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One of the most widely used options for minimal/moderate sedation in pediatric patients is oral midazolam, as it presents an alternative to less well‐accepted routes of administration (eg, intravenous or intranasal) of this well‐known efficacious and well‐tolerated short‐acting benzodiazepine. A systematic review of the literature was conducted in order to identify clinical studies evaluating the effectiveness of oral midazolam for sedation in pediatric patients in the context of premedication before anesthesia or during diagnostic/treatment procedures. The percentage of responders (response rate) after single administration of oral midazolam was evaluated and compared versus placebo in a subset of placebo‐controlled studies. The range of oral midazolam doses providing effective sedation in the different pediatric age subsets was analyzed in order to assess optimum dosing strategies. A total of 25 pediatric clinical studies, utilizing a variety of measures of sedation effectiveness, were selected. These studies included a total of 1472 patients (aged 4 months‐18 years) treated with midazolam (0.25‐1.5 mg/kg) and 138 patients treated with placebo. The response rates [95% confidence interval] with oral midazolam ranged from 36.7% [21.6%, 54.9%] to 97.8% [86.1%, 99.7%], while with placebo response rates ranged from 4.0% [0.6%, 23.5%] to 41.0% [29.4%, 53.6%]. When considering the 4 placebo‐controlled studies, the odds ratios [95% confidence interval] for the comparison of midazolam vs. placebo ranged from 13.4 [5.0, 36.0] to 25.9 [6.7, 100.6]. The analysis of subgroups by context of sedation showed response rates [95% confidence interval] with oral midazolam ranging from 36.7% [21.6%, 54.9%] to 97.0% [94.8%, 98.3%] for anesthetic premedication and from 56.1% [43.1%, 68.4] to 97.8% [86.1%, 99.7%] for medical procedures. The efficacy of midazolam for pediatric minimal/moderate sedation from a dose of 0.25 mg/kg and above was demonstrated. The probability of occurrence of adverse events and over‐sedation increases with increasing doses.

Background Sedatives are essential drugs in every intensive care unit in order to ensure the patient's optimal level of comfort. Avoiding conditions of over- and under-sedation is a challenge in a neonatal intensive care setting. Drug administration could be optimized by the concomitant use of objective methods to assess the level of sedation. Aims We aimed to look at the ability of different methods (Neonatal Pain, Agitation and Sedation Scale, amplitude-integrated Electroencephalogram, and Bispectral Index), and their combination, in detecting different level of sedation. Methods Twenty-seven neonates among whom 17 were receiving sedatives with or without opiate analgesics were monitored using the Neonatal Pain, Agitation and Sedation Scale, the amplitude-integrated Electroencephalogram, and the Bispectral Index. According to the expert opinion of two trained neonatologists, patients were categorized into three groups: no, light, and deep sedation. Four hours of simultaneous assessment of the Neonatal Pain, Agitation and Sedation Scale scores, Burdjalov scores (to summarize the amplitude-integrated Electroencephalogram trace), and Bispectral Index values were considered for the comparative analysis across these groups. Results All three methods could differentiate patients who were not sedated from those who were deeply sedated: median score 12 and 9, respectively, (95% CI of difference = 1.99-5.99, P = 0.001) for the amplitude-integrated Electroencephalogram Burdjalov score; median 1 and -5, respectively, (95% CI of difference = 2.99-8.00, P = 0.001) for the Neonatal Pain, Agitation and Sedation Scale; and median 48 and 37, respectively, (CI of difference = 1.77-22.00, P = 0.043) for the Bispectral Index. However none of them, used alone, was able to differentiate light and deep sedation: median score 10 and 9, respectively, for the amplitude-integrated Electroencephalogram Burdjalov score; median -2 and -5, respectively, for the Neonatal Pain, Agitation and Sedation Scale; and median 48 and 37, respectively, for the Bispectral Index. Only the amplitude-integrated Electroencephalogram and the Neonatal Pain, Agitation and Sedation Scale were able to differentiate between the conditions of no sedation and light sedation. Also, according to the area under the curves values, the combination of the Neonatal Pain, Agitation and Sedation Scale with the Burdjalov score derived from the amplitude-integrated Electroencephalogram showed the best accuracy in differentiating light and deep sedation. Conclusion While none of the three methods alone was able to precisely differentiate between different levels of sedation, we suggest that using a combination of amplitude-integrated Electroencephalogram and Neonatal Pain, Agitation and Sedation Scale can be useful to distinguish between light and deep sedation in neonatal patients.

SummaryBackground Hydrostatic or pneumatic reduction of intussusception is an invasive procedure that is stressful and may be painful for a child. Resistance of the child may increase the duration of the procedure and decrease success rate of reduction. Analgesia can help to reduce pain, but not necessarily resistance. General anesthesia increases success rate of reduction. However, it requires the presence of an anesthesiologist, and may lead to anesthesia-related complications. Procedural sedation with esketamine could be a safe alternative. Aim The aim of this study was to compare hydrostatic reduction using morphine analgesia compared to procedural sedation with esketamine in terms of success rate, adverse events, and duration of reduction. Methods A retrospective case-cohort comparison study was performed with two groups of patients who had undergone hydrostatic reduction for ileocolic intussusception and received morphine analgesia (n = 37) or esketamine sedation (n = 20). Until July 2013, reduction was performed after intravenously administered morphine. Hereafter, a new protocol for procedural sedation was implemented and reduction was performed after administration of esketamine. Cases were matched for age and duration of symptoms. Results No adverse events requiring intervention other than administration of oxygen were reported for either group. Success rate of reduction using esketamine sedation was 90% vs 70% using morphine analgesia, risk ratio (RR) 1.29, 95% CI[0.93-1.77]. Recurrence rate using esketamine sedation was 10% vs 15% using morphine analgesia, RR 0.67, 95% CI[0.12-3.57]. Reduction time was shorter using esketamine sedation (Median 5 minutes, IQR 9 minutes) vs morphine analgesia (Median 8 minutes, IQR 16 minutes, P = .04, Median difference 3, 95% CI[−1.50-8.75]). Median hospital stay in the esketamine group was 1.5 days (IQR 1.8) vs 2 days (IQR 5.3) in the morphine group. Conclusion No serious adverse events were recorded. In comparison to morphine analgesia, with esketamine there was weak evidence for a higher success rate, lower recurrence rate, shorter duration, and shorter length of hospital stay.

