Incidence of bradycardia in pediatric patients receiving dexmedetomidine anesthesia: a meta-analysis

Dexmedetomidine: Shifting Paradigms in Neonatal Sedation and Pain Control

BACKGROUND

Newborns, including preterm infants, are capable of responding to pain. Recurrent pain exposure is associated with suboptimal motor development, cognitive impairments, abnormal brain growth, and maladapted nociceptive reactions.

PROBLEM

Current agents, primarily opioids and benzodiazepines, raise major concerns due to their adverse effects, including insufficient sedation or analgesia, withdrawal, depressed respiratory effort, tolerance, and occasional paradoxical agitation. Commonly used drugs such as midazolam and morphine have been shown to induce neuroapoptosis and neurodevelopmental abnormalities in animal studies. Evaluation-Dexmedetomidine: As a specific alpha-2 adrenergic agonist, dexmedetomidine causes a significantly lower reduction in breathing effort. It has over 800 times greater affinity for alpha-2 receptors compared to alpha-1 receptors. Common side effects include bradycardia and hypotension. Prolonged use may necessitate a transition to clonidine during the weaning process. Dexmedetomidine can be administered intravenously as a bolus or infusion or intranasally. Indications include sedation and analgesia for mechanical ventilation, therapeutic hypothermia, procedural premedication, and as an adjunct to inhalational anesthesia and nerve-blocking agents. Research across varying age groups has demonstrated that dexmedetomidine shortens periods of invasive ventilation and decreases the need for other sedatives. Neonatal studies suggest that dexmedetomidine may help accelerate the achievement of full enteral feeds and can be safely administered within specific dosage ranges without causing significant adverse events that would necessitate abrupt discontinuation.

CONCLUSIONS

Dexmedetomidine can be used alone or in combination with other agents. By increasing the use of dexmedetomidine, it is possible to reduce the dosage of concurrent medications, thereby minimizing the risk of complications while still achieving the desired sedation and analgesia.

Effectiveness of buccal administration of dexmedetomidine and ketamine combination in paediatric dental sedation: A randomized controlled clinical trial

BACKGROUND

Pain and anxiety can be considerable obstacles while treating paediatric dental patients. Moderate sedation is needed to treat uncooperative patients.

AIM

This study aimed to compare the effectiveness of buccal administration of dexmedetomidine-ketamine combination versus dexmedetomidine.

DESIGN

Fifty-six uncooperative children were randomly assigned into two groups: Group I received buccal dexmedetomidine (2 μg/kg) and ketamine (2 mg/kg) (DEX-KET), whereas Group II received buccal dexmedetomidine (4 μg/kg) (DEX). The effects of drugs were evaluated based on changes in vital signs, onset and duration of sedation, sedation level, analgesia, ease of treatment and procedural adverse effects.

RESULTS

There were no significant differences in vital signs or sedation onset between the two groups. DEX-KET group showed shorter recovery time than DEX group (p < .0001). There were no statistically significant differences between both groups regarding sedation level at optimum sedation and during operative procedure (p = .064, p = .069 respectively). The ease of treatment was significantly better in DEX-KET group than in DEX group (p = .048). Procedural side effects and analgesic effects of the sedative drugs were comparable between both groups.

CONCLUSION

The combination of dexmedetomidine and ketamine delivered buccally provided a better method of delivering care to uncooperative children with more rapid recovery than dexmedetomidine.

Comparative evaluation of intravenous versus intranasal dexmedetomidine on emergence delirium and hemodynamics in pediatric patients undergoing adenotonsillectomy: a randomized controlled trial

Background

Dexmedetomidine effectively prevents emergence delirium in children. However, intravenous dexmedetomidine is frequently associated with hemodynamic instability and delayed recovery. Intranasal dexmedetomidine has been proposed as a method of reducing these side effects. This study aimed to evaluate the effects of intranasal versus intravenous dexmedetomidine on emergence recovery and hemodynamics in children undergoing adenotonsillectomy.

