the Ketofol group in comparison with other groups. The differences between Ketofol with Ketamine and Ketodex groups were 9.8 min (95% CI, [2.5 to 17.1]) and 8.3 min (95% CI, [1.5 to 15.1]). CONCLUSION Ketodex, as well as ketofol, were effective and safe combinations with good recovery profiles and hemodynamic stability for adult PSA in ED.
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Affiliation(s)
- Mehrdad Esmaillian
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Soheila Kouhestani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Azizkhani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Farhad Heydari
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad Raza Safavi
- Department of Anesthesiology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Zhang J, Yin J, Li Y, Zhang Y, Bai Y, Yang H. Effect of dexmedetomidine on preventing perioperative respiratory adverse events in children: A systematic review and meta‑analysis of randomized controlled trials. Exp Ther Med 2023; 25:286. [PMID: 37206556 PMCID: PMC10189613 DOI: 10.3892/etm.2023.11985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/15/2023] [Indexed: 05/21/2023] Open
Abstract
The most common critical incidents in pediatric anesthesia are perioperative respiratory adverse events (PRAEs). The present meta-analysis aimed to assess the preventive effect of dexmedetomidine on PRAEs in children. Dexmedetomidine is a highly selective α2-adrenoceptor agonist that provides sedation, anxiolysis and analgesic effects without causing respiratory depression. Dexmedetomidine can diminish airway and circulatory responses during extubation in children. Original randomized controlled trial data were analyzed to study the putative effect of dexmedetomidine on PRAEs. By searched the Cochrane Library, EMBASE and PubMed, a total of ten randomized controlled trials (1,056 patients) was identified. PRAEs included cough, breath holding, laryngospasm, bronchospasm, desaturation (percutaneous oxygen saturation <95%), body movement and pulmonary rales. Compared with placebo, dexmedetomidine resulted in a significant reduction of incidence of cough, breath holding, laryngospasm and emergence agitation. The incidence of PRAEs was significantly reduced in dexmedetomidine compared with active comparators group. Moreover, dexmedetomidine decreased heart rate and increased post-anesthesia care unit stay duration by 11.18 min. The present analysis suggested that dexmedetomidine improved the airway function and decreased risks associated with general anesthesia in children. The present data demonstrated that dexmedetomidine may be a good choice to prevent PRAEs in children.
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Affiliation(s)
- Junli Zhang
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
- Correspondence to: Miss Junli Zhang or Dr Hongyuan Yang, Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, 1 Hetai Road, Lunan, Tangshan, Hebei 063000, P.R. China
| | - Jing Yin
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
| | - Yuanyuan Li
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
| | - Yu Zhang
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
| | - Yaowu Bai
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
| | - Hongyuan Yang
- Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, Tangshan, Hebei 063000, P.R. China
- Correspondence to: Miss Junli Zhang or Dr Hongyuan Yang, Department of Anesthesiology, Tangshan Maternal and Child Health Care Hospital, 1 Hetai Road, Lunan, Tangshan, Hebei 063000, P.R. China
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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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Geetha K, Padhy S, Karishma K. Comparison of single-shot nebuliser protocol between dexmedetomidine and ketamine in children undergoing magnetic resonance imaging. J Perioper Pract 2022; 32:346-353. [PMID: 34523382 DOI: 10.1177/17504589211037461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sedation for magnetic resonance imaging mandates deep sedation to ensure patient immobility. The nebulised route of drug delivery carries the advantage of good bioavailability and safety profile. We aimed to compare the efficacy and safety of nebulised dexmedetomidine and ketamine for sedation in children undergoing magnetic resonance imaging. METHODS A total of 71 children, aged two to eight years scheduled for outpatient magnetic resonance imaging were randomly allocated to receive nebulised dexmedetomidine 2 μg/kg (group D) or nebulised ketamine 2 mg/kg (group K) 30min before magnetic resonance imaging. RESULTS Nebulised dexmedetomidine (2 μg/kg) resulted in faster onset and significantly better sedation scores with rapid clear-headed recovery. Ketamine resulted in better venepuncture scores but was associated with more neuropsychological events at recovery. CONCLUSION Nebulised dexmedetomidine at 2 μg/kg provides rapid onset of satisfactory sedation, with good parental separation and a quicker and more clear-headed recovery, allowing for a smooth magnetic resonance imaging experience.
