Journal of Anesthesia and Surgery | Volume 7 | Issue 1 | 2020-05-18

A comparative study of the use of midazolam and dexmedetomidine in surgical interventions of the lower extremities in children

esmira nasibova

Abstract

The perioperative period is a stressful moment for most patients undergoing surgery, especially in children. An estimated 50-75% of children undergoing surgery experience severepain and anxiety throughout the entire operationalperiod.The most common drug for reducing preoperative anxiety in children is midazolam, which has a fast onset and short duration of action. Studies have shown that premedication with dexmedetomidine effectively reduces anxiety during separation of children from their parents before surgery and provides good postoperative sedation and analgesia. The Aim of the Study: A comparative assessment of the sedative effect of dexmedetomidine and midazolamintheintra- and postoperativeperiod in children with traumatic interventions of the lower extremities. Material and Research Methods: The study included 58 children aged 3 to 14 years operated on for lower limb injuries. All patients, depending on the type of sedation, were divided into 3 groups. In group I (n = 26), surgical interventions were performed under general anesthesia (propofol, fentanyl, esmeron and isoflurane) without sedation in the postoperative period, in group II (n = 16) sedation in the perioperative period was performed with dexmedetomidine and in group III (n = 16) midazolam. The Results of the Study: In the course of the study, we found a significantly high level of sedation and anesthesia in patients of group I and II during traumatological operations of the lower extremities.The dexmedetomidine and midazolam used in the study provided the necessary degree of sedation at the minimum effective dosage combined with caudal anesthesia. On the other hand, in our study, it was not possible to identify differences in the sedative effect between the studied drugs. In the II and III groups of patients, mild or moderate degree of sedation was achieved during the early postoperative period.It should also be noted that in none of the patients receiving dexmedetomidine and midazolam in the dosages we chose in the early postoperative period, there were no episodes of respiratory depression, no significant complications in the form of arterial hypotension and bradycardia were found.

