Premedication with midazolam nasal spray: an alternative to oral midazolam in children

Efficacy and Tolerability of Intranasal Midazolam Administration for Antiseizure Treatment in Adults: A Systematic Review

OBJECTIVE

The objective of this study was to assess the efficacy and tolerability of intranasal midazolam (in-MDZ) administration for antiseizure treatment in adults.

METHODS

Embase and Medline literature databases were searched. We included randomized trials and cohort studies (excluding case series) of adult patients (≥ 18 years of age) examining in-MDZ administration for epilepsy, epileptic seizures, or status epilepticus published in English between 1985 and 2022. Studies were screened for eligibility based on predefined criteria. The primary outcome was the efficacy of in-MDZ administration, and the secondary outcome was its tolerability. Extracted data included study design, patient characteristics, intervention details, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

A total of 12 studies with 929 individuals treated with in-MDZ were included. Most studies were retrospective, with their number increasing over time. Administered in-MDZ doses ranged from 2.5 to 20 mg per single dose. The mean proportion of successful seizure termination after first in-MDZ administration was 72.7% (standard deviation [SD] 18%), and the proportion of seizure recurrence or persistent seizures ranged from 61 to 75%. Most frequent adverse reactions to in-MDZ were dizziness (mean 23.5% [SD 38.6%]), confusion (one study; 17.4%), local irritation (mean 16.6% [SD 9.6%]), and sedation (mean 12.7% [SD 9.7%]).

CONCLUSIONS

Administration of in-MDZ seems promising for the treatment of prolonged epileptic seizures and seizure clusters in adults. Limited evidence suggests that intranasal administration is safe. Further research is warranted because of the heterogeneity of cohorts, the variation in dosages, and the lack of uniformity in defining successful seizure termination.

Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

Comparison of medication acceptance of intranasal midazolam administered by parents versus doctors in children - A randomized trial

BACKGROUND

The positive effects of midazolam as a premedication in pediatric patients are well documented. Although there are many studies regarding the route and dosage of administration, literature does not have any evidence on the outcome of medication acceptance based on the person administering the drug.

AIM

The aim of this study was to compare the medication acceptance and preoperative anxiolysis of intranasal midazolam administered by parents and anesthesiologists.

MATERIALS AND METHODS

This prospective randomized study was conducted in sixty children belonging to the American Society of Anesthesiologists Class 1 or 2 belonging to either sex, aged between 1 and 9 years, undergoing elective surgeries. Group P received intranasal midazolam administered by parents, whereas Group D received intranasal midazolam administered by doctors. Various scores were assessed.

RESULTS

Children were more sedated in Group P. Clinically, medication acceptance was better in Group P when compared with Group D, but a statistically significant difference in medication acceptance was seen only in patients who are >4 years of age. Parental separation, Ramsay Sedation Score, and mask acceptance were better in Group P than in Group D.

CONCLUSION

Intranasal midazolam when given by parents produces better preoperative anxiolysis and easier parental separation as compared with administration by a medical staff.

Comparative Study of Oral Midazolam Syrup and Intranasal Midazolam Spray for Sedative Premedication in Pediatric Surgeries

Introduction:

Midazolam is a water-soluble benzodiazepine which is frequently administered by intravenous and oral routes. Its nasal spray has become recently available.

Materials and Methods:

In this study, after obtaining clearance from the ethical committe, 66 patients between the age group of 4 and 10 years comparable in demographic variables were randomly allocated into two groups of 33 each. Group “O” received oral midazolam (0.5 mg/kg) 20 min before induction. Group “N” received intranasal midazolam (0.2 mg/kg) 20 min before induction. The heart rate and blood pressure (systolic, diastolic, and mean) and oxygen saturation (SPO₂) were recorded.

Statistical Analysis Used:

The statistical analysis was done using SPSS (Statistical Package for the Social Sciences) version 15.0 software. The values were represented in number (%) and mean±sd.

Results:

Satisfactory sedation scores were better in nasal spray group than oral group. Satisfactory ease of induction scores, recovery times, and postanesthesia recovery scores were better in the nasal spray group than in the oral group.

Conclusion:

Nasal midazolam spray is acceptable and is a good alternative to oral midazolam as premedication in the pediatric population.

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.

Comparison of ease of administration of intranasal midazolam spray and oral midazolam syrup by parents as premedication to children undergoing elective surgery

BACKGROUND

The efficacy of midazolam as premedication in children for providing pre-operative sedation and reducing parental separation anxiety has been well established. Many studies have compared the effectiveness and medication acceptance of midazolam via oral and intranasal routes. In this study, we have compared the ease of administration of oral midazolam syrup and intranasal midazolam spray as premedication, administered by parents to children.

METHODS

Ninety children were randomly allocated into one of the two groups: group N received nasal midazolam spray 0.2 mg/kg and group O received oral midazolam syrup 0.5 mg/kg administered by the parent. The parent recorded ease of administration score and facial hedonic score. The observer recorded modified medication acceptance score. Vitals and sedation scores were assessed at specific intervals. Thirty minutes after drug administration the child was separated from the parent, and parental separation anxiety score was recorded. Mask acceptance score was recorded after application of mask upon arrival in the OT.

RESULTS

Oral midazolam syrup was found to have better ease of administration than intranasal midazolam spray as felt by the parent. Medication acceptance was better for oral midazolam. Both the groups had similar sedation scores at 15 and 30 min. Children in the oral group had a better reduction in parental separation anxiety at 30 min after drug administration and better mask acceptance than the nasal group.

CONCLUSION

Oral midazolam syrup is easier for parents to administer and has better medication acceptance in children when compared to intranasal midazolam spray.

Oral Dexmedetomidine Versus Midazolam as Anesthetic Premedication in Children Undergoing Congenital Heart Surgery

Background:

Premedication is required for reducing anxiety and child’s struggling against mask acceptance on anesthesia in pediatric surgery for congenital heart disease. Midazolam has been widely used for this purpose, but because of its side effects, finding an effective replacement with less complication is necessary.

Objectives:

In the present study, we compared the efficacy of oral midazolam versus dexmedetomidine in terms of anxiolysis and mask acceptance behavior.

Patients and Methods:

Sixty children aged between 2 and 12 years, and scheduled for on-pump surgery due to a congenital heart disease were randomly assigned into two groups. Oral midazolam (0.5 mg/kg up to 15 mg per patient) and dexmedetomidine (2 µg/kg) were administered 45 minutes pre-anesthesia. Children’s anxiety, mask acceptance behavior, hemodynamic measures, and cardiopulmonary outcomes were recorded and compared.

Results:

The mean age of patients was 3.96 ± 2.04 years. Twenty-eight (46.7%) patients were females. Two drugs have similar effects on cardiopulmonary outcomes and hemodynamic measures (P > 0.05). They equally relieved the children’s anxiety (mean sedation score 1.93 ± 0.63 and 2.0 ± 0.63 for midazolam and dexmedetomidine groups, respectively; P > 0.05), while dexmedetomidine showed a better effect on improving the mask acceptance behavior (mean mask acceptance score 2.58 ± 0.6 and 1.6 ± 0.67 for midazolam and dexmedetomidine, respectively; P < 0.05).

Conclusions:

It appears reasonable to apply oral premedication with dexmedetomidine 45 minutes before transferring the patient to the operating room when he or she is more prone to resist inhalation anesthesia induction.

Is fasting duration important in post adenotonsillectomy feeding time?

Background:

Adenotonsillectomy is a common otolaryngology surgery. Nausea and vomiting are the most common complications of this procedure with a prevalence ranging from 49% to 73 %.

Objectives:

Our aim was to evaluate the effects of short time fasting protocol on decreasing postoperative pain, nausea and vomiting, and initiation of oral feeding after adenotonsillectomy.

Patients and Methods:

120 children aged 4 to 14 years candidates for adenotonsillectomy were randomly divided into intervention and control groups (n = 120, 60 in each group). Each patient of the intervention group was given oral dextrose 10% as much volume as he could consume at 3 and 6 hours prior to the operation. All the data including pain severity, nausea and vomiting of the patients, the time of oral feeding initiation etc. were gathered in checklists after the operation. Statistical analyses were then performed using Statistical Package for the Social Sciences (SPSS) software version 16. Descriptive statistical methods and mean difference test for independent groups and chi square test or Fisher exact test, and if regression needed model test were applied. A P value of 0.05 or less was considered statistically significant.

