Intravenous Midazolam Sedation Research Articles

Necessity of pharyngeal anesthesia during transoral gastrointestinal endoscopy: a randomized clinical trial.

The necessity for pharyngeal anesthesia during upper gastrointestinal endoscopy is controversial. This study aimed to compare the observation ability with and without pharyngeal anesthesia under midazolam sedation. This prospective, single-blinded, randomized study included 500 patients who underwent transoral upper gastrointestinal endoscopy under intravenous midazolam sedation. Patients were randomly allocated to pharyngeal anesthesia: PA+ or PA- groups (250 patients/group). The endoscopists obtained 10 images of the oropharynx and hypopharynx. The primary outcome was the non-inferiority of the PA- group in terms of the pharyngeal observation success rate. The pharyngeal observation success rates in the pharyngeal anesthesia with and without (PA+ and PA-) groups were 84.0% and 72.0%, respectively. The PA- group was inferior (p=0.707, non-inferiority) to the PA+ group in terms of observable parts (8.33 vs. 8.86, p=0.006), time (67.2 vs. 58.2 seconds, p=0.001), and pain (1.21±2.37 vs. 0.68±1.78, p=0.004, 0-10 point visual analog scale). Suitable quality images of the posterior wall of the oropharynx, vocal fold, and pyriform sinus were inferior in the PA- group. Subgroup analysis showed a higher sedation level (Ramsay score ≥5) with almost no differences in the pharyngeal observation success rate between the groups. Non-pharyngeal anesthesia showed no non-inferiority in pharyngeal observation ability. Pharyngeal anesthesia may improve pharyngeal observation ability in the hypopharynx and reduce pain. However, deeper anesthesia may reduce this difference.

2. Evaluation of Maximum Safe Dose of IV Midazolam Used in Dental Intravenous Conscious Sedation

Intravenous (IV) midazolam sedation is commonly used in the delivery of dentistry for phobic patients. There is currently no guidance on a maximum dose for use specifically in dentistry. Dentists practice with the BNF recommended maximum dose of 7.5mg, however, this is often exceeded. We aim to evaluate prescribing and propose recommendations for a maximum dose for dentists.

What lies behind the pain after shoulder dislocation?

A 38-year-old man presented to our emergency room with severe pain and inability to mobilize his right shoulder joint after a violent blunt trauma during his work. The humeral head was palpable anteriorly, with the loss of normal contour of the deltoid and acromion prominent posteriorly and laterally, as it occurs in the anterior shoulder dislocation. The shoulder was easily reduced on 1st attempt using 1.5 mg/kg intravenous fentanyl and 0.5 mg/Kg intravenous midazolam sedation in the emergency room. After the procedure, he complained of pain at the right humeral head, so we performed an X-Ray.

Usefulness of Continuous Low-Dose Fentanyl in Combination with Dexmedetomidine and Midazolam for Intravenous Sedation: A Randomised Controlled Trial.

Intravenous dexmedetomidine (DEX) and midazolam (MZ) are currently used to achieve sedation in dental surgery under local anaesthesia. However, the efficacy of low-dose fentanyl (FEN) in combination with DEX and MZ sedation remains unclear. Therefore, we implemented a prospective randomised controlled trial to investigate the intra- and postoperative analgesic effects, intraoperative respiratory and circulatory dynamics, and frequency of intra- and postoperative adverse events of continuous low-dose fentanyl administration with DEX and MZ sedation. Patients aged 20–64 years scheduled for dental surgery under sedation were randomly assigned to the DEX+MZ (DM) or DEX+MZ+FEN (DMF) group. DEX was administered at 4 μg/kg/h for 10 min and then reduced to 0.7 μg/kg/h until the end of surgery. MZ was administered at 0.04 mg/kg upon the initial administration of DEX and 0.02 mg/kg every hour thereafter. In the DMF group, FEN infusion was administered at 2 μg/kg/h during the initial administration of DEX and then reduced to 1 μg/kg/h after 10 min until the end of surgery. Primary outcomes were intra- and postoperative analgesic efficacies, whereas secondary outcomes were intraoperative respiratory and circulatory dynamics. The total amount of intraoperative local anaesthetic administered and the heart rate were significantly lower in the DMF group than in the DM group (P = 0.044 and P < 0.01, respectively). No significant difference was observed in the frequency of postoperative administration of analgesics and intra- and postoperative adverse events. These findings demonstrated that low-dose FEN infusion in combination with DEX and MZ sedation in dental surgery provides intraoperative analgesia and suppresses tachycardia with little effect on blood pressure and respiratory dynamics and without effect on postoperative analgesia.

