Comparison of Oral Clonidine, Oral Dexmedetomidine, and Oral Midazolam for Premedication in Pediatric Patients Undergoing Elective Surgery

Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam.

The Beneficial Effect of Preoperative dexmedetomidine in controlling postoperative pain, nausea, and Vomiting After Orthognathic Surgery: A Triple-blind Randomized Clinical Trial

PURPOSE

Controlling postoperative pain and nausea (PONV) following orthognathic surgery can be challenging. The aim of the study was to assess the efficacy of dexmedetomidine (DEX) in reducing pain and preventing nausea and vomiting in subjects undergoing orthognathic surgery.

METHODS

The authors implemented a triple-blinded, randomized clinical trial. Healthy adults with class III jaw deformity scheduled for bimaxillary orthognathic surgery were included. Subjects were randomized to the DEX or placebo groups. The DEX group received premedication with DEX 1 μg/kg IV over 10 minutes followed by a maintenance dose (0.2 μg/kg/hour). while the placebo group received normal saline. The primary outcome variables were postoperative pain, postoperative nausea, and postoperative vomiting . Pain was assessed using a visual analog scale at 1, 3, 6, 12, 18, and 24 hours, postoperatively). Nausea and vomiting were recorded throughout the postoperative period. Statistical analysis was performed using χ², t test, and repeated measures ANOVA with a P value < .05 considered significant.

RESULTS

A total of 60 consecutive subjects with a mean age of 24.6 ± 3.5 years completed the study. There were 38 females (63.33%) and 22 males (36.66%). The mean visual analog scalewas significantly lower in the DEX group at all time-points (P < .05). There was a significantly greater demand for rescue analgesics in the placebo group compared to the DEX group (P = .01). Fourteen subjects (46.7%) in the placebo group and one subject (3.3%) in the DEX group reported nausea (P < .001). Postoperative vomiting was not observed in any of the subjects.

CONCLUSION

Premedication with DEX can be considered a viable treatment option for reducing postoperative pain and postoperative nausea after bimaxillary orthognathic surgery.

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.

Cardiorespiratory Response to Sedative Premedication in Preschool Children: A Randomized Controlled Trial Comparing Midazolam, Clonidine, and Dexmedetomidine

PURPOSE

Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia.

DESIGN

A single-center randomized controlled trial.

METHODS

This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2-6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg^-1 (MID), oral clonidine 4 mcg/kg^-1 (CLO), or intranasal dexmedetomidine 2 mcg/kg^-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period.

FINDINGS

The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min^-1, CLO 20.6±2.6 min^-1, DEX 20.2±1.7 min^-1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min^-1; CLO, 87.4±9.6 min^-1; DEX, 87.6±7.9 min^-1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group.

CONCLUSIONS

When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.

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.

Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries

Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction.

Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg⁻¹, Group D with intranasal dexmedetomidine 2 μg kg⁻¹, and Group M + D with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time.

Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001).

Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹ had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine

INTRODUCTION

Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2-6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation.

PATIENTS AND METHODS

In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2-6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively.

RESULTS

Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group.

CONCLUSIONS

In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.

Paediatric preoperative sedation practices in tertiary maternity and children's hospitals in China: a questionnaire survey

Background

Preoperative anxiety is a common problem in the paediatric population, and several studies have reported that it is related to adverse events such as emergence delirium and postoperative psychological and behavioural changes. In recent years, increasing attention has been paid to paediatric preoperative anxiety in China. A variety of strategies, including sedatives, parental presence, and audio-visual interventions, have been used to relieve paediatric preoperative anxiety, but there is no well-recognised procedure for paediatric preoperative sedation. Therefore, this study aimed to investigate current paediatric preoperative sedation practices in tertiary children’s hospitals in China.

Methods

All tertiary maternity and children’s hospitals registered with the National Health Commission of the People’s Republic of China were invited to participate in an electronic survey, which included information on the preoperative sedation caseload, sites where preoperative sedation was performed, preoperative sedation methods used in different age groups, choice of sedatives, contraindications for premedication, staff structure for sedative administration and monitoring, and patient-monitoring practices.

