Troubleshooting

Always escalate to the responsible medical officer or anaesthetist if a problem is not resolving or if you are uncertain about the child’s safety.

Inadequate Sedation

This is the most common issue with intranasal dexmedetomidine.

Child is not sedated at 30 minutes

Onset typically takes 20–45 minutes. Do not conclude that the drug has not worked at 30 minutes. Continue monitoring and reassess at 45 minutes.

Child is not sedated at 45 minutes

1. Review the administration — did the child cry, sneeze, or spit immediately after? Was the correct dose delivered to both nostrils? Was the MAD device used correctly?
2. Assess UMSS — even a UMSS of 1 (calm, cooperative) may be sufficient for simple premedication or cannulation.
3. Notify the medical officer — a single repeat dose of 1 mcg/kg (maximum 50 mcg) may be considered after senior review.
4. Consider an alternative approach — if intranasal dexmedetomidine has failed and the procedure cannot wait, the anaesthetist should assess whether an alternative strategy is appropriate (oral midazolam, inhalational induction without premedication, etc.).

Drug Loss at Administration

If the child cried, sneezed, or pulled away during administration:

• Note the estimated proportion of dose lost
• Wait the full 45 minutes before concluding sedation is inadequate
• Inform the medical officer
• If sedation is clearly inadequate at 45 minutes and you believe significant drug was lost, a repeat dose may be considered (senior review required)

A calmer administration environment — dim lighting, parent holding the child, distraction — reduces the risk of drug loss.

Bradycardia

Clinically significant bradycardia is less common with intranasal than intravenous dexmedetomidine but can occur.

Oxygen Desaturation

Significant desaturation is uncommon at standard doses in a healthy child with a patent airway.

1. Reposition — jaw thrust or lateral position to open the airway
2. Stimulate — call the child’s name; gentle physical stimulation
3. Apply supplemental oxygen via face mask
4. Call for help if SpO₂ does not improve promptly with the above
5. Prepare for bag-mask ventilation if the child is not breathing adequately

Review all co-administered sedatives or analgesics — additive effects are a common cause.

Prolonged Sedation

Dexmedetomidine has a half-life of approximately 2 hours; sedation beyond 2–3 hours is not expected at standard doses.

• If the child remains at UMSS 2–3 beyond the expected duration, notify the medical officer
• Continue monitoring until discharge criteria are met — do not discharge early
• There is no reversal agent — management is supportive (monitoring, airway, position)
• Review for any inadvertent double dose or concurrent sedatives

Vomiting

Vomiting under sedation carries an aspiration risk.

• Turn child to lateral position immediately
• Clear the airway — suction if available
• Assess level of consciousness and airway patency
• Call for medical review
• Do not proceed with elective procedures until fully recovered

When to Call for Immediate Help

Call a MET or equivalent immediately if:

• SpO₂ <90% not responding to repositioning and oxygen
• Child is unresponsive to stimulation (UMSS 4)
• Significant bradycardia not responding to stimulation
• Vomiting with reduced consciousness
• Any concern that the child is in immediate danger