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

Intranasal Dexmedetomidine-Esketamine Combination Premedication versus Monotherapy for Reducing Emergence Delirium and Postoperative Behavioral Changes in Pediatric Tonsillectomy and/or Adenoidectomy: A Randomized Controlled Trial

Purpose

Emergence delirium and postoperative negative behavioral changes (PNBC) are common complications in pediatric anesthesia. This study evaluated whether intranasal premedication combining dexmedetomidine and esketamine more effectively reduces these complications compared to either drug alone in children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia.

Patients and Methods

This randomized, double-blind trial involved 198 children aged 2-5 years undergoing tonsillectomy and/or adenoidectomy. Participants received intranasal premedication with either dexmedetomidine (2 μg/kg), esketamine (1 mg/kg), or their combination (dexmedetomidine 1 μg/kg plus esketamine 0.5 mg/kg). The primary outcome was the incidence of emergence delirium, defined as a Pediatric Anesthesia Emergence Delirium (PAED) scale score ≥ 10. Secondary outcomes included the incidence of PNBC, sedation depth, easiness of separation from parents, acceptance of the mask for induction, emergence time, postoperative pain score, parental satisfaction, and adverse events.

Results

The combination premedication significantly reduced emergence delirium incidence (9.4%) compared to esketamine alone (38.1%; relative risk [RR] 0.25, 95% confidence interval [CI] 0.11-0.57, p < 0.001), but not compared to dexmedetomidine alone (17.2%; RR 0.55, 95% CI 0.21-1.39, p = 0.193). PNBC incidence at day 7 was lower with the combination (28.1%) versus dexmedetomidine (48.4%; RR 0.58, 95% CI 0.36-0.93, p = 0.018), but not significantly different from esketamine alone (20.6%; RR 1.38, 95% CI 0.74-2.58, p = 0.326). The combination also provided significantly superior sedation, improved ease of separation from parents, better acceptance of the mask for induction, shorter emergence time, and higher parental satisfaction than both monotherapies.

Conclusion

In children undergoing tonsillectomy and/or adenoidectomy with sevoflurane anesthesia, intranasal dexmedetomidine-esketamine premedication more effectively reduces emergence delirium compared to esketamine alone and PNBC compared to dexmedetomidine alone. This combination also improves sedation, shortens emergence times, and enhances parental satisfaction compared to monotherapy without significant adverse effects.

Trial Registration

The Chinese Clinical Trial Registry, ChiCTR2300076709.

Intranasal atomized dexmedetomidine alone or in combination with ketamine or midazolam to sedate healthy dogs

A prospective, randomized, blinded experiment was conducted to compare the effects of intranasal (IN) dexmedetomidine (Dex, 10 µg/kg; n=12) alone or combined with midazolam (DexM, 0.3 mg/kg; n=12) or ketamine (DexK, 2 mg/kg; n=12) in healthy dogs. Ease of administration (EA1), total administration time (TAT), time for first (TA1) and second nostril administration (TA2), and adverse events during atomization were recorded. Two days later, EA2 was assessed by IN atomization of injectable water as an additional outcome variable. Onset of sedation was evaluated, along with behavioral scores and physiological parameters from T0 (baseline) to T120. Statistical analyses included Chi-square, one-way ANOVA or Kruskal-Wallis, repeated measures or Friedman's ANOVA, and Wilcoxon's tests. Significance was p≤0.05. Onset of sedation was 12.9 ± 4.1, 18.2 ± 7.5, and 9.9 ± 4.3 mins (mean ± SD) for Dex, DexM, and DexK, respectively. Onset was shorter in DexK compared to DexM (p=0.002), explaining the lower behavioral scores in DexM at T15. All dogs in Dex and DexK reached adequate sedation, with peak sedation occurring at T30, while some dogs in DexM never reached adequate sedation and this group peaked at T45. Adverse events such as saliva drooling and pawing at the nose were significantly higher in DexM and DexK, explaining their differences in TA2, TAT, and EA1 comparing to Dex. EA2 was also higher in Dex compared to DexM and DexK. In conclusion, Dex was better tolerated in dogs and DexK showed faster and more profound sedative effects. Due to paradoxical excitement, unpredictable sedation, and nasal irritation, DexM is not recommended.

