Dexmedetomidine is effective and safe during NIV in infants and young children with acute respiratory failure

Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care

AIM

This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care.

METHODS

A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score.

RESULTS

Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 μg/kg/h (IQR = 0.60-1.71 μg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion.

CONCLUSION

Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study

Background and objectives

Non-invasive ventilation (NIV) is used in intensive care units (ICUs) to treat of respiratory failure. Sedation and analgesia are effective and safe for improving compliance in patients intolerant to NIV. Our study aimed to evaluate the effects of dexmedetomidine, remifentanil, and propofol on the clinical outcomes in NIV intolerant patients.

Methods

This prospective randomized cohort study was conducted in a tertiary ICU, between December 2018 and December 2019. We divided a total of 120 patients into five groups (DEXL, DEXH, REML, REMH, PRO). IBM SPSS Statistics 20 (IBM Corporation, Armonk, New York, USA) was used to conduct the statistical analyses.

Results

The DEXL, DEXH, REML, and REMH groups consisted of 23 patients each while the PRO group consisted of 28 patients. Seventy-five patients (62.5%) became tolerant of NIV after starting the drugs. The NIV time, IMV time, ICU LOS, hospital LOS, intubation rate, side effects, and mortality were significantly different among the five groups (P = 0.05). In the groups that were given dexmedetomidine (DEXL, and DEXH), NIV failure, mortality, ICU LOS, and hospital LOS were lower than in the other groups.

Conclusion

In this prospective study, we compared the results of three drugs (propofol, dexmedetomidine, and remifentanil) in patients with NIV intolerance. The use of sedation increased NIV success in patients with NIV intolerance. NIV failure, mortality, ICU LOS, IMV time, and hospital LOS were found to be lower with dexmedetomidine.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations

Aim

This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV).

Background

NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation.

Methods

Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done.

Review results

Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile.

Conclusion

Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations.

How to cite this article

Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.

Dexmedetomidine for Sedation During Pediatric Noninvasive Ventilation

BACKGROUND

Noninvasive ventilation (NIV) facilitates management of acute respiratory failure without intubation. Many pediatric patients cannot tolerate the discomfort associated with noninvasive support and require sedation with agents that may decrease respiratory drive. Dexmedetomidine does not decrease respiratory drive, and we hypothesized that its use would increase tolerance of noninvasive respiratory support without increasing risk for intubation.

METHODS

A retrospective chart review was performed of all subjects at least 3 months of age with acute respiratory failure requiring NIV who were admitted to the pediatric ICU at a children's hospital for a 3-y period from 2015-2018. Subjects were stratified to those receiving continuous dexmedetomidine versus those not receiving sedation. Medical history was reviewed for developmental delay (DD) or intellectual disability (ID) as well as basic demographic information. To control the association between these variables with both dexmedetomidine use and intubation, augmented inverse probability weighting was utilized to establish equivalent baselines between the dexmedetomidine and no-sedation groups. Primary outcome was intubation rate within 6 h of initiation of dexmedetomidine infusion or NIV.

RESULTS

Based on the strong association between age and dexmedetomidine use, a statistical model including subjects > age 5 was not able to be generated, and these subjects were excluded from final analysis. One-hundred eight subjects were included in the final statistical analysis, with 60 receiving dexmedetomidine and 48 receiving no sedation. Dexmedetomidine was effective at reducing agitation, with no difference noted in intubation rate at 6 h between subjects receiving dexmedetomidine versus no sedation (13.1 vs 12.4%).

CONCLUSIONS

Dexmedetomidine may allow tolerance of NIV in acute respiratory failure without increasing risk for intubation, especially in preschool age patients and those with DD or ID. A larger study involving multiple centers would help support our conclusions.

Effect of dexmedetomidine and propofol sedation on the prognosis of children with severe respiratory failure: a systematic review and meta-analysis

BACKGROUND

During treatment of acute respiratory failure (ARF) in children, sedation can reduce pain, improve tolerance, and reduce the incidence of adverse events, so selecting an appropriate sedation strategy is very important for improving prognosis and quality of life. Both dexmedetomidine and propofol have good sedative effects, so we investigated the application of these drugs in critically ill children with ARF by literature search and meta-analysis.

