The Board of Directors has developed a consensus document related to the core competencies for providers of deep sedation. This document is now published on our website and will hopefully assist our members in working with their own institutions related to education and credentialing of sedation providers. These recommendations were made and unanimously agreed upon by the Board of SPS. Comments and suggestions are welcome.
Comforting and reassuring children during painful procedures is a natural instinct for many people. But what we think should be comforting is not always as it seems. I would like to thank these authors for embracing the task of understanding why “comforting” statements may not comfort children, but often results in increased fear and distress.
This article (published in the July 2010 issue of Pain) is the first step to understanding what is it about our language that is comforting and what increases fear and anxiety. It examines not only the word choice, but also intonation and facial expression of the individual speaking. While most of the tests showed only small effect size, it provides us with the initial clues as to how to better construct phrases and to be more aware of tone of voice.
While most of the outcomes of this study may seem very logical to those who frequently work with children, it is reassuring to have some evidence to support those beliefs. For example, one would assume that distraction would be interpreted as less fearful than reassurance. It is interesting that neither non-informative reassurance nor informative reassurance would be interpreted by children as less fearful. It also seems logical that children in this age range would be able to interpret happy facial expressions that could outweigh their interpretation of what was being said or the associated intonation changes. However, it was very interesting to note that when children were interpreting fearful facial expressions, children tended to rely on the vocal cues more to understand the information being present. While few of the results showed a large impact it continues to encourage us to think about what is being said and how it is said.
While I find this article fascinating and look forward to learning more about how to optimize interactions with children during painful procedures I question how often children in a painful situation are actually looking at the parent when they are “comforting” them. Many “comfort” positions we employ for children in the 5-10 year old age range are either being hugged by the parent, with the face of the child either turned to the side or gently snuggled to the chest, or sitting on the parent’s lap facing away from the parent. While it is clear from this study that facial expression provides more reliable information to the child than content of speech or intonation the opportunity for visualizing parents during painful procedures seems quite limited. Perhaps that question will be answered in future research.
Peggy Riley, RN, MN, MPH
Dexmedetomidine is a potent α-2 agonist with sedative and analgesic properties. Dexmedetomidine exhibits α-2:α-1 specificity that is eight times greater than clonidine. Its’ sedative and anxiolytic properties are a result of its α-2 receptor specificity in the spinal cord and central nervous system. Dexmedetomidine has a much shorter half life than clonidine (2-3 hours vs. 12-24 hours). This pharmacokinetic profile can facilitate brief periods of deep sedation often needed for imaging procedures in pediatric sedation.
Use in MRI
Evidence supports the use of dexmedetomidine for sedation in mechanically ventilated adult patients. There has been increasing interest in the clinical application of dexmedetomidine in the pediatric population. High dose dexmedetomidine (3mcg/kg IV load over 10 minutes with an infusion of 1 mcg/kg/hour) has been used successfully for sedation of children undergoing sedation for MRI. Using this dose, Mason et al noted bradycardia and a 20% drop in blood pressure with minimal change in respiratory parameters.
Buccal and Intranasal
Antilla et al documented the high bioavailability(73%-92%) when dexmedetomidine was given via the buccal route. Onset occurred in 10-15 minutes with a peak effect at 90 minutes. Yuen et al demonstrated the efficacy of intranasal dexmedetomidine when used in a dose of 2mcg/kg as a premedication. Others have found dexmedetomidine, when used in a dose of 2 mcg/kg intranasal, to be an equivalent premedication to 0.5 mg/kg of po midazolam.
On the basis of this information, we have used intranasal dexmedetomidine as a premedication in a number of patients. Since this drug has a neutral pH it is virtually painless when given intranasally. In addition, the use of the nasal MAD (mucosal atomization device) has allowed quick and even administration of the drug.
We reported the case of an uncooperative 10 year old autistic child that was scheduled for MRI under general anesthesia in which we gave a dose of dexmedetomidine (4 mcg/kg IN) as a premed to assist in further care. Given this dose, this child calmed and fell asleep in the stretcher within 20 minutes. Minimal change in heart rate and blood pressure were noted. The child in fact slept through the duration of the scan without additional medication or anesthesia. He was recovered in the PACU for an hour and was discharged.
Since then, we have used the dose of 4 mcg/kg IN for short scans (CT) with success. We have also used this for ABR’s and repeated half the dose IN if the patient aroused during the study. It should be noted that for intranasal administration we use the undiluted product which is 100 mcg/ml. This allows for administration of a small volume which is dispensed quickly.
All of this is anecdotal and should be studied further. However, it is my belief that IN dexmedetomidine given alone or in combination with another drug such as ketamine may have broad application for sedation in children. I suspect that this type of sedation would work well for dental procedures, EEG, EMG, PICC line placement, and imaging such as VCUG.
Joyce Phillips, MD, FAAP
Department of Anesthesiology
University of New Mexico
Do you have experience with IN Dex?
For those who are already using IN Dex, please take a moment to make a brief comment below about your experience.
How do I use the MAD device?
Below is a link to a video that describes the use or the MAD.
Other Useful Articles