Running head: PREMEDICATIONS IN PEDIATRIC 1

Premedications in Pediatric Anesthesia: Comparing Efficacy of Dexmedetomidine and

Midazolam

Allison B. Hensley, RN

James Madison University

PREMEDICATIONS IN PEDIATRIC 2

Abstract

FOR EBLR part 1 assignment you do not need to write an abstract

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Premedications in Pediatric Anesthesia: Comparing Efficacy of Dexmedetomidine and

Midazolam

Premedication in pediatric patients has been proven successful in decreasing anxiety prior

to any procedure involving anesthesia (Keles & Kocaturk, 2018). While preoperative

cooperation is necessary, decreasing emergence agitation is also important. For this literature

review, we will be examining the effects of dexmedetomidine in comparison to midazolam when

given as premedications to pediatric patients. At my place of work, midazolam is a commonly

used premedication among pediatric patients undergoing dental anesthesia procedures. However,

some disadvantages observed with this medication include respiratory depression, a lack of

analgesic effect, and negative postoperative behavior (Sajid, Mohamed, & Jumaila, 2019). As a

nurse in a dental office, my role involves assisting our dental anesthesiologist (DA), as well as

our certified registered nurse anesthetist (CRNA) in caring for pediatric patients both

preoperatively and postoperatively. Communicating patient experiences and behavior to my team

is crucial in generating positive patient outcomes, with a common aim to provide current best

practice. In this review, dexmedetomidine is being examined as a potential alternative to

midazolam.

Population

For this review we will be focusing on the pediatric population between 1 and 12 years of

age. Within this age range, approximately 50 percent of patients present with significant

preoperative apprehension and fear (Jannu, Mane, Dhorigol, & Sanikop, 2016). According to

Sajid, Mohamed and Jumaila (2019), the percentage is even higher at 60%-70%. An increase in

anxiety occurs once they are separated from their parent(s) or family members. Emergence

agitation (EA) is also a common issue among this population, which include behaviors such as
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thrashing, kicking, and uncontrollable crying. The child may wake up experiencing

hallucinations and disorientation, which may lead to additional nursing care, and a delayed

discharge from recovery (Keles & Kocaturk, 2018). In instances such as these, pharmacologic

agents may be indicated and used as premedications in order to assist in child-parent separation,

and promote a smooth induction of anesthesia ( Chatrath, Kumar, Sachdeva, & Thakur, 2018).

Intervention

The use of dexmedetomidine as a premedication for pediatric procedures has been on the

rise. Advantages of dexmedetomidine as a premedication include it’s sedative, analgesic, and

anti-anxiety properties, with minimal respiratory depression ( Mohite, Baliga, Thosar, & Rathi,

2019). In addition, dexmedetomidine has been found to reduce the severity of EA among

children, making the overall experience less frightening for both the patient and family (Sajid et

al., 2019). This can be linked to the longer duration of dexmedetomidine, in that this

premedication lasts the duration of the procedure, aiding in a calm postoperative period (Chatrath

et al., 2018). In providing adequate sedation, along with cardiovascular and respiratory stability,

dexmedetomidine is now being preferred over midazolam by many providers (Prabhu &

Mehandale, 2017).

Current standard of care

The current practice within our dental office involves the use of oral midazolam as a

premedication prior to dental procedures. While this medication provides reliable sedation and

an amnesic effect for our pediatric patients, it also has it’s disadvantages. These include a bitter

taste when administered orally, a decrease in respirations, a lack of analgesic properties, and

occasionally paradoxical reactions (Keles & Kocaturk, 2018). Patients often refuse or spit out

this premedication when administered orally. While midazolam promotes a smooth induction
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into anesthesia, it does not seem to have a direct impact on decreasing EA. It has been shown

that effective treatment of post-operative pain has been linked to a reduced incidence of EA

(Prabhu & Mehandale, 2017). Without analgesic effects, patients who are given midazolam as a

premedication are at higher risk for EA, in comparison with dexmedetomidine (Keles &

Kocaturk, 2018).