SummaryBackground Perioperative care for children with autism spectrum disorder may be challenging. Previous investigators recommend development of an individualized perioperative management plan with caregiver involvement. Aim The primary goal was to determine the usefulness of an individualized plan based on the decision to provide preoperative sedation stratified by autism spectrum severity level. Secondary goals were to assess the effectiveness of the plan based on subjective assessment of patient behavior at induction of anesthesia and caregiver satisfaction. Methods We developed an individualized plan for each child with autism spectrum disorder scheduled for anesthesia. Children were categorized by autism spectrum disorder severity level. With institutional ethics approval, we conducted a retrospective chart review to document need for preoperative sedation, sedation stratified by autism spectrum disorder severity level, behavior at induction, and caregiver satisfaction. Results Between 2012 and 2014, we successfully prepared a plan for 246 (98%) of 251 surgical or diagnostic procedures in 224 patients. Severity level was distributed as 45% Severity Level 1 and Asperger's, 25% Severity Level 2, and 30% Severity Level 3. The majority (90%) of cases were scheduled as day surgery. Preoperative sedation increased with increasing severity level: Severity Level 1 (21%) or Asperger's (31%), Severity Level 2 (44%), and Severity Level 3 (56%). The odds ratio for sedation use was 5.5 [CI: 2.6-11.5, P

SummaryBackground Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. Aim The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. Method All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. Results An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. Conclusion The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers.

SummaryBackground and aim Pediatric ophthalmic examinations can be conducted under sedation either by chloral hydrate or by dexmedetomidine. The objective was to compare the success rates and quality of ophthalmic examination of children sedated by intranasal dexmedetomidine vs oral chloral hydrate. Methods One hundred and forty-one children aged from 3 to 36 months (5–15 kg) scheduled to ophthalmic examinations were randomly sedated by either intranasal dexmedetomidine (2 μg·kg−1, n = 71) or oral chloral hydrate (80 mg·kg−1, n = 70). The primary endpoint was successful sedation to complete the examinations including slit-lamp photography, tonometry, anterior segment analysis, and refractive error inspection. The secondary endpoints included quality of eye position, intraocular pressure, onset time, duration of examination, recovery time, discharge time, any side effects during examination, and within 48 h after discharge. Results Sixty-one children were sedated by dexmedetomidine with a success rate of 85.9%, which is significantly higher than that by chloral hydrate (64.3%) [OR 3.39, 95% CI: 1.48–7.76, P = 0.003]. Furthermore, children in the dexmedetomidine group displayed better eye position in anterior segment analysis than in chloral hydrate group median difference. All children displayed stable hemodynamics and none suffered hypoxemia in both groups. Oral chloral hydrate induced higher percentages of vomiting and altered bowel habit after discharge than dexmedetomidine. Conclusions Intranasal dexmedetomidine provides more successful sedation and better quality of ophthalmic examinations than oral chloral hydrate for small children.

SummaryBackground Many children with Trisomy 21 have neurologic or behavioral problems that make it difficult for them to remain still during noninvasive imaging studies, such as transthoracic echocardiograms (TTEcho). Recently, intranasal dexmedetomidine sedation has been introduced for this purpose. However, dexmedetomidine has been associated with bradycardia. Children with Trisomy 21 have been reported to have a higher risk of bradycardia and airway obstruction with sedation or anesthesia compared to children without Trisomy 21. Objective Our aim was to quantify the incidence of age-defined bradycardia and other adverse effects in patients with Trisomy 21 under sedation for TTEcho using a variety of sedation and anesthesia techniques available and utilized at our institution in this challenging patient population, including intranasal dexmedetomidine, oral pentobarbital, general anesthesia with propofol, and general anesthesia with sevoflurane. Our primary hypothesis was that intranasal dexmedetomidine sedation would result in a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens. Methods This is a retrospective, observational study of 147 consecutive patients with Trisomy 21 who were sedated or anesthetized for transthoracic echocardiography. Efficacy of sedation was defined as no need for rescue sedation or conversion to an alternate technique. Lowest and highest heart rate, systolic blood pressure, oxygen saturation, and PR interval from formal electrocardiograms were extracted from the electronic medical record. These data were compared to age-defined normal values to determine adverse events. Results Four methods of sedation or anesthesia were utilized to perform sedated transthoracic echocardiography: general anesthesia with sevoflurane by mask, general anesthesia with sevoflurane induction followed by intravenous propofol maintenance, oral pentobarbital, and intranasal dexmedetomidine. Intranasal dexmedetomidine 2.5 mcg·kg−1 was an effective sedative as a single dose for TTEcho in 37 of 41 (90%) cases. Oral pentobarbital 5 mg·kg−1 as a single dose for young children with Trisomy 21 was effective in 55 of 75 (73%) cases. Intranasal dexmedetomidine sedation was not associated with a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens, when compared to oral pentobarbital for patients under 2 years of age and general anesthesia for children 3 years and older. The two general anesthesia groups showed lowest heart rates of 66.9 ± 15.9 min−1 for sevoflurane and 69.0 ± 11.5 min−1 for sevoflurane–propofol. Hypotension was present in all groups ranging between an incidence of 56% in the sevoflurane group to 11% in the oral pentobarbital group. Oxygen saturation and clinically significant desaturation occurred in 14% of the oral pentobarbital group. Conclusion Intranasal dexmedetomidine sedation was not associated with a significantly higher risk of bradycardia in patients with Trisomy 21, compared with other sedative or anesthetic regimens.

