Continuing Medical Education

Prospective evaluation of dexmedetomidine for noninvasive

procedural sedation in children*
John W. Berkenbosch, MD; Patricia C. Wankum, MD; Joseph D. Tobias, MD

LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Define the side effects of dexmedetomidine.
2. Describe the potential advantages and disadvantages of dexmedetomidine versus conventional sedation.
3. Recall the current view of the mechanism of action of dexmedetomidine.
Dr. Tobias has disclosed that he is a consultant/advisor to and is on the speakers bureau of Hospira. The remaining authors have
disclosed that they have no relationships or interests in any commercial companies pertaining to this educational activity. The
authors have disclosed that the use of dexmedetomidine has not been approved by the FDA as discussed in this article.
Wolters Kluwer Health has identified and resolved any faculty conflicts of interest regarding this educational activity.
Visit the Pediatric Critical Care Medicine Web site (www.pccmjournal.org) for information on obtaining continuing medical
education credit.

Objective: Children often require sedation for lengthy noninva- failing sedation with chloral hydrate and/or midazolam. Sedation
sive procedures. Conventional agents such as chloral hydrate, ben- was induced with 0.92 ⴞ 0.36 ␮g/kg over 10.3 ⴞ 4.7 mins and
zodiazepines, or barbiturates have been associated with sedation maintained with an infusion of 0.69 ⴞ 0.32 ␮g/kg/hr. All procedures
failure, respiratory depression, and paradoxic agitation. Dexmedeto- were completed. Heart rate, blood pressure, and respiratory rate
midine is a newer ␣2-adrenergic receptor agonist with sedative decreased (p < .0001) but remained within normal limits for age.
properties and minimal respiratory depression. We hypothesized that End-tidal CO2 exceeded 50 mm Hg in seven of 404 measurements
it would be an effective agent for these procedures. (1.7%). Mean recovery time was 84 ⴞ 42 mins and was significantly
Design: Prospective case series. longer in the rescue (117 ⴞ 41 mins) vs. primary (69 ⴞ 34 mins)
Setting: Tertiary care children’s hospital. group (p < .0001). No patient developed agitation during recovery.
Patients: Children undergoing noninvasive procedures. Conclusions: Dexmedetomidine provided effective sedation in
Interventions: Children were sedated with dexmedetomidine children undergoing noninvasive procedures and represents an
given as a bolus of 0.5–1.0 ␮g/kg over 5–10 mins followed by an alternative sedative choice for this population. (Pediatr Crit Care
infusion of 0.5–1.0 ␮g/kg/hr. Vital signs, sedative effectiveness, Med 2005; 6:435–439)
recovery patterns, and complications were prospectively recorded. KEY WORDS: procedural sedation; pediatric; radiology; magnetic
Measurements and Main Results: Forty-eight patients, aged 6.9 resonance imaging; electroencephalography
ⴞ 3.7 yrs, were sedated. Fifteen received dexmedetomidine after

N oninvasive radiologic and ties, procedure-related anxiety, and the The ideal agent for these procedures
neurophysiologic studies need for a near-motionless state during remains elusive. Benzodiazepines may be
play an increasingly impor- these studies, children often require deep effective in the older child who has only
tant role in the evaluation of sedation, especially for lengthier studies mild procedure-related anxiety but may
both acute and chronic pediatric disease. such as magnetic resonance imaging not provide a sufficient depth of sedation
Due to children’s developmental capaci- (MRI) or nuclear medicine scans. in other, more difficult children. Due to
its ease of administration, safety profile,
and limited effects on the electroenceph-
*See also p. 493. Professor, Department of Child Health (PCW), Uni- alogram, chloral hydrate remains a pop-
Associate Professor, Pediatrics/Pediatric Critical versity of Missouri, Columbia, MO. ular choice but is associated with an un-
Care, University of Louisville, Kosair Children’s Hos- Copyright © 2005 by the Society of Critical Care predictable onset and duration of action
pital, Louisville, KY (JWB); Vice-Chairman, Depart-
ment of Anesthesiology, Chief, Division of Pediatric
Medicine and the World Federation of Pediatric Inten- and moderate failure rate, particularly in
sive and Critical Care Societies children who are older and/or with un-
Anesthesiology and Pediatric Critical Care, Profes-
sor, Anesthesiology and Pediatrics (JDT), Assistant DOI: 10.1097/01.PCC.0000163680.50087.93 derlying neurologic disorders (1–3). Bar-