Keywords: Dexmedetomidine, Midazolam, Anesthesia

Full text

The perioperative period is a stressful moment for most patients undergoing surgery, especiallyinchildren [1-6] . An estimated 50-75% of children undergoing surgery experience severepain and anxiety throughout the entire operational period [7] . Studies have shown that anxiety can lead to negative behaviors in the postoperative period, as 54% of children show them already 2 weeks after surgery and 20% continue to show them for 6 months [8-10] . Therefore, it is necessary to find ways to eliminate perioperative anxiety, since some pediatric patients have significant postoperative anxiety. The most common drug for reducing preoperative anxiety in children is midazolam, which has a fast onset and short duration of action. However, midazolam is not an ideal drug because it has several undesirable effects, including postoperative changes in behavior, anxiety, cognitive impairment, and paradoxical reactions. In addition, midazolam is also ineffective in preventing the occurrence of agitation in children [11] . Thus, more appropriate drugs are needed to improve the perioperative safety and comfort of children. Dexmedetomidine is a highly selective -2 adrenergic receptor agonist with a wide range of pharmacological properties. Dexdor has a sympatholytic effect by reducing the release of norepinephrine by the sympathetic nerve endings. The sedative effect of dexdor is associated with a decrease in excitation in the bluish nucleus of noradrenergic neurons located in the brain stem [12,13] . Studies have shown that premedication with dexmedetomidine effectively reduces anxiety during separation of children from their parents before surgery and provides good postoperative sedation and analgesia. The Aim of the Study A comparative assessment of the sedative effect of dexmedetomidine and midazolamintheintra- and postoperative period in children with traumatic interventions of the lower extremities. Materials and Methods The study included 58 children aged 3 to 14 years operated on for lower limb injuries.All patients, depending on the type of sedation, were divided into 3 groups.In group I (n = 26), surgical interventions were performed under general anesthesia (propofol, fentanyl, esmeron and isoflurane) without sedation in the postoperative period, in group II (n = 16) sedation in the perioperative period was performed with dexmedetomidine and in group III (n = 16) midazolam.Assessment of the depth of sedation, as well as the effectiveness of analgesia was carried out 2, 8 and 16 hours after surgery.In II and III groups, surgical interventions were performed under caudal anesthesia in combination with one of the sedatives. Patients of group II received demedametidomidine at a dose of 1 g / kg per os in the ward as premedication, then they entered the operating room in a drowsy state.In the operating room, sedation was continued by intravenous administration of a solution (200 g of dexmedetomidine diluted in 48 ml of physiological saline) using a Braun perfuser at a rate of 0.5 g / kg / hour.After this, the patient was transferred to the left side and a caudal block with ropivacaine was performed at a rate of 4 mg / kg. In the II group of patients, premedication was carried out by midazolam at the rate of 0.5 mg / kg per os.In the operating room, in patients of the second group, sedation was continued by intravenous administration of a solution (1 ml-5 mg of midazolam diluted in 19 ml of physiological saline) using a perfuser at a rate of 0.05 mg / kg / hour.Patients of all groups in the dynamics studied the heart rate, blood pressure, SpO2.To assess postoperative analgesia, pain rating scales based on the Wong-Baker face image for children over 3 years old, an objective pain scale by Hanallah et al. Were used to assess the degree of sedation in the early postoperative period, the Ramsay scale was used, and the excitation rating scale was Richmond sedation. Results In the I control group in the postoperative period, an increase in heart rate was observed, as follows: heart rate after 2 hours - 125 14.5 per minute, after 8 hours 115.4 10.9 per minute, and after 16 hours - 121.5 13.2 per minute. After 2 hours, the average blood pressure was 126.3 3.2 mm Hg, diastolic blood pressure was 68.3 6.4 mm Hg; after 8 hours - average blood pressure - 130.4 6.8 mm Hg, diastolic blood pressure - 64.2 6.2 mm Hg; after 16 hours - average arterial pressure - 132.4 8.6 mm Hg, diastolic blood pressure - 71.4 4.2 mm Hg.The pain intensity on the Wong-Baker scale was: after 2 hours - 0.85 0.6 points, after 8 hours - 0.6 0.4 points, after 16 hours - 0.96 0.25 points and on the scale Hanallah - 2.2 1.2 points, after 8 hours - 1.22 0.6 points and after 16 hours 1.09 0.8 points, due to the presence of minor pain.In patients of group II, in whom dexmedetomidine was used as a sedative, pulse rate and increase in blood pressure were not observed in comparison with patients of group I.When assessing the intensity of pain, the following data were obtained: on the Wong-Baker scale: 0.65 0.5 points after 2 hours, 0.33 0.48 points after 8 hours, and 0.66 after 16 hours 0.52 points and on the Hanallah scale - after 2 hours 0.54 0.8 points, after 8 hours - 0.44 0.50 points and after 16 hours 0.64 0.9 points, which indicated the absence pains. In the III group of patients in whom midazolam was used