SummaryBackground Patients with mucopolysaccharidoses (MPS) are generally considered high risk for anesthesia care, owing to disease-related factors. Sanfilippo syndrome type A (MPS IIIA) is the most frequently occurring MPS. Anesthesia-specific information for MPS IIIA is not readily available in the literature. Objectives To report post hoc analyses on anesthesia care and outcomes from a 2-year study of the natural history of patients with untreated MPS IIIA (NCT01047306). Methods Subjects were ≥1 year of age, developmental age ≥1 year, and without significant central nervous system impairment (other than that due to MPS IIIA) or issues that would preclude study procedures. Procedures requiring general anesthesia included brain/abdominal magnetic resonance imaging, lumbar puncture, and echocardiography. Sedation, intubation, and extubation procedures as well as postoperative airway problems were recorded at baseline and 6, 12, and 24 months of age. Results Twenty-five patients (baseline age, 13–220 months) received a total of 94 general anesthetics. Patients successfully received oral sedation prior to 76 of 94 anesthetics. No patients required airway intervention or oxygen supplementation during sedation. All anesthesia providers described facemask ventilation and endotracheal intubations as ‘easy’. All subjects were successfully extubated after completion of the procedures. No patients required reintubation. Six (24%) patients had episodes of postoperative airway problems: wheezing (7/94, 7.4%), croup (6/94, 6.4%), and laryngospasm (2/94, 2.1%). Conclusion We found no change in the modified Cormack–Lehane intubation grades in 25 Sanfilippo syndrome type A children over the 2-year study period.

Summary Introduction The goal of this study was to identify the etiology of events and demographics of patients that experience complications requiring activation of the Rapid Response Team (RRT) during the first 24 h following anesthetic care. Methods We performed a retrospective review of the Quality Improvement database from the Department of Anesthesiology & Pain Medicine at Nationwide Children's Hospital. The database was searched to identify those patients who had a RRT evaluation activated within 24 h of receiving anesthesia or procedural sedation. These patients' charts were reviewed to obtain demographic information, etiology of the RRT call, and outcomes. Results The study cohort included 106 RRT calls that were made over a 3-year period. Six patients were excluded from analysis due to incomplete datasets. One hundred patients remained for analysis including 60 males and 40 females. Patients ranged in age from 0.08 to 31.21 years (7.8 ± 7.7 years, median 5.3 years). Seventy-one patients were American Society of Anesthesiologists' (ASA) status 3 or 4 and 29 patients were ASA status 1 or 2. Five calls were made for patients who had undergone procedural sedation while the other 95 were on patients who received general anesthesia. The average time to the RRT call after the end of anesthetic care was 11.4 ± 6.6 h. Respiratory concern was the most common reason for RRT initiation, accounting for 71 of the 100 calls. Forty-nine patients had a recent respiratory illness, chronic respiratory-related disease, or history of preterm birth. Fifty patients (50%) were transferred to a higher level of care following the RRT consult. There was no significant difference between age, gender, ASA status, or etiology of the event for patients transferred vs those who were not. A significant difference was noted in the Pediatric Early Warning Score of patients transferred to a higher level of care in comparison to patients who remained on the floor (4 ± 2 vs 3 ± 2, P = 0.0097). Conclusion RRT calls were most common for respiratory concerns. High ASA status, general anesthesia administration, and the presence of acute or chronic conditions prior to anesthetic administration predispose a patient to perioperative complications resulting in the need for an RRT call.

The career of Dr Charles J. Coté covered a period of major advances in pediatric anesthesia patient safety. Dr Coté (1946 --), Professor Emeritus in Anaesthesia at Harvard Medical School, helped develop pediatric sedation guidelines, conducted influential clinical research, edited a major textbook, and promoted pediatric anesthesia training fellowships in low- and middle-income countries. Based on a series of interviews with Dr Coté, this article reviews the career of this Robert M. Smith Award winner through the lens of improvements in pediatric sedation and anesthesia patient safety., (© 2020 John Wiley & Sons Ltd.)

Summary Introduction Propofol and midazolam are widely used for pediatric magnetic resonance imaging (MRI) sedation. Increasing depth of sedation may be associated with airway obstruction. A neck collar supporting the mandible and maintaining the head in slight extension may be beneficial in maintaining airway patency. Aim of the study Primary aim: To assess upper airway size with and without a neck collar during pediatric MRI sedation with propofol–midazolam. Secondary aim: To evaluate complications encountered during the procedure. Materials and Methods Sixty patients aged 2–4 years scheduled for MRI of the brain were selected. They were sedated with intramuscular midazolam 0.1 mg·kg−1 30 min before the procedure. Patients were sedated with i.v. propofol 1 mg·kg−1 and continued with 50–100 μg·kg−1·min−1. T1 3D fast-field echo axial sequence from the nasopharyngeal roof to subglottic region was taken with and without application of a neck collar. Airway dimensions were measured and analyzed at the base of the tongue, soft palate, and at the epiglottis. Results At the base of the tongue and soft palate, the cross-sectional area (CSA) and the anteroposterior diameter of the airway were respectively statistically significantly higher when the neck collar was applied. The CSA at the epiglottis was significantly less with application of the neck collar. Complications were not significantly different between the two sequences. Conclusion Application of a soft neck collar in children aged 2–4 years may enhance the retropalatal and retroglossal airway dimensions during pediatric sedation in the supine position.

Summary Background Use of sedative agents for difficult to manage children during dental procedures has been indicated for years, but neither the agent nor the route has been found to be ideal. Objectives The aim of the study was to evaluate and compare the efficacy and safety of oral dexmedetomidine (D) and ketamine (K) in producing moderate sedation among uncooperative pediatric dental patients. Methods This prospective, triple-blind, randomized comparative study included 112 ASA grade I children of both sexes aged 3–10 years, who satisfied all the inclusion criteria. They were randomly divided into four groups and ketamine 8 mg·kg−1 (K) or dexmedetomidine 3 μg·kg−1 (D1), 4 μg·kg−1 (D2) and 5 μg·kg−1 (D3) were given orally. Similar dental procedures were performed in these patients, and effects of these drugs were assessed in terms of changes in vital signs, onset and duration of sedation, analgesia, and amnesia. Secondary outcomes such as level of sedation, behavior, adverse effects, and overall success were also measured. Results The onset of sedation was significantly rapid with K and D3 as compared to D1 and D2. Recovery from sedation was fastest in group D1. Intra- and postoperative analgesia and anterograde amnesia were highest with K and least with D1, while D3 produced analgesia comparable to K. In K treated group, vomiting was observed in five patients and two patients exhibited emergence phenomenon. Overall, highest success rate was observed in D3 group. Conclusions Given by oral route, the novel sedative dexmedetomidine provides dose-dependent effective analgo-sedation, comparable to ketamine, with less adverse effects.