A Novel Pain Relief Approach for the Treatment of Multiple Dental Caries and Pulpitis

Anxiety and stress toward treatment can hamper treatment completion in patients with dental caries and pulpitis. Therefore, effective management of post-treatment pain is important because poor pain management can lead to patient dissatisfaction. Ultrasound-guided nerve blocks provide good postoperative analgesia in maxillofacial surgeries. These surgeries can be performed under general or local anesthesia without complications. Here, we present the case of a patient with dental phobia who was successfully treated with these techniques. The patient was a 22-year-old woman with a history of manic-depressive illness who presented with 23 decayed teeth. She had previously undergone vital pulp therapy; however, post-treatment pain led to treatment-related stress, and the patient discontinued the dental treatment. She preferred the dental treatment to be completed with as little pain as possible and wanted to avoid a pulpectomy. The patient’s history of heavy use of non-steroidal anti-inflammatory drugs (NSAIDs) made her resistant to NSAIDs. As a result, the analgesic effect of NSAIDs could not be expected. After intravenous midazolam and propofol sedation, an ultrasound-guided inferior alveolar nerve block was performed bilaterally, and 0.375% ropivacaine was used as a local anesthetic. The patient did not complain of post-operative pain, and no post-operative analgesics were required.

Characteristics of Intravenous Midazolam Sedation with Nitrous Oxide in Pediatric Dental Treatment

Midazolam is a short-acting benzodiazepine that is widely used in pediatric dental sedation. However, its clinical effectiveness as an intravenous sedative agent in children has not been widely documented. A retrospective study was conducted to evaluate the efficacy and safety of intravenous midazolam and nitrous oxide inhalation sedation in pediatric dental treatment.&lt;br/&gt;The subjects were 115 patients (118 cases) who received dental treatment under intravenous midazolam and nitrous oxide inhalation sedation. Demographic factors, general health status, sedation time, midazolam and nitrous oxide dosage, and success rate of sedation were evaluated from electronic medical records.&lt;br/&gt;Behavioral management was the main reason of choosing sedation. Mean duration of sedation was 56.7 minutes for surgical treatment, and 74.4 minutes for restorative treatment. The initial dosage of intravenous midazolam was 0.051 ± 0.019 mg/kg. In 34 cases (28.8%), additional midazolam of 0.036 ± 0.057 mg/kg was delivered during the treatment. The concentration of nitrous oxide was maintained between 40% and 50%. The success rate of sedation was 99% (n = 117). In 1 case, laryngospasm occurred and the patient was reversed with benzodiazepine antagonist, flumazenil.&lt;br/&gt;Intravenous midazolam sedation with nitrous oxide was shown to be clinically effective for the dental treatment in children, if administered by trained personnel and patients are carefully selected in accordance with guidelines.

Prevention of hypoxemia during endobronchial ultrasound-guided transbronchial needle aspiration: Usefulness of high-flow nasal cannula.