Pediatr Crit Care Med 2005 Vol. 6, No. 4 435

biturates, most commonly pentobarbital equate sedation or those who woke before Table 1. Sedation scoring system
or methohexital, are used in other insti- procedure completion.
Informed consent was obtained from a par- Score Definition
tutions but may also be associated with
sedation failure, prolonged sedation, re- ent before each sedation. Sedation was admin-
istered and supervised by a pediatric intensiv- 1 Awake and alert
spiratory depression, hypotension, and 2 Drowsy, easily aroused
ist in accordance with the published
recovery-related agitation (4 – 6). Due to guidelines of the American Academy of Pedi- 3 Frequently drowsy, drifts off to sleep
its rapid recovery time, propofol has be- atrics (14). All patients had been without oral during conversation
come a popular agent, but it, too, may be 4 Somnolent, minimal response to
intake for ⱖ4 hrs before the start of the pro-
physical stimulation
associated with respiratory depression cedure and had a functional intravenous cath-
and hypotension, and its use in some eter in place. Patients were continuously mon-
institutions or jurisdictions is restricted itored by the intensivist or a registered nurse
to anesthesiologists, limiting its availabil- throughout the procedure. Heart rate, respi-
ratory rate, and oxyhemoglobin saturation ratory effects of dexmedetomidine, the lowest
ity.
(SpO2) were continuously monitored in all pa- heart rate, blood pressure, respiratory rate,
Dexmedetomidine is a relatively new, and SpO2 recorded during sedation adminis-
tients, as was end-tidal CO2 (PetCO2) via nasal
␣2-adrenergic receptor agonist with both cannula whenever possible. Noninvasive blood tration were compared with baseline values
sedative and analgesic properties (7). It is pressure was measured every 5 mins during using a paired Student’s t-test. We considered
classified as a sedative and has been ap- the procedure and every 15 mins thereafter p ⬍ .05 as significant.
proved by the U.S. Food and Drug Admin- until the patient was awake (sedation score ⫽
istration for sedation in adults in inten- 1). Supplemental oxygen via nasal cannula RESULTS
sive care unit (ICU) settings for up to 24 was provided if SpO2 decreased below 93%.
hrs. In this setting, it has been reported Dexmedetomidine was diluted in 0.9% sa- Demographics. Forty-eight patients,
to provide effective sedation (8). We re- line to a final concentration of 1– 4 ␮g/mL. aged 6.9 ⫾ 3.7 yrs (range 5 months to 16
cently reported a similar experience in Depth of sedation was assessed using a modi- yrs), were sedated. Thirty-three received
fication of the University of Michigan Sedation dexmedetomidine primarily, whereas 15
mechanically ventilated children (9). Due
Scale (15) (Table 1). Due to the need for near- received it after failing sedation with
to limited respiratory depression (10), we motionlessness during most studies, deep se-
have also found it useful to control symp- chloral hydrate (n ⫽ 7), midazolam (n ⫽
dation was striven for with adequate sedation
toms of polysubstance withdrawal (11) defined as minimal response to transfer from 1), or both (n ⫽ 7). Patients were sedated
and refractory cyclic vomiting syndrome the gurney to the MRI scanner (sedation score for MRI (n ⫽ 46), electroencephalogram
(12) in spontaneously breathing children. ⫽ 3 or 4). Based on doses used during ICU followed immediately by MRI (n ⫽ 3),
After positive preliminary experience sedation (9), sedation was intended to be in- electroencephalogram (n ⫽ 3), and nu-
with dexmedetomidine for noninvasive duced with an initial bolus of 0.5 ␮g/kg clear medicine (n ⫽ 1) studies. The specif-
procedural sedation (13), we hypothe- dexmedetomidine administered over 5 mins (a ics of the procedures performed and under-
