Comparison of oral dexmedetomidine and midazolam for premedication and emergence delirium in children after dental procedures under general anesthesia: a retrospective study

Effective doses of midazolam oral solution for the prevention of preoperative anxiety in paediatric patients

BACKGROUND

More than 60% children exhibit anxiety before undergoing an anesthetic-surgical procedure, particularly among pre-school paediatric patients. Oral midazolam can provide procedural sedation for children prior to anesthesia. However, extemporaneous solutions of midazolam are usually prepared from injectable drug solutions, leading to inconsistent efficacy due to variable preparation methods. Xiaoerjing® is the first commercially available oral formulation of midazolam for procedural sedation in children in China. Despite the recommended dosage range of 0.25-0.5 mg/kg, its effective dose is still largely unknown.

AIM

To determine the 95% effective dose (ED95) of midazolam oral solution (Xiaoerjing®) for alleviating preoperative anxiety in children prior to mask induction of general anesthesia.

DESIGN

The study included 61 children between the ages of 1 and 6 years undergoing elective surgery under general anesthesia. The first patient received a single dose of 0.5 mg/kg midazolam oral solution, which was adjusted for subsequent patients using the biased coin design method based on their response to the previous dose. Doses were increased or decreased at the rate of 0.1 mg/kg. An effective response was defined as having a modified Ramsay sedation score ≥3a, separation anxiety score ≤2, and mask acceptance score ≤2 during inhalational anesthesia induction.

RESULTS

Fifty-six children were included in the final analysis. Of those, sedation was successful in 50 patients, with a median separation time of 15 (IQR: 25) min. Midazolam oral solution has an ED95 of 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg) for relieving preoperative anxiety in children. No adverse events occurred following drug administration.

CONCLUSION

Midazolam oral solution is a safe and effective medication for relieving preoperative anxiety in children. The ED95 of a single oral dose of midazolam oral solution is 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg).

Perioperative Staff's Experiences of Premedication for Children

PURPOSE

Providing perioperative care for children who express anxiety or react with negative anxiety-associated consequences can be a challenge. The use of premedication is established as an important intervention for young children before surgery, yet research into care providers' experiences of premedication is limited. The aim of this study was to explore perioperative staff's experiences of premedication for preschool-age children.

DESIGN

A descriptive inductive qualitative study was performed based on focus group discussions.

METHODS

A purposive sample of a team from the operating department with experience in anesthetizing and caring for children in the perioperative period was interviewed in small focus groups: five preoperative and postoperative care nurses, five nurse anesthetists, and five anesthesiologists. The transcribed text was categorized using qualitative content analysis.

FINDINGS

The content analysis revealed three themes: a matter of time, do not wake the sleeping bear, and on responsive tiptoes.

CONCLUSIONS

Care providers must adapt their work to the child's emotional state of mind and needs, allowing time for the child to trust and accept the premedication and for the premedication to reach its peak effect. Premedication provides light sleep preoperatively, which requires careful treatment of the child to avoid emotional reactions, and the postoperative path is most peaceful when the premedication supports a long duration of sedation. Our findings highlight the need for safety precautions and a permissive and flexible organization with the goal of achieving a smooth and safe journey for the child in the perioperative path.

The Median Effective Dose of Dexmedetomidine for the Inhibition of Emergence Delirium in Preschool Children Undergoing Tonsillectomy and/or Adenoidectomy: A Retrospective Dose-response Trial

The incidence of emergence delirium (ED) is higher in preschool children undergoing tonsillectomy and/or adenoidectomy. The purpose of this study was to determine the median effective dose (ED50) of dexmedetomidine (DEX) for the inhibition of ED in preschool children by using probit regression analysis. A total of 140 anesthesia records were retrieved and divided into seven groups based on the infusion rate of DEX: .2, .25, .3, .35, .4, .45, and .5 μg·kg-1·h-1. The Pediatric Anesthesia Emergence Delirium Scale (PAEDS) was used to assess ED in preschool children, and ED was defined as a PAEDS score ≥ 10. Probit regression analysis revealed that the ED50 and ED95 of DEX were .31 μg·kg-1·h-1 (95% CI: .29-.35) and .48 μg·kg-1·h-1 (95% CI: .44-.56), respectively. Probit(p) = -2.84 + 9.28 × ln (Dose), (χ2 = 1.925, P = .859). The PAEDS score was significantly increased in the ED group, and the rate of bradycardia was significantly decreased in the ED group compared with the without ED group (27.3% vs 54.1%, P = .02). DEX can effectively inhibit the ED in preschool children undergoing tonsillectomy and/or adenoidectomy, however, bradycardia was the main complication.