Hypoxemia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is often encountered even in patients without respiratory impairment before the procedure. The aim of this study was to evaluate the efficacy of a high-flow nasal cannula (HFNC) in preventing hypoxemia during EBUS-TBNA. The present investigation was designed as a prospective pilot study. Eligible subjects were adults who could undergo EBUS-TBNA under intravenous midazolam sedation. The main exclusion criteria were as follows: age > 80 years with impaired oxygenation and peripheral oxygen saturation (SpO2) < 95% at room air. The primary outcome was the oxygenation level during the procedure. Cutaneous carbon dioxide tension (PcCO2) and complications were evaluated as secondary outcomes. HFNC use was started at an inspired O2 fraction of 30% and was titrated to maintain SpO2 over 90%. The lowest SpO2 values during EBUS-TBNA were retrospectively compared between patients who underwent HFNC and those were given a conventional nasal cannula as a historical control group. Twelve patients received HFNCs. The mean lowest SpO2 during the procedure was 93%. Although the mean SpO2 tended to decrease in the early stages, it remained over 90% throughout the procedure. The mean highest PcCO2 was 39 mmHg (range, 30-46 mmHg). There were no major complications. In patients who underwent EBUS-TBNA using a conventional nasal cannula, the mean lowest SpO2 was 88%, which was significantly lower than that in the HFNC cases (p = 0.005). HFNC could be an effective and safe device for prevention of hypoxemia during EBUS-TBNA.

Percutaneous endoscopic gastrostomy under conscious sedation in patients with amyotrophic lateral sclerosis is safe: an observational study.

Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes muscle weakness with respiratory and swallowing dysfunction, eventually leading to death. Permanent enteral feeding is indicated in almost all patients. A percutaneous endoscopic gastrostomy (PEG) tube is considered the first choice, usually performed under conscious sedation (intravenous midazolam). Guidelines are very cautious with respect to sedation in ALS because of the risk for respiratory complications. In our tertiary referral hospital, conscious sedation has been used for many years.Our aim was to review 30-day complications in PEG performed under conscious sedation in ALS patients (without noninvasive positive pressure ventilation during the procedure). A retrospective review, including all ALS patients undergoing PEG under conscious sedation from October 2009 to April 2016, was performed. Analysis included 45 (44% men) patients receiving intravenous midazolam sedation (mean dose 5 mg) during PEG placement, age 36-91 years (mean: 68.7 years). Forced vital capacity (FVC) was 24-116% (mean 68%), of which mild to moderate dysfunction (FVC 50-69%) was present in 42.2% of patients and (very) severe dysfunction (FVC <50%) in 8.8%. No respiratory complications (e.g. aspiration pneumonia) were observed. Other complications, for example, infection, bleeding and peritonitis occurred in, respectively, 8.9, 2.2 and 0%. Mean survival after PEG placement was 13.4 months (range: 1-45 months). Conscious sedation during PEG insertion in ALS patients did not lead to respiratory complications or to an increase in other complications. Our data indicate that conscious sedation can be used safely in ALS patients with mild to moderate pulmonary dysfunction.

Evaluation of clinical effectiveness in the provision of intravenous midazolam sedation for anxious dental patients

The use of conscious sedation for patients is a valuable and effective method of anxiety management in the dental setting, provided it is delivered by an appropriately trained team in a suitable environment and with systems in place to ensure safe delivery of care.

Clinical comparative study on Nitrous Oxide inhalation versus intravenous propofol and Midazolam sedation in Transnasal Gastroscopy.

Objective:To investigate the Clinical practice value of nitrous oxide inhalation and intravenous propofol and midazolam sedation in transnasal gastroscopy.Method:From December 2012 to April 2014, two hundred patients receiving painless transnasal gastroscopy on a voluntary basis were selected in Endoscopy center, The First People’s Hospital of GuiYang. Patients were divided into two groups: Group-1 consisted of one hundred patients sedated by nitrous oxide inhalation and Group-2 consisted of one hundred patients sedated by intravenous propofol and midazolam. Patients were then examined by transnasal gastroscopy. Patient blood pressure, heart rate, pulse rate and oxygen saturation before, during and after gastroscopy were recorded for both groups. The duration of the gastroscopy and the time of awakening were also recorded. After examination, the patients were asked to assess the level of discomfort experiences during the gastroscopy procedure.Results:All patients successfully underwent the transnasal gastroscopy. There were 57 males and 43 females in the nitrous oxide inhalation group with an average age of 43.11±8.27 years. The average duration of examination and time of awaking in the nitrous oxide inhalation group was of 152.7±9.80 secs and 50±7.89 secs respectively. For the intravenous propofol and midazolam sedation group, there were 53 males and 47 females with an average age of 41.26±7.98 years. The average duration of examination and time of awaking in the intravenous propofol and midazolam sedation group was of 149.07±10.25 seconds and 390±20.89# seconds respectively. The two groups showed no significant difference in the duration of examination. There was no difference in the age or sex. The former had a less significant impact on heart rate, oxygen saturation and blood pressure, while the intravenous propofol and midazolam sedation decreased blood pressure dramatically and this effect persisted after examination.Conclusion:Nitrous oxide inhalation has higher safety and tolerance with a brighter application prospect for transnasal gastroscopy.