METHODS

We searched Embase, The Cochrane Library, PubMed, Ovid, Clinicaltrials.org, and Google Scholar for randomized controlled trials (RCTs) preferentially but not exclusively, and used RevMan 5.4 to analyze the screened literature.

RESULTS

Seven studies were included in the quantitative meta-analysis, with a total of 1,188 patients. There was no significant difference in the effect of dexmedetomidine and propofol on the duration of tracheal intubation in children with ARF [mean difference (MD) =-0.05; 95% confidence interval (CI): (-0.42, 0.32); Z=0.26; P=0.79], but dexmedetomidine sedation could reduce the intensive care unit (ICU) stay in children with ARF [MD =-0.62; 95% CI: (-1.08, -0.16); Z=2.65; P=0.008], and shorten the total hospital stay [MD =-1.94; 95% CI: (-2.63, -1.25); Z=5.48; P<0.00001]. There was no significant effect on mortality between the two groups [odds ratio (OR) =0.48; 95% CI: (0.19, 1.25); Z=1.50; P=0.13]. The incidence rate of bradycardia with dexmedetomidine sedation was higher than with propofol [OR =12.30; 95% CI: (2.28, 66.47); Z=2.92; P=0.004], and the incidence of hypotension was also higher [OR =6.99, 95% CI: (1.22, 39.86); Z=2.19; P=0.03].

DISCUSSION

Compared with propofol, dexmedetomidine can significantly reduce the ICU stay and hospital stay. However, bradycardia and hypotension may occur during the use of dexmedetomidine, which requires close attention and timely intervention.

Use of continuous infusion of clonidine for sedation in critically ill infants and children

BACKGROUND

Adequate sedation and analgesia are required for critically ill children in order to minimize discomfort, reduce anxiety, and facilitate care. This is commonly achieved through a combination of opioids and benzodiazepines. Prolonged use of these agents is associated with tolerance and withdrawal. Clonidine as an adjunctive sedative agent may reduce sedation-related adverse events.

OBJECTIVE

Our first aim was to describe the indication for clonidine administration and its secondary effects in a mixed cohort of critically ill children. Our secondary aim was to measure the consumption of sedatives during two study periods: before and after the use of clonidine in our pediatric intensive care unit (PICU).

METHODS

This was a single-center study conducted in a tertiary PICU and encompassed retrospective chart review of patients who received clonidine between November 2013 and April 2015. We collected data on clonidine dosage, duration of administration, indication for the prescription, and potential side effects. We analyzed the total consumption of sedatives over 18 months, before and after the introduction of clonidine in our sedation protocol.

RESULTS

A total of patients received clonidine, with a mean age of 2.2 ± 2.8 years. The primary reason for intensive care admission was respiratory failure (48%). The main indication for clonidine administration was increasing requirement for morphine and midazolam (60%). The mean duration of clonidine infusion was 9 ± 7.3 days. Bradycardia and hypotension occurred in five patients (11.6%) and nine patients (21%), respectively. These side effects did not result in any major intervention. Younger age was a risk factor for clonidine-associated bradycardia. We observed a significant decrease in morphine and midazolam consumption with clonidine as a comedication. Compared with the pre-study period, consumption decreased by 19.7% for morphine and by 59% for midazolam (calculated as milligram/admission).

CONCLUSION

Continuous infusion of clonidine in critically ill children is safe and effective. Clonidine is a sedative-sparing agent and this can help reduce complications associated with prolonged use of opioids and benzodiazepines.