The effect of dexmedetomidine-ketamine combination versus dexmedetomidine on behavior of uncooperative pediatric dental patients: a randomized controlled clinical trial

OBJECTIVE

Uncooperative behavior in pediatric dentistry is one of the most common manifestations of dental anxiety. Managing anxious patients can be attained by moderate sedation. This study aimed to compare the effect of sedation by dexmedetomidine-ketamine combination (DEX-KET) versus dexmedetomidine (DEX) on behavior of uncooperative pediatric dental patients.

METHODOLOGY

In total, 56 uncooperative healthy children (3-5 years old) requiring dental treatment were divided randomly into two groups: Group I (study group), which received buccal dexmedetomidine (2 μg/kg) and ketamine (2 mg/kg), and Group II (control group), which received only buccal dexmedetomidine (4 μg/kg). Drugs effects were assessed in terms of hemodynamic parameters, patient's drug acceptance, child behavior, postoperative effect of sedation, amnesic effect, incidence of adverse events, as well as procedural induced stress measured by salivary secretory immunoglobulin A (s-IgA).

RESULTS

Hemodynamic results did not reveal a statistically significant difference between the two study groups (P>0.05). There was a significant difference in patient's acceptance to sedative drug between both groups, favoring DEX (p=0.005). Children who received DEX-KET showed significantly better behavior than those who received DEX for local anesthesia (p=0.017) and during operative procedure (p=0.037). Adverse events, post-operative and amnesic effects of drugs were comparable in both groups (p>0.05). Moreover, the mean difference in the salivary s-IgA levels between initial and final value was not statistically significant between both groups (p=0.556).

CONCLUSION

Both DEX-KET combination and DEX alone are effective in providing hemodynamic stability. DEX-KET combination significantly improved the behavior of sedated children compared to DEX alone but the drug acceptance was decreased in the DEX-KET group. Both regimens did not have a negative effect on postoperative behavior of children and had comparable amnesic effect with no significant adverse events. Salivary s-IgA is not considered a potential stress biomarker in sedated children.

Intranasal esketamine versus esketamine-dexmedetomidine combination for premedication in pediatric patients undergoing strabismus surgery: a randomized controlled trial

Background

Preoperative fear and anxiety are prevalent in children undergoing surgery. The combination of esketamine and dexmedetomidine has been proposed as a promising premedication for enhancing preoperative sedation and analgesia. This study compared the premedication efficacy of intranasal esketamine alone and esketamine-dexmedetomidine combination in pediatric patients undergoing strabismus surgery.

Methods

One hundred and eighty preschool children aged 2-6 years scheduled for strabismus surgery were enrolled and randomly assigned to one of the three groups: intranasal premedication with esketamine 2 mg/kg (Group K), esketamine 1 mg/kg and dexmedetomidine 1 µg/kg (Group KD1), or esketamine 0.5 mg/kg and dexmedetomidine 2 µg/kg (Group KD2). The primary outcome was the level of sedation following the intervention, as measured by the modified Yale preoperative anxiety scale (mYPAS) and sedation scale (SS). Secondary outcomes included onset time of sedation, the successful rate of peripheral intravenous cannulation, parental separation anxiety scale (PSAS), mask acceptance scale (MAS), wake-up time, duration of stay in the post-anesthesia care unit (PACU), and premedication-related adverse effects.

Results

After premedication, the mYPAS score gradually decreased in the three groups, with lower values in Group K than in Group KD1 and Group KD2 patients in 1, 5, and 10 min. SS in Group KD1 and Group KD2 steadily increased until 40 min after premedication, while SS in Group K increased in the first 5 min after premedication and maintained consistent levels during the remaining time. Sedation onset was substantially faster in Group K patients (11.4±7.8 min) than Group KD1 (18.1±7.5 min, P=0.006) and Group KD2 (18.4±6.8 min, P<0.001). PSAS, separation status, the successful rate of peripheral intravenous cannulation, and MAS were comparable among groups. There was no significant difference in terms of emergence time or duration of stay in the PACU among groups. More gastrointestinal events were observed in Group K (P<0.001).

Conclusions

Intranasal premedication with 2 mg/kg esketamine produced a more rapid onset of sedation accompanied by more gastrointestinal reactions compared with a combination of esketamine and dexmedetomidine.

Trial Registration

ClinicalTrials.gov identifier: NCT04757675.