Effectiveness of perioperative low-dose esketamine infusion for postoperative pain management in pediatric urological surgery: a prospective clinical trial

BACKGROUND

Postoperative pain is common in pediatric urological surgery. The study assess the impact of perioperative intravenous infusion of low-dose esketamine on postoperative pain in pediatric urological surgery.

METHODS

Pediatric patients (n = 80) undergoing urological surgery were randomized into four groups. Patients in the control group were administered an analgesic pump containing only hydromorphone at a dose of 0.1 mg/kg (Hydromorphone Group 1, H1) or 0.15 mg/kg (Hydromorphone Group 2, H2). Patients in the experimental group were injected intravenously with 0.3 mg/kg of esketamine (Esketamine group 1, ES1) or equal volume of saline (Esketamine Group 2, ES2) during anesthesia induction. Esketamine 1.0 mg/kg and hydromorphone 0.1 mg/kg were added to the analgesic pump. Face, Leg, Activity, Crying, and Comfort (FLACC) scale or the Numerical Rating Scale (NRS) and adverse effects were recorded at 2, 6, 24, and 48 h postoperatively. Additionally, total and effective PCA button presses were recorded.

RESULTS

In comparison to the H1 group, the pain scores were notably reduced at all postoperative time points in both the ES1 and H2 groups. The ES2 group exhibited lower pain scores only at 24 and 48 h postoperatively. When compared to the H2 group, there were no significant differences in pain scores at various postoperative time points in the ES2 group. However, the ES1 group demonstrated significantly lower pain scores at 6, 24 and 48 h postoperatively, and these scores were also significantly lower than those observed in the ES2 group. The total and effective number of PCA button presses in the ES1, ES2 and H2 group were lower than that in the H1 group (P < 0.001). The incidence of adverse effects within 48 h after surgery was 15% in ES1, 22% in ES2, 58% in H1, and 42% in H2, respectively (P = 0.021).

CONCLUSIONS

The use of low-dose esketamine infusion in analgesia pump can effectively alleviates postoperative pain in pediatric urological patients, leading to a significant reduction in the number of analgesic pump button press. The combined approach of perioperative anesthesia induction and analgesia pump administration is recommended for optimal pain management in these patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry- ChiCTR2300073879 (24/07/2023).

Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures

INTRODUCTION

Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature.

METHODOLOGY

A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model.

RESULTS

Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I2=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I2=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I2=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I2=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents.

CONCLUSION

DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.

Effects of Pharmacological Intervention on Recovery After Sevoflurane Anesthesia in Children: a Network Meta-analysis of Randomized Controlled Trials

Sevoflurane, commonly administered to children as anesthesia, often leads to emergence delirium (ED). Currently, a consensus is lacking among clinicians regarding pharmacological interventions to improve recovery. To determine an effective approach, we compared the effects of several drugs in lowering the incidence of ED after sevoflurane anesthesia in children.We searched online databases for relevant randomized controlled trials (59 studies selected; 5199 NMA-eligible participants) and performed a frequentist network meta-analysis (NMA). This study was registered on PROSPERO (number CRD: 42022329939).All included studies had a low to moderate risk of overall bias. The incidence of ED after sevoflurane anesthesia in children differed according to other drugs administered, and were ranked from high to low according to the surface under the cumulative ranking curve (SUCRA).Sufentanil (91.2%) and dexmedetomidine (77.6%) were more likely to reduce the incidence (SUCRA value) of ED, whereas the placebo (6.5%), ramelteon (11.1%), and magnesium (18%) were less likely to reduce the incidence of ED. Remifentanil (89.3%) ranked first in shortening emergence time, followed by placebo (82.4%) and ketamine (69.7%). Placebo shortened extubation time, followed by remifentanil (66.5%) and alfentanil (61.4%).Sufentanil and remifentanil lowered sevoflurane-induced ED incidences among children and shortened the emergence time more effectively than other drugs. Most adjuvant drugs that are combined with sevoflurane either do not change or may even prolong extubation time. Further research and clinical trials are required to support and update these conclusions.

