A randomised study of intranasal dexmedetomidine and oral ketamine for premedication in children

Abstract

SummaryWe studied the effects of intranasal dexmedetomidine combined with oral ketamine for premedication in children. One hundred and sixty children aged between 2 and 6 years were randomly allocated to one of four groups: 1 lg.kg À1 intranasal dexmedetomidine with 3 mg.kg À1 oral ketamine (Group 1); 1 lg.kg À1 intranasal dexmedetomidine with 5 mg.kg À1 oral ketamine (Group 2); 2 lg.kg À1 intranasal dexmedetomidine with 3 mg.kg À1 oral ketamine (Group 3); and 2 lg.kg À1 intranasal dexmedetomidine with 5 mg.kg À1 oral ketamine (Group 4). Sedation levels 10, 20 and 30 min after premedication were evaluated using a 5-point sedation scale. A 4-point emotional state score was used to evaluate patients when they were separated from their parents and their response to intravenous cannulation or facemask application. Approximately 90% of patients readily accepted premedication and onset times of acceptable sedation were similar in all four groups. Patients in Group 4 were significantly more sedated than those in Group 1 after 30 min (p = 0.036). A significantly higher proportion of patients in Group 3 (84%) and Group 4 (87%) accepted intravenous cannulation compared with those in Group 1 (40%) and Group 2 (54%) (p = 0.001).We conclude that the administration of 2 lg.kg À1 intranasal dexmedetomidine and 3 mg.kg À1 oral ketamine was the optimal combination, with children being easily separated from their parent, accepting intravenous cannulation and without causing excessive side-effects or postoperative complications. The transfer of reluctant children from the ward to the operating suite may cause long-term psychological trauma [1]. Furthermore, forced induction of anaesthesia may lead to personality and behavioural changes in between 17 and 57% of children including sleepwalking, bed-wetting and irritability [2]. Effective communication, premedication and anaesthetic induction with parental presence help reduce pre-operative anxiety in children. Premedication is common, but there is no widely accepted drug regimen [3]. Orally administered ketamine is currently one of the most popular drugs [4], but it can cause excessive salivation, nystagmus and other side effects [5]. Dexmedetomidine is a relatively new a 2 -adrenergic receptor agonist and clinical studies have demonstrated that intranasal administration in both adults and children achieves satisfactory pre-operative sedation [6][7][8]. Although dexmedetomidine is effective when used as a sole premedicant, the application of a facemask or attempts at venipuncture have been reported to wake patients and result in 944

Emergence delirium: a narrative review

“…In a study where 80 pediatric patients were given oral ketamine 6 mg/kg, 18% developed ED, much lower than the 56% reported in the placebo group [76]. These results coincided with a randomized clinical trial by Eghbal et al, which determined low dose ketamine during induction of anesthesia improved both emergence agitation and postoperative pain following adenotonsillectomy in children [79]. Similarly, Abu-Shahwan and Chowdary's randomized double blind study of 85 children aged 4-7 years demonstrated that treatment with ketamine 0.25 mg/kg decreased the incidence of emergence agitation [77].…”

“…Debate about the efficacy of ketamine in the management of ED is largely driven by earlier studies that linked ketamine to an increased risk of ED [1,[73][74][75]. However, more recent studies have contradicted these findings [76][77][78][79]. In a study where 80 pediatric patients were given oral ketamine 6 mg/kg, 18% developed ED, much lower than the 56% reported in the placebo group [76].…”

Comparison of rescue techniques for failed chloral hydrate sedation for magnetic resonance imaging scans—additional chloral hydrate vs intranasal dexmedetomidine

“…Previous studies have shown that intranasal dexmedetomidine is an effective way to sedate children . It is relatively easy to administer and has a higher bioavailability .…”

“…In our experience, children often refused to receive a second dose of chloral hydrate, probably due to its bitter caustic taste, whereas all children showed good tolerance to intranasal administration of dexmedetomidine. Previous studies have shown that intranasal dexmedetomidine is an effective way to sedate children (9,26). It is relatively easy to administer and has a higher bioavailability (27).…”

How clinical registries can make a difference in hip fracture care

“…Although it is cur-rently not licensed for administration by this route it has proved successful both as a premedicant and as a sedative for nonpainful procedures. Jia et al studied childen who were administered combinations of intranasal dexmedetomidine and oral ketamine in a variety of doses [19]. They concluded that 2 lg.kg À1 intranasal dexmedetomidine together with 3 mg.kg À1 oral ketamine was the optimal combination, with children being easily separated from their parent, accepting intravenous cannulation and there were no excessive side-effects or postoperative complications.…”