Possible mediators for perioperative respiratory adverse events discussed


Investigators compared the effects of midazolam, dexmedetomidine, and saline control on the appearance of perioperative respiratory adverse events in children.

Perioperative respiratory adverse events (PRAEs) are often seen in children after they get an adenotonsillectomy (AT), one of the most common procedures children receive worldwide. ATs are performed for treating sleep-disordered breathing and obstructive sleep apnea syndrome (OSAS). In a recent study, investigators tested for causes of perioperative respiratory adverse events (PRAEs) in children. The goal of the study was to control factors which lead to respiratory complications.

Benzodiazepine midazolam is the most frequent form of preoperative pharmacologic anxiolysis given to children, though recently α-2 agonist dexmedetomidine has been equally common. These are intranasal formulations, allowing children to take them without intravenous access. However, these medicines, along with analgesics such as opioids and anesthetics, may make PRAEs more likely to appear. This is not certain, as data is inconclusive.

Investigators conducted a clinical trial comparing the appearance of PRAES in 384 children after receiving midazolam, dexmedetomidine, or saline control. The midazolam group had the highest rate of PRAEs at 56.5%, followed by the saline control group at 40.8% and the dexmedetomidine group at 24.2%.

Prior studies indicated that dexmedetomidine and midazolam are similarly effective for anxiolysis, but dexmedetomidine is favorable for preventing emergence delirium. In this study, investigators hypothesized that preoperative midazolam and dexmedetomidine would lead to less PRAEs appearing in children.

Investigators found that PRAEs are 5 times more likely to appear in children with OSAS when they undergo AT. As OSAS also leads to higher sensitivity toward opioids, patients were recommended to be given half of a normal opioid dosing.

The patients in this study were clinically diagnosed with OSAS, and investigators were unsure how accurate these diagnoses were. OSAS diagnoses have been recorded with an accuracy range of 30% to 85%. This led to the patients in the trial possibly having unequal levels of OSAS severity.

At the end of the study, investigators concluded that there was still much complexity surrounding preoperative anxiolytic use, and suggested that all medications be carefully considered in the context of each child’s needs and risks.


Dalesio NM, Kudchadkar SR. Perioperative respiratory adverse events after pediatric adenotonsillectomy—evaluating the role of preoperative pharmacologic anxiolysis. JAMA Network Open. 2022;5(8):e2225482. doi:10.1001/jamanetworkopen.2022.25482

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