Dexmedetomidine-Ketamine or Dexmedetomidine-Midazolam Nebulised Drug Combination As a Premedicant in Children: A Randomised Clinical Trial

Overview

Journal Turk J Anaesthesiol Reanim

Publisher Galenos Publishing House

Specialty Anesthesiology

Date 2022 Oct 27

PMID 36301288

Authors

Tanvi Dhiman

Versha Verma

Ravinder Kumar Verma

Shelly Rana

Jai Singh

Isha Badhan

Affiliations

Soon will be listed here.

Abstract

Objective: This study was designed to evaluate the clinical efficacy of 2 low-dose nebulised drug combinations of dexmedetomidine-ketamine and dexmedetomidine-midazolam as a premedication in children scheduled for surgery under general anaesthesia.

Methods: Sixty children classified as American Society of Anesthesiologists physical status I, aged between 3 and 10, listed to undergo elective surgeries under general anaesthesia were enrolled in this prospective, randomised, and double-blind trial. Patients were randomly allocated to receive nebulised premedication approximately 30 minutes before the induction of anaesthesia. Group DK (n=30) received combined nebulised dexmedetomidine and ketamine (1 μg kg-1+1 mg kg-1 ) and the dexmedetomidine-midazolam (DM) group (n=30) received combined nebulised dexmedetomidine and midazolam (1 μg kg-1+0.1 mg kg-1 ). All children were anaesthetised with a protocolised anaesthesia technique. The primary end point was the level of sedation when the child was first seen in the operating room 30 minutes after nebulisation. The secondary end points were parental separation and ease of induction, ease of acceptance of IV cannula, mask acceptance, postoperative analgesia, and wake-up behaviour.

Results: Studied groups were comparable in demographic data (age, weight, and sex) and duration of anaesthesia. Level of sedation at 30 minutes was significantly greater in the DM group than in the DK group (P =.013) while the two were comparable in parental separation and ease of induction (P =.808). Group DK exhibited superior ease of acceptance of IV cannula (P =.001), mask acceptance score (P =.001), and postoperative analgesia (P =.021). Hemodynamic parameters and oxygen saturation remained comparable at all time intervals as also the wake-up behaviour.

Conclusions: The nebulised combination of low-dose ketamine and dexmedetomidine was a superior combination producing acceptable sedation with enhanced ease of IV acceptance, mask acceptance, and postoperative analgesia in children.

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References

Hicks C, von Baeyer C, Spafford P, van Korlaar I, Goodenough B . The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001; 93(2):173-183. DOI: 10.1016/S0304-3959(01)00314-1. View

Levanen J, Makela M, Scheinin H . Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology. 1995; 82(5):1117-25. DOI: 10.1097/00000542-199505000-00005. View

Peltoniemi M, Hagelberg N, Olkkola K, Saari T . Ketamine: A Review of Clinical Pharmacokinetics and Pharmacodynamics in Anesthesia and Pain Therapy. Clin Pharmacokinet. 2016; 55(9):1059-77. DOI: 10.1007/s40262-016-0383-6. View

Kain Z, Mayes L, Caldwell-Andrews A, Karas D, McClain B . Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006; 118(2):651-8. DOI: 10.1542/peds.2005-2920. View

Plambech M, Afshari A . Dexmedetomidine in the pediatric population: a review. Minerva Anestesiol. 2014; 81(3):320-32. View

Zanaty O, El Metainy S . A comparative evaluation of nebulized dexmedetomidine, nebulized ketamine, and their combination as premedication for outpatient pediatric dental surgery. Anesth Analg. 2015; 121(1):167-171. DOI: 10.1213/ANE.0000000000000728. View

Khan Z, Ferguson C, Jones R . alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role. Anaesthesia. 1999; 54(2):146-65. DOI: 10.1046/j.1365-2044.1999.00659.x. View

Hammer G, Philip B, Schroeder A, Rosen F, Koltai P . Prolonged infusion of dexmedetomidine for sedation following tracheal resection. Paediatr Anaesth. 2005; 15(7):616-20. DOI: 10.1111/j.1460-9592.2005.01656.x. View

Kain Z, Caldwell-Andrews A, Maranets I, McClain B, Gaal D, Mayes L . Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004; 99(6):1648-1654. DOI: 10.1213/01.ANE.0000136471.36680.97. View

10.

Abdallah C, Hannallah R . Premedication of the child undergoing surgery. Middle East J Anaesthesiol. 2012; 21(2):165-74. View

11.

Jia J, Chen J, Hu X, Li W . A randomised study of intranasal dexmedetomidine and oral ketamine for premedication in children. Anaesthesia. 2013; 68(9):944-9. DOI: 10.1111/anae.12312. View

12.

Bhat R, Santhosh M, Annigeri V, Rao R . Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study. Anesth Essays Res. 2016; 10(2):349-55. PMC: 4864701. DOI: 10.4103/0259-1162.172340. View

13.

Qiao H, Xie Z, Jia J . Pediatric premedication: a double-blind randomized trial of dexmedetomidine or ketamine alone versus a combination of dexmedetomidine and ketamine. BMC Anesthesiol. 2017; 17(1):158. PMC: 5708105. DOI: 10.1186/s12871-017-0454-8. View

14.

Anttila M, Penttila J, Helminen A, Vuorilehto L, Scheinin H . Bioavailability of dexmedetomidine after extravascular doses in healthy subjects. Br J Clin Pharmacol. 2003; 56(6):691-3. PMC: 1884292. DOI: 10.1046/j.1365-2125.2003.01944.x. View

15.

Kain Z, Mayes L, OConnor T, Cicchetti D . Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996; 150(12):1238-45. DOI: 10.1001/archpedi.1996.02170370016002. View

16.

Neville D, Hayes K, Ivan Y, McDowell E, Pitetti R . Double-blind Randomized Controlled Trial of Intranasal Dexmedetomidine Versus Intranasal Midazolam as Anxiolysis Prior to Pediatric Laceration Repair in the Emergency Department. Acad Emerg Med. 2016; 23(8):910-7. DOI: 10.1111/acem.12998. View

17.

Mason K, Michna E, DiNardo J, Zurakowski D, Karian V, Connor L . Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients. Radiology. 2002; 225(2):457-65. DOI: 10.1148/radiol.2252011786. View

18.

Abdel-Ghaffar H, Kamal S, El Sherif F, Mohamed S . Comparison of nebulised dexmedetomidine, ketamine, or midazolam for premedication in preschool children undergoing bone marrow biopsy. Br J Anaesth. 2018; 121(2):445-452. DOI: 10.1016/j.bja.2018.03.039. View

19.

Gharde P, Chauhan S, Kiran U . Evaluation of efficacy of intranasal midazolam, ketamine and their mixture as premedication and its relation with bispectral index in children with tetralogy of fallot undergoing intracardiac repair. Ann Card Anaesth. 2007; 9(1):25-30. View