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Is dexmedetomidine the gold standard for pediatric procedural sedation and anxiolysis?
Rev Assoc Med B ras 2017; 63(4):299-300 299
POINT OF VIEW
Is dexmedetomidine the gold standard for pediatric procedural
sedation and anxiolysis?
Eduardo Mekitarian F ilho1*
1MD, MSc, PhD, Pediatric Intensive Care Unit, Universidade de São Paulo, São Paulo, SP, Brazil
Study conducted at Pediatric Intensive Care Unit, Universidade de São Paulo, São Paulo, SP, Brazil
Article received: 7/28/2016
Accepted for publication: 10/19/2016
*Correspondence:
Unidade de Terapia Intensiva Pediátrica, USP
Address: Av. Dr. Enéas de Carvalho Aguiar, 647
São Paulo, SP – Brazil
Postal code: 05467-000
Pediatric procedural sedation is a growing issue in the
emergency setting, and finding the right drug to perform
safe and effective sedation is still a challenge. I would like
to discuss the article “Double-blind randomized controlled
trial of intranasal dexmedetomidine versus intranasal
midazolam as anxiolysis prior to pediatric laceration repair
in the emergency department,” by Neville et al.,1 which is
currently in press in the Academic Emergency Medicine
Journal. The authors randomized 38 children to receive
either intranasal dexmedetomidine (DEX) or intranasal
midazolam before laceration repairs, and chose as pri-
mary outcome the anxiety score at the time of patient
positioning for the repair. The proportion of patients
who were classified as not anxious at the position for
procedure was significantly higher in the dexmedetomidine
group (70%) versus the midazolam group (11%). Authors
concluded that intranasal DEX is an alternative with good
results for anxiolysis prior to painful procedures in chil-
dren compared to midazolam.
DEX is a highly selective α2 adrenergic agonist that
offers some unique and unmatched sedation characteris-
tics.2 Without pediatric labeling, DEX has been studied for
pediatric sedation and anxiolysis, intravenously or using
other administration routes, such as intranasal (IN). In
contrast to all other sedatives, DEX produces a sleep som-
nolence state which closely resembles that of non-REM
sleep on electroencephalogram.3 DEXmaintains spontane-
ous ventilation, has minimal respiratory effects and pre-
serves upper airway tone, making it an attractive choice for
pediatric procedural sedation and anxiolysis.
The majority of pediatric sedation literature on DEX
described its application for non-painful radiological imag-
ing studies such as MRI, computerized tomography scans,
and nuclear medicine studies. A few studies addressed this
sedative for anxiolytic purposes. Some authors studied
DEX alone or carried out clinical trials comparing it with
other drugs. Recently, Sidhu et al. 4 studied 105 ASA 1-2
surgical patients comparing IN DEX with IN clonidine.
Using an initial dose of 2 mcg/kg of IN DEX, satisfactory
anxiolysis was achieved in 88.5% of these patients and in
60% of the clonidine patients, with significantly less rescue
analgesia requirements in the DEX group. Another recent
and very interesting study was conducted by Yao et al.5 with
90 children receiving 1-2 mcg/kg of INDEX prior to laryn-
geal mask insertion, which concluded that patients receiv-
ing 2 mcg/kg had significant lower alveolar concentrations
of sevoflurane prior to the procedure and less emergency
delirium after it.
The two studies above described were the only ones
focused on DEX premedication in children, prior to two
meta-analyses 6,7 published in 2014 that verified the effi-
cacy and safety of premedication with DEX in children,
alone or associated with midazolam. Together, the authors
pooled 24 randomized controlled trials and concluded
that DEX is superior to midazolam premedication because
it resulted in enhanced preoperative sedation and de-
creased postoperative pain. In addition, DEX premedica-
tion provided clinical benefits that included reduced re-
quirements for rescue analgesia and reduced agitation or
delirium and shivering during the postoperative period.
Our group has previously studied IN DEX and mid-
azolam for pediatric procedural sedation, and we felt
that the quality of anxiolysis and sedation provided by
IN DEX8,9 was far superior. However, we selected two
prospective cohorts and our primary outcomes were time
to sedation and rates of failed sedation. As we didn’t