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Affiliation(s)
- K Geetha
- Department of Anaesthesiology and Intensive Care, Nizams Institute of Medical Sciences, Hyderabad, India
| | - Shibani Padhy
- Department of Anaesthesiology and Intensive Care, Nizams Institute of Medical Sciences, Hyderabad, India
| | - K Karishma
- Department of Anaesthesiology and Intensive Care, Nizams Institute of Medical Sciences, Hyderabad, India
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7
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Yang CQ, Yu KH, Huang RR, Qu SS, Zhang JM, Li YL. Comparison of different sedatives in children before general anaesthesia for selective surgery: A network meta-analysis. J Clin Pharm Ther 2022; 47:1495-1505. [PMID: 36029118 DOI: 10.1111/jcpt.13763] [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: 04/08/2022] [Revised: 07/11/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE It is estimated that 60% of children undergoing anaesthesia develop severe preoperative anxiety. The anxiety is associated with adverse reactions. Sedatives such as dexmedetomidine, midazolam, clonidine, ketamine, and melatonin can be used as premedication against preoperative anxiety. However, no consensus has been reached on the choice of pre-anaesthetic sedatives in children before selective surgery. Therefore, the current network meta-analysis (NMA) was carried out to evaluate different sedatives in children aged between 1 and 7 before general anaesthesia for selective surgery. METHODS Randomized clinical trials (RCTs) were retrieved from Pubmed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases from inception to October 22, 2021. Primary outcomes showed satisfactory sedation at parent separation and also at induction or mask acceptance. Secondary outcomes were those related to added benefits and side effects. The present NMA was conducted using the R software. Results of the study were reported as Relative Risk (RR) or Mean Difference (MD) at a 95% credible intervals (CrIs). RESULTS AND DISCUSSION A total of 48 trials were included in the present study. It was found that the effectiveness of dexmedetomidine, midazolam, clonidine, and ketamine were superior to that of placebo in satisfactory sedation at parent separation and induction or mask acceptance. There was no significant difference between melatonin and placebo in satisfactory sedation at induction or mask acceptance. Dexmedetomidine, ketamine, clonidine, and melatonin were superior to placebo in reducing emergence delirium (ED). In addition, midazolam prolonged the length of stay in the post anaesthesia care unit (PACU) as compared with placebo. Dexmedetomidine caused a significant reduction in systolic blood pressure (SBP) and heart rate (HR). Nevertheless, it was noted that the hemodynamic changes were roughly within safety limits. WHAT IS NEW AND CONCLUSION It was evident that the studied drugs can provide effective sedation with exception of melatonin and placebo. However, it was found that midazolam, ketamine, and clonidine lead to several side effects. The findings of the present study supported that dexmedetomidine, especially intranasal administration, has potential in the optimal selection of the sedatives for premedication in children. This is because the drug has effective sedation, reduced incidence of ED, side effects, and onset time.
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Affiliation(s)
- Chuan-Qi Yang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Kai-Hua Yu
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Rong-Rong Huang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Shan-Shan Qu
- The First Clinical Medical College of Lanzhou University, Lanzhou, China.,The Reproductive Medicine Center, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jun-Mei Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yu-Lan Li
- Department of Anesthesiology, The First Hospital of Lanzhou University, Lanzhou, China
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Arun N, Choudhary A, Kumar M. Comparative Study of Intranasal Dexmedetomidine Versus Intranasal Ketamine as Premedicant in Children. Cureus 2022; 14:e26572. [PMID: 35936118 PMCID: PMC9351598 DOI: 10.7759/cureus.26572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Pre-operative anxiety in children not only makes induction difficult but it is also associated with an increase in the requirement of analgesics, the incidence of post-operative nausea and vomiting (PONV), emergence delirium (ED), and postoperative maladaptive behavioral changes. It can be reduced effectively by pharmacological interventions. In a quest to find the ideal premedicant and non-invasive way of its administration, we decided to compare intranasal (IN) dexmedetomidine with IN ketamine as a premedicant in pediatric patients. Aims and objectives: To compare sedation score, mask acceptance score (MAS) during induction, the incidence of ED, and other adverse events in both groups. Material and methods: Some 60 children, between 1 and 8 years of age of either sex undergoing surgical procedures were included in this study and randomly divided into two groups (Group D and Group K). Thirty minutes prior to induction of anesthesia, patients of Group D received dexmedetomidine 1 mcg kg-1 in 1 mL of 0.9% saline intranasally and patients of Group K received ketamine 5 mg kg-1 in 1 mL of 0.9% saline intranasally through calibrated dropper (0.5 mL in each nostril) in a recumbent position. Incidences of sneezing or coughing after IN administration of study drugs were recorded. The subsequent sedation scores were assessed using MOASS at 15 min, then at 30 min following premedication at the time of parental separation. After shifting patients to operation theater inhalation induction was done. MAS at induction and any adverse effects were recorded. Results: Children in Group K were found to be significantly more sedated at 30 min after administration of premedication and mask acceptance was also better (p value < 0.0001 with a confidence interval, CI=95%). But the incidence of ED and PONV was high. Conclusion: Intranasal dexmedetomidine (1 mcg kg-1) is clinically less effective as a premedicant in terms of sedation and mask acceptance in older children as compared to ketamine (5 mg kg-1), but associated with fewer incidence of ED and PONV. We recommend the usage of IN dexmedetomidine in a higher dose (1.5-2 mcg kg-1), through nebulization/atomizer for the desired level of sedation and mask acceptance.
