University Of Michigan Sedation Scale Research Articles

Bispectral Index versus the University of Michigan Sedation Scale in assessing sedation depth during pediatric drug-induced sleep endoscopy.

Bispectral Index (BIS) and University of Michigan Sedation Scale (UMSS) were two commonly used methods of monitoring the sedation depth, but their correlation was not clear. The purpose of this study is to ascertain if BIS correlates with UMSS in determining the sedation level during pediatric drug-induced sleep endoscopy (DISE). One-hundred children, aged 36-143 months, with ASA I~II grade, were enrolled. They were subject to general anesthesia for an elective adenotonsillectomy. Two drug regimens were used. After UMSS ≥ 3, the sites of airway obstructions were located by checking the supraglottic airway structures with a fibrous laryngoscope. UMSS scores, BIS values, electromyography (EMG), and signal quality indices (SQIs) were recorded at the pre-medication and pre-DISE baseline (T0), 5 min subsequent to medication administration but prior to DISE initiation (T1), 1 min after DISE was initiated (T2), 1 min after DISE was completed (T3), 1 min subsequent to tracheal intubation (T4), 1 min following extubation (T5), and 30 min past extubation (T6). There were strong correlations between BIS monitor readings and UMSS scores for total and two regimens. Kappa values revealed moderate agreement between BIS and UMSS for total and two regimens. The agreement rates were 67.47% for the total, 61.43% for Regimen 1, and 73.42% for Regimen 2, respectively. BIS correlates with UMSS in determining the sedation level during pediatric DISE for two regimens. BIS might serve as an appropriate indicator of sedation intensity when UMSS could not be used.

Rectal Sedation With Ketamine and Midazolam in the Management of Uncooperative Children During Dental Treatment: A Case Series and Method Description.

Background In pediatric dentistry, sedation aims to eliminate anxiety to facilitate the completion of dental procedures. Sedation in children is a multidimensional field that includes the child, parents/guardians, and the health care team. The rectal route is generally painless, making it suitable for children who are afraid of needles. This route has several advantages over the oral route, including reduced patient cooperation requirements, a faster and more predictable onset, and less physical trauma than the intravenous and intramuscular routes. This case series aimed to evaluate the effectiveness and success rate of rectal sedation with ketamine and midazolam in the management of uncooperative children during dental treatment. Case presentation Ten healthy children with definitely negative behavior were enrolled in this study. Each child was given7 mg/kg of ketamine in combination with midazolam 0.1 mg/kg by the rectal route. The mean onset sedation time was 9.5 minutes, and pulpotomy procedures were done. Behavioral response was monitored throughout treatment using theOhio State University Behavioral RatingScale(OSUBRS), and the depth of sedation was measured using the University of Michigan Sedation Scale (UMSS). The Houpt General Behavior Scale was used to estimate the treatment success rate based on the overall behavior rating. All 10 cases showed good anxiolysis and cooperation following rectal administration, with no side effects observed. Conclusions Rectal administration of ketamine in combination with midazolam may be considered a reliable method in the management of uncooperative children during dental treatment. No adverse effects were observed during or after the sedation procedure.

Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes

BackgroundNitrous oxide (N2O) has multiple benefits in paediatric procedural sedation (PPS), but use is restricted by its limited analgesic properties. Analgesic potency could be increased by combining N2O and intranasal...

Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis.

Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effectswhile benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED.However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.

The utility of the perfusion index as an indicator of anesthetic depth for repeated propofol sedation in children: An observational study.

