Is midazolam superior to triclofos and hydroxyzine as premedicant in children?

Safety and efficacy of oral Triclofos in the ophthalmic evaluation of children with pediatric glaucoma: An observational study

Purpose:

Oral Triclofos is widely used as a sedative agent in children. However, the role of Triclofos as a sedative agent in children undergoing ophthalmological procedures has not been adequately studied. The aim of this study was to determine the safety and efficacy of oral Triclofos in children suffering from pediatric glaucoma who were undergoing ocular examination.

Methods:

80 children aged less than 5 years were assessed for eligibility for the trial after taking hospital ethical committee approval. The children were administered 80 mg/kg of oral Triclofos and Ramsay sedation score was measured every 5 min starting from 20 min after administration of the drug. If the child was not adequately sedated after 30 min, additional dose of 05 mg/kg was administered every 5 min till 60 min of drug administration. The procedure was considered a failure and general anesthesia (GA) administered if Ramsay sedation score was ≤4 after 60 min of initial drug administration. Heart rate and arterial oxygen saturation were measured throughout the period of sedation. The duration of sedation and incidence of side effects was also noted.

Results:

A total of 73 patients underwent the study. The mean age of children was 23.4 months (SD – 14.72) and mean weight was 12 kg (SD – 3.84). The mean dose of Pedicloryl (Triclofos) used was 83.8 mg/kg and the median duration of onset was 25 min. 64 children completed examination successfully, 2 children had to be administered GA during the procedure. There were no major side effects.

Conclusion:

Administration of oral Triclofos in a dose of 80 mg/kg body weight was safe and effective in children less than 5 years of age undergoing ocular examination.

Self-produced audio-visual animation introduction alleviates preoperative anxiety in pediatric strabismus surgery: a randomized controlled study

Background

Hospital anxiety caused by strabismus surgery has an unpleasant and disturbing feeling for both children and their parents. This study aimed to determine the effect of viewing a self-produced audio-visual animation introduction on preoperative anxiety and emergence agitation of pediatric patients undergoing strabismus surgery.

Methods

In this prospective randomized study, 1 hundred children scheduled for strabismus surgery with aged 3 ~ 6 years. The children were randomly divided into 2 groups (n = 50 for each), Group A: using a self-produced audio-visual animation introduction; Group C: controlled group without audio-visual animation introduction. Children’s preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) at different time points: the night before surgery(T1), at pre-anesthetic holding room(T2), and just before anesthesia induction(T3). The Spielberger State-Trait Anxiety Inventory (STAI) was used to record the anxiety of parents at T1,T2 and T3. The incidence and the degree of emergence agitation were recorded.

Results

The mYPAS scores at T2 and T3 were higher than T1(p < 0.05) in both groups. The average score of mYPAS in Group A was significantly lower than in Group C at T2 and T3(p < 0.05). The STAI scores in Group A at T2 and T3 were significantly lower than in Group C(p < 0.05). The incidence of agitation in Group A was lower than that in Group C(p < 0.05).

Conclusions

Based on the findings, viewing a self-produced audio-visual animation can effectively alleviate the preoperative anxiety for both children and their parents in pediatric strabismus surgery, and it was effective for reducing emergence agitation as well.

Trial registration

The trial was prospectively registered before patient enrollment at Chinese Clinical Trial Registry (Clinical Trial Number: ChiCTR1900025116, Date: 08/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01922-6.

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.

Triclofos Sodium for Pediatric Sedation in Non-Painful Neurodiagnostic Studies

AIM

Triclofos sodium (TFS) has been used for many years in children as a sedative for painless medical procedures. It is physiologically and pharmacologically similar to chloral hydrate, which has been censured for use in children with neurocognitive disorders. The aim of this study was to investigate the safety and efficacy of TFS sedation in a pediatric population with a high rate of neurocognitive disability.

METHODS

The database of the neurodiagnostic institute of a tertiary academic pediatric medical center was retrospectively reviewed for all children who underwent sedation with TFS in 2014. Data were collected on demographics, comorbidities, neurologic symptoms, sedation-related variables, and outcome.