Dexmedetomidine in Psychiatry: Repurposing of its Fast-Acting Anxiolytic, Analgesic and Sleep Modulating Properties

Drug repurposing is a strategy to identify new indications for already approved drugs. A recent successful example in psychiatry is ketamine, an anesthetic drug developed in the 1960s, now approved and clinically used as a fast-acting antidepressant. Here, we describe the potential of dexmedetomidine as a psychopharmacological repurposing candidate. This α₂-adrenoceptor agonist is approved in the US and Europe for procedural sedation in intensive care. It has shown fast-acting inhibitory effects on perioperative stress-related pathologies, including psychomotor agitation, hyperalgesia, and neuroinflammatory overdrive, proving potentially useful in clinical psychiatry. We offer an overview of the pharmacological profile and effects of dexmedetomidine with potential utility for the treatment of neuropsychiatric symptoms. Dexmedetomidine exerts fast-acting and robust sedation, anxiolytic, analgesic, sleep-modulating, and anti-inflammatory effects. Moreover, the drug prevents postoperative agitation and delirium, possibly via neuroprotective mechanisms. While evidence in animals and humans supports these properties, larger controlled trials in clinical samples are generally scarce, and systematic studies with psychiatric patients do not exist. In conclusion, dexmedetomidine is a promising candidate for an experimental treatment targeting stress-related pathologies common in neuropsychiatric disorders such as depression, anxiety disorders, and posttraumatic stress disorder. First small proof-of-concept studies and then larger controlled clinical trials are warranted in psychiatric populations to test the feasibility and efficacy of dexmedetomidine in these conditions.

Effects of preoperative nasal spray esketamine on separation anxiety and emergence agitation in pediatric strabismus surgery: A randomized clinical trial

OBJECTIVE

To investigate the effects of preoperative nasal spray esketamine on separation anxiety and postoperative emergence agitation in pediatric strabismus surgery.

METHOD

Ninety children aged 3 to 6 years who underwent elective strabismus surgery were randomly divided into 3 groups that received 0.5 mg/kg (group S1), 1 mg/kg of esketamine (group S2), and the same volume of normal saline (group C) by nasal spray 10 minutes before surgery. The observation indicators of this test include the Ramsay sedation score, separation anxiety score, mask induction score, and the incidences of postoperative emergence agitation. Patient's heart rate, blood oxygen, post anesthesia care unit stay time, and any adverse events were recorded.

RESULTS

The Ramsay sedation score was significantly lower in group C than those in groups S1 and S2 (P < .001). The separation anxiety scores and the mask induction scores were significantly higher in group C than those in groups S1 and S2 (P < .001). The incidences of emergence agitation in groups S1 and S2 were significantly lower than that in C group (P < .001). No obvious clinical complication was observed.

CONCLUSION

Preoperative nasal spray esketamine reduced the preoperative separation anxiety and decrease emergence agitation in pediatric strabismus surgery.