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Ali RM, Mahmoud NMY. The effect of nebulized dexmedetomidine as sedative premedication in pediatrics undergoing cochlear implantation. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2079901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Rania M Ali
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Noura M. Youssri Mahmoud
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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10
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Li BL, Luo H, Huang JX, Zhang HH, Paquin JR, Yuen VM, Song XR. Using intranasal dexmedetomidine with buccal midazolam for magnetic resonance imaging sedation in children: A single-arm prospective interventional study. Front Pediatr 2022; 10:889369. [PMID: 35989987 PMCID: PMC9386185 DOI: 10.3389/fped.2022.889369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Although numerous intravenous sedative regimens have been documented, the ideal non-parenteral sedation regimen for magnetic resonance imaging (MRI) has not been determined. This prospective, interventional study aimed to investigate the efficacy and safety of buccal midazolam in combination with intranasal dexmedetomidine in children undergoing MRI. METHODS Children between 1 month and 10 years old requiring sedation for MRI examination were recruited to receive buccal midazolam 0.2 mg⋅kg-1 with intranasal dexmedetomidine 3 μg⋅kg-1. The primary outcome was successful sedation following the administration of the initial sedation regimens and the completion of the MRI examination. RESULTS Sedation with dexmedetomidine-midazolam was administered to 530 children. The successful sedation rate was 95.3% (95% confidence interval: 93.5-97.1%) with the initial sedation regimens and 97.7% (95% confidence interval: 96.5-99%) with a rescue dose of 2 μg⋅kg-1 intranasal dexmedetomidine. The median sedation onset time was 10 min, and a significant rising trend was observed in the onset time concerning age (R = 0.2491, P < 0.001). The wake-up and discharge times significantly correlated with the duration of the procedure (R = 0.323, P < 0.001 vs. R = 0.325, P < 0.001). No oxygen deficiency nor medication intervention due to cardiovascular instability was observed in any of the patients. History of a prior failed sedation was considered a statistically significant risk factor for failed sedation in the multivariate logistic regression model [odds ratio = 4.71 (95% confidence interval: 1.24-17.9), P = 0.023]. CONCLUSION In MRI examinations, the addition of buccal midazolam to intranasal dexmedetomidine is associated with a high success rate and a good safety profile. This non-parenteral sedation regimen can be a feasible and convenient option for short-duration MRI in children between 1 month and 10 years.
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Affiliation(s)
- Bi Lian Li
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hao Luo
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jun Xiang Huang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huan Huan Zhang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Joanna R Paquin
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Vivian M Yuen
- Department of Anesthesiology and Perioperative Medicine, Hong Kong Children's Hospital, Hong Kong, Hong Kong SAR, China
| | - Xing Rong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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11
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Lin J, Wu C, Zhao D, Du X, Zhang W, Fang J. The Sedative Effects of Inhaled Nebulized Dexmedetomidine on Children: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:865107. [PMID: 35669400 PMCID: PMC9163573 DOI: 10.3389/fped.2022.865107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Children that need surgery and medical examinations are often uncooperative, and preoperative sedation is necessary. We aimed to assess the safety and efficacy of inhaled nebulized dexmedetomidine in children for sedation that underwent medical examinations or surgery. METHODS We systematically searched PubMed, Web of science, Embase, and Cochrane library, for randomized controlled trials of Intranasal dexmedetomidine using a spray or a mucosal atomization device in children undergoing examination or elective surgery. We included all studies that analyzed the sedation efficiency of intranasal dexmedetomidine in children. RESULTS Ten studies with 1,233pediatric patients were included. Compared to other sedation treatments, inhaled nebulized dexmedetomidine showed similar sedation satisfaction [risk ratio RR: 1.02; 95% confidence interval (CI): 0.87-1.18; P = 0.83; I2 = 72%]. there was also no statistical difference in the success rate of separation from parents (RR: 0.96; 95% CI: 0.82-1.12; P = 0.58; I2 = 67%), and mask acceptability (RR: 1; 95% CI: 0.83-1.20; P = 0.99; I2 = 35%). But it is worth mentioning that nebulized dexmedetomidine combined with ketamine provided better sedation satisfaction (RR: 0.69; 95% CI: 0.49-0.96; I2 = 49%) and more satisfactory separation from parents (RR: 0.85; 95% CI: 0.74-0.97; I2 = 0%). Moreover, nebulized dexmedetomidine reduced the occurrences of nausea and vomiting (RR: 0.28; 95% CI: 0.15-0.51; P < 0.01; I2 = 10%) and emergence agitation (RR: 0.30; 95% CI: 0.18-0.49; P < 0.01; I2 = 0%). There are no hypotension or arrhythmia reported that required intervention in all articles. CONCLUSION Compared to other premedication treatments, inhaled nebulized dexmedetomidine provided equivalent sedation satisfaction for the examination or preoperative sedation of children, but it reduced the occurrences of emergence agitation and postoperative nausea and vomiting.