RESULTS

The study population consisted of 869 children (58.2% male) of median age 25 months (range 5-200 months); 364 (41.2%) had neurocognitive diagnoses, mainly seizures/epilepsy, hypotonia, or developmental delay. TFS was used for routine electroencephalography in 486 (53.8%) patients and audiometry in 401 (46.2%). Mean (± SD) dose of TFS was 50.2 ± 4.9 mg/kg. Median time to sedation was 45 min (range 5-245), and median duration of sedation was 35 min (range 5-190). Adequate sedation depth was achieved in 769 cases (88.5%). Rates of sedation-related adverse events were low: apnea, 0; desaturation ≤ 90%, 0.2% (two patients); and emesis, 0.35% (three patients). None of the children had hemodynamic instability or signs of poor perfusion. There was no association between desaturations and the presence of hypotonia or developmental delay.

CONCLUSION

TFS, when administered in a controlled and monitored environment, may be safe for use in children, including those with underlying neurocognitive disorders.

Impact of Etiology on Efficacy of Oral Triclofos in Recording Pediatric Electroencephalography: A Tertiary Care Center Study

Background and Objectives:

Oral triclofos is a frequently used sedative in pediatric age to record sleep Electroencephalography (EEG). This study is aimed to assess efficacy, safety profile, need for second dose, and rescheduling of oral triclofos in relation to etiology.

Materials and Methods:

This is a retrospective study done enrolling all children aged 6 months to 5 years referred for EEG over 1 year. After a trial for natural sleep, the first dose of oral triclofos was given. If a child does not sleep after an hour, the second dose was given and rescheduled if does not sleep even with the second dose. Age, sex, diagnosis, sleep latency, sleep duration, adverse effects, EEG findings, patients needing second dose, and rescheduling were noted. Descriptive statistics and Chi-square test were used to analyze data.

Results:

A total of 384 children required oral triclofos. The common etiologies for sleep study were atypical febrile seizures, hypoxic-ischemic encephalopathy (HIE) sequelae, and behavioral disorders such as autism and attention-deficit hyperactive disorder (ADHD). Including the second dose, we were able to successfully record sleep EEG in 372 (96.8%) patients. Rescheduling was required in 3.2% of patients. Mean sleep-onset latency was 36 min and mean sleep duration was 84 min. Single dose was sufficient in 329 (85.6%) and the second dose in 55 (14.4%). Thirty (38.5%) children of HIE sequelae (P < 0.001) required the second dose followed by behavioral disorders (29.1%, P = 0.03). Irritability, vomiting, and dizziness were common side effects which resolved spontaneously.

Conclusions:

Oral triclofos was effective as sedative for recording EEG. Children with HIE sequelae and behavioral disorders such as autism/ADHD more commonly required second dosing and rescheduling.

Comparison of Oral Triclofos and Oral Midazolam as Premedication in Children undergoing Elective Surgery

Background:

Children who have experienced previous hospital admission, operation, procedures, and needle pricks are more reactive to subsequent anesthetic procedures. Many sedative agents have been used for the purpose of premedication, but few of them can be given orally, thus avoiding the pricks. Midazolam, being one such choices, can be given orally, intranasally, and parenterally but has unpredictable response. Triclofos, available as sweet syrup, is a phosphorylated derivative of chloral hydrate, has been proven to be effective within 30 min in doses of 25–75 mg/kg. Hence, this study compares triclofos hydrochloride with midazolam oral to know the efficacy of both the drugs as premedication.

Aim:

This study aims to assess sedation score, level of anxiety/resistance, and behavior of the child in the preoperative period.

Settings and Design:

After parental and institutional approval, a total of 70 children were studied based on computer-generated randomization and divided into groups M and T of 35 each.

Materials and Methods:

Group M patients received oral midazolam 0.5 mg/kg. Group T patients received commercially available triclofos syrup containing 100 mg/ml of drug in dose of 75 mg/kg. The response of children to taste of premedication was noted, whether completely ingested or not. In case of vomiting, the child was excluded from further study.

Statistical Analysis:

Numerical variables were analyzed using Student's paired t-test and other variables using Mann–Whitney U-test, Fisher exact test, and Friedman ANOVA.

