Intranasal dexmedetomidine in pediatrics: update of current knowledge

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.

Clinical evaluation of the sedative, antinociceptive and cardiorespiratory effects of intranasal dexmedetomidine combined with methadone in healthy dogs

In this prospective, randomised, blinded clinical study, we compared the sedative, antinociceptive and cardiorespiratory effects of intranasal (IN) dexmedetomidine at 5 μg/kg (diluted with 0.03 mL/kg NaCl 0.9%, DEX) with or without methadone (0.3 mg/kg; DEXMET), through a mucosal atomization device to one nostril in twenty healthy client-owned dogs. At 5-min intervals over 45 min, sedation score, onset, cardiopulmonary variables, mechanical nociceptive thresholds (MNTs) were assessed, also ease of administration, adverse effects, and response to IV catheterization. Statistical analysis employed t-test, the Mann-Whitney U, repeated measures ANOVA and Chi-square tests as appropriate (P < 0.05). Higher sedation ocurred in DEXMET (7 [5-10]) compared to DEX (5 [2-7]) from 15 to 30 min (P < 0.01, median [interquartile range]). Heart rate was lower in DEXMET (P < 0.01; 65% reduction vs. 41% in DEX, P = 0.001). The MNTs were higher in DEXMET than DEX from 15 to 45 min (P < 0.01), peaking at T30 (17.1 ± 3.8, DEXMET and 8.5 ± 5.4 N, DEX). No differences were observed in mean arterial blood pressure and respiratory rate. Intranasal administration was considered easy for 8 dogs per group. Reverse sneezing (8 dogs; P < 0.001), sialorrhea and retching (4 and 2 dogs, respectively) occurred in DEXMET. Response to catheterisation was lower in DEXMET than DEX (P = 0.039; 2 and 7 dogs, respectively). In conclusion, intranasal methadone (0.3 mg/kg) increased the sedative and antinociceptive effects produced by dexmedetomidine (5 μg/kg) in healthy dogs and resulted in lower heart rate.

Efficacy of Intranasal Atomized Dexmedetomidine for Sedation in Surgical Removal of Impacted Mandibular Third Molars: A Prospective Study

AIMS AND OBJECTIVES

To assess the efficacy of dexmedetomidine atomized intranasally for sedation during surgical removal of impacted mandibular third molars.

MATERIALS AND METHODS

A prospective randomized trial was conducted on 25 anxious patients between the ages of 18 and 40 who had impacted the lower third molars. An intranasal atomization device was used to give the medication 30 minutes prior to the surgical procedure. The Ramsay sedation score and Observer's assessment of alertness/sedation score were used to assess intranasal sedation.

RESULTS

The results of our study state that the sedative effect began to take effect between 30 and 45 minutes later and was nearly back to baseline by 105 minutes after the administration of intranasal dexmedetomidine.

CONCLUSION

Intranasal delivery of 1.5mg/kg atomized dexmedetomidine for patients undergoing surgical removal of impacted mandibular third teeth is safe, feasible, and clinically efficient in daycare settings based on the sedation scores, and secondary variables which were assessed.

A comprehensive overview of clinical research on dexmedetomidine in the past 2 decades: A bibliometric analysis

Introduction: Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist with sedative, analgesic, anxiolytic, and opioid-sparing properties. A large number of dexmedetomidine-related publications have sprung out in the last 2 decades. However, no bibliometric analysis for clinical research on dexmedetomidine has been published to analyze hot spots, trends, and frontiers in this field. Methods: The clinical articles and reviews related to dexmedetomidine, published from 2002 to 2021 in the Web of Science Core Collection, were retrieved on 19 May 2022, using relevant search terms. VOSviewer and CiteSpace were used to conduct this bibliometric study. Results: The results showed that a total of 2,299 publications were retrieved from 656 academic journals with 48,549 co-cited references by 2,335 institutions from 65 countries/regions. The United States had the most publications among all the countries (n = 870, 37.8%) and the Harvard University contributed the most among all institutions (n = 57, 2.48%). The most productive academic journal on dexmedetomidine was Pediatric Anesthesia and the first co-cited journal was Anesthesiology. Mika Scheinin is the most productive author and Pratik P Pandharipande is the most co-cited author. Co-cited reference analysis and keyword analysis illustrated hot spots in the dexmedetomidine field including pharmacokinetics and pharmacodynamics, intensive care unit sedation and outcome, pain management and nerve block, and premedication and use in children. The effect of dexmedetomidine sedation on the outcomes of critically ill patients, the analgesic effect of dexmedetomidine, and its organ protective property are the frontiers in future research. Conclusion: This bibliometric analysis provided us with concise information about the development trend and provided an important reference for researchers to guide future research.

Nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children: a single centre audit

The purpose of this study is to audit the efficacy and safety of intranasal dexmedetomidine sedation for non-invasive procedural sedation in children provided by nurses of the procedural sedation (PROSA) team in the University Hospitals Leuven. Efficacy (successful sedation as sole sedative) and safety (cardiorespiratory monitoring, saturation) were assessed. In this audit, prospectively recorded data were extracted from the medical files in 772 patients between 4 weeks to 18 years old, who underwent sedation with intranasal dexmedetomidine (2-4 µg/kg) by the nurse-driven PROSA team, following pre-screening on risk factors. Ninety-one percent of the patients were successfully sedated (single dose, monotherapy), 60 patients (7.8%) needed an additional intervention during sedation, 37 (4.8%) needed an extra dose of intranasal dexmedetomidine, and 14 (1.8%) received an additional other sedative. Successful sedation rates were higher in younger children, and medical imaging was the most common indication. Sedation failed in 12 (1.6%) patients, with 10 of them failed to fall asleep. Adverse events were limited in number (n = 13, 1.7%) and severity: 4 patients had a low heart rate (one received atropine), one had an irregular heart rate, and 7 desaturation events were described. Hypotension was treated with normal saline in one case.

CONCLUSIONS

In this nurse-driven PROSA setting, intranasal dexmedetomidine is effective and safe for non-invasive procedural sedation in an a priori low risk group of paediatric patients.

WHAT IS KNOWN

• Procedural sedation outside the operating theatre or intensive care units is increasingly used, including sedation performed by non-anaesthesiologists or nurses. This resulted in the development of procedural sedation and analgesia (PROSA) teams. • Off-label use of intranasal dexmedetomidine in children is increasing, with a limited number of audits on this practice, its safety and efficacy.

WHAT IS NEW

• In an audit on 772 procedures, nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children within a structured framework was safe and effective. • Imaging (CT, MRI) was the most common procedural indication in our study, but also nuclear imaging techniques were included.

Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis

BACKGROUND

Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0-8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques.

METHODS

Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0-8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events.

RESULTS

Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91-0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92-0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14-0.65); for oral pentobarbital 99% (95% CI: 0.90-1.00); for rectal thiopental 92% (95% CI: 0.85-0.96); for oral melatonin 75% (95% CI: 0.54-0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38-0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78-0.99); and for inhaled sevoflurane 98% (95% CI: 0.97-0.99).

CONCLUSIONS

We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease

BACKGROUND

Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children.

METHODS

Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg.

RESULTS

A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg.

CONCLUSIONS

Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

Dexmedetomidine premedication increases preoperative sedation and inhibits stress induced by tracheal intubation in adult: a prospective randomized double-blind clinical study

OBJECTIVE

The aim of this prospective randomized double-blind study is to evaluate whether oral dexmedetomidine (DEX) premedication could increase sedation in order to reduce preoperative anxiety and inhibit stress response during general anesthesia tracheal intubation.

MATERIALS

A total of 100 ASA I and II adult patients undergoing elective neurosurgery were randomly divided into the control group (C group, n = 50) and the oral DEX premedication (DEX group, n = 50). Patients were administrated 4 μg/kg dexmedetomidine orally pre-anesthesia 120 min. Hemodynamic variables were monitored and recorded from premedication to 10 min after tracheal intubation. The primary outcome, the sedation level of all participants, was evaluated by Richmond Agitation Sedation Scale (RASS), and Numerical Rating Scale was to measure their intensity of thirst and satisfaction of patients' family members. During general anesthesia induction, the total dosage of induction anesthetics and complications relative to anesthesia induction were recorded. After tracheal intubation, blood sample was drain from radial atrial line to measure levels of adrenocorticotropic hormone (ACTH) and cortisol.