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Affiliation(s)
- Jun Lin
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Chujun Wu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dizhou Zhao
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Xuhang Du
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wangzhi Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jieyu Fang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Cai YH, Wang CY, Li Y, Chen J, Li J, Wu J, Liu HC. Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries. Front Pharmacol 2021; 12:648699. [PMID: 34975463 PMCID: PMC8714926 DOI: 10.3389/fphar.2021.648699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 11/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction. Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg−1, Group D with intranasal dexmedetomidine 2 μg kg−1, and Group M + D with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time. Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001). Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg−1 plus oral midazolam 0.5 mg kg−1 had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.
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Affiliation(s)
- Yu-Hang Cai
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Cheng-Yu Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yang Li
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jia Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jun Li
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzheng Wu
- Department of Anesthesiology, Cincinnati Children’s Hospital, Cincinnati, OH, United States
- Correspondence: Junzheng Wu, ; Hua-Cheng Liu,
| | - Hua-Cheng Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- Correspondence: Junzheng Wu, ; Hua-Cheng Liu,
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13
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Li HP, Liu KP, Yao L. Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis. Am J Emerg Med 2021; 50:442-448. [PMID: 34492589 DOI: 10.1016/j.ajem.2021.08.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication. METHODS Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events. RESULTS 15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia. CONCLUSIONS DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.
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Affiliation(s)
- Hong-Pei Li
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Kun-Peng Liu
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China.
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Li B, Hou H, Bai J, Zhang M, Li S, Zheng J. Paediatric preoperative sedation practices in tertiary maternity and children's hospitals in China: a questionnaire survey. BMC Pediatr 2021; 21:336. [PMID: 34372814 PMCID: PMC8351349 DOI: 10.1186/s12887-021-02802-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Preoperative anxiety is a common problem in the paediatric population, and several studies have reported that it is related to adverse events such as emergence delirium and postoperative psychological and behavioural changes. In recent years, increasing attention has been paid to paediatric preoperative anxiety in China. A variety of strategies, including sedatives, parental presence, and audio-visual interventions, have been used to relieve paediatric preoperative anxiety, but there is no well-recognised procedure for paediatric preoperative sedation. Therefore, this study aimed to investigate current paediatric preoperative sedation practices in tertiary children’s hospitals in China. Methods All tertiary maternity and children’s hospitals registered with the National Health Commission of the People’s Republic of China were invited to participate in an electronic survey, which included information on the preoperative sedation caseload, sites where preoperative sedation was performed, preoperative sedation methods used in different age groups, choice of sedatives, contraindications for premedication, staff structure for sedative administration and monitoring, and patient-monitoring practices. Results All 81 hospitals participating in our study completed the survey, and 38 hospitals (46.9 %) provided their preoperative sedation protocols. Twenty-four hospitals performed fewer than 5,000 preoperative sedation cases annually, and 9 hospitals performed more than 10,000 cases annually. Preoperative sedation was performed in preoperative preparation areas, preoperative holding areas, and operation rooms in 47.4 %, 26.3 %, and 13.2 % of hospitals, respectively. Sedatives were the most used interventions for paediatric preoperative sedation in all age groups, and the most widely used sedatives were propofol (intravenous) and dexmedetomidine (intranasal). The most common contraindications were American Society of Anesthesiologists class ≥ 3, emergency operation, and airway infection within 2 weeks. Sedatives were administered mainly by anaesthesiologists (63.2 %), and children were monitored mainly by anaesthesiologists (44.7 %) and nurses (39.5 %) after administration. Pulse oximetry was the most widely used monitoring device. Conclusions Fewer than half of the tertiary maternity and children’s hospitals in China provide paediatric preoperative sedation service, and the service practices vary widely. Further improvements are required to ensure the quality of paediatric preoperative sedation services and establish standard operating procedures.
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Affiliation(s)
- Bo Li
- Department of Anaesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
| | - Huiyan Hou
- Department of Anaesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
| | - Jie Bai
- Department of Anaesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
| | - Mazhong Zhang
- Department of Anaesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China.,Paediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
| | - Shengde Li
- Department of Anaesthesiology, Qingdao Women and Children's Hospital, 217 Liaoyang Xi Road, 266000, Qingdao, Shandong, China.
| | - Jijian Zheng
- Department of Anaesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China. .,Paediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China.
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15
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Liu W, Yu Q, Jiang R, Liu F, Dong Y, Tang W. Comparison of Low-Dose Sevoflurane Inhalation With Intranasal Ketamine as Rescue Sedation After Intranasal Dexmedetomidine Failure in Outpatient Children Undergoing MRI: A Randomized Control Trial. J Perianesth Nurs 2021; 36:492-498. [PMID: 34257012 DOI: 10.1016/j.jopan.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/27/2020] [Accepted: 11/01/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE The present study aimed to evaluate the effectiveness and safety of low-dose inhalation of sevoflurane through a face mask as a rescue remedy for sedation compared with intranasal ketamine in outpatient children undergoing magnetic resonance imaging (MRI). DESIGN A prospective randomized control study. A total of 336 children scheduled for 3.0T MRI but were inadequately sedated after initial intranasal dexmedetomidine (3 μg/kg) were randomly divided into two groups. METHODS We used the following protocol for each group: group S, inhalation of low-dose sevoflurane (end-expiratory concentration, 0.4%) through a face mask; group K, intranasal ketamine (2 mg/kg). The success rates were compared between groups as the primary endpoint. The induction time, scan time, recovery time, time to return to baseline functional status, parental and radiologist satisfaction, occurrence of adverse events, and other secondary endpoints were also compared. FINDINGS Successful rescue sedation in groups S and K was achieved in 160 (95.2%) and 138 (82.1%) patients, respectively. Compared with group K, group S needed fewer repeat sequences and showed a significantly shorter induction time (5.7 ± 0.5 vs. 10.9 ± 2.7 min; P < 0.001), recovery time (27.4 ± 6.3 vs. 53.8 ± 15.2 min; P < 0.001), and time to return to baseline functional status (3.4 ± 0.6 vs. 6.1 ± 1.1 h; P < 0.001). Radiologist satisfaction, parental satisfaction, and parental desire to repeat the same sedation method were significantly higher in the sevoflurane group. CONCLUSION Our results suggest that the inhalation of low-dose sevoflurane through a face mask can provide effective and safe rescue sedation in 1- to 6-year-old outpatient children undergoing MRI, and yields a higher success rate, shorter induction and recovery times, and higher satisfaction than the intranasal ketamine method.
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Affiliation(s)
- Wei Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Qian Yu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Rui Jiang
- National Clinical Research Center for Child Health and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fengzhi Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Yanfu Dong
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Wen Tang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China.
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16
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Tervonen M, Kallio M, Peltoniemi O. National survey revealed variable practices in paediatric procedural sedation and patient monitoring. Acta Anaesthesiol Scand 2021; 65:747-754. [PMID: 33590877 DOI: 10.1111/aas.13799] [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: 10/05/2020] [Revised: 01/21/2021] [Accepted: 02/06/2021] [Indexed: 11/30/2022]
Abstract
Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.
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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
| | - 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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Brown AF, Einhorn LM. Successful Combination of Neuraxial and Regional Anesthesia in a Child With Advanced Spinal Muscular Atrophy Type 1 Receiving Maintenance Nusinersen Therapy: A Case Report. A A Pract 2021; 14:e01206. [PMID: 32784322 DOI: 10.1213/xaa.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive condition characterized by degeneration of the anterior horn cells of the spinal cord, which causes progressive muscle atrophy and weakness. SMA type 1 is the most common type and is associated with severe disability and early mortality. Concomitant restrictive respiratory physiology often manifests with significant implications for anesthetic management. Here, we describe a successful spinal anesthetic for orthopedic surgery in an SMA type 1 patient receiving intrathecal nusinersen maintenance therapy, an antisense oligonucleotide designed to increase expression of the survival motor neuron protein, and the first US Food and Drug Administration-approved drug to treat SMA.
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Affiliation(s)
- Alison F Brown
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Kumar A, Kohli A. Comeback of ketamine: resurfacing facts and dispelling myths. Korean J Anesthesiol 2021; 74:103-114. [PMID: 33423410 PMCID: PMC8024210 DOI: 10.4097/kja.20663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/17/2022] Open
Abstract
Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.