Results:

The amount of Acetaminophen administered for the intervention group was significantly lower than the control group, and also the time of oral feeding initiation was significantly shorter in the intervention group than the control group (P < 0.005). Pain severity at all occasions following surgery was significantly lower in the intervention group than the control group (P < 0.001). Although frequency of nausea at recovery time was significantly lower in the intervention group than the control group (P < 0.002), there were no significant differences in frequency of nausea between the two groups at other postoperative occasions. Postoperative vomiting frequency was not significant between the two groups at any occasions.

Conclusions:

The findings of this survey showed that shortening the duration of pre-adenotonsillectomy fasting period and hydration of patients several hours prior to the operation might be effective in decreasing postoperative pain and facilitating postoperative oral feeding initiation. Nevertheless this method does not seem to prevent postoperative nausea and vomiting.

Effects of preoperative use of oral dextromethorphan on postoperative need for analgesics in patients with knee arthroscopy

Background

Studies have shown that N-methyl-D-aspartate receptor (NMIDA) plays an essential role in postoperative pain. It seems that use of NMDA receptor antagonists such as Dextromethorphan intensifies the analgesic effects of opioids.

Objectives

In this study, we evaluated the effect of preoperative administration of Dextromethorphan on postoperative pain reduction.

Patients and Methods

This double blind randomized clinical trial was conducted on arthroscopic surgery candidates. Participants were randomly allocated to interventions and assigned to two groups of Dextromethorphan and placebo. In Dextromethorphan group, the patients received 1 mg/kg Dextromethorphan orally the night before the operation. Pain severity based on the visual analog scale (VAS) up to 16 hours postoperation, use of opioids, and the first request for analgesics were recorded postoperatively.

Results

A total of 112 patients in the Dextromethorphan (n = 54) and placebo groups (n = 58) were evaluated. No significant difference was detected between the two groups for age, sex or ASA. The mean amount of opioid consumption was significantly lower in patients who received Dextromethorphan (10.7 ± 5.6 mg) compared to the placebo group (13.1 ± 5.6 mg), (P = 0.03). The mean time until the first opioid request in patients who received Dextromethorphan was longer than that in the placebo group (P = 0.01).

Conclusions

The study results demonstrated that preemptive use of Dextromethorphan reduced postoperative pain and opioid consumption.

Evaluation of a low dose ketamine in post tonsillectomy pain relief: a randomized trial comparing intravenous and subcutaneous ketamine in pediatrics

BACKGROUND

Pain control in children is still a therapeutic dilemma. Preschool patients are affected from undesirable effects of postoperative pain more than adults. Tonsillectomy is associated with a high incidence of postoperative pain, not only complicating the recovery, but also delaying patients discharge.

OBJECTIVES

Despite employing different surgical and anesthetic strategies in post-tonsillectomy pain relief, this is still a clinical problem. The study was designed to evaluate the efficacy of a low dose ketamine in post tonsillectomy pain relief.

PATIENTS AND METHODS

Our prospective randomized double blinded study enrolled 75 pediatric patients (3-10 years old) who were scheduled for a tonsillectomy procedure. Patients were randomly assigned to one of three groups receiving; intravenous (IV) ketamine 0.5mg/kg, subcutaneous (SC) ketamine 0.5 mg/kg and placebo at the end of the operation. Post-operative pain score was assessed using modified CHEOPS.

RESULTS

In our study we did not find any significant difference among the three groups regarding sex, age, and weight, duration of operation, hemodynamic stability, and nausea and vomiting. However, in ketamine groups, pain score and analgesic consumption were significantly lower (P < 0.00). The efficacy of the both ketamine groups was similar.

CONCLUSIONS

The study demonstrated that the both subcutaneous and intravenous injections of ketamine, at the end of the operation, were safe and effective for post-tonsillectomy pain control. Ketamine reduced postoperative analgesic medications consumption without increasing the risk of complications.