Does sevoflurane add to outpatient procedural sedation in children? A randomised clinical trial

Oral midazolam vs. intranasal dexmedetomidine plus oral midazolam for sedation of pediatric outpatients: a double-blinded randomized controlled trial

BACKGROUND

Moderate to deep sedation is required for dental treatment of children with dental anxiety. Midazolam is the most commonly used sedative, whereas intranasal dexmedetomidine is increasingly used in pediatric sedation.

OBJECTIVE

The aim of this trial was to compare the sedative efficacy of oral midazolam alone with that of intranasal dexmedetomidine plus oral midazolam during dental treatment of children with dental anxiety.

DESIGN

In total, 83 children (aged 3-12 years) scheduled to undergo dental sedation were randomized to receive oral midazolam (0.5 mg/kg) and intranasal placebo, or oral midazolam (0.5 mg/kg) plus intranasal dexmedetomidine (2 µg/kg). The primary outcome was the rate of successful sedation for dental treatment. Secondary outcomes were the onset time and adverse events during and after treatment. Data analyses involved descriptive statistics and nonparametric tests.

RESULTS

The rate of successful sedation was significantly higher in combination group (P = 0.007), although the sedation onset time was significantly longer in combination group (17.5 ± 2.4 min) than in monotherapy group (15.7 ± 1.8) (P = 0.003). No children required medical intervention or oxygen therapy for hemodynamic disturbances, and the incidences of adverse events had no significant difference between groups (P = 0.660).

CONCLUSION

Combined treatment with oral midazolam (0.5 mg/kg) and intranasal dexmedetomidine (2 µg/kg) is more significantly effective for managing the behavior of non-cooperative children during dental treatment, compared to oral midazolam (0.5 mg/kg) alone. (Chinese Clinical Trial Registry: ChiCTR2100042300) TRIAL REGISTRATION: ChiCTR2100042300, Clinical trial first registration date: 17/01/2021.

Sevoflurane Exposure in Neonates Perturbs the Expression Patterns of Specific Genes That May Underly the Observed Learning and Memory Deficits

Exposure to commonly used anesthetics leads to neurotoxic effects in animal models-ranging from cell death to learning and memory deficits. These neurotoxic effects invoke a variety of molecular pathways, exerting either immediate or long-term effects at the cellular and behavioural levels. However, little is known about the gene expression changes following early neonatal exposure to these anesthetic agents. We report here on the effects of sevoflurane, a commonly used inhalational anesthetic, on learning and memory and identify a key set of genes that may likely be involved in the observed behavioural deficits. Specifically, we demonstrate that sevoflurane exposure in postnatal day 7 (P7) rat pups results in subtle, but distinct, memory deficits in the adult animals that have not been reported previously. Interestingly, when given intraperitoneally, pre-treatment with dexmedetomidine (DEX) could only prevent sevoflurane-induced anxiety in open field testing. To identify genes that may have been altered in the neonatal rats after sevoflurane and DEX exposure, specifically those impacting cellular viability, learning, and memory, we conducted an extensive Nanostring study examining over 770 genes. We found differential changes in the gene expression levels after exposure to both agents. A number of the perturbed genes found in this study have previously been implicated in synaptic transmission, plasticity, neurogenesis, apoptosis, myelination, and learning and memory. Our data thus demonstrate that subtle, albeit long-term, changes observed in an adult animal's learning and memory after neonatal anesthetic exposure may likely involve perturbation of specific gene expression patterns.

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

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.

Effect of sevoflurane anaesthesia on nasal mask in endoscopic retrograde cholangiopancreatography: is it a preferred alternative?

Background/aim

Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation. Propofol provides adequate sedation and amnesia at subhypnotic doses, but safe guarding the patient’s airway is important for preventing respiratory depression or u28ba events. This study compared sedation levels, operator satisfaction, intraoperative and recovery characteristics using sevoflurane with nasal mask and propofol in ERCP.

Material and methods

Sixty-one patients underwent ERCP (Group I: propofol, n = 31; Group II, sevoflurane, n = 30), with sedation controlled by the Ramsay sedation scale (RSS). The patients’ demographic data, procedure length, overall drug dose, hemodynamic changes, duration of recovery and Aldrete scores during recovery were evaluated. In addition, satisfaction of the gastroenterologist was evaluated.

Results

The mean sphincterotomy satisfaction scores were statistically significant (P= 0.043). The Aldrete scores and RSS of the groups were similar; there was a significant difference between groups at the beginning of the procedure regarding peripheric oxygen saturations and Group II’s saturation levels increased during sedation.

Conclusion

In ERCP, propofol infusion provides shorter recovery duration and adequate sedation levels. Sevoflurane and oxygen with a nasal mask can be chosen to generate specific anaesthesia in patients, especially for strong airway support and safety treating hypoxemic patients.

Disruption of Rapid Eye Movement Sleep Homeostasis in Adolescent Rats after Neonatal Anesthesia

BACKGROUND

Previous studies suggest that rapid eye movement sleep rebound and disruption of rapid eye movement sleep architecture occur during the first 24 h after general anesthesia with volatile anesthetics in adult rats. However, it is unknown whether rapid eye movement sleep alterations persist beyond the anesthetic recovery phase in neonatal rats. This study tested the hypothesis that rapid eye movement sleep disturbances would be present in adolescent rats treated with anesthesia on postnatal day 7.

