Sedation For Non-invasive Procedures Research Articles

DEXMEDETOMIDINE AND MIDAZOLAM INTRAMUSCULAR SEDATION IN BROWNBANDED BAMBOO SHARKS (CHILOSCYLLIUM PUNCTATUM).

Bamboo sharks are some of the most common elasmobranch species in zoos and aquaria and are frequently sedated for medical exams, treatments, and research. This study investigated the use of an IM sedation protocol of a single dose of dexmedetomidine (0.05 mg/kg) and midazolam (2.0 mg/kg) in brownbanded bamboo sharks (Chiloscyllium punctatum). Sharks were serially monitored every 5 min for heart rate, branchial beats, righting reflex, coelomic response, cloacal response, pelvic fin reflex, response to noxious stimulus, voluntary movement, and ability to swim. This sedation dose was effective at rapidly and significantly decreasing responses to tactile and noxious stimuli with minimal respiratory depression and was quickly reversible with atipamezole (0.5 mg/kg) and flumazenil (0.05 mg/kg). Sedated sharks developed a mild metabolic acidosis evidenced by a significant increase in lactic acid (mean < 0.37 mmol/L presedation, 4.2 mmol/L after reversal) and decrease in blood pH (mean 7.464 presedation, 7.277 after reversal); however, clinical intervention was not required. This protocol should be further investigated in different elasmobranch species but is promising for providing sedation for noninvasive procedures in brownbanded bamboo sharks.

Nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children: a single centre audit

In this nurse-driven PROSA setting, intranasal dexmedetomidine is effective and safefor non-invasive procedural sedation in an a priori low risk group of paediatric patients. • Procedural sedation outside the operating theatre or intensive care units is increasingly used, including sedation performed by non-anaesthesiologists or nurses. This resulted in the development of procedural sedation and analgesia (PROSA) teams. • Off-label use of intranasal dexmedetomidine in children is increasing, with a limited number of audits on this practice, its safety and efficacy. • In an audit on 772 procedures, nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children within a structured framework was safe and effective. • Imaging (CT, MRI) was the most common procedural indication in our study, but also nuclear imaging techniques were included.

Sleep deprivation did not enhance the success rate of chloral hydrate sedation for non-invasive procedural sedation in pediatric patients.

In Asian countries, oral chloral hydrate is the most commonly used sedative for non-invasive procedures. Theoretically, mild sleep deprivation could be considered as one of assisted techniques. However, there is no consensus on sleep deprivation facilitating the sedation during non-painful procedures in children. The aim of our study is to analyze the clinical data of children undergoing non-invasive procedural sedation retrospectively and to evaluate the association between mild sleep deprivation and sedative effects in non-invasive procedures. Consecutive patients undergoing chloral hydrate sedation for non-invasive procedures between December 1, 2019 to June 30, 2020 were included in this study. The propensity score analysis with 1: 1 ratio was used to match the baseline variables between patients with sleep deprivation and non-sleep deprivation. The primary outcome was the failure rate of sedation with the initial dose. The secondary outcomes included the failure rate of sedation after supplementation of chloral hydrate, the incidence of major and minor adverse events, initial and supplemental dose of chloral hydrate, and the length of sedation time. Of the 7789 patients undergoing chloral hydrate sedation, 6352 were treated with sleep deprivation and 1437 with non-sleep deprivation. After propensity score matching, 1437 pairs were produced. The failure rate of sedation with initial chlorate hydrate was not significantly different in two groups (8.6% [123/1437] vs. 10.6% [152/1437], p = 0.08), nor were the failure rates with supplemental chlorate hydrate (0.8% [12/1437] vs. 0.9% [13/1437], p = 1) and the length of sedation time (58 [45, 75] vs. 58 [45, 75] min; p = 0.93). The current results do not support sleep deprivation have a beneficial effect in reducing the pediatric chloral hydrate sedation failure rate. The routine use of sleep deprivation for pediatric sedation is unnecessary.