Outcome

According to Prabhu and Mehandale (2017), the administration of dexmedetomidine as a

premedication is superior to midazolam in that it provides smooth induction and recovery,

reduces the occurrence of EA and provides better overall analgesic effect. In the dental setting, it

is important to minimize emotional trauma among pediatric patients. Patients who have negative

dental experiences as children have a lower occurrence of maintaining proper oral hygiene and

dental care in adulthood (Mohite et al., 2019). In addition to the advantages of dexmedetomidine,

it has also been linked to a postoperative reduction of nausea and vomiting (Mohite et al., 2019).

It is anticipated that the use of dexmedetomidine as a premedication will generate higher positive

outcomes among pediatric patients undergoing dental anesthesia in comparison to midazolam.

Clinical setting

Pediatric patients who generally have low levels of cooperation during dental visits, also

present with uncooperative behaviors during the preoperative period for dental anesthesia (Keles

& Kocaturk, 2018). Thus, the need for a premedication is necessary for successful dental

procedures. In the past, non-pharmacologic control techniques were used in instances such as

these. These included things such as voice control, restraints and intimidation (Keles &

Kocaturk, 2018). Often, these methods were not therapeutic, and proved inadequate in

completion of required dental treatment. These control techniques are not used within our dental
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clinic. As a nurse, I aim to provide a positive experience within our office for both the patient

and their families. Recent studies has shown that administering dexmedetomidine as a

premedication is more therapeutic in comparison to midazolam. My goal is to use current best

practice within my occupation, and advocating for updated changes within the world of

anesthesia is necessary in achieving this goal.

Research question

For the pediatric patient, does the use of dexmedetomidine as a premedication aid in

parental separation, and reduce the future risk of emergence agitation in comparison with

midazolam?

PICO

P - Pediatric population within a dental clinic with proposed treatment to be completed

under general anesthesia.

I – Administration of dexmedetomidine to pediatric patients as a pre-anesthetic

medication.

C – Administration of midazolam to pediatric patients prior to their procedure.

O – Administration of dexmedetomidine as a premedication to pediatric patients will

lessen separation anxiety from parents and decrease the occurrence of emergence agitation.
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References

Chatrath, V., Kumar, R., Sachdeva, U., & Thakur, M. (2018). Intranasal Fentanyl,

Midazolam and Dexmedetomidine as Premedication in Pediatric Patients. Anesthesia, essays and

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Jannu, V., Mane, R. S., Dhorigol, M. G., & Sanikop, C. S. (2016). A comparison of oral

midazolam and oral dexmedetomidine as premedication in pediatric anesthesia. Saudi journal of

anaesthesia, 10(4), 390–394. https://doi.org/10.4103/1658-354X.177333

Keles, S., & Kocaturk, O. (2018). Comparison of oral dexmedetomidine and midazolam

for premedication and emergence delirium in children after dental procedures under general

anesthesia: a retrospective study. Drug design, development and therapy, 12, 647–653.

https://doi.org/10.2147/DDDT.S163828

Mohite, V., Baliga, S., Thosar, N., & Rathi, N. (2019). Role of dexmedetomidine in

pediatric dental sedation. Journal of dental anesthesia and pain medicine, 19(2), 83–90.

https://doi.org/10.17245/jdapm.2019.19.2.83

Prabhu, M. K., & Mehandale, S. G. (2017). Comparison of oral dexmedetomidine versus

oral midazolam as premedication to prevent emergence agitation after sevoflurane anaesthesia in

paediatric patients. Indian journal of anaesthesia, 61(2), 131–136. https://doi.org/10.4103/0019-

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Sajid, B., Mohamed, T., & Jumaila, M. (2019). A comparison of oral dexmedetomidine

and oral midazolam as premedicants in children. Journal of Anaesthesiology Clinical

Pharmacology, 35(1), 36–40. https://doi.org/10.4103/joacp.JOACP_20_18