Children receiving proton therapy require repeated sedation. In this study, we aimed to investigate the utility of the perfusion index (PI) for evaluating consciousness level during repeated propofol sedation. In this prospective observational study, children aged from birth to 19 years old scheduled for proton therapy under repeated propofol sedation were enrolled. The primary outcome was the equivalence of PI values 5 min after anesthesia induction on consecutive sedation. Total consumption of propofol during sedation, time to reach the University of Michigan sedation scale (UMSS) score 1 after end of proton therapy, and duration of post-anesthesia care unit (PACU) stay were recorded. The PI values measured 5 min after induction of anesthesia were not equivalent to each other in consecutive sedation except for the second versus third (1st vs. 2nd: 97.5% CI: -1.34, 0.91; p = 0.206, 0.034; 2nd vs. 3rd: 97.5% CI: -0.87, 0.94; p = 0.023, 0.036 3rd vs. 4th: 97.5% CI: -2.08, -0.26; p < 0.99, <0.001; 4th vs. 5th: 97.5% CI: 0.21, 2.28; p < 0.001, >0.99; respectively). In consecutive sedation, there was not a significantly different difference in the time to reach UMSS score 1 (p > 0.99, all) for total consumption of propofol, time to reach UMSS score 1 after the end of proton therapy, and duration of PACU stay. During repeated propofol sedation in children, PI was insufficient to be used as an indicator of consciousness level assessment. However, we suggest that the information related to repeated sedation provided by this study may be helpful in clinical practice.

Choice and adequacy of sedation in critically ill mechanically ventilated children: A single center prospective observational study

Background: Sedation management is a crucial element of pediatric critical care medicine, aiming at reducing children's anxiety, distress, and oxygen demand. Prolonged administration of sedatives may result in drug tolerance and physical dependency. Abrupt discontinuation of these drugs in children may cause withdrawal symptoms. Our study aims to evaluate the choice and adequacy of sedation in ventilated children using the University of Michigan Sedation Scale score.Subjects and Methods: All the children aged between 1 and 12 years who were subjected to invasive ventilation during the time period October 2019 to June 2021 in the tertiary care pediatric intensive care unit (PICU) were included in the study.Results: Of the 35 children enrolled in the study, most of them spend the majority of their time in adequate sedation which accounts for around 87.1% of the total time of ventilation. Fentanyl and midazolam were the most frequently used drug combination. Oversedation and undersedation accounted for 7.9% and 5% of total ventilation hours, respectively. Out of 35 children, 10 (28%) developed iatrogenic withdrawal symptoms and 4 (11%) developed severe withdrawal symptoms.Conclusions: Fentanyl and midazolam were the most frequently used drug combination for attaining adequate sedation in our PICU. Irrespective of adequate sedation, no increase in the incidence of iatrogenic withdrawal syndrome, undersedation, or oversedation was noted in our study population.

The safety and efficacy of esketamine in comparison to dexmedetomidine during drug-induced sleep endoscopy in children with obstructive sleep apnea hypopnea syndrome: A randomized, controlled and prospective clinical trial.

Background and Purpose: Data and high-quality studies of anesthetic methods for children with obstructive sleep apnea hypopnea syndrome (OSAHS) who undergo drug-induced sleep endoscopy (DISE) are limited. Research on pediatric DISE using esketamine has never been reported before. To test the safety and efficacy of esketamine during DISE in children with OSAHS, we compare esketamine (Group K) with dexmedetomidine (Group D) in this study. Methods: 100 children with ASA Ⅰ∼Ⅱ grade, prepared for an elective adenotonsillectomy under general anesthesia, were enrolled in this study and randomized into two groups. Midazolam 0.1mg/kg was administered intravenously for both groups. In Group D a 1μg/kg bolus of dexmedetomidine was given over 10min followed by the infusion rate 1μg/kg/hr to the end of DISE. Group K received a 1.0mg/kg IV bolus of esketamine over 10s followed by the infusion rate 1mg/kg/hr to the end of DISE. Results: Group K had a higher percentage of success than Group D (p = 0.008). The onset time of Group K was shorter than that of Group D (p = 0.000). The University of Michigan Sedation Scale (UMSS) score of Group K was higher than that of Group D (p = 0.005). The risk of adverse effects (AEs) was lower in Group K (p = 0.000). In Group D, systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) all decreased, while in Group K, SBP, DBP, and HR hardly changed. Conclusion: Esketamine in comparison to dexmedetomidine provides more effective and safer depth of anesthesia for OSAHS pediatric DISE by ensuring short onset time, deep sedation, and few AEs. Clinical Trial Registration: ClincalTrials.gov, identifier NCT04877639.

