SummaryPrevious studies have shown that 1 lg.kg )1 intranasal dexmedetomidine produces significant sedation in children aged between 2 and 12 years. This investigation was designed to evaluate the onset time. One hundred children aged 1-12 years of ASA physical status 1-2 undergoing elective surgery were randomly allocated to five groups. Patients in groups A to D received intranasal dexmedetomidine 1 lg.kg. Patients in Group E received intranasal placebo (0.9% saline). Children from groups A, B, C, D and E had intravenous cannulation attempted at 30, 45, 60, 75 and 45 min respectively after intranasal drug or placebo administration. Vital signs, behaviour and sedation status of the children were assessed regularly until induction of anaesthesia. More children from groups A to D achieved satisfactory sedation at the time of cannulation when compared to group E (p < 0.001). The proportion of children who achieved satisfactory sedation was not significantly different among groups A to D. Overall 62% of the children who received intranasal dexmedetomidine had satisfactory sedation at the time of cannulation. The median (95% CI) time for onset of sedation was 25 (25-30) min. The median (95% CI) duration of sedation was 85 (55-100) min. Dexmedetomidine, a selective a2 agonist, has a sedative action via the locus coeruleus with EEG activity similar to natural sleep. It produces analgesia as well as sedation and has minimal or no effect on respiratory rate or tidal volume [1,2]. There is increasing evidence that dexmedetomidine is an effective and safe sedative in children in the critical care setting [3-6], for various diagnostic procedures [7][8][9][10][11][12][13] and pre-operatively [14][15][16]. Previous investigations have shown that 1 lg.kg )1 intranasal dexmedetomidine produces significant sedation in healthy adults [17] and in children aged between 2 and 12 years [15]. Intranasal application is a relatively non-invasive and easy route of administration which has the additional benefit of not requiring patient cooperation as would be the case for swallowing the medication or retaining it sublingually. It is well tolerated and does not have an unpleasant taste or pungency. Although it is established that intranasal dexmedetomidine is an effective sedative for premedication in children [14][15][16], no data have been published on its onset time or duration of action in the paediatric population. In healthy adult volunteers the onset time was about 45 min [17]. The primary aim of this investigation was to evaluate the optimal time to perform intravenous cannulation in children after 1 lg.kgintranasal dexmedetomidine. Intravenous cannulation was chosen as an endpoint because intravenous induction is commonly employed in children [18] and because the timing could be controlled, whereas the time of anaesthetic induction, which is a more commonly used endpoint in paediatric premedication studies, is too dependent on the operating theatre schedule. Secondary outcomes of this investigation included onset time and durati...

SummaryWe compared sedation levels in children following administration of intranasal dexmedetomidine. One hundred and sixteen children aged between 1 and 8 years were enrolled in this prospective, randomised trial. Children were assigned to receive either intranasal dexmedetomidine 1 lg.kg )1 (Group 1) or 2 lg.kg )1 (Group 2). Thirty-one (53%) patients from Group 1 and 38 (66%) patients from Group 2 were satisfactorily sedated at the time of anaesthetic induction. Logistic regression showed a significant interaction effect (p = 0.049), with the odds ratio between Group 2 over Group 1 estimated as 1.1 (95% CI 0.5-2.7) for the 1-4 year age group, and 10.5 (95% CI 1.4-80.2) for the 5-8 year age group. Both doses produced a similar level of satisfactory sedation in children aged 1-4 years, whereas 2 lg.kg )1 resulted in a higher proportion of satisfactory sedation in children aged 5-8 years. There were no adverse haemodynamic effects. We conclude that intranasal dexmedetomidine in a premedication dose of 2 lg.kg )1 resulted in excellent sedation in children. Dexmedetomidine is an a 2 -adrenergic receptor agonist that provides sedation without respiratory depression. Clinical trials have demonstrated that intranasal dexmedetomidine in a dose of 1 lg.kg )1 produces satisfactory sedation in between 53% and 57% of children at anaesthetic induction [1,2]. There are also reports using higher doses of intranasal dexmedetomidine [3]. We compared the sedative effect of 1 lg.kg )1 intranasal dexmedetomidine with those of 2 lg.kg )1 for premedication in children aged 1-8 years and hypothesised that the higher dose would produce satisfactory sedation in more children at the time of anaesthetic induction. MethodsThis study was approved by the local research ethics committee and written informed consent was obtained from the parents or legal guardians of all the patients. Children weighing between 7 and 17 kg, of ASA physical status 1 or 2, aged 1-8 years, who were scheduled for elective surgery at either Queen Mary Hospital, Hong Kong (QMH) or the University of Malaya, Kuala Lumpur Malaysia (UM) were enrolled in the study. If the child understood and discussed the need for premedication, then his ⁄ her assent was also obtained. Exclusion criteria included known allergy or

Geriatric hip fracture is one of the commonest fractures in orthopaedic trauma. There is a trend of further increase in its incidence in the coming decades. Besides the development of techniques and implants to overcome the difficulties in fixation of osteoporosis bone, the general management of the hip fracture is also very challenging in terms of the preparation of the generally poorer pre-morbid state and complicate social problems associated with this group of patients. In order to cope with the increasing demand, our hospital started a geriatric hip fracture clinical pathway in 2007. The aim of this pathway is to provide better care for this group of patients through multidisciplinary approach. From year 2007 to 2009, we had managed 964 hip fracture patients. After the implementation of the pathway, the pre-operative and the total length of stay in acute hospital were shortened by over 5 days. Other clinical outcomes including surgical site infection, 30 days mortality and also incidence of pressure sore improved when compared to the data before the pathway. The rate of surgical site infection was 0.98%, and the 30 days mortality was 1.67% in 2009. The active participation of physiotherapists, occupational therapists as well as medical social workers also helped to formulate the discharge plan as early as the patient is admitted. In conclusion, a well-planned and executed clinical pathway for hip fracture can improve the clinical outcomes of the geriatric hip fractures.

SummaryWhen providing total intravenous anaesthesia, careful selection of end-points is required in titrating dose to effect during induction. Although propofol and remifentanil have predominantly different pharmacodynamic effects, they are seen to interact in achieving loss of consciousness and analgesia. To highlight these differences, we performed a double-blind, randomised controlled trial, comparing one group of patients receiving propofol alone (n = 42) with another group receiving remifentanil plus propofol (n = 46) as a target-controlled infusion of remifentanil (Minto; 3 ng.ml À1 ). Propofol was also titrated using a target-controlled infusion (Marsh effect model) to produce loss of response to tactile and vocal stimuli, and subsequently to loss of response to pain. The effect-site concentration of propofol at which 50% of patients lost tactile/verbal response was 2.9 lg.ml À1 in the propofol only group and 2.4 lg.ml À1 in the remifentanil with propofol group. In contrast, loss of pain response occurred at 4.4 lg.ml À1 in the propofol group, and 2.7 lg.ml À1 in the remifentanil with propofol group, with correspondingly lower bispectral index values. Judicious use of analgesia in total intravenous anaesthesia can have a propofol-sparing effect and potentially minimise the suppression of brain electrical activity.