Intranasal Procedural Sedation and Analgesia in Children
Intranasal midazolam has been used as a sedative/anxiolytic and an antiepileptic. It has become well accepted as a means of providing sedation for radiologic imaging and prior to induction of anesthesia, alone or in combination intranasal regimens. In 2012, Baldwa and colleagues compared the effects of intranasal midazolam doses of 0.2 and 0.3 mg/kg as a premedication in 60 children undergoing elective surgery. The two doses were compared for the level of sedation and ease of parental separation. Patients were also graded according to their acceptance of the dose and willingness to have their face mask placed. Overall, acceptance of the intranasal route was rated as good in 23.4% of children, fair in another 43.4%, and poor in 33.4%. There was a significantly higher percentage of patients in the 0.3 mg/kg group who were adequately sedated at 10 minutes (70% versus 40% in the 0.2 mg/kg group, p = 0.04). Separation from parents was also rated as easier in the higher dose group, with 66.7% of patients achieving a score of excellent, good, or fair at 10 minutes, compared to only 30% of the children given the lower dose (p = 0.005). Transient adverse effects were common, with 60% of children experiencing nasal irritation, 42% having conjunctival congestion, and 30% having increased salivation. There were no cases of oxygen desaturation or bradycardia.
Another recent paper by Filho and colleagues demonstrated the utility of intranasal midazolam for sedation during computed tomography. The authors of this observational study evaluated 58 children (1–40 months of age) receiving a total of 60 scans. The mean initial dose was 0.42 + 0.03 mg/kg, with a range of 0.37–0.51 mg/kg. Fifteen patients required a second dose. Mean time to adequate sedation was 15.2 + 9.4 minutes, with a mean time to recovery of 51.1 + 25.3 minutes. Image quality was rated as excellent in 93.3% of cases, with 98.3% having no imaging artifacts. Only four patients failed to become adequately sedated. Paradoxical agitation occurred in 5% of the patients, with prolonged recovery time and emesis each occurring in 1.7%. Due to the relatively young age of the patients in this study, assessing nasal irritation was difficult, but the authors reported that 28.3% of patients cried during drug administration.
It has been suggested that premedication with lidocaine can reduce the discomfort associated with intranasal midazolam. In a prospective open-label study of 46 children between 5 and 50 months of age, Chiaretti and colleagues used a single puff of lidocaine spray (10 mg) given by the patients' parents to provide a local anesthetic effect immediately before a 0.5 mg/kg intranasal midazolam dose was administered. The mean time to effective sedation was 6.9 + 2.4 minutes, with a mean duration of 23.1 + 10.3 minutes. The authors found a high rate of acceptance by the children and favorable ratings for this regimen by both parents and physicians.
Midazolam
Intranasal midazolam has been used as a sedative/anxiolytic and an antiepileptic. It has become well accepted as a means of providing sedation for radiologic imaging and prior to induction of anesthesia, alone or in combination intranasal regimens. In 2012, Baldwa and colleagues compared the effects of intranasal midazolam doses of 0.2 and 0.3 mg/kg as a premedication in 60 children undergoing elective surgery. The two doses were compared for the level of sedation and ease of parental separation. Patients were also graded according to their acceptance of the dose and willingness to have their face mask placed. Overall, acceptance of the intranasal route was rated as good in 23.4% of children, fair in another 43.4%, and poor in 33.4%. There was a significantly higher percentage of patients in the 0.3 mg/kg group who were adequately sedated at 10 minutes (70% versus 40% in the 0.2 mg/kg group, p = 0.04). Separation from parents was also rated as easier in the higher dose group, with 66.7% of patients achieving a score of excellent, good, or fair at 10 minutes, compared to only 30% of the children given the lower dose (p = 0.005). Transient adverse effects were common, with 60% of children experiencing nasal irritation, 42% having conjunctival congestion, and 30% having increased salivation. There were no cases of oxygen desaturation or bradycardia.
Another recent paper by Filho and colleagues demonstrated the utility of intranasal midazolam for sedation during computed tomography. The authors of this observational study evaluated 58 children (1–40 months of age) receiving a total of 60 scans. The mean initial dose was 0.42 + 0.03 mg/kg, with a range of 0.37–0.51 mg/kg. Fifteen patients required a second dose. Mean time to adequate sedation was 15.2 + 9.4 minutes, with a mean time to recovery of 51.1 + 25.3 minutes. Image quality was rated as excellent in 93.3% of cases, with 98.3% having no imaging artifacts. Only four patients failed to become adequately sedated. Paradoxical agitation occurred in 5% of the patients, with prolonged recovery time and emesis each occurring in 1.7%. Due to the relatively young age of the patients in this study, assessing nasal irritation was difficult, but the authors reported that 28.3% of patients cried during drug administration.
It has been suggested that premedication with lidocaine can reduce the discomfort associated with intranasal midazolam. In a prospective open-label study of 46 children between 5 and 50 months of age, Chiaretti and colleagues used a single puff of lidocaine spray (10 mg) given by the patients' parents to provide a local anesthetic effect immediately before a 0.5 mg/kg intranasal midazolam dose was administered. The mean time to effective sedation was 6.9 + 2.4 minutes, with a mean duration of 23.1 + 10.3 minutes. The authors found a high rate of acceptance by the children and favorable ratings for this regimen by both parents and physicians.