Mask Acceptance Research Articles

Nebulized Dexmedetomidine for Sedation and Mask Acceptance in Pediatric Patients Undergoing Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PurposeCompare nebulized dexmedetomidine to other sedatives while assessing the level of sedation, mask acceptance, and parental separation anxiety in the pediatric population undergoing surgery. DesignSystematic review and meta-analysis. MethodsMEDLINE (PubMed), Google Scholar, CINAHL, the Cochrane Review Database, Google Scholar, and gray literature were searched for evidence. Risk ratio (RR) and standardized mean difference (SMD) were used to estimate outcomes with suitable effect models. The quality of evidence was rated using the Risk of Bias and the Grades of Recommendation, Assessment, Development, and Evaluation approach. FindingsEight studies (n = 615) were included in the review. Over 30 minutes following premedication, nebulized dexmedetomidine yielded comparable sedation scores to other nebulized treatments (SMD, −0.09; 95% confidence interval [CI], −0.45 to 0.28; P = .64). Subgroup analyses revealed that nebulized dexmedetomidine provided more satisfactory sedation levels compared with midazolam (SMD, −0.82; 95% CI, −1.37 to −0.26; P = .004), although it did not provide a satisfactory sedation level as ketamine (SMD, 0.34; 95% CI, 0.01 to 0.67; P = .04). Furthermore, patients receiving nebulized dexmedetomidine showed higher rates of satisfactory mask acceptance (RR, 1.32; 95% CI, 1.08 to 1.59; P = .007) and favorable parental separation outcomes (RR, 1.17; 95% CI, 1.04 to 1.32; P = .01). ConclusionsNebulized dexmedetomidine is efficacious versus nebulized midazolam but not nebulized ketamine for preprocedural sedation for pediatric patients undergoing general anesthesia. Nonetheless, it demonstrated superior results in facilitating parental separation and mask acceptance.

Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study.

Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

COMPARISON OF ORAL CLONIDINE AND ORAL MIDAZOLAM AS PRE-MEDICATION FOR PEDIATRIC SURGERY IN CHILDREN

Objectives: The objectives of the study are to compare the efficacy and safety of oral midazolam (0.5 mg/kg) and oral clonidine (3 μg/kg) as pre-medicant in pediatric age children undergoing surgical intervention. Methods: The present study was conducted at the Department of Anesthesiology and Critical Medicine, Sri Aurobindo Medical College and Postgraduate Institute, Indore (M.P.). We had included 60 children undergoing pediatric surgical intervention during the study period of 1–1/2 years of age 2–10 years. These children were randomized to receive either midazolam or clonidine. After obtaining consent from the parents, these children were included in the study. Pediatric separation anxiety score (PSAP) was used for the assessment of anxiety and mask acceptance scale was used for the assessment of mask acceptance. Comparison of means between the two groups was done using unpaired “t” test, and association between two non-parametric variables was done using Pearson Chi-square test. A p<0.05 was taken as statistically significant. Results: The mean age in midazolam group was 5.50±3.18 years and in clonidine group was 5.56±4.44 years. The mean age was comparable between the two groups (p=0.954). In both groups, there was male predominance. Mask acceptance was also better in clonidine group compared to midazolam group (p=0.001). Sedation was more in clonidine group compared to midazolam group, but it was not statistically significant (p=0.136). Wake-up behaviors of the patients were comparable between the two groups (p=0.777). The hemodynamics were comparable between the two groups at majority of the time intervals (p>0.05). We found clonidine to be better in comparison to midazolam in providing sedation and patients were easily consolable compared to midazolam group patients. Conclusion: We conclude that clonidine as a pre-medicant in patients undergoing pediatric surgical intervention is better as compared to midazolam with slightly higher sedation in clonidine group. We recommend the use of clonidine as a pre-medicant in patients undergoing pediatric surgical intervention.

The use of a scented face mask in pediatric patients may facilitate mask acceptance before anesthesia induction.