RESULTS

RASS scores at 60 min after premedication and on arrival in the operating room were significantly reduced in the DEX group (P < 0.001). Oral DEX premedication not only increased the intensity of thirst but also the satisfaction of their family members (P < 0.001). The cortisol level after tracheal intubation was deduced by oral DEX premedication (P < 0.05). Oral DEX premedication reduced heart rate (HR) and mean arterial pressure (MAP) on arrival in the operating room, and HR when tracheal intubation (P < 0.05). During the whole process of anesthesia induction, although the lowest MAP in two groups were not significantly different, the lowest HR was significantly lower in the DEX group (P < 0.05). Oral DEX premedication might reduce HR from premedication to 10 min after tracheal intubation. However MAP was reduced just from premedication to on arrival in the operating room. Total induction dosages of propofol, midazolam, sulfentanil and rocuronium were similar in two groups (P > 0.05), as well as the complications relative to anesthesia induction and cases of rescue dopamine therapy were similar (P > 0.05).

CONCLUSION

Oral DEX 4 μg/kg premedication was an efficient intervention to increase preoperative sedation and reduce stress reaction induced by general anesthesia tracheal intubation, but also it was with the stable hemodynamic during the process of general anesthesia tracheal intubation, and improved the satisfaction of patients' family members. In this study, the sparing-anesthetic effect of 4 μg/kg DEX oral premedication was not significant, and this would be needed to study in future.

TRIAL REGISTRATION

This trail was registered at Chinese Clinical Trial Registry ( https://www.chictr.org.cn , Jie Gao) on 15/04/2021, registration number was ChiCTR2100045458.

Dexmededomidine in pediatric unilateral internal inguinal ring ligation

BACKGROUND

Safe and effective analgesia strategy remains one of the priorities for pediatric inguinal hernia treatment.

AIM

To explore safety and efficacy of dexmededomidine monotherapy for postoperative analgesia in children who received laparoscopic unilateral internal inguinal ring ligation.

METHODS

This randomized single-center controlled trial included 390 children (aged 1-3 years, ASA grade I-II), randomly divided into a dexmededomidine group (D group), a dexmededomidine + sufentanil group (DS group), and a sufentanil group (S group). The primary endpoint was percentage of children with the Face, Legs, Activity, Cry, and Consolability (FLACC) score ≤ 3 points 2 h after surgery.

RESULTS

The comparisons of the FLACC scores at 2, 4, 6, 8, 12, and 24 h were not significantly different among the three groups (P > 0.05). The sedative effects in the D group were significantly better than those in the S group (P > 0.05), but not significantly different from those in the DS group. The incidence of nausea and vomiting was significantly lower in the D group than in the S group and DS group (P > 0.05).

CONCLUSION

Analgesic effects of dexmededomidine monotherapy are comparable to those of sufentanil alone or in combination with dexmededomidine for children who underwent laparoscopic unilateral internal inguinal ring ligation, with better sedative effects and a lower incidence of adverse events.

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.

A Single Low Dose of Dexmedetomidine Efficiently Attenuates Esketamine-Induced Overactive Behaviors and Neuronal Hyperactivities in Mice

Introduction: Esketamine (Esk) (S(+)-ketamine) is now used as an alternative to its racemic mixture, i. e., ketamine in anesthesia. Esk demonstrated more powerful potency and rapid recovery in anesthesia and less psychotomimetic side effects comparing with ketamine, but Esk could still induce psychological side effects in patients. This study was to investigate whether dexmedetomidine (Dex) can attenuate the Esk-induced neuronal hyperactivities in Kunming mice. Methods: Dexmedetomidine 0.25, 0.5, and 1 mg/kg accompanied with Esk 50 mg/kg were administrated on Kunming mice to assess the anesthesia quality for 1 h. The indicators, such as time to action, duration of agitation, duration of ataxia, duration of loss pedal withdrawal reaction (PWR), duration of catalepsy, duration of righting reflex (RR) loss, duration of sedation, were recorded for 1 h after intraperitoneal administration. The c-Fos expression in the brain was detected by immunohistochemistry and Western Blot after 1 h of administration. Considering the length of recovery time for more than 1 h in Dex and Dex with Esk groups, other mice were repeatedly used to evaluate recovery time from the administration to emerge from anesthesia. Results: Dexmedetomidine dose-dependently increased recovery time when administrated with Esk or alone. Dex combined with Esk efficiently attenuated the duration of agitation, ataxia, and catalepsy. Dex synergically improved the anesthesia of Esk by increasing the duration of sedation, loss of RR, and loss of PWR. Esk induced the high expression of c-Fos in the cerebral cortex, hippocampus, thalamus, amygdala, hypothalamus, and cerebellum 1 h after administration. Western Blot results indicated that Dex at doses of 0.25, 0.5, and 1 mg/kg could significantly alleviate the Esk-induced c-Fos expression in the mice brain. Conclusion: Dexmedetomidine ranged from 0.25 to 1 mg/kg could improve the anesthesia quality and decreased the neuronal hyperactivities and the overactive behaviors when combined with Esk. However, Dex dose-dependently increased the recovery time from anesthesia. It demonstrated that a small dose of Dex 0.25 mg/kg could be sufficient to attenuate Esk-induced psychotomimetic side effects without extension of recovery time in Kunming mice.

