Dexmedetomidine for sedation during electroencephalographic analysis in children with autism, pervasive developmental disorders, and seizure disorders

doi:10.1016/j.jclinane.2008.03.004

Journal of Clinical Anesthesia

Volume 20, Issue 5, August 2008, Pages 364-368

https://doi.org/10.1016/j.jclinane.2008.03.004 Get rights and content

Abstract

Study Objective

To assess the efficacy of dexmedetomidine in providing sedation during electroencephalographic (EEG) analysis in children with autism, seizure disorders, or pervasive developmental disorders (PDDs).

Design

Retrospective chart review.

Setting

University medical center.

Measurements

The charts of 42 children, aged two to 11 years, who received dexmedetomidine for sedation during EEG analysis, were studied. Information collected included route of administration of dexmedetomidine (oral and/or intravenous [IV]), loading dose, and infusion rate. Heart rate, blood pressure, respiratory rate, and level of sedation were monitored every 5 minutes, and oxygen saturation was monitored continuously during the procedure. Interventions (administration of fluid or use of an anticholinergic agent) for hypotension or bradycardia were identified.

Main Results

18 children received oral dexmedetomidine (range, 2.9-4.4 μg/kg) before placement of an IV. Forty patients received an IV loading dose of dexmedetomidine (2.1 ± 0.8 μg/kg), which was given in increments of 0.5 to one μg/kg every three to 5 minutes until a sedation score of 3 to 4 was achieved. Effective sedation was eventually achieved in all patients. An IV infusion of dexmedetomidine was started (1.5 ± 0.2 μg kg⁻¹ hr⁻¹) in all patients. During performance of the EEG, adjustments in the infusion rate (increase or decrease) or additional bolus doses were necessary in 25 patients. No significant hemodynamic or respiratory effects were noted.

Conclusions

Dexmedetomidine provides effective sedation during EEG analysis in children with autism or PDD.

Introduction

Autism is the most severe form of those disorders commonly classified as pervasive developmental disorders (PDDs). Associated central nervous system involvement is common, with up to 30% of patients having some type of seizure disorder [1], [2], [3]. As such, electroencephalographic (EEG) analysis is frequently performed in patients with autism and other types of PDD. To successfully accomplish such testing, sedation is required. In many centers, chloral hydrate is the most frequently used agent, although the literature reports a high failure rate and a 6% incidence of vomiting [4], [5]. Other commonly used agents for sedation, such as propofol, benzodiazepines, or barbiturates, may affect the EEG, thereby rendering accurate interpretation more difficult [6].

Dexmedetomidine (Precedex; Hospira Pharmaceuticals, Lake Forest, IL) is an α₂-adrenergic agonist that is currently approved by the US Food and Drug Administration (FDA) for intravenous (IV) administration by continuous infusion for up to 24 hours for the sedation of adults during mechanical ventilation in an intensive care unit (ICU) setting. Initial experience in the pediatric population has shown the drug's efficacy for sedation during mechanical ventilation as well as procedural sedation during noninvasive radiologic imaging [7], [8], [9], [10]. Given its unique mechanism of action and limited effects on hemodynamic and respiratory function, dexmedetomidine may offer specific advantages over other agents commonly used for procedural sedation. We report our experience with dexmedetomidine to provide sedation during EEG testing in children with autism, seizures, and other PDD.

Section snippets

Materials and methods

This study was approved by the Institutional Review Board of the University of Missouri (Columbia, MO). We retrospectively reviewed records of the pediatric sedation service and identified pediatric patients who had received dexmedetomidine during EEG testing. Demographic data obtained included age, weight, gender, and primary diagnosis. Information regarding dexmedetomidine included doses administered by bolus and continuous infusion and the route of administration (oral or IV). In accordance

Results

The cohort for the study included 42 patients, 32 boys and 10 girls, ranging in age from two to 11 years (5.6 ± 2.4 yrs) and in weight from 11 to 54 kg (23 ± 6.2 kg). Primary diagnoses included autism (27), neurobehavioral disorder (8), and seizure disorder (7). Eight patients had previously failed sedation on a separate day with oral chloral hydrate (100 mg/kg). All 42 patients were receiving medications for treatment of their autism, PDD, or underlying seizure disorder. Concomitant

Discussion

Our preliminary data suggest that dexmedetomidine provides effective sedation with an acceptable adverse effect profile in children with autism, PDD, and seizure disorders during EEG analysis. As with other sedative agents, we noted interpatient variability in dosing requirements, further emphasizing the need to titrate sedative agents to achieve the desired effect. The obvious limitations of the current study involve its retrospective nature, thereby making it possible that specific adverse

References (30)