Premedication Propofol Dose to Prevent Emergency Delirium

Objective: One of the most common complications in general anesthesia is the Emergence delirium (ED). Many agents have been studied for prevention of ED, among which propofol has been successfully used. However, there is no information about the optimal dosage of this agent considering the ultimate outcome and the adverse effects; therefore, aimed to assess in this study. Method : 70 children undergoing general anesthesia using propofol, fentanyl, and atracurium were assessed. Participants were allocated randomly to treatment with either propofol 1 mg/kg (n = 35) or 0.5 mg/kg (n = 35) by the end of the anesthesia. The Pediatric Anesthesia Emergence Delirium (PAED) Scale, Face, Legs, Activity, Cry, Consolability (FLACC) scale, and the University of Michigan Sedation Scale (UMSS) were assessed by 10-minute intervals. Post-anesthesia care unit (PACU) stay and adverse effects were registered and compared as well. Results: Duration of PACU stay (P < 0.001), PAED (P = 0.001), and UMSS (P = 0.003) were remarkably lower among low-dose propofol-treated children in the assessment at the 30th minute, while there were no significant differences in FLACC scores between the groups (P > 0.05). Apnea was found in a patient (2.85%) treated with high-dose propofol and decreased oxygen saturation was demonstrated in 5 (14.28%) and 2 (5.71%) participants in high- versus low-dose propofol. None of the patients experienced postoperative nausea and vomiting. Conclusion: Based on the current study, propofol 0.5 mg/kg by the end of anesthesia could efficiently prevent ED incidence and reduce time of PACU stay and adverse effects compared to a high dose of 1 mg/kg.

Recent Advances in the Clinical Value and Potential of Dexmedetomidine

Dexmedetomidine, a highly selective α2-adrenoceptor agonist, has sedative, anxiolytic, analgesic, sympatholytic, and opioid-sparing properties and induces a unique sedative response which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Recent studies indicate several emerging clinical applications via different routes. We review recent data on dexmedetomidine studies, particularly exploring the varying routes of administration, experimental implications, clinical effects, and comparative advantages over other drugs. A search was conducted on the PubMed and Web of Science libraries for recent studies using different combinations of the words “dexmedetomidine”, “route of administration”, and pharmacological effect. The current routes, pharmacological effects, and application categories of dexmedetomidine are presented. It functions by stimulating pre- and post-synaptic α2-adrenoreceptors within the central nervous system, leading to hyperpolarization of noradrenergic neurons, induction of an inhibitory feedback loop, and reduction of norepinephrine secretion, causing a sympatholytic effect, in addition to its anti-inflammation, sleep induction, bowel recovery, and sore throat reduction effects. Compared with similar α2-adrenoceptor agonists, dexmedetomidine has both pharmacodynamics advantage of a significantly greater α2:α1-adrenoceptor affinity ratio and a pharmacokinetic advantage of having a significantly shorter elimination half-life. In its clinical application, dexmedetomidine has been reported to present a significant number of benefits including safe sedation for various surgical interventions, improvement of intraoperative and postoperative analgesia, sedation for compromised airways without respiratory depression, nephroprotection and stability of hypotensive hemodynamics, reduction of postoperative nausea and vomiting and postoperative shivering incidence, and decrease of intraoperative blood loss. Although the clinical application of dexmedetomidine is promising, it is still limited and further research is required to enhance understanding of its pharmacological properties, patient selection, dosage, and adverse effects.

Anesthesia, Sedation, and Unplanned Extubation of Tracheal Intubation in Children with Severe Pneumonia

We randomly divided 200 children with severe pneumonia who met the indications for tracheal intubation into 2 groups in this prospective study. One group that received dexmedetomidine for sedation was recorded as the dexmedetomidine group (n = 100), and the group that received midazolam for sedation was recorded as the midazolam group (n = 100). We compared the anesthesia sedation scores, time to fall asleep, time to wake up from anesthesia, related hemodynamic parameters, and adverse reactions between the two groups of children. The failure mode and effect analysis method (FMEA) was also used to investigate the causes of unplanned extubation (UEX) of tracheal intubation in 32 children with severe pneumonia. Our conclusion is as follows: (1) Compared with midazolam, the comprehensive effect of dexmedetomidine on children with severe pneumonia undergoing tracheal intubation for anesthesia and sedation is better, it can effectively shorten the anesthesia induction time and the recovery time after stopping the drug, and there are few adverse reactions, which is worthy of application and promotion. (2) UEX is an important risk factor in the monitoring and nursing of children with severe pneumonia tracheal intubation, and the nursing method of PDCA cycle management is particularly important for them.

Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging

Background:

Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging.

