Mesbah Kiaei M. et al., 2023: Comparison of the Effectiveness of Dexmedetomidine-Ketamine and Midazolam-Ketamine Regimens in Sedation of Children Treated with Extracorporeal Shock Wave Lithotripsy.
Mesbah Kiaei M, Movassaghi G, Mohaghegh Dolatabadi M, Zamani MM, Ahmadi H.
Assistant Professor of Anesthesiology, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran.
Anesthesiologist, School of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran.
Abstract
Background: Despite the high acceptability of the extracorporeal shock wave lithotripsy (ESWL) procedure in the treatment of urinary stones at all ages, it is necessary to use a variety of analgesic drugs during the procedure, especially among children.
Objectives: We aimed to evaluate the effect of dexmedetomidine-ketamine (DK) and midazolam-ketamine (MK) compounds in the sedation of children (2-6 years old) undergoing ESWL.
Methods: This randomized, double-blind clinical trial was performed on children aged 2 to 6 years with renal stones undergoing ESWL. The participants were randomly assigned to the DK and MK regimen groups (dexmedetomidine, 0.05 mcg/kg within 10 minutes infusion; midazolam, 0.05 mg/kg within 3 minutes infusion; ketamine, 0.5 mg/kg bolus injection). The patients were assessed with respect to sedation degree, post-procedure hemodynamic status, recovery time and awakening, and operator satisfaction.
Results: Recovery time was significantly shorter in the DK group than in the MK group. Also, the DK regimen was more analgesic than the MK regimen; therefore, the need to repeat ketamine administration was less. There was no difference between the 2 methods in terms of cooperation at the time of separation of children from their parents, patient cooperation during the procedure, average verbal response time and average cooperation time after entering recovery, and operator satisfaction with the operation. No side effects were observed in the 2 groups.
Conclusions: Ketamine with dexmedetomidine is associated with greater analgesia and shorter recovery time; however, sedation time was longer (insignificant) in ketamine with midazolam than in ketamine with dexmedetomidine. Thus, ketamine with dexmedetomidine is more preferred.
Anesth Pain Med. 2023 Apr 13;13(3):e129776. doi: 10.5812/aapm-129776. eCollection 2023 Jun. PMID: 38021338 FREE PMC ARTICLE
Comments 1
“ESWL treatment in children is commonly conducted under general anaesthesia.” (1) The EAU Guidelines (2) state “good treatment outcomes are more likely to require the administration of general anaesthesia to children. With improvements in modern (second and third generation) lithotripters, successful treatment using intravenous sedation, patient controlled analgesia or no medication at all has been increasingly performed in a select population of older, co-operative children.”
If analgosedation works out well as in the present study, I wonder why general anesthesia is still used. My experience with analgosedation was not very rewarding but I am not an anaesthetist.
The present paper deals with 2 groups of 30 patients aged 2 - 6 years treated under sedation. The Ramsay sedation score (RSS) used to describe the status of sedation has 6 levels: in level 4 the patient exhibits brisk response to light glabellar tap or loud auditory stimulus. In level 5 patients exhibit a sluggish response to light glabellar tap or loud auditory stimulus and in level 6 patient exhibits no response. A value of 4 out of 6 was accepted as a sufficiently acceptable sedative level.
Full cooperation without moving was achieved in 100 – 90 % and operator satisfaction was achieved in 90 - 86.7 %. However, 60 to 86% of the children needed an extra dose of ketamine during the procedure to achieve sufficient analgesia. I guess because they were not cooperative. No urologist is co-author. It would be interesting to know how often refocussing was necessary.
1 Peng T, et al. Minimally invasive surgery for pediatric renal and ureteric stones: A therapeutic update. Front Pediatr. 2022 Aug 18;10:902573. doi: 10.3389/fped.2022.902573.
2 Skolarikos A, et al. EAU Guidelines on Urolithiasis. EAU Guidelines Office; 2023.
Peter Alken