SummaryAims Clonidine may be used intraoperatively to decrease emergence delirium in children, but the drug's impact on postoperative sedation is poorly quantified. Methods A prospective audit of children (≤15 years) undergoing (adeno) tonsillectomy or adenoidectomy over a period of 4 months was carried out. All children received sevoflurane for induction and maintenance of anesthesia. The use of clonidine as an adjunct was left to the discretion of the anesthesiologist. Postoperative sedation was assessed using the University of Michigan Sedation Scale (UMSS) at 30 min intervals until discharge. Arousal was characterized using a zero asymptote model. The impact of clonidine dose on half-time to an awake state after anesthesia was investigated using nonlinear mixed effects models. Survival analysis was used to explore the effect of clonidine dose on discharge time. Results The mean age of children (n = 177) was 5.4 sd 3.3 years, range 0.8–15.0 years and weight was 23.8 sd 11.4 kg, range 10.0–76.4 kg. There were 73 children given clonidine 0.29–4.80 mcg·kg−1 after induction. The half-time to emergence was 10.8 (95% CI 8.5, 13.2) min. Emergence half-time was increased to 15 min with clonidine 0.5 mcg·kg−1, 20 min with clonidine 1.5 mcg·kg−1, 25 min with clonidine 2 mcg·kg−1 and 65 min with clonidine 4 mcg·kg−1. Clonidine doses 0.5–3 mcg·kg−1 did not affect hospital discharge time. Conclusions Clonidine administered intraoperatively for (adeno) tonsillectomy or adenoidectomy prolonged emergence from anesthesia. Doses of 0.5–3 mcg·kg−1 caused greater sedation in the postanesthesia care unit but did not impact on hospital discharge times.

Summary Background and Objectives Dexmedetomidine (D) can prolong the duration of local anesthetics, but the effect of caudal dexmedetomidine on the potency of levobupivacaine (L) for caudal block has not been investigated. This study was designed to determine the effect of caudal dexmedetomidine on levobupivacaine for caudal block in pediatric patients. Methods Eighty-nine children scheduled for elective inguinal hernia repair or hydrocele were randomly assigned to one of the three groups: Group L (caudal levobupivacaine), Group LD1 (levobupivacaine plus 1 μg·kg−1 dexmedetomidine), or Group LD2 (levobupivacaine plus 2 μg·kg−1 dexmedetomidine). The primary endpoint was the minimum local anesthetic concentration (MLAC), which was determined using the Dixon up-and-down method. The secondary endpoints were the duration of analgesia and sedation. Results The MLAC values (sd) of caudal levobupivacaine were 0.103 (0.01)%, 0.068 (0.02)%, and 0.055 (0.03)% in Groups L, LD1, and LD2, respectively. The values of EC50 and EC95 (95% CI) of caudal levobupivacaine from logistic regression analysis were 0.094 (0.083–0.105)% and 0.129 (0.1–0.159)%, 0.058 (0.044–0.072)% and 0.106 (0.067–0.144)%, and 0.046 (0.033–0.059)% and 0.091 (0.055–0.127)% in Groups L, LD1, and LD2, respectively. The mean durations of analgesia in the postoperative period were 141, 378, and 412 min in Groups L, LD1, and LD2, respectively (L vs LD1 or LD2, P

Summary Background Ensuring appropriate levels of sedation for critically ill children is integral to pediatric critical care. Traditionally, clinicians have used subjective scoring tools to assess sedation levels. The SNAP II uses dual frequency processed electroencephalography to evaluate brain activity and may provide an objective assessment of sedation levels. Objective This study attempts to find an objective method to monitor sedation in critically ill pediatric patients. We compared the SNAP II, a processed electroencephalography device, with the State Behavioral Scale (SBS), a subjective sedation scoring tool. We hypothesize that the SNAP II correlates with the SBS and has less observer bias. Methods This was an IRB approved prospective, observational study. Patients receiving intravenous sedation while being mechanically ventilated were enrolled after informed consent. After the SNAP II monitoring electrodes were attached, blinded bedside nurses assessed sedation levels using the SBS. SNAP indices were collected and compared with SBS scores to determine correlation. Results We compared 417 paired data points from 15 patients using Pearson's correlation and least squares means to determine correlation between the SBS and SNAP indices. No correlation was observed. Using covariance model patterning for repeated measures to adjust for covariates again showed no correlation. Conclusion The SNAP index does not correlate with SBS scores in our pediatric intensive care unit (PICU). Its use cannot be recommended to measure levels of sedation in our population. Future research should continue to explore objective ways of measuring sedation in critically ill children.

SummaryObjectives Intussusception is the most frequent cause of bowel obstruction in children. Although enema is usually used as the initial treatment, surgery may be required in more than 50% of patients. General anesthesia (GA) has been suggested to increase the rate of enema success. The purpose of this study was to evaluate whether GA increases the success rate of reduction by air enema. Methods In this retrospective single-center study from 1989 to the end of June 2008, patients receiving air enema for intussusception reduction were studied. Multivariable analysis using propensity score was performed to compare the success rate between patients receiving sedation or GA. Results The success rate of air enema increased from 72% in 1989 to the current rate of 90%. When time elapsed between first symptoms and enema was >12 h, the success rate decreased significantly (Odds Ratio 0.67 [0.56–0.81], P

Summary Introduction Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics. Materials and methods ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg−1) followed by infusion of 10–20 μg·kg−1·min−1 or group M (midazolam) loading dose of (0.02 mg·kg−1) followed by 1–2 μg·kg−1·min−1. The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002). Results A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly. Conclusions Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.

