Intranasal esketamine combined with oral midazolam provides adequate sedation for outpatient pediatric dental procedures: a prospective cohort study

Severe dental phobia or failure to cooperate with treatment are very common in outpatient pediatric dentistry. Personalized and appropriate noninvasive anesthesia methods can save medical expenses, improve treatment efficiency, reduce the anxiety of children, and improve the satisfaction of nursing staff. Currently, there is little conclusive evidence for noninvasive moderate sedation strategies in pediatric dental surgery. MATERIALS AND METHODS: The trial was conducted from May 2022 to September 2022. Each child was first given midazolam oral solution 0.5 mg·kg(−1), and when the Modified Observer’s Assessment of Alertness and Sedation score reached 4, a biased coin design up-down method was used to adjust the dose of esketamine. The primary outcome was the ED(95) and 95% CI of intranasal esketamine hydrochloride with midazolam 0.5 mg·kg(−1). Secondary outcomes included the onset time of sedation, treatment and awakening times, and the incidence of adverse events. RESULTS: A total of 60 children were enrolled; 53 children were successfully sedated but 7 were not. The ED(95) of intranasal esketamine with 0.5 mg·kg(−1) midazolam oral liquid for the treatment of dental caries was 1.99 mg·kg(−1) (95% CI 1.95–2.01 mg·kg(−1)). The mean onset time of sedation for all patients was 43.7±6.9 min. 15.0 (10–24.0) min for examination and 89.4±19.5 min for awakening. The incidence of intraoperative nausea and vomiting was 8.3%. Adverse reactions such as transient hypertension and tachycardia occurred during the operations. CONCLUSION: The ED(95) of intranasal esketamine with 0.5 mg·kg(−1) midazolam oral liquid for the outpatient pediatric dentistry procedure under moderate sedation was 1.99 mg·kg(−1). For children aged 2–6 years with dental anxiety who require dental surgery, anesthesiologists may consider using midazolam oral solution combined with esketamine nasal drops for noninvasive sedation after a preoperative anxiety scale evaluation.