Scented face masks are commonly used during the induction phase of anesthesia. The present study investigated whether the use of a scented mask improved mask acceptance before the slow induction of anesthesia in pediatric patients. This prospective, randomized controlled trial enrolled patients aged 2-10 years who were scheduled to undergo surgery under general anesthesia. Patients were randomly assigned to either of regular unscented (control group) or scented (experimental group) face masks before anesthesia induction with a parent. The primary outcome was the mask acceptance score, rated on a validated 4-point from 1 point (not afraid; easily accepts the mask) to 4 points (afraid of a mask; crying or struggling). The secondary outcome was heart rate assessed by pulse oximetry in the pediatric ward before transfer to the operating room (OR), at the entrance to the OR, at the patient notification of mask fitting by the anesthesiologist, and after mask fitting. Seventy-seven patients were accessed for eligibility, with 67 enrolled in the study: 33 in the experimental group and 34 in the control group. Mask acceptance was significantly greater among patients aged 2-3 years in the experimental than in the control group (p < 0.05). The use of a scented mask can improve mask acceptance before anesthesia induction with a parental presence in pediatric patients aged 2-3 years.Clinical Trial Registration: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000040819.

COMPARISON OF ORAL MIDAZOLAM,ORAL DEXMEDETOMIDINE AND ORAL MIDAZOLAM KETAMINE COMBINATION FOR PREMEDICATION IN PAEDIATRIC SURGERY

Background: Children especially age group &lt;10years undergoing operation may experience preoperative anxiety &amp; may be uncooperative.This uncooperative behavior of children may be observed at the time of separation from parents, venipuncture or mask application. Untreated anxiety may lead to difficult induction, greater rescue analgesic needs, emergence delirium (ED), behavioural &amp; postoperative psychological effects. An atraumatic premedication, calm separation from parents can minimize these problems and a smooth induction of anaesthesia can be achieved.Method : Prospective randomized double blind active controlled study was conducted in Government medical college &amp; hospital, Aurangabad from 2018 to 2020 after Institution Ethics Committee approval. 75 ASA I &amp; II subjects aged between 2 to 5 year weighing less than 15 Kg posted for elective paediatric surgery under general anaesthesia at tertiary care centre were selected. They were randomly allocated into 3 groups Group M ,Group M K &amp; Group D with 25 subjects in each group using computer generated randomization list. Oral premedication was given in each group 30 minutes before surgery.Baseline heart rate,SBP and RR measured before administering premedication and at 10 minutes intervals up to 30 to 45 minutes after premedication. Results: Sedation &amp; anxiolysis score at induction[S1] was significant higher in Group M K&amp; Group D [p Value &lt;0.05] compared to Group M. Sedation at the time of separation from parents [S2] was better in Group M K &amp; Group D compared to Group M[p Value &lt;0.05].Sedation during Mask Acceptance[S3] was better in Group M K &amp; Group D compared to Group M[p Value &lt;0.05].Wake up Behaviour [when the patient recovers from anaesthesia at end of surgery [S4] ] was assessed &amp; Subjects were more Sedated[post anaesthesia] in Group D when compared to Group m &amp; Group M K[p Value &lt;0.05]. Time taken for maximum change in vital parameters was more in Group D followed by Group M K and Group M respectively p Value 0.001].There was significant changes in Vital parameters in Group D compared to Group M &amp; Group M K .Bradycardia p Value 0.00044] &amp; Hypotension [p Value 0.01]was more significant in Group D when compared to Group MK &amp;Group M Conclusion: Oral Midazolam (0.2mg/kg) &amp; Ketamine (2mg/kg) combination &amp; oral Dexmedetomidine (0.5 g/kg) both provide satisfactory sedation levels &amp; offers significant ease of separation from parents with satisfactory mask acceptance in children&lt;10 years compared to oral Midazolam alone.