NapoliK.L. et al.
Safety and efficacy of chloral hydrate sedation in children undergoing echocardiography
J Pediatr
(1996)
KorogluA. et al.
Sedative, hemodynamic and respiratory effects of dexmedetomidine in children undergoing magnetic resonance imaging examination: preliminary results
Br J Anaesth
(2005)
HayashiY. et al.
Alpha-2 adrenoreceptor agonists and anaesthesia
Br J Anaesth
(1993)
ThorntonC. et al.
Effects of dexmedetomidine on isoflurane requirements in healthy volunteers. 2: Auditory and somatosensory evoked responses
Br J Anaesth
(1999)
MiyazakiY. et al.
Dexmedetomidine reduces seizure threshold during enflurane anaesthesia in cats
Br J Anaesth
(1999)
DeykinE.Y. et al.
The incidence of seizures among children with autistic syndromes
Am J Psychiatry
(1979)
OlsonI. et al.
Epilepsy in autism and autistic-like conditions
Arch Neurol
(1998)
VolkmanF.R. et al.
Seizure disorder in autism
J Am Acad Child Psychiatry
(1990)
RummP.D. et al.
Efficacy of sedation of children with chloral hydrate
South Med J
(1990)
WangB. et al.
Effect of sedative and hypnotic doses of propofol on the EEG activity of patients with or without a history of seizure disorder
J Neurosurg Anesthesiol
(1997)

TobiasJ.D. et al.

Sedation during mechanical ventilation in infants and children: dexmedetomidine versus midazolam

South Med J

(2004)

NicholsD.P. et al.

Rescue sedation with dexmedetomidine for diagnostic imaging: a preliminary report

Pediatr Anaesth

(2005)

BerkenboschJ.W. et al.

Prospective evaluation of dexmedetomidine for noninvasive procedural sedation in children

Pediatr Crit Care Med

(2005)

American Academy of Pediatrics Committee on Drugs

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures

Pediatrics

(1992)

MehtaU.C. et al.

EEG sedation for children with autism

J Dev Behav Pediatr

(2004)

Cited by (48)