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery.

BackgroundAnxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique.MethodsThe medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients.ResultsIn total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications.ConclusionsOur results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae.

Inhalation of 50% Oxygen Does Not Impair Respiratory Depression During Midazolam Sedation

To investigate how inhalation of 50% oxygen during intravenous midazolam sedation affects respiratory variables and thus the availability of oxygen. Study subjects were 21 healthy adult volunteers (American Society of Anesthesiologists physical status I). They were allocated to undergo midazolam sedation during high-concentration oxygen inhalation (group H) or during normal air inhalation (group N) in a single-blinded randomized crossover design, with an interval of at least 3days between the 2 sedation sessions. In each experiment, midazolam 0.05mg/kg was administered, after which the following variables were measured for 40minutes: oxygen saturation by pulse oximetry (SpO2), end-tidal carbon dioxide partial pressure (ETCO2), respiration rate (RR), tidal volume (VT), and minute volume (MV). Subsequently, flumazenil 0.5mg was administered, and the same variables were measured for 10minutes. SpO2 decreased after midazolam administration in the 2 groups. SpO2 in group H was higher than that in group N at all time points. RR increased and VT decreased after midazolam administration in the 2 groups; however, in contrast to SpO2, the levels of these parameters did not meaningfully differ between groups at any time point. MV remained unchanged in the 2 groups. ETCO2 decreased similarly after midazolam administration in the 2 groups. Inhalation of 50% oxygen during midazolam sedation did not enhance respiratory depression by midazolam. This suggests that high-concentration oxygen inhalation during midazolam sedation could prevent hypoxia.

The use of volatile anesthetic agents for long-term critical care sedation (VALTS): study protocol for a pilot randomized controlled trial.

BackgroundSedatives are administered to 85 % of intensive care unit (ICU) patients. The most commonly used sedatives are intravenous benzodiazepines and propofol. These agents are associated with over-sedation in 40 to 60 % of patients, which can lead to prolonged intubation, delirium and drug-induced hypotension. Evidence is increasing that volatile anesthetic agents are associated with faster extubation times, improved cardiovascular stability with no end-organ toxicity in comparison to our standard intravenous agents for short-term critical care sedation. Use of volatile agents within the ICU is a novel technique using a specialized delivery and scavenging system, which requires staff training and cultural acceptance. This pilot randomized controlled trial aims to assess the safety and feasibility of delivering volatile agents for long-term patient sedation in the ICU with limited or no experience of this technique.Methods/DesignThis is a prospective multicenter pragmatic pilot RCT that is blinded to the data analyst. This study aims to recruit 60 adult ICU patients requiring mechanical ventilation and sedation for more than 48 h. Patients will be randomized 2:1 to receive inhaled isoflurane (40 patients) or intravenous midazolam and/or propofol (20 patients) sedation. Sedation is titrated to a targeted Sedation Analgesia Score (SAS) using an explicit sedation-analgesia algorithm until extubation or tracheostomy. Primary safety and feasibility outcomes will assess atmospheric volatile concentration levels and adherence to our sedation-analgesia protocol. Secondary outcomes include time to extubation, duration of ventilation, quality of sedation, delirium, vasoactive drug support, length of stay, serum fluoride levels and mortality.DiscussionThis pilot project will serve as the basis for a larger RCT that will be powered for important clinical outcomes.Trial RegistrationClinicalTrials.gov, NCT01983800 (registration date 2 July 2013).