Preoperative sedation in children with congenital heart disease: 50% and 95% effective doses, hemodynamic effects, and safety of intranasal dexmedetomidine

Study objectiveTo determine the 50% and 95% effective doses (ED50 and ED95, respectively), hemodynamic effects, and safety of intranasal dexmedetomidine for preoperative sedation in pediatric patients with congenital heart disease (CHD) with a left-to-right shunt. DesignDouble-blind sequential allocation trial. SettingPediatric preoperative waiting area. Patients86 pediatric patients ASA physical status II–III scheduled for cardiac surgery, aged1-month to 6-years-old with left-to-right type CHD. InterventionsChildren were divided into three groups according to age: infants (1 month–1 year), toddlers (1–3 years), and preschoolers (3–6 years). The first patient in all groups received intranasal dexmedetomidine (2 μg/kg), using the up-and-down Dixon method, and the and the next patient's dose was dependent on the previous patient's response. MeasurementsAssessment using the Modified Observer's Assessment of Alertness/Sedation Scale and the Mask Acceptance Scale was performed before and every 5 min after treatment. Pulse oxygen saturation and heart rate were recorded at baseline, at 10-min intervals, and after admission to the operating room. Systolic pulmonary artery pressure was measured before anesthesia induction. Main resultsThe respective ED50 (95% confidence interval [CI]) and ED95 (95% CI) values for preoperative sedation using intranasally administered dexmedetomidine were 3.1 (2.8–3.3) and 3.5 (3.3–4.0) μg/kg for infants; 3.4 (3.2–3.6) and 3.9 (3.7–4.4) μg/kg for toddlers; and 2.4 (2.2–2.6) and 2.9 (2.6–3.3) μg/kg for preschoolers. ED50 was lower for preschoolers than for toddlers (p < 0.001) and infants (p = 0.044). No obvious difference in ED50 was found between infants and toddlers. There was no significant difference in sedation onset time among the groups, and no adverse events were observed during sedation in all patients. ConclusionsIntranasal dexmedetomidine can be safety used for preoperative sedation inchildren with CHD and is effective for sedation when dosed appropriately.Trial registrationclinicaltrials.gov (ChiCTR2100047472); registered 20 June 2021.

The effect of using tablet computer on surgical stress: A single-blinded randomized controlled trial

The purpose of our study was to evaluate the effects of tablet computer method on children with and without anxiety. The study was designed as a prospective single-blinded randomized controlled trial. The population of the study were 300 patients between the ages of 4 and 10 years old who were scheduled for their first elective surgery for phimosis-inguinal hernia-hydrocele-undescended testis-hypospadias. The initial anxiety scores of the patients were evaluated using modified-Yale Preoperative Anxiety Scale (mYPAS). Group-Midazolam, Group-Tablet, Group-Control were formed by applying randomization to the patients. The anxiety levels of the patients were evaluated in the waiting room using mYPAS after 0.5mg/kg midazolam or tablet computer. Patient anxiety about separation from their families was evaluated with Parental Separation Anxiety Scale (PSAS), and reactions to the anaesthesia mask were evaluated with Mask Acceptance Scale (MAS). Also, the time spent by the patients in the Post-Operative Care Unit (PACU) was evaluated. Post-Hospitalization Behavior Questionnaire (PHBQ) scores of the patients were determined by the anesthesiologist one week after the surgery. The study compared the anxiety levels in groups. There were significant differences in the post-anxiolytic-mYPAS-scores and percentages of decrease from the preoperative baseline measurements (p<0.001 and p<0.001). There were significantly more children who were easily separated from their parents (PSAS-Score 1) in Group-Midazolam (p<0.01). The children in Group-Midazolam also accepted the masks more readily (MAS-Score 1) than other (p<0.001). Differences in the duration of the recovery time and mean PHBQ-scores between the groups were also significant (p<0.001 for each). For children with anxiety, the recovery time for those in Group-Midazolam was significantly longer than other. For children without anxiety (p<0.001), the duration of the recovery time in Group-Midazolam was also found to be significantly longer than other. The PHBQ-scores of the children in Group-Control with anxiety and without anxiety were significantly higher than other (p<0.05 for each). Also, there were significant differences in the distribution of the PSAS-scores between the children with and without anxiety. Anxiety had no impact on the distribution of the MAS-scores (p=0.045 and p=0.100). Playing tablet-based games in the preoperative period enabled pediatric patients to be more comfortable while waiting in their rooms, leaving their families, and applying an anaesthetic mask. In pediatric patient with and without anxiety, midazolam separation from the family and accepting the anesthesia mask is easiest in midazolam, second in those who are given a tablet computer.