To investigate whether nasal aerosol clonidine can reduce the onset time of preoperative sedation.Premedication is common in the pediatric population, but the optimal agent and administration route is still a matter of debate. Clonidine has many beneficial effects in the perioperative period. Clonidine nasal drops produce a similar sedative effect as after oral administration but do not reduce the onset time. Nasal aerosol administration of drugs is generally more effective than drops and an option to decrease the onset time of clonidine.Pediatric ASA status 1 and 2 patients were randomized to receive placebo (P), clonidine 3-4 μg kg(-1) (C4), or clonidine 7-8 μg kg(-1) (C7) as a nasal aerosol. Acceptance of administration, pre- and postoperative sedation, and adverse events were assessed.A total of 60 patients were enrolled with a median age of 3.5 years (range 0.7-6.9) and median weight of 14.8 kg (range 10-25). In the C7 group, 55% of the children were found adequately sedated at 30 min as compared to 32% in the C4 group (P = 0.1202). At 45 min, adequate sedation was seen in 65% of the patients in both C4 and C7 groups, which were both found to be significantly higher compared with the placebo control group (14%) (P-values = 0.0027 and 0.0013, respectively). The postoperative sedation profile did not differ between the three study groups.Clonidine administered as nasal aerosol (3-8 μg kg(-1)) was not found to achieve adequate preoperative sedation within 30 min of administration. Despite its sedative properties, no prolongation of postoperative sedation was noted compared with placebo.

Gamma-hydroxybutyrate (GHB) may be an interesting hypnotic agent in burn patients because of its good respiratory or hemodynamic tolerance. However, its clinical and electroencephalographic (EEG) sedative effects are not yet described in children. The aim of this prospective and randomized study was to assess clinical and EEG effects of increasing intravenous (IV) doses of GHB in burn children requiring sedation for burn wound cares.Thirty six children hospitalized in a burn care unit were included and randomly assigned into three groups (G) according to the single IV dose of GHB they received before burn wound care: 10 mg · kg(-1) in G10, 25 mg · kg(-1) in G25, or 50 mg · kg(-1) in G50. All patients received oral premedication (morphine and hydroxyzine) 30 min before GHB injection. Respiratory rate, heart rate, pulse oximetry, and bispectral index (BIS) were continuously monitored. Depth of sedation was clinically assessed using Observer's Assessment of Alertness and Sedation (OAAS) Score, every 2 min until recovery (i.e., OAAS = 4).Median age was 17.5 [12-34] months. Whatever the dose, BIS decreased after IV GHB. Nadir value of BIS was significantly lower in G25 and G50 than in G10, as was for OAAS score. Nadir values were reached after same delays in G25 and G50. Duration of sedation was dose-dependent.Bispectral index decreased after GHB injection and was correlated with OAAS score. Deep sedation can be safely achieved with IV doses of 25 or 50 mg · kg(-1), but the last dose was associated with prolonged duration of clinical sedation.

Herniorraphy is a common surgical intervention in infants, particularly in those born prematurely. Prematurity and perioperative sedation have been shown to be risk factors for postoperative apnea. However, their influence upon PACU stay duration has not been evaluated. The goal of this study was to investigate predictive factors for PACU stay in infants undergoing herniorraphy.This study is a retrospective analysis of perioperative data in infants6 months of age undergoing herniorraphy during the period November 2007-November 2009. Collected data included age, gestational age at birth, post-conceptional age, weight, weight at birth, type of anesthesia (spinal vs general), perioperative administration of opioids and paracetamol, duration of surgery, duration of PACU stay, and apnea in PACU. Data analysis used classification and regression trees (CART) with a 10-fold cross-validation.Two hundred and ninety-six patients were included in the analysis. Five parameters were found to predict the duration of PACU stay: a post-conceptional age below 45 weeks, prematurity, general anesthesia, postoperative opioid administration, and the use of intraoperative regional analgesia. CRT method allows constructing a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross-validation were 79.7% and 76.6%, respectively.Our study allows construction of an accurate predictive tree for PACU stay during herniorraphy in infants6 months. Parameters found to influence the duration of PACU stay were related to anesthesia techniques and perinatal outcomes.

Every anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single-injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow-up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.

Regional anesthesia in children has reached in the last decades a widespread approval and today is a valid and effective technique used in the daily activity in many pediatric centres. Data from surveys and studies show the very low rate of complications and suggest that the use of regional techniques in children is at least as safe as general anesthesia alone. Despite these evidences there are aspects still creating discussions on the best approach to avoid or prevent risks and on the way to make this techniques more and more reliable and safe. Compartment syndrome, test dose, loss-of-resistance technique and blocks performed under general anesthesia are examples of, sometimes, never-ending stories; this review without the presumption to solve every problem shows the more recent data to offer, if possible, the best updated-answer on these topics.

Pediatric sedation continues to change in terms of the professionals who provide this care, those who produce original research on this topic, guidelines and literature concerning risk, medications employed, and methods for training for new providers. Some of the changes could be categorized as 'evolutionary' or gradual in nature and predictable - such as the changing role of anesthesiologists in the field of pediatric sedation and the use of the well-established dissociative sedative, ketamine. Other changes in pediatric sedation are more radical or 'revolutionary'. They include reconsideration of what is defined as an 'adverse event' during sedation, the use of propofol or dexmedetomidine, and the application of human patient simulation for training. This review will highlight the ongoing changes in the dynamic field of pediatric sedation by focusing on some of the important progress (both evolutionary and revolutionary) that has occurred across the varied specialties that provide this care.

We detail the limitations of the current paradigm of the sedation continuum - a tool ubiquitous to all sedation care settings and now a quarter century old. Definitions in this existing taxonomy are based on patient responsiveness to verbal and/or tactile stimuli, and the inherent subjectivity of this focus has both challenged the reliable assessment of adverse event risk and precluded clear delineation of sedation boundaries, e.g., what is the dividing line between moderate and deep sedation? We present the rationale to support a broadening of this sedation continuum precept to include an objective mechanism to predict the ongoing risk of serious adverse events, and then propose sequential steps for the development of such a restructured framework. This process, while ambitious, would yield a clear and consistent language to facilitate quality assurance, provide an objective framework for standardized sedationist training and credentialing, and permit inclusion into computerized decision-support algorithms to facilitate more precise sedative delivery. It is important to clearly delineate this goal now to permit design and initiation of the requisite research.

