Oral Dexmedetomidine for Parental Separation in Pediatrics Undergoing Adenotonsillectomy
Condition: Adenotonsillectomy
Study type: Interventional
Phase: Phase 4

Summary: 
      The efficacy of oral dexmedetomidine as sedative versus a combination of oral midazolam plus
      oral ketamine were compared regarding to satisfactory separation from parents, satisfactory
      mask induction and postoperative rescue analgesia in Pediatrics undergone Adenotosillectomy
    

Detailed description: 
      After obtaining approval from the research Ethics Committee of the Suez Canal University
      Hospitals and written informed consent from the parents of each participant, 74 American
      Society of Anesthesiologists (ASA) physical status I and ІІ children aged 3-10 years
      scheduled for adenotonsillectomy under general anesthesia were enrolled into the study.

      Patients were randomly assigned into one of two equal groups on alternative basis using
      closed envelope method; 37 patients for each group.

      Group (D): Patients who received oral dexmedetomidine (4 µg/kg) mixed with apple juice to
      fill the syringe up to 10 ml.

      Group (MK): Patients who received a combination of oral midazolam (0.5 mg/kg) and oral
      ketamine (1 mg/kg) mixed with apple juice to fill the syringe up to 10 ml.

      Methods:

      I- Preoperative visit:

      During the preoperative visit, the following was done:

        1. A written informed consent from the parents of each participant was obtained.

        2. The techniques were explained to the parents including benefits and complications.

      II- Preoperative assessment:

      This includes:

      A) Medical history:

        1. Medical disorders (as diabetes, heart, chest, liver or kidney diseases).

        2. Past history of operations, hospitalization or blood transfusion.

        3. Past anesthetic history with impact on previous airway problems during previous
           surgeries, hypersensitivity to anesthetic medications, any previous postoperative
           complications that could be attributed to anesthesia.

        4. Family history for specific anesthetic problems like malignant hyperthermia.

      B) Physical examination:

      1- General examination. 2- Vital signs (heart rate, blood pressure, respiratory rate and
      temperature). 3- Heart, chest and abdominal examinations.

      C) Anesthetic assessment:

        1. Examination of the limbs for prediction of difficult cannulation.

        2. Airway assessment.

        3. Fasting hours: none of children were given any solid food 6 hours before the operation,
           but they were allowed to take clear fluids, soft drink or water until 2 hours before
           induction of anaeshesia.

      D) Laboratory investigations:

        1. Complete blood count (CBC).

        2. Prothrombin time (PT), international normalized ratio (INR) and partial tissue
           thromboplastin time (PTT).

      III- Demograghic data:

      The patient's age, sex, weight, height and body mass index (BMI)were recorded.

      IV-Intraoperative assessment:

        1. Airway devices, anesthesia machine, ventilator, flowmeters and equipments were checked
           promptly.

        2. Randomization: participants were randomly allocated to one of two equal groups, (group
           D) using orally given dexmedetomidine and (group MK) using orally given
           midazolam/ketamine using block randomization.

           Concealed allocation: closed envelope method for randomization containing code for
           dexmedetomidine group (D) or midazolam/ketamine group (MK). To ensure allocation
           concealment, the envelopes will be prepared by anesthesia nurse not involved in the
           study. Those enrolled after written informed consent were asked to pick one concealed
           envelope from the box and hand it over to the investigator concerned. The investigator
           then assigned to either (D) or (MK) according to the envelope code.

           Blinding: patients were blinded after assignment to interventions and randomly assigned
           into one of two equal groups. It was double blinded since the investigator was not aware
           of both groups.

        3. During the preoperative visit, the researcher explained to the child and family what was
           done in the morning of surgery. The child was blinded to the used drug and was asked to
           choose a sealed envelope with his/her code number inside. The name, file number and body
           weight were recorded on the sealed envelope after been chosen. The on duty anesthetist
           was blinded to the premedication.