Methods

A total of 139 children, aged 3-10 years, who were scheduled for elective adenotonsillectomy were randomly assigned to receive intravenous dexmedetomidine (IV DEX group) or intranasal dexmedetomidine (IN DEX group), or saline (control group) after anesthesia induction. The primary outcome was the highest score on the pediatric anesthesia emergence delirium (PAED) score during the first 30 min after awakening. Secondary outcomes included the perioperative blood pressure and heart rate, time to awakening, postoperative pain score, and length of post-anesthesia care unit (PACU) stay.

Results

The highest PAED and pain scores were significantly lower in the IV and IN DEX groups than those in the control group during the first 30 min after awakening. However, no significant differences were observed between the IV and IN DEX groups. Notably, patients in the IN DEX group exhibited a significantly lower PAED score at 2 h and lower pain scores at 2, 4, and 6 h postoperatively than those in the IV DEX group. Patients in the IV DEX group exhibited a significantly longer awakening time and length of PACU stay than those in the IN DEX and control groups. In the IV DEX group, the heart rate was significantly lower perioperatively than at baseline, while this effect was not observed in the IN DEX group.

Conclusion

Both intravenous and intranasal administration of dexmedetomidine after induction of anesthesia effectively improved emergence delirium and pain intensity in children undergoing adenotonsillectomy. Intranasal administration of dexmedetomidine provided more stable hemodynamics and more prolonged analgesia and sedation than intravenous infusion of dexmedetomidine.

Clinical Trial Registration

https://www.chictr.org.cn/showproj.html?proj=180658.

Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study

BACKGROUND

Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects.

METHODS

We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID).

RESULTS

Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034).

CONCLUSIONS

Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Prevalence of Bradycardia After Induction of General Anesthesia and Associated Factors Among Surgical Pediatric Patients. A Prospective Observational Study

Background

Heart rate is the main determinant factor of the child's cardiac output in the first year of life. Thus, bradycardia decreases cardiac output leading to fatal cardiac arrhythmias, cardiac arrest, and even death. The objective of this study is to determine the prevalence of bradycardia and its associated factors after induction of general anesthesia among pediatric patients operated at Hawassa University Comprehensive Specialized Hospital (HUCSH).

Methods

Prospective observational study was employed at HUCSH by using a systematic random sampling technique. Pediatric surgical patients less than 6 years old were included in the study. Data were entered into Epi data statistical software (version 4.6.0.) and exported to SPSS (version 25.0). Categorical data were analyzed using chi-square statistics, and continuous data were analyzed using Student's t-test. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression.

Results

The prevalence of bradycardia among 205 pediatric patients included in this study was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (halothane), difficult intubation, intraoperative complications, and significant surgical blood loss were independently associated with bradycardia.

Conclusion

The prevalence of bradycardia after induction of general anesthesia was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (particularly with halothane), difficult intubation, intraoperative complications such as hypoxia, and significant blood loss were significantly associated with bradycardia.

Safety and quality in paediatric procedural sedation: what really matters?

PURPOSE OF REVIEW

This review gives an overview of the safety aspects for paediatric procedural sedation and a discussion of possibilities for optimizing structure, processes and outcomes.

RECENT FINDINGS

Procedural sedation in paediatric patients is performed by providers of different specialties and compliance with safety standards is a basic requirement regardless of provider specialty. This includes preprocedural evaluation, monitoring, equipment and profound expertise of sedation teams. The choice of sedative medications and the possibility of incorporating nonpharmacological methods play an important role for optimal outcome. In addition, an ideal outcome from the patient's perspective includes optimized processes and clear and empathetic communication.

SUMMARY

Institutions providing paediatric procedural sedation must ensure the comprehensive training of sedations teams. Furthermore, institutional standards for equipment, processes and optimal choice of medication depending on performed procedure and comorbidities of the patient must be established. At the same time, organizational and communication aspects should be considered.

