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Dexmedetomidine for Sedation During Noninvasive Ventilation in Pediatric Patients*

Venkatraman, Rasika MD1; Hungerford, James L. MD2,3; Hall, Mark W. MD1; Moore-Clingenpeel, Melissa MS1,4; Tobias, Joseph D. MD1,5,6

Pediatric Critical Care Medicine: September 2017 - Volume 18 - Issue 9 - p 831–837
doi: 10.1097/PCC.0000000000001226
Feature Articles

Objectives: To describe the use of dexmedetomidine for sedation in a large cohort of nonintubated children with acute respiratory insufficiency receiving noninvasive ventilatory support.

Design: Single-center, retrospective, observational cohort study.

Setting: A large quaternary-care PICU.

Patients: The study cohort included 202 children receiving noninvasive ventilatory and a dexmedetomidine infusion within 48 hours of PICU admission over a 6-month period.

Interventions: None.

Measurements and Main Results: The primary respiratory diagnoses in the cohort (median age, 2 yr) included status asthmaticus (60%) and bronchiolitis (29%). Dexmedetomidine was infused for a median of 35 hours with a median hourly dose across the patient cohort of 0.61 μg/kg/hr (range, 0.4–0.8 μg/kg/hr). The target sedation level was achieved in 168 patients (83%) in the cohort for greater than or equal to 80% of the recorded values over the entire noninvasive ventilatory course, with dexmedetomidine as the only continuously administered sedative agent. While vital signs were frequently abnormal relative to age-based norms, clinical interventions were needed rarely to treat bradycardia (13%), hypotension (20%), and hypopnea (5%). The most frequently used of these interventions was a dexmedetomidine dose reduction, fluid bolus, and titration of noninvasive ventilatory support. Five patients (2.5%) required endotracheal intubation: three due to progression of their respiratory illness, one with septic shock, and one with apnea requiring resuscitation. In 194 of 202 patients (96%), the outcome of the noninvasive ventilatory course was successful with the patient being weaned from noninvasive respiratory support to nasal cannula or room air.

Conclusions: Dexmedetomidine was often effective as a single continuous sedative infusion during pediatric noninvasive ventilatory. Cardiorespiratory events associated with its use were typically mild and/or reversible with dose reduction, fluid administration, and/or noninvasive ventilatory titration. Prospective studies comparing dexmedetomidine with other agents in this setting are warranted.

1Division of Critical Care, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH.

2Emory Sleep Center, Emory University, Atlanta, GA.

3Critical Care Medicine, Children's Healthcare of Atlanta, Children’s at Egleston, Atlanta, GA.

4Biostatistics Core, The Research Institute at Nationwide Children’s Hospital, Columbus, OH.

5Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH.

6Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH.

*See also p. 893.

Drs. Venkatraman, Hall, and Moore-Clingenpeel disclosed off-label product use of dexmedetomidine for longer durations than are currently approved by the Food and Drug Administration. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies