Clinical Characteristics of Intranasal Dexmedetomidine for Sedation in Children Undergoing Non-painful Procedures

Background: Dexmedetomidine (DEX) is an alpha-2 receptor agonist that can provide sedation for non-painful procedures in children. DEX can be administered by the intranasal (IN) instead of intravenous route, the latter being potentially technically challenging, and associated with pain and distress. However, there is substantial variation in how IN DEX is used, and it is unclear how effective different IN DEX regimens are for different procedures. We aimed to describe clinically-relevant outcomes (e.g. adequacy of sedation, time to clinically-meaningful endpoints, adverse events) associated with different IN DEX regimens for different types of non-painful procedures.

Methods: We conducted a multicenter prospective observational cross-sectional study of children ages 2 months to 18 years receiving IN DEX sedation undergoing a non-painful procedure. Dose of IN DEX, use of adjunct sedatives, and decision to use parenteral sedatives were made by the treating clinician. Descriptive measures of patient and sedation characteristics and adverse events were reported. Time to onset of sedation, procedure start, procedure completion, and discharge readiness were collected. The Pediatric Sedation State Scale was used to assess sedation adequacy. A multivariable regression model was used to assess associations between patient and sedation characteristics and failed sedations (i.e. received parenteral sedative and/or uninterpretable test results).

Results: We enrolled 578 patients from 7 sites. Mean age was 3 years, 217 (37.5%) were female. Procedures performed included 314 auditory brainstem response tests, 132 magnetic resonance imaging scans, 89 echocardiograms, 34 electroencephalograms, and 9 computed tomography scans . Mean procedure duration was 45.7 min. Mean total IN DEX dose was 3.3 mcg/kg (95% CI 3.2, 3.4), 230 (39.8%) received an adjunct sedative (82 received IN midazolam, 136 oral midazolam). Mean times from IN DEX administration to onset of sedation, procedure start, and discharge readiness were 33.9, 35.2, and 115 minutes, respectively. There were 432 (74.7%) patients with PSSS scores of 2 or 3 for ≥90% of the procedure. There were no patients who had a cardiovascular adverse event that required an intervention. Airway/breathing interventions administered in response to an event were jaw thrust (4 patients), repositioning (2), and blow-by oxygen (4). No patients required emergent anesthesia assistance, emergent airway placement/intubation, or admission to the hospital. There were 48 (8.3%) failed sedations. Administering IN DEX without an adjunct sedative was associated with failed sedation (OR 5.9, 95% CI 2, 17.3).

Conclusion: IN DEX, with or without adjunct sedatives, is effective for providing adequate sedation for a large proportion of children undergoing non-painful procedures, although sedations without adjunct sedatives were associated with failed sedations. There were no serious adverse events that required an intervention.