Premedication Propofol Dose to Prevent Emergency Delirium.

Objective: One of the most common complications in general anesthesia is the Emergence delirium (ED). Many agents have been studied for prevention of ED, among which propofol has been successfully used. However, there is no information about the optimal dosage of this agent considering the ultimate outcome and the adverse effects; therefore, aimed to assess in this study. Method : 70 children undergoing general anesthesia using propofol, fentanyl, and atracurium were assessed. Participants were allocated randomly to treatment with either propofol 1 mg/kg (n = 35) or 0.5 mg/kg (n = 35) by the end of the anesthesia. The Pediatric Anesthesia Emergence Delirium (PAED) Scale, Face, Legs, Activity, Cry, Consolability (FLACC) scale, and the University of Michigan Sedation Scale (UMSS) were assessed by 10-minute intervals. Post-anesthesia care unit (PACU) stay and adverse effects were registered and compared as well. Results: Duration of PACU stay (P < 0.001), PAED (P = 0.001), and UMSS (P = 0.003) were remarkably lower among low-dose propofol-treated children in the assessment at the 30th minute, while there were no significant differences in FLACC scores between the groups (P > 0.05). Apnea was found in a patient (2.85%) treated with high-dose propofol and decreased oxygen saturation was demonstrated in 5 (14.28%) and 2 (5.71%) participants in high- versus low-dose propofol. None of the patients experienced postoperative nausea and vomiting. Conclusion: Based on the current study, propofol 0.5 mg/kg by the end of anesthesia could efficiently prevent ED incidence and reduce time of PACU stay and adverse effects compared to a high dose of 1 mg/kg.

A Comparison of Intranasal Dexmedetomidine, Esketamine or a Dexmedetomidine-Esketamine Combination for Induction of Anaesthesia in Children: A Randomized Controlled Double-Blind Trial.

Objective: To compare the efficacy of dexmedetomidine, esketamine or combined intranasal administration on the induction of inhalation anaesthesia in children. Methods: Ninety children aged 1–6 years were randomly allocated into three equal groups to be premedicated with either intranasal dexmedetomidine 2 μg/kg (Group D), esketamine 1 mg/kg (Group S), or dexmedetomidine 1 μg/kg combined with esketamine 0.5 mg/kg (Group DS). The primary endpoint was the Induction Compliance Checklist (ICC) Scale. Secondary outcomes included the sedation success rate; the modified Yale Preoperative Anxiety Scale score; the time of reaching up to two points on the University of Michigan Sedation Scale (UMSS); Parental Separation Anxiety Scale; anaesthesiologist satisfaction with induction based on the visual analogue scale; emergence agitation scale score; and adverse effects. Results: The children in the DS group showed a high degree of cooperation with inhalation anaesthesia induction, and their ICC score was significantly lower than that of the D and S groups (p = 0.001), but there was no difference between the D and S groups. The success rate of sedation was higher in Group DS (90%) than in Group D (70%) and Group S (53.3%) (p = 0.007). Anaesthesiologist satisfaction with induction was significantly higher in Group DS than in Groups D and S (p = 0.001). The incidence of emergence agitation and the Paediatric Anaesthesia Emergence Delirium (PAED) score in the DS group were lower than those in the D and S groups. Conclusions: Preoperative intranasal administration of dexmedetomidine combined with esketamine can significantly improve the cooperation of children with inhalation anaesthesia masks. It is a sedation method that has a high success rate and reduces the incidence and degree of emergence agitation.

