November 1, 2013 Volume 77, Number 11
SEE Question

According to a recent small study, preoperative administration of nasal dexmedetomidine, compared to buccal administration, will MOST likely change which of the following at parental separation?


(A) Heart rate
(B) Oxygen saturation
(C) Sedation score
(D) Respiratory rate 


Alpha-2 agonists such as clonidine and dexmedetomidine have been effectively utilized as anxiolytic agents in children. A recent study compared the administration of nasal and buccal dexmedetomidine for use as a premedication in children undergoing elective surgery. Dexmedetomidine is not approved by the U.S. Food and Drug Administration for either of these routes of administration. The study consisted of a prospective, randomized, double-blinded design. The study participants (n = 62) were two to six years of age and classified as American Society of Anesthesiologists physical status I or II who were scheduled for elective surgery. The surgical procedures included in this study were circumcision, inguinal hernia repair, and tonsillectomy/adenoidectomy. The children were assigned to one of the following groups:


  • Group N (n = 31) received 1 μg/kg-1 (100 μg/mL) of
    dexmedetomidine intranasally (drug administered in divided
    doses into both nostrils)
  • Group B (n = 31) received 1 μg/kg-1 (100 μg/mL) of
    dexmedetomidine buccally (drug rinsed in the mouth)

    Each group also received the same volume of distilled water as a placebo to the site not receiving the study drug. All participants received the study drug approximately 45 minutes prior to induction of anesthesia. The primary end point of the study was the sedation score at parental separation. Secondary end points included patient anxiety, quality of mask acceptance, and changes in vital signs during the sedation period. Sedation was evaluated using the Observer Assessment of Alertness and Sedation Scale, which ranges from 1 (deep sleep) to 5 (alert).


    Both groups were similar in regard to age, weight (approximately 16 kg average), height, and sex. The authors reported no significant differences between groups N and B in heart rate, respiratory rate, and oxygen saturation before or after the administration of dexmedetomidine. There were no reports of respiratory depression, severe bradycardia, or oxygen desaturation. Unlike other orally administered sedatives, no child in either group complained of a bad smell or taste during drug administration. Dexmedetomidine is reportedly tasteless.


    The authors reported that the median sedation score for group N was significantly lower (better sedation) than for group B at 45 minutes after administration of dexmedetomidine. A satisfactory degree of sedation after 45 minutes was reported in all group N patients and in 51 percent of group B patients. A satisfactory sedation score upon parental separation was present in 78 percent of group N but in only 26 percent of group B.


    Satisfactory parental separation and mask acceptance were reported to be significantly higher in group N than group B. Mask acceptance during induction of general anesthesia was reported to be good or excellent in 80 percent of group N but in none of the patients in group B.


    The authors concluded that dexmedetomidine provides superior premedication for children and the nasal route is more effective than the buccal route. Study limitations reported by the authors include possible decreased buccal absorption due to patients swallowing the medication and use of unvalidated sedation scales. While the sample size was small, the effect size was very large.


    Answer: C


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  • Cimen ZS, Hanci A, Sivrikaya GU, Kilinc LT, Erol MK. Comparison of buccal and nasal dexmedetomidine premedication for pediatric patients. Paediatr Anaesth. 2013;23(2):134-138.
  • Lerman J, Sampathi V, Watt S. Induction, maintenance, and emergence from anesthesia. In: Gregory GA, Andropoulos DB, eds. Gregory’s Pediatric Anesthesia. 5th ed. New York, NY: Wiley-Blackwell; 2012:344.