Jampana S, Harrison LC, McCall J, Ferrante RR, Winer JC, Kink RJ, Rogers NG. Evaluation of Intranasal Fentanyl and Midazolam Among Inpatient Pediatric Patients. Hosp Pediatr. 2024 Oct 1;14(10):e439-e442. doi: 10.1542/hpeds.2024-007819. PMID: 39301611.

Full text access for Children’s and Emory users.

Abstract
Objectives: The use of intranasal (IN) analgesics and sedatives has been studied among pediatrics patients in the emergency department and outpatient settings. However, less is known about their usage in inpatient settings. This study aims to evaluate the indications and safety profile for IN fentanyl and midazolam usage in pediatric patients admitted to a large tertiary care children’s hospital.

Methods: This study is a retrospective chart review of admitted patients receiving IN fentanyl and/or midazolam over a 6-year period. Indications for medication use, medication dosages, patient characteristics, and any serious adverse drug reactions were recorded. Reported serious adverse outcomes include use of reversal agents as well as any documented respiratory depression, hypotension, or need for escalation of care.

Results: Of 156 patients included, 119 (76%) received IN midazolam alone, 20 (13%) patients received IN fentanyl alone, and 17 (11%) patients received both medications. The most common applications for IN medication administration were nasogastric tube placements (n = 62), peripheral intravenous line insertions (n = 30), peripherally-inserted central catheter placements (n = 23), and lumbar punctures (n = 16). No serious adverse events were reported.

Conclusions: This study suggests that IN fentanyl and midazolam were administered to pediatric inpatients undergoing routine procedures without serious adverse drug reactions being reported. Although these findings are encouraging, more prospective studies are needed before wider implementation of IN fentanyl and midazolam administration in pediatric inpatients.

---

Ismail MIA, Aldmour A, Al-Husinat L, El-Gendy GA, Mansour SW. A Comparison of the Use of Propofol versus Midazolam for Pediatric Magnetic Resonance Imaging Sedation: Retrospective Cohort Study. Ann Afr Med. 2024 Oct 1;23(4):669-673. French, English. doi: 10.4103/aam.aam_109_23. Epub 2024 Sep 14. PMID: 39279171.

Full text access for Children’s and Emory users.

Abstract 
The aim of the present study: The aim of the present study was to do a comparison of the recovery profiles and airway-related adverse events of pediatric magnetic resonance imaging (MRI) sedation patients who received propofol alone to those who received midazolam alone.

Methods: This retrospective cohort study was approved by the Mutah University Ethical Approval Committee (No. 2378). A search of the patients’ medical records was performed between September 2021 and April 2022 to identify children aged 4 months-11 years who received propofol or midazolam for MRI sedation. The patients were subdivided into two groups: Those who had propofol alone (propofol group) and those who received midazolam (midazolam group) for pediatric MRI sedation. In propofol group, a 1-2 mg/kg of propofol bolus was given to have a deep sedation (Ramsay Sedation Scale score of 5). Patients in midazolam group received 0.05 mg/kg of midazolam. During the maintenance state of sedation, the patient received 150 µg/kg/min of propofol, and the infusion rate was adjusted in 25 μg/kg/min increments up or down at the discretion of the anesthesiologists to maintain a state of deep sedation. The major targets of this study were recovery profiles (time to awake and time to discharge) and airway-related intervention ratios in pediatric MRI sedation patients. Patient demographics, MRI sedation, and recovery data, including propofol induction dose, airway intervention, and sedation-related adverse events from the pediatric sedation recovery unit were also collected.

Results: The mean (standard deviation [SD]) propofol induction dose was higher compared to midazolam group (2.4 [0.7] mg vs. 1.3 [0.5] mg; mean difference, 1.1 mg; P < 0.001). The mean (SD) infusion rate was higher in propofol group compared to midazolam group (161.3 [37.6] μg/min/kg vs. 116.2 [25.6] μg/min/kg; mean difference 45.1 μg/min/kg; P < 0.001). The mean (SD) propofol total dose was higher in propofol group compared to midazolam group (236.3 [102.4] mg vs. 180.7 [80.9] mg; mean difference, 155.4 mg; P < 0.001). The mean (SD) time to awake was longer in midazolam group compared to propofol group (21.2 [5.6] min vs. 23.0 [7.1] min; mean difference, 1.8 min; P < 0.001). The mean (SD) time to discharge was longer in midazolam group compared to propofol group (34.5 [6.9] min vs. 38.6 [9.4] min; mean difference, 4.1 min; 95% confidence interval, 3.0-5.1; P < 0.001).

Conclusion: The administration of midazolam during pediatric MRI sedation can decrease the frequency of airway complications without prolonging the clinically significant recovery profile.

---

Palmese S, Bilancio G, Caterino V, De Anseris AG, Perciato S, Siglioccolo A, Gammaldi R. Combination of Intranasal Dexmedetomidine and Midazolam for Sedation in Pediatric Magnetic Resonance Imaging: A Retrospective Observational Study. Pediatr Emerg Care. 2024 Jun 1;40(6):430-433. doi: 10.1097/PEC.0000000000003086. Epub 2023 Dec 3. PMID: 38048550.

Full text access for Children’s and Emory users.

Abstract
Background: Intranasal dexmedetomidine associated with midazolam has been used for pediatric magnetic resonance imaging studies because immobility is a fundamental requirement for correct execution. Many studies have shown dexmedetomidine to be a good option for non-operating room sedation. However, identifying the optimal dose remains a key challenge, especially for pediatric patients.

Methods: All medical records of 139 pediatric patients who underwent sedation for magnetic resonance imaging studies between September 2021 and November 2022 at the University Hospital of Salerno, Italy, were retrospectively reviewed about success rate and adverse events. Our protocol required dosing 30 minutes before the procedure. Patients weighing up to 40 kg received intranasal dexmedetomidine (3 μg/kg) with intranasal midazolam (0.2 mg/kg). Those weighing more than 40 kg received intranasal dexmedetomidine (2 μg/kg) with midazolam orally (0.3 mg/kg; maximum dose, 15 mg).

Results: A total of 139 pediatric patients, with age range between 2 months and 16 years, median (95% confidence interval) of 3 (3-5) years, and weight range between 4 and 70 kg, median (95% confidence interval) of 19 (15-24) kg, were reviewed.The procedure was satisfactorily completed in 93.5% (130 patients) ( P < 0.01). Only 9 (6.5%) patients completed the procedure with general anesthesia; there are hot adverse events.

Conclusions: Our experience with association of intranasal dexmedetomidine and midazolam has a high success rate, with high effectiveness and safety.