Phenobarbital induces specific hepatic cytochrome P-450 enzyme pathways causing increased clearance of hepatically metabolized drugs. In this study, we investigated the duration and additional anesthetic requirement during Magnetic resonance imaging (MRI) in epileptic children with or without phenobarbital monotherapy. In ASA I-II, 128 children, aged 1-10 years, were included. Group I: epileptic children without anti-epileptic therapy and Group II: children with phenobarbital monotherapy. The initial sedative drugs were 0.1 mg·kg(-1) midazolam with 2 mg·kg(-1) ketamine. An additional 1 mg·kg(-1) ketamine was administrated if required. Rescue propofol (0.5 mg·kg(-1)) was provided and repeated to maintain sedation. The duration and consumption of additional sedative requirements was recorded. The duration of initial and two consequent additional sedative requirements was shorter in Group II (P = 0.0001, P = 0.001 and P = 0.27, respectively). Additional ketamine doses required for adequate sedation were lower in Group I (P = 0.016). We suggest that the variability in response to the initial sedative agents during MRI requires titration of additive sedation with ketamine in epileptic children on phenobarbital monotherapy.

When electroencephalogram (EEG) activity is recorded for diagnostic purposes, the effects of sedative drugs on EEG activity should be minimal. This study compares the sedative efficacy and EEG effects of dexmedetomidine and midazolam.EEG recordings of 60 pediatric subjects with a history of simple febrile convulsions were performed during physiologic sleep. All of these patients required sedation to obtain follow-up (control) EEGs. Subjects in Group D received 0.5 μg·kg(-1) of dexmedetomidine, and those in Group M received 0.1 mg·kg(-1) of midazolam. For rescue sedation, the same doses were repeated to maintain a Ramsey sedation score level of between 4 and 6.The mean doses that were required for sedation were 0.76 μg·kg(-1) of dexmedetomidine and 0.38 mg·kg(-1) of midazolam. Diastolic blood pressure and HR were lower in Group D than in Group M (P0.05). Hypoxia was observed in 11 (36.7%) subjects in Group M and none in Group D; this was statistically significant (P0.001). Frontal and parieto-occipital (PO) EEG frequencies were similar during physiologic sleep and dexmedetomidine sedation. However, EEG frequencies in these areas (P0.001) and PO EEG amplitude (P = 0.030) were greater during midazolam sedation than during physiologic sleep.Dexmedetomidine is a suitable agent to provide sedation for EEG recording in children. There is less change in EEG peak frequency and amplitude after dexmedetomidine than after midazolam sedation.

A descriptive tool or validated scale of consciousness is desirable in infants to test the value of any depth of anesthesia monitor.We have reviewed published descriptions and scales of observed behavior that may be applicable to the study of infants during the transition from anesthesia to wakefulness.Potentially useful scales were found that had been developed for the assessment and study of natural sleep, neurological state, arousal, anesthesia, sedation, coma, and pain. Scales or criteria of behavior had been developed for anesthetised children, but there were no agreed definitions or criteria specifically for anesthetised infants or neonates.Criteria for awakening of infants from anesthesia need to be developed and agreed.

Significant advances in perinatal and neonatal medicine over the last 20 years and the recent emergence of fetal surgery has resulted in anesthesia providers caring for a growing number of infants born at the margin of viability. Anesthetic management in this patient population has to take into consideration the immature function of many vital organ systems as well as the effects of the underlying disease processes, which can frequently lead to severe physiological derangements. Accordingly, premature infants presenting for major surgeries early in life can represent a significant anesthetic challenge. However, even with advanced anesthetic and surgical management and optimal intensive care, extremely premature infants face substantial postoperative morbidity and mortality, as well as prolonged hospital courses. In this article, we will discuss the following questions: How far have we come in improving outcomes of extreme prematurity? And what will the future medical and societal challenges be, as we continue to redefine the limits of viability?

To test the hypothesis that high-dose dexmedetomidine can be successfully used for pediatric magnetic resonance imaging (MRI) sedation without significant hemodynamic compromise.The dexmedetomidine dose required to achieve optimal sedation is often higher than its recommended dose. High doses of dexmedetomidine can lead to significant hemodynamic side effects.Dexmedetomidine use for pediatric MRI over a 1-year period was retrospectively reviewed. A dexmedetomidine bolus of 2 μg·kg(-1) intravenous followed by 1 μg·kg(-1)·h(-1) infusion was used. Dexmedetomidine efficacy, side effects, timing of side effects, and additional use of medications were analyzed. Data were compared by t-test, Mann-Whitney rank-sum test, Fisher's exact test, and anova.High-dose dexmedetomidine was used in 77 patients, and MRI was completed in 76 (99%) patients. A second bolus of dexmedetomidine was required in 28 (36%) patients, and 22 (29%) patients required additional medications (midazolam, fentanyl, or ketamine) for adequate sedation. A 25% decrease in blood pressure (BP) was observed in 10.5%, a transient increase in BP in 3.9%, and a heart rate60 min(-1) in 7.9% of cases. These side effects resolved spontaneously. There were no apneas or respiratory depression. Vital sign changes, recovery time, and discharge time were not significantly different in subgroups of patients receiving one or two boluses of dexmedetomidine with or without additional medications. Transient hypertension was more common in patients receiving two boluses of dexmedetomidine (P = 0.048).High-dose dexmedetomidine can be successfully used for pediatric MRI sedation, but a significant number of children require additional medications for optimal control. Hemodynamic side effects resolved spontaneously. High-dose dexmedetomidine did not result in respiratory depression.