Reported side effects of intravenous midazolam sedation when used in paediatric dentistry: a review.

Intravenous (IV) midazolam may be of value as an alternative paediatric dental sedation technique, but there is some apprehension concerning its routine use due to a lack of evidence regarding its safety and side effects. To review all available literature reporting the side effects of IV midazolam in children undergoing dental procedures. Both randomised controlled trials (RCT) and non-randomised studies were reviewed. Reported side effects were categorised as either significant or minor, and the percentage prevalence of significant or minor side effects per episode of treatment was calculated. Five RCTs were included, in which no significant side events were reported; however, minor side effects were recorded (n = 33, 19.5%), with paradoxical reaction being the most common (n = 11, 6.5%). Six non-randomised studies were included, in which no significant side effects were reported; however, minor side effects were reported (n = 118, 16.8%) with paradoxical reaction being the most common (n = 89, 12.7%). Although no significant side effects were recorded, of the minor side effects reported paradoxical reaction was the most common. Due to inconsistency in side effect reporting, the authors suggest the application of a standardised adverse event reporting tool for future studies of sedation in paediatric dentistry.

A Comparison of Hemodynamic Responses and Patient Comfort In Catract Surgery With And Without Midazolam As Sedation.

To investigate if pre-block intravenous sedation using Midazolam minimizes pain, reduces pain recall, and attenuates hemodynamic responses to peribulbar block.A prospective study with intravenous sedation Midazolam 0.02 mg/kg body weight prior to peribulbar block were evaluated for hemodynamic responses and patient comfort in cataract surgery. Intravenous sedation with Midazolam in cataract surgery prior to peribulbar block reduced pain recall and haemodynamic responses to peribulbar block and improved patient satisfaction.

Application of dexmedetomidine for awake tracheal intubation with Shikani optical stylet in patients receiving cervical vertebral surgery

Objective To compare the clinical efficacy of dexmedetomidine (Dex) with Midazolam for awake tracheal intubation with Shikani optical stylet in patients undergoing cervical vertebral surgery,and evaluate the clinical value of Dex.Methods Thirty ASA Ⅰ-Ⅱ patients undergoing cervical vertebral surgery and slow induction of anesthesia were randomly assigned to Dex group (group D,n=15) and Midazolam group (group M,n=15).The group D received a loading dose of 1 μg/kg Dex intravenously over 10 min,and followed by continuous infusion at a rate of 1 μg·kg-1·h-1 in group D; Group M received 0.08 mg/kg Midazolam intravenously and followed by 0.02 mg/kg intermittent bolus until the desired depth of sedation was reached.After the topical upper airway anaesthesia with 150 mg of 2％ lidocaine,awake orotracheal intubation was performed using Shikani optical stylet.The intubation conditions (coughing,limb movement),the tolerance to intubation and the level of cooperation of the patient were evaluated.The time of intubation,the frequency of intubation,adverse effects or complications such as hemodynamic change,injury in pharyngo-oral cavity,respiratory depression were observed.The incidence and severity of sore throat and memory of intubation were recorded at 24 h after surgery.Results There was no difference between group in the time required for intubation and the frequency of successful intubation (P＞0.05).Compared to group M,the extremities s movement,the tolerance to intubation,the level of cooperation and hemodynamic changes of the patients in group D were better (P＜0.05).The respiratory depression was observed in three cases in group M.There were two cases in the group M and one case in the group D who have vague memory of intubation at 24 h after surgery.Conclusions Slow induction of Dex is more desirable than Midazolam for intravenous sedation,for it provides favorable conditions and tolerance,few side effects for awake orotracheal intubation with Shikani optical stylet in patients undergoing cervical vertebral surgery. Key words: Cervical vertebrae; Tracheal intubation; Dexmedetomide; Shikani optical stylet

Deep sedation in patients undergoing atrioventricular nodal reentry tachycardia ablation.