Materials and Methods:

A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID (n = 81) with dose of 0.3 mg.kg and DEX (n = 81) with dose of 3 μg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by t test and chi-square test.

Results:

Decreasing in MBP and HR was higher in DEX group than MID group (P < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, P = 0.001) was lower in DEX group. Parents (P < 0.001) and physician (P < 0.001) satisfaction score was higher in DEX group than the MID group.

Conclusion:

Using 3 μg/kg intranasal DEX for sedation of 1–6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.

Comparison of dexmedetomidine with midazolam for dental surgery: A systematic review and meta-analysis

INTRODUCTION

Dexmedetomidine and midazolam have become important approaches for the sedation of dental surgery. However, the comparison of these 2 drugs for the sedation of dental surgery has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of dexmedetomidine versus midazolam for dental surgery.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials (RCTs) assessing the influence of dexmedetomidine versus midazolam on dental surgery are included. Two investigators independently have searched articles, extracted data, and assessed the quality of included studies. Meta-analysis is performed using the random-effect model.

RESULTS

Five RCTs and 420 patients are included in the meta-analysis. Compared with midazolam intervention for dental surgery, dexmedetomidine intervention has similar lowest SpO2, lowest heart rate and lowest systolic blood pressure, duration of surgery, and total volume of local anesthetic, but is associated with stable and reduced lowest diastolic blood pressure.

CONCLUSIONS

Similar benefits of dexmedetomidine and midazolam intervention are observed for the sedation of dental surgery in terms of SpO2, heart rate, systolic blood pressure, and the volume of local anesthetic, but dexmedetomidine may result in more stable diastolic blood pressure.

Ketamine Enhances Intranasal Dexmedetomidine-Induced Sedation in Children: A Randomized, Double-Blind Trial

Purpose

To compare the efficacy of intranasal dexmedetomidine and dexmedetomidine-ketamine premedication in preschool children undergoing tonsillectomy.

Patients and Methods

We enrolled 66 children with American Society of Anesthesiologists physical status I or II, aged 3–7 years undergoing tonsillectomy. Patients were randomly allocated to receive intranasal premedication with either dexmedetomidine 2 μg kg⁻¹ (Group D) or dexmedetomidine 2 μg kg⁻¹ and ketamine 2 mg kg⁻¹ (Group DK). The primary outcome was the sedation level assessed by the Modified Observer’s Assessment of Alertness/Sedation Scale (MOAA/S) 30 min after intervention. The minimal clinically relevant difference in the MOAA/S score was 0.5. Secondary outcomes included sedation onset time, parental separation anxiety, acceptance of mask induction, emergence time, emergence delirium, postoperative pain intensity, length of stay in the post-anesthesia care unit (PACU), and adverse effects.

Results

At 30 min after premedication, the MOAA/S score was lower in Group DK than in Group D patients (median: 1.0, interquartile range [IQR]: 1.0–2.0 vs median: 3.0, IQR: 2.0–3.0; P<0.001), with a median difference of 1.0 (95% confidence interval [CI]: 1.0–2.0, P<0.001). Patients in Group DK showed considerably faster onset of sedation (15 min, 95% CI: 14.2–15.8 min) than Group D (24 min, 95% CI: 23.2–24.8 min), with a median difference of 8.0 min (95% CI: 7.0–9.0 min, P<0.001). Both parental separation and facemask acceptance scores were lower in Group DK than in Group D patients (P=0.012 and P=0.001, respectively). There was no significant difference in emergence time, incidence of emergence delirium, postoperative pain scores, and length of stay in the PACU between the two groups.

Conclusion

Intranasal premedication with a combination of dexmedetomidine and ketamine produced better sedation for pediatric tonsillectomy than dexmedetomidine alone.

Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients

Emergence from anesthesia can be associated with a wide spectrum of cognitive and behavioral dysregulation in children, including delirium or acute brain dysfunction. This period of neurobehavioral recovery can be further confounded by pain, anxiety, and fear. The implementation of monitoring for level of consciousness, pain, and delirium using valid pediatric tools is necessary to avoid misdiagnosis due to overlapping symptomatology and support appropriate management. Understanding the epidemiology of delirium in the postoperative setting will require consistent use of accurate terminology in the medical literature. The current interchangeable use of the terms “emergence agitation” and “emergence delirium” needs to be highlighted and awareness of differences in patient conditions and assessment tools is essential. We discuss epidemiology of emergence agitation and delirium in the pediatric population, and the challenges for future delineation of monitoring and management. Furthermore, we describe the possible impact of long-term consequences of emergence delirium among infants and children, and the necessary areas of future research.

The Effect of Dexmedetomidine on Emergence Agitation or Delirium in Children After Anesthesia-A Systematic Review and Meta-Analysis of Clinical Studies

Background: We conducted this systematic review and meta-analysis to investigate the clinical effect of dexmedetomidine in preventing pediatric emergence agitation (EA) or delirium (ED) following anesthesia compared with placebo or other sedatives. Methods: The databases of Pubmed, Embase, and Cochrane Library were searched until 8th January 2020. Inclusion criteria were participants with age<18 years and studies of comparison between dexmedetomidine and placebo or other sedatives. Exclusion criteria included adult studies; duplicate publications; management with dexmedetomidine alone; review or meta-analysis; basic research; article published as abstract, letter, case report, editorial, note, method, or protocol; and article presented in non-English language. Results: Fifty-eight randomized controlled trials (RCTs) and five case-control trials (CCTs) including 7,714 patients were included. The results showed that dexmedetomidine significantly decreased the incidence of post-anesthesia EA or ED compared with placebo [OR = 0.22, 95% CI: (0.16, 0.32), I 2 = 75, P < 0.00001], midazolam [OR = 0.36, 95% CI: (0.21, 0.63), I 2 = 57, P = 0.0003], and opioids [OR = 0.55, 95% CI: (0.33, 0.91), I 2 = 0, P = 0.02], whereas the significant difference was not exhibited compared with propofol (or pentobarbital) [OR = 0.56, 95% CI: (0.15, 2.14), I 2 = 58, P = 0.39], ketamine [OR = 0.43, 95% CI: (0.19, 1.00), I 2 = 0, P = 0.05], clonidine [OR = 0.54, 95% CI: (0.20, 1.45), P = 0.22], chloral hydrate [OR = 0.98, 95% CI: (0.26, 3.78), P = 0.98], melatonin [OR = 1.0, 95% CI: (0.13, 7.72), P = 1.00], and ketofol [OR = 0.55, 95% CI: (0.16, 1.93), P = 0.35]. Conclusion: Compared with placebo, midazolam, and opioids, dexmedetomidine significantly decreased the incidence of post-anesthesia EA or ED in pediatric patients. However, dexmedetomidine did not exhibit this superiority compared with propofol and ketamine. With regard to clonidine, chloral hydrate, melatonin, and ketofol, the results needed to be further tested due to the fact that only one trial was included for each control drug.

Comparison of Intranasal Dexmedetomidine and Oral Midazolam for Premedication in Pediatric Dental Patients under General Anesthesia: A Randomised Clinical Trial

The aim of this study was to compare the effects of preoperative intranasal dexmedetomidine and oral midazolam on preoperative sedation and postoperative agitation in pediatric dentistry. A total of 60 children (ASA grade I, aged 3-6 years) scheduled for elective pediatric dental treatment were randomly divided into the dexmedetomidine (DEX) and midazolam (MID) groups. Ramsay sedation score, parental separation anxiety scale, mask acceptance scale, pediatric anesthesia emergence delirium scale, and hemodynamic parameters were recorded. The Ramsay sedation scale and hemodynamic parameters of the children were observed and recorded immediately before administration and 10, 20, and 30 min after administration. A satisfactory mask acceptance scale rate was 93.33% in both MID and DEX groups, and there was no significant difference between the two groups (p > 0.05). The proportions of children that "successfully separated from their parents" were 93.33% (MID) and 96.67% (DEX). No significant difference was found between the two groups (p > 0.05). The incidence of agitation was 20% in the MID group and 0% in the DEX group, and the difference was statistically significant (p < 0.05). Intranasal dexmedetomidine and oral midazolam provided satisfactory sedation. No significant difference between the two groups was found in terms of parental separation anxiety and mask acceptance (p > 0.05). The incidence of postoperative pediatrics emergence delirium was significantly lower in the DEX group (p < 0.05).