In recent years, the importance of appropriate intra-operative anesthesia and analgesia during cardiac surgery has become recognized as a factor in postoperative recovery. This includes the early perioperative management of the neonate undergoing radical surgery and more recently the care surrounding fast-track and ultra fast-track surgery. However, outside these areas, relatively little attention has focused on postoperative sedation and analgesia within the pediatric intensive care unit (PICU). This reflects perceived priorities of the primary disease process over the supporting structure of PICU, with a generic approach to sedation and analgesia that can result in additional morbidities and delayed recovery. Management of the marginal patient requires optimisation of not only cardiac and other attendant pathophysiology, but also every aspect of supportive care. Individualized sedation and analgesia strategies, starting in the operating theater and continuing through to hospital discharge, need to be regarded as an important aspect of perioperative care, to speed the process of recovery.

Various combinations of propofol and ketofol have been described for the provision of procedural sedation in both adults and children. Utilization of 'ketofol' for deep sedation during prolonged pediatric orthopedic procedures has not previously been described.During an orthopedic aid trip, a 1:1 mixture of propofol and ketamine (200 mg of each drawn up to 22 ml) was utilized to provide deep sedation or general anesthesia as an adjunct to regional analgesia for lower limb surgery. Details for 18 patients having a total of 19 procedures were recorded with a record of intraoperative and postoperative parameters including initial bolus doses and infusion rates of ketofol required to produce deep sedation.Mean operating time was 153.7 min (range 64-241 min). The mean initial bolus dose of ketofol was 0.19 ml·kg(-1) (range 0.1-0.5 ml·kg(-1) ) or 1.7 mg·kg(-1) each of propofol and ketamine (range 0.9-4.5 mg·kg(-1) ). The mean upper limit of the infusion rate required to maintain deep sedation was 0.19 ml·kg(-1) ·h(-1) (range 0.07-0.26 ml·kg(-1) ·h(-1) ) or 1.7 mg·kg(-1) ·h(-1) (range 0.6-2.4 mg·kg(-1) ·h(-1) ) and the mean lower limit of the infusion rate was 0.08 ml·kg(-1) ·h(-1) (range 0.02-0.13 ml·kg(-1) ·h(-1) ) or 0.7 mg·kg(-1) ·h(-1) (range 0.2-1.2 mg·kg(-1) ·h(-1) ). The mean initial bolus dose of ketofol was 0.19 ml·kg(-1) (range 0.1-0.5 ml·kg(-1) ). There were no episodes of hypo- or hypertension or of desaturation. Mean time to eye opening after infusion cessation was 5.1 min (median 2 min; range 0-17 min).Ketofol successfully produced deep sedation for prolonged pediatric orthopedic procedures in conjunction with regional analgesia. Further research to confirm its safety and applicability to a wider range of settings is required.

Propofol is widely used for pediatric sedation. However, increasing depth of propofol sedation is associated with airway narrowing and obstruction. The aim of this study was to objectively assess airway patency during a low-dose propofol-based sedation regimen by measuring upper airway size and configuration with magnetic resonance imaging (MRI) in spontaneously breathing infants and children.Magnetic resonance images of the upper airway were obtained in 138 infants and children, aged up to 6 years. Cross-sectional area, anteroposterior dimension, and transverse dimension were measured at the level of the soft palate, the base of the tongue, and the tip of the epiglottis. Sedation was induced with i.v. midazolam 0.1 mg·kg(-1) , nalbuphine 0.1 mg·kg(-1) , and propofol 1 mg·kg(-1) and maintained with propofol 5 mg·kg(-1) ·h(-1) .Median (IQR) age was 36 (15, 48) months, and mean body weight was 13.7 ± 5.6 kg. Airway patency was maintained in all infants and children. The narrowest part of the pharyngeal airway was measured at the level of the base of the tongue. Anteroposterior dimensions were narrower than transverse dimensions in all age groups at all measurement sites. Transverse dimensions increased with age at all measurement sites, while anteroposterior dimensions did not increase comparably. No patient demonstrated respiratory or cardiovascular adverse events. All MRI were completed successfully without sedation failure.Airway patency was maintained in all infants and children sedated with this low-dose propofol-based sedation regimen.

We prospectively assessed the efficacy and side effects of four sedation techniques in our dental clinic: oral midazolam, intranasal (IN) midazolam, IN midazolam combined with oral transmucosal fentanyl citrate (OTFC), and IN midazolam combined with IN sufentanil.With IRB approval, a nonrandomized open label study of moderate sedation in children undergoing dental surgery was administered during a 6 -month period. The sedation regimen was rotated daily at the anesthesiologist's discretion. Each sedation was monitored by a research nurse who assessed the quality of sedation and the frequency of complications. All children were monitored during the procedure and recovery for at least 20 min, before discharge based on the University of Michigan Sedation and Ohio State behavior rating scores.One hundred and two children were sedated in the dental clinic during this period. The sedation was successful in 73% (range 64% to 88%) of the children. The time to onset was greatest with OTFC (37 min) and least with IN midazolam (17 min) compared with the other two groups (20 and 30 min). Recovery after OTFC was prolonged (39 min) significantly compared with the other three groups (26.5-30 min). Efficacy of sedation and frequency of complications (9% incidence of nausea and 6% of mild hemoglobin desaturation) were similar among the groups.All four sedation regimens were equally effective in this cohort of healthy children. The onset and recovery with OTFC was significantly delayed compared with the other regimens. The frequency of side effects was small; there were no side effects in the PO midazolam group.

Limited duration of analgesia is among the limitations of single caudal injection with local anesthetics. Therefore, the purpose of this study was to evaluate the effectiveness and safety of bupivacaine in combination with either neostigmine or tramadol for caudal block in children undergoing inguinal herniorrhaphy.In a double-blinded randomized trial, sixty children undergoing inguinal herniorrhaphy were enrolled to receive a caudal block with either 0.25% bupivacaine (1 ml x kg(-1)) with neostigmine (2 microg x kg(-1)) (group BN) or tramadol (1 mg x kg(-1)) (group BT). Hemodynamic variables, pain and sedation scores, additional analgesic requirements, and side effects were compared between two groups.Duration of analgesia was longer in group BT (17.30 +/- 8.24 h) compared with group BN (13.98 +/- 10.03 h) (P = 0.03). Total consumption of rescue analgesic was significantly lower in group BT compared with group BN (P = 0.04). There were no significant differences in heart rate, mean arterial pressure, and oxygen saturation between groups. Adverse effects excluding the vomiting were not observed in any patients.In conclusion, tramadol (1 mg x kg(-1)) compared with neostigmine (2 microg x kg(-1)) might provide both prolonged duration of analgesia and extended time to first analgesic in caudal block.

