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      Comparison of Oral Clonidine, Oral Dexmedetomidine, and Oral Midazolam for Premedication in Pediatric Patients Undergoing Elective Surgery

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          Abstract

          Background:

          Midazolam has been commonly used orally for premedication in children. A search for a better alternative continues to overcome its side effects. Recently alpha-2 agonists, clonidine, and dexmedetomidine have been used for premedication in children.

          Aim:

          To study and compare the efficacy of oral clonidine, oral dexmedetomidine, and oral midazolam for premedication in pediatric surgical patients.

          Settings and Design:

          This prospective, randomized, double blind study was conducted in a tertiary care hospital.

          Materials and Methods:

          The study was conducted in ninety children of either sex, in the age group of 4–12 years and the American Society of Anesthesiologists Physical status I, posted for ophthalmic surgery. Patients were randomly allocated to one of the three groups of thirty patients each: Group M: Oral midazolam 0.5 mg/kg body weight, Group D: Oral dexmedetomidine 4 μg/kg body weight, and Group C: Oral clonidine 4 μg/kg body weight. Patients were assessed for sedation, anxiolysis, and change in heart rate and blood pressure in the preoperative area. Behavior of children at separation from parents, mask acceptance, and side effects if any were noted.

          Statistical Analysis:

          Data analysis was performed by unpaired Student's t-test and Chi-square test.

          Results:

          Children in oral midazolam group achieved faster onset of sedation, higher sedation score, and lower anxiety score as compared to other two groups. The Group D and Group M were comparable as regards behavior at separation from parents ( P = 0.236), but Group D was significantly better than Group C ( P = 0.031). The three groups were comparable as regards providing satisfactory mask acceptance ( P = 0.163). A number of children with easy separation from parents and excellent mask acceptance were significantly more in Group M as compared to Groups C and D ( P = 0.028 and P = 0.012, respectively). Group C and Group D showed a lower mean arterial pressure at 45 min ( P < 0.001) and 60 min after premedication ( P < 0.001) as compared to Group M.

          Conclusion:

          Oral midazolam is superior to the oral clonidine, and oral dexmedetomidine with faster onset of sedation, higher sedation score, lower anxiety score, and greater number of children with easy separation and excellent mask acceptance.

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          Most cited references 27

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          alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role.

          Clonidine has proved to be a clinically useful adjunct in clinical anaesthetic practice as well as in chronic pain therapy because it has both anaesthetic and analgesic-sparing activity. The more selective alpha-2 adrenoceptor agonists, dexmedetomidine and mivazerol, may also have a role in providing haemodynamic stability in patients who are at risk of peri-operative ischaemia. The side-effects of hypotension and bradycardia have limited the routine use of alpha-2 adrenoceptor agonists. Investigations into the molecular pharmacology of alpha-2 adrenoceptors have elucidated their role in the control of wakefulness, blood pressure and antinociception. We discuss the pharmacology of alpha-2 adrenoceptors and their therapeutic role in this review. The alpha-2 adrenoceptor agonists are agonists at imidazoline receptors which are involved in central blood pressure control. Selective imidazoline agonists are now available for clinical use as antihypertensive agents and their pharmacology is discussed.
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            A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial.

            Midazolam is the most commonly used premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving compliance at induction of anesthesia. Clonidine, an alpha(2) agonist, has been suggested as an alternative. Dexmedetomidine is a more alpha(2) selective drug with more favorable pharmacokinetic properties than clonidine. We designed this prospective, randomized, double-blind, controlled trial to evaluate whether intranasal dexmedetomidine is as effective as oral midazolam for premedication in children. Ninety-six children of ASA physical status I or II scheduled for elective minor surgery were randomly assigned to one of three groups. Group M received midazolam 0.5 mg/kg in acetaminophen syrup and intranasal placebo. Group D0.5 and Group D1 received intranasal dexmedetomidine 0.5 or 1 microg/kg, respectively, and acetaminophen syrup. Patients' sedation status, behavior scores, blood pressure, heart rate, and oxygen saturation were recorded by an observer until induction of anesthesia. Recovery characteristics were also recorded. There were no significant differences in parental separation acceptance, behavior score at induction and wake-up behavior score. When compared with group M, patients in group D0.5 and D1 were significantly more sedated when they were separated from their parents (P < 0.001). Patients from group D1 were significantly more sedated at induction of anesthesia when compared with group M (P = 0.016). Intranasal dexmedetomidine produces more sedation than oral midazolam, but with similar and acceptable cooperation.
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              Bioavailability of dexmedetomidine after extravascular doses in healthy subjects.

              To determine the absolute bioavailability of extravascularly administered dexmedetomidine, a novel a2-adrenoceptor agonist, in healthy subjects. Single 2 microg x kg-1 doses of dexmedetomidine were given intravenously, intramuscularly, perorally and buccally (where the solution is not swallowed) to 12 healthy male subjects. The drug concentration-time data were analysed using linear one-compartment (buccal and peroral data), or two-compartment modelling (intravenous data), or noncompartmental methods (intramuscular data). Mean (95% CI) absolute bioavailability after peroral, buccal and intramuscular administration was 16% (12-20%), 82% (73-92%) and 104% (96-112%), respectively. Dexmedetomidine is well absorbed systemically through the oral mucosa, and therefore buccal dosing may provide an effective, noninvasive route to administer the drug.
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                Author and article information

                Journal
                Anesth Essays Res
                Anesth Essays Res
                AER
                Anesthesia, Essays and Researches
                Medknow Publications & Media Pvt Ltd (India )
                0259-1162
                2229-7685
                Jan-Mar 2017
                : 11
                : 1
                : 185-191
                Affiliations
                Department of Anaesthesia, Rajarajeswari Medical College, Bengaluru, Karnataka, India
                [1 ]Department Of Anaesthesia And Intensive Care, Vardhman Mahavir Medical College And Safdarjung Hospital, New Delhi, India
                Author notes
                Address for correspondence: Dr. Nidhi Agrawal, House No. 22, Samachar Apartments, Mayur Vihar Phase 1 Extension, New Delhi - 110 091, India. E-mail: nidhi.agrawal1970@ 123456gmail.com
                Article
                AER-11-185
                10.4103/0259-1162.194586
                5341645
                28298782
                Copyright: © 2017 Anesthesia: Essays and Researches

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                Categories
                Original Article

                premedication, clonidine, dexmedetomidine, midazolam, pediatric

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