Moderate and deep sedation for non-invasive paediatric procedures in tertiary maternity and children\u2019s hospitals in China: a questionnaire survey from China

BackgroundModerate and deep sedation are well-established techniques in many developed countries, and several guidelines have been published. However, they have received attention in China only in recent years. The aim of this study is to investigate current paediatric sedation practices in tertiary children’s hospitals and tertiary maternity and children hospitals in China.MethodsAll tertiary children’s hospitals and tertiary maternity and children hospitals registered with the National Health Commission of the People’s Republic of China were invited to participate in an electronic survey, which included information on the sedation caseload, facility availability, staff structure, clinical skill requirements for sedation providers, fasting guidelines, patient-monitoring practices, and choice of sedatives.ResultsFifty-eight of the 63 hospitals that completed the survey (92.1%) provided moderate and deep sedation. Dedicated sedation rooms and post-sedation recovery rooms were found in 14 (24.1%) and 19 (32.8%) hospitals, respectively. Sedation for non-invasive procedures was primarily performed by anaesthesiologists (69.0%); however, 75.9% of the sedation providers had not received paediatric basic or advanced life-support training. Children were asked to fast from clear liquids for at least 2 h in 44.8% of hospitals and up to 6 h in 5.2% of hospitals; they were asked to fast from solid food/milk for at least 4 h in 27.6% of hospitals and more than 8 h in 1.7% of hospitals. The most commonly used sedative in all groups was chloral hydrate. For rescue, propofol was the most widely used sedative, particularly for children older than 4 years.ConclusionsModerate and deep sedation practices vary widely in tertiary children’s hospitals and tertiary maternity and children hospitals in China. Optimised practices should be established to improve the quality of moderate and deep sedation.

Intranasal Dexmedetomidine as a Sedative for Pediatric Procedural Sedation.

This study seeks to evaluate the efficacy and safety of intranasal (IN) dexmedetomidine as a sedative medication for non-invasive procedural sedation. Subjects 6 months to 18 years of age undergoing non-invasive elective procedures were included. Dexmedetomidine (3 mcg/kg) was administered IN 40 minutes before the scheduled procedure time. The IN dexmedetomidine cohort was matched and compared to a cohort of 690 subjects who underwent sedation for similar procedures without the use of dexmedetomidine to evaluate for observed events/interventions and procedural times. One hundred (92%) of the 109 included subjects were successfully sedated with IN dexmedetomidine. There were no significant differences in the rate of observed events/interventions in comparison to the non-dexmedetomidine cohort. However, the IN dexmedetomidine group had a longer postprocedure sleep time when compared to the non-dexmedetomidine cohort (p < 0.001), which had a significant effect on recovery time (p = 0.024). Also, the dexmedetomidine cohort had longer procedure time and total admit time (p < 0.001 and p = 0.037, respectively). IN dexmedetomidine may be used for non-invasive pediatric procedural sedation. Subjects receiving IN dexmedetomidine had a similar rate of observed events/interventions as the subjects receiving non-dexmedetomidine sedation, with the exception of sleeping time. Also, patients sedated with IN dexmedetomidine had longer time to discharge, procedure time, and total admit time in comparison to other forms of sedation.

High-dose dexmedetomidine for noninvasive pediatric procedural sedation and discharge readiness.

The University of North Carolina's (UNC) Pediatric Sedation Service adopted a noninvasive procedural sedation protocol that uses dexmedetomidine in children based on review of literature that reported fast recovery times and low morbidity. This study aimed to compare dexmedetomidine discharge readiness times observed at UNC with those previously published with a hypothesis that the discharge times at UNC are longer than those previously published. A secondary aim was to evaluate the safety profile of the protocol. Pediatric outpatients (6 months-18 years) who received dexmedetomidine per protocol for a noninvasive procedure or study from January 2011 through April 2012 were included in this retrospective chart review. A total of 615 patient encounters were evaluated. Patients received bolus doses of 2 μg·kg(-1) over 10 min for up to three doses followed by a 1 μg·kg(-1) ·h(-1) infusion (group 1) or a 1.5 μg·kg(-1) ·h(-1) infusion (group 2). Primary outcomes included time to sedation, time to arousal, and time to discharge. No significant differences between the dosing groups were noted. Time to discharge was significantly shorter for group 1 (79 min) than for group 2 (101 min). The range of discharge times at UNC was 78.7-100.9 min compared to previous studies that report recovery times of 24.8-35.2 min. Dexmedetomidine arousal and discharge times observed at UNC were longer than anticipated when compared to literature. The safety profile of the drug was comparable to prior studies.

Neurologic Withdrawal Symptoms Following Abrupt Discontinuation of a Prolonged Dexmedetomidine Infusion in a Child

Dexmedetomidine is a α(2)-adrenergic agonist which possesses sedative, analgesic, and anxiolytic properties. It is approved for short-term use in adults to provide sedation while mechanically ventilated and for noninvasive procedural sedation. An increased number of anecdotal reports describe the use dexmedetomidine in children. Cardiovascular withdrawal symptoms have been reported in the literature. However, there have been few published reports of neurologic withdrawal symptoms following discontinuation of prolonged infusions of dexmedetomidine. We describe a 2 year-old child who received a prolonged continuous infusion (263 hours) of dexmedetomidine as an adjunctive sedative agent. Following abrupt discontinuation of dexmedetomidine, the patient presented with symptoms suggestive of neurological withdrawal. The symptoms gradually resolved over two days without further intervention, and the patient had full resolution of symptoms and was discharged home with no further neurologic sequelae.

