Pediatric Drugs

, Volume 19, Issue 2, pp 107–111 | Cite as

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

  • Giorgio CozziEmail author
  • Stefania Norbedo
  • Egidio Barbi
Current Opinion


Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine’s impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.


Dexmedetomidine Chloral Hydrate Sedative Agent Procedural Sedation Intranasal Route 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Authors’ contributions

All authors, SN, GC and EB, contributed equally to the manuscript. All authors, SN, GC and EB, read and approved the manuscript and approved its submission to the journal.

Compliance with Ethical Standards

Conflict of interest

The authors SN, GC and EB declare that they do not have any conflict of interest.


The authors, SN, GC and EB, declare they did not receive any funding or grant for this manuscript.


  1. 1.
    Roback NG, Carlson DW, Babl FE, Kennedy RM. Update on pharmacological management of procedural sedation for children. Curr Opin Anasthesiol. 2016;29:S21–35.CrossRefGoogle Scholar
  2. 2.
    Sulton C, McCraken C, Simon HK, Hebbar K, Reynolds J, Cravero J, et al. Pediatric procedural sedation using dexmedetomidine: a report from the Pediatric Sedation Research Consortium. Hosp Pediatr. 2016;6:536–44.CrossRefPubMedGoogle Scholar
  3. 3.
    Haselkorn T, Whittemore AS, Udaltsova N, Friedman GD. Short-term chloral hydrate administration and cancer in humans. Drug Saf. 2006;29:67–77.CrossRefPubMedGoogle Scholar
  4. 4.
    Pershad J, Palmisano P, Nichols M. Chloral hydrate: the good and the bad. Pediatr Emerg Care. 1999;15:432–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Napoli KL, Ingall CG, Martin GR. Safety and efficacy of chloral hydrate sedation in children undergoing echocardiography. J Pediatr. 1996;129:287–91.CrossRefPubMedGoogle Scholar
  6. 6.
    D’agostino J, Terndrup TE. Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care. 2000;16:1–4.Google Scholar
  7. 7.
    Valenzuela DG, Kumar DS, Atkins CL, Beers A, Kozak FK, Chadha NK. Chloral hydrate sedation for auditory brainstem response (ABR) testing in children: safety and effectiveness. Int J Pediatr Otorhinolaryngol. 2016;83:175–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Stephen MC, Mathew J, Varghese AM, Kurien M, Mathew GA. A randomized controlled trial comparing intranasal midazolam and chloral hydrate for procedural sedation in children. Otolaryngol Head Neck Surg. 2015;153:1042–50.CrossRefPubMedGoogle Scholar
  9. 9.
    Sury MR, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK. Development of a nurse-led sedation service for paediatric magnetic resonance imaging. Lancet. 1999;353:1667–71.CrossRefPubMedGoogle Scholar
  10. 10.
    Hare M. Question 1. Chloral hydrate or midazolam: which is better for sedating children for painless diagnostic imaging? Arch Dis Child. 2012;97:750–2.CrossRefPubMedGoogle Scholar
  11. 11.
    Buck ML. The use of chloral hydrate in infants and children. Pediatr Pharmacother. 2005;11:1–4.Google Scholar
  12. 12.
    Nordt SP, Rangan C, Hardmaslani M, Clark RF, Wendler C, Valente M. Pediatric chloral hydrate poisoning and death following outpatient procedural sedation. J Med Toxicol. 2014;10:219–22.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Cotè CJ, Karl HW, Notterman DA, Wemberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;106:633–44.CrossRefPubMedGoogle Scholar
  14. 14.
    Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, et al. EMCS Panel on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51:378–99.CrossRefPubMedGoogle Scholar
  15. 15.
    Rumm PD, Takao RT, Fox DT, Atkinson SW. Efficacy of sedation of children with chloral hydrate. South Med J. 1990;83:1040–3.CrossRefPubMedGoogle Scholar
  16. 16.
    Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics. 2000;105:E42.CrossRefPubMedGoogle Scholar
  17. 17.