METHODS

Forty-four neonatal rats were randomly allocated to treatment with anesthesia consisting of midazolam, nitrous oxide, and isoflurane or control conditions for 2 h or 6 h. Electroencephalographic and electromyographic electrodes were implanted and recordings obtained between postnatal days 26 and 34. The primary outcome was time spent in rapid eye movement sleep. Data were analyzed using two-tailed unpaired t tests and two-way repeated measures analysis of variance.

RESULTS

Rats treated with midazolam, nitrous oxide, and isoflurane exhibited a significant increase in rapid eye movement sleep three weeks later when compared with control rats, regardless of whether they were treated for 2 h (174.0 ± 7.2 min in anesthetized, 108.6 ± 5.3 in controls, P < 0.0001) or 6 h (151.6 ± 9.9 min in anesthetized, 108.8 ± 7.1 in controls, P = 0.002).

CONCLUSIONS

Treatment with midazolam, nitrous oxide, and isoflurane on postnatal day 7 increases rapid eye movement sleep three weeks later in rats.

Fear and anxiety managing methods during dental treatments: a systematic review of recent data

INTRODUCTION

The management of anxiety and fear of patients experiencing medical treatment is always a major issue. Dentistry is a branch of medicine that is daily in managing these problems, especially in the case of pediatric patients. Odontophobia can be managed in different ways, and the purpose of this study is to eventually review which methods are currently accepted and which are the most effective.

EVIDENCE ACQUISITION

The literature analysis was conducted on a number of articles, suitably skimmed, after a first research, obtained from the most common scientific databases. The number of works included in the review is 28.

EVIDENCE SYNTHESIS

From the RCTs evaluated we could highlight that there are different methods in the literature, equally effective and certainly conditioned by the systemic condition of the patient. Another chapter instead turns out to be that linked to the management of the syndromic patient.

CONCLUSIONS

It is clear that there are different methods and equally different ways to manage our patients in the event of non-cooperation in the case of dental care. In addition to proper management by the clinician, in the literature methods linked to audiovisual distractions, hypnosis or pharmacological methods that produce conscious sedation are effectively reported.

Conscious Sedation in Dentistry

Invasive dental procedures can be performed only with local anesthesia; in some cases, it may be useful to combine the administration of drugs to obtain anxiolysis with local anesthesia. Sedation required level should be individually adjusted to achieve a proper balance between the needs of the patient, the operator, and the safety of the procedure. Surgical time is an important factor for post-operative phases, and this could be greatly increased by whether the patient interrupts the surgeon or if it is not collaborative. In this manuscript some dentistry-used methods to practice conscious sedation have been evaluated. This manuscript could be a useful reading on the current state of conscious sedation in dentistry and an important starting point for future perspectives. Surely the search for safer drugs for our patients could have beneficial effects for them and for the clinicians.

Psychological Factors in Dental Patient Care: Odontophobia

Dentistry and oral health are at the heart of the systemic health of humans. Often this branch of medicine is underestimated either due to socioeconomic reasons or due to fear. In fact, in dentistry, there is often a widespread condition of odontophobia among patients. A clinician's knowledge of this condition, and an accompanying understanding of how to successfully manage it, is surely one of the first steps to gaining a patient's trust and maintaining his or her patronage. Being able to manage a dental phobic patient in the best way is the key to successful therapy. Psychological techniques often have to work alongside dentistry in managing these patients. A future perspective concerns precisely the implementation of non-invasive practices such as hypnosis in the management of the latter.

Randomized clinical trial on the efficacy of intranasal or oral ketamine-midazolam combinations compared to oral midazolam for outpatient pediatric sedation

Purpose

The optimal sedative regime that provides the greatest comfort and the lowest risk for procedural sedation in young children remains to be determined. The aim of this randomized, blinded, controlled, parallel-design trial was to evaluate the efficacy of intranasal ketamine and midazolam as the main component of the behavioral guidance approach for preschoolers during dental treatment.

Materials and methods

Children under seven years of age, with caries and non-cooperative behavior, were randomized into three groups: (KMIN) intranasal ketamine and midazolam; (KMO) oral ketamine and midazolam; or (MO) oral midazolam. The dental sedation appointments were videotaped, and the videos were analyzed using the Ohio State University Behavioral Rating Scale (OSUBRS) to determine the success of the sedation in each group. Intra- and postoperative adverse events were recorded. Data analysis involved descriptive statistics and non-parametric tests (P < 0.05, IBM SPSS).

Results

Participants were 84 children (28 per group; 43 boys), with a mean age of 3.1 years (SD 1.2). Children’s baseline and the dental sedation session characteristics were balanced among groups. The success of the treatment as assessed by the dichotomous variable ‘quiet behavior for at least 60% of the session length’ was: KMIN 50.0% (n = 14; OR 2.10, 95% CI 0.71 to 6.30), KMO 46.4% (n = 13; OR 1.80, 95% CI 0.62 to 5.40), MO 32.1% (n = 9) (P = 0.360). Adverse events were minor, occurred in 37 of 84 children (44.0%), and did not differ among groups (P = 0.462).

Conclusion

All three regimens provided moderate dental sedation with minor adverse events, with marked variability in the behavior of children during dental treatment. The potential benefit of the ketamine–midazolam combination should be further investigated in studies with larger samples.

Trial registration

ClinicalTrials.gov, identifier: NCT02447289. Registered on 11 May 2015, named “Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO).”

Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed.

MAIN RESULTS

We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both.

AUTHORS' CONCLUSIONS

There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.