Results

All 81 hospitals participating in our study completed the survey, and 38 hospitals (46.9 %) provided their preoperative sedation protocols. Twenty-four hospitals performed fewer than 5,000 preoperative sedation cases annually, and 9 hospitals performed more than 10,000 cases annually. Preoperative sedation was performed in preoperative preparation areas, preoperative holding areas, and operation rooms in 47.4 %, 26.3 %, and 13.2 % of hospitals, respectively. Sedatives were the most used interventions for paediatric preoperative sedation in all age groups, and the most widely used sedatives were propofol (intravenous) and dexmedetomidine (intranasal). The most common contraindications were American Society of Anesthesiologists class ≥ 3, emergency operation, and airway infection within 2 weeks. Sedatives were administered mainly by anaesthesiologists (63.2 %), and children were monitored mainly by anaesthesiologists (44.7 %) and nurses (39.5 %) after administration. Pulse oximetry was the most widely used monitoring device.

Conclusions

Fewer than half of the tertiary maternity and children’s hospitals in China provide paediatric preoperative sedation service, and the service practices vary widely. Further improvements are required to ensure the quality of paediatric preoperative sedation services and establish standard operating procedures.

Retrospective Comparison of Intramuscular Admixtures of Ketamine and Dexmedetomidine Versus Ketamine and Midazolam for Preoperative Sedation

Precooperative children and patients with intellectual disabilities often require intramuscular (IM) sedation prior to the induction of general anesthesia (GA). Ketamine is an effective preinduction sedative but can produce significant adverse side effects. Dexmedetomidine, a sedative with sympatholytic and analgesic properties, may provide advantages when used in combination with ketamine. This retrospective study evaluated the efficacy and safety of IM ketamine with dexmedetomidine for preoperative sedation. We conducted a chart review of all patients (n = 105) treated for dental rehabilitation who received either IM ketamine and dexmedetomidine (study group, n = 74) or IM ketamine and midazolam (control group, n = 31) prior to induction of GA. No significant difference (p = .14) was observed in the time interval from IM administration to operating room entry (median [interquartile range]) between the study and control groups (5 [4-8] vs 5 [2-7] minutes). Patients who received IM dexmedetomidine exhibited significantly lower mean arterial pressures throughout the induction (p = .004) and had lower heart rates (p = .01) throughout the intraoperative period compared with patients who did not receive dexmedetomidine. The combination of dexmedetomidine and ketamine may provide effective and safe IM sedation prior to the induction of GA.

Dexmedetomidine is superior to midazolam for sedation and cerebral protection in postoperative hypertensive intracerebral hemorrhage patients: a retrospective study

OBJECTIVE

Dexmedetomidine has a good sedative effect and does not affect the judgment of the patient's consciousness level. However, its effectiveness for sedation and cerebral protection after craniotomy in hypertensive intracerebral hemorrhage (HICH) patients is unknown.

METHODS

A retrospective study of 164 postoperative HICH patients who underwent sedation with dexmedetomidine or midazolam was conducted. The Ramsay sedation score, mean arterial pressure (MAP), heart rate (HR), pulse oxygen saturation (SpO₂), and respiratory rate were measured at the indicated time points. Human soluble protein-100β (S-100β) and neuron-specific enolase (NSE) levels were also compared between the two groups.

RESULTS

Dexmedetomidine treatment showed a significantly better effect than midazolam on decreasing the frequency of apparent agitation. The MAP and HR, but not the SpO_2, were significantly decreased and lower than those in midazolam group. Detection of plasma S-100β and NSE proteins revealed a significant decrease in the dexmedetomidine group compared with the midazolam group. The 6-month follow-up evaluation indicated a significantly better prognosis of postoperative HICH patients treated with dexmedetomidine than for those treated with midazolam.

CONCLUSIONS

Dexmedetomidine is effective for sedation in postoperative HICH patients and may be beneficial for their outcome.

A Comparative Evaluation of Oral Clonidine, Dexmedetomidine, and Melatonin As Premedicants in Pediatric Patients Undergoing Subumbilical Surgeries

INTRODUCTION

Sedative premedication is the mainstay of pharmacological therapy in children undergoing surgeries. This study compares preoperative melatonin, clonidine, and dexmedetomidine on sedation, ease of anesthesia induction, emergence delirium, and analgesia.