MEG pharmacology: Sedation and optimal MEG acquisition
2022, Clinical Neurophysiology
Utility of a Structured Teaching Approach, Rehearsal, and Training for Patients With Autism Spectrum Disorder to Avoid Physical Restraint During Induction of Anesthesia
2022, Journal of Perianesthesia Nursing
Citation Excerpt :
The rehearsal was a good opportunity to observe the patient's behavior and to decide how to customize our approach. Many reports recommend the use of oral premedication with sedative drugs for patients with ASD.10,15-17 However, administration of oral sedative drugs does not always provide sufficient sedation and may contribute to delayed emergence from anesthesia.
We aimed to determine whether the use of a structured teaching approach, rehearsing, and training (SRT) for anesthesia induction in patients with autism spectrum disorder (ASD) could reduce the need for physical restraint.
Retrospective observational study
We retrospectively analyzed 63 patients (4 to 40 y old) with ASD who underwent general anesthesia for dental treatment. Patients were divided into SRT (n = 22) and non-SRT (n = 41) groups. In the SRT group, patients were presented with a visual guide based on a structured teaching approach at the pre-anesthetic consultation. The guide comprised photographs of the places, tools, and processes that the patient would experience prior to anesthesia induction. Patients then practiced these processes (rehearsal). Patients in the non-SRT group were administered anesthesia in a conventional manner without SRT.
The percentage of patients needing physical restraint was significantly lower in the SRT (3/22, 13%) than in the non-SRT group (21/41, 51%, P < .001).
The SRT method reduces the need for physical restraint in patients with ASD during anesthesia induction.
Procedural sedation in children with autism spectrum disorders in the emergency department
2019, American Journal of Emergency Medicine
Children with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED.
We performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009–December 2016. Data were collected on children 1–18 years of age with ASD who were sedated in the ED.
There were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation.
Children with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.
The role of melatonin to attain electroencephalograms in children in a sub-Saharan African setting
2017, Seizure
Limited access to electroencephalograms (EEGs) in sub-Saharan Africa results in a high patient load attending the few neurophysiology units. The state of sleep in children improves yield and reduces artefact of EEGs. Melatonin induces “natural sleep” without the risk of airway compromise. This study evaluated the effectiveness of oral melatonin to attain electroencephalograms in South African children.
Children undergoing EEG who were unable to cooperate or required sleep EEG, received oral melatonin (3 mg < 15 kg; 6 mg > 15 kg). A retrospective control group received chloral hydrate. Outcome measures were the proportion of children who slept, useful EEG study data, sleep latency and duration, artefacts and EEG study abnormalities.
173 children were recruited, 88 (51%) male, median age 4 years 9 months (range 0–14 years). 87% achieved stage 2 sleep. Median sleep latency was 44.5 min and duration of sleep was 25 min (range 18.5–29 min). Children had no post-sedation irritability, persistent drowsiness, nor any other adverse events or deferments for inter-current illnesses. Sedation with melatonin was less successful in children with developmental and behavioural problems (χ² = 6.18, P = 0.046), with a higher rate of artefacts (χ² = 5.83, P = 0.05).
33.5% (n = 58) had abnormal EEG studies, which was comparable to a historical cohort sedated with chloral hydrate (45.5%) (χ² = 1.22, P = 1.27). Also for artefacts (79% melatonin group versus 86% chloral hydrate group) (χ² = 0.63, P = 0.42).
Melatonin is effective and safe in inducing sleep for EEG recording in our setting.
Sedation with dexmedetomidine for conducting electroencephalogram in a patient with Angelman syndrome: A case report
2016, Brazilian Journal of Anesthesiology
A síndrome de Angelman (SA) é caracterizada por retardo mental grave, distúrbio da fala e desordem convulsiva. Essa condição genética rara está associada a alterações do receptor GABA_A. Pacientes portadores de SA necessitam ser sedados durante a feitura de eletroencefalograma (EEG), indicado para fins diagnósticos ou controle evolutivo. A dexmedetomidina, cuja ação independe do receptor GABA, promove sono semelhante ao fisiológico e pode viabilizar a feitura desse exame em pacientes com SA.
Paciente feminina, 14 anos, portadora de SA, fez EEG sob sedação com dexmedetomidina. O procedimento transcorreu sem intercorrências e não foi registrada bradicardia ou depressão respiratória. O exame foi interpretado com sucesso e atividade epileptiforme não foi observada.
A dexmedetomidina promoveu sedação satisfatória, foi bem tolerada e possibilitou a interpretação do EEG em paciente com SA e desordem convulsiva.
Angelman syndrome is characterized by severe mental retardation and speech and seizure disorders. This rare genetic condition is associated with changes in GABA_A receptor. Patients with Angelman syndrome need to be sedated during an electroencephalogram ordered for diagnostic purposes or evolutionary control. Dexmedetomidine, whose action is independent of GABA receptor, promotes a sleep similar to physiological sleep and can facilitate the performing of this examination in patients with Angelman syndrome.
Female patient, 14 years old, with Angelman syndrome; electroencephalogram done under sedation with dexmedetomidine. The procedure was uneventful and bradycardia or respiratory depression was not recorded. The examination was successfully interpreted and epileptiform activity was not observed.
Dexmedetomidine promoted satisfactory sedation, was well tolerated and enabled the interpretation of the electroencephalogram in a patient with Angelman syndrome and seizure disorder.
Feasibility of sleep-deprived EEG in children
2016, European Journal of Paediatric Neurology
Citation Excerpt :
Failure to attempt a sleep EEG was evaluated by both prospective and retrospective studies, that greatly varied in sample size, and especially in age range, including subjects aged 1 month–17 years. Sedation failure was reported in 2%–9% of the children with chloral hydrate,19–22 8%–17% with hydroxyzine,19–21 0%–13% with dexmedetomidine,22–24 8%–28% with melatonin25,26 and 56% with promethazine.27 Sedation failure with non-pharmacologic sedation alternatives was 3% for music therapy28 and 45% for partial sleep-deprivation.9
Non-sedated EEG recording in children can be technically challenging, particularly when behavioral disorders are present. We aimed to assess the feasibility and the efficacy of non-sedated sleep-deprived EEG in children with behavioral disorders and in young children.
We retrospectively reviewed the EEG recordings and computerized medical records of all pediatric inpatients at least 2-month-old that had a sleep-deprived EEG during a 5-year period between 2009 and 2014.
We present the data of 261 children, 142 (54%) boys, mean age 7.9 ± 4.9 years, 67 (26%) aged 0.5–4 years. Behavioral disorders were reported in 38 (15%) of the patients. Mean recording duration was 50.8 ± 12.5 min, and mean sleep duration- 31.8 ± 15.2 min. Thirty-seven (14%) patients slept less than 15 min during the EEG, including 19 (7%) patients with no sleep during the recording. Sleep duration and the presence of interictal epileptiform discharges did not significantly differ between children with/without behavioral disorders and in those younger/older than 4 years. Patients that did not fall asleep during the EEG did not differ from the others regarding presence of behavioral disorders or age.
These results suggest that non-sedated sleep-deprived EEG is feasible in young children and in those with behavioral disorders. Further studies are needed in order to better characterize the etiologies of sleepless pediatric sleep-deprived EEG recordings.

View all citing articles on Scopus

View full text

Original contributionDexmedetomidine for sedation during electroencephalographic analysis in children with autism, pervasive developmental disorders, and seizure disorders

Abstract

Study Objective

Design

Setting

Measurements

Main Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

J Pediatr

Br J Anaesth

Br J Anaesth

Br J Anaesth

Br J Anaesth

The incidence of seizures among children with autistic syndromes

Am J Psychiatry

Epilepsy in autism and autistic-like conditions

Arch Neurol

Seizure disorder in autism

J Am Acad Child Psychiatry

Efficacy of sedation of children with chloral hydrate

South Med J

Effect of sedative and hypnotic doses of propofol on the EEG activity of patients with or without a history of seizure disorder

J Neurosurg Anesthesiol

Sedation during mechanical ventilation in infants and children: dexmedetomidine versus midazolam

South Med J

Rescue sedation with dexmedetomidine for diagnostic imaging: a preliminary report

Pediatr Anaesth

Prospective evaluation of dexmedetomidine for noninvasive procedural sedation in children

Pediatr Crit Care Med

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures

Pediatrics

EEG sedation for children with autism

J Dev Behav Pediatr

Original contribution
Dexmedetomidine for sedation during electroencephalographic analysis in children with autism, pervasive developmental disorders, and seizure disorders