You're gonna put WHAT up that kid's nose? Intranasal dexmedetomidine for pediatric sedation

nasal syringe 2

A young child presents to your ED after falling off his swing and landing directly on his forehead. He’s going to need some stitches. Unfortunately, he just doesn’t want to cooperate, is not at all entertained by your Dora the Explorer stickers, and the tearful parents are refusing to assist with any bedside YouTube distraction. It’s time to provide some pharmacological assistance to make it less traumatic for both patient and provider.

A popular option here is to reach for intranasal midazolam. It does cause respiratory depression[1] and depending on your staff and hospital policy, may require a whole procedural sedation protocol. It’s also reported to be quite unpleasant when squirted up the nose.[2]

Another option is to give intranasal dexmedetomidine a shot (spray?). It’s an alpha-2 agonist similar to clonidine with anxiolytic and sedative properties and has the advantage of having no respiratory side effects. It is beginning to gain popularity in pediatrics as an intranasal drug, as the absorbance through the nasal mucosa allows for a course of action (about 20 minutes for acceptable sedation and then under one hour to arousal)^{^[3]}^{,^[4],^[5]} appropriate for minor procedures that are common in children. The most common side effects are transient – mild hypotension and/or bradycardia usually requiring no pharmacological intervention^{^[6]}. It’s also never been reported to produce marked nasal irritation, as is the case with midazolam.

Thus far, most of the studies on using dexmedetomidine for pediatric sedation are in the anesthesia and dental literature, but the first one in the ED was recently published.^{^[7]} The study randomized 38 patients to receive either intranasal (IN) midazolam or dexmedetomidine prior to laceration repair in the ED. Encounters were then videotaped and scored by a blinded, independent viewer for anxiety at various points during the procedure using the Yale Anxiety Preoperative Scale (measuring activity, vocalizations, emotional expressivity, state of arousal and use of parental support). Secondary outcomes included anxiety according to parents, patient satisfaction, complications, successful completion of procedure, and need for additional sedation. The study found that the dexmedetomidine group was slightly less anxious at the time of patient positioning, but there were no statistically significant differences for the other outcomes. The only complication was one episode of emesis in a child that received midazolam.

up the nose

This is a small study and should be interpreted with appropriate caution. But it is backed up by similar studies in the anesthesia and dental world as being safe and effective. One RCT with 72 children using intranasal dexmetomidine vs. midazolam before general anesthesia for dental work found that the children receiving dexmedetomidine were generally more sedated and experienced lower post-op complications.⁵ A second RCT evaluating 90 children prior to general anesthesia for adenoidectomy found no difference between the two groups.^{^[8]} Neither of these trials reported any major complications. A prospective, observational study on 115 children using dexmetomidine for sedation during TEE found that it achieved satisfactory sedation with only 1 patient requiring supplemental oxygen and no episodes of hemodynamic instability.³ A similar prospective study with 60 patients receiving IN dexmetomidine for sedation prior to CT revealed effective sedation after 13 minutes with only 3 adverse events recorded: 1 patient had prolonged recovery of more than 2 hours, 1 patient had transient hypoxemia requiring no intervention, and 1 patient vomited.⁴

So what’s the conclusion? The jury is definitely still out on this one, but dexmedetomidine does seem to be effective at providing sedation and has what seems to be a favorable side effect profile. More studies are needed in the ED, but it has the potential to replace midazolam as the anxiolytic of choice in the peds ED, pending more robust data. For now, it’s another tool in our arsenal of sedation for kids that need procedures or imaging and should be considered especially if the patient is at risk for respiratory depression.

By Dr. Kyle Kelson. Special thanks to Dr. Ian deSouza .

[1]Intranasal administration of midazolam: pharmacokinetic and pharmacodynamic properties and sedative potential. Fukuta O1, Braham RL, Yanase H, Kurosu K. ASDC J Dent Child. 1997 Mar-Apr;64(2):89-98.

[2] Premedication with midazolam in young children: a comparison of four routes of administration. Kogan A1, Katz J, Efrat R, Eidelman LA. Paediatr Anaesth. 2002 Oct;12(8):685-9.

^{^[3]} Intranasal dexmedetomidine for sedation in children undergoing transthoracic echocardiography study–a prospective observational study. Li BL1, Ni J1, Huang JX1, Zhang N1, Song XR1, Yuen VM2. Paediatr Anaesth. 2015 Sep;25(9):891-6. doi: 10.1111/pan.12687. Epub 2015 May 9.

^{^[4]} Intranasal Dexmedetomidine for Sedation for Pediatric Computed Tomography Imaging. Eduardo Mekitarian Filho, PhD, Fay Robinson, MPH, Werther Brunow de Carvalho, MD, PhD, Alfredo Elias Gilio, MD, Keira P. Mason, MD. The Journal of Pediatrics. May 2015. Volume 166, Issue 5, Pages 1313–1315.e1

^{^[5]} Intranasal dexmedetomidine vs midazolam for premedication in children undergoing complete dental rehabilitation: a double-blinded randomized controlled trial. Sheta SA, Al-Sarheed MA, Abdelhalim AA. Paediatr Anaesth. 2014 Feb;24(2):181-9. doi: 10.1111/pan.12287. Epub 2013 Nov 15.

^{^[6]} Clinical uses of dexmedetomidine in pediatric patients. Phan H1, Nahata MC. Paediatr Drugs. 2008;10(1):49-69.

^{^[7]}Double-blind randomized controlled trial of intranasal dexmedetomidine versus intranasal midazolam as anxiolysis prior to pediatric laceration repair in the emergency department. Neville DN, Hayes KR, Ivan Y, McDowell ER, Pitetti RD. Acad Emerg Med. 2016 Apr 30. doi: 10.1111/acem.12998.

^{^[8]} Dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia.
Akin A1, Bayram A, Esmaoglu A, Tosun Z, Aksu R, Altuntas R, Boyaci A. Paediatr Anaesth. 2012 Sep;22(9):871-6. doi: 10.1111/j.1460-9592.2012.03802.x. Epub 2012 Jan 23.