MATERIALS AND METHODS

One hundred and five children, 3-8 years, either sex, ASA I/II, posted for infraumbilical surgery, randomized to receive clonidine 5 mcg/kg (Group C), dexmedetomidine 3 mcg/kg (Group D), and melatonin 0.2 mg/kg (Group M) 45 minutes before surgery. Preoperative Sedation/Anxiety and Child-Parent Separation Score (CPSS) were assessed. Identical anesthesia technique was utilized. Emergence delirium (Watcha score) and postoperative pain (Objective Pain Scale score) were monitored postoperatively.

RESULTS

Patients were demographically comparable. Sedation score >Grade 3 was absent. Grades 1/2/3 were present in 10/19/6 (Group C), 2/26/7 (Group D), and 7/26/2 (Group M). Grade 1 CPSS was present in 42.6% (Group C), 37.1% (Group D), and 28.6% (Group M). Pediatric Anesthesia Behavior Score (PABS) was comparable between Groups C and D (p = 0.224; 95% CI -0.090 to 0.604) and Groups C and M (p = 0.144; 95% CI -0.633 to 0.061) while PABS was better in Group D compared to Group M (p = 0.0007; 95% CI -0.890 to -0.195). Watcha scores were 33/2/0/0 (Group C), 34/1/0/0 (Group D), and 32/2/1/0 (Group M) immediately after extubation. Scores were 31/4/0/0 (Group C), 33/2/0/0 (Group D), and 31/4/0/0 (Group M) at 30 minutes and 28/7/0/0 (Group C), 29/6/0/0 (Group D), and 24/11/0/0 (Group M) at 1 hour. The scores were comparable (p > 0.05). Objective Pain Scale scores were comparable between Groups C and D and Groups C and M (p > 0.05). Lower scores were present in Group D compared to M (p = 0.023).

CONCLUSION

Melatonin, clonidine, and dexmedetomidine are efficacious for producing preoperative sedation, reducing anxiety, postoperative pain, and emergence delirium.

A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis

Background

The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions.

Methods

PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences.

Results

We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups.

Conclusions

Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

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.

Safety and efficacy of clonidine on postoperative vomiting and pain in pediatric ophthalmic surgery: A systematic review and meta-analysis

BACKGROUND

Postoperative vomiting and pain are common, unpleasant phenomena in pediatric patients undergoing ophthalmic surgery. Clonidine has antiemetic and analgesic properties and thus may be used as premedication to reduce postoperative vomiting and pain.

AIM

To assess whether clonidine premedication may safely decrease postoperative vomiting and postoperative pain in pediatric patients who received an ophthalmic surgery.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases from their inception to September 2018. Randomized clinical trials comparing clonidine premedication with a placebo or an active comparator that investigated postoperative vomiting or postoperative pain in pediatric patients undergoing ophthalmic surgery were included. The primary outcome was postoperative vomiting. The secondary outcome was postoperative pain. We also evaluated the safety of clonidine premedication by tracking hemodynamic instability associated with its use.

RESULTS

Ten studies with 979 patients were eligible for inclusion. Clonidine achieved a significantly lower incidence of postoperative vomiting within 6 hours postoperatively, 6-24 hours postoperatively, and at the end of the study (risk difference: -0.15; 95% confidence interval: -0.32 to -0.05; risk difference: -0.15; 95% confidence interval: -0.29 to 0.01; and risk difference: -0.23; 95% confidence interval: -0.34 to -0.12, respectively) than placebo. For the subgroup of patients who received strabismus surgery, clonidine produced a lower incidence of postoperative vomiting than placebo (risk difference: -0.19; 95% confidence interval: -0.29 to -0.05). Compared to benzodiazepine, clonidine achieved a lower incidence of postoperative vomiting at the end of the study (risk difference: -0.19; 95% confidence interval: -0.31 to -0.07); the effect was only observed in patients receiving clonidine 4 μg/kg. Furthermore, children receiving clonidine had lower postoperative pain scores, lower analgesic requirements, and more of them were pain-free compared to those who received a placebo. No patient using clonidine had any major hemodynamic instability.

CONCLUSION

Compared to placebo or benzodiazepine, clonidine premedication was effective in reducing postoperative vomiting in pediatric patients undergoing ophthalmic surgery. Clonidine premedication also provided more reduction in postoperative pain when compared to placebo. The use of clonidine premedication was not associated with adverse hemodynamic events.