Effectiveness of buccal administration of dexmedetomidine and ketamine combination in paediatric dental sedation: A randomized controlled clinical trial

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.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Intranasal Atomization of Ketamine, Medetomidine and Butorphanol in Pet Rabbits Using a Mucosal Atomization Device

A non-invasive method of drug delivery, intranasal atomization, has shown positive results in human medicine and in some animal species. The objective of this study was to evaluate the effects of intranasal atomization, compared to intramuscular administration, of a mix of anesthetic drugs in pet rabbits. In total, 104 mixed-breed pet rabbits, undergoing various types of surgery, received a combination of ketamine, medetomidine, and butorphanol (20, 0.4, and 0.2 mg/kg) by intranasal atomization using a Mucosal Atomization Device (Group MAD) or intramuscular administration (Group IM). When required, isoflurane was dispensed through a face mask. At the end of the procedures, atipamezole was administered using the same routes in the respective Groups. There were no differences in time to loss of righting reflex between the groups, while differences were found for the need for isoflurane (higher in Group MAD) and recovery time, occurring earlier in Group MAD. The results suggest that intranasal atomization of a combination of ketamine, medetomidine, and butorphanol produces a lighter depth of anesthesia in pet rabbits, compared to intramuscular administration. Intranasal atomization can be performed to administer sedative and anesthetic drugs, avoiding the algic stimulus related to the intramuscular inoculation of drugs.

Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives

To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.

Data Sources

PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley).

Methods

A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs.

Results

One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons.

Conclusion

Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

The impact of emergence delirium on hospital length of stay for children who underwent tonsillectomy/adenotonsillectomy: an observational retrospective study

BACKGROUND

Emergence Delirium (ED) is a combination of disturbance of perception and psychomotor agitation that is common in pediatric patients after general anesthesia, especially at preschool age. Since the effect of ED on the length of stay has been studied in adults but infrequently in children, the aim of this study was to investigate the relationship between ED and length of stay in this population.

METHODS

A single center, retrospective, observational study was carried out in children who underwent tonsillectomy or adenotonsillectomy. The Pediatric Anesthesia Emergence Delirium (PAED) scale was used to assess ED. In addition to the time to hospital discharge (time frame 24 hours), drugs used, comorbidities, early postoperative complications, and pain were investigated if potentially associated with the complication.

RESULTS

Four hundred sixteen children aged from 1.5 to 10 years (183 female, 233 male) were included. ED occurred in 25.5% of patients (n = 106). Patients were divided into the ED group and the No-ED group. The discharge time was similar in both groups. No significant differences were observed in the frequency of postoperative complications. The use of fentanyl or dexmedetomidine did not affect ED occurrence. The frequency of pain was greater in the ED group, both in the recovery room and in the ward (p = 0.01).

CONCLUSIONS

The occurrence of ED in children after tonsillectomy/adenotonsillectomy did not extend the length of stay.

Comparison of different sedatives in children before general anaesthesia for selective surgery: A network meta-analysis

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.

A Comparison of Intranasal Dexmedetomidine, Esketamine or a Dexmedetomidine-Esketamine Combination for Induction of Anaesthesia in Children: A Randomized Controlled Double-Blind Trial

Objective: To compare the efficacy of dexmedetomidine, esketamine or combined intranasal administration on the induction of inhalation anaesthesia in children.

Methods: Ninety children aged 1–6 years were randomly allocated into three equal groups to be premedicated with either intranasal dexmedetomidine 2 μg/kg (Group D), esketamine 1 mg/kg (Group S), or dexmedetomidine 1 μg/kg combined with esketamine 0.5 mg/kg (Group DS). The primary endpoint was the Induction Compliance Checklist (ICC) Scale. Secondary outcomes included the sedation success rate; the modified Yale Preoperative Anxiety Scale score; the time of reaching up to two points on the University of Michigan Sedation Scale (UMSS); Parental Separation Anxiety Scale; anaesthesiologist satisfaction with induction based on the visual analogue scale; emergence agitation scale score; and adverse effects.

Results: The children in the DS group showed a high degree of cooperation with inhalation anaesthesia induction, and their ICC score was significantly lower than that of the D and S groups (p = 0.001), but there was no difference between the D and S groups. The success rate of sedation was higher in Group DS (90%) than in Group D (70%) and Group S (53.3%) (p = 0.007). Anaesthesiologist satisfaction with induction was significantly higher in Group DS than in Groups D and S (p = 0.001). The incidence of emergence agitation and the Paediatric Anaesthesia Emergence Delirium (PAED) score in the DS group were lower than those in the D and S groups.