        4. Parents were not aware of the premedication components, but oriented and agreed with our
           protocol. In the morning of operation, the study medications were prepared by a trained
           nurse into identical 10 ml syringes that were sequentially numbered. Each labeled
           syringe was mixed with apple juice to be given to the children. Premedication was given
           by one of the parents under supervision of anesthetist.

        5. Premedication phase:The attending anesthetist in pre-anesthesia area reported the onset
           of premedication and level of sedation and the occurrence of vomiting was also
           monitored; children who vomited were excluded from the study. Thirty minutes after
           premedication, Parents accompanied their children till the Red-Line of the operating
           room, but their presence in the induction room was not be permitted according to the
           policy of the hospital.

      Premedication was given orally to the children in the preanaesthetic room. (Group D) patients
      received dexmedetomidine(4 µg/kg) mixed with apple juice to fill the syringe up to 10 ml
      given orally and (group MK) patients received a combination of midazolam (0.5 mg/kg) and
      ketamine (1 mg/kg) mixed with apple juice to fill the syringe up to 10 ml and given orally.

      Level of Sedation was assessed by Sedation Score (adapted from Wilton et al)(125)

      Sedation and anxiolytics were evaluated in untouched patients. Then additional evaluation of
      cooperation e.g. (placement of the pulse oximetry sensor, electrocardiogram electrodes and
      mask induction of anesthesia) was performed.

      The sedation score values were condensed to a variable consisting of three categories:

      (Levels 1 and 2) Unacceptable conditions. (Levels 3 and 4) Acceptable conditions. (Level 5)
      Unacceptable deep sedation.

      The behavior of the child during preoperative period was evaluated by the anesthesiologist
      using sedation score; the rating was performed at five different times:

      (1) 2.5 minutes after oral drug administration. (2) 5 minutes after oral drug administration.
      (3)During separation from parents (at levels 3 and 4). (4) During introduction of the
      anesthesia mask to the child. (5) Immediately postoperative in PACU.

      Whatever satisfaction of sedation was achieved or not after 60 min, anesthesia induction was
      performed.

      Onset of sedation was defined as: the minimum time interval necessary for the child to become
      drowsy or asleep.

      Peak sedative effect was defined as: the time interval from drug administration to reach the
      maximum level of sedation.

      Both of onsets of sedation and peak sedative effect were recorded. Sedation and Anxiety
      levels were recorded every 15 min for a maximum time of 60 min after premedication In case a
      child came to the operating room already asleep, a steal induction was attempted.

      Assessment of drug reaction after drug administration:

      1=Crying 2=Not crying 3=Excessive salivation 4=Sneezing 5=cough

      Evaluation of drug taste by 4-point scale after oral drug administration:

        1. Good 3= Bitter

        2. Indifferent 4= Unpleasant

      6- Induction Phase: Children were transferred to the operating room; inhalational induction
      via transparent face mask (Jackson-Rees modification of Ayer's T-piece) was done using
      sevoflurane (Abbott, Abbott Park, Illinois, USA)started at a concentration of 1% and then
      increased every three breaths to a maximum of 8 % in 100% oxygen (6 L /min).The anesthetist
      asked the child to blow the balloon.

      Five-point scale was used to assess Mask acceptance:

        1. = Combative, crying

        2. = Moderate fear of the mask, not easily calmed

        3. = Cooperative with reassurance

        4. = Calm, cooperative

        5. = Asleep

           Mask induction scores of 1 and 2 were considered unsatisfactory. Scores of 3-5 were
           considered a successful response to premedication.

           After loss of consciousness, an intravenous line was inserted and when adequate depth of
           anesthesia was reached, endotracheal tube of appropriate size for the age and weight of
           the child was placed and patient was allowed to breathe spontaneously.

      7- Intraoperative Monitoring: Monitoring equipment (Datex-Ohmeda, Helsinki, Finland™) was
      connected to each patient with standard monitoring including ECG, Non invasive blood
      pressure, Respiratory Rate, Pulse oximetry, Temperature and both inspiratory and
      end-expiratory Capnography.