6-␮g/kg/hr infusion). If adequate sedation was lying diagnoses/indications for the entire
sized that it could be effectively used to
not achieved with this, the infusion was con- group as well as for the primary and rescue
provide routine sedation for children re- tinued at 6 ␮g/kg/hr until the patient fell
quiring these procedures. The current se- groups are provided in Table 2.
asleep. Sedation was maintained with an ini-
ries represents the first prospective eval- Sedation. For the entire group, seda-
tial infusion rate of 0.5 ␮g/kg/hr, which was
uation of dexmedetomidine for sedation titrated as needed to maintain a near-
tion was induced with 0.92 ⫾ 0.36 ␮g/kg
in this setting and adds to the limited motionless state during the procedure. (range 0.30 –1.92 ␮g/kg) of dexmedeto-
data regarding dexmedetomidine use in Data Collection. The following data were midine over 10.3 ⫾ 4.7 mins and was
the pediatric population. prospectively recorded. Demographic infor- maintained with infusions of 0.69 ⫾ 0.32
mation was collected including gender, ␮g/kg/hr (range 0.25–1.14 ␮g/kg/hr). The
weight, age, underlying diagnoses at the time mean procedure duration was 47 ⫾ 16
METHODS of procedure, and the procedure performed. mins. The mean recovery time was 84 ⫾
Sedation-related information was recorded in- 42 mins. All studies were successfully
Sedation. This study was approved by the cluding induction and maintenance doses of completed and no patient developed re-
Institutional Review Board of the University of dexmedetomidine, doses of failed sedatives
Missouri. Pediatric patients requiring sedation
covery-related agitation. Although the
used before “rescue” with dexmedetomidine,
for noninvasive procedures were enrolled. Pa- duration of induction (defined as the time
nature of many of the studies being per-
tients received dexmedetomidine as their pri- from when the induction bolus was initiated formed, specifically MRI, precluded for-
mary sedative if they were deemed poor can- to when the patient was adequately sedated), mal assessment of sedation depth during
didates for sedation with chloral hydrate or if duration of the procedure, recovery time (de- the actual procedure, sedation scores im-
they had failed previous sedation attempts fined as the time from discontinuation of the mediately before initiation of the proce-
with chloral hydrate. Criteria for poor candi- dexmedetomidine infusion to when the pa- dure indicated deep sedation (sedation
dates included age ⬎4 yrs and/or the presence tient had returned to baseline level of alert- scores of 3 [n ⫽ 28] and 4 [n ⫽ 20]).
of an underlying neurobehavioral disorder and ness), recovery patterns, and any other com- For the group receiving dexmedetomi-
were based on unpublished data from our in- plications. dine primarily, sedation was induced with
stitution showing a significant increase in Data Analysis. Quantitative data are pre- 0.95 ⫾ 0.35 ␮g/kg (range 0.45–1.92 ␮g/
chloral hydrate sedation failure rates in these sented as the mean ⫾ SD. Differences in in-
two populations. Dexmedetomidine was used
kg) administered over 10.8 ⫾ 5.0 mins (p
duction and maintenance dexmedetomidine
as rescue sedation in children of any age who doses, vital sign changes, and recovery pat- ⫽ not significant compared with overall
were inadequately sedated to allow procedure terns between patients receiving dexmedeto- and rescue groups) and maintained with
completion following administration of chlo- midine primarily or as rescue sedation were infusions of 0.67 ⫾ 0.30 ␮g/kg/hr (range
ral hydrate and/or benzodiazepines. This in- compared using an unpaired Student’s t-test. 0.25–1.14 ␮g/kg/hr, p ⫽ not significant
cluded either patients who never achieved ad- To maximally identify the adverse cardiorespi- compared with overall and rescue

