Dexmedetomidine as a primary sedative agent after single-stage airway reconstruction.

OBJECTIVE: To examine the outcomes of children receiving dexmedetomidine after single-stage airway reconstruction. STUDY DESIGN: Historical cohort study. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Of 61 eligible patients, 50 children undergoing single-stage airway reconstruction were included in the study. Thirty children received dexmedetomidine (Dex) as a primary sedative agent, and 20 received a more traditional sedation protocol (no Dex). Primary outcomes included complications, intubation lengths, and lengths of pediatric intensive care unit (PICU)/hospital admission. Secondary analysis incorporating polypharmacy and age was performed using multivariate linear regression models. RESULTS: Median age was 18.0 months. Age, sex, and weight were similar between the groups. Intubation length was equal in the 2 groups, and there were no statistical differences between lengths of PICU or hospital stay after extubation. Similarly, overall and individual complications were all similar, and there was no difference between the 2 groups in the amount of polypharmacy administered. On multivariate analysis, polypharmacy and younger age were independently correlated with an increase in overall complications, and polypharmacy alone was correlated with an increased length of stay after extubation. CONCLUSION: The use of dexmedetomidine as a primary sedation agent after single-stage airway surgery does not appear to improve outcomes or decrease the need for additional pharmacologic agents. Polypharmacy was associated with an increase in overall complications and an increased length of stay after extubation. Although success can be expected in greater than 90% of these surgical patients, the optimal postoperative sedation management remains challenging.

Case report: an unforeseen peril of parental presence during induction of anesthesia.

Parental presence during induction of anesthesia is a common practice to allay perioperative anxiety in the pediatric population. We present the first documented case in the anesthesia literature of parental interruption of induction of anesthesia. The report is to inform practitioners of the need for perioperative screening, education, and contingency planning to prepare for the possibility of familial disruption during pediatric inductions, cesarean deliveries, and other practice settings that may have lay people present.

The effect of dexmedetomidine during myringotomy and pressure-equalizing tube placement in children.

BACKGROUND: Bilateral myringotomy (BMT) is a commonly performed otolaryngologic procedure in children. OBJECTIVES: To examine the effects of intranasal dexmedetomidine, an α(2)-adrenoceptor agonist, on time-averaged pain scores, pain control, need for rescue analgesia, and agitation scores in children undergoing BMT. METHODS: We designed a trial to enroll 160 children randomized to one of four groups: two study groups, dexmedetomidine (1 or 2 µg·kg(-1)), or two control groups representing our institutional standards of practice (intranasal fentanyl-2 µg·kg(-1) or acetaminophen as needed postoperatively). RESULTS: After 101 children were enrolled, patient caregivers observed that some enrollees were excessively sedated and required prolonged postanesthesia care unit (PACU) stay. This observation led to an unplanned interim analysis and early trial termination. After data were collected, severe nonnormality of pain and agitation scores necessitated a switch of the outcome to assess repeated measurements of the proportion of patients with pain, severe pain, and agitation. Demographics, time to emergence, and agitation were similar among all groups. The risk of requiring acetaminophen rescue (P < 0.0001) and proportion of patients having pain (P = 0.016) was significantly higher in one control group (rescue analgesia only) compared with fentanyl or dexmedetomidine groups. Importantly, length of stay in the PACU was significantly longer in dexmedetomidine-2 µg·kg(-1)-treated compared with dexmedetomidine-1 µg·kg(-1)-treated, fentanyl-treated, or the control group, P = 0.0037. CONCLUSIONS: In this trial, we were unable to answer the original question as to the role of dexmedetomidine on time-averaged pain and agitation scores after BMT. However, our findings clearly demonstrate that in children undergoing BMT, at higher doses, dexmedetomidine significantly prolongs length of stay in the PACU.

High-dose dexmedetomidine increases the opioid-free interval and decreases opioid requirement after tonsillectomy in children.

PURPOSE: Dexmedetomidine, a selective α(2) adrenoreceptor agonist, has analgesic and sedative properties, minimal impact on respiratory parameters, and reportedly decreases analgesic requirements after surgery. Given its pharmacodynamic profile, dexmedetomidine might have a role for postoperative pain control in children undergoing tonsillectomy. In this study, we hypothesized that dexmedetomidine would delay and decrease opioid requirements after tonsillectomy. METHODS: In a double-blind controlled trial, participants undergoing tonsillectomy were randomized to receive one intravenous dose of fentanyl (1 µg·kg(-1) or 2 µg·kg(-1)) or dexmedetomidine (2 µg·kg(-1) or 4 µg·kg(-1)) immediately after endotracheal intubation. Primary outcomes included requirement for rescue morphine in the initial postoperative period. RESULTS: One hundred and one children were enrolled. During the postoperative period, dexmedetomidine (2 and 4 µg·kg(-1) groups combined) significantly prolonged the opioid-free interval of children who underwent tonsillectomy compared with fentanyl (1 and 2 µg·kg(-1) groups combined) (P < 0.001). Children treated with dexmedetomidine 2 µg·kg(-1) vs dexmedetomidine 4 µg·kg(-1) had similar cumulative incidence curves for time to morphine rescue, whereas there was a small difference in time to first morphine rescue administration when comparing fentanyl 1 µg·kg(-1) vs fentanyl 2 µg·kg(-1). Furthermore, length of stay in the postanesthesia care unit was significantly longer for children treated with dexmedetomidine vs children treated with fentanyl (P = 0.0016). CONCLUSIONS: High-dose dexmedetomidine decreases opioid requirements, prolongs the opioid-free interval after tonsillectomy, and prolongs length of stay in the postanesthesia care unit. It is conceivable that these early opioid-sparing effects could benefit patients at risk for respiratory complications early in the postoperative course after tonsillectomy (e.g., patients with obstructive sleep apnea). (ClinicalTrials.gov number, NCT00654511).

The use of dexmedetomidine to facilitate acute discontinuation of opioids after cardiac transplantation in children.

OBJECTIVE: To report the use of dexmedetomidine to facilitate rapid opioid and benzodiazepine withdrawal in children with transplanted hearts and to review the receptor physiology and pharmacodynamic impact of dexmedetomidine on the denervated heart. DESIGN: Case series. SETTING: Intensive care unit at a tertiary pediatric medical center. PATIENTS: The series included a 6-month-old infant with pulmonary atresia who had a 3-month exposure to high-dose opioids and benzodiazepines and had undergone cardiac transplantation 4 wks before the use of dexmedetomidine and a 7-yr-old boy who had been sedated while undergoing extracorporeal membrane oxygenation for 3 wks before transplantation and started to receive dexmedetomidine 3 days after transplantation. INTERVENTION: Administration of dexmedetomidine to facilitate the discontinuation of opioids and benzodiazepine. MAIN RESULT: Successful rapid withdrawal from opioids and benzodiazepines while maintaining hemodynamic stability. CONCLUSION: To our knowledge, this report describes the first use of dexmedetomidine to facilitate opioid withdrawal in children with a cardiac transplant. Dexmedetomidine allowed for the preservation of satisfactory hemodynamic parameters during acute withdrawal from opioids in children with denervated hearts.