Presentation on theme: "Dexmedetomidine as a Pediatric Anesthetic Premedication to Reduce Anxiety and to Deter Emergence Delirium Renee Vicari RN, BSN, CCRN, SRNA Oakland University/Beaumont."— Presentation transcript:
1Dexmedetomidine as a Pediatric Anesthetic Premedication to Reduce Anxiety and to Deter Emergence DeliriumRenee Vicari RN, BSN, CCRN, SRNAOakland University/Beaumont HospitalGraduate Program of Nurse Anesthesia
2Mountain, BW. , Smithson, L. , Cramolini, M. , Wyatt, TH. , Newman, M 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),
3IntroductionPublished in the June issue of American Association of Nurse Anesthetists (AANA) Journal.Study was approved by both an affiliated university and the hospital institutional review board.
4Key Terms!Emergence Delirium (ED)- is a mental disturbance common in children during recovery from general anesthesia.Symptoms:Combative movementsThrashing, excitabilityDisorientationInconsolable cryingStudies also report that the incidence of ED in children ranges from 20-30%.Why is this important to us as anesthesia providers? During ED, children risk injuring themselves by dislodging IV tubes or drains, bleeding from OR site, hurting themselves or others and increasing their pain level.
5Purpose 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.
6Review 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 anxietyTemper tantrums
7Review 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 useDexmedeteomidine shows promise as a medication to reduce anxiety and potentially reduce the occurrence or severity of ED.
8Hypothesis 2 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.
9Study Randomized Prospective Double-blinded design Children were recruited to participate in this study by receiving a packet of information once their dental restoration surgical procedures were scheduled.Families who received the information were contact by phone to determine their interest in the study and to help answer any questions regarding the study.
10Inclusion Criteria Included 41 children Aged 1 to 6 years old Undergoing dental restorations and possible tooth extraction.
11Exclusion Criteria Known allergies to midazolam and or dexmedetomidine Developmental delay or mental retardation-as reported by the parentsHistory of EDASA classification greater than IIAny previous reactions to anesthesia
12Methods Obtained 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 dexmedetomidineStaff and members of research team blinded to assignments and medication administered.
13Methods Both medications were prepared in similar syringes Prepared with cherry-flavored syrup
14Dexmedetomidine (Precedex) Non-selective alpha-2 adrenergic agonistSedative and opioid sparing effectsExpensive-$495.79IV infusion mcg/kg/hrMinimal respiratory depressionAdverse effects:N/VBradycardiaHypotensionFeverIn the heart, alpha agonists decrease tachycardia through the block of the cardioaccelerator nerve and produce bradycardia through the vagomimetic action. In the peripheral vasculature, there are both vasoldilatory action through sympatholysis and vasoconstriction by direct action on the alpha adrenceptors on smooth muscle cells.
15Midazolam (Versed) Benzodiazepine Amnestic and anxiolytic properties 0.5mg-1.0mg/kg PO in childrenAdverse effects:HeadacheDrowsinessConfusionN/VBlood pressure changes
16Instruments 3 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 parentsPSAS of 1-2 acceptablePSAS of 3-4 were difficult separations
17InstrumentsMask Acceptance Scale (MAS)-ability to accept the anesthesia maskMAS scale is a 4-point Likert scale1=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 satisfactoryScore of 3-4 was unsatisfactory
18Instruments Pediatric Anesthesia Emergence Delirium Scale (PAEDS) Based on 5 criteria:Makes eye contact with caregiverActions are purposefulAware of his or her surroundingsRestlessInconsolableOut of 20 points, a score greater than 10 indicates ED.All research members were trained on data collection and how to score each tool to ensure interrater reliability of rating scales.
19Data AnalysisPearson X2 analysis was performed to determine differences between both groups for anxietyIndependent 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
20Procedures Study medication administered 30 minutes prior to OR Pulse oximetry and blood pressure monitored every 15 minutesResearch team member accompanied child to surgery and the PSAS was scored at this time-30 minutes after child received medicationIn OR with nurse anesthetist, team member calculated the MAS score
21Procedures Study anesthesia protocol: Mask induction with sevoflurane and nitrous oxideIsoflurane used for maintenanceSpontaneous ventilation was maintained if possibleMuscle relaxants were avoided, if possible, if ventilatory support needed.Anticholinergic drugs were avoidedOdansetron (0.2mg/kg) and dexamethsone (0.25mg/kg) were administeredFentanyl for analgesia (1 to 2 mcg/kg)Local anesthestic per surgeon
22Procedures Taken to PACU after surgery Observed for 1 hour PAEDS score was determined once child aroused or peak of ED
23Results 41 subjects recruited between May 2006 and June 2007 21 (51%) males20 (49%) femalesMean age 4 years old27 (65%) white9 (22%) African American5 (12%) Hispanic
24ResultsNo 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)
26Results Out of 41 subjects 8 children (20%) experienced ED3 of the 8 were in the experiemental (dexmedetomidine) group5 were in the control (Midazolam) groupNo significant difference between the 2 groups (t=1.023, P=0.313)
27DiscussionStudy was able to demonstrate that 4mcg/kg PO of dexmedetomidine resulted in no adverse effectsNo difference between the midazolam and dexmedetomidine groups in blood pressure or oxygenation stability
28Strengths Double-blinded study All subjects remained in study Equal number of males and femalesDetailed and precise anesthesia protocol while child is anesthetizedSpecific surgery-all subjects underwent same surgery
29Limitations Limited 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 buccalBioavailability is 16% (oral) compared to 82% (buccal)
30Conclusion Not FDA approved for children….yet More studies needed to examine child-friendly dexmedetomidine preparations and its effect on ED