Clonidine in pediatric anesthesia: the new panacea or a drug still looking for an indication?

PURPOSE OF REVIEW

Clonidine, an α2-receptor agonist is a widely used drug in pediatrics with a large scope of indications ranging from prevention of postoperative emergence agitation, analgesia, anxiolysis, sedation, weaning to shivering. In the era of 'opioid-free' medicine with much attention be directed toward increasing problems with opioid use, clonidine due to its global availability, low cost and safety profile has become an even more interesting option.

RECENT FINDINGS

Increasing evidence from randomised clinical trials support the use of clonidine in healthy children in the perioperative setting. Clonidine appears to significantly reduce postoperative emergence agitation, opioid consumption, shivering, nausea and vomiting. In addition, emerging evidence support the use of clonidine for sedation of critically ill children in ICUs. In this review, the current evidence for clonidine in pediatrics is described and analyzed including a meta-analysis for prevention of emergence agitation.

SUMMARY

Clonidine appears a safe and beneficial drug with moderate to high-quality evidence supporting its use in pediatric anesthesia. However, for some indications and populations such as children younger than 12 months old and those with hemodynamic instability, there is an urgent need for high-quality trials.

Effect of ancillary drugs on sevoflurane related emergence agitation in children undergoing ophthalmic surgery: a Bayesian network meta-analysis

BACKGROUND

The comparative efficacy of ancillary drugs on sevoflurane related emergence agitation (EA) in children undergoing ophthalmic surgery remains controversial.

METHODS

The databases were retrieved in an orderly manner from the dates of their establishment to October, 2018, including PubMed, The Cochrane Library and Web of Science, to collect randomized controlled trials (RCT) of different anesthetic drugs combined with sevoflurane for ophthalmic surgery. Then a network meta-analysis was conducted using R and Stata 12.0 softwares.

RESULTS

The meta-analysis showed that, in reducing sevoflurane related EA, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine were superior to placebo (P < 0.05). The network meta-analysis showed that the effects of ancillary drugs combine with sevoflurane in reducing risk of EA in children undergoing ophthalmic surgery was superior to placebo: dexmedetomidine (OR = 0.17, 95% CrI 0.12-0.22), ketamine (OR = 0.30, 95% CrI 0.11-0.49), propofol (OR = 0.24, 95% CrI 0.09-0.63), fentanyl (OR = 0.16, 95% CrI 0.08-0.56), midazolam (OR = 0.20, 95% CrI 0.09-0.40), sufentanil (OR = 0.27, 95% CrI 0.14-0.41), remifentanil (OR = 0.18, 95% CrI 0.08-0.54) and clonidine (OR = 0.14, 95% CrI 0.07-0.41). The SUCRA of placebo, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil, clonidine were respectively 0.26, 77.93, 27.71, 42.8, 69.43, 52.89, 59.83, 57.62 and 61.53%.

CONCLUSIONS

The effects of dexmedetomidine combine with sevoflurane in reducing risk of emergence agitation in children undergoing ophthalmic surgery was superior to other drugs.

Description of typical personality factors and events that lead to anxiety at induction of anesthesia in French children

BACKGROUND

Preventive strategies are available to reduce preoperative anxiety in children, the ideal time for implementing such strategies remains poorly determined.

AIMS

The aim of this study was to determine psychological factors and events involved in the development of preoperative anxiety in children.

METHODS

This study consisted of prospective evaluations of anxiety trait and state during the preoperative period. Attendance at a preanesthetic consultation is obligatory for all patients undergoing surgery in France. Anxiety trait and state assessments were quantified in mothers and children before and after the preanesthetic consultation using visual analog and faces numerical scales. Preoperative anxiety in children was assessed immediately before induction of anesthesia using an analog scale. Other data recorded included demographic and medical data and type of hospital stay. Univariate and multivariate logistic regression analyses were used.

RESULTS

Overall 111 consecutive patients were included. The following factors emerged leading to anxiety state at induction of anesthesia: maternal anxiety state before the preanesthetic consultation, a feeling of not being reassured by the anesthesiologist, maternal anxiety state after the consultation, and anxiety trait in the child. Logistic regression found this combination of factors (OR = 4 [1.4 -12]) and inpatient stay (OR = 3 [1.4-7]), predicting anxiety with an accuracy of 69%.

