Reynolds J, Sedillo DJ. The Evolving Role of Intranasal Dexmedetomidine for Pediatric Procedural Sedation. Hosp Pediatr. 2018 Jan 23. [Epub ahead of print]

Commentary on: Use of intranasal dexmedetomidine as a solo sedative for magnetic resonance imaging of infants. 

“For decades, chloral hydrate (CH) was the standard agent used to provide sedation for noninvasive pediatric procedures. [1] The drug had a long history of safe administration by nonanesthesia providers, which in many institutions included registered nurses. [2,3] Despite reasonably high reported rates of success, CH had a number of disadvantages: a variable half-life in young children, clinical resedation, and a potential role as a neuroapoptotic agent in the developing brain. [4,5] Perhaps the greatest disadvantage was the loss of the oral formulation in the US market, limiting its availability.

After the loss of oral CH, many institutions evolved to an intravenous (IV) sedation regimen with propofol. [6] Propofol was an attractive agent because of its high success rate, rapid onset, and short recovery. However, this change in practice presented new challenges because propofol is typically administered only by pediatric providers with advanced training in deep sedation or anesthesiologists. These deep sedation systems often require more intensive resource utilization (IV catheter placement, advanced monitoring systems, postanesthesia care, etc), which may have economic consequences for both the patient and the health care system.

For many years, IV dexmedetomidine has been used for sedation in the critical care setting. [7] In 2008, Mason et al [8] took the next step in the evolution of pediatric procedural sedation by demonstrating that high-dose IV dexmedetomidine (3 mg/kg IV load followed by a 2 mg/kg per hour infusion) could be administered as a single agent to achieve high rates of success for completion of MRI. This practice was adopted at many institutions. Because dexmedetomidine can also be administered intranasally, further research demonstrated that high-dose intranasal dexmedetomidine (IN DEX) could be used to achieve similar rates of success for auditory brainstem responses, computed tomography, and echocardiography. [9–11]

In this issue of Hospital Pediatrics, we have an article reporting on the successful use of IN DEX to accomplish MRI in infants. [12] Although this is just the most recent report in an ever-expanding body of literature on the use of IN DEX, it is the first study in which a high rate of success for MRI with IN DEX as a single agent was demonstrated. Perhaps more interesting is that this was accomplished in a population historically considered to be at higher risk for sedation-related adverse events. [6]”