Intranasal Procedural Sedation and Analgesia in Children
Intranasal Procedural Sedation and Analgesia in Children
Over the past five years, dexmedetomidine has become a common option for providing IV sedation and analgesia in children. While most often administered as a continuous infusion in the intensive care unit, dexmedetomidine is increasingly being studied as an alternative to standard agents for intranasal administration. Within the past year alone, four new randomized comparison studies of pediatric intranasal dexmedetomidine have been published, representing work in four different universities in three countries.
In their 2012 study in Anaesthesia, Yuen and colleagues randomized 116 children between 1 and 8 years of age to receive an intranasal dexmedetomidine dose of either 1 mcg/kg or 2 mcg/kg as a pre-induction sedative. Adequate sedation at the time of induction was achieved in 53% of the children in the lower dose group versus 66% in the higher dose group (p = 0.049). The difference between the two doses was more noticeable in the children between 5 and 8 years of age, where the 2 mcg/kg dose resulted in significantly more patients achieving satisfactory sedation, than in the 1–4 year olds who responded the same to both doses.
Cimen and colleagues enrolled 62 children (2–6 years of age) scheduled to undergo minor elective surgery into a randomized, double-blind trial comparing buccal and intranasal dexmedetomidine as a pre-induction sedative. A 1 mcg/kg dose of dexmedetomidine was given in both groups 45 minutes prior to anesthetic administration. Sedation scores were significantly higher in the intranasal group, beginning at the 10 minutes and continuing until the final assessment at 45 minutes. Ease of parental separation was considered satisfactory in 75.5% of the intranasal group, compared to only 16.2% of the buccal group. Acceptance of face mask placement was also significantly higher (80.6% versus 0, both p < 0.0001). There were no differences in heart rate, respiratory rate, or oxygen saturation between groups.
Gyanesh and colleagues at the Global Hospital in Chennai, India, compared intranasal dexmedetomidine and ketamine for procedural sedation in children undergoing an MRI. A total of 150 children between 1 and 10 years of age were randomized to receive either 1 mcg/kg intranasal dexmedetomidine, 5 mg/kg intranasal ketamine, or saline 30 minutes prior to placement of an IV catheter. There were no significant differences in the children's response to administration of the drug. As expected, fewer children in the two treatment groups withdrew or fought against IV placement than in the control group (p < 0.01). There was no difference in response between dexmedetomidine and ketamine. The anesthesiologist was satisfied with cannulating conditions in 90.4% of the dexmedetomidine cases, 82.7% of the ketamine cases, and 21.7% of the controls. Rates of parent satisfaction were similar, with 97.3% of the parents of the children given dexmedetomidine, 92.4% of the parents of children given ketamine, and 41.6% of the parents of the controls considering their child to be adequately sedated. There were no significant differences in adverse effects among the groups and no serious events.
The combination of intranasal dexmedetomidine and oral ketamine for premedication prior to induction of anesthesia was recently studied by Jia and colleagues. These authors randomized 160 children between 2 and 6 years of age into one of four groups: 1) 1 mcg/kg intranasal dexmedetomidine with 3 mg/kg oral ketamine, 2) 1 mcg/kg intranasal dexmedetomidine and 5 mg/kg oral ketamine, 3) 2 mcg/kg intranasal dexmedetomidine and 3 mg/kg oral ketamine, and 4) 2 mcg/kg intranasal dexmedetomidine and 5 mg/kg oral ketamine. Overall, 90% of the children accepted their premedication regimen. Onset times were similar among the groups. Patients in group 4 were significantly more sedated than those in group 1 at 30 minutes (p = 0.036). Acceptance of IV placement was significantly higher in groups 3 and 4 (84% and 87%, respectively) than in groups 1 and 2 (40% and 54%, p = 0.001). The authors suggest that a regimen of 2 mcg/kg intranasal dexmedetomidine and 3 mg/kg oral ketamine may be optimal for providing sedation and anxiolysis in young children prior to surgery.
