Intranasal dexmedetomidine vs oral midazolam and ketamine for procedural sedation in children

Sedation of pediatric patients has particular complications, since the youngster must remain motionless for proper administration of radiotherapy, remote monitoring of the child is challenging, and sedation is repeated. Recently study showed, for fractionated RT, intranasal dexmedetomidine delivers a more tolerable sedation than oral ketamine with midazolam.

A combination of oral midazolam and ketamine is utilised for procedural sedation in radiology and the radiation suite. The combination of midazolam and ketamine is intended to boost effectiveness and reduce adverse effects, although it is not without unwanted effects and failures. Other important disadvantages include inconsistent absorption and vomiting, which result in unexpected reactions and neurotoxicity owing to the recurrent use of these medications during fractionated radiation therapy. Researchers assessed the effectiveness of intranasal dexmedetomidine to generate superior sedation than the oral midazolam–ketamine combination and as a safe alternative to the latter in paediatric cancer patients undergoing fractionated radiation therapy.

Ninety children aged 3 to 6 years who were scheduled to receive 21 fractions of RT were randomly assigned to receive either intranasal dexmedetomidine 2 mg/kg (group D) or oral midazolam 0.2 mg/kg and ketamine 5 mg/kg (group MK). The 21 fractionated radiation treatments were separated into three subgroups of seven consecutive exposures: 1–7, 8–14, and 15–21. The major objective was to establish the success rate of sedation. Secondary objectives were the sedation score obtained, the duration to adequate sedation and discharge, the need for rescue ketamine, and side effects.

In the three following RT subgroups, sessions 1–7, 8–14, and 15–21, the incidence of effective sedation was 82%, 75.6%, and 66.7% in group D, compared to 40%, 24.4%, and 13.3% in group MK, respectively. (P < 0.001). There was a decline in successful sedation across the groupings. Group D had effective sedation and release sooner than group MK (P = 0.000) More patients in group MK needed rescue ketamine (P = 000).

Numerous trials using propofol, midazolam, and/or ketamine for sedation in RT have been conducted. It has been linked to consequences such as sepsis, cardiovascular issues, and respiratory difficulties. Dexmedetomidine has a favourable adverse effect profile with little adverse haemodynamic and respiratory effects, is well-tolerated, and effective in non-invasive procedures, according to one of the biggest evaluations conducted on the use of dexmedetomidine in paediatric patients. On the other hand, several adverse consequences of infusions have been identified. There were We saw no adverse effects in the dexmedetomidine group, with the exception of one patient who vomited. They preserved hemodynamic stability and oxygen saturation. However, dexmedetomidine currently has a unique position in the perioperative care of children. Dexmedetomidine administered intranasally induces adequate sedation in paediatric patients undergoing recurrent radiotherapy. Compared to the oral combination of midazolam and ketamine, the success rate of sedation in repeated sessions is higher. It is also more secure and has a faster start of effect and recuperation time.

Reference –

Das, Rekha; Das, Rajat; Jena, Manoranjan1; Janka, Janaki; Mishra, Sunita. Procedural sedation in children for fractionated radiation treatment: Intranasal dexmedetomidine versus oral midazolam and ketamine. Indian Journal of Anaesthesia: October 2022 - Volume 66 - Issue 10 - p 687-693.

doi: 10.4103/ija.ija_340_22