The relationship between the effect-site concentration of propofol and sedation scale in children: a pharmacodynamic modeling study

BackgroundContinuous infusion of propofol has been used to achieve sedation in children. However, the relationship between the effect-site concentration (Ce) of propofol and sedation scale has not been previously examined. The objective of this study was to investigate the relationship between the Ce of propofol and the University of Michigan Sedation Scale (UMSS) score in children with population pharmacodynamic modeling.MethodsA total of 30 patients (aged 3 to 6 years) who underwent surgery under general anesthesia with propofol and remifentanil lasting more than 1 h were enrolled in this study. Sedation levels were evaluated using the UMSS score every 20 s by a 1 μg/mL stepwise increase in the Ce of propofol during the induction of anesthesia. The pharmacodynamic relationship between the Ce of propofol and UMSS score was analyzed by logistic regression with nonlinear mixed-effect modeling.ResultsThe estimated Ce50 (95% confidence interval) of propofol to yield UMSS scores equal to or greater than n were 1.84 (1.54–2.14), 2.64 (2.20–3.08), 3.98 (3.66–4.30), and 4.78 (4.53–5.03) μg/mL for n = 1, 2, 3, and 4, respectively. The slope steepness for the relationship of the Ce versus sedative response to propofol (95% confidence interval) was 5.76 (4.00–7.52).ConclusionsWe quantified the pharmacodynamic relationship between the Ce of propofol and UMSS score, and this finding may be helpful to predict the sedation score at the target Ce of propofol in children.Trial registrationhttp://www.clinicaltrials.gov (No.: NCT03195686, Date of registration: 22/06/2017).

Validation of the Ramsay scale for invasive procedures under deep sedation in pediatrics.

The Ramsay scale is the most widely used scale during pediatric procedures although it has not been formally validated. To validate the Ramsay scale during invasive procedures under sedation in pediatrics. A prospective analytic study was conducted in two hospitals. All patients ≥6months that were undergoing invasive procedures under sedation were enrolled. All were recorded, and these videos were edited and randomized. 150 videos were scored by four observers (a pediatrician, a pediatric intensive care unit nurse, an anesthetist, and an operating room nurse). All videos were scored with the Ramsay scale and University of Michigan Sedation Scale. Observers were blinded to drug administration. Construct validity was measured through Wilcoxon test paired samples after administration of sedatives. Criterion validity, intra-observer reliability, and interobserver correlation were evaluated by comparing the scores of the scales using Spearman's correlation coefficient. Interobserver agreement was measured using the intraclass correlation coefficient. To assess test-retest reliability, 50 videos were randomly selected and reevaluated. Sixty-five patients were included. Construct validity was demonstrated through changes in the Ramsay scale scoring after administration of sedatives (p<.0001). Regarding criterion validity, the Ramsay scale had a high correlation with the UMSS (ρ=0.621). Intra-observer agreement was ρ=0.884. The Ramsay scale showed interobserver reliability with an intraclass correlation coefficient=0.94 when comparing it with the University of Michigan Sedation Scale. Internal consistency was α=0.91. Regarding applicability, in our study, it was applied in two hospitals in different areas by four professionals from distinct categories. The Ramsay scale is valid, reliable, and applicable to monitoring sedation for invasive procedures under deep sedation in pediatrics.

The addition of clonidine to ropivacaine in rectus sheath nerve blocks for pediatric patients undergoing laparoscopic appendectomy: A double blinded randomized prospective study