Overexpression of miR‑375 reverses the effects of dexamethasone on the viability, migration, invasion and apoptosis of human airway epithelial cells by targeting DUSP6

Airway epithelial cell (AEC) dysfunction has been proven to be involved in the pathogenesis of asthma, which may be induced by the use of dexamethasone (Dex). The altered expression of microRNAs (miRNAs/miRs) has been found in asthma. However, the detailed mechanisms responsible for the effects of miR-375 on Dex-induced AEC dysfunction remain elusive. Thus, the present study aimed to elucidate these mechanisms. Following treatment with Dex for 0, 6, 12 and 24 h, AEC viability, migration, invasion and apoptosis were examined using Cell Counting Kit-8 (CCK-8), wound healing and Transwell assays, and flow cytometry, respectively. The expression levels of miR-375, dual specificity phosphatase 6 (DUSP6) and apoptosis-related proteins (Bcl-2, Bax, cleaved caspase-3) were measured using reverse transcription-quantitative polymerase chain reaction and western blot analysis. The target genes and potential binding sites of miR-375 and DUSP6 were predicted using TargetScan and confirmed using dual-luciferase reporter assay. The viability, migration, invasion and apoptosis of Dex-treated AECs were further assessed with or without miR-375 and DUSP6. In the AECs (9HTE cells), Dex treatment suppressed cell viability and miR-375 expression, whereas it promoted cell apoptosis and the expression of DUSP6, the target gene of miR-375. The overexpression of miR-375 reversed the effects of Dex treatment on miR-375 expression, cell viability, migration and invasion, and apoptosis-related protein expression; in turn, these effects were reversed by the overexpression of DUSP6, with the exception of miR-375 expression. On the whole, the present study demonstrates that the overexpression of miR-375 counteracts the effects of Dex treatment on AEC viability, migration, invasion and apoptosis by targeting DUSP6. Thus, it was suggested that the downregulated expression of miR-375 may be a therapeutic target for AEC dysfunction.

Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review

Many critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.

The Impact of Preintubation Noninvasive Ventilation on Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

There is evidence that noninvasive ventilation decreases the need for invasive mechanical ventilation. However, children with pediatric acute respiratory distress syndrome who fail noninvasive ventilation may have worse outcomes than those who are intubated without exposure to noninvasive ventilation. Our objective was to evaluate the impact of preintubation noninvasive ventilation on children with pediatric acute respiratory distress syndrome.

DESIGN

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial.

SETTING

Thirty-one PICUs in the United States.

PATIENTS

Children 2 weeks to 17 years old with pediatric acute respiratory distress syndrome receiving invasive mechanical ventilation, excluding those admitted with tracheostomies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,427 subjects receiving invasive mechanical ventilation, preintubation noninvasive ventilation was used in 995 (41%). Compared with subjects without preintubation noninvasive ventilation use, subjects with preintubation noninvasive ventilation use were more likely to have a history of seizures (10% vs 8%; p = 0.04) or cancer (11% vs 6%; p < 0.001) and have moderate or severe pediatric acute respiratory distress syndrome by the end of their first full day of invasive mechanical ventilation (68% vs 60%; p < 0.001). Adjusting for age, severity of illness on PICU admission, and baseline functional status, preintubation noninvasive ventilation use resulted in longer invasive mechanical ventilation duration (median 7.0 vs 6.0 d), longer PICU (10.8 vs 8.9 d), and hospital (17 vs 14 d) lengths of stay, and higher 28-day (5% vs 4%) and 90-day (8% vs 5%) inhospital mortalities (all comparisons p < 0.001). Longer duration of noninvasive ventilation before intubation was associated with worse outcomes.

CONCLUSIONS

In children with pediatric acute respiratory distress syndrome, preintubation noninvasive ventilation use is associated with worse outcomes when compared with no preintubation noninvasive ventilation use. These data can be used to inform the design of clinical studies to evaluate best noninvasive ventilation practices in children with pediatric acute respiratory distress syndrome.

Delirium in the NICU: Risk or Reality?

Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.

Prevention of Withdrawal in Pediatric Patients Receiving Long-term Dexmedetomidine Infusions

OBJECTIVE

Determine if the addition of clonidine was associated with a decreased incidence of dexmedetomidine withdrawal in patients who received prolonged dexmedetomidine infusions.

METHODS

This was a retrospective observational cohort study conducted at a single-center PICU in an academic children's hospital. Children 1 month to 18 years of age who received dexmedetomidine infusion for 5 days or longer were included in the study.

