To manage the behavior of the children with high levels of dental anxiety, the combination of inhalation sedation with intranasal midazolam can be efficiently used.
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.
Ivana Fajertag, Vlado Janković, Maja Sujica et al.· Serbian Journal of Anesthesi...· 0 citations
BACKGROUND
Dental anxiety presents a significant barrier to treatment. Conscious sedation is widely used to alleviate anxiety. Although remimazolam has demonstrated its efficacy and advantages for outpatient dental procedures, research on the effective dose of remimazolam combined with esketamine remains limited. Thus, the purpose of our research was to estimate the effective dose of remimazolam with esketamine for conscious sedation in patients with dental anxiety undergoing outpatient dental surgery.
METHODS
The study enrolled outpatients with dental anxiety aged 18-65 years who received dental operations and were classified under ASA grades I-II. Using the modified Dixon up-and-down method, each patient was first administered by infusing esketamine 0.1 mg/kg, followed by an assigned dose of remimazolam. The initial dose of remimazolam was 0.1 mg/kg, with a dose gradient of 0.01 mg/kg. Sedation success was defined as achieving a MOAA/S score of 3-4 within 5 min after the initial loading dose, without requiring additional remimazolam. The primary outcome was the ED50 of remimazolam and its 95% confidence interval (CI). Secondary outcomes included security indicators, patient satisfaction and memory of the procedure, dentist satisfaction, duration of treatment, and discharge time.
RESULTS
The study achieved 10 transition points (from sedation success to failure) with a total enrollment of 32 individuals. The ED50 and ED95 of remimazolam with 0.1 mg/kg esketamine, for conscious sedation during outpatient dental surgery, were 0.069 mg/kg (95% CI: 0.050-0.080 mg/kg) and 0.099 mg/kg (95% CI: 0.085-0.200 mg/kg), respectively. No circulatory and respiratory adverse events requiring intervention were observed during anesthesia induction.
CONCLUSIONS
For outpatient dental procedures in patients with dental anxiety, the ED50 and ED95 of remimazolam with esketamine for conscious sedation were 0.069 mg/kg and 0.099 mg/kg, respectively. The ED50 provides a preliminary reference for initial dose selection in this clinical setting. However, the wide confidence interval of the ED95 limits its clinical utility and requires validation in larger studies.
TRIAL REGISTRATION
This study was registered in the Chinese Clinical Trial Registry (ChiCTR2500104775; first registered on 23/06/2025).
Mengjiao Che, Cuiyao Kang, Cuiyun Zhou et al.· BMC Anesthesiology· 0 citations
BACKGROUND
Preoperative sedation in children is necessary as it is a common source of distress, potentially leading to difficult induction. Intranasal dexmedetomidine bypasses hepatic metabolism and has good availability. It is non invasive, easy with minimal respiratory depression. This study aimed to observe safety, efficacy, sedation level and parental separation score following a fixed dose of 1.5 mcg/kg Methods: A cross sectional study design was conducted among 43 children posted for elective surgeries. After informed consent and assent were obtained, intranasal DEX 1.5mcg/kg was administered. Satisfactory sedation was defined as a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of ? 3, and satisfactory parental separation as a score of ? 2 on a 4-point scale. Physiological parameters (HR, RR, SPO2 were monitored for 30 minutes. Statistical analysis involved the use of SAS version 9.4.
RESULTS
Satisfactory sedation ? 3 was achieved in 93.0% of subjects by 30 minutes (95% CI: 80.9%-98.5%). Similarly, satisfactory parent-child separation ? 2 score was achieved in 93.0% of subjects. Mean heart rate progressively decreased from 107.12±14.20 at baseline to 85.47 ± 7.29 beats per minute at 30 minutes, which was well tolerated.
CONCLUSIONS
Intranasal DEX at a dose of 1.5 mcg/kg is safe and effective premedication for paediatric patients, which results in successful sedation with tolerated changes in vitals.