Abstract No.: ABS3251: A comparative study of oral clonidine and oral midazolam as premedication in paediatric surgery.

Background & Aims:Premedication plays animportant role in allowing smooth parent-child separation. Oral midazolam 1hour before surgery,as a premedication in children-is considered safeandeffective at separation and induction. Oral clonidine 1hour before surgery-providessedation, anxiolysis, analgesia. The aim of the study was to access the parent-separation anxiety score and mask acceptance score.Methods:A total of 60 children, aged 2 to 10 years and American Society of Anesthesiologists (ASA) physical status classification of I–II, were included after random allocation into two groups. Group C- oral clonidine 3 µg/kg, Group M- oral midazolam (0.5 mg/kg) were given as premedication 1 hour before surgery. Patients were assessed for parent separation anxiety score (PSAS) and mask acceptance score. Patients were monitored for pulse, blood pressure, saturation at regular intervals. Statistical analysis was done using Pearson chi square test.Results:There was a significant association between the groups and PSAS (P=0.001). Lower PSAS was seen in clonidine as compared to midazolam. Significant association was found between the groups and Mask acceptance scale (MAS) (P=0.001). Excellent maskacceptance was seen in clonidine as compared to midazolam group.Conclusion:From our observations and data analysis. we concluded that clonidine is better than midazolam when used as premedication and provides better parent separation score and mask acceptance in paediatric patients undergoing surgery.

Comparison of oral Midazolam versus Combination of Low Dose Oral Midzolam–Ketamine for Premedication in Paediatric Surgical Patients

Background and need for study: One of the challenge faced by paediatric anaesthesiologist is the allaying of fear of a child in the preoperative period. Among the commonly used premedicant in children, midazolam is the front runner. A combination low dose of ketamine and midazolam have been tried to overcome the deficiencies of ketamine and midazolam alone. Aims: This research was planned to compare the effectiveness of combination of low dose midzolam–ketamine with oral midazolam alone as a premedicant in paediatric patients in terms of degree of sedation, separation from parents, mask acceptance, and postoperative recovery Design: Prospective, randomised, double blind controlled study. Methods: Sixty children of ASA physical status I or II, aged between 1 and 12 years, who were scheduled to undergo elective minor surgery were randomised into two groups M and MK of thirty children each. Children in group M were administered with oral midazolam 0.5 mg.kg-1 mixed with 2 ml of honey and group MK were administered with combination of low dose oral midzolam (0.25 mg.kg-1) &amp; oral ketamine (3 mg.kg-1) for premedication mixed with 2 ml of honey. Patient was assessed for parental separation anxiety, mask acceptance, level of sedation and emergence delirium. Statistical Analysis: Difference with respect to anxiety at separation from parents and tolerance to mask between the two groups was analysed using chi-square test . Difference with respect to incidence and severity of emergence delirium between the two groups was analysed using an independent sample t test . The P &lt;0.05 was considered significant. Results: Parental separation was acceptable in 23 patients (76.7%) in group M and 28 patients in (93.3%) in group MK (Table 2, 3). Mask acceptance was satisfactory in 13 (43.3%) in group M and 19(63.3%) in group MK. Post-operative delirium was noted in one patient in each group. Conclusion: The low dose mixture of ketamine and midazolam provides better parental separation and mask acceptance with better cooperation during induction of anaesthesia.

Comparative Study between Dexmedetomidine vs Midazolam-Fentanyl on Emergence Agitation in Children Undergoing Cochlear Implantation in Sohag University Hospital

