Sedation Using Dexmedetomidine in Pediatric Burn Patients

Abstract

Maintaining appropriate sedation and analgesia in pediatric burn patients can be quite challenging and often requires high doses of analgesics and anxiolytics because tolerance quickly develops. Escalating doses of opioids and benzodiazepines provide little additional benefit while increasing the incidence of side effects. Dexmedetomidine (DEX) is a novel alpha2-adrenergic agonist that provides sedation, anxiolysis, and analgesia with much less respiratory depression than other sedatives. In addition, DEX stimulation of alpha2 receptors on pancreatic beta cells may inhibit insulin secretion. Hyperglycemia has not been studied specifically in patients receiving DEX. Therefore, we hypothesized that DEX would improve sedation compared with our standard sedation regimen. In addition, we studied the effects of DEX on blood glucose levels. We performed a retrospective chart review of 65 pediatric burn patients (42 boys, 23 girls) in the intensive care unit admitted between 2001 and 2004 who received DEX infusion because of failure to achieve adequate sedation with our standard regimen of opioids and benzodiazepines. We recorded age, TBSA burn size, weight, dose and duration of infusion, adequacy of sedation before and after initiation of DEX, blood glucose levels before and after DEX, and the presence or absence of mechanical ventilation. The mean age was 5 years (range, 0.6-17), burn size was 36% TBSA (range, 3-94), and weight was 26 kg (range, 8-100). All patients were rated "inadequately sedate" before DEX infusion was initiated at 0.2 mug/kg/hr and titrated to effect. Twenty-six patients received a loading dose of 1 mug/kg. The average duration of DEX infusion was 11 days (range, 2-50), and no tachyphylaxis was noted. The mean dose was 0.5 mug/kg/hr (range, 0.1-2). Infusions were weaned over the course of 12 to 24 hours without evidence of rebound hypertension or withdrawal. With DEX titration, all patients were rated "adequately sedate," even though all were sedation failures with opioids and benzodiazepines. Eleven of 42 patients receiving ventilatory support were extubated while on DEX infusion, and no patient showed evidence of DEX induced respiratory depression. Patient's blood glucose levels averaged 121.2 +/- 8.9 mg/dl while on DEX infusion and 117.1 +/- 12.1 mg/dl while off, a nonsignificant difference.

Safety and Effectiveness of Dexmedetomidine in the Pediatric Intensive Care Unit (SAD–PICU)

“…This result contradicts earlier findings in smaller pediatric critical care studies, which indicated that dexmedetomidine was associated with adequate sedation in greater than 90% of cases. 3,24,27 However, investigators in previous studies used different methods of evaluating sedation, for example, using alternative evaluation tools or counting the number of rescue bolus doses. In addition, lack of familiarity with dexmedetomidine, especially immediately after its addition to the hospital formulary, may have led to less than optimal use.…”

Dexmedetomidine reduces cranial temperature in hypothermic neonatal rats

“…It is recommended for short-term use only, less than 48 h. Minimal efficacy, pharmacokinetic, and safety data exist for neonates. Despite limited testing and without current Food and Drug Administration approval, the off-label use of DEX in pediatric and neonatal intensive care units is increasing (10)(11)(12). Since DEX can provide sedation and prevent shivering, it is a viable alternative to opioids for neonatal intensive care units patients undergoing therapeutic hypothermia as treatment for HIE.…”

Use of Dexmedetomidine Infusion With Subanaesthetic Dose of Ketamine for Minor Surgical Procedures: A Study

“…Owens et al [6] in their study found that 2.9% of the patients who received ketamine during sedation experienced side effects such as desaturation, apnoea, hypotension. Walker et al [23] found that no respiratory depression associated with the use of dexmedetomidine had occurred. Taghinia et al [24] also reported that dexmedetomidine decreases the frequency of oxygen desaturation and reduces the amounts of narcotic and anxiolytic requirement.…”