Asystole in 2 Pediatric Patients During Dexmedetomidine Infusion

INTRODUCTION

Bradycardia is a known side effect of dexmedetomidine. Reports of sinus pauses or asystole, however, are rare. We present 2 cases of pediatric patients who developed asystole on a dexmedetomidine infusion.

SUMMARY OF CASES

An 8-week-old male with RSV bronchiolitis and acute hypoxemic respiratory failure was started on dexmedetomidine for sedation at 0.2 mcg/kg/h with a maximum dose of 0.7mcg/kg/h. On Hospital day (HD) 4, on dexmedetomidine at 0.7 mcg/kg/h, he developed intermittent episodes of bradycardia with heart rates in the 60 s. Echocardiogram on HD 6 showed normal function. On HD 7, he began having periods of asystole lasting up to 6 seconds. Dexmedetomidine was discontinued, with the resolution of episodes of asystole after 6 hours. A 27-month-old male with a congenital left diaphragmatic hernia and pulmonary hypertension who had been weaned off sildenafil 6 months earlier underwent re-repair of left diaphragmatic hernia. Postoperatively he remained intubated and paralyzed. Dexmedetomidine was started at 0.3 mcg/kg/h for sedation, with a maximum dose of 1.2 mcg/kg/h. An echocardiogram on HD 3 showed good function with mild to moderate pulmonary hypertension. That evening, with dexmedetomidine at 1.1 mcg/kg/h, he developed a 15 second period of asystole requiring CPR. Dexmedetomidine was discontinued, and he was started on a midazolam infusion with no further episodes.

DISCUSSION

Both cases occurred in patients without cardiac conduction defects or on negative chronotropic or sympatholytic medications that have been associated with dexmedetomidine-induced asystole. We hypothesize that both episodes of asystole were due to increased patient-related vagal tone exacerbated by dexmedetomidine.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease

BACKGROUND

Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children.

METHODS

Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg.

RESULTS

A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg.

CONCLUSIONS

Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial

Background

Low-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children.

Methods

Seventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation-Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events.

Results

Statistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44-6.2) vs. 6.25 (4.21-7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75-21) and 22.5 (22-24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay.

Conclusion

Low-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay.

Dexmedetomidine as a sole sedative for procedural sedation in preterm and neonate infants: A retrospective analysis

BACKGROUND

Many different sedation concepts for magnetic resonance imaging have been described for prematurely and term-born infants, ranging from "no sedation" to general anesthesia. Dexmedetomidine is an alpha-2 receptor agonist that is frequently used to sedate older children, because the anesthesiologist can easily adjust sedation depth, the patient maintains spontaneous breathing, and awakens rapidly afterwards.

AIMS

The present study evaluates whether dexmedetomidine could safely be used as the sole sedative for prematurely and term-born infants less than 60 weeks postconceptional age undergoing diagnostic procedures.

METHODS

We performed a retrospective monocentric analysis of n = 39 prematurely and term-born infants (<60 weeks postconceptional age or a body weight <5 kg) who were sedated with dexmedetomidine for an MRI at a German university hospital from August 2016 to November 2018.

RESULTS

Successful imaging was achieved in all cases. The median initial bolus of dexmedetomidine administered over 10 min was 1.39 μg kg^-1 body weight (range 0.34-3.64 μg kg^-1 ), followed with a continuous infusion at a median rate of 1.00 μg kg^-1  h^-1 (range 0.5-3.5 μg kg^-1  h^-1 ); however, 3 patients (7%) needed some additional sedation (ketamine or propofol). All patients, including 10 infants who had previously required respiratory support, underwent the procedure without any relevant desaturation or apnea. Bradycardia was observed in up to 15 out of 39 cases (38.5%), but only four (10.3% in total and 26.7% of bradycardia) required atropine.