Background:General anesthesia and deep sedation can be used during cardiac EPS to relief pain and provide comfort and immobility, but many electrophysiologists avoid sedation for better arrhythmia induction.Objective:To determine anesthesia effects in ablation procedures in adults, we used intravenous anesthetic agents in patients who underwent slow pathway ablation.Patients and Methods:One hundred patients who were to undergo radiofrequency catheter ablation were randomly assigned to with and without intravenous anesthesia groups. All patients had palpitation with a documented electrocardiography (ECG) compatible with atrio-ventricular nodal reentrant tachycardia (AVNRT). We used propofol, fentanyl and midazolam for intravenous sedation. Electrophysiological parameters were checked for the two groups and compared before and after the ablation.Results:Electrophysiological parameters were not significantly different in the two groups. In the anesthetic group, patients were more satisfied with the procedure (P value < 0. 001).Conclusions:Intravenous anesthesia could be done safely in patients who underwent electrophysiological procedures. It had no effect on arrhythmia induction or slow pathway ablation in patients with documented AVNRT.

Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients

BackgroundChildren and parents experience significant anxiety and distress during the preoperative period. This is important because preoperative anxiety in children is associated with adverse postoperative outcome. So we suggest behaviorally oriented preoperative anxiety intervention program based on the anesthesia and psychology with smartphone application, world-widely used.MethodsA total 120 patients (aged 1-10 years old) who were scheduled for elective surgery under general anesthesia was included in this randomized controlled trial. We randomized the patients into three groups, with using intravenous (IV) midazolam sedation (M group), with using smartphone application program (S group), and with using low dose IV midazolam plus smartphone application program (SM group). And the child anxiety was assessed using the modified Yale Preoperative Anxiety Scale (mYPAS) at holding area, 5 min after intervention, entrance to operating room.ResultsIn all three groups, mYPAS after intervention were lower than the preoperative holding area (M group 52.8 ± 11.8 vs 41.0 ± 7.0, S group 59.2 ± 17.6 vs 36.4 ± 7.3, SM group 58.3 ± 17.5 vs 26.0 ± 3.4). A comparison of mYPAS scores between each group showed that the S group reduced anxiety lower than M group (P < 0.01), and the SM group exhibited significantly lower anxiety than the two other groups (P < 0.01).ConclusionsThe preoperative preparation program using smartphone application is simple and customized by individual development that effective in the reduction of preoperative anxiety.

Rate of onset of inhibition of gut-wall and hepatic CYP3A by clarithromycin

To determine the extent and time-course of hepatic and intestinal cytochrome P450 3A (CYP3A) inactivation due to the mechanism-based inhibitor clarithromycin. Intestinal and hepatic CYP3A inhibition was examined in 12 healthy volunteers following the administration of single and multiple doses of oral clarithromycin (500 mg). Intestinal biopsies were obtained under intravenous midazolam sedation at baseline and after the first dose, on days 2-4, and on days 6-8 of the clarithromycin treatment. The formation of 1'-hydroxymidazolam in biopsy tissue and the serum 1'-hydroxymidazolam:midazolam ratio were indicators of intestinal and hepatic CYP3A activity, respectively. Intestinal CYP3A activity decreased by 64 % (p = 0.0029) following the first dose of clarithromycin, but hepatic CYP3A activity did not significantly decrease. Repeated dosing of clarithromycin caused a significant decrease in hepatic CYP3A activity (p = 0.005), while intestinal activity showed little further decline. The CYP3A5 or CYP3A4*1B genotype were unable to account for inter-individual variability in CYP3A activity. Following the administration of clarithromycin, the onset of hepatic CYP3A inactivation is delayed compared to that of intestinal CYP3A. The time-course of drug-drug interactions due to clarithromycin will vary with the relative contribution of intestinal and hepatic CYP3A to the clearance and bioavailability of a victim substrate.

