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Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

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A Letter to the Editor to this article was published on 28 June 2017

Abstract

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine’s impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

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References

  1. Roback NG, Carlson DW, Babl FE, Kennedy RM. Update on pharmacological management of procedural sedation for children. Curr Opin Anasthesiol. 2016;29:S21–35.

    Article  CAS  Google Scholar 

  2. Sulton C, McCraken C, Simon HK, Hebbar K, Reynolds J, Cravero J, et al. Pediatric procedural sedation using dexmedetomidine: a report from the Pediatric Sedation Research Consortium. Hosp Pediatr. 2016;6:536–44.

    Article  PubMed  Google Scholar 

  3. Haselkorn T, Whittemore AS, Udaltsova N, Friedman GD. Short-term chloral hydrate administration and cancer in humans. Drug Saf. 2006;29:67–77.

    Article  PubMed  Google Scholar 

  4. Pershad J, Palmisano P, Nichols M. Chloral hydrate: the good and the bad. Pediatr Emerg Care. 1999;15:432–5.

    Article  CAS  PubMed  Google Scholar 

  5. Napoli KL, Ingall CG, Martin GR. Safety and efficacy of chloral hydrate sedation in children undergoing echocardiography. J Pediatr. 1996;129:287–91.

    Article  CAS  PubMed  Google Scholar 

  6. D’agostino J, Terndrup TE. Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care. 2000;16:1–4.

  7. Valenzuela DG, Kumar DS, Atkins CL, Beers A, Kozak FK, Chadha NK. Chloral hydrate sedation for auditory brainstem response (ABR) testing in children: safety and effectiveness. Int J Pediatr Otorhinolaryngol. 2016;83:175–8.

    Article  PubMed  Google Scholar 

  8. Stephen MC, Mathew J, Varghese AM, Kurien M, Mathew GA. A randomized controlled trial comparing intranasal midazolam and chloral hydrate for procedural sedation in children. Otolaryngol Head Neck Surg. 2015;153:1042–50.

    Article  PubMed  Google Scholar 

  9. Sury MR, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK. Development of a nurse-led sedation service for paediatric magnetic resonance imaging. Lancet. 1999;353:1667–71.

    Article  CAS  PubMed  Google Scholar 

  10. Hare M. Question 1. Chloral hydrate or midazolam: which is better for sedating children for painless diagnostic imaging? Arch Dis Child. 2012;97:750–2.

    Article  PubMed  Google Scholar 

  11. Buck ML. The use of chloral hydrate in infants and children. Pediatr Pharmacother. 2005;11:1–4.

    Google Scholar 

  12. Nordt SP, Rangan C, Hardmaslani M, Clark RF, Wendler C, Valente M. Pediatric chloral hydrate poisoning and death following outpatient procedural sedation. J Med Toxicol. 2014;10:219–22.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Cotè CJ, Karl HW, Notterman DA, Wemberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;106:633–44.

    Article  PubMed  Google Scholar 

  14. Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, et al. EMCS Panel on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51:378–99.

    Article  PubMed  Google Scholar 

  15. Rumm PD, Takao RT, Fox DT, Atkinson SW. Efficacy of sedation of children with chloral hydrate. South Med J. 1990;83:1040–3.

    Article  CAS  PubMed  Google Scholar 

  16. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics. 2000;105:E42.

    Article  CAS  PubMed  Google Scholar 

  17. Mahmoud M, Mason KP. Dexmedetomidine: review, update, and future considerations of paediatrics perioperative and periprocedural applications and limitations. Br J Anaesth. 2015;115:171–82.

    Article  CAS  PubMed  Google Scholar 

  18. Wolfe TR, Braude DA. Intranasal medication delivery for children: a brief review and update. Pediatric. 2010;126:532–7.

    Article  Google Scholar 

  19. Cimen ZS, Hanci A, Sivrikaya GU, Kilinc LT, Erol MK. Comparison of buccal and nasal dexmedetomidine premedication for pediatric patients. Paediatr Anaesth. 2013;23:134–8.

    Article  PubMed  Google Scholar 

  20. Faritus SZ, Khazaee-Koohpar M, Ziyaeifard M, Mehrabanian MJ. Oral dexmedetomidine versus midazolam as anesthetic premedication in children undergoing congenital heart surgery. Anesth Pain Med. 2015;22:e25032.