Efficacy and Safety of Midazolam Oral Solution for Sedative Hypnosis and Anti-anxiety in Children: A Systematic Review and Meta-Analysis

Background: Midazolam is recommended by health guidelines for sedation and hypnosis in children. Oral solution is a suitable dosage form for children. But there is no conclusive evidence for sedative-hypnosis and antianxiety effects by midazolam oral solution in children. Methods: Relevant studies were identified through searching PubMed, Embase, Cochrane Library, CINAHL, International Pharmaceuticals, four Chinese electronic databases, and relevant lists. Two reviewers independently selected trials, assessed trial quality, and extracted the data. Results: Eighty-nine randomized controlled trials (RCTs) comparing midazolam oral solution with placebo or blank (n = 33), dexmedetomidine (n = 15), ketamine (n = 11), different midazolam doses (n = 10), midazolam injection (n = 8), chloral hydrate (n = 7), diazepam (n = 5), N2O (n = 5), triclofos (n = 4), butorphanol (n = 2), fentanyl (n = 2), hydroxyzine (n = 1), and thiopental (n = 1) were identified. Meta-analysis showed no significant difference in the success rate and duration of sedation and hypnosis between midazolam oral and injectable solution (P > 0.05). The success rate of sedation and hypnosis of midazolam was higher than that of ketamine [risk ratio (RR) = 1.32, 95% CI (1.07, 1.62), I 2 = 0%, P < 0.01]. No significant difference was found in the success rate of sedation and hypnosis, mask acceptance, and parental separation between midazolam oral solution and dexmedetomidine (P > 0.05), and the result of one cohort study was consistent. The results of RCTs and a prospective cohort study showed that the incidence of adverse drug reactions (ADR) was 19.57% (189/966). Incidence of adverse reactions between dose groups of (0.25, 0.5] and (0.5, 1.0] mg/kg was similar [Pf (95% CI) = 0.10 (0.04, 0.24) and Pf (95% CI) = 0.09 (0.02, 0.39), respectively], higher than that of the dose group of (0, 0.25] mg/kg [Pf (95% CI) = 0.01 (0.00, 0.19)]. Conclusions: Available evidence suggests that midazolam oral solution is as good as midazolam injection and dexmedetomidine and is better than ketamine. Based on efficacy and safety results, an oral midazolam solution dose of 0.5-1 mg/kg is recommended for children.

[Oral trans-mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial]

OBJECTIVES

Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia.

METHODS

Ninety patients aged (3-6 years), ASA I-II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 μg.kg^-1 (Group DEX I), 1 μg.kg^-1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects.

RESULTS

The patients' demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p = 0.007), 10 minutes (p = 0.034), 30 minutes (p = 0.022), 45 minutes (p = 0.034) and 60 minutes (p = 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p = 0.011), 10 minutes (p = 0.037) and 30 minutes (p = 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 minutes (p = 0.020), and lower mean arterial pressure at 30 minutes, (p = 0.040), 45 minutes (p = 0.002) and 60 minutes (p = 0.006) with no significant differences between groups in other time points.

CONCLUSION

This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo.

TRIAL REGISTRATION

Clinical Trials.gov trial registry: NCT02720705.

Oral trans-mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial

Objectives

Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia.

Methods

Ninety patients aged (3–6 years), ASA I‒II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 µg.kg⁻¹ (Group DEX I), 1 µg.kg⁻¹ (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects.

Results

The patients’ demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p = 0.007), 10 minutes (p = 0.034), 30 minutes (p = 0.022), 45 minutes (p = 0.034) and 60 minutes (p = 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p = 0.011), 10 minutes (p = 0.037) and 30 minutes (p = 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 min (p = 0.020), and lower mean arterial pressure at 30 minutes, (p = 0.040), 45 minutes (p = 0.002) and 60 minutes (p = 0.006) with no significant differences between groups in other time points.