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Affiliation(s)
- Abhijit Kumar
- Department of Anesthesiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amit Kohli
- Department of Anesthesiology, Maulana Azad Medical College, New Delhi, India
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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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Chen C, Cheng X, Lin L, Fu F. Preanesthetic nebulized ketamine vs preanesthetic oral ketamine for sedation and postoperative pain management in children for elective surgery: A retrospective analysis for effectiveness and safety. Medicine (Baltimore) 2021; 100:e24605. [PMID: 33578565 PMCID: PMC7886447 DOI: 10.1097/md.0000000000024605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/11/2021] [Indexed: 01/05/2023] Open
Abstract
Preoperative anxiety is a major problem in children leading to a poor outcome. Preanesthetic oral ketamine is generally used in children but has less bioavailability due to the first-pass effect. Even ketamine has an unpleasant taste. Preanesthetic inhaled ketamine is also reported effective and safe in children. The objectives of the study were to compare the effectiveness and safety of preanesthetic nebulized ketamine against preanesthetic oral ketamine for sedation and postoperative pain management in children.Children received 10 mg/kg oral ketamine (children received preanesthetic oral ketamine [OK cohort], n = 142), or nebulized with 3 mg/kg ketamine (children were preanesthetic nebulized with ketamine [NK cohort], n = 115), or received apple juice (children suspectable to preoperative ketamine and received apple juice only [OA cohort], n = 126) before anesthesia for elective surgery. Data regarding preoperative hemodynamic parameters, sedation score measurements, postoperative pain management, postoperative nausea and vomiting management, and postoperative complications were collected and analyzed.Preoperative hemodynamic parameters for oral and nebulized ketamine administration were stable. Nebulized ketamine was provided higher sedation than apple juice (P = .002, q = 4.859) and oral ketamine (P = .002, q = 3.526). Children of NK cohort had required fewer fentanyl consumption until discharge than those of OA (55.45 ± 7.19 μG/ child vs 65.15 ± 15.24 μG/ child, P < .0001, q = 9.859) and OK (55.45 ± 7.19 μG/child vs 60.19 ± 8.12 μG/child, P < .0001, q = 4.953) cohorts. Children of the NK cohort had consumed higher ondansetron syrup than those of the OA cohort but fewer than those of the OK cohort until discharge. Gastrointestinal side effects were reported in the OK cohort, and nose irritation and drowsiness were reported in the NK cohort.Like preanesthetic oral ketamine, preanesthetic inhaled ketamine also has safety for children. Preanesthetic inhaled ketamine can provide effective sedation in low doses during operation than preanesthetic oral ketamine.Level of evidence: III.
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Pansini V, Curatola A, Gatto A, Lazzareschi I, Ruggiero A, Chiaretti A. Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:189. [PMID: 33569491 PMCID: PMC7867955 DOI: 10.21037/atm-20-5177] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.
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Affiliation(s)
- Valeria Pansini
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Antonietta Curatola
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gatto
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Ilaria Lazzareschi
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
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Poonai N, Coriolano K, Klassen T, Heath A, Yaskina M, Beer D, Sawyer S, Bhatt M, Kam A, Doan Q, Sabhaney V, Offringa M, Pechlivanoglou P, Hickes S, Ali S. Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol. BMJ Open 2020; 10:e041319. [PMID: 33303457 PMCID: PMC7733175 DOI: 10.1136/bmjopen-2020-041319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction. METHODS AND ANALYSIS This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047. ETHICS AND DISSEMINATION Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results. TRIAL REGISTRATION NUMBER NCT0419525.
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Affiliation(s)
- Naveen Poonai
- Departments of Paediatrics and Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Kamary Coriolano
- Departments of Paediatrics and Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Terry Klassen
- Max Rady College of Medicine, Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Paediatrics, Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, Manitoba, Canada
| | - Anna Heath
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, UK
| | - Maryna Yaskina
- Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada
| | - Darcy Beer
- Department of Paediatrics, Children's Hospital of Winnipeg, Winnipeg, Manitoba, Canada
| | - Scott Sawyer
- Department of Paediatrics, Children's Hospital of Winnipeg, Winnipeg, Manitoba, Canada
| | - Maala Bhatt
- Department of Paediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - April Kam
- Department of Paediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Quynh Doan
- Department of Paediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Vikram Sabhaney
- Department of Paediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Serena Hickes
- Department of Paediatrics, Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, Manitoba, Canada
| | - Samina Ali
- Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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23
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Elshafeey AEAM, Youssef GFK, Elsalam EHA, Saleh M, Mahrose R. Comparative study between intranasal dexmedetomidine and intranasal ketamine as a premedication for anxiolysis and sedation before pediatric general anesthesia. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2020; 12:51. [DOI: 10.1186/s42077-020-00104-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/11/2020] [Indexed: 09/01/2023]
Abstract
Abstract
Background
This study compared dexmedetomidine versus ketamine as regard sedation and anxiolysis produced by giving them through intranasal route to pediatric patients undergoing adenotonsillectomy. This study was double-blinded randomized comparative prospective interventional clinical study done in Ain Shams University Hospital (El Demerdash Hospital) on 76 pediatric patients who underwent adenotonsillectomy, and they were randomly allocated equally into two main groups; group D received 2 μg/kg intranasal dexmedetomidine and group K received 5 μg/Kg intranasal ketamine 30 min before the operation, and the aim of this study was to compare the efficacy of intranasal dexmedetomidine versus intranasal ketamine for anxiolysis and sedation to alleviate stress, agitation, and anxiety in children before general anesthesia and for promoting good level of sedation for them.
