dexmedetomidine as a pediatric anesthetic premedication to reduce anxiety and to deter emergence...
TRANSCRIPT
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Dexmedetomidine as a Pediatric Anesthetic
Premedication to Reduce Anxiety and to
Deter Emergence Delirium
Renee Vicari RN, BSN, CCRN, SRNAOakland University/Beaumont HospitalGraduate Program of Nurse Anesthesia
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Mountain, BW., Smithson, L., Cramolini, M., Wyatt, TH., Newman, M. (2011). Dexmedetomidine as a pediatric anesthetic premedication to reduce anxiety and to deter emergence delirium. AANA Journal, 79(3), 219-224.
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IntroductionPublished in the June 2011 issue of American
Association of Nurse Anesthetists (AANA) Journal.
Study was approved by both an affiliated university and the hospital institutional review board.
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Key Terms!Emergence Delirium (ED)- is a mental
disturbance common in children during recovery from general anesthesia.Symptoms:
Combative movementsThrashing, excitabilityDisorientationInconsolable crying
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Purpose of StudyTo compare the effects of oral
dexmedetomidine and midazolam in reducing anxiety and ED in children aged 1 to 6 years receiving dental restoration.
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Review of LiteratureKain and colleagues reported that pre-operative
anxiety may be linked to emergence delirium.
54% of their subjects had negative behavior patterns at 2 weeks and 20% of these continued for up to 6 months. Follow-up study found that children with pre-operative
anxiety had a higher excitement score in PACU and negative behaviors at home.Bad dreamsWaking up cryingSeparation anxiety Temper tantrums
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Review of LiteratureSevoflurane, perioperative medications and pain
increase ED.
Midazolam most common medication used pre-op to reduce anxiety.
Dexmedetomidine IV shown to reduce ED when given intraoperative.
Limited studies on dexmedetomidine use in childrenRestricted to IV use
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Hypothesis2 Part Hypothesis:
Oral dexmedetomidine is as effective as midazolam in reducing anxiety, as measured by tool assessing separation from parent and acceptance of mask, prior to surgery.
Oral dexmedetomidine reduces the incidence and severity of ED in pediatric population.
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Study
RandomizedProspectiveDouble-blinded design
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Inclusion CriteriaIncluded 41 children
Aged 1 to 6 years old
Undergoing dental restorations and possible tooth extraction.
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Exclusion CriteriaKnown allergies to midazolam and or
dexmedetomidine
Developmental delay or mental retardation-as reported by the parents
History of ED
ASA classification greater than II
Any previous reactions to anesthesia
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MethodsObtained informed consent
Subjects were randomly assigned to 1 of 2 groupsControl group:
Received 0.5mg/kg of oral midazolamExperimental group:
Received 4mcg/kg of oral dexmedetomidine
Staff and members of research team blinded to assignments and medication administered.
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MethodsBoth medications were prepared in similar
syringes
Prepared with cherry-flavored syrup
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Dexmedetomidine (Precedex)
Non-selective alpha-2 adrenergic agonist
Sedative and opioid sparing effects
Expensive-$495.79
IV infusion-0.2-0.7mcg/kg/hr
Minimal respiratory depression
Adverse effects: N/V Bradycardia Hypotension Fever
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Midazolam (Versed)Benzodiazepine
Amnestic and anxiolytic properties
0.5mg-1.0mg/kg PO in children
Adverse effects:HeadacheDrowsinessConfusionN/VBlood pressure changes
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Instruments3 instruments used
Parental Separation Anxiety Scale (PSAS) -4 point scale1=easy separation2=whimpers, but is easily reassured, not clinging3=cries and cannot be easily reassured, but not
clinging to parents4=crying and clinging to parents
PSAS of 1-2 acceptable
PSAS of 3-4 were difficult separations
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InstrumentsMask Acceptance Scale (MAS)-ability to accept the
anesthesia mask
MAS scale is a 4-point Likert scale 1=excellent (unafraid, cooperative, accepts mask
readily) 2=good (slight fear of mask, easily reassured) 3=fair (moderate fear of mask, not calmed with
reassurance) 4=poor (terrified, crying, or combative)
Score of 1-2 was satisfactory
Score of 3-4 was unsatisfactory
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InstrumentsPediatric Anesthesia Emergence Delirium Scale
(PAEDS)
Based on 5 criteria:Makes eye contact with caregiverActions are purposefulAware of his or her surroundingsRestless Inconsolable
Out of 20 points, a score greater than 10 indicates ED.
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Data AnalysisPearson X2 analysis was performed to
determine differences between both groups for anxiety
Independent sample t test was used to determine differences between occurrence and severity of ED in both groups.
Level of significance was set at P=0.05
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ProceduresStudy medication administered 30 minutes prior
to OR
Pulse oximetry and blood pressure monitored every 15 minutes
Research team member accompanied child to surgery and the PSAS was scored at this time-30 minutes after child received medication
In OR with nurse anesthetist, team member calculated the MAS score
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ProceduresStudy anesthesia protocol:
Mask induction with sevoflurane and nitrous oxide Isoflurane used for maintenance Spontaneous ventilation was maintained if possible Muscle relaxants were avoided, if possible, if ventilatory
support needed. Anticholinergic drugs were avoided Odansetron (0.2mg/kg) and dexamethsone (0.25mg/kg)
were administered Fentanyl for analgesia (1 to 2 mcg/kg) Local anesthestic per surgeon
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ProceduresTaken to PACU after surgery
Observed for 1 hour
PAEDS score was determined once child aroused or peak of ED
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Results41 subjects recruited between May 2006 and June
2007
21 (51%) males
20 (49%) females
Mean age 4 years old
27 (65%) white
9 (22%) African American
5 (12%) Hispanic
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ResultsNo difference in mean blood pressure values in
the 2 groups (t=0.852, P=0.399)
No difference in the pulse oximetry values in the 2 groups (t=0.459, P=0.649)
No difference in separation from parents between the 2 groups (X2=0.478, P=0.489)
No statistically significant differences between the 2 group with acceptance of the anesthesia mask (X2=0.602, P=0.438)
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Results
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ResultsOut of 41 subjects
8 children (20%) experienced ED3 of the 8 were in the experiemental
(dexmedetomidine) group5 were in the control (Midazolam) group
No significant difference between the 2 groups (t=1.023, P=0.313)
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DiscussionStudy was able to demonstrate that 4mcg/kg PO
of dexmedetomidine resulted in no adverse effects
No difference between the midazolam and dexmedetomidine groups in blood pressure or oxygenation stability
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StrengthsDouble-blinded study
All subjects remained in study
Equal number of males and females
Detailed and precise anesthesia protocol while child is anesthetized
Specific surgery-all subjects underwent same surgery
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LimitationsLimited sample size
Absence of fluctuations in blood pressure and heart rate (common side effect) with dexmedetomidine may indicate that 4 mcg/kg was too low to be clinically effective.
Used oral dexmedetomidine instead of buccal Bioavailability is 16% (oral) compared to 82%
(buccal)
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ConclusionNot FDA approved for children….yet
More studies needed to examine child-friendly dexmedetomidine preparations and its effect on ED
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