Procedural sedation with dexmedetomidine for pediatric endoscopic retrograde cholangiopancreatography guided stone retraction

Pediatric endoscopic retrograde cholangiopancreatography (ERCP) is currently used as a diagnostic and therapeutic procedure [1]. Compared to adults, pediatric patients experience different physiological effects with respect to discomfort, anxiety, and pain responses. Therefore, appropriate analgesia and amnesia are more frequently required for pediatric patients. Various methods of sedation, including general anesthesia, can be used for pediatric ERCP [2]. Although the use of dexmedetomidine for sedation in pediatric patients in various circumstances is reported, few studies have reported its use in pediatric ERCP. Here, we report our experience with dexmedetomidine for ERCP-guided stone retraction in a pediatric patient. A 10-year-old boy weighing 29 kg was referred to our department for deep sedation. He presented with obstructive jaundice, and a CT scan revealed a small stone at the distal common bile duct. Five days earlier, ERCP-guided stone retraction was performed under intravenous midazolam (3 doses of 0.1 mg/kg) sedation by a gastroenterologist. Stone retraction failed because of inadequate sedation, but the duct was successfully visualized using fluoroscopy. ERCP-guided stone retraction was therefore rescheduled. Before the second procedure, informed consent was obtained from the patient's parents. After arrival at the ERCP suite, the patient was monitored using electrocardiography and pulse oximetry, and his noninvasive blood pressure (BP) and bispectral index (BIS) were checked. He was calm and cooperative. His vital signs, BIS values and Observer's Assessment of Alertness/Sedation scores were closely monitored and recorded (Table 1) during sedation. Table 1 Values During the Procedure The patient was positioned in the prone position with his head turned toward the operator. A 0.7 µg/kg loading dose of dexmedetomidine was intravenously administered over 10 minutes followed by a maintenance infusion of 0.5 µg/kg/h. Just prior to the procedure, 0.5 mg/kg ketamine and 0.5 µg/kg fentanyl were intravenously administered consecutively. His oxygen saturation (SpO2) decreased to 85% for a second. When the scope was inserted, his SpO2 recovered to 100%. He breathed spontaneously with oxygen supplementation via nasal prongs. The procedure was completed with minimal reductions in BP and heart rate. After completing of the procedure, dexmedetomidine infusion was discontinued. The patient was then positioned in the supine position. He remained in the ERCP suite for 15 minutes, after which he was then discharged to the general ward, where his complete recovery was confirmed by anesthesiologists. The patient did not complain of postoperative nausea or vomiting and did not exhibit emergence agitation/delirium. Dexmedetomidine is a highly selective α2 adrenoceptor agonist that has many advantages over other sedatives. In addition to producing sedative, analgesic, and anxiolytic effects, it provides respiratory stability [3]. It was first used as a sedative for patients being intubated in the intensive care unit. It was then used for sedation during many medical and surgical procedures without intubation. In addition, many studies have reported the use of dexmedetomidine in pediatric patients despite the lack of Food and Drug Administration approval [3]. Among pediatric patients, dexmedetomidine has been used for procedural sedation, particularly in diagnostic radiology. As a sedative, dexmedetomidine maintains spontaneous respiration and preserves oxygenation and ventilation even at deep sedation. However, it is neither a complete anesthetic nor a complete analgesic [4]. Therefore, adjunctive analgesics are required during painful procedures. Because the half-life of dexmedetomidine is relatively long, its use as a sedative is limited. Small doses and brief exposures may reduce the risk of prolonged recovery and delayed discharge from the recovery room and hospital [4]. In the present case, the total procedural and infusion times were short, and the patient recovered completely from the sedation within 30 minutes with no adverse events. Sedation with topical pharyngeal anesthesia has developed into a safe and common alternative to general anesthesia in pediatric endoscopy because of short-acting opioids and specific narcotic and benzodiazepine medications. General anesthesia is still used in younger patients, particularly when intolerance in anticipated and after considering the higher complexity of procedures in patients with smaller anatomies [1]. In the present case, the stone was located in the distal common bile duct. Therefore, positional changes and other complicated situations were not required. Possible pain due to stone retraction was prevented with ketamine and fentanyl. Furthermore, visualization of the duct was previously performed during the first procedure; the stone removal was therefore fast and gentle. When patients are treated with appropriate analgesics, sedation with dexmedetomidine for pediatric ERCP would be safe and associated with better outcomes than sedation with other sedatives.