Skip to main content
Skip to main content

AAP Gateway

Advanced Search »

User menu

  • Login
  • Submit Manuscript
  • Alerts
  • Subscribe
  • aap.org

Menu

  • AAP Grand Rounds
  • AAP News
  • Hospital Pediatrics
  • NeoReviews
  • Pediatrics
  • Pediatrics in Review
  • Journal CME
  • AAP Career Center
  • AAP Current Policy
  • Pediatric Collections
  • AAP Journals Catalog

Sections

    • Login
    • Submit Manuscript
    • Alerts
    • Subscribe
    • aap.org

    Sign up for Insight alerts highlighting editor-chosen studies with the greatest impact on clinical care.

    Get Involved! Hospital Pediatrics is accepting nominations for Editorial Board positions.

    Advertising Disclaimer »

    Tools and Links

    Hospital Pediatrics
    February 2018, VOLUME 8 / ISSUE 2
    Commentaries

    The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation

    Jason Reynolds, Daniel J. Sedillo
    • Article
    • Info & Metrics
    • Comments
    Loading
    Download PDF

    For decades, chloral hydrate (CH) was the standard agent used to provide sedation for noninvasive pediatric procedures.1 The drug had a long history of safe administration by nonanesthesia providers, which in many institutions included registered nurses.2,3 Despite reasonably high reported rates of success, CH had a number of disadvantages: a variable half-life in young children, clinical resedation, and a potential role as a neuroapoptotic agent in the developing brain.4,5 Perhaps the greatest disadvantage was the loss of the oral formulation in the US market, limiting its availability.

    After the loss of oral CH, many institutions evolved to an intravenous (IV) sedation regimen with propofol.6 Propofol was an attractive agent because of its high success rate, rapid onset, and short recovery. However, this change in practice presented new challenges because propofol is typically administered only by pediatric providers with advanced training in deep sedation or anesthesiologists. These deep sedation systems often require more intensive resource utilization (IV catheter placement, advanced monitoring systems, postanesthesia care, etc), which may have economic consequences for both the patient and the health care system.

    For many years, IV dexmedetomidine has been used for sedation in the critical care setting.7 In 2008, Mason et al8 took the next step in the evolution of pediatric procedural sedation by demonstrating that high-dose IV dexmedetomidine (3 µg/kg IV load followed by a 2 µg/kg per hour infusion) could be administered as a single agent to achieve high rates of success for completion of MRI. This practice was adopted at many institutions. Because dexmedetomidine can also be administered intranasally, further research demonstrated that high-dose intranasal dexmedetomidine (IN DEX) could be used to achieve similar rates of success for auditory brainstem responses, computed tomography, and echocardiography.9–11

    In this issue of Hospital Pediatrics, we have an article reporting on the successful use of IN DEX to accomplish MRI in infants.12 Although this is just the most recent report in an ever-expanding body of literature on the use of IN DEX, it is the first study in which a high rate of success for MRI with IN DEX as a single agent was demonstrated. Perhaps more interesting is that this was accomplished in a population historically considered to be at higher risk for sedation-related adverse events.6

    The reported dose of IN DEX for sedated pediatric procedures ranges from 2.5 to 4 µg/kg.10,11,13 Previous reports of MRI sedation with IN DEX have revealed a high failure rate with IN DEX as a single agent or have added adjuvant midazolam to achieve procedure completion.14,15 In this report, the authors note a completion rate of 94.2% using a single dose of 4 µg/kg without adjuvant medications. Although there are many possible explanations for this finding, infants may represent a special subset of patients who respond exceptionally well to the hypnotic effects of dexmedetomidine. This is supported by the authors of 2 recent studies that revealed the median effective dose of IN DEX required for procedure completion was lower in children 1 to 12 months of age as compared with children 13 to 36 months of age.16,17

    This finding is important because of the ongoing debate about potential sedative and/or anesthetic neurotoxicity. There is emerging evidence, however, that suggests dexmedetomidine does not induce neuroapoptosis and may even be neuroprotective in the setting of other neurotoxic agents.18 So in light of the recent Food and Drug Administration warning about sedative and/or anesthetic agents in children, any sedation or anesthesia regimen that reduces or eliminates the use of potentially neurotoxic agents like propofol and includes dexmedetomidine would seem to be good for this vulnerable population.19,20

    The second notable finding of this study is the patient population. Children <1 year of age are generally considered to be at greatest risk for sedation-related adverse events.6 Although this report does not have the power to comment on safety, when taken in the context of the larger body of evidence, IN DEX is starting to emerge as a hypnotic agent that may be lower risk, especially when compared with other agents that are generally felt to induce deep sedation or general anesthesia. This is consistent with what we know about the action of dexmedetomidine because it tends to preserve airway tone and respiratory drive.21 Given this distinction, should the paradigm for administering IN DEX require the same support systems as for deep sedation?