Study objectiveThe primary goal of this study was to determine if the addition of clonidine to ropivacaine prolonged periumbilical numbness compared to ropivacaine alone in pediatric patients receiving ultrasound guided rectus sheath nerve blocks for laparoscopic appendectomy. The secondary goals were to evaluate differences in perioperative pain scores, analgesic consumption, sedation, anxiolysis, and hemodynamic effects from clonidine. DesignThis was a single center, randomized, double-blinded prospective study. SettingThis study was conducted within the pediatric operating rooms at the Children’s Hospital of Pittsburgh, a large university-based academic medical center. PatientsFifty pediatric patients (ages 10-17 years old) without pre-existing cognitive impairment, developmental delay or chronic pain undergoing laparoscopic appendectomy during weekday hours were enrolled and randomized to control versus intervention groups. InterventionUltrasound guided rectus sheath nerve block injections were performed at the beginning of surgery with either ropivacaine 0.5% plus normal saline or ropivacaine 0.5% plus clonidine (2 mcg/kg, maximum of 100 mcg). MeasurementsThe duration of periumbilical numbness, Numeric Pain Rating Scale scores, University of Michigan Sedation Scale, State-Trait Anxiety Inventory for Children, analgesic consumption, heart rate, blood pressure, and mean arterial pressures, were recorded for each patient at several time points in the perioperative setting. Main resultsThere were no significant differences in demographic characteristics between groups. The median duration of periumbilical numbness did not significantly differ between the ropivacaine only and the ropivacaine plus clonidine groups 540.0 minutes [360.0 -1015.0] (median [interquartile range (IQR)]) versus 823.5 minutes [509.5- 1080.0], p = 0.451. There were no significant differences in perioperative analgesic consumption, pain and anxiety scores, PACU sedation, or hemodynamic instability. ConclusionsThe addition of clonidine did not significantly prolong rectus sheath nerve block duration and was well tolerated in pediatric patients. Perioperative analgesia, hemodynamics, anxiety, and PACU sedation did not differ between groups. Trial registrationClinical Trials NCT02439281

The Effect of Intravenous Deep Sedation on Behaviour of Non Cooperative Children in the Dental Office- An Interventional Study

Introduction: Recently, there has been an increasing need for sedation techniques to reduce anxiety in children undergoing painful diagnostic and therapeutic procedures. Therefore, multiple tactics (oral sedation, Intravenous (IV) sedation) were devised to help practitioners manage such cases. Aim: To determine the efficiency and effects of propofol on the behaviour of anxious children during dental treatment. Materials and Methods: This interventional study was conducted at Damascus University, Damascus, Syria, from August 2018 to September 2020. Total 23 children aged 3 to 6 years who were physically healthy (American Society of Anesthesiologists I (ASA I) and uncooperative (negative or definitely negative according to Frankel’s behaviour scale) were included to determine the effects of intravenous propofol on their behaviour during treatment. Behaviour during treatment was evaluated using the Ohio State University Behavioural Rating Scale (OSUBRS). Also, the sedation level was evaluated using the University of Michigan Sedation Scale (UMSS). Mann-Whitney test was used to compare the levels of behaviour and degrees of sedation between males and females. The significance level was set at p-value &lt;0.05. Results: Behaviour according to OSUBRS and degree of sedation according to UMSS during treatment were favourable, and treatment was completed for all participants. The Mann-Whitney test showed no statistically significant difference between males and females regarding the level of behaviour (p-value=0.605) or the degree of sedation (p-value=0.376). A strong positive relationship between treatment time and awakening time was found using the Pearson’s correlation coefficient (0.813, p-value&lt;0.01). Conclusion: In the presence of an anaesthesiologist, intravenous propofol deep sedation was considered effective in managing anxious and uncooperative children during dental treatment.

Validity and reliability of the Niño Jesús Hospital procedural sedation scale under deep sedation-analgesia

IntroductionThe Niño Jesús Hospital procedural sedation scale (Madrid) (NJHPSS) has not been validated. Patients and methodsA prospective analytical study was conducted in 2 hospitals on patients ≥6 months undergoing invasive procedures using sedation-analgesia with propofol or midazolam and fentanyl. All were monitored using the bispectral index (BIS). Videos were made of each procedure, which were then edited and randomised. A total of 150 videos were rated by four observers using the NJHPSS, the University of Michigan sedation scale (UMSS), and the Ramsay Scale (RS). These observers were blinded to the BIS, and at the time of drug administration. To assess test-retest reliability, 50 of the initial 150 randomly selected videos were re-assessed. ResultsThe study included a total of 65 patients. Construct validity was demonstrated by changes in scores after administering sedatives (p<.0001). The NJHPSS had a very low correlation with the BIS (r=−0.166), and a moderate correlation with the UMSS (r=0.497) and the RS (r=0.405).The within-observer agreement was high (ρ=0.793). The NJHPSS gave a good interobserver reliability when compared with the UMSS (ICC=0.88) and the RS (ICC=0.86), and there was none with the BIS. Internal consistency was moderate (α=0.68). As regards the applicability, this scale has been used in two hospitals in several areas by four professionals of different categories. ConclusionsThe NJHPSS is valid, reliable and applicable for sedation monitoring in invasive procedures under deep sedation-analgesia in paediatric patients. The NJHPSS has worse properties than the UMSS and the SR.