    Mahmoud M, Mason KP. Dexmedetomidine: review, update, and future considerations of paediatrics perioperative and periprocedural applications and limitations. Br J Anaesth. 2015;115:171–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Wolfe TR, Braude DA. Intranasal medication delivery for children: a brief review and update. Pediatric. 2010;126:532–7.CrossRefGoogle Scholar
  19. 19.
    Cimen ZS, Hanci A, Sivrikaya GU, Kilinc LT, Erol MK. Comparison of buccal and nasal dexmedetomidine premedication for pediatric patients. Paediatr Anaesth. 2013;23:134–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Faritus SZ, Khazaee-Koohpar M, Ziyaeifard M, Mehrabanian MJ. Oral dexmedetomidine versus midazolam as anesthetic premedication in children undergoing congenital heart surgery. Anesth Pain Med. 2015;22:e25032.Google Scholar
  21. 21.
    Tobias JD, Cravero JP. Procedural sedation for infants, children and adolescents. First ed. American Academy of Pediatrics section on Anesthesiology and Pain Medicine; 2016.Google Scholar
  22. 22.
    Tobias JD. Dexmedetomidine and ketamine: an effective alternative for procedural sedation? Paediatr Crit Care Med. 2012;13:423–7.CrossRefGoogle Scholar
  23. 23.
    McVey JD, Tobias JD. Dexmedetomidine and ketamine for sedation during spinal anaesthesia in children. J Clin Anesth. 2010;22:538–45.CrossRefPubMedGoogle Scholar
  24. 24.
    Akin A, Bayram A, Esmaoglu A, Tosun Z, Aksu R, Altuntas R, et al. Dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia. Paediatr Anaesth. 2012;22:871–6.CrossRefPubMedGoogle Scholar
  25. 25.
    US Food and Drug Administration. Safety Announcement: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. 2016; Available at: Accessed 24 Jan 2017.
  26. 26.
    Disma N, Hansen TG. Pediatric anesthesia and neurotoxicity: can findings be translated from animals to humans? Minerva Anestesiol. 2016;82:791–6.PubMedGoogle Scholar
  27. 27.
    Sanders RD, Sun P, Patel S, Li M, Maze M, Ma D. Dexmedetomidine provides cortical neuroprotection: impact on anaesthetic-induced neuroapoptosis in the rat developing brain. Acta Anaesthesiol Scand. 2010;54:710–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Degos V, Charpentier TL, Chhor V, Brissaud O, Lebon S, Schwendimann L, et al. Neuroprotective effects of dexmedetomidine against glutamate agonist-induced neuronal cell death are related to increased astrocyte brain-derived neurotrophic factor expression. Anesthesiology. 2013;118:1123–32.CrossRefPubMedGoogle Scholar
  29. 29.
    Li Y, Zeng M, Chen W, Liu C, Wang F, Han X, et al. Dexmedetomidine reduces isofluorane induced neuroapoptosis partly by preserving PI3K/Akt pathway in the hippocampus of neonatal rats. PLoS One. 2014;9:e93639.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Alam A, Suen KC, Hana Z, Sanders RD, Maze M, Ma D. Neuroprotection and neurotoxicity in the developing brain: an update on the effects of dexmedetomidine and xenon. Neurotoxicol Teratol. 2017. doi: 10.1016/ Scholar
  31. 31.
    Mason KP, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth. 2008;18:403–11.CrossRefPubMedGoogle Scholar
  32. 32.
    Mason KP, Lubisch NB, Robinson F, Roskos R. Intramuscular dexmedetomidine sedation for pediatric MRI and CT. AJR Am J Roentgenol. 2011;197:720–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Mason KP, Lubisch N, Robinson F, Roskos R, Epstein MA. Intramuscular dexmedetomidine: an effective route of sedation preserves background activity for pediatric electroencephalograms. J Pediatr. 2012;161:927–32.CrossRefPubMedGoogle Scholar
  34. 34.
    Yuen VM, Hiu TW, Irwin MG, Yuen MK. A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Anesth Analg. 2008;106:1715–21.CrossRefPubMedGoogle Scholar
  35. 35.