CONCLUSIONS

These results indicate that dexmedetomidine can be safely used for procedural sedation in the high-risk cohort of prematurely and term-born infants less than 60 weeks postconceptional age. Apnea during procedural sedation and subsequent stay in the recovery room is avoided, but bradycardia remains a relevant risk that may require treatment.

Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis

OBJECTIVE

To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication.

METHODS

Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events.

RESULTS

15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia.

CONCLUSIONS

DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.

The Effect of Continuous Field Block through Intercostal Muscles after Atrial Septal Defect Closure via a Mini-Right Thoracotomy in Pediatric Patients

BACKGROUND

Postoperative pain management in thoracotomy patients often is difficult. Furthermore, pediatric patients present more challenges because of their inability to effectively communicate their pain intensity. The purpose of this study was to evaluate the use of continuous field block through intercostal muscles as postoperative pain management in pediatric thoracotomy.

METHODS

Between 2014 and 2018, 11 patients underwent an ASD closure using a cardiopulmonary bypass via a mini-right thoracotomy through the fourth intercostal space. At the time of chest closure, a single-shot field block via the fourth intercostal muscles was performed with levobupivacaine (0.6 mg/kg). The first five patients were only given the single-shot field block (Single group). The remaining six patients were given levobupivacaine continuously (0.1 mg/kg/hr) through an indwelling catheter until the chest tube removal (Continuous group). The groups' vital signs, total amounts of acetaminophen used, postoperative courses were compared.

RESULTS

Although the heart rate did not differ between the groups, the respiratory rate was significantly higher in the Single group versus the Continuous group at 16 and 32 hr post-surgery (35.6 ± 9.7/min vs. 18.5 ± 4.7/min; p=0.007, 43.0 ± 10.4 vs. 25.3 ± 3.1; p=0.042, respectively). The accumulated dosage of acetaminophen given by postoperative day 2 was significantly higher in the Single group versus the Continuous group (55.3 ± 22.1 mg/kg vs. 7.8 ± 17.4 mg/kg; p=0.012).

CONCLUSIONS

Continuous field block via intercostal muscles after ASD closure via a mini-right thoracotomy in children was effective to stabilize the vital signs and reduce the analgesic medication use.

Dexmedetomidine leading to profound bradycardia in a pediatric liver transplant recipient

Dexmedetomidine, an α₂ -agonist, is used in the PICU for its sedative properties as it minimally affects respiratory status. However, hemodynamic instability is one of its known side effects. There is limited published experience with its use in pediatric liver transplant. We present a case of a 9-month-old infant who received a deceased donor liver transplantation for biliary atresia and received an IV dexmedetomidine infusion for sedation starting at 20 hours post-operatively. The patient received an IV bolus of 0.08 mcg/kg followed by an increase to 1 mcg/kg/hour. She was also receiving a fentanyl infusion for sedation at the time of dexmedetomidine initiation. Approximately 3 hours after initiation, she developed bradycardia as low as 30 beats-per-minute with an associated sinus pause of 7 seconds. She was given chest compressions by the bedside nurse briefly before arousing and becoming agitated. Evaluation of other etiologies for the patient's bradycardia was unrevealing. Thus, bradycardia was attributed to dexmedetomidine therapy which was discontinued without recurrence. Hemodynamic instability, specifically bradycardia, is known to occur with dexmedetomidine administration. As this medication is primarily metabolized by the liver, its use immediately after transplantation, when liver function is still recovering, may be associated with an increased risk of side effects. Understanding risk factors for bradycardia and hemodynamic instability early after liver transplantation, particularly with dexmedetomidine, is critical to allow clinicians to identify the patients for higher risk for dexmedetomidine side effects.

Circulating microRNA-30a-5p, microRNA-101-3p, microRNA-140-3p and microRNA-141-3p as potential biomarkers for dexmedetomidine response in pediatric patients

PURPOSE

The aim of this study was to investigate the expression levels of plasma miR-30a-5p, miR-101-3p, miR-140-3p and miR-141-3p and their relationship to dexmedetomidine efficacy and adverse effects in pediatric patients.

