Safety & Efficacy of Intranasal Dexmedetomidine, Fentanyl & Midazolam in the Pediatric Emergency Room

Pain Clinical Trial

Official title:

A Double-blinded, Randomized Trial Comparing the Safety & Efficacy of Intranasal Dexmedetomidine, Intranasal Fentanyl & Intranasal Midazolam in the Pediatric Emergency Room

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05057689
• Other study ID #: 261081
• Status: Not yet recruiting
• Phase: Phase 2
• Start date: October 2022
• Est. completion date: December 2023

Study information

• Verified date: July 2022
• Source: University of Arkansas
• Contact: Jonathan Chang, MD
• Phone: 501-364-1050
• Email: JChang3[@]uams.edu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The hypothesis is that intranasal dexmedetomidine will provide significantly more effective analgesia and anxiolysis for subjects undergoing a simple laceration repair when compared to either intranasal fentanyl or intranasal midazolam.

Additional hypotheses include that there will be 1) no significant increase in adverse effects between drugs and 2) significantly higher satisfaction rates for both subject experience and ease of laceration repair based on structured, proceduralist feedback.

Description:

Intranasal medications are rapidly gaining popularity as agents for analgesia and anxiolysis in the pediatric hospital setting. One of the primary reasons for the popularity of intranasal medications is ease of administration combined with favorable pharmacokinetics. It has been well established that children identify venipuncture as one of the most painful and anxiety-producing procedures during time spent in the hospital, and these experiences have been shown to have a more lasting impact, producing increased anxiety and fear at subsequent visits. Although oral and rectal administration of analgesics are also non-invasive, bioavailability, time to onset, and half-lives are significantly longer with these routes of administration in comparison to intranasal administration. Multiple studies have shown that intranasal fentanyl, midazolam, and dexmedetomidine have similar pharmacokinetics to intravenous preparations and reach adequate serum levels in both the blood and cerebrospinal fluid. In the pediatric emergency room setting, intranasal fentanyl and midazolam have been shown to provide effective analgesia and anxiolysis for a variety of settings, including pain management (e.g. pain associated with long bone fractures, burns, incision and drainage) and pre-procedural sedation/anxiolysis (e.g. radiological imaging).Numerous studies have examined the safety and efficacy of intranasal fentanyl and midazolam, and several studies have examined the efficacy of intranasal dexmedetomidine for non-painful procedural sedation. To date, two studies have compared the use of intranasal dexmedetomidine and intranasal midazolam or intranasal dexmedetomidine, intranasal fentanyl, and intranasal midazolam for anxiolysis in painful procedural sedations. However, as of 2020, no previous studies have compared the use of intranasal dexmedetomidine, intranasal fentanyl, and intranasal midazolam for painful procedures in the pediatric emergency setting.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 180
• Est. completion date: December 2023
• Est. primary completion date: December 2023
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 2 Years to 6 Years

Eligibility

Inclusion Criteria:

• Primary complaint of "laceration"

• 2 years to 6 years of age (inclusive)

• Initial presentation at the Arkansas Children's Hospital (ACH) Emergency Department

Exclusion Criteria:

• Prior allergic reaction to fentanyl or midazolam or dexmedetomidine

• Prior major adverse reaction to fentanyl or midazolam (e.g. seizure-like activity, paradoxical reaction, hallucinations)

• Nasal injury/deformity

• Potential for altered pain perception (e.g. autism, severe sensory-neural disturbances)

• History of adverse reaction to sedation/anesthesia

• History of cardiac arrhythmia

• History of liver dysfunction

• Concurrent injuries that would necessitate higher levels of care (e.g. inpatient admission, immediate evaluation in the operating room (OR), etc.)

• Complex (multi-layer) lacerations or those requiring subspecialty consultation for repair

• American Society of Anesthesiology (ASA) score = 3

• Use of analgesics (with the exception of ibuprofen or acetaminophen) or anxiolytics in the immediate pre-examination period (within 4 hours)

Related Conditions & MeSH terms

• Acute Stress Disorder
• Anxiety
• Emergencies
• Pain
• Stress Disorders, Traumatic, Acute

Intervention

Drug:
• Intranasal Dexmedetomidine (4 mcg/kg)
Dexmedetomidine 100 mcg/mL (concentration of 200 mcg/2 mL) will be atomized for intranasal administration at a dose of 4 mcg/kg (0.04 mL/kg) according to a weight-based dosing chart prior to laceration repair. The maximum dose will be 200 mcg.
• Intranasal Fentanyl (2 mcg/kg)
Fentanyl 50 mcg/mL (concentration of 100 mcg/2 mL) will be atomized for intranasal administration at a dose of 2 mcg/kg (0.04 mL/kg) according to a weight-based dosing chart prior to laceration repair. The maximum dose will be 100 mcg.
• Intranasal Midazolam (5 mg/kg)
Midazolam 5 mg/mL (concentration of 10 mg/2 mL) will be atomized for intranasal administration at a dose of 0.3 mg/kg (0.06 mL/kg) according to a weight-based dosing chart prior to laceration repair. The maximum dose will be 10 mg.

Locations

Country	Name	City	State
United States	Arkansas Children's Hospital	Little Rock	Arkansas

Sponsors (1)

Lead Sponsor	Collaborator
University of Arkansas

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Pain using the Face, Legs, Activity, Cry, Consolability (FLACC) scale	Analgesia in subjects undergoing simple laceration repair will be compared across the three investigational drug products (intranasal dexmedetomidine, intranasal fentanyl, and intranasal midazolam) using the FLACC scale.	through the procedure, an average of 1 day
Primary	Anxiety using the modified Yale Preoperative Anxiety Scale (mYPAS) behavior observation tool	Anxiolysis in subjects undergoing simple laceration repair will be compared across the three investigational drug products (intranasal dexmedetomidine, intranasal fentanyl, and intranasal midazolam) using the modified Yale Preoperative Anxiety Scale (mYPAS) behavior observation tool.	through the procedure, an average of 1 day
Secondary	Satisfaction rates for subject experience across the three study drugs based on parent/legally authorized representative (LAR) survey	Parent/LAR will be asked to complete a follow-up survey so that parent/LAR can provide feedback on the level of satisfaction with the laceration repair experience.	within 1 week of the laceration repair, average of 5 days
Secondary	Satisfaction rates for surgical repair across the three study drugs based on proceduralist survey	Proceduralist will be asked to complete a follow-up survey to provide feedback on the level of satisfaction with the laceration repair experience.	within 1 week of the laceration repair, average of 5 days