Intranasal Dexmedetomidine 

Intranasal dexmedetomidine is a sedative agent that has recently gained popularity in pediatric procedural sedation and analgesia. Dexmedetomidine is a highly lipophilic agent, allowing rapid absorption through the nasal mucosa and a rapid onset of action.⁶ This makes intranasal administration an attractive alternative to intravenous administration, mainly when intravenous access is difficult to obtain or maintain, as is often the case for pediatric cases. 

Intranasal dexmedetomidine effectively provides sedation and analgesia for various pediatric procedures, including laceration repair, reduction of fractures and dislocations, and diagnostic imaging studies.¹ It has also shown a favorable safety profile in pediatrics.³ Adverse events are rare and tend to be mild, the most common being agitation or distress upon waking from sedation.¹² Compared to other sedative agents such as midazolam, intranasal dexmedetomidine has been shown to have a more rapid onset of action and a shorter duration of sedation, allowing for a more rapid recovery and discharge from the healthcare facility.⁷ There have been no reported cases of respiratory depression associated with the use of intranasal dexmedetomidine in pediatrics.⁴  

One potential benefit of intranasal dexmedetomidine is the reduced risk of oversedation compared to other sedative agents.⁸ This is thought to be due to the ability of dexmedetomidine to selectively target specific areas of the brain responsible for arousal and sedation, resulting in a more targeted and controllable level of sedation.¹⁴ Additionally, intranasal dexmedetomidine has been associated with a reduced need for rescue medications, such as opioids, to maintain an adequate level of sedation.⁹ This may result in a lower risk of respiratory depression and other adverse events associated with the use of opioids.⁹   

Despite the potential benefits of intranasal dexmedetomidine, there are several considerations to keep in mind when using this agent for pediatric procedural sedation and analgesia. One potential concern is the lack of published data in specific pediatric population subgroups, such as children under six months or those with significant comorbidities.² In these cases, it may be necessary to exercise caution and consider alternative sedative agents. Another consideration is cost, which may be more expensive than other sedative agents.² The sedative’s high cost may restrict its usage in specific healthcare settings or for patients needing adequate insurance coverage.² 

Chronic pain is a significant public health problem, affecting a large portion of the adult population and resulting in significant morbidity and disability.⁵ Intranasal dexmedetomidine can be used as an adjuvant to opioid therapy and has been shown to improve pain control and decrease opioid requirements in adult patients with chronic pain.¹¹ In addition to its use in procedural sedation and analgesia, intranasal dexmedetomidine effectively reduces agitation in adult patients, with a rapid onset of action and a favorable safety profile.^9,12 Agitation can be a challenging and distressing symptom for both patients and healthcare providers.^9,12 

Research has shown this drug to be a safe and effective option for procedural sedation and analgesia in pediatrics and adults.^1,10 Its rapid onset of action, short duration of sedation, and favorable safety profile make it a valuable addition to the sedative armamentarium for practitioners. More research must be done to understand the possible benefits and drawbacks of usage in adults and children, especially in specific subgroups like young children or those with many health problems. 

References 

1. Behrle, N., Birisci, E., Anderson, J., Schroeder, S., & Dalabih, A. (2017). Intranasal Dexmedetomidine as a Sedative for Pediatric Procedural Sedation. The journal of pediatric pharmacology and therapeutics: JPPT : the official journal of PPAG, 22(1), 4–8. https://doi.org/10.5863/1551-6776-22.1.4 

2. Fan, L., Lim, Y., Wong, G. S., & Taylor, R. (2021). Factors affecting successful use of intranasal dexmedetomidine: a cohort study from a national paediatrics tertiary centre. Translational pediatrics, 10(4), 765–772. https://doi.org/10.21037/tp-20-358 

3. Li, L., Zhou, J., Yu, D., Hao, X., Xie, Y., & Zhu, T. (2020). Intranasal dexmedetomidine versus oral chloral hydrate for diagnostic procedures sedation in infants and toddlers: A systematic review and meta-analysis. Medicine, 99(9), e19001. https://doi.org/10.1097/MD.0000000000019001 