Ketamine is a general anesthetic agent widely used for pediatric procedural sedation outside the operating theater by nonanesthesiologists. In a setting where efficacy and safety of the agent are paramount, there are conflicting recommendations in terms of optimal mode of parenteral administration, as well as optimal dosage and need for the coadministration of adjunctive agents to decrease side effects. We investigated existing evidence to determine whether ketamine should be best administered intravenously or intramuscularly. This analysis was made difficult by limited direct comparisons of both modes of parenteral administration and a lack of consistent definitions for key outcomes such as 'effectiveness,''adverse events,''hypoxia,''ease of completion of the procedure,' and 'satisfaction' across studies that have evaluated ketamine. Based on large data sets, the safety and efficacy of both modes of administration are broadly similar. Although data on head to head comparisons of intravenous and intramuscular ketamine is limited, based on our analysis, we conclude that the trends indicate ketamine is ideally administered intravenously.

Spinal anesthesia (SA) is widely used for awake regional anesthesia in ex-preterm infants scheduled for herniotomy. Awake caudal anesthesia (CA) is suggested as an alternative approach for these patients and type of surgery. The aim of this study was to compare efficacy and complications of the two different techniques.Two historical populations of 575 ex-preterm infants undergoing herniotomy under awake SA (n = 339; 1998-2001) and under awake CA (n = 236; 2001-2009) were investigated. Data are compared using t-test and chi-square tests (P0.05).The SA group consisted of 339 patients, they were born after 32.0 (3.3) weeks of gestation on average with a mean birth weight of 1691 g (725). The CA group consisted of 236 patients born after 32.1 weeks (3.7) with a mean birth weight of 1617 g (726). At the time of operation, the total age was 41.37 (3.6) and 41.28 (4.0), respectively, for SA and CA patients, and the corresponding weights were 3326 (1083) g and 3267 (931) g for SA and CA patients, respectively. For SA, significantly more puncture attempts were needed (1.83 vs 1.44, P0.001). Surgery was performed under pure regional anesthesia in 85% (SA) and 90.1% (CA) (ns). A change to general anesthesia was necessary in 7.7% (SA) and 3.9% (CA) (ns). Overall, intra- and postoperative complications were not statistically different.Caudal anesthesia was shown to be technically less difficult than SA and to have a higher success rate. Its application as awake regional anesthesia technique in these patients seems more appropriate than SA.

This prospective study examines the dose-response effects of dexmedetomidine on upper airway morphology in children with no obstructive sleep apnea (OSA).To determine the effect of increasing doses of dexmedetomidine on static and dynamic magnetic resonance (MR) images of the upper airway in spontaneously breathing children with no OSA.General anesthetics and sedatives attenuate upper airway muscle activity, rendering the airway vulnerable to obstruction. Dose-response effects of dexmedetomidine on upper airway of children are not known. We prospectively examined the dose-response effects of dexmedetomidine on upper airway morphology in children.Increasing doses of dexmedetomidine was administered to 23 children scheduled for MR imaging of the brain while breathing spontaneously via the native airway. Static axial and dynamic sagittal midline MR ciné images of the upper airway were obtained during low (1 mcg.kg(-1).h(-1)) and high (3 mcg.kg(-1).h(-1)) doses of dexmedetomidine. The airway anteroposterior diameter, transverse diameter, and cross-sectional areas were measured manually by two independent observers. Static airway measurements were taken at the level of the nasopharyngeal airway (sagittal images) and retroglossal airway (RGA) (sagittal and axial images). Dynamic change in cross-sectional area of airway between inspiration and expiration was considered a measure of airway collapsibility.Static axial measurements of RGA did not change with increasing dose of dexmedetomidine. Most sagittal airway dimensions demonstrated clinically modest, although statistically significant, reductions with high dose compared to low dose dexmedetomidine. Although, the dynamic changes in nasopharyngeal and retroglossal area with respiration were marginally greater for high dose than for low dose dexmedetomidine, no subject exhibited any clinical evidence of airway obstruction.Upper airway changes associated with increasing doses of dexmedetomidine in children with no OSA are small in magnitude and do not appear to be associated with clinical signs of airway obstruction. Even though these changes are small, all precautions to manage airway obstruction should be taken when dexmedetomidine is used for sedation.

To examine the effects of dexmedetomidine sedation on EEG background and epileptiform activity in children, comparing it to natural sleep.To provide quantitative and qualitative descriptions of the effect of dexmedetomidine sedation on the EEG of children.Children with intractable epilepsy admitted for surgery undergo 5 days of continuous EEG monitoring as well as nuclear medicine imaging studies with dexmedetomidine for sedation. Continuous EEG monitoring of each child during both natural sleep and dexmedetomidine-induced sedation provides a unique opportunity to evaluate the effects of dexmedetomidine on the EEG of children.Sixteen children undergoing dexmedetomidine sedation for nuclear medicine studies and simultaneous continuous EEG monitoring were studied. EEG segments during sedation were compared to samples of naturally occurring stage II sleep from the same child. Standard visual EEG analysis, quantification of delta, theta, alpha, beta, and total RMS power, number and location of spike foci, and frequency of spike activity were compared.The EEG during dexmedetomidine sedation resembled stage II sleep. During sedation, statistically significant increases in power of 16% for theta (P = 0.01), 21% for alpha (P = 0.03), and 40% for beta (P0.01) were observed, but not for delta (P = 0.63) or total EEG power (P = 0.61). Spike frequency increased by 47% during sedation but no new spike foci or seizures were observed.Dexmedetomidine sedation elicited an EEG pattern similar to that of Stage II sleep with modest increases in theta, alpha, and beta activity. Dexmedetomidine does not hinder interpretation of the EEG, suggesting that it may be a uniquely useful agent for EEG sedation in children.