Results:

Sedation score at 5 min interval from 0 to 30 min showed P = 0.54, 0.71, 0.65, 0.92, 0.29, 0.42, and 0.15; none were statistically significant. Anxiety score during parental separation, intravenous cannulation, and mask application were also similar in both the groups.

Conclusion:

From data obtained, it can be concluded that parenteral formulation of either midazolam or triclofos can be safely used as premedicant in 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.

Efficacy and safety of oral triclofos as sedative for children undergoing sleep electroencephalogram: An observational study

OBJECTIVES

Triclofos may be a better sedative in view of better palatability and less gastric irritation as compared to chloral hydrate. This study aimed to assess the efficacy of triclofos (a commonly used sedative in India) as a sedative for sleep electroencephalogram (EEG) study in children.

METHODS

This prospective observational study was carried out in a tertiary care pediatric center. Consecutive children aged 6 months to 5 years referred for sleep EEG evaluation were recruited. Their clinical details were noted in a proforma after an informed consent. After a trial for natural sleep, oral triclofos was administered. Sleep parameters and adverse effects were noted.

RESULTS

One-hundred and sixty children were then enrolled. EEG was successfully recorded in 149 (93.1%) children. Median latency of sleep onset was 30 min and median duration of sleep was 90 min. The adverse effects in the following 24 h were mild and included dizziness, irritability, and vomiting.

CONCLUSIONS

Oral triclofos was found to be an effective sedative for EEG in children with minimal adverse effects.

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

BACKGROUND AND AIMS

The perioperative behavioural studies demonstrate that children are at greater risk of experiencing turbulent anaesthetic induction and adverse behavioural sequelae. We aimed to compare the efficacy of midazolam 0.5 mg/kg with triclofos sodium 100 mg/kg as oral premedication in children undergoing elective surgery.

METHODS

In this prospective, randomised and double-blind study, sixty children posted for elective lower abdominal surgery were enrolled. The patients were randomly divided into midazolam group (Group M) and triclofos sodium group (Group T) of thirty each. Group M received oral midazolam 0.5 mg/kg 30 min before induction, and Group T received oral triclofos sodium 100 mg/kg 60 min before induction. All children were evaluated for level of sedation after premedication, behaviour at the time of separation from parents and at the time of mask placement for induction of anaesthesia. Mann-Whitney U-test was used for comparing the grade of sedation, ease of separation and acceptance of face mask.

RESULTS

Oral midazolam produced adequate sedation in children after premedication in comparison to oral triclofos (P = 0.002). Both drugs produced successful separation from parents, and the children were very cooperative during induction. No adverse effects attributable to the premedicants were seen.

CONCLUSIONS

Oral midazolam is superior to triclofos sodium as a sedative anxiolytic in paediatric population.

A Randomized Controlled Trial Comparing Intranasal Midazolam and Chloral Hydrate for Procedural Sedation in Children

Objectives

To evaluate the efficacy and safety of intranasal midazolam and chloral hydrate syrup for procedural sedation in children.

Study Design

Prospective randomized placebo-controlled trial (double blind, double dummy).

Setting

Tertiary care hospital over 18 months.

Subjects and Methods

Eighty-two children, 1 to 6 years old, undergoing auditory brainstem response testing were randomized to receive either intranasal midazolam with oral placebo or chloral hydrate syrup with placebo nasal spray. Intranasal midazolam was delivered at 0.5 mg/kg (100 mcg per spray) and oral syrup at 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologist’s satisfaction, time to recovery, and number of attempts.

Results

Forty-one children were in each group, and no major adverse events were noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with the intranasal midazolam group (33%). Significant difference in time to recovery was noted in the chloral hydrate group (78 minutes) versus the intranasal midazolam group (108 minutes). The parents’ and audiologist’s satisfaction was higher for chloral hydrate (95% and 75%) than for intranasal midazolam (49% and 29%, respectively). Overall, sedation was 95% with chloral hydrate versus 51% with intranasal midazolam. Both drugs maintained sedation.

Conclusions

Intranasal midazolam and chloral hydrate are both safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam, with an earlier time to onset of sedation, a faster recovery, better satisfaction among parents and the audiologist, and successful sedation.