Dexmedetomidine for Procedural Sedation in Children With Autism and Other Behavior Disorders

Dexmedetomidine has been increasingly in use for pediatric noninvasive procedural sedation. This retrospective study examined experience in children with autism and other neurobehavioral disorders, populations often difficult to sedate. Records of children with autism or neurobehavioral disorders sedated with dexmedetomidine at Chris Evert Children's Hospital and Kosair Children's Hospital were reviewed. Demographic and sedation-related data were collected, including sedative doses, time to sedation, efficacy, and complications. Comparisons of sedative doses, efficacy between autism and neurobehavioral patients, and analysis of age-related factors were performed. In all, 315 patients were sedated, most commonly for magnetic resonance imaging. Mean induction and total dexmedetomidine doses were 1.4 +/- 0.6 and 2.6 +/- 1.6 microg/kg, respectively, with no differences between autism and neurobehavior patients. Most patients (90%) patients received concomitant midazolam. There was an age-related decrease in dexmedetomidine dose, independent of midazolam use. Seven patients required intervention for hypotension, bradycardia, or both, and only one adverse respiratory event (obstruction requiring nasopharyngeal airway placement) occurred. There were two episodes of overt recovery-related agitation. All but four procedures were successfully completed (4/315, or 98.7%). Dexmedetomidine with or without midazolam was an effective sedative in this population. The regimen appeared to be well tolerated with few adverse events, including recovery-related agitation, and appears to be an attractive option for this population.

Hemodynamic effects of dexmedetomidine sedation for CT imaging studies

Dexmedetomidine sedation for radiological imaging studies is a relatively recent application for this drug. Previous studies have demonstrated some haemodynamic effects of dexmedetomidine, however, the effects remain poorly described in children. The aim of this study was to better define the effect of age on heart rate (HR) and blood pressure changes in children sedated for CT imaging with dexmedetomidine. At our institution dexmedetomidine is given for sedation for CT imaging as a bolus of 2 mcg.kg(-1) over 10 min followed by an infusion of 1 mcg.kg(-1).h(-1) with a second bolus if required. Detailed quality assurance data sheets document patient demographics, sedation outcomes, adverse events, and hemodynamic data are recorded for each patient. A total of 250 patients (range 0.1-10.6 years) received dexmedetomidine. ANOVA revealed strong evidence for changes in HR and mean arterial blood pressure during bolus and infusion relative to presedation values (P < 0.001). These changes were apparent in each age group and similar between groups. During the first bolus and during infusion, 82% and 93% of patients respectively were within the age-based normal range for HR. For mean arterial blood pressure, 70% of patients were within the normal range during first bolus and 78% during infusion. In the pediatric population studied, intravenous dexmedetomidine sedation was associated with modest fluctuations in HR and blood pressure. Hemodynamic changes were independent of age, required no pharmacologic interventions and did not result in any adverse events. By anticipating these possible hemodynamic effects and avoiding dexmedetomidine in those patients who may not tolerate such fluctuations in HR and blood pressure, dexmedetomidine is an appropriate sedative for children undergoing CT imaging.

Pediatric Research and Scholarship: Another Gordian Knot?