    Jia JE, Chen JY, Hu X, Li WX. A randomized study of intranasal dexmedetomidine and oral ketamine for premedication in children. Anaesthesia. 2013;68:944–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Li BL, Zhang N, Huang JX, et al. A comparison of intranasal dexmedetomidine for sedation in children administered either by atomizer or by drops. Anaesthesia. 2016;71:522–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Mekitarian Fihlo E, Robison F, de Carvalho WB, Gilio AE, Mason KP. Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging. J Pediatr. 2015;166:1313–5.CrossRefGoogle Scholar
  38. 38.
    Baier NM, Mendez SS, Kimm D, Velazquez AE, Schroeder AR. Intranasal dexmedetomidine: an effective sedative agent for electroencephalogram and auditory brain response testing. Paediatr Anaesth. 2016;26:280–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Reynolds J, Rogers A, Medellin E, Guzman JA, Watcha MF. A prospective, randomized, double-blind trial of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response (ABR) testing. Paediatr Anaesth. 2016;26:286–93.CrossRefPubMedGoogle Scholar
  40. 40.
    Miller J, Xue B, Hossain M, Zhang MZ, Loepke A, Kurth D. Comparison of dexmedetomidine and chloral hydrate sedation for transthoracic echocardiography, in infants and toddlers: a randomized clinical trial. Paediatr Anaesth. 2016;26:266–72.CrossRefPubMedGoogle Scholar
  41. 41.
    Ambi US, Joshi C, Ganeshnavar A, Adarsh E. Intranasal dexmedetomidine for paediatric sedation for diagnostic magnetic resonance imaging studies. Indian J Anaesth. 2012;56:587–8.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    O’Mara K, Gal P, Wimmer J, Ransom JL, Carlos RQ, Dimaguila MA, et al. Dexmedetomidine versus standard therapy with fentanyl for sedation in mechanically ventilated premature neonates. J Pediatr Pharmacol Ther. 2012;17:252–62.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Lam F, Bhutta AT, Tobias JD, Gossett JM, Morales L, Gupta P. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease. Pediatr Cardiol. 2012;33:1069–77.CrossRefPubMedGoogle Scholar
  44. 44.
    Chrysostomou C, Schulman SR, Herrera Castellanos M, Cofer BE, Mitra S, da Rocha MG, et al. A phase II/III, multicenter, safety, efficacy, and pharmacokinetics study of dexmedetomidine in preterm and term neonates. J Pediatr. 2014;164:276–82.CrossRefPubMedGoogle Scholar
  45. 45.
    Zhang W, Wang Z, Song X, Fan Y, Tian H, Li B. Comparison of rescue techniques for failed chloral hydrate sedation for magnetic resonance imaging scans—additional chloral hydrate vs intranasal dexmedetomidine. Paediatr Anaesth. 2016;26:273–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Gan X, Lin H, Chen J, Lin Z, Lin Y, Chen W. Rescue sedation with intranasal dexmedetomidine for pediatric ophthalmic examination after chloral hydrate failure: a randomized, controlled trial. Clin Ther. 2016;38:1522–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Zhang W, Fan Y, Zhao T, Chen J, Zhang G, Song X. Median effective dose of intranasal dexmedetomidine for rescue sedation in pediatric patients undergoing magnetic resonance imaging. Anesthesiology. 2016;125:1130–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Li BL, Yuen VM, Song XR, Ye J, Ni J, Huang JX, et al. Intranasal dexmedetomidine following failed chloral hydrate sedation in children. Anaesthesia. 2014;69:240–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Reynolds J, Rogers A, Capehart S, Manyang P, Watcha MF. Retrospective comparison of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response exams. Hosp Pediatr. 2016;6:166–71.CrossRefPubMedGoogle Scholar
  50. 50.
    Gumus H, Bayram AK, Poyrazoglu HG, Canpolat DG, Per H, Canpolat M, et al. Comparison of effects of different dexmedetomidine and chloral hydrate doses used in sedation on electroencephalography in pediatric patients. J Child Neurol. 2015;30:983–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Emergency DepartmentInstitute for Maternal and Child Health IRCCS “Burlo Garofolo”TriesteItaly

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