Emergence delirium is one of the more common complications of pediatric anesthesia. Multiple definitions exist for this phenomenon, the best probably being non-purposeful action consistent with an apparent lack of awareness of one’s environment (Malarbi and colleagues, Pediatric Anesthesia 2011, article not posted to website for the sake of simplicity). This definition highlights the difference between pain and emergence delirium. Children in the recovery room may be upset for a variety of reasons, including pain and delirium. A therapy that lessened the intensity of both pain and delirium without compromising normal physiology would be ideally suited for these patients.

In an imperfect world, no perfect drug exists. Fortunately dexmedetomidine provides multiple advantages for pediatric patients while having a limited side effect profile. Guler and colleagues examined the effectiveness of a single dose of dexmedetomidine in reducing delirium. With a dose of 0.5 mcg/kg at the end of surgery, this group effectively prevented agitation. Note table 2 on page 764. In addition to it’s sedation effect, dexmedetomidine had an analgesic effect. Note table 3 of the same paper, severe pain in these children was found in less than half the number of children than in the placebo group. Olutoye and colleagues examined the analgesic properties of dexmedetomidine specifically. His group compared dexmedetomidine to morphine as an analgesic. This group found that dexmedetomidine 1 mcg/kg was comparable to morphine 0.1 mg/kg as a pain control agent in adenotonsilectomy patients (table 1, page 492).

The side effect profile of dexmedetomidine largely revolves around hemodynamic effects. The drug has little effect on respiratory drive or nausea, common problem areas in children. Dexmedetomidine does predictably lower heart rate and blood pressure. These changes are often well tolerated at a dose of 0.5-1 mcg/kg as described above. Mason and colleagues describe a more problematic bradycardic response to dexmedetomidine at doses of 3 mcg/kg. Her patients also demonstrated an exagerated hypertensive response to rescue glycopyrrolate. This paper is included to demonstrate the potential worst case scenario of glycopyrrolate use in conjunction with high dose dexmedetomidine.