Dexmedetomidine
Over the past five years, dexmedetomidine has become a common option for providing IV sedation and analgesia in children. While most often administered as a continuous infusion in the intensive care unit, dexmedetomidine is increasingly being studied as an alternative to standard agents for intranasal administration. Within the past year alone, four new randomized comparison studies of pediatric intranasal dexmedetomidine have been published, representing work in four different universities in three countries.
In their 2012 study in Anaesthesia, Yuen and colleagues randomized 116 children between 1 and 8 years of age to receive an intranasal dexmedetomidine dose of either 1 mcg/kg or 2 mcg/kg as a pre-induction sedative. Adequate sedation at the time of induction was achieved in 53% of the children in the lower dose group versus 66% in the higher dose group (p = 0.049). The difference between the two doses was more noticeable in the children between 5 and 8 years of age, where the 2 mcg/kg dose resulted in significantly more patients achieving satisfactory sedation, than in the 1–4 year olds who responded the same to both doses.
Cimen and colleagues enrolled 62 children (2–6 years of age) scheduled to undergo minor elective surgery into a randomized, double-blind trial comparing buccal and intranasal dexmedetomidine as a pre-induction sedative. A 1 mcg/kg dose of dexmedetomidine was given in both groups 45 minutes prior to anesthetic administration. Sedation scores were significantly higher in the intranasal group, beginning at the 10 minutes and continuing until the final assessment at 45 minutes. Ease of parental separation was considered satisfactory in 75.5% of the intranasal group, compared to only 16.2% of the buccal group. Acceptance of face mask placement was also significantly higher (80.6% versus 0, both p < 0.0001). There were no differences in heart rate, respiratory rate, or oxygen saturation between groups.
Gyanesh and colleagues at the Global Hospital in Chennai, India, compared intranasal dexmedetomidine and ketamine for procedural sedation in children undergoing an MRI. A total of 150 children between 1 and 10 years of age were randomized to receive either 1 mcg/kg intranasal dexmedetomidine, 5 mg/kg intranasal ketamine, or saline 30 minutes prior to placement of an IV catheter. There were no significant differences in the children's response to administration of the drug. As expected, fewer children in the two treatment groups withdrew or fought against IV placement than in the control group (p < 0.01). There was no difference in response between dexmedetomidine and ketamine. The anesthesiologist was satisfied with cannulating conditions in 90.4% of the dexmedetomidine cases, 82.7% of the ketamine cases, and 21.7% of the controls. Rates of parent satisfaction were similar, with 97.3% of the parents of the children given dexmedetomidine, 92.4% of the parents of children given ketamine, and 41.6% of the parents of the controls considering their child to be adequately sedated. There were no significant differences in adverse effects among the groups and no serious events.
The combination of intranasal dexmedetomidine and oral ketamine for premedication prior to induction of anesthesia was recently studied by Jia and colleagues. These authors randomized 160 children between 2 and 6 years of age into one of four groups: 1) 1 mcg/kg intranasal dexmedetomidine with 3 mg/kg oral ketamine, 2) 1 mcg/kg intranasal dexmedetomidine and 5 mg/kg oral ketamine, 3) 2 mcg/kg intranasal dexmedetomidine and 3 mg/kg oral ketamine, and 4) 2 mcg/kg intranasal dexmedetomidine and 5 mg/kg oral ketamine. Overall, 90% of the children accepted their premedication regimen. Onset times were similar among the groups. Patients in group 4 were significantly more sedated than those in group 1 at 30 minutes (p = 0.036). Acceptance of IV placement was significantly higher in groups 3 and 4 (84% and 87%, respectively) than in groups 1 and 2 (40% and 54%, p = 0.001). The authors suggest that a regimen of 2 mcg/kg intranasal dexmedetomidine and 3 mg/kg oral ketamine may be optimal for providing sedation and anxiolysis in young children prior to surgery.
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