sedation in pediatric patients

1. R 2 . M O H A M M A D
A Comparative Assessment of Intranasal and Oral
Dexmedetomidine for Procedural Sedation in
Pediatric Dental Patients

2. Introduction
• Fear and pain are the most powerful influences affecting attitude
toward use of dental services.
• Management of anxiety and unwanted mobility in children during
dental treatment has markedly reduced after the introduction of
procedural sedation and analgesia (PSA).
• A variety of drugs and various routes of administration (oral,
transmucosal, rectal. etc.) each of them having their own pros and cons.

3. Introduction
 Oral Route
• The Most preferred route of drug administration as it is safe,
convenient, cost-effective, universally acceptable, easy to administer,
needleless, and with no requirement of specialized training.
 Disadvantages have also been reported for this route such as bad
taste, gastric irritation, and varied bioavailability due to well-known
factors .
 To overcome these disadvantages, intranasal route has been considered
as an effective alternative.

4. Introduction
Intranasal Route
• It is relatively easy, noninvasive, has rapid onset of action due to rich
blood supply of nasal mucosa and bypassing of first-pass hepatic
metabolism.
• Many studies have reported that intranasal route is an effective route
to administer premedication and sedation to pediatric patients.
 Dexmedetomidine
 Newer drug, approved by the Food and Drug Administration in 1999,
to be used in humans for short-term sedation in the ICU.
 It is a highly selective α2-agonist which has both sedatives as well as
analgesic properties and is devoid of respiratory depressant effect.

5. AIM
 This study was aimed to evaluate and compare the
safety and efficacy of dexmedetomidine
administered through oral and intranasal route for
procedural sedation in pediatric dental patients.

6. Materials and Methods
 Forty-four systemically healthy children (ASA Type I) aged between 4
and 9 years
 patients were randomly divided into four groups on the basis of route
and dose to be used for drug administration i.e. Dexmedetomidine .
 Two groups for intranasal administration of dexmedetomidine
• Group 1 – 2 μg/kg of body weight.
• Group 2 – 2.5 μg/kg of body weight.
• Two groups for oral administration of dexmedetomidine.
• Group 3 – 4 μg/kg of body weight .
• Group 4 – 5 μg/kg of body weight .

7. Materials and Methods
 During the administration of drug, the children were evaluated for
behavior response, and after the administration of drug, they were
evaluated for onset of sedation, depth of sedation, ease of completion of
treatment, recovery from sedation, and any incidence of adverse effects
 For Intranasal Route, half volume of the total required drug
administered into each nostril with the child in semi-recumbent or in
parent’s lap using an insulin injection syringe without needle.
 For Oral Administration, the drug was mixed with a sweetened mango
drink. All the dental procedures were carried out by single operator in
the presence of an anesthesiologist.

8. Materials and Methods

9. Materials and Methods
 The sedation session (treatment outcome) was considered safe and
“successful” if:
(1) Response to treatment score of “2”or “3” (satisfactory) and sedation
score of “3” or “4” (adequate sedation)
(2) Physiological parameters remained within 20% of baselines values.
(3) Oxygen saturations remained at 90% or greater.
(4) Physical restraints were not required during the dental procedure.
(5) No major side effects were observed during and after sedation.

10. Results

11. Results

12. Results

13. DISCUSSION
 Intanasal rout has gained popularity and pace in the past few years due
to several significant advantages. This route has been used primarily as
a means of circumventing the need for injection or bitter tasting oral
drugs in children.
 The nasal mucosa has a rich vascular supply, therefore, immediate
absorption of drug takes place directly in the systemic circulation .
Another reason for faster onset can be due to rapid achievement of
adequate levels in cerebrospinal fluid.
 The results of this study showed intranasal dexmedetomidine to be a
safe and effective agent for procedural sedation in pediatric dental
patients with good patient compliance.

14. Conclusion
 It was procedurally highlighted during our study that ,
dexmedetomidine acts like an almost ideal sedative for procedural
sedation.
 All parameters and the higher dose of intranasal dexmedetomidine was
found to be more potent for induction of procedural sedation.
 Oral dexmedetomidine with both doses (4 and 5 μg/kg ) could not
produce an adequate depth of sedation as compared to the nasal route,

15. A Comparison of the Effectiveness of Oral Midazolam –N2O Versus Oral
Ketamine – N2O in Pediatric Patients-An in–Vivo Study
 INTRODUCTION
 Immature children, fearful and anxious children, medically and physically
disabled children are commonly indicated for conscious sedation technique .
 Behavioral management alone is unfortunately not sufficient.
 Conscious sedation is widely used in dentistry to help anxious patients undergo
dental treatment with minimal stress.