METHODS

The expression levels of miR-30a-5p, miR-101-3p, miR-140-3p and miR-141-3p were measured by qRT-PCR in plasma of 133 pediatric patients receiving dexmedetomidine for preoperative sedation. We analyzed the relationship between miRNA abundance and dexmedetomidine response, including sedative effect and adverse effects, and assessed the predictive power of miRNAs for drug response.

RESULTS

Among 133 pediatric patients, 111 patients were dexmedetomidine responders (UMSS ≥ 2) and 22 patients were non-responders (UMSS < 2). We observed higher expression levels of miR-101-3p and miR-140-3p in dexmedetomidine responders compared with non-responders (P < 0.05, P < 0.0001). In contrast, there was no significant difference in the expression levels of miR-30a-5p and miR-141-3p between responders and non-responders (P > 0.05). The plasma levels of miR-101-3p and miR-30a-5p were markedly downregulated in patients who experienced hypotension and bradycardia, respectively (P < 0.05). MiR-101-3p and miR-140-3p demonstrated a potential discriminatory ability between dexmedetomidine responders and non-responders, with AUC of 0.64 (P < 0.05) and 0.77 (P < 0.0001), respectively. The AUC of miR-101-3p in distinguishing patients without hypotension was 0.63 (P < 0.05). The AUC of miR-30a-5p in distinguishing patients without bradycardia was 0.74 (P < 0.05).

CONCLUSION

Our study demonstrated that circulating miR-101-3p, miR-140-3p and miR-30a-5p might be used as a blood-based marker for dexmedetomidine efficacy and safety in pediatric patients.

Observation of the Sedative Effect of Dexmedetomidine Combined With Midazolam Nasal Drops Before a Pediatric Craniocerebral MRI

OBJECTIVE

This study aimed to investigate the sedative effect of dexmedetomidine combined with midazolam nasal drops before a pediatric craniocerebral magnetic resonance imaging (MRI).

METHODS

Eighty children who needed an MRI examination were enrolled in the present study and randomly divided into 2 groups: the observation group (dexmedetomidine combined with midazolam nasal drops) and the control group. After the children were given the medication, their heart rate, blood oxygen saturation (SpO2), and respiratory rate were continuously monitored and the adverse reactions such as nausea and vomiting, cough, restlessness, heart rate slowdown, and respiratory depression were observed.

RESULTS

The difference in the onset time between the 2 groups was not statistically significant (P > 0.05), but the duration was significantly longer in the observation group than in the control group (P < 0.01) and the examination success rate were significantly higher in the observation group than in the control group (P < 0.05).

CONCLUSION

The protocol of 3 μg/kg of a dexmedetomidine injection combined with 0.3 mg/kg of midazolam nasal drops is safe, easy to operate, and has a high success rate, which is worthy of clinical promotion.

Dexmedetomidine for Prolonged Sedation in the PICU: A Systematic Review and Meta-Analysis

OBJECTIVES

We aimed to systematically describe the use of dexmedetomidine as a treatment regimen for prolonged sedation in children and perform a meta-analysis of its safety profile.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and CINAHL were searched from inception to November 30, 2018.

STUDY SELECTION

We included studies involving hospitalized critically ill patients less than or equal to 18 years old receiving dexmedetomidine for prolonged infusion (≥ 24 hr).

DATA EXTRACTION

Data extraction included study characteristics, patient demographics, modality of dexmedetomidine use, associated analgesia and sedation details, comfort and withdrawal evaluation scales, withdrawal symptoms, and side effects.

