Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review

Abstract

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

Pharmacologic Procedural Distress Management During Laceration Repair in Children

“…However, another study noted patient complaints with oral ketamine because of its bitter taste 17 . These findings align with prior reviews that reported patients experiencing the most irritation with intranasal midazolam 3 . While intranasal midazolam has the benefits of requiring a lower dose than oral midazolam to achieve adequate sedation, the intranasal irritation may prompt a need for physical restraint.…”

“…Of note, 2 of the more recently published included studies found that intranasal midazolam was either equivalent or more favorable to oral midazolam 28,29 . The trade-off, however, was a significantly lower administration tolerance with the intranasal route 3 . Overall, clinicians must carefully consider available treatment options alongside their health service and patient impact factors.…”

“…28,29 The trade-off, however, was a significantly lower administration tolerance with the intranasal route. 3 Overall, clinicians must carefully consider available treatment options alongside their health service and patient impact factors. These include AEs, available and/or patient-preferred routes of administration, need for additional sedation, ED LOS, and satisfaction of patients, parents, or staff.…”

“…17 These findings align with prior reviews that reported patients experiencing the most irritation with intranasal midazolam. 3 While intranasal midazolam has the benefits of requiring a lower dose than oral midazolam to achieve adequate sedation, the intranasal irritation may prompt a need for physical restraint. Tolerability for oral routes may be improved by using a flavoring agent.…”

“…Laceration repair is one of the most common anxiety-inducing procedures for children, 1 accounting for nearly half of all procedures in Canadian emergency departments (EDs) and 8.2% of ED visits in the United States 2,3 . A successful laceration repair requires a child to be calm, yet suboptimal distress management is continually reported in ED settings 4–7 …”