    This debate is likely a circular one in the context of the standard sedation scales. A recent proposal for a pediatric sedation state may help change the current paradigm of a sedation scale.22 Whereas the sedation scale can tell us the depth of sedation, the pediatric sedation state can tell us if the conditions are adequate for procedure completion without adverse events. The data currently available would suggest that IN DEX can reliably provide conditions adequate for procedure completion without serious adverse events. If these findings can be confirmed, then perhaps we could rethink the systems of deep sedation for many noninvasive pediatric procedures with enormous implications for patient access and cost.

    Lastly, the majority of the current literature discusses the clinical efficacy of IN DEX for pediatric procedural sedation. Missing from many investigations on pediatric procedural sedation is the patient and parent experience. With IN DEX, we are no longer talking about 1 IV medication versus another. Rather, we are talking about 1 experience that is likely to be vastly different from another. IN DEX generally avoids the need for IV placement and the associated needle-related pain and distress in children.23 But how does this experience compare with the intranasal administration of a medication? There are also substantial differences between agents and routes in terms of the duration and process of sleep induction as well as the quality of recovery.24

    In summary, this small study12 is an important contribution to the existing literature. IN DEX is an important consideration for children who require sedation for nonpainful pediatric procedures, especially young children and infants. More data from large, prospective, multicenter studies would allow us to draw more definitive conclusions regarding safety. Careful consideration of the pediatric sedation state is needed so that we might better define the systems required to safely provide sedation with IN DEX. Equally important will be the closer examination of the patient and parent experience. Although the practice of pediatric procedural sedation has evolved considerably over the last decade, there is still much work to be done as we continue to look for ways to optimize this important component of the care we provide to children.

    Footnotes

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References

    1. ↵
      1. Delgado J,
      2. Toro R,
      3. Rascovsky S,
      4. et al
      . Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol. 2015;45(1):108–114
      OpenUrlCrossRefPubMed
    2. ↵
      1. Valenzuela DG,
      2. Kumar DS,
      3. Atkins CL,
      4. Beers A,
      5. Kozak FK,
      6. Chadha NK
      . Chloral hydrate sedation for auditory brainstem response (ABR) testing in children: safety and effectiveness. Int J Pediatr Otorhinolaryngol. 2016;83:175–178
      OpenUrl
    3. ↵
      1. Vade A,
      2. Sukhani R,
      3. Dolenga M,
      4. Habisohn-Schuck C
      . Chloral hydrate sedation of children undergoing CT and MR imaging: safety as judged by American Academy of Pediatrics guidelines. AJR Am J Roentgenol. 1995;165(4):905–909
      OpenUrlPubMedWeb of Science
    4. ↵
      1. Pershad J,
      2. Palmisano P,
      3. Nichols M
      . Chloral hydrate: the good and the bad. Pediatr Emerg Care. 1999;15(6):432–435
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      1. Mellon RD,
      2. Simone AF,
      3. Rappaport BA
      . Use of anesthetic agents in neonates and young children. Anesth Analg. 2007;104(3):509–520
      OpenUrlCrossRefPubMedWeb of Science
    6. ↵
      1. Cravero JP,
      2. Beach ML,
      3. Blike GT,
      4. Gallagher SM,
      5. Hertzog JH
      ; Pediatric Sedation Research Consortium. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795–804
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Czaja AS,
      2. Zimmerman JJ
      . The use of dexmedetomidine in critically ill children. Pediatr Crit Care Med. 2009;10(3):381–386
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Mason KP,
      2. Zurakowski D,
      3. Zgleszewski SE,
      4. et al
      . High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth. 2008;18(5):403–411
      OpenUrlCrossRefPubMed
    9. ↵
      1. Reynolds J,
      2. Rogers A,
      3. Medellin E,
      4. Guzman JA,
      5. Watcha MF
      . A prospective, randomized, double-blind trial of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response (ABR) testing. Paediatr Anaesth. 2016;26(3):286–293
      OpenUrl
    10. ↵
      1. Li BL,
      2. Ni J,
      3. Huang JX,
      4. Zhang N,
      5. Song XR,
      6. Yuen VM
      . Intranasal dexmedetomidine for sedation in children undergoing transthoracic echocardiography study—a prospective observational study. Paediatr Anaesth. 2015;25(9):891–896
      OpenUrlCrossRefPubMed
    11. ↵
      1. Mekitarian Filho E,
      2. Robinson F,
      3. de Carvalho WB,
      4. Gilio AE,
      5. Mason KP
      . Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging. J Pediatr. 2015;166(5):1313–1315.e1
      OpenUrlCrossRefPubMed
    12. ↵
      1. Gokhan O,
      2. Mir Hyder A
      . Use of intranasal dexmedetomidine as a solo sedative for magnetic resonance imaging of infants. Hosp Pediatr. 2018;141(2)
    13. ↵
      1. Reynolds J,
      2. Rogers A,
      3. Capehart S,
      4. Manyang P,
      5. Watcha MF
      . Retrospective comparison of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response exams. Hosp Pediatr. 2016;6(3):166–171
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Ambi US,
      2. Joshi C,
      3. Ganeshnavar A,
      4. Adarsh E
      . Intranasal dexmedetomidine for paediatric sedation for diagnostic magnetic resonance imaging studies. Indian J Anaesth. 2012;56(6):587–588
      OpenUrlCrossRefPubMed
    15. ↵
      1. Sulton C,
      2. Kamat P,
      3. Mallory M,
      4. Reynolds J
      . The use of intranasal dexmedetomidine and midazolam for sedated magnetic resonance imaging in children: a report from the Pediatric Sedation Research Consortium [published online ahead of print June 12, 2017]. Pediatr Emerg Care. doi:10.1097/PEC.0000000000001199
    16. ↵
      1. Yu Q,
      2. Liu Y,
      3. Sun M,
      4. et al
      . Median effective dose of intranasal dexmedetomidine sedation for transthoracic echocardiography in pediatric patients with noncyanotic congenital heart disease: an up-and-down sequential allocation trial. Paediatr Anaesth. 2017;27(11):1108–1114
      OpenUrl
    17. ↵
      1. Zhang W,
      2. Fan Y,
      3. Zhao T,
      4. Chen J,
      5. Zhang G,
      6. Song X
      . Median effective dose of intranasal dexmedetomidine for rescue sedation in pediatric patients undergoing magnetic resonance imaging. Anesthesiology. 2016;125(6):1130–1135
      OpenUrl
    18. ↵
      1. Perez-Zoghbi JF,
      2. Zhu W,
      3. Grafe MR,
      4. Brambrink AM
      . Dexmedetomidine-mediated neuroprotection against sevoflurane-induced neurotoxicity extends to several brain regions in neonatal rats. Br J Anaesth. 2017;119(3):506–516
      OpenUrl
    19. ↵
      1. Bjur KA,
      2. Payne ET,
      3. Nemergut ME,
      4. Hu D,
      5. Flick RP
      . Anesthetic-related neurotoxicity and neuroimaging in children: a call for conversation. J Child Neurol. 2017;32(6):594–602
      OpenUrl
    20. ↵
      US Food and Drug Administration. FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Available at: https://www.fda.gov/Drugs/DrugSafety/ucm532356.htm. Accessed December 3, 2017
    21. ↵
      1. Mason KP,
      2. Lerman J
      . Review article: dexmedetomidine in children: current knowledge and future applications. Anesth Analg. 2011;113(5):1129–1142
      OpenUrlCrossRefPubMedWeb of Science
    22. ↵
      1. Cravero JP,
      2. Askins N,
      3. Sriswasdi P,
      4. Tsze DS,
      5. Zurakowski D,
      6. Sinnott S
      . Validation of the pediatric sedation state scale. Pediatrics. 2017;139(5):e20162897
      OpenUrlAbstract/FREE Full Text
    23. ↵
      1. Uman LS,
      2. Birnie KA,
      3. Noel M,
      4. et al
      . Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013;(10):CD005179
    24. ↵
      1. Lee WK,
      2. Kim MS,
      3. Kang SW,
      4. Kim S,
      5. Lee JR
      . Type of anaesthesia and patient quality of recovery: a randomized trial comparing propofol-remifentanil total i.v. anaesthesia with desflurane anaesthesia. Br J Anaesth. 2015;114(4):663–668
      OpenUrlCrossRefPubMed
    • Copyright © 2018 by the American Academy of Pediatrics
    View Abstract
    PreviousNext