DATA SYNTHESIS

Literature search identified 32 studies, including a total of 3,267 patients. Most of the studies were monocentric (91%) and retrospective (88%); one was a randomized trial. Minimum and maximum infusion dosages varied from 0.1-0.5 µg/kg/hr to 0.3-2.5 µg/kg/hr, respectively. The mean/median duration range was 25-540 hours. The use of a loading bolus was reported in eight studies (25%) (range, 0.5-1 µg/kg), the mode of weaning in 11 (34%), and the weaning time in six of 11 (55%; range, 9-96 hr). The pooled prevalence of bradycardia was 2.6% (n = 10 studies; 14/387 patients; 95% CI, 0.3-7.3; I = 75%), the pooled prevalence incidence of bradycardia was 2.6% (n = 10 studies; 14/387 patients; 95% CI, 0.3-7.3; I = 75%), the pooled incidence of hypotension was 6.1% (n = 8 studies; 19/304 patients; 95% CI, 0.8-15.9; I = 84%). Three studies (9%) reported side effects' onset time which in all cases was within 12 hours of the infusion starting.

CONCLUSIONS

High-quality data on dexmedetomidine use for prolonged sedation and a consensus on correct dosing and weaning protocols in children are currently missing. Infusion of dexmedetomidine can be considered relatively safe in pediatrics even when longer than 24 hours.

Dexmedetomidine aggravates hypotension following mesenteric traction during total gastrectomy: a randomized controlled trial

BACKGROUND

Mesenteric traction syndrome (MTS), which is characterized by arterial hypotension and tachycardia following mesenteric traction (MT), frequently occurs during abdominal surgery. Dexmedetomidine, commonly used in general anesthesia during major surgery, has a sympatholytic effect and attenuates the compensatory response to hypotension.

OBJECTIVE

Assess the effect of dexmedetomidine on hypotension following mesenteric traction.

DESIGN

Prospective, randomized, controlled clinical trial.

SETTING

Department of Anesthesiology, Zhenjiang First People's Hospital in China.

PATIENTS AND METHODS

Patients were randomly divided into three groups. Dexmedetomidine, 0.5 or 1.0 µg/kg, was intravenously administered over 15 minutes before skin incision followed by a maintenance rate of 0.5 µg/kg/h in groups D1 and D2, respectively; saline was administered in group C.

MAIN OUTCOME MEASURE(S)

The duration of hypotension, heart rate and plasma norepinephrine level in patients with MTS were recorded within 60 minutes following MT.

SAMPLE SIZE

75 patients.

RESULTS

The duration of hypotension in the MTS patients in group D1 and D2 was significantly longer than that in groups C (D1 vs. C, P<.05; D2 vs. C, P<.01). Significantly more phenylephrine was required to treat hypotension in group D1 and D2 than was required for patients in group C (P<.05). The increase in heart rate during the first 15 minutes of MT in group D2 was significantly attenuated compared to that in group C (P<.0083). The increases in norepinephrine levels during the first 15 minutes of MT in group C were significantly higher than those in groups D1 and D2 (P<.0167).

CONCLUSION

Adjunctive dexmedetomidine in general anesthesia aggravates hypotension during MTS in open total gastrectomy.

LIMITATIONS

Postoperative complications were not evaluated.

CONFLICT OF INTEREST

None.

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).

Incidence and risk factors of bradycardia in pediatric patients undergoing intranasal dexmedetomidine sedation

BACKGROUND

Dexmedetomidine is widely used for non-invasive pediatric procedural sedation. However, the hemodynamic effects of intravenous dexmedetomidine are a concern. There has been a growing interest in the application of intranasal dexmedetomidine as a sedative in children.

OBJECTIVE

To investigate the incidence of bradycardia in children undergoing intranasal dexmedetomidine sedation and to identify the associated risk factors.

METHODS

Data pertaining to pediatric patients who underwent intranasal dexmedetomidine sedation for non-invasive investigations at the Kunming Children's Hospital between October 2017 and August 2018 were retrospectively analyzed.

RESULTS

Out of 9984 children who qualified for inclusion, 228 children (2.3%) developed bradycardia. The incidence of bradycardia in the group that received additional dose of dexmedetomidine was higher than that in the group that did not receive additional dose (9.2% vs 16.7%; P = .003). The incidence of bradycardia in males was higher than that in females (2.6% vs 1.8%; P = .007). On multivariate logistic regression, only male gender showed an independent association with the occurrence of bradycardia (odds ratio 1.48; 95% confidence interval 1.11-1.97; P = .008).