ABSTRACT Background: Surgery of cochlear implantation is a great advance in otology for patients with deaf mutism, but it carries a great challenge to the anesthesiologist. Objective: The aim of the current work was to compare effect of bolus Dexmedetomidine infusion versus bolus Midazolam- fentanyl infusion as regards; emergence agitation & recovery time, hemodynamics, postoperative pain and complication. Patient and Methods: This study included a total of 40 pediatric patients (ASA I or II), undergoing cochlear implantation, attending at Sohag University Hospital. They were randomized divided into dexmedetomidine (D) group and midazolam (M) group. Results: There was no significant difference between both groups as regard intraoperative mean blood pressure. There was a significant difference at discharge time. There was statistically insignificant decrease in heart rate (HR) in group D than M group. There was statistically significant difference at 1 min and discharge measurements. There was a highly significant difference between both groups as the time for recovery being more rapid in D group than in M group. Mask Acceptance Scale (MAS) was better within D group than M group without statistically significant difference. There was a no significant difference in emergence agitation between both groups. There was no significant difference between both groups as regard objective pain score. As regard nausea and vomiting, there was a highly significant difference between both groups. Conclusion: It could be concluded that dexmedetomidine infusion in cochlear implantation in pediatric patients was equal as midazolam-fentanyl in inducing hypotension, emergence agitation and giving post-operative analgesia. However, dexmedetomidine infusion is better as regardrapid recovery without inducing nausea and vomiting.

Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomised trial.

Pre-operative anxiety in children has been associated with adverse clinical outcomes such as difficulty in anaesthesia induction, emergence delirium and negative postoperative behavioural changes. Therefore, pre-operative anxiety should be alleviated in both children and clinicians. We investigated the effect on pre-operative anxiety of premedication with midazolam, playing video games or watching a cartoon about anaesthesia. A prospective randomised trial. Single-centre study performed between August 2018 and June 2019. We enrolled 138 patients aged 5 to 8 years undergoing elective surgery. After evaluating baseline (T0) anxiety levels using the modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-operative holding area, 0.5 mg kg-1 oral midazolam was given to Group M, a tablet with videogame applications was given to Group T, and Group S watched the cartoon 'Şüko Is Being Operated'. mYPAS values were recorded a further three times: 20 min after the intervention (T1), while entering the operating room (T2), and during mask induction of anaesthesia (T3). The primary endpoint was the change in children's anxiety levels from baseline. The secondary endpoint was cooperation during mask induction. The baseline mYPAS scores were comparable (40.7, 42.6 and 40.7 in groups M, S and T respectively). The mean mYPAS scores at T1 were 32.6, 34.7, 26.8 and at T2 were 38.6, 42.7, 35 in groups M, S and T, respectively. There were significant differences between groups S and T at T1 and T2 (P < 0.001, P = 0.010). A significant decrease was found in Group T compared with both groups M and S from T0 to T1 (P = 0.002). mYPAS values at T3 were 38.3, 43.7, 39.5 in groups M, S and T, respectively, with no difference between the groups (P = 0.224). Mask acceptance scores were similar in all groups (P = 0.912). The passive teaching technique of watching a video for reducing anxiety levels was not effective. However, active distraction with videogames was found to be a valuable method to reduce pre-operative anxiety. ClinicalTrials.gov identifier: NCT03530670.

Randomised Comparison between the Efficacy of Two Doses of Nebulised Dexmedetomidine for Premedication in Paediatric Patients.

ObjectiveNebulised dexmedetomidine can be an easy alternative for preoperative sedation in paediatric patients, but data regarding its efficacy are very limited.MethodsThis prospective, randomised, double-blind study included 66 patients aged between 1 and 8 years. Patients were divided into two groups as D2 and D3. The D2 group received 2 μg kg−1 of nebulised dexmedetomidine, and the D3 group received 3 μg kg−1 of nebulised dexmedetomidine preoperatively. All the patients received general anaesthesia and caudal epidural analgesia with 0.75 mL kg−1 of 0.2% ropivacaine. Parental Separation Anxiety Scale at 30 min after the end of nebulisation, Mask Acceptance Score (MAS) during induction, haemodynamic variables, emergence agitation and duration of caudal analgesia were compared between the groups. Statistical analysis was done using Mann-Whitney U test and chi-square test. A p-value <0.05 was accepted as significant.ResultsAll the parameters were comparable between the D2 and D3 groups; however, significantly more number of younger children was observed in the D3 group. Hence, further analysis was done after division into the lower age (1–3 years) and higher age (4–8 years) groups. In lower age group children, satisfactory parental separation was achieved in 100% of the patients in the D3 group compared to 20% of those in the D2 group (p=0.00). MAS was significantly better in the D3 group in both the lower (p=0.019) and higher (p=0.036) age groups.ConclusionWe conclude that nebulised dexmedetomidine in a dose of 3 μg kg−1 provides better parental separation and mask acceptance in younger children.