RESULTS

Fifty patients met the inclusion criteria with 15 patients who received clonidine and 35 who received a dexmedetomidine wean alone. Withdrawal criteria included blood pressure changes, heart rate changes, and documented agitation. Overall, there was no difference in change in blood pressure or documented agitation between groups. Patients who did not receive clonidine had a greater number of heart rate readings above normal for age following discontinuation of the infusion, yet this was not statistically significant. Potentially more importantly, the addition of clonidine did not impact the duration of dexmedetomidine wean or the PICU length of stay after dexmedetomidine discontinuation.

CONCLUSIONS

The addition of clonidine while weaning a long-term dexmedetomidine infusion did not lead to lower blood pressures or agitation, but did lead to decreased percentage of heart rates above the age-appropriate range. The clinical significance of this is unknown, and further investigation is warranted. The addition of clonidine did not decrease time to weaning off dexmedetomidine or shorten PICU length of stay.

Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic-Narrative Overview

It has become a standard measure in recent years to utilise evidence-based practice, which is associated with a greater need to implement and use advanced, reliable methods of summarising the achievements of various scientific disciplines, including such highly specialised approaches as personalised medicine. The aim of this paper was to discuss the current state of knowledge related to improvements in "nursing" involving management of delirium in intensive care units during the SARS-CoV-2 pandemic. This narrative review summarises the current knowledge concerning the challenges associated with assessment of delirium in patients with COVID-19 by ICU nurses, and the role and tasks in the personalised approach to patients with COVID-19.

Weaning of Children With Burn Injury by Noninvasive Ventilation: A Clinical Experience

The aim of this study was to report the respiratory management of a cohort of infants admitted to a Pediatric Intensive Care Unit (PICU) over a 7-year period due to severe burn injury and the potential benefits of noninvasive ventilation (NIV). A retrospective review of all pediatric patients admitted to PICU between 2009 and 2016 was conducted. From 2009 to 2016, 118 infants and children with burn injury were admitted to our institution (median age 16 months [IQR = 12.2-20]); 51.7% of them had face burns, 37.3% underwent tracheal intubation, and 30.5% had a PICU stay greater than 7 days. Ventilated patients had a longer PICU stay (13 days [IQR = 8-26] vs 4.5 days [IQR = 2-13]). Both ventilation requirement and TBSA% correlated with PICU stay (r = .955, p < .0001 and r = .335, p = .002, respectively), while ventilation was best related in those >1 week (r = .964, p < .0001 for ventilation, and r = -.079, p = .680, for TBSA%). NIV was introduced in 10 patients, with the aim of shorten the invasive ventilation requirement. As evidenced in our work, mechanical ventilation is frequently needed in burned children admitted to PICU and it is one of the main factors influencing PICU length of stay. No difference was found in terms of PICU length of stay and invasive mechanical ventilation time between children who underwent NIV and children who did not, despite children who underwent NIV had a larger burn surface. NIV can possibly shorten the total invasive ventilation time and related complications.

Remifentanil versus dexmedetomidine for treatment of cardiac surgery patients with moderate to severe noninvasive ventilation intolerance (REDNIVIN): a prospective, cohort study

BACKGROUND

The use of sedation to noninvasive ventilation (NIV) patients remains controversial, however, for intolerant patients who are uncooperative, administration of analgesics and sedatives may be beneficial before resorting to intubation. The aim of this study was to evaluate the efficacy of remifentanil (REM) versus dexmedetomidine (DEX) for treatment of cardiac surgery (CS) patients with moderate to severe NIV intolerance.

METHODS

This prospective cohort study of CS patients with moderate to severe NIV intolerance was conducted between January 2018 and March 2019. Patients were treated with either REM or DEX, decided by the bedside intensivist. Depending on the treatment regimen, the patients were allocated to one of two groups: the REM group or DEX group.

