Efficacy and safety of intranasal midazolam, S-ketamine, and dexmedetomidine as premedication for pediatric tonsillectomy: A comparative study (premedication in pediatric tonsillectomy study)
TL;DR
S-ketamine provides superior analgesia and reduces intraoperative opioid requirements without compromising sedation or anxiolysis, suggesting it may be a preferable option in this population of children undergoing tonsillectomy.
Abstract
Introduction: More than 50% of children experience significant preoperative anxiety, which adversely affects anesthetic management and postoperative behavior. Premedication in pediatric patients should facilitate parental separation, venous cannulation, and smooth induction, while minimizing respiratory depression, particularly relevant in children undergoing tonsillectomy for airway obstruction. Intranasal administration offers rapid absorption, predictable effects, and non-invasive delivery. The main goal of this study is to compare the efficacy and safety of intranasal midazolam, S-ketamine, and dexmedetomidine as premedication in children undergoing tonsillectomy under general anesthesia. Methods: In this prospective, randomized study, 90 children aged 1-7 years (ASA I-II) were allocated to three groups (n=30 each) receiving intranasal midazolam (0.2 mg/kg), S-ketamine (0.1 mg/kg), or dexmedetomidine (1 µg/kg), 30 minutes preoperatively. Sedation (Ramsay scale), separation anxiety, and mask acceptance (MAS scale) were assessed. Intraoperative hemodynamics and opioid consumption were recorded. Postoperative sedation (Ramsay), pain (FLACC/FACES scales), and postoperative excitation (PAED scale) were evaluated. Children with sleep apnea or drug allergies were excluded. Results: No significant differences were observed between groups in separation anxiety or mask acceptance. Intraoperative fentanyl consumption differed significantly, with lower requirements in the S-ketamine group. Significant intergroup differences were also found in systolic blood pressure and heart rate after induction. Postoperative pain scores were significantly lower in children receiving S-ketamine compared with midazolam and dexmedetomidine. Conclusion: Intranasal premedication is effective and safe in pediatric tonsillectomy. S-ketamine provides superior analgesia and reduces intraoperative opioid requirements without compromising sedation or anxiolysis, suggesting it may be a preferable option in this population.