436 Pediatr Crit Care Med 2005 Vol. 6, No. 4

groups). The mean recovery time was 69 heart rate (12.9 ⫾ 12.3 beats/min) and the pediatric practitioner. Although nu-
⫾ 34 mins (p ⫽ not significant compared blood pressure (19.0 ⫾ 18.4 mm Hg) com- merous sedatives are available for use in
with overall group, p ⫽ .0001 compared pared with baseline (p ⬍ .0001), but nei- this population, few combine all the
with rescue group). Patients in this group ther variable decreased below the 5th per- properties of an ideal sedative including
received no other sedatives, anxiolytics, centile for age. There were no episodes of reliability of sedation, predictability of
and/or analgesics during their sedation/ sinus pause. There were statistically signif- duration, short recovery time, and lim-
procedure. icant but clinically unimportant decreases ited cardiorespiratory effects. The current
For the group receiving dexmedetomi- in respiratory rate (3.0 ⫾ 3.5 breaths/min, study represents the largest series to date
dine as rescue sedation, sedation was in- p ⬍ .0001) and SpO2 (2.6 ⫾ 2.0%, p ⬍ .0001). describing the use of dexmedetomidine
duced with 0.83 ⫾ 0.33 ␮g/kg (range No patient developed hypoxemia (SpO2 sedation for noninvasive pediatric proce-
0.30 –1.40 ␮g/kg) administered over 9.3 ⬍93%) or required supplemental oxygen. dures. Our results suggest that it can be
⫾ 3.8 mins (p ⫽ not significant com- Baseline PetCO2 data are not available as an effective agent for these patients, ei-
pared with overall and primary groups) many patients would not tolerate preseda- ther when used primarily or when used as
and maintained with infusions of 0.73 ⫾ tion placement of nasal cannula. However, a rescue agent for patients failing seda-
0.38 ␮g/kg/hr (range 0.48 –1.04 ␮g/kg/hr; following sedation induction and cannula tion with more historically conventional
p ⫽ not significant compared with overall placement, PetCO2 exceeded 50 mm Hg in
sedatives.
and primary groups). The mean recovery only seven of 404 measurements (1.7%).
Dexmedetomidine appeared to be well
time was 117 ⫾ 41 mins (p ⫽ .01 com- These values occurred in two patients (one
tolerated. Sedation induction was smooth
pared with overall group and p ⫽ .0001 each in the primary and rescue groups),
with no patient demonstrating the agita-
compared with primary group). Rescue and the maximum PetCO2 value measured
tion or disorientation frequently seen with
patients had received a mean of 90 ⫾ 17 was 52 mm Hg. There were no significant
mg/kg chloral hydrate (n ⫽ 14) and/or differences in vital signs changes between chloral hydrate (2) or barbiturates. Rather,
0.09 ⫾ 0.05 mg/kg midazolam (n ⫽ 8) the primary and rescue groups. our patients remained calm and conversive
before receiving dexmedetomidine. with the sedation staff until they fell asleep.
Cardiorespiratory Effects. A compari- Although the sedation induction time was
DISCUSSION slightly longer than one might hope for
son of the changes in vital signs in each of
the three groups is presented in Table 3. Sedation of children for noninvasive with an intravenous agent (⫾10 mins), the
There were significant decreases in both procedures can often be a challenge for transition from conversive to asleep was
generally quick, occurring over 2–3 mins.
This induction time is shorter and less vari-
Table 2. Summary of procedures and indications by group able than that reported with chloral hy-
drate (mean 21–29 mins, range 5–240
Group
mins) (1, 2) and similar to that experienced
Diagnosis Entire (n ⫽ 48) Primary (n ⫽ 33) Rescue (n ⫽ 15) with using barbiturates (9 ⫾ 1 min) (6).
Although more rapid administration of the
Procedure induction bolus is possible, this may in-
EEG 4 1 3 crease the risk of bradycardia or sinus
MRI head 41 27 14
MRI, other 6 5 2 pause (16).
Nuclear medicine 1 1 0 Recovery from sedation was also
Diagnosis smooth, with no agitation or disorientation
Acute encephalopathy 2 1 1 reported. This is important since recovery-
Autism 4 3 1
Behavior disorder 5 4 1 related agitation can also be a significant
Brain tumor 3 0 3 problem with both chloral hydrate (1, 2)
Developmental delay 13 9 4 and barbiturate (5) sedation. This recovery
Knee fracture 1 1 0 pattern is also significant in that ⬎20% of
Headache 8 8 0
Joubert’s syndrome 1 1 0 our patients had a neurobehavioral diagno-
Renal obstruction 1 1 0 sis. These patients can be especially difficult
Static encephalopathy 1 1 0 to sedate, with a high risk of significant
Seizures 12 8 4 sedation-related agitation or combative-
Syrinx 1 1 0
Torticollis 2 1 1 ness, especially with chloral hydrate (JW
Berkenbosch, unpublished data, 2003).
EEG, electroencephalogram; MRI, magnetic resonance imaging. Further evaluation of the effects of dexme-

Table 3. Summary of vital sign changes during dexmedetomidine sedation

Group 2 BP, mm Hg 2 HR, beats/min 2 RR, breaths/min 2 Sao2, %

Overall (n ⫽ 48) 19.0 ⫾ 18.4 (16.6 ⫾ 14.0) 12.9 ⫾ 12.3 (12.4 ⫾ 12.6) 3.0 ⫾ 3.5 (13.4 ⫾ 16.1) 2.6 ⫾ 2.0 (2.6 ⫾ 2.1)
Primary (n ⫽ 33) 15.5 ⫾ 14.6 (13.8 ⫾ 12.9) 12.2 ⫾ 12.0 (12.0 ⫾ 14.0) 3.3 ⫾ 3.7 (14.8 ⫾ 17.3) 2.1 ⫾ 2.0 (2.1 ⫾ 2.0)
Rescue (n ⫽ 15) 31.1 ⫾ 29.4 (26.7 ⫾ 21.4) 14.5 ⫾ 13.0 (13.0 ⫾ 9.4) 2.3 ⫾ 2.9 (10.4 ⫾ 12.8) 3.2 ⫾ 1.6 (3.3 ⫾ 1.6)

BP, blood pressure; HR, heart rate; RR, respiratory rate; SaO2, arterial oxygen saturation; numbers in parentheses, the absolute decrease in each
parameter listed.

Pediatr Crit Care Med 2005 Vol. 6, No. 4 437

detomidine on sedation-related behaviors with sedation patterns reported with The doses of dexmedetomidine used in
in this population would be valuable. dexmedetomidine during mechanical this study are moderately higher than
Although the length of the recovery ventilation, wherein patients tend to be those reported for use during ICU seda-
period is relatively long (69 mins) com- calm and comfortable when left alone but tion (0.25– 0.75 ␮g/kg/hr) (8, 9, 17, 18).
pared with agents like propofol, these rouse more easily when stimulated than In fact, we based our initial sedation prac-
times also compare favorably to those re- when sedated with other agents (17). We tices on these reports, initially using a
ported with chloral hydrate (20 –120 observed similar behavior, with some pa- 0.5-␮g/kg induction and 0.5-␮g/kg/hr
mins) (1, 2) and barbiturates (30 – 60 tients rousing somewhat during transfer maintenance dose regimen. Although the
mins) (5, 6). It is probable that the recov- to the MRI table but rapidly settling once modest degree of patient movement ex-
ery period could be decreased by earlier the transfer and monitor placement were perienced with these doses in the ICU can
discontinuation of the infusion, but this complete. usually be tolerated, in the MRI scanner
must be balanced with an increased risk Despite its high affinity for the ␣2- vs. it prevented the acquisition of technically
of patient waking with subsequent move- ␣1-adrenergic receptor (1620:1), signifi- adequate studies, so deeper sedation, and
ment before completion of the study. cant cardiovascular effects, such as bra- subsequently higher drug doses, were re-
Further evaluation of this balance would dycardia, sinus pause, and hypotension, quired.
also be helpful. The increased recovery have been reported with dexmedetomi- Although not a primary goal of this
time in the rescue group is likely reflec- dine (16). We observed some of these study, our ability to use dexmedetomi-
tive of polypharmacy. effects too, recording mean decreases in dine as a rescue sedative bears some dis-
Outside of the operating room, early heart rate and blood pressure of 13% and cussion. Due to their convenience and
clinical applications with dexmedetomi- 19%, respectively. However, the clinical safety profile, enteral agents such as chlo-
dine focused on its use during mechani- significance of these changes remains un- ral hydrate or methohexital remain pop-
cal ventilation in the ICU, in both adults clear as neither variable decreased below ular choices. However, depending on the
(8, 17, 18) and children (9). However, the 5th percentile for age. In addition, procedure, failure rates of 20 –30% have
preprocedure blood pressure was ⬎50th been reported with both agents (6, 24),
experience with dexmedetomidine during
percentile for age and gender in more often requiring that the procedure be re-
spontaneous ventilation, when respira-
than two thirds of our patients, consis- scheduled. This may result in significant
tory effects are more pertinent, remains
tent with the preprocedure anxiety many
limited. In adults, clinical experience is inconvenience and distress for both the
of our patients admitted to feeling. Thus,
limited to use as an intramuscular anes- patient and his or her family. Although
it is likely that relief of this anxiety by
thetic premedication (19) or as an infu- the ability to provide rescue sedation is
sedation may have exacerbated true drug-
sion in the immediate postextubation pe- most significantly related to the experi-
related decreases in heart rate and blood
riod (8, 17). In these studies, respiratory ence and/or qualifications of the sedation
pressure. Furthermore, all patients had
rates and PaCO2 either are not reported providers, often meaning the availability
been nil per os for at least 4 hrs, and a
(19) or remain unchanged (8, 17). In of anesthesia and/or dedicated sedation
degree of intravascular volume depletion
spontaneously breathing children, services, certain rescue techniques such
may have also played a role in blood pres-
dexmedetomidine has been reported to sure decreases. as inhalational anesthesia or propofol are
effectively manage symptoms of polysub- Although significant respiratory de- not available to all practitioners. In many
stance drug withdrawal and postoperative pression has not been reported with institutions and licensure jurisdictions,
agitation (11) and acute episodes of cyclic dexmedetomidine, we noted a small but the use of propofol, an anesthetic by clas-
vomiting syndrome (12) and to control statistically significant decrease in both sification, is limited to anesthesiologists
shivering in the postanesthetic period respiratory rate and SpO2. These changes or anesthesia-based practitioners.
(11, 20). Although respiratory variables were clinically insignificant and no pa- Dexmedetomidine, on the other hand, is
other than respiratory rate and arterial tient became hypoxemic. Although our classified as a sedative and should be
oxygen saturation were not specifically sample size was small, this compares fa- available to any practitioners whose li-
evaluated in these studies, no adverse vorably with the findings of Malviya et al. censure and institutional credentialing
events were recorded. (22), who reported a 5.5% incidence of allow them to administer sedative agents.
To the best of our knowledge, the cur- hypoxemia overall, including a 5.3% in- However, as it is also a new agent, indi-
rent report represents the largest series cidence during sedation with chloral hy- vidual practitioners are encouraged to
evaluating dexmedetomidine for pediatric drate, in 1,140 children sedated by non- verify the drug’s status within their own
noninvasive procedural sedation and ex- anesthesiologists. Our finding that PetCO2 institutions and licensure jurisdictions.
pands on our earlier experience (13). Due rarely exceeded 50 mm Hg supports the With the increasing development of non-
to the analgesic properties of dexmedeto- limited effects of dexmedetomidine on anesthesiologist-based pediatric sedation
midine, one might also postulate use for respiration but implies that these effects services, through which sedation is pro-
invasive procedural sedation, although do exist and that ongoing monitoring and vided by pediatric intensivists, hospital-
the only data available regarding this use vigilance are required. Consistent with ists, or advanced practice nurses, the
refer to a failed attempt on our part to use this, Belleville et al. (23) reported an al- availability of dexmedetomidine as an al-
dexmedetomidine for upper gastrointes- tered CO2 response curve, decreased ternative rescue sedative should improve
tinal endoscopy sedation. Although sleep minute ventilation during hypercarbia patient and family satisfaction as well as
was easily induced, the patient woke im- (PetCO2 of 55 mm Hg), and occasional the efficiency of MRI and other scanner
mediately on insertion of the endoscope periods of apnea following a 2-␮g/kg bo- use by avoiding lengthy delays between
and required an alternative sedation reg- lus of dexmedetomidine to healthy when the scanner is ready and the patient
imen (21). However, this is consistent adults. falls asleep.