The Quest for a DISE Protocol

OBJECTIVE

The objective of this quality initiative project was to modify our existing institutional drug-induced sleep endoscopy (DISE) protocol so that the surgeon could consistently determine obstructive breathing patterns while minimizing children's discomfort.

METHODS

A quality initiative study utilizing the well-described plan-do-study-act (PDSA) process was conducted at a tertiary hospital for children with polysomnogram-documented obstructive sleep apnea who were undergoing DISE. A 4-point Likert measurement tool was created. Change in each Likert rating with subsequent PDSA cycle was tested with the Wilcoxon rank sum test (Mann-Whitney), and change across all PDSA cycles was tested with the Kruskal-Wallis equality-of-populations rank test.

RESULTS

After a series of 4 PDSA cycles with 81 children, the DISE protocol was streamlined from 14 to 9 steps. There was significant improvement for all aspects of the DISE, with a final overall median rating of 1 (excellent) for intravenous (IV) placement, scope insertion, and anesthesiologist and surgeon satisfaction (P < .01).

DISCUSSION

For sleep surgeons, DISE is quickly becoming what bronchoscopy is to the airway surgeon. Utilizing inhalational agents to obtain IV access and insert the flexible scope in the rapid "on-off" fashion optimizes DISE success regardless of the primary sedation medication and allows ample time for these agents to dissipate.

IMPLICATIONS FOR PRACTICE

Adoption of a DISE protocol that includes nasal premedication and inhalational volatile gases for IV and scope insertion at the onset provides a more predictable level of sedation that is well tolerated by the patient, enabling the otolaryngologist to create an obstructive sleep apnea treatment plan.

Intranasal dexmedetomidine combined with local anesthesia for conscious sedation during breast lumpectomy: A prospective randomized trial

Breast lumpectomy is usually performed under general or local anesthesia. To the best of our knowledge, whether conscious sedation with intranasal dexmedetomidine and local anesthesia is an effective anesthetic technique has not been studied. Thus, the present study aimed to investigate the effectiveness of conscious sedation with intranasal dexmedetomidine combined with local anesthesia in breast lumpectomy, and to identify its optimal dose. A prospective randomized, double-blinded, placebo-controlled, single-center study was designed, and patients undergoing breast lumpectomies were recruited based on the inclusion and exclusion criteria. All patients were randomly allocated to four groups: i) Local anesthesia with 0.9% intranasal saline (placebo); local anesthesia with ii) 1 µg.kg⁻¹; iii) 1.5 µg.kg⁻¹; or iv) 2 µg.kg⁻¹ intranasal dexmedetomidine. The sedation status, pain relief, vital signs, adverse events, and satisfaction of patient and surgeon were recorded. Patients in the three dexmedetomidine groups were significantly more sedated and experienced less pain compared with the placebo group 45 min after intranasal dexmedetomidine administration and during 30 min in the post-anesthesia care unit. Patients in the 1.5 µg.kg⁻¹ group were more sedated compared with the 1 µg.kg⁻¹ group (without reaching statistical significance), whereas the 1.5 µg.kg⁻¹ group exhibited a similar level of sedation 45 min after intranasal dexmedetomidine administration compared with the 2 µg.kg⁻¹ group. In addition, patients in the 1 and 1.5 µg.kg⁻¹ group experienced no adverse hemodynamic effects. Patient and surgeon satisfaction were greater in the 1.5 µg.kg⁻¹ group compared with the 1 and 2 µg.kg⁻¹ groups. Taken together, the results of the present study suggested that conscious sedation with intranasal dexmedetomidine and local anesthesia may be an effective anesthetic for breast lumpectomy surgery, and that the optimal dose for intranasal dexmedetomidine administration may be 1.5 µg.kg⁻¹, as it resulted in good sedation and patient satisfaction without adverse effects.