Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department

In recent years, dexmedetomidine has gained traction as a treatment for anxiolysis in the emergency department (ED). When used with an atomizer, it may also be given intranasally for anxiolysis. The primary objective was to determine the level of ED provider satisfaction and comfort with intranasal (IN) dexmedetomidine for anxiolysis in pediatric patients with behavioral agitation and/or acute psychosis. The secondary objectives included determining safety, rates of therapy failure, and ED length of stay compared with oral midazolam. The efficacy of IN dexmedetomidine versus oral midazolam in patients with autism spectrum disorder (ASD) was also evaluated.

This was a single-center, prospective study in a pediatric ED from March 1 to December 31, 2021. Patients were included in the study if the ED provider requested IN dexmedetomidine anxiolysis and completed a postadministration survey. Safety and efficacy outcomes were assessed by chart review and compared with patients who received oral midazolam during the same study period. Efficacy was defined as the rate of treatment failure, as the need for procedural termination, progression to procedural sedation, or the requirement of additional medications for anxiolysis.

Sixty-two patients received IN dexmedetomidine {median dose [interquartile range (IQR)] of 3.05 [2.04-4.00] μg/kg/dose} compared with 58 who received oral midazolam [median (IQR) dose of 0.29 (0.25-0.48) mg/kg/dose). Providers reported high comfort and satisfaction scores, with median (IQR) scores of 90 (75-100) and 88 (60-100) of 100. Twenty-nine percent of patients experienced treatment failure, most commonly because of the need for additional medications. Those who received IN dexmedetomidine had a longer ED length of stay (6.0 vs 4.4 hours, P = 0.010). Among the patients with ASD, those who received IN dexmedetomidine had a lower rate of treatment failure compared with oral midazolam (21.2% vs 66.7%, P = 0.039).

This study demonstrates that IN dexmedetomidine has high levels of provider comfort and satisfaction, moderately high success rate, and a promising safety profile. In addition, IN dexmedetomidine may be superior to oral midazolam in patients with ASD for anxiolysis, but additional studies are needed.