4. Gupta, A., Dalvi, N. P., & Tendolkar, B. A. (2017). Comparison between intranasal dexmedetomidine and intranasal midazolam as premedication for brain magnetic resonance imaging in pediatric patients: A prospective randomized double blind trial. Journal of anaesthesiology, clinical pharmacology, 33(2), 236–240. https://doi.org/10.4103/joacp.JOACP_204_16 

5. Mills, S. E. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology and associated factors in population-based studies. British journal of anaesthesia, 123(2), e273–e283. https://doi.org/10.1016/j.bja.2019.03.023  

6. Mohite, V., Baliga, S., Thosar, N., & Rathi, N. (2019). Role of dexmedetomidine in pediatric dental sedation. Journal of dental anesthesia and pain medicine, 19(2), 83–90. https://doi.org/10.17245/jdapm.2019.19.2.83 

7. Panda, S., Pujara, J., Chauhan, A., Varma, A., Venuthurupalli, R., Pandya, H., & Patel, S. (2021). Comparative study of intranasal dexmedetomidine v/s midazolam for sedation of pediatric patients during transthoracic echocardiography. Annals of cardiac anaesthesia, 24(2), 224–229. https://doi.org/10.4103/aca.ACA_17_20 

8. Sado-Filho, J., Corrêa-Faria, P., Viana, K. A., Mendes, F. M., Mason, K. P., Costa, L. R., & Costa, P. S. (2021). Intranasal Dexmedetomidine Compared to a Combination of Intranasal Dexmedetomidine with Ketamine for Sedation of Children Requiring Dental Treatment: A Randomized Clinical Trial. Journal of clinical medicine, 10(13), 2840. https://doi.org/10.3390/jcm10132840 

9. Seppänen, S. M., Kuuskoski, R., Mäkelä, K. T., Saari, T. I., & Uusalo, P. (2021). Intranasal Dexmedetomidine Reduces Postoperative Opioid Requirement in Patients Undergoing Total Knee Arthroplasty Under General Anesthesia. The Journal of arthroplasty, 36(3), 978–985.e1. https://doi.org/10.1016/j.arth.2020.09.032 

10. Shetty, S. K., & Aggarwal, G. (2016). Efficacy of Intranasal Dexmedetomidine for Conscious Sedation in Patients Undergoing Surgical Removal of Impacted Third Molar: A Double-Blind Split Mouth Study. Journal of maxillofacial and oral surgery, 15(4), 512–516. https://doi.org/10.1007/s12663-016-0889-3 

11. Tang, C., & Xia, Z. (2017). Dexmedetomidine in perioperative acute pain management: a non-opioid adjuvant analgesic. Journal of pain research, 10, 1899–1904. https://doi.org/10.2147/JPR.S13938 

12. Uusalo, P., Guillaume, S., Siren, S., Manner, T., Vilo, S., Scheinin, M., & Saari, T. I. (2020). Pharmacokinetics and Sedative Effects of Intranasal Dexmedetomidine in Ambulatory Pediatric Patients. Anesthesia and analgesia, 130(4), 949–957. https://doi.org/10.1213/ANE.0000000000004264 

13. Uusalo, P., Seppänen, S. M., & Järvisalo, M. J. (2021). Feasibility of Intranasal Dexmedetomidine in Treatment of Postoperative Restlessness, Agitation, and Pain in Geriatric Orthopedic Patients. Drugs & aging, 38(5), 441–450. https://doi.org/10.1007/s40266-021-00846-6 

14. Weerink, M. A. S., Struys, M. M. R. F., Hannivoort, L. N., Barends, C. R. M., Absalom, A. R., & Colin, P. (2017). Clinical Pharmacokinetics and Pharmacodynamics of Dexmedetomidine. Clinical pharmacokinetics, 56(8), 893–913. https://doi.org/10.1007/s40262-017-0507-7