Comparative Study of Oral Clonidine and Midazolam as Premedication in Pediatric Patients Undergoing Tonsillectomy

Background and Aim: Anxiety and fear of operation, injections, physicians, operation theatre environment and parental separation are all traumatizing experiences in children. The aim of the study was to compare the effects of oral midazolam and oral clonidine as premedication in children undergoing tonsillectomy .The preoperative sedation, anxiolytic, acceptance of mask for induction of anaesthesia, intravenous cannulation and post-operative recoverywere assessed in both groups. Methods: Aprospective randomized double blinded study of 100 patients of age group 4 -12 yrs undergoing tonsillectomy under general anaesthesia were selected. They were divided into 2 groups of 50 patients each. Group A (oral clonidine) received 4 mcg/kg 90 minutes before induction. Group B (oral midazolam) received 0.5 mg/kg 90 minutes before induction. The sedation and anxiety score was noted at the time of parental separation. The reaction to IV cannulation was assessed by sedation and anxiety scoring at the same time all of them were taken under GA with controlled ventilation. The Mask acceptance was graded by 5 point scoring system .Grade 3,4 and 5 are satisfactory.They were monitored throughout the surgery for any complications. Post operative status was assessed by Modified Objective Pain score. Results: The sedation score and anxiety score at venipuncture was better with clonidine group with statistical significance (p&lt; 0.000 and&lt;0.003). The mask acceptance was better with clonidine group with statistical significance (p &lt;0.000).Postoperative score was also better with clonidine group with statistical significance of p value &lt;0.000. Conclusion: We concluded that oral clonidine and midazolam can be used as better premedicants to produce optimal sedation and emotional state.Clonidine 4 μg / kg has been shown to be a more effective premedication for children undergoing elective tonsillectomy than midazolam 0.5mg/kg

A comparison of midazolam and zolpidem as oral premedication in children, a prospective randomized double-blinded clinical trial.

Anxiety associated with pediatric surgery can be stressful. Midazolam is a well-accepted anxiolytic in this setting. However, there are cases in which this medication is not effective. Zolpidem is a short-acting nonbenzodiazepine hypnotic drug that is administered orally and has quick onset of action (~15 minutes), and 2-3 hour duration. Based on the theory that impaired perception following oral zolpidem administration would suppress the development of anxiety, we sought to compare zolpidem to midazolam for pediatric preoperative anxiety. This prospective randomized double-blinded clinical trial was designed to compare the effectiveness of oral midazolam and zolpidem for anxiety premedication. Eighty ASA class I-II pediatric patients between 2 and 9 years old, surgery >2 hours, and at least 23 hours postoperative admission were included in the study. Randomization was done with 0.5 mg/kg midazolam or 0.25 mg/kg zolpidem administered orally. The primary outcome measure was between group difference in patient anxiety at the time of separation using the Modified Yale Preoperative Anxiety Scale. Secondary outcomes included emergence delirium and mask acceptance at induction. There was no significant difference in Modified Yale Preoperative Anxiety Scale scores at separation between midazolam (median/interquartile range = 26.7/23.3-36.6) and zolpidem (median/interquartile range = 30.0/23.3-56.6) groups, difference 0.01 (95% CI -3E-5 , 3E-2 ; P = 0.07). Mask acceptance score was significantly better in the midazolam group. There was no significant difference in emergence delirium scores between groups. This study demonstrates that zolpidem, as dosed, was similar to midazolam with regard to anxiety scoring, and inferior with regard to mask acceptance scores.

Flavored Anesthetic Masks for Inhalational Induction in Children.