A Population Pharmacokinetic Model of Intravenous Dexmedetomidine for Mechanically Ventilated Children after Neurosurgery.

Dexmedetomidine is a selective alpha-2 adrenergic agonist with concurrent sedative and analgesic effects, and it is being increasingly used in pediatric anesthesia and intensive care. This study aimed to investigate the pharmacokinetics of intravenous dexmedetomidine in mechanically ventilated children in the intensive care unit (ICU) after neurosurgery. Pediatric patients aged 2–12 years, who were mechanically ventilated in ICU after neurosurgery, were allocated into a low-dose (n = 15) or high-dose (n = 14) group. The low-dose group received dexmedetomidine at a loading dose of 0.25 µg/kg for 10 min, followed by a maintenance dose of 0.25 µg/kg/h for 50 min, whereas the high-dose group received dexmedetomidine at a loading dose of 0.5 µg/kg for 10 min, followed by a maintenance dose of 0.5 µg/kg/h for 50 min. Serial blood samples were collected for a pharmacokinetic analysis up to 480 min after the end of the infusion. The sedative effect of dexmedetomidine was assessed using the Bispectral Index and University of Michigan Sedation Scale. Adverse reactions, electrocardiography findings, and vital signs were monitored for a safety assessment. A population pharmacokinetic analysis was performed using non-linear mixed effects modeling. Dexmedetomidine induced a moderate-to-deep degree of sedation during infusion in both groups. The pharmacokinetics of dexmedetomidine were best described by a two-compartment disposition model with first-order elimination kinetics. The parameters were standardized for a body weight of 70 kg using an allometric power model. The population estimates (95% confidence interval) per 70 kg body weight were as follows: clearance of 81.0 (72.9–90.9) L/h, central volume of distribution of 64.2 (50.6–81.0) L, intercompartment clearance of 116.4 (90.6–156.0) L/h, and peripheral volume of distribution of 167 (132–217) L. No serious adverse reactions or hemodynamic changes requiring the discontinuation of dexmedetomidine were observed. Dexmedetomidine had increased clearance and volume of distribution in mechanically ventilated children in ICU after neurosurgery, thereby indicating the need to adjust the dosage to obtain a target plasma concentration.

Validity of bispectral index monitoring during deep sedation in children with spastic cerebral palsy undergoing injection of botulinum toxin.

BackgroundThis prospective study aimed to determine whether the bispectral index (BIS) is a valid objective tool for differentiating adequate from inadequate deep sedation in spontaneously breathing children with cerebral palsy (CP).MethodsPropofol was titrated to increase the level of sedation with a continuous infusion of remifentanil at a rate of 0.05 μg/kg/min while maintaining spontaneous ventilation in 22 children with spastic CP, aged 3–18 years. The depth of sedation was assessed using the University of Michigan Sedation Scale (UMSS) and the Modified Observer’s Assessment of Alertness and Sedation (MOAAS) scale. Receiver operating characteristic curve analysis was performed to determine the cutoff BIS values for deep sedation, defined as a UMSS score of 3–4 and a MOAAS score of 0–1.ResultsThe BIS values significantly changed with the increase in the level of sedation across both the UMSS and MOAAS scores (P < 0.001). The BIS values correlated with the UMSS (r = −0.795, P < 0.001) and MOAAS (r = 0.815, P < 0.001) scores. The cutoff BIS value to detect adequate deep sedation in children with CP was 61.5 (UMSS score: sensitivity 0.860, specificity 0.814; MOAAS score: sensitivity 0.794, specificity 0.811).ConclusionsThe BIS value strongly correlates with the clinical sedation scales, such as the UMSS and MOAAS, during deep sedation in children with CP. Therefore, BIS monitoring can be used as a valid tool for assessing the level of propofol sedation in spontaneously breathing children with CP undergoing a botulinum toxin injection.

Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam.

This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children. This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age>5years and weight>20kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5mg/kg (max 15mg) or intranasal dexmedetomidine at a dose of 2mcg/kg (max 100mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug. The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P=.03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P=1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure. Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.

Rectal ketamine during paediatric burn wound dressing procedures: a randomised dose-finding study

BackgroundWorldwide, ketamine is used during paediatric procedures, but no recommendations are available regarding a suitable dose for rectal administration during procedures involving high levels of pain and/or anxiety such as burn wound dressing change. MethodsWe evaluated three different single doses of rectally administered racemic ketamine mixed with a fixed dose of 0.5mg/kg of midazolam. In total, 90 children – aged 6 months to 4 years – were randomised 1:1:1 to receive 4mg/kg (K-4 group), 6mg/kg (K-6 group) or 8mg/kg (K-8 group) of racemic ketamine for a maximum of three consecutive procedures. Primary outcome measure was procedural pain evaluated by Face, Legs, Activity, Cry, Consolability (FLACC) behavioural scale. Secondary outcome included feasibility and recovery time. Patient safety was evaluated using surrogate outcomes. ResultsIn total, 201 procedures in 90 children aged 19±8months were completed. The median maximum pain was FLACC 0 in all groups (p=0.141). The feasibility was better for groups K-6 (p=0.049) and K-8 (p=0.027) compared with K-4, and the mean recovery time was the longest for group K-8 (36±22min) compared with groups K-4 (25±15min; p=0.003) and K-6 (27±20min; p=0.025). Median maximum sedation measured by the University of Michigan Sedation Scale (UMSS) was higher in group K-8 compared with group K-4 (p<0.0001) and K-6 (p=0.023). One child in group K-8 had a study drug-related serious adverse event — laryngospasm/airway obstruction. No rescue analgosedative medication was administered for group K-6. ConclusionsA rectally administered mixture of racemic ketamine (6mg/kg) and midazolam (0.5mg/kg) during paediatric burn dressing procedures with a duration of approximately 30min provides optimal conditions regarding pain relief, feasibility, recovery time and patient safety, with no need for rescue analgosedative medication.

Combined nitrous oxide 70% with intranasal fentanyl for procedural analgosedation in children: a prospective, randomised, double-blind, placebo-controlled trial

ObjectiveNitrous oxide 70% (N2O 70%) is an excellent medication for procedural analgosedation (PAS), yet the limit of its analgesic power remains uncertain; therefore, a combination with intranasal fentanyl (INF) was...

Effects of two dosing cohorts of dexmedetomidine as a primary sedative in critically ill infants with respiratory failure

Background Despite being increasingly used, prospective randomized dose-finding studies on dexmedetomidine (DEX) sedation in infants are deficient. Aim The aim was to compare the efficacy of two fixed dosing cohorts of DEX as a primary sedative in the pediatric ICU. Patients and methods Thirty-seven pediatric ICU mechanically ventilated infants (1–12 months) with acute respiratory failure were randomly allocated to receive DEX infusion without a loading dose: 0.5 µg/kg/h (group I, intermediate dose, n=18) or 0.35 µg/kg/h (group II, low dose, n=19) up to 72 h. The primary outcome was University of Michigan Sedation Scale (UMSS). Secondary outcomes were supplemental sedation or analgesia, hemodynamics, withdrawal adverse effects, withdrawal assessment tool-version 1, and ICU and length of hospital stay. Results Duration of DEX infusion was (48.8±21.7 vs 37.8±21.3 h) in groups I and II (P=0.127). UMSS scores were significantly lower in group II. Supplemental sedation was needed in two patients in group II. Total ICU and hospital length of stay were 6.2±1.4 vs 3.6±1.9 days, P Conclusion Two doses produced adequate sedation with comparable opioid sparing. The low dose was associated with lower UMSS scores, more agitation following DEX discontinuation, and lower ICU and length of hospital stay.