RESULTS

A total of 90 patients were enrolled in this study (52 in the REM group and 38 in the DEX group). The mitigation rate, defined as the percentage of patients who were relieved from the initial moderate to severe intolerant status, was greater in the REM group than DEX group at 15 min and 3 h (15 min: 83% vs. 61%, P=0.029; 3 h: 92% vs. 74%, P=0.016), although the mean mitigation rate (81% vs. 85%, P=0.800) was comparable between the two groups. NIV failure, defined as reintubation or death over the course of study, was comparable between the two groups (19.2% vs. 21.1%, respectively, P=0.831). There were no significant differences between the two groups in other clinical outcomes, including tracheostomy (15.4% vs. 15.8%, P=0.958), in-hospital mortality (11.5% vs. 10.5%, P=0.880), ICU length of stay (LOS) (7 vs. 7 days, P=0.802), and in-hospital LOS (17 vs. 19 days, P=0.589).

CONCLUSIONS

REM was as effective as DEX in CS patients with moderate to severe NIV intolerance. Although the effect of REM was better than that of DEX over the first 3 h, the cumulative effect was similar between the two treatments.

Dexmedetomidine: What's New for Pediatrics? A Narrative Review

Over the past few years, despite the lack of approved pediatric labelling, dexmedetomidine’s (DEX) use has become more prevalent in pediatric clinical practice as well as in research trials. Its respiratory-sparing effects and bioavailability by various routes are only some of the valued features of DEX. In recent years the potential organ-protective effects of DEX, with the possibility for preserving neurocognitive function, has put it in the forefront of clinical and bench research. This comprehensive review focused on the pediatric literature but presents relevant, supporting adult and animal studies in order to detail the recent growing body of literature around the pharmacology, end-organ effects, organ-protective effects, alternative routes of administration, synergetic effects, and clinical applications, with considerations for the future.

Efficacy of premedication with intranasal dexmedetomidine for removal of inhaled foreign bodies in children by flexible fiberoptic bronchoscopy: a randomized, double-blind, placebo-controlled clinical trial

Background

Tracheobronchial foreign body aspiration in children is a life-threatening, emergent situation. Currently, the use of fiberoptic bronchoscopy for removing foreign bodies is attracting increasing attention. Oxygen desaturation, body movement, laryngospasm, bronchospasm, and breath-holding are common adverse events during foreign body removal. Dexmedetomidine, as a highly selective α₂-adrenergic agonist, produces sedative and analgesic effects, and does not induce respiratory depression. We hypothesized that intranasal dexmedetomidine at 1 μg kg − 1 administered 25 min before anesthesia induction can reduce the incidence of adverse events during fiberoptic bronchoscopy under inhalation general anesthesia with sevoflurane.

Methods

In all, 40 preschool-aged children (6–48 months) with an American Society of Anesthesiologists physical status of I or II were randomly allocated to receive either intranasal dexmedetomidine at 1 μg·kg − 1 or normal saline at 0.01 ml kg^− 1 25 min before anesthesia induction. The primary outcome was the incidence of perioperative adverse events. Heart rate, respiratory rate, parent-child separation score, tolerance of the anesthetic mask, agitation score, consumption of sevoflurane, and recovery time were also recorded.

Results

Following pre-anesthesia treatment with either intranasal dexmedetomidine or saline, the incidences of laryngospasm (15% vs. 50%), breath-holding (10% vs. 40%), and coughing (5% vs. 30%) were significantly lower in patients given dexmedetomidine than those given saline. Patients who received intranasal dexmedetomidine had a lower parent–child separation score (P = 0.017), more satisfactory tolerance of the anesthetic mask (P = 0.027), and less consumption of sevoflurane (38.18 ± 14.95 vs. 48.03 ± 14.45 ml, P = 0.041). The frequency of postoperative agitation was significantly lower in patients given intranasal dexmedetomidine (P = 0.004), and the recovery time was similar in the two groups.

Conclusions

Intranasal dexmedetomidine 1 μg·kg^− 1, with its sedative and analgesic effects, reduced the incidences of laryngospasm, breath-holding, and coughing during fiberoptic bronchoscopy for FB removal. Moreover, it reduced postoperative agitation without a prolonged recovery time.

Trail registration

The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800017273) on July 20, 2018.