CONCLUSIONS

The overall incidence of bradycardia in children after sole use of intranasal dexmedetomidine sedation was 2.3%. Male children showed a 1.48-fold higher risk of bradycardia. However, the blood pressure of the children who developed bradycardia was within the normal range. Simple wake-up can effectively manage bradycardia induced by intranasal dexmedetomidine sedation.

A non-randomized controlled study of total intravenous anesthesia regimens for magnetic resonance imaging studies in children

BACKGROUND AND AIMS

We studied the efficacy and safety of different total intravenous anesthesia used for pediatric magnetic resonance imaging (MRI).

MATERIAL AND METHODS

Children of 1-7 years age (n = 88), undergoing MRI received a loading dose of dexmedetomidine 1 μg/kg over 10 min, ketamine 1 mg/kg, and propofol 1 mg/kg in sequence. University of Michigan Sedation Scale (UMSS) of 3 was considered an acceptable level for starting the scan. Rescue ketamine 0.25-0.5 mg/kg was given if UMSS remained <3. After the loading dose of drugs, some children attained UMSS = 4 or progressive decline in heart rate, therefore, did not receive any infusion. The rest received either dexmedetomidine (0.7 μg/kg/h) (n = 35) or propofol (3 mg/kg/h) (n = 38) infusion for maintenance. Ketamine 0.25 mg/kg was used as rescue. Sedation failure was considered if either there was inability to complete the scan at the pre-set infusion rate, or there was need for >3 ketamine boluses or serious adverse events occurred. Statistical Package for Social Sciences 20 was used for analysis.

RESULTS

Initiation of scan was 100% successful with median induction time of 10 min. Maintenance of sedation was successful in 100% with dexmedetomidine and 97.4% with propofol infusion. Recovery time (25 min v/s 30 min), discharge time (35 min v/s 60 min), and total care duration (80 min v/s 105 min) were significantly less with propofol as compared to dexmedetomidine (P = 0.002, 0.000, and 0.000, respectively). There were no significant adverse events observed.

CONCLUSION

Dexmedetomidine 1μg/kg, ketamine 1 mg/kg, and propofol 1 mg/kg provide good conditions for initiation of MRI. Although dexmedetomidine at 0.7μg/kg/h and propofol at 3 mg/kg/h are safe and effective for maintenance, propofol provides faster recovery.

Values of heart rate at rest in children and adults living at different altitudes in the Andes

Introduction

The heart rate (HR) is useful for the monitoring of patients, but almost no studies have been found which describe their variations according to different geographic locales and altitudes using centiles in children and adults.

Methodology

Descriptive, cross-sectional study of secondary data. Measurements were taken with a calibrated pulse oximeter; our participants resided in host cities for more than 2 months and underwent clinical evaluations by physicians. The results were categorized according to their age group and the altitude of residence using centile charts.

Results

Our sample size consisted of 6,289 subjects across different villages in Peru. Using Pearson correlation between HR and altitude, it was found in the group of patients aged 1–5 years, a coefficient of -0.118 (p value = 0.012), in the group of patients aged 6–17, 0.047 (p value = 0.025), in the group of patients aged 18–50, -0.044 (p value = 0.041) and for the group of patients aged 51–80, 0.042 (p value = 0.256). In the groups of 1–5, 6–17 and 18–50 years of age, the variations were negligible but statistically significant due to our large sample size. When all of the data was evaluated, HR values were also found to have negligible variations according to the residence altitude, with a Pearson coefficient of -0.033 (p value = 0.009). Centiles charts were used to describe the distribution of HR for different age groups by altitude of residence.

Conclusion

There are minimal variations of the HR according to the altitude of residence in all age groups.