Conclusions: Preoperative intranasal administration of dexmedetomidine combined with esketamine can significantly improve the cooperation of children with inhalation anaesthesia masks. It is a sedation method that has a high success rate and reduces the incidence and degree of emergence agitation.

Using intranasal dexmedetomidine with buccal midazolam for magnetic resonance imaging sedation in children: A single-arm prospective interventional study

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.

The efficacy and safety of dexmedetomidine in preventing emergence delirium in paediatric patients following ophthalmic surgery: a systematic review and meta-analysis of randomised controlled trials

Background

The leading cause of emergence delirium (ED) in children postoperatively is the exposure to inhalational anaesthetics. ED can occur immediately after waking from anaesthesia, making patients generally uncooperative and agitated. Dexmedetomidine has sedative and analgesic effects and helps to reduce agitation and delirium and improve hemodynamic stability and the recovery of respiratory function; in addition to decreasing pain intensity, it is also well known for helping reduce nausea and vomiting.

Objectives

This updated systematic review meta-analysis investigate and summarise currently available evidence on the use of dexmedetomidine to prevent ED, reduce postoperative nausea and vomiting (PONV) and decrease the need for rescue analgesia in paediatric patients undergoing ophthalmic surgery.

Methods

The medical databases EMBASE, PubMed and Cochrane Library were searched for randomised controlled trials published between January 2020 and August 2022 that used Dexmedetomidine in paediatric patients undergoing ophthalmic surgery. The protocol was prospectively registered with PROSPERO (CRD42022343622). The review was accomplished according to the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’, and the meta-analysis was conducted by using RevMan5.4. These studies examine the efficacy of dexmedetomidine in preventing ED in children undergo ophthalmic surgery. The Cochrane ROB-1 was used to assess risk of bias (ROB).

Results

Eight studies comprised of 629 participants, of which 315 received dexmedetomidine and 314 placebos were examined. PAED score identified ED following surgery. A review and meta-analysis indicated that dexmedetomidine reduces ED incidence (RR = 0.39; 95% CI 0.25–0.62). Similarly, it reduces the use of rescue analgesia (RR = 0.38; 95% CI 0.25–0.57). However, dexmedetomidine did not help prevent PONV since no difference was found between groups (RR = 0.33; 95% CI 0.21–0.54).

Conclusion

This review showed that dexmedetomidine helped to reduce ED incidence in paediatric patients after ophthalmic surgery and reduced the need for rescue analgesia compared to placebo or other medications.

The Sedative Effects of Inhaled Nebulized Dexmedetomidine on Children: A Systematic Review and Meta-Analysis

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.

Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis

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.

Intranasal Dexmedetomidine Compared to a Combination of Intranasal Dexmedetomidine with Ketamine for Sedation of Children Requiring Dental Treatment: A Randomized Clinical Trial

Outpatient pediatric sedation is challenging. This study aimed to test intranasal dexmedetomidine efficacy as a single drug or combined with ketamine (DK) to sedate children undergoing dental treatment. Children < 7 years were randomized into dexmedetomidine 2 mcg/kg and ketamine 1 mg/kg (DK) or dexmedetomidine 2.5 mcg/kg (D) groups. Videos from the dental sedation allowed the systematic assessment of children's behavior (primary outcome) according to the Ohio State University Behavioral Rating Scale (OSUBRS). Secondary outcomes were parental and dentist satisfaction, adverse events, and recovery time. The data were analyzed descriptively and through regression models. Participants were 88 children (44 per group; 50 boys). The duration of quiet behavior (OSUBRS) was higher than 50% (DK mean 58.4 [standard deviation 38.1]; D 55.2 [39.1]; p = 0.225). Parents (DK 78.0 [32.2]; D 72.7 [35.1]; p = 0.203) and dentists (KD 62.7 [41.0]; D 62.8 [40.1]; p = 0.339) were overall satisfied. Adverse events occurred in 16 cases (DK n = 10, 62.5%; D n= 6, 37.5%; p = 0.104) and were minor. The median recovery time in the DK group was 1.3 times greater than in group D (p < 0.05). Intranasal sedation with dexmedetomidine alone is equally efficacious and satisfactory for pediatric sedation with fewer adverse events and faster recovery than the DK combination.