To evaluate the clinical efficacy of masking the odor of inhalational agents using fruit flavors on the anxiety behavior and compliance of children for inhalational induction. A prospective randomized double blind, placebo controlled study was conducted on 60 unpremedicated children in the age group of 4-12 y. Thirty children received anesthetic masks smeared with a flavor of child's choice while the other 30 children were induced using masks without flavor. Anxiety was assessed using modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-op room and during inhalational induction. Mask acceptance was graded by Induction Compliance Checklist (ICC). The cost-effectiveness of flavored anesthetic masks was compared to that of commercially available pre-scented masks. The baseline anxiety in the two groups was comparable. The number of children demonstrating high levels of anxiety at anesthetic induction was similar in flavored and non-flavored mask groups (p 0.45). The compliance to mask induction was also equally good (p 0.99). The authors found significant difference in the cost of flavored mask (INR 56.45 per mask) as compared to commercially available pre-scented masks (INR 660 per mask). The authors observed a placebo effect that reduced the pre-op anxiety in the control group which probably made the quality of induction equivalent with flavored and non-flavored masks. Therefore, using a flavored anesthetic mask is cost-effective than using a commercially available pre-scented mask.

“Comparative evaluation of intranasal dexmedetomidine and intranasal midazolam for premedication in children undergoing anesthesia”: A 1-year double-blind randomized controlled trial

Introduction: Children undergoing surgical procedures can experience significant anxiety and distress during perioperative period. Use of sedative premedication helps to reduce anxiety and facilitate a smooth induction of anesthesia. Midazolam is the most commonly used premedication agent with adverse effects such as behavioral changes, hiccups, and paradoxical hyperactive reactions. Dexmedetomidine, a highly selective α-2 agonist, has sedative properties. Aims and Objectives: The aim and objective of this study was to compare the efficacy of intranasal dexmedetomidine and intranasal midazolam for premedication in pediatric age group for parental separation anxiety and acceptance of anesthesia mask. Materials and Methods: This study included 60 American Society of Anesthesiologists I–II patients aged 1–10 years undergoing lower abdominal and lower limb surgeries under caudal epidural anesthesia. Ethical committee's clearance and informed consent were obtained. Patients were allocated into two groups by a computer-generated randomization table to receive 0.2 mg/kg intranasal midazolam in Group M and 1 μg/kg dexmedetomidine in Group D intranasally using 1 ml tuberculin syringe. The Parental Separation Anxiety Scale (PSAS) and Mask Acceptance Scale (MAS) were assessed by an anesthesiologist blinded to the drug given. Heart rate and oxygen saturation were monitored till the end of the procedure. Results: Demographic data were comparable in both groups (P > 0.05). Mean PSAS was 1.2 ± 0.40 in dexmedetomidine group and 1.6 ± 0.56 in midazolam group (P = 0.003). Mean mask acceptance score (MAS) at the time of induction was 1.7 ± 0.59 in dexmedetomidine group and 2.1 ± 0.58 in midazolam group (P = 0.02). Conclusion: Intranasal dexmedetomidine 1 μg/kg is an effective alternative for premedication in children undergoing anesthesia and it results in better parent separation and better mask acceptance at the time of induction when compared to intranasal midazolam 0.2 mg/kg without much side effects or complications.

Comparison of oral dexmedetomidine versus oral midazolam as premedication to prevent emergence agitation after sevoflurane anaesthesia in paediatric patients.

Background and Aims:Sevoflurane is the most often used inhalational agent in paediatric anaesthesia, but emergence agitation (EA) remains a major concern. Oral midazolam and parenteral dexmedetomidine are known to be effective in controlling EA. We attempted to elucidate whether oral dexmedetomidine is better than midazolam in controlling EA.Methods:Prospective double-blinded study involving ninety patients aged 1–10 years, undergoing elective surgeries of <2 h of expected duration under sevoflurane general anaesthesia, randomised to receive either midazolam (Group A) or dexmedetomidine (Group B) as oral premedication was carried out to record level of sedation before induction, haemodynamic parameters and recovery time. Incidence and severity of EA, post-operative pain and requirement of rescue analgesic were assessed at 0, 5, 15, 30 and 60 min postoperatively.Results:Data were analysed applying Student's t-test and Chi-square test using SPSS software. Mask acceptance was better in Group B (97.8% vs. 73.4%, P < 0.001). Mean arterial pressure was lower in Group B (P < 0.001) though clinically not significant. More rescue analgesic was required in Group A (5.6% vs. 0%). There was no significant difference in adverse effects. Although there was a higher incidence of EA in Group A (Aono's score 3 and 4; 40% vs. 4.4%), none of them required intervention (paediatric anaesthesia emergence delirium score >10; 0 vs. 0).Conclusion:Premedication with oral dexmedetomidine provides smooth induction and recovery, reduces the EA and provides better analgesia and sedation as compared to oral midazolam.

