IN Midazolam vs IN Dexmedetomidine vs IN Ketamine During Minimal Procedures in Pediatric ED

Pain in young children has been universally under-recognized due to their inability to describe or localize pain. Improvements in pharmacological interventions are necessary to optimize patient and family experience and allow for successful and efficient procedure completion. This is the first study that will compare three intranasal medications (Intranasal Midazolam, Dexmedetomidine, and Ketamine) to evaluate the length of stay after medication administration along with patient and provider satisfaction. The objective of this study is to demonstrate superior intranasal anxiolysis for pediatric laceration repairs with the shortest emergency department stay and highest patient and provider satisfaction. Based on previous studies and medication pharmacokinetics, we hypothesize that Intranasal Ketamine will have the shortest Emergency Department (ED) stay followed by Midazolam and then Dexmedetomidine with the longest stay; however, Dexmedetomidine will have the highest patient and provider satisfaction followed by Ketamine and then Midazolam.

Children commonly present to ED with injuries requiring procedures that can be painful or require a child to be absolutely still. Pain in young children has been universally under-recognized due to their inability to describe or localize pain. Multiple surveys of parents and families have showed that ED satisfaction is highly dependent on the degree of pain a patient experiences and the efforts made to alleviate the pain. Therefore, improvements in pharmacological interventions are necessary to optimize patient and family experience and allow for successful and efficient procedure completion.

Intranasal Midazolam is widely used for minimal procedural anxiolysis in pediatric population. Intranasal medication delivery has the highest parent and provider satisfaction with the advantage of avoiding painful needle stick and faster absorption compared to oral or intramuscular medication. Midazolam is a gamma-aminobutyric acid (GABA) receptor agonist that can provide anxiolysis and amnesia but no analgesia. Intranasal Midazolam has a rapid onset of 5-10 minutes with peak at 30 minutes. There have been limited studies evaluating the length of stay or time to discharge after medication administration with an average length of stay of about 30 minutes. It has been shown to be safe and effective in children for minor procedures; however, intranasal Midazolam is notoriously noxious and irritating to nasal mucosa and requires larger volumes for intranasal dosing. Main side effects include respiratory depression and hypotension. It is also known to cause paradoxical reaction with hyperactivity, agitation, and restlessness especially in developmentally delayed or children with Autism or behavioral concerns. Therefore, several new studies have evaluated other newer intranasal medications for minor procedures including intranasal Dexmedetomidine and intranasal Ketamine.

Dexmedetomidine is an alpha 2 agonist that mirrors sleep in children and can provide anxiolysis and minimal analgesia. Intranasal dosages that have provided adequate minimal sedation is 2-4mcg/kg (max dosage 100-200mcg) with wide range of onset 10-45 mins with average 30 minutes and peak at 90 minutes. Unlike Midazolam, it preserves airway reflexes without clinically significant hemodynamic instability in children. Studies have also shown that it is well tolerated by children and preferred in children with Autism and behavioral concerns.

Ketamine is an N-methyl-D-aspartate (NMDA) antagonist that provides both anxiolysis and analgesia. It is widely used in ED settings for intravenous procedural sedation; however, intranasal route provides non-invasive method of medication administration. Gutherie et al conducted a study demonstrating intranasal Ketamine providing safe and successful anxiolysis and analgesia in pediatric patients in an ED setting. Intranasal dosage of 3-5mg/kg (max dosage 100-200mg) provides optimal onset of action within 10 minutes with peak at 15-20 minutes and duration of 45-60 minutes. It has few significant side effects including the rare laryngospasm and recovery agitation, however, it preserves airway reflexes and favorable in hemodynamic instability.

Previous Studies:

Limited studies have demonstrated anxiolysis with patient and provider satisfaction or time to discharge after medication administration comparing intranasal Midazolam to intranasal Dexmedetomidine or intranasal Ketamine in a pediatric emergency medicine setting. Neville et al conducted a study comparing intranasal Dexmedetomidine and intranasal Midazolam prior to laceration repair in a pediatric emergency department and concluded that patients who received Dexmedetomidine had less anxiety at the time of positioning for the procedure. Several other studies have demonstrated similar outcomes with better patient and provider satisfaction in pre-operative settings, imaging, and dental settings. Surendar et al is the only study that compared all three intranasal medications. The study included uncooperative pediatric patients in a dental setting. Although overall differences were not statistically significant, the onset of sedation was rapid among Intranasal Ketamine and Midazolam groups but overall success was highest in Dexmedetomidine group.

Objective/Aims/Hypothesis:

This is the first study that will compare all three intranasal medications to evaluate the length of stay after medication administration along with patient and provider satisfaction. The objective of this study is to demonstrate superior intranasal anxiolysis for pediatric laceration repairs with the shortest emergency department stay and highest patient and provider satisfaction. The primary outcome will measure the time to discharge after medication administration. Other measurements with include patient's anxiety using previously validated scale Modified Yale Preoperative Anxiety Scale (mYPAS) and physician and parent satisfaction using 5 point Likert scale. Based on previous studies and medication pharmacokinetics, we hypothesize that Ketamine will have the shortest ED stay followed by Midazolam and then Dexmedetomidine with the longest stay; however, Dexmedetomidine will have the highest patient and provider satisfaction followed by Ketamine and then Midazolam.

Eligibility Criteria:
Inclusion Criteria:

* Age 1-5 years old
* Presents to the ED for suture repair for lacerations less than or equal to 5cm in length
* Parent(s)/Caregiver(s) speak English

Exclusion Criteria:

* Younger than 12 months of age or older than 5 years old
* Suture repair needed for lacerations are greater than 5cm in length
* Known allergy or adverse effect to Midazolam, Dexmedetomidine, Ketamine, or any other sedatives
* Any abnormal vital signs for age, especially heart rate and blood pressure
* History of Cardiac, respiratory, renal, or liver disease
* Known electrolyte abnormalities
* Any ocular trauma, nasal injury, nasal deformity, significant nasal congestion, abnormalities in the nasal or oral mucosa, facial deformity, or facial injury
* Home medications include beta blockers or any other blood pressure lowering agents Classified American Society of Anesthesiologists III and above
* Known or anticipated difficult airway
* Abnormal neurological exam
* Parent(s)/Caregiver(s) do not speak English