     

    Advertising Disclaimer »

    View this article with LENS
    PreviousNext
    Email

    Thank you for your interest in spreading the word on Hospital Pediatrics.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation
    (Your Name) has sent you a message from Hospital Pediatrics
    (Your Name) thought you would like to see the Hospital Pediatrics web site.

    Alerts
    Sign In to Email Alerts with your Email Address
    Citation Tools
    The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation
    Jason Reynolds, Daniel J. Sedillo
    Hospital Pediatrics Feb 2018, 8 (2) 115-117; DOI: 10.1542/hpeds.2017-0247

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Share
    The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation
    Jason Reynolds, Daniel J. Sedillo
    Hospital Pediatrics Feb 2018, 8 (2) 115-117; DOI: 10.1542/hpeds.2017-0247
    del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
    Print
    PDF
    Insight Alerts
    • Table of Contents
    • Early Release
    • Current Issue
    • Past Issues
    • Collections
    • Author Guidelines
    • Editorial Board
    • Editorial Policies
    • LENS
    • Overview
    • Reviewer Guidelines
    • Submit My Manuscript

    Subjects

    • Radiology
      • Radiology
    • Anesthesiology/Pain Medicine
      • Anesthesiology/Pain Medicine
    Back to top

             

    Copyright © 2019 by American Academy of Pediatrics

    International Access »

    Terms of Use
    The American Academy of Pediatrics (AAP) takes the issue of privacy very seriously. See our Privacy Statement for information about how AAP collects, uses, safeguards and discloses the information collected on our Website from visitors and by means of technology.
    FAQ

     

    AAP Pediatrics