as sedation, a significant decrease in heart rate, mean arterial pressure, and diastolic blood pressure was also noted in relation to the control group.When assessing pain according to the above-mentioned scales, the following results were obtained: on the Wong-Baker scale: 0 points, after 2 hours - 0.1 0.1 points, after 16 hours - 0.15 0.1 and on the Hanallah scale - 0 points, after 8 hours - 0.2 0.1 points and after 16 hours 0.11 0.2 points, which was interpreted as a complete absence of pain. After transferring the patient from the operating room to the ward, in parallel with the assessment of pain, sedation was evaluated.In group I, for the entire observation period, the patients were all anxious and cried. In group II, where dexdor was used as a sedative, the patients were drowsy and calmly reacted to the voice by opening their eyes. In group III, when using midazolam, all patients were in a state of mild sedation, dozing, but reacted to touch or to a loud sound.It was also noted that in patients of groups II and III 2 and 8 hours after surgery, the sedation level was significantly higher than in patients of group I. When assessing sedation on the Ramsay scale at a more distant time after surgery (16 hours), there were no differences in the level of sedation between all the studied groups. Thus, in the course of the study, we found a significantly high level of sedation and anesthesia in patients of group I and II during traumatological operations of the lower extremities.The dexmedetomidine and midazolam used in the study provided the necessary degree of sedation at the minimum effective dosage combined with caudal anesthesia. On the other hand, in our study, it was not possible to identify differences in the sedative effect between the studied drugs.In the II and III groups of patients, mild or moderate degree of sedation was achieved during the early postoperative period.It should also be noted that in none of the patients receiving dexmedetomidine and midazolam in the dosages we chose in the early postoperative period, there were no episodes of respiratory depression, no significant complications in the form of arterial hypotension and bradycardia were found. Conclusion 1. Dexemedetomidine and midazolam are effective sedation drugs in combination with caudal anesthesia for traumatic surgery in children, both in the intra- and postoperative period. 2. In our study, at our chosen doses of these drugs, no complications were detected. References 1. Chrysostomou , C . , Schmitt , C . G. Dexmedetomidine: s edation, analgesia and beyond. ( 2008 ) Expert Opin Drug MetabToxicol 4(5): 619 6 27. PubMed │ CrossRef │ Others 2. Walker , J . , Maccallum , M . , Fischer , C . , et al. Sedation using dexmedetomidine in pediatric burn patients. ( 2006 ) J Burn Care Res 27(2): 206 2 10 . PubMed │ CrossRef │ Others 3. Ozcengiz, D . , Gunes, Y . , Ozmete, O. Oral melatonin, dexmedetomidine, and midazolam for prevention of postoperative agitation in children. ( 2011 ) J Anesth 25 (2) : 184 188. PubMed │ CrossRef │ Others 4. Mukherjee, A . , Das, A . , Basunia, S . R. Emergence agitation prevention in paediatric ambulatory surgery: A comparison between intranasal Dexmedetomidine and Clonidine. ( 2015 ) J Res Pharm Pract 4 (1) : 24 30. PubMed │ CrossRef │ Others 5. Bong, C . L . , Yeo, A . S . , Fabila, T. A pilot study of dexmedetomidine sedation and caudal anesthesia for inguinal hernia repair in infants. ( 2016 ) Paediatr Anaesth 26 (6) : 621 627. PubMed │ CrossRef │ Others 6. Pasin, L . , Febres, D . , Testa, V. , et al. Dexmedetomidine vs midazolam as preanesthetic medication in children: a meta-analysis of randomized controlled trials. ( 2015 ) Paediatr Anaesth 25 (5) : 468 476. PubMed │ CrossRef │ Others 7. Akin, A . , Bayram, A . , Esmaoglu, A. , et al. Dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia. ( 2012 0 Paediatr Anaesth 22 (9) : 871 876. PubMed │ CrossRef │ Others 8. Kapur, A . , Jain, K . , Goyal, A. , et al. Oral Midazolam Sedation for uncooperative children in outpatient paedodontics: time for reappraisal. ( 2016 ) SAAD Dig 32: 14 16. PubMed │CrossRef│ Others 9. Ni, J . , Wei, J . , Yao, Y. , et al. Effect of dexmedetomidine on preventing postoperative agitation in children: a meta-analysis. ( 2015 ) PloSOne 10 (5) : e0128450. PubMed │ CrossRef │ Others 10. Oza, V . P . , Parmar, V . , Badheka, J. , et al. Comparative study of postoperative analgesic e ffect of intraperitonea l instillationof dexmedetomidine with bupivacaine and bupivacainealone after laparoscopic surgery. ( 2016 ) J Minim Access Surg 12 (3) : 260 264 . PubMed │ CrossRef │ Others 11. Sharma, A . , Kumar, N . J . , Azharuddin, M. , et al. Evaluation of low-dose dexmedetomidine and neostigmine with bupivacaine for postoperative analgesia in orthopedic surgeries: a prospective randomized double-blindstudy. ( 2016 ) J Anaesthesiol Clin Pharmacol 32 (2) : 187 191 . PubMed │ CrossRef │ Others 12. Candiotti , K . A . , Bergese , S . D . , Bokesch , P . M . , et al. Monitored anesthesia care with dexmedetomidine: a prospective, randomized, double-blind, multicenter trial. ( 2010 ) Anesth Analg 110(1): 47 56 . PubMed │ CrossRef │ Others 13. Tong, Y . , Ren, H . , Ding, X. , et al. Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudalanesthesia: a meta-analysis. ( 2014 ) Paediatr Anaesth 24 (12) : 1224 1230 . PubMed │ CrossRef │ Others