Effects of Two Intranasal Dexmedetomidine Doses as Premedication on Sevoflurane EC50 for Successful Laryngeal Mask Airway Placement in Children.

Objective To observe the effects of two different intranasal dexmedetomidine doses as premedication on the EC50 of sevoflurane for successful laryngeal mask airway placement in children. Methods Children aged 3-6 years, of American Society of Anesthesiologists physical status 1, and scheduled for plastic surgery were enrolled in this study. Children were assigned to receive either spray administration of intranasal dexmedetomidine 1 μg/kg (group D1, n=21) or 2 μg/kg (group D2, n=20) approximately 30 minutes before anesthesia. Anesthesia was induced with sevoflurane up to 8% in 100% O2, with fresh gas flow set to 6 L/min. After the pupil fixed to the middle position, sevoflurane dial setting was reduced to 5% and fresh gas flow reduced to 3 L/min. The endtidal sevofluran (ETsevo) concentration for laryngeal mask airway insertion sustained for 10 minutes after vein intubation, which was determined according to the Dixon's up and down method. The initial endtidal sevoflurane concentration in each group was set at 2%. ETsevo was increased/decreased (1:1.2) in the next patient according to the response to laryngeal mask airway insertion. Bispectral index, mask acceptance, all response to laryngeal mask airway insertion, and ETsevo of laryngeal mask airway insertion of children were recorded. Results The bispectral index value was 77.4±3.6 in group D2, which was significantly lower than that (87.4±1.9) in group D1 when children entered operation room (P<0.05). Mask acceptance was 76.2% in group D1 and 90.0% in group D2. The EC50 of sevoflurane for laryngeal mask airway insertion was 1.09% (95% CI=0.89%-1.28%) in group D2, which was lower than 1.59% (95% CI=1.41%-1.78%) in group D1 (P<0.05). Conclusion Compared with the dose of 1 μg/kg, spray administration of intranasal dexmedetomidine 2 μg/kg as premedication can reduce the sevoflurane EC50 for successful laryngeal mask airway placement in children.

Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study

Background:Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant.Aims:To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients.Settings and Design:Prospective randomized double-blind study.Subjects and Methods:After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 μg/kg dexmedetomidine intranasally and in group DK received 1 μg/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale.Statistical Analysis Used:Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05.Results:Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups.Conclusions:Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.

Supplementary Low - Dose Oral Ketamine Provides Better Parental Separation and Face Mask Acceptance

Background: Anesthesia is stressful for children and parents. Although anxiolytics can keep children calm, side effects may exist. No single method shows a clear advantage in keeping the child calm and cooperative. This study aimed to test the efficacy and safety of adding a small dose ketamine to midazolam-based oral premedication on child-parents separation and acceptance of face mask. Methods: Eighty preschool children scheduled for elective surgeries were included. Patients were allocated into 2 groups: A control group (group C), patients received oral midazolam 0.5mg/kg, and a study group (group S), patients the same dose of midazolam in addition to ketamine 2mg/kg. Child reaction to parent separation and parent satisfaction was rated according to separation and satisfaction scores. Induction of anesthesia was carried out using Sevoflurane 6 Vol% in 100% oxygen via face mask; child’s acceptance of the mask was reported. Results: Group (S) children were more cooperative regarding parents separation and acceptance of the face mask than group (C) children (P=0.000&0.02) respectively. No child developed deep sedation in both groups and Sedation score was more satisfactory in group (S), with better parent satisfaction in the same group (p=0.008, P=0.03respectively). Conclusion: Adding a small dose oral ketamine to midazolambased premedication in preschool children proved to be a safe and effective technique in improving child -parent separation and pleasant face mask acceptance.