Mona Sharma, Swagat Gongal, B. Yadav et al.· Journal of Nepal Health Rese...· 0 citations
Background: Preoperative anxiety in children undergoing surgery can complicate anesthetic induction and adversely affect perioperative outcomes. Intranasal administration of premedication is a non-invasive route that provides rapid drug absorption and good patient compliance. This study compared the efficacy of intranasal ketamine and intranasal dexmedetomidine as premedication in pediatric patients undergoing elective surgery. Methods: This double-blind randomized controlled trial was conducted at the Department of Anesthesia, Children's Hospital Lahore, from January 2026 to May 2026. A total of 134 children aged 2–6 years with American Society of Anesthesiologists (ASA) physical status I or II undergoing elective ENT surgery were randomly assigned to receive either intranasal ketamine (5 mg/kg; Group K, n = 67) or intranasal dexmedetomidine (1 μg/kg; Group D, n = 67). The primary outcome was effective mask acceptance, defined as a Mask Acceptance Score (MAS) ≤2 during anesthetic induction. Secondary outcomes included hemodynamic parameters, induction time, and adverse events, including coughing, sneezing, and postoperative nausea and vomiting (PONV). Results: Baseline demographic and clinical characteristics were comparable between the groups. Effective mask acceptance (MAS ≤2) was achieved in 85.1% of children receiving dexmedetomidine compared with 67.2% receiving ketamine (p < 0.05). Poor mask acceptance (MAS = 3) occurred more frequently in the ketamine group (32.8%) than in the dexmedetomidine group (14.9%). Heart rate, oxygen saturation, and induction time did not differ significantly between groups (p > 0.05). The incidence of postoperative nausea and vomiting was higher in the ketamine group (25.4%) than in the dexmedetomidine group (10.4%), although the difference was not statistically significant. Similarly, coughing and sneezing were more frequent with ketamine, but not statistically significant. Conclusion: Intranasal dexmedetomidine provided significantly better mask acceptance than intranasal ketamine while maintaining comparable hemodynamic stability and induction time. Although adverse events were numerically fewer with dexmedetomidine, these differences were not statistically significant. Intranasal dexmedetomidine appears to be the preferred premedication for facilitating smooth anesthetic induction in pediatric patients undergoing elective surgery.
Arifa Sultan, Saeedah Asaf· Aposta: Revista de Ciencias...· 0 citations
OBJECTIVES
To compare the clinical efficacy of oral montelukast versus intranasal fluticasone furoate in reducing the severity of sleep-disordered breathing (SDB) among children with adenotonsillar hypertrophy.
METHODS
A prospective randomized clinical trial was conducted between 9/2022 and 4/2023, including children aged 2-15 years with SDB and adenotonsillar hypertrophy. At baseline, all participants underwent symptom assessment using the Pediatric Sleep Questionnaire (PSQ), followed by physical examination. Subjects were randomized to receive either oral montelukast or intranasal fluticasone furoate for two months. Following treatment, the children were re-evaluated, and if no clinical improvement was observed, surgery was scheduled.
RESULTS
Sixty-seven children with a mean age of 5.25 years (45, 67% males) were included. The median PSQ score improved in the montelukast group from 0.45 to 0.28 (p = 0.003) and in the fluticasone furoate group from 0.43 to 0.36 (p = 0.006) with comparable efficacy (p = 0.292). The prevalence of moderate-to-severe sleep apnea decreased from 67% to 41% with montelukast (p = 0.035) and from 81% to 60% with fluticasone furoate (p = 0.016). While both medications significantly reduced adenoid size (p < 0.001 and p < 0.001, respectively), only montelukast significantly reduced tonsillar size (p = 0.008).
CONCLUSIONS
Both montelukast and fluticasone furoate reduced the pediatric SDB severity. While both medications significantly decreased adenoid size, only montelukast significantly decreased tonsillar size. Therefore, fluticasone furoate may be appropriate for adenoid hypertrophy, while montelukast is favored for concurrent tonsillar hypertrophy. These treatments may serve as alternatives to surgery in selected cases. Further studies are needed to evaluate their long-term efficacy.
S. Rothman, Ronly Har-Even, Ofer Israel et al.· International Journal of Ped...· 0 citations
This study evaluated the efficacy and safety of a sedation protocol through the nares combining dexmedetomidine with midazolam and butorphanol in cockatiels. Six adults were enrolled in a randomized, 4 treatment, 4 period crossover trial comparing a control regimen (midazolam 3 mg/kg and butorphanol 3 mg/kg) with three combinations including dexmedetomidine at 0.04, 0.06, or 0.08 mg/kg, administered through the nares. The volume of all treatments was standardized to the volume of the highest dose of dexmedetomidine administered (2 mL/kg) with sterile saline solution. Sedation scores, respiratory rate, heart rate, and cloacal temperature were recorded for 10 min after drug administration and during 15 min of manual restraint, followed by flumazenil and atipamezole via the nares for reversal. All birds completed all treatments; mild sneezing occurred but no clinically relevant respiratory complications were observed. Medium and high dose dexmedetomidine produced higher sedation scores and lower respiratory rate, heart rate, and body temperature during restraint than the control regimen, whereas the control group showed increased respiratory rate, suggesting insufficient suppression of restraint induced stress. In all groups, sedation and physiological variables returned to near baseline values within 15 min after reversal, and no serious adverse events occurred. These findings indicate that administration through the nares dexmedetomidine at 0.06 or 0.08 mg/kg combined with midazolam and butorphanol provides deeper, more stable, and reversible sedation and improved control of stress responses in cockatiels and may represent a clinically useful protocol in this species.
Sakura Isayama, Mizuki Tanahashi, Seiko Doi et al.· Journal of Veterinary Medica...· 0 citations