    Google Scholar 

  21. Tobias JD, Cravero JP. Procedural sedation for infants, children and adolescents. First ed. American Academy of Pediatrics section on Anesthesiology and Pain Medicine; 2016.

  22. Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Paediatr Crit Care Med. 2012;13:423–7.

    Article  Google Scholar 

  23. McVey JD, Tobias JD. Dexmedetomidine and ketamine for sedation during spinal anaesthesia in children. J Clin Anesth. 2010;22:538–45.

    Article  CAS  PubMed  Google Scholar 

  24. Akin A, Bayram A, Esmaoglu A, Tosun Z, Aksu R, Altuntas R, et al. Dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia. Paediatr Anaesth. 2012;22:871–6.

    Article  PubMed  Google Scholar 

  25. US Food and Drug Administration. Safety Announcement: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. 2016; Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/UCM533197.pdf. Accessed 24 Jan 2017.

  26. Disma N, Hansen TG. Pediatric anesthesia and neurotoxicity: can findings be translated from animals to humans? Minerva Anestesiol. 2016;82:791–6.

    PubMed  Google Scholar 

  27. Sanders RD, Sun P, Patel S, Li M, Maze M, Ma D. Dexmedetomidine provides cortical neuroprotection: impact on anaesthetic-induced neuroapoptosis in the rat developing brain. Acta Anaesthesiol Scand. 2010;54:710–6.

    Article  CAS  PubMed  Google Scholar 

  28. Degos V, Charpentier TL, Chhor V, Brissaud O, Lebon S, Schwendimann L, et al. Neuroprotective effects of dexmedetomidine against glutamate agonist-induced neuronal cell death are related to increased astrocyte brain-derived neurotrophic factor expression. Anesthesiology. 2013;118:1123–32.

    Article  CAS  PubMed  Google Scholar 

  29. Li Y, Zeng M, Chen W, Liu C, Wang F, Han X, et al. Dexmedetomidine reduces isofluorane induced neuroapoptosis partly by preserving PI3K/Akt pathway in the hippocampus of neonatal rats. PLoS One. 2014;9:e93639.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Alam A, Suen KC, Hana Z, Sanders RD, Maze M, Ma D. Neuroprotection and neurotoxicity in the developing brain: an update on the effects of dexmedetomidine and xenon. Neurotoxicol Teratol. 2017. doi:10.1016/J.ntt.2017.01.001.

    PubMed  Google Scholar 

  31. Mason KP, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth. 2008;18:403–11.

    Article  PubMed  Google Scholar 

  32. Mason KP, Lubisch NB, Robinson F, Roskos R. Intramuscular dexmedetomidine sedation for pediatric MRI and CT. AJR Am J Roentgenol. 2011;197:720–5.

    Article  PubMed  Google Scholar 

  33. Mason KP, Lubisch N, Robinson F, Roskos R, Epstein MA. Intramuscular dexmedetomidine: an effective route of sedation preserves background activity for pediatric electroencephalograms. J Pediatr. 2012;161:927–32.

    Article  CAS  PubMed  Google Scholar 

  34. Yuen VM, Hiu TW, Irwin MG, Yuen MK. A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Anesth Analg. 2008;106:1715–21.

    Article  CAS  PubMed  Google Scholar 

  35. Jia JE, Chen JY, Hu X, Li WX. A randomized study of intranasal dexmedetomidine and oral ketamine for premedication in children. Anaesthesia. 2013;68:944–9.

    Article  CAS  PubMed  Google Scholar 

  36. Li BL, Zhang N, Huang JX, et al. A comparison of intranasal dexmedetomidine for sedation in children administered either by atomizer or by drops. Anaesthesia. 2016;71:522–8.

    Article  CAS  PubMed  Google Scholar 

  37. Mekitarian Fihlo E, Robison F, de Carvalho WB, Gilio AE, Mason KP. Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging. J Pediatr. 2015;166:1313–5.

    Article  Google Scholar 

  38. Baier NM, Mendez SS, Kimm D, Velazquez AE, Schroeder AR. Intranasal dexmedetomidine: an effective sedative agent for electroencephalogram and auditory brain response testing. Paediatr Anaesth. 2016;26:280–5.