438 Pediatr Crit Care Med 2005 Vol. 6, No. 4

 One possible disadvantage of dexme- itation. Due to its short duration of ac- tional experience with dexmedetomidine in
detomidine is that it is somewhat more tion, it may be reasonably argued that pediatric patients. South Med J 2003; 96:
costly than other sedatives, the hospital propofol is a more attractive agent for 871– 875
cost for a 200-␮g vial being $57.20. This such sedations, but this is countered by 12. Khasawinah TA, Ramirez A, Berkenbosch
compares with $7.34 per 200-mg vial for the restricted access to propofol dis- JW, et al: Preliminary experience with
dexmedetomidine in the treatment of cyclic
propofol (one to two vials per patient), cussed here. Despite the absence of sig-
vomiting syndrome. Am J Ther 2003; 10:
$0.54 per 1000 mg for chloral hydrate nificant adverse events in this study, it
303–307
liquid, and $44.22 per 1000-mg vial for must be remembered that adverse cardio- 13. Nichols DP, Berkenbosch JW, Tobias JD: Res-
pentobarbital. However, this difference is respiratory effects may occur with any cue sedation with dexmedetomidine for diag-
small when compared with the overall sedative and that appropriate monitoring nostic imaging. Paediatr Anaesth, In Press
charge for an MRI evaluation (several should be in place during all sedations, as 14. American Academy of Pediatrics, Committee
thousands of dollars). Furthermore, one well as immediate access to both resusci- on Drugs, Section on Anesthesiology. Guide-
must also consider the additional costs of tation equipment and personnel. It is also lines for the elective use of conscious seda-
prolonged postsedation monitoring or important that further evaluation of tion, deep sedation, and general anesthesia in
scanner inefficiency due to prolonged se- dexmedetomidine in this and other pop- pediatric patients. Pediatrics 1985; 76:
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