Nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children: a single centre audit.

The purpose of this study is to audit the efficacy and safety of intranasal dexmedetomidine sedation for non-invasive procedural sedation in children provided by nurses of the procedural sedation (PROSA) team in the University Hospitals Leuven. Efficacy (successful sedation as sole sedative) and safety (cardiorespiratory monitoring, saturation) were assessed. In this audit, prospectively recorded data were extracted from the medical files in 772 patients between 4 weeks to 18 years old, who underwent sedation with intranasal dexmedetomidine (2-4 µg/kg) by the nurse-driven PROSA team, following pre-screening on risk factors. Ninety-one percent of the patients were successfully sedated (single dose, monotherapy), 60 patients (7.8%) needed an additional intervention during sedation, 37 (4.8%) needed an extra dose of intranasal dexmedetomidine, and 14 (1.8%) received an additional other sedative. Successful sedation rates were higher in younger children, and medical imaging was the most common indication. Sedation failed in 12 (1.6%) patients, with 10 of them failed to fall asleep. Adverse events were limited in number (n = 13, 1.7%) and severity: 4 patients had a low heart rate (one received atropine), one had an irregular heart rate, and 7 desaturation events were described. Hypotension was treated with normal saline in one case. CONCLUSIONS: In this nurse-driven PROSA setting, intranasal dexmedetomidine is effective and safe for non-invasive procedural sedation in an a priori low risk group of paediatric patients. WHAT IS KNOWN: • Procedural sedation outside the operating theatre or intensive care units is increasingly used, including sedation performed by non-anaesthesiologists or nurses. This resulted in the development of procedural sedation and analgesia (PROSA) teams. • Off-label use of intranasal dexmedetomidine in children is increasing, with a limited number of audits on this practice, its safety and efficacy. WHAT IS NEW: • In an audit on 772 procedures, nurse-driven intranasal dexmedetomidine administration as sedation for non-invasive procedures in children within a structured framework was safe and effective. • Imaging (CT, MRI) was the most common procedural indication in our study, but also nuclear imaging techniques were included.

Pediatric Procedural Sedation and Analgesia (PROSA) in the Leuven University Hospitals: An Audit on Efficacy and Safety.

The hospital can be a stressful environment for a child. To address the increase in demands for pediatric procedural sedation, the PROSA team initiative was started in the Leuven University Hospitals in 2014. In this study, we assessed the efficacy and safety of this project since its initiation. Demographic (age, sex) and clinical (procedure, sedation method) data were prospectively registered by the dedicated PROSA team. Anonymized data (11/2014-6/2021) were extracted to a database for analysis. Data on 5090 procedures were available. The median age was 4.8 years. The sedation was successful in 98% of patients, be it classified as 'technically difficult' in 3.3%. Of the 2% of failed procedures, 69% were due to inadequate sedation and 31% to logistic reasons unrelated to sedation (such as puncture problem, suboptimal bowel preparation). The overall adverse event incidence was 2% and occurred predominantly during gastro-coloscopy or bronchoscopy. Pethidine/midazolam was used in 81 cases, nitrous oxide in 10 cases. A saturation decrease with oxygen supply was the documented adverse event in 83 cases. There were no deaths reported. With the current training and implementation, PROSA is effective with a success rate of 98% and an adverse event rate of 2%.

Intranasal Dexmedetomidine as Sedative for Medical Imaging in Young Children: A Systematic Review to Provide a Roadmap for an Evidence-Guided Clinical Protocol.

There is an increasing need for effective anxiety and pain reduction during medical imaging procedures in children, addressed by non-pharmacological or pharmacological approaches. Dexmedetomidine is a fairly recently marketed, selective α2-adrenergic agonist that can be administered intranasally. To develop an evidence-guided clinical protocol, we investigated the (side) effects, preconditions and safety aspects following intranasal dexmedetomidine administration in children (1 month-5 years) for procedural sedation during medical imaging. To this end, a systematic search (PubMed, Embase and CINAHL (12/2021)) was performed to identify studies on intranasal dexmedetomidine for procedural sedation for medical imaging (computer tomography and magnetic resonance imaging). Following screening and quality assessment, eight studies were retained. Nasal nebulization was considered the best administration method, dosing varied between 2 and 4 µg/kg (age-dependent) 30-45 min prior to imaging and contraindications or restrictions with respect to oral intake were somewhat consistent across studies. Valid sedation scores and monitoring of vital signs were routinely used to assess sedation and the need for rescue dosing (different approaches), whereas discharge was generally based on Aldrete score (score ≥ 9). Heart rate, blood pressure and saturation were routinely monitored, with commonly observed bradycardia or hypotension (decrease by 20%). Based on these findings, a roadmap for evidence-guided clinical protocol was generated.

Glycemic control in the pediatric intensive care unit of Leuven: two years of experience.

Stress hyperglycemia and hypoglycemia are associated with increased mortality and morbidity in critically ill patients. Three randomized controlled trials, in the surgical, medical, and pediatric intensive care unit (PICU) of the Leuven University in Belgium, demonstrated the beneficial response of tightly controlling blood glucose levels within age-adjusted narrow limits by applying intensive insulin therapy. Follow-up studies could not confirm the results obtained in the Leuven studies but revealed the complexity associated with tight glycemic control (TGC). This article gives an overview of the methodological aspects typical of the Leuven TGC concept, with the focus on the PICU. Differences between the adult and the PICU are described. This overview article might help other ICUs by addressing potential differences in clinical practice when implementing TGC.

Assessment of blood glucose control in the pediatric intensive care unit: extension of the glycemic penalty index toward children and infants.

BACKGROUND: The glycemic penalty index (GPI) is a measure to assess blood glucose (BG) control in critically ill adult patients but needs to be adapted for children and infants. METHOD: The squared differences between a clinical expertise penalty function and the corresponding polynomial function are minimized for optimization purposes. The average of all penalties (individually assigned to all BG readings) represents the patient-specific GPI. RESULTS: Penalization in the hypoglycemic range is more severe than in the hyperglycemic range as the developing brains of infants and children may be more vulnerable to hypoglycemia. Similarly, hypoglycemia is also more heavily penalized in infants than in children. CONCLUSIONS: Extending the adult GPI toward the age-specific GPI is an important methodological step. Long-term clinical studies are needed to determine the clinically acceptable GPI cut-off level.