      Heart rate and blood pressure were recorded before premedication as a baseline then every 15
      min until discharge.

      8- Maintenance phase:

        -  The anesthetic was delivered in concentration that maintained a stable heart rate, blood
           pressure and respiratory rate (base line ±20%).

        -  Sevoflurane was reduced to 1.5-2 vol% in (30: 70%) oxygen and air ratio.

        -  Ventilation was assisted if the end-tidal carbon dioxide increased to ≥ 45 mmHg to be
           stabilized between 35-40 mmHg.

        -  At the end of procedure, anesthetic gas was discontinued and maintained on O2 100% >
           5L/min

        -  Endotracheal tube was removed when the child showed adequate recovery from anesthesia;
           child was transferred to PACU for monitoring of vital signs till discharge to the ward.

      At the end of anesthesia and before leaving operating room, assessment of recovery according
      to Modified Aldrete Recovery Score was done.

      Adequate recovery was achieved if the score =10

      9- Postoperative Period: Child was transferred to the post anesthesia care unit (PACU) for
      monitoring of vital signs till discharge to the ward.

      In the PACU, parents were allowed to remain at the child's bedside immediately upon
      admission. A trained anesthesiologist, blinded to patient group assignment had been stayed
      with the patient until discharge to the ward.

      Objective Pain Discomfort Score: was assessed, the intensity of pain immediately
      postoperatively, 30, 60 and 120 min thereafter (Objective Pain Discomfort Scale > 6 means
      pain and discomfort).

      The parameters of this scale were:

      Blood Pressure:

      2 = > 20% preoperatively

      1 = 11-20 % above preoperative 0 = < 11% preoperative

      Crying:

      2 =Crying not responding to TLC (Tender, Loving, Care)

        1. = Crying but responds to TLC

      0 = Not crying

      Moving:

      2 = Thrashing

      1 = Restless 0 = None

      Behavior:

      2 = Hysterical

      1 = Mild 0 = Patient asleep or calm

      Verbal evaluation (language):

      2 = Moderate pain (localizes verbally or pointing)

      1 = Mild pain (cannot localize) 0 = Asleep or no pain

      Assessment of agitation:

      The state of agitation was assessed at arrival in the recovery room 30, 60 and 120 min
      postoperatively by means of a modified objective pain discomfort scale.

      The modified objective pain Discomfort scale include movement, crying, and behavior items
      from the full OPS. For these three items, which constituted the modified OPS, the total
      possible score was 6.

      Agitation was defined by a total score of ≥ 3 for these three items.

      Patients were discharged when they were awake, had stable vital signs for at least 1 hour,
      had no pain or only mild pain, had not vomited for 1 hour, were able to tolerate clear fluid
      by mouth, and had no bleeding.

      Duration of anaesthesia, duration of surgery, emergence time (time from the end of surgery
      till extubation) and recovery time (time from extubation till discharge from recovery): were
      recorded.

      Time to the first request of postoperative analgesia: was recorded. The rescue analgesic was
      i.v.paracetamol at a dose of 15 mg/kg and if ineffective, fentanyl 0.5µg/kg bolus up to a
      total dose of 2µg/kg was used.

      Complications of level of sedation (such as bradycardia, postoperative pain, shivering, PONV
      and emergence delirium): were recorded.
    

Intervention name(s): Dexmedetomidine; Midazolam/Ketamine
Intervention type(s): Drug; Combination Product
Intervention description(s): Dexmedetomidine mixed with juice was given to the child orally preoperatively.; Midazolam/Ketamine was mixed with juice and given to the child orally preoperatively
Other intervention name(s): Alpha 2 agonist; Dormicum/Katalar
Intervention MeSH terms: Midazolam; Dexmedetomidine; Ketamine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Prevention
Keywords: Dexmedetomidine; Adenotonsillectomy; Parental Separation; Face Mask Acceptance