Peter J. Davis, MD Appearing in this issue of the journal are four clinical papers on the use of dexmedetomidine in children (1–4). Previous studies of the use of this drug in children have dealt with sedation in the intensive care unit (5), prevention of postoperative agitation associated with sevoflurane anesthesia (6,7), and sedation for noninvasive procedures (8–12). These articles also illustrate a number of subtle concerns that are relevant to drug development in children and the ethical principles that guide research in human subjects as proposed by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, and summarized in the Belmont Report. In a randomized study of 30 pediatric cardiac surgical patients anesthetized with isoflurane and undergoing cardiopulmonary bypass (CPB), Mukhtar et al. (1) evaluated the effects of a continuous dexmedetomidine infusion on patients’ underlying hemodynamics and neuroendocrine system compared with patients receiving a saline control infusion. The authors infused dexmedetomidine after anesthetic induction until the termination of CPB. Dexmedetomidine attenuated the increase in the neuroendocrine markers of stress caused by sternotomy and CPB. In addition, dexmedetomidine provided better intraoperative hemodynamic stability in children with congenital heart disease. The report focused on hemodynamic outcome and did not address how this drug affected tracheal extubation time, recovery, length of hospital stay, or long-term outcome. Thus, the reader is left to ponder whether the reduction in the cortisol and norepinephrine, markers of neuroendocrine response, affect outcome. Moreover, we do not know how to titrate dexmedetomidine or if the optimum dose was administered. Are there dexmedetomidine doserelated adverse effects in this population? Should the dose be altered at the start of CPB? What is the effect of the fluctuation in the patient’s temperature (37° to 25° and return) on plasma levels achieved using a standard infusion rate? Why was dexmedetomidine not continued until the end of surgery? Why did the dexmedetomidine infusion not allow for less anesthetic administration, as had been shown in an adult study (13)? Did dexmedetomidine improve hemodynamic stability after bypass? Although this study measured biochemical endpoints to assess stress response, can we infer that the effect of this drug will be as salutary as the effect of opioids in the mortality of children having surgery for congenital heart disease? These questions were not answered because the study was not funded, limiting the number of subjects and the resources available to the investigators. Had this study been funded by the pharmaceutical manufacturer, the authors could have enrolled more patients, perhaps included other study centers, assayed blood for dexmedetomidine concentrations, developed pharmacokinetic models of dexmedetomidine in this population, and performed a pharmacodynamic concentration-versus-response analysis. In a study of 60 children undergoing magnetic resonance imaging, From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Department of Anesthesia, Stanford University, Stanford, California; Department of Anesthesiology, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Accepted for publication March 22, 2006. Address correspondence and reprint requests to Peter J. Davis, MD, Professor of Anesthesia and Pediatrics Anesthesiologistin-Chief, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213. Address e-mail to davispj@anes.upmc.edu. Copyright © 2006 International Anesthesia Research Society DOI: 10.1213/01.ANE.0000220033.34889.CE

A Prospective Evaluation of Dexmedetomidine for Non-invasive Procedural Sedation in Children

Berkenbosch, John W. MD; Wankum, Patricia C. MD; Tobias, Joseph D. MD Author Information

Prospective evaluation of dexmedetomidine for noninvasive procedural sedation in children*

Children often require sedation for lengthy noninvasive procedures. Conventional agents such as chloral hydrate, benzodiazepines, or barbiturates have been associated with sedation failure, respiratory depression, and paradoxic agitation. Dexmedetomidine is a newer alpha(2)-adrenergic receptor agonist with sedative properties and minimal respiratory depression. We hypothesized that it would be an effective agent for these procedures. Prospective case series. Tertiary care children's hospital. Children undergoing noninvasive procedures. Children were sedated with dexmedetomidine given as a bolus of 0.5-1.0 microg/kg over 5-10 mins followed by an infusion of 0.5-1.0 microg/kg/hr. Vital signs, sedative effectiveness, recovery patterns, and complications were prospectively recorded. Forty-eight patients, aged 6.9 +/- 3.7 yrs, were sedated. Fifteen received dexmedetomidine after failing sedation with chloral hydrate and/or midazolam. Sedation was induced with 0.92 +/- 0.36 microg/kg over 10.3 +/- 4.7 mins and maintained with an infusion of 0.69 +/- 0.32 microg/kg/hr. All procedures were completed. Heart rate, blood pressure, and respiratory rate decreased (p < .0001) but remained within normal limits for age. End-tidal CO(2) exceeded 50 mm Hg in seven of 404 measurements (1.7%). Mean recovery time was 84 +/- 42 mins and was significantly longer in the rescue (117 +/- 41 mins) vs. primary (69 +/- 34 mins) group (p < .0001). No patient developed agitation during recovery. Dexmedetomidine provided effective sedation in children undergoing noninvasive procedures and represents an alternative sedative choice for this population.

A Prospective Evaluation of Dexmedetomidine for Non-invasive Procedural Sedation in Children

Pediatric Critical Care Medicine is proud to present translations of selected abstracts into Chinese, French, Italian, Japanese, Portuguese, and Spanish. We sincerely thank the following for their important work on these translations: Xun-mei Fan, MD, and Hao-xun Tang, MD (Chinese), Jacques Lacroix, MD, and Jean-Christophe Mercier, MD (French), Giuseppe A. Marraro, MD (Italian), Hirokazu Sakai, MD (Japanese), Francisco Cunha, MD, and José Manuel Aparício, PhD, MD (Portuguese), and Eduardo Schnitzler, MD, Santiago Campos, MD, and Pablo G. Minces, MD (Spanish).

A Prospective Evaluation of Dexmedetomidine for Non-invasive Procedural Sedation in Children

Berkenbosch, John W. MD; Wankum, Patricia C. MD; Tobias, Joseph D. MD Author Information