Results
Results of this study as regards sedation level that was assessed by modified Ramsay sedation score showed that there was statistically significant difference between both groups at 10, 20, and 30 min from intranasal application of the drug (P value < 0.05), the median (IQR) of sedation score at 10, 20, and 30 min preoperative in group D was (2 (2 – 2)), (3 (3 – 4)), (4 (4 – 5)) compared to (2 (2 – 3)), (3 (2 – 3)), (4 (3 – 4)) in group K respectively which revealed that there was better and effective sedation in group D more than in group K, this difference was statistically significant but clinically insignificant as both drugs produced an acceptable level of sedation and decreased the level of anxiety in children.
Conclusion
Both drugs produce effective and favorable sedation level with superiority to dexmedetomidine in sedation scores and time of onset of sedation, and also there was little decrease in heart rate and mean arterial pressure which is favorable during such surgeries; also, there was accepted level of cannulation and parental separation scores, and the parents were highly satisfied with the procedure and were grateful for us due to alleviating stress and anxiety from them and from their children.
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24
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Heath A, Yaskina M, Pechlivanoglou P, Rios D, Offringa M, Klassen TP, Poonai N, Pullenayegum E. A Bayesian response-adaptive dose-finding and comparative effectiveness trial. Clin Trials 2020; 18:61-70. [PMID: 33231105 DOI: 10.1177/1740774520965173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/AIMS Combinations of treatments that have already received regulatory approval can offer additional benefit over Each of the treatments individually. However, trials of these combinations are lower priority than those that develop novel therapies, which can restrict funding, timelines and patient availability. This article develops a novel trial design to facilitate the evaluation of New combination therapies. This trial design combines elements of phase II and phase III trials to reduce the burden of evaluating combination therapies, while also maintaining a feasible sample size. This design was developed for a randomised trial that compares the properties of three combination doses of ketamine and dexmedetomidine, given intranasally, to ketamine delivered intravenously for children undergoing a closed reduction for a fracture or dislocation. METHODS This trial design uses response-adaptive randomisation to evaluate different dose combinations and increase the information collected for successful novel drug combinations. The design then uses Bayesian dose-response modelling to undertake a comparative effectiveness analysis for the most successful dose combination against a relevant comparator. We used simulation methods determine the thresholds for adapting the trial and making conclusions. We also used simulations to evaluate the probability of selecting the dose combination with the highest true effectiveness the operating characteristics of the design and its Bayesian predictive power. RESULTS With 410 participants, five interim updates of the randomisation ratio and a probability of effectiveness of 0.93, 0.88 and 0.83 for the three dose combinations, we have an 83% chance of randomising the largest number of patients to the drug with the highest probability of effectiveness. Based on this adaptive randomisation procedure, the comparative effectiveness analysis has a type I error of less than 5% and a 93% chance of correcting concluding non-inferiority, when the probability of effectiveness for the optimal combination therapy is 0.9. In this case, the trial has a greater than 77% chance of meeting its dual aims of dose-finding and comparative effectiveness. Finally, the Bayesian predictive power of the trial is over 90%. CONCLUSIONS By simultaneously determining the optimal dose and collecting data on the relative effectiveness of an intervention, we can minimise administrative burden and recruitment time for a trial. This will minimise the time required to get effective, safe combination therapies to patients quickly. The proposed trial has high potential to meet the dual study objectives within a feasible overall sample size.
