Monitoring
Minimum Monitoring Requirements
All children receiving intranasal dexmedetomidine must be monitored from the time of administration until they meet discharge criteria.
| Parameter | Frequency |
|---|---|
| SpO₂ | Continuous from time of administration |
| Heart rate | Continuous (pulse oximeter or cardiac monitor) |
| Respiratory rate | Every 15 minutes |
| Blood pressure | Every 15–30 minutes once sedated |
| Sedation score (UMSS) | Every 15 minutes once sedation begins |
| Level of consciousness | Every 15 minutes |
A parent or carer should remain with the child throughout. One clinical staff member must be immediately available and not simultaneously responsible for other sedated patients.
Sedation Scoring
University of Michigan Sedation Scale (UMSS)
The UMSS is the preferred sedation scoring tool for children receiving intranasal dexmedetomidine.
| Score | Description |
|---|---|
| 0 | Awake and alert |
| 1 | Minimally sedated — tired/sleepy, responds appropriately to verbal conversation and stimulation |
| 2 | Moderately sedated — somnolent, easily aroused with light tactile stimulation or simple verbal command |
| 3 | Deeply sedated — deep sleep, arousal only with significant physical stimulation |
| 4 | Unarousable — no response to significant physical stimulation |
Target UMSS:
- Premedication and procedural sedation: UMSS 2
- MRI sedation: UMSS 2–3
A score of 4 is not a target and warrants immediate assessment.
Positioning and Airway
- Keep the child in a semi-recumbent or lateral position once sedated — do not leave supine and unattended
- Keep airway equipment (suction, bag-mask, oxygen) immediately available at the bedside
- Reassess airway position at each monitoring interval
Haemodynamic Thresholds
Bradycardia
| Heart Rate | Action |
|---|---|
| Age-appropriate lower limit to 10 bpm below | Monitor closely; notify medical officer |
| >10 bpm below age-appropriate lower limit | Assess clinical status; call medical officer |
| Symptomatic bradycardia at any rate | Stimulate child; call for urgent medical review |
Oxygen Saturation
| SpO₂ | Action |
|---|---|
| 94–96% | Reposition airway; apply supplemental oxygen; increase monitoring frequency |
| <94% | Stimulate child; apply supplemental oxygen; call medical officer urgently |
| <90% at any point | Call for immediate help; open airway; bag-mask ventilation if required |
Discharge Criteria
The child must meet all of the following before discharge from the monitored area:
- UMSS 0 or 1 (returning to baseline level of consciousness)
- Haemodynamically stable — heart rate and blood pressure within normal range for age
- SpO₂ ≥96% on room air
- Maintaining and protecting own airway
- No vomiting in the last 30 minutes
- Parent/carer present and aware of post-sedation instructions
- Minimum 60 minutes observed from time of administration (even if apparently awake)
Discharge instructions should advise carers that the child may remain drowsy for several hours and should not be left unsupervised near water, heights, or roads.
Documentation
Record in the clinical notes:
- Time and dose of intranasal dexmedetomidine administered
- Volume delivered to each nostril and whether administration was complete
- Any distress, crying, or sneezing at the time of administration
- Onset time (UMSS reaching target)
- All monitoring observations with timestamps
- Time of discharge and carer instructions given