16. INRODUCTION
 Oral rout is the commonly used route.
 The perfect premedication in children ought to be adequate, fast, and reliable
in onset, have negligible symptoms, quick end, and an a traumatic course of
administration .
 The premedicaments utilized for this study were oral Midazolam and Ketamine
0.5mg/kg and 5mg/kg respectively.
 Conscious sedation with combination methods increases the adequacy and
wellbeing. So N2O-O2 can be joined with other routes and agents.

17. INTRODUCTION
• MIDAZOLAM
o Midazolam can be given in the dose of 0.5-0.75mg/kg orally
o it has fast onset of activity, absence of significant side effects, powerful in
directing patient conduct.
• ketamine
o It is a very much recorded anesthetic and analgesic with a wide margin of
safety and keeps up defensive reflexes .

18. Aim
 The aim of the study was to evaluate and compare the effectiveness of
oral Midazolam – N2O and oral Ketamine – N2O by considering
various psychological parameters of the child.

19. Material And Methods
 Thirty cooperative but apprehensive children ,3-9 years ,normal range
of weight categorized ASA I and II.
 With multiple primary carious teeth indicated for extraction.
 in combination with N2O-O2, patients received oral Midazolam
0.5mg/kg with N2O-O2 inhalation in the first appointment and oral
ketamine 5mg/kg with N2O-O2 inhalation in the follow up
appointment.
 Full verbal and written explanation of the procedure was provided to
parents regarding the sedation

20. Material And Methods
 Palatable syrup was made by adding sorbitol 45 g, sucrose 15 g,
saccharine 0.2 g, sodium benzoate 0.15 g, citrus extract 2 g, and
distilled water to convey it to 100 ml.
 A 10 ml of diluent was titrated to 10 ml of IV drug to achieve a final
dose of 0.5mg of Midazolam per ml and 90 ml of diluent is titrated to
10 ml of IV drug to achieve a final dose of 5mg of ketamine per ml for
oral use.

21. Material And Methods

22. Material And Methods
 The scheduled drug oral midazolam in the form of syrup was administered to
the patient and the onset of sedation was monitored using ( Houpt’s Sedation
Rating scale).
 First, 100% Oxygen was delivered for 3 minutes at an appropriate flow rate.
 Nitrous oxide was gradually introduced by slowly increasing the concentration
at increments of 10% in oxygen to a final dose of 30% in oxygen.
 Local anesthesia (2% lidocaine with epinephrine 1:100,000) was given.
 The same protocol at first visit was followed but oral ketamine in addition with
nitrous oxide and oxygen was used instead of oral midazolam in addition with
nitrous oxide and oxygen.

23. Results

24. Results

25. Discussion
 Sedation is commonly indicated for fearful and physical or mentally
handicapped children .
 Oral premedication was decided for this study as this is more suitable,
most safe and easiest method of medication administration.
 Advantages of oral drug administration are that they are more acceptable,
safe, have minimal side effects, minimal equipment and no specialized
training.
 Midazolam is administered in the oral measurements of 0.5-0.75 mg/kg
and 3-10 mg/kg of ketamine administered orally, has a high margin of
safety as the defensive reflexes are normally kept up .
 Oral midazolam at the dose of 0.5mg/kg has shown to produce good
anxiolysis when used as premedication . And reported rare side effects

26. Discussion
 Oral ketamine at 5mg/kg provides safe, successful, high-quality
sedation for young children undergoing dental extractions under local
anesthesia .
 The addition of nitrous oxide (30% and above) to a combination of
sedative agents results in the reduced need for higher doses of the other
agent.
 Respiratory rate was increased after ketamine sedation than midazolam
and pulse rate marginally increased after midazolam sedation than
with ketamine.
 However comparing midazolam and ketamine with respect to pulse and
respiratory rates, there was statistically no significant difference
between the two drugs.

27. Discussion
 Comparison of the psychomotor effects between the two groups oral
midazolam - N2O group performed marginally better than oral
ketamine –N2O.
 Oral midazolam at a dose of 0.5 mg/kg produces minimal side effects
and successful premedicament and on the other hand, 5mg/kg oral
ketamine provides high margin of safety as the protective reflexes are
usually maintained .

28. Conclusion
 Oral midazolam – N2O and oral ketamine N2O as sedative regimens
were found to be safe and effective and their use greatly reduced the
patient anxiety during the therapeutic procedure.
 Overall the findings in the present study suggested that no significant
difference was observed pertaining to pulse rate, oxygen saturation,
respiratory rate, psychological effects, objective signs and subjective
symptoms.
 Psychomotor effect of the midazolam group appeared marginally better
than ketamine group.

29. Thank you