CONCLUSION

The present study identified a combination of psychological factors and events associated with the development of anxiety at induction of anesthesia in children. Parental anxiety impacts upon children and occurs before the preanesthetic consultation. This result may assist clinicians to prescribe personalized preventive strategies against anxiety.

Palliative Sedation with Oral Medicines in an Infant with Generalized Severe Junctional Epidermolysis Bullosa

Generalized severe junctional epidermolysis bullosa is a rare mechanobullous skin disorder that is uniformly fatal. We present the case of an infant who received palliative pain management and ultimately proportionate palliative sedation. However, because of the extent of the patient's skin disease, we were unable to provide palliative medication through parenteral routes. We discuss the provision of enteral palliative sedation, including the pharmacology, and creative use of medications to achieve sufficient palliation in this difficult and unique situation.

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

Background

Premedication is the most common way to minimize distress in children entering the operating room and to facilitate the smooth induction of anesthesia and is accomplished using various sedative drugs before the children are being transferred to the operating room. The aim of this study was to compare the effect of oral dexmedetomidine (DEX) and oral midazolam (MID) on preoperative cooperation and emergence delirium (ED) among children who underwent dental procedures at our hospital between 2016 and 2017.

Patients and methods

The medical records of 52 children, who were American Society of Anesthesiologists I, aged between 3 and 7 years, and who underwent full-mouth dental rehabilitation under general anesthesia (GA), were evaluated. Twenty-six patients were given 2 µg/kg of DEX, while another 26 patients were given 0.5 mg/kg of MID in apple juice as premedication agents. The patients’ scores on the Ramsay Sedation Scale (RSS), Parental Separation Anxiety Scale (PSAS), Mask Acceptance Scale, Pediatric Anesthesia Emergence Delirium Scale (PAEDS), and hemodynamic parameters were recorded from patients’ files. The level of sedation of children had been observed just before premedication and at 15, 30, and 45 min after premedication. The data were analyzed using a chi-square test, Fisher’s exact test, Student’s t-test, and analysis of variance in SPSS.

Results

The Mask Acceptance Scale and PSAS scores and RSS scores at 15, 30, and 45 min after premedication were not statistically different (p>0.05) in both groups, whereas the PAEDS scores were significantly lower in the DEX group (p<0.05).

Conclusion

Oral DEX provided satisfactory sedation levels, ease of parental separation, and mask acceptance in children in a manner similar to MID. Moreover, children premedicated with DEX experienced lesser ED than those premedicated with MID.

The Effect of Oral Dexmedetomidine Premedication on Preoperative Cooperation and Emergence Delirium in Children Undergoing Dental Procedures

INTRODUCTION

The aim of this study was to detect the effect of 1 μg/kg of oral dexmedetomidine (DEX) as premedication among children undergoing dental procedures.

MATERIALS AND METHODS

The study involved 100 children between 2 and 6 years of age, ASA I, who underwent full-mouth dental rehabilitation. The DEX group (n = 50) received 1 μg/kg DEX in apple juice, and the control group (n = 50) received only apple juice. The patients' scores on the Ramsay Sedation Scale (RSS), parental separation anxiety scale, mask acceptance scale, and pediatric anesthesia emergence delirium scale (PAEDS) and hemodynamic parameters were recorded. The data were analyzed using chi-square test, Fisher's exact test, Student's t-test, and analysis of variance in SPSS.

RESULTS

RSS scores were significantly higher in the DEX group than group C at 15, 30, and 45 min (p < 0.05). More children (68% easy separation, 74% satisfactory mask acceptance) in the DEX group showed satisfactory ease of parental separation and mask acceptance behavior (p < 0.05). There was no significant difference in the PAEDS scores and mean hemodynamic parameters of both groups.

CONCLUSIONS

Oral DEX administered at 1 μg/kg provided satisfactory sedation levels, ease of parental separation, and mask acceptance in children but was not effective in preventing emergence delirium. The trial was registered (Protocol Registration Receipt NCT03174678) at clinicaltrials.gov.