Efficacy of midazolam as oral premedication in children in comparison to triclofos sodium

Role of nebulised dexmedetomidine, midazolam or ketamine as premedication in preschool children undergoing general anaesthesia-A prospective, double-blind, randomised study

Background and Aims

Preschool age children are psycho-biologically vulnerable to all surgical procedures. In this study, we investigated the effect of nebulised dexmedetomidine, midazolam and ketamine as sedative premedication for alleviating parental separation anxiety, facilitating face mask acceptance and reducing emergence agitation in paediatric patients undergoing general anaesthesia.

Methods

A prospective, randomised, double-blind study was done involving 96 children of age 3-7 years, randomly allocated into three equal groups and pre-medicated with either nebulised dexmedetomidine 2 mg/kg (GroupD), midazolam 0.2 mg/kg (GroupM) or ketamine 2 mg/kg (Group K). The scores of sedation scale, parental separation anxiety scale, mask acceptance scale and emergence agitation scale were recorded along with haemodynamic parameters. Two-way repeated measures analysis of variance (ANOVA), post hoc test and Kruskal-Wallis test were used for statistical analysis.

Results

A statistically significant difference in sedation score was seen between the different study groups, χ²(2) = 8.561, P = 0.014 with mean rank sedation score of 56.50 for Group D, 38.92 for Group M and 43.84 for Group K. Parental separation anxiety scale score and Mask acceptance scale score also showed statistically significant difference between the different study groups, χ²(2) = 9.369, P = 0.009 and χ²(2) = 11.97, P = 0.003, respectively.

Conclusion

Nebulisation with dexmedetomidine produced easy parental separation, more satisfactory sedation and face mask acceptance with less postoperative agitation than nebulisation with midazolam or ketamine.

Enhancing cooperation during pediatric ultrasound: Oral midazolam versus conventional techniques

Background and Aims:

Ultrasound is a safe and non-invasive method for detecting numerous pathologies. Pediatric patients are often uncooperative which leads to decreased quality and increased time of scan. We compared the conventional means alone and combination of oral midazolam for the above cited purpose.

Material and Methods:

This double blind prospective study (CTRI/2016/06/007030) was conducted after obtaining due approval from institutional ethical committee. One hundred Children aged 2-6 years belonging to ASA class 1 or 2, posted for high resolution ultrasonography of abdomen were included in the study. They were randomised to receive midazolam 0.3 mg/kg mixed in 20 mL of apple juice (Group I) or 20 mL of apple juice alone (Group II) 20 minutes prior to the procedure. The parameters assessed were level of cooperation, sonologist's satisfaction, total scan time, heart rate and SpO₂.

Results:

Out of 100 patients, 44 patients of group I and 42 of group II were analysed. The cooperation score was significantly higher in Group I (35%) than Group II (19%). Likert scale revealed very satisfied and satisfied rating in 61.3% (Group I) and 21.4% (Group II). The time taken by sonologist and number of attempts were significantly less in Group I than Group II. There was no difference in discharge time between the groups. There was no reportable adverse event in either group.

Conclusion:

Oral midazolam is a safe and effective agent to aid routine abdominal ultrasonography in pediatric patients.

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.

Efficacy of intranasal dexmedetomidine versus oral midazolam for paediatric premedication

Background and Aims:

Premedication is an integral component of paediatric anaesthesia which, when optimal, allows comfortable separation of the child from the parent for induction and conduct of anaesthesia. Midazolam has been accepted as a safe and effective oral premedicant. Dexmedetomidine is a selective alpha-2 agonist with sedative and analgesic effects, which is effective through the transmucosal route. We compared the efficacy and safety of standard premedication with oral midazolam versus intranasal dexmedetomidine as premedication in children undergoing elective lower abdominal surgery.

Methods:

This was a prospective randomised double-blinded trial comparing the effects of premedication with 0.5 mg/kg oral midazolam versus 1 μg/kg intranasal dexmedetomidine in children between 2 and 12 years undergoing abdominal surgery. Sedation scores at separation and induction were the primary outcome measures. Behaviour scores and haemodynamic changes were secondary outcomes. Student's t-test and Chi-square were used for analysis of the variables.

Results:

Sedation scores were superior in Group B (dexmedetomidine) than Group A (midazolam) at separation and induction (P < 0.001). The behaviour scores at separation, induction and wake up scores at extubation were similar between the two groups. The heart rate and blood pressure showed significant differences at 15, 30 and 45 min in Group B but did not require pharmacological intervention for correction.

Conclusion:

Intranasal dexmedetomidine at a dose of 1 μg/kg produced superior sedation scores at separation and induction but normal behavioural scores in comparison to oral midazolam in paediatric patients.