    Article  PubMed  Google Scholar 

  39. Reynolds J, Rogers A, Medellin E, Guzman JA, 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;26:286–93.

    Article  PubMed  Google Scholar 

  40. Miller J, Xue B, Hossain M, Zhang MZ, Loepke A, Kurth D. Comparison of dexmedetomidine and chloral hydrate sedation for transthoracic echocardiography, in infants and toddlers: a randomized clinical trial. Paediatr Anaesth. 2016;26:266–72.

    Article  PubMed  Google Scholar 

  41. Ambi US, Joshi C, Ganeshnavar A, Adarsh E. Intranasal dexmedetomidine for paediatric sedation for diagnostic magnetic resonance imaging studies. Indian J Anaesth. 2012;56:587–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. O’Mara K, Gal P, Wimmer J, Ransom JL, Carlos RQ, Dimaguila MA, et al. Dexmedetomidine versus standard therapy with fentanyl for sedation in mechanically ventilated premature neonates. J Pediatr Pharmacol Ther. 2012;17:252–62.

    PubMed  PubMed Central  Google Scholar 

  43. Lam F, Bhutta AT, Tobias JD, Gossett JM, Morales L, Gupta P. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease. Pediatr Cardiol. 2012;33:1069–77.

    Article  PubMed  Google Scholar 

  44. Chrysostomou C, Schulman SR, Herrera Castellanos M, Cofer BE, Mitra S, da Rocha MG, et al. A phase II/III, multicenter, safety, efficacy, and pharmacokinetics study of dexmedetomidine in preterm and term neonates. J Pediatr. 2014;164:276–82.

    Article  CAS  PubMed  Google Scholar 

  45. Zhang W, Wang Z, Song X, Fan Y, Tian H, Li B. Comparison of rescue techniques for failed chloral hydrate sedation for magnetic resonance imaging scans—additional chloral hydrate vs intranasal dexmedetomidine. Paediatr Anaesth. 2016;26:273–9.

    Article  CAS  PubMed  Google Scholar 

  46. Gan X, Lin H, Chen J, Lin Z, Lin Y, Chen W. Rescue sedation with intranasal dexmedetomidine for pediatric ophthalmic examination after chloral hydrate failure: a randomized, controlled trial. Clin Ther. 2016;38:1522–9.

    Article  CAS  PubMed  Google Scholar 

  47. Zhang W, Fan Y, Zhao T, Chen J, Zhang G, Song X. Median effective dose of intranasal dexmedetomidine for rescue sedation in pediatric patients undergoing magnetic resonance imaging. Anesthesiology. 2016;125:1130–5.

    Article  CAS  PubMed  Google Scholar 

  48. Li BL, Yuen VM, Song XR, Ye J, Ni J, Huang JX, et al. Intranasal dexmedetomidine following failed chloral hydrate sedation in children. Anaesthesia. 2014;69:240–4.

    Article  CAS  PubMed  Google Scholar 

  49. Reynolds J, Rogers A, Capehart S, Manyang P, Watcha MF. Retrospective comparison of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response exams. Hosp Pediatr. 2016;6:166–71.

    Article  PubMed  Google Scholar 

  50. Gumus H, Bayram AK, Poyrazoglu HG, Canpolat DG, Per H, Canpolat M, et al. Comparison of effects of different dexmedetomidine and chloral hydrate doses used in sedation on electroencephalography in pediatric patients. J Child Neurol. 2015;30:983–8.

    Article  PubMed  Google Scholar 

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Authors’ contributions

All authors, SN, GC and EB, contributed equally to the manuscript. All authors, SN, GC and EB, read and approved the manuscript and approved its submission to the journal.

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Authors and Affiliations

  1. Emergency Department, Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, via dell’Istria 65/1, 34132, Trieste, Italy

    Giorgio Cozzi, Stefania Norbedo & Egidio Barbi

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  1. Giorgio Cozzi
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  2. Stefania Norbedo
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  3. Egidio Barbi
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Correspondence to Giorgio Cozzi.

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The authors SN, GC and EB declare that they do not have any conflict of interest.

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The authors, SN, GC and EB, declare they did not receive any funding or grant for this manuscript.

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Cozzi, G., Norbedo, S. & Barbi, E. Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate. Pediatr Drugs 19, 107–111 (2017). https://doi.org/10.1007/s40272-017-0217-5

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