Conclusion

This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo.

Trial registration

Clinical Trials.gov trial registry: NCT02720705.

The effect of midazolam administration for the prevention of emergence agitation in pediatric patients with extreme fear and non-cooperation undergoing dental treatment under sevoflurane anesthesia, a double-blind, randomized study

Background: Sevoflurane is generally the preferred anesthetic agent for general anesthesia in pediatric patients, due to its rapid induction and recovery characteristics. However, it has been recognized that a major complication is emergence agitation when awakening from general anesthesia. The aim of this study was to evaluate the occurrence rate of emergence agitation in the operating room and postoperative recovery area following intraoperative administration of midazolam to pediatric patients under general anesthesia. Patients and methods: One hundred and twenty pediatric patients undergoing dental treatment under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=40 each in the 0.1 mg/kg midazolam, 0.05 mg/kg midazolam, and control with saline groups). Midazolam or saline was injected intravenously approximately 30 minutes before the end of the dental treatment. We used the Richmond Agitation and Sedation Scale (RASS) to assess the level of sedation and drowsiness at emergence phase in the operating room. We also used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level of agitation and delirium at the full recovery phase from anesthesia in the recovery area. Results: At the emergence phase, the incidence of emergence agitation in the 0.1 mg/kg midazolam group was significantly lower than in the other groups (p=0.0010). At the recovery phase, there was no significant difference among the three groups. The odds ratio between PAED score and RASS score was 4.0 using logistic regression analysis. The odds ratio between PAED score and Disability was 2.5. Conclusion: Administration of a single dose of 0.1 mg/kg midazolam dose significantly decreases the incidence of severe emergence agitation at the emergence after sevoflurane anesthesia, but not at the recovery phase. Furthermore, the evaluation of sedative and agitation condition using RASS score at emergence from anesthesia is useful to predict occurrence of agitation in the recovery phase.

The comparison of dexmedetomidine and ketamine for pediatric dental surgery: A meta-analysis of randomized controlled studies

INTRODUCTION

Dexmedetomidine and ketamine are used for the sedation of pediatric dental surgery. We conduct a systematic review and meta-analysis to compare the sedation of dexmedetomidine and ketamine for pediatric dental surgery.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) assessing the influence of dexmedetomidine versus ketamine on pediatric dental surgery are included. Two investigators independently have searched articles, extracted data, and assessed the quality of included studies. This meta-analysis is performed using the random-effect model.

RESULTS

Four RCTs involving 163 children are included in the meta-analysis. Compared with ketamine for pediatric dental surgery, dexmedetomidine results in comparable sedation level (very low quality, 2 RCTs, n = 40; Std. MD = -0.26; 95% CI = -0.74 to 0.23; P = .31), intraoperative analgesia scores (very low quality, 2 RCTs, n = 98; Std. MD = 0.17; 95% CI = -0.23 to 0.57; P = .40), postoperative analgesia scores (very low quality, 2 RCTs, n = 98; Std. MD = 0.23; 95% CI = -0.17 to 0.62; P = .27), DBP (very low quality, 3 RCTs, n = 123; Std. MD = -0.38; 95% CI = -1.04 to 0.27; P = .25) and SpO2 (very low quality, 3 RCTs, n = 123; Std. MD = 0.24; 95% CI = -0.20 to 0.69; P = .28), but significantly decreases heart rate (very low quality, 3 RCTs, n = 123; Std. MD = -1.51; 95% CI = -2.75 to -0.27; P = .02) and SBP (very low quality, 3 RCTs, n = 123; Std. MD = -0.62; 95% CI = -1.16 to -0.08; P = .02), longer recovery time (very low quality, 3 RCTs, n = 138; Std. MD = 1.74; 95% CI = 0.23 to 3.25; P = .02).

CONCLUSIONS

Dexmedetomidine and ketamine have similar sedation, analgesia scores, and hemodynamic balance, but very low quality of the evidence (GRADE) is revealed in this meta-analysis.