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Affiliation(s)
- Anna Heath
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Biostatistics, University of Toronto, Toronto, ON, Canada.,Department of Statistical Science, University College London, London, United Kingdom
| | - Maryna Yaskina
- Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David Rios
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Terry P Klassen
- University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Naveen Poonai
- Schulich School of Medicine and Dentistry, London, ON, Canada.,Children's Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Biostatistics, University of Toronto, Toronto, ON, Canada
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25
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Staudt GE, Eagle SS. DEX Marks the Spot: Finding the Optimal Sedation Regimen for Pediatric Patients Undergoing Sedated Transthoracic Echocardiography. J Cardiothorac Vasc Anesth 2020; 34:1556-1557. [PMID: 32199686 DOI: 10.1053/j.jvca.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Genevieve E Staudt
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Susan S Eagle
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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26
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Wang S, Pei L. Anaesthesia and orphan disease: A 2-year-old with neuronal ceroid lipofuscinosis. Eur J Anaesthesiol 2020; 37:138-141. [PMID: 31913935 DOI: 10.1097/eja.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Shuying Wang
- From the Department of Anesthesiology, The First Affiliated Hospital, China Medical University, Shenyang, China (SW, LP)
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27
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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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28
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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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29
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Anupriya J, Kurhekar P. Randomised Comparison between the Efficacy of Two Doses of Nebulised Dexmedetomidine for Premedication in Paediatric Patients. Turk J Anaesthesiol Reanim 2019; 48:314-320. [PMID: 32864647 PMCID: PMC7434347 DOI: 10.5152/tjar.2019.78889] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/14/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Nebulised dexmedetomidine can be an easy alternative for preoperative sedation in paediatric patients, but data regarding its efficacy are very limited. Methods This prospective, randomised, double-blind study included 66 patients aged between 1 and 8 years. Patients were divided into two groups as D2 and D3. The D2 group received 2 μg kg−1 of nebulised dexmedetomidine, and the D3 group received 3 μg kg−1 of nebulised dexmedetomidine preoperatively. All the patients received general anaesthesia and caudal epidural analgesia with 0.75 mL kg−1 of 0.2% ropivacaine. Parental Separation Anxiety Scale at 30 min after the end of nebulisation, Mask Acceptance Score (MAS) during induction, haemodynamic variables, emergence agitation and duration of caudal analgesia were compared between the groups. Statistical analysis was done using Mann-Whitney U test and chi-square test. A p-value <0.05 was accepted as significant. Results All the parameters were comparable between the D2 and D3 groups; however, significantly more number of younger children was observed in the D3 group. Hence, further analysis was done after division into the lower age (1–3 years) and higher age (4–8 years) groups. In lower age group children, satisfactory parental separation was achieved in 100% of the patients in the D3 group compared to 20% of those in the D2 group (p=0.00). MAS was significantly better in the D3 group in both the lower (p=0.019) and higher (p=0.036) age groups. Conclusion We conclude that nebulised dexmedetomidine in a dose of 3 μg kg−1 provides better parental separation and mask acceptance in younger children.
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Affiliation(s)
- Jindal Anupriya
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to-be University), Kancheepuram, Tamilnadu, India
| | - Pranjali Kurhekar
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to-be University), Kancheepuram, Tamilnadu, India
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30
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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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31
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Oriby ME. Comparison of Intranasal Dexmedetomidine and Oral Ketamine Versus Intranasal Midazolam Premedication for Children Undergoing Dental Rehabilitation. Anesth Pain Med 2019; 9:e85227. [PMID: 30881910 PMCID: PMC6412317 DOI: 10.5812/aapm.85227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Background Dental rehabilitation surgery is associated with significant fear and anxiety with subsequent psychological disturbances. Midazolam has been used frequently as a premedication. However, it may be associated with side effects. Dexmedetomidine and ketamine combination has been suggested as an effective premedication in improving preoperative sedation and analgesia. Objectives This study compared the effects of combined intranasal dexmedetomidine and oral ketamine versus intranasal midazolam on anxiolysis and postoperative analgesia. Methods Seventy-six children (aged two to six years) undergoing dental rehabilitation under general anesthesia were assigned randomly to one of the two groups (n = 38 each) receiving either intranasal dexmedetomidine at 2 µg/kg and oral ketamine at 3 mg/kg (Group DK) or intranasal midazolam at 0.2 mg/kg (group M) 30 minutes prior to the anesthesia induction. The sedation levels and parental separation state were evaluated. Time to recovery, postoperative rescue analgesia, and postoperative adverse effects were assessed. Results Seventy-six children completed the study. Patients in group DK had significantly lower sedation scores than those in group M after 20 and 30 min (P < 0.05). The rate of satisfactory separation showed no statistically significant difference between the two groups 30 minutes after the administration of premedication (P = 0.926). A significantly higher number of patients in group M required rescue analgesic (42%) compared to those in group DK (16%) (P = 0.012). Conclusions Premedication with intranasal dexmedetomidine 2 µg/kg and oral ketamine 3 mg/kg is a rapid and effective alternative in children undergoing dental rehabilitation when compared to intranasal midazolam 0.2 mg/kg.
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Affiliation(s)
- Mohamed E Oriby
- Department of Anesthesia and Surgical Intensive Care, Tanta University, Tanta, Egypt
- Anesthesia Department, Magrabi Center, Doha, Qatar
- Corresponding Author: Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Doha, Qatar. PO Box: 23293, Tel: +974-33059056,
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32
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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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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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