A Phase 3 interventional study of Dexmedetomidine and Midazolam Nasal Spray in Laceration of Skin and Distress, Emotional, sponsored by London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's. Recruiting at 1 site in Canada. Open to participants aged 2 Years to 12 Years. Per ClinicalTrials.gov, last updated 2025-04-30.
Sponsored by London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's · Phase 3, Interventional, and Treatment
This is a 3-arm adaptive clinical trial to the optimal light sedative for reducing distress during laceration repair in children. The investigators will compare intranasal (IN) dexmedetomidine, IN midazolam, and nitrous oxide (N20). The primary outcome is the Observational Scale of Behavioral Distress - Revised (OSBD-R).
Accounting for almost half of all procedures performed, lacerations are the most common reason for an ED visit in children. There is consistent evidence that children experience considerable distress during laceration repair, despite routine application of topical anesthetic, lidocaine-epinephrine-tetracaine (LET). Certified child life specialists (CCLSs) can help children cope with distress but are not widely available. Untreated distress in childhood can lead to anxiety, needle phobia, and fear of medical care as adults. The American Academy of Pediatrics and American Academy of Pediatric Dentistry strongly recommend minimizing discomfort and controlling behavior and movement during procedures but there is no specific guidance on laceration repair. Many children require pharmacologic anxiolysis for laceration repair but evidence for the most effective agent is lacking. Although anxiolytics such as midazolam and nitrous oxide (N2O) are frequently used, there are drawbacks including variable efficacy and nasal irritation in the case of midazolam and lack of cooperation in younger children in the case of N2O. IN dexmedetomidine is a potentially effective anxiolytic for laceration repair that could overcome these limitations.
IN dexmedetomidine is a relatively new anxiolytic with sedative and analgesic properties. It is tasteless, non-irritative, and highly concentrated (100 mcg/mL). A maximum dose of 200 mcg/2 mL can be given with 2 pairs of 0.5 mL IN sprays. The investigator's team published a systematic review of IN dexmedetomidine for distressing procedures. It was well tolerated by more than 90% of children and provided adequate anxiolysis in more children (79%) versus conventional anxiolytics (midazolam, chloral hydrate) (60%). Only one trial investigated IN dexmedetomidine in children for laceration repair and 70% were deemed "not anxious" compared to IN midazolam (11%). However, the study focused on initial positioning rather than repair. For proof of concept and to identify the optimal dose and feasibility of IN dexmedetomidine, we completed a pilot of 55 children undergoing laceration repair. All children tolerated IN administration, the consent rate was 82%, and there were no serious adverse events (AE). A dose of 3 mcg/kg balanced efficacy with duration of sedation, in line with others' findings.
Oral midazolam is the most common anxiolytic for laceration repair in children. However, onset and duration of action and efficacy can be unreliable and its bitter taste leads to poor compliance. IN midazolam using a mucosal atomizer device (MAD) is increasingly popular because it overcomes these limitations. Compared to oral midazolam, IN midazolam has a shorter onset of action (28 vs 34 minutes) but causes nasal irritation in up to 40% of patients. In addition, IN midazolam has variable efficacy for laceration repair and more adverse effects compared to nitrous oxide or IN dexmedetomidine. The largest study of IN midazolam was a retrospective study of combination IN midazolam plus fentanyl. A lower dose of midazolam (0.2 mg/kg) resulted in fewer adverse effects (0.7%) than with higher doses (2-5%). Adding IN fentanyl provided superior efficacy where only 2.4% of patients experienced a treatment failure.
The second most common anxiolytic is inhaled N2O, a tasteless gas that is administered in a concentration of 30-70% with oxygen. N2O is safe and effective for minor painful procedures. Peak effect is rapid (2 minutes) and effects dissipate quickly (3 minutes) upon discontinuation. Minor adverse effects occur in less than 10% of patients. However, based on the United Kingdom National Clinical Guideline Centre, it's unclear whether uncooperative children will comply with N2O administration. The investigators' recently completed systematic review of 29 trials of N2O for painful procedures in children found 50% N2O was superior to subcutaneous lidocaine, placebo, and oral midazolam. Only 5 trials focused on laceration repair but they were small and limited by non-validated or no measures of anxiety .
Despite frequent use of anxiolytics such as midazolam and N2O, The investigators' national survey found that 80% of Canadian paediatric ED physicians strongly believed that "children experience significant enough distress to warrant anxiolysis" and it would "improve the patient care experience". To improve care, a rigorous trial of a novel anxiolytic, IN dexmedetomidine, and dissemination of the research findings is needed.
174 studies on the registry are indexed under Lacerations; 43 are open to participants now.
This study's planned enrollment of 300 is above the median of 65 across 128 interventional studies indexed under Lacerations.
Browse Lacerations studies →London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's is the lead sponsor of 331 studies on the registry; 137 are open to participants now.
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i) Age 2-12.99 years [highest incidence of laceration repair] ii) Single or grouped lacerations separated by no more than 2 cm for which the treating physician believes repair does not require IV sedation iii) Repair to involve sutures and performed by ED physician or designate (trainee) iv) Child or caregiver desires anxiolysis for laceration repair [justification: incorporates family preferences based on their prior experiences or beliefs about child's response] vii) Local anesthesia planned to involve topical anesthetic (LET), infiltrated lidocaine, ring, or thenar block
Exclusion Criteria:
i) Sedative, anxiolytic, or alpha-2-adrenergic receptor agonist \< 24 hours prior to interventions (may compound sedative effect and increase the SAE risk). 24-hours encompasses the duration of sedation of most agents.
ii) to any intervention iii) Occlusion of > 1 nostril due to polyps, septal deviation, or foreign body (may prevent drug absorption) iv) Hemodynamic abnormalities: bradycardia or hypotension \< 2 SD of age-related normal value v) IND : Pre-existing renal insufficiency, uncorrected mineralocorticoid deficiency, pulmonary hypertension, uncorrected cyanotic heart disease, cardiac conduction disorder, pulmonary hypertension, pulmonary edema, vitamin B12 or folate disorder, phenylketonuria, or psychosis vi) Sedation contraindications: Impaired level of consciousness or respiratory instability vii) N2O contraindications: Conditions associated with potential accumulation of gas within body spaces viii) Suspected or confirmed pregnancy (as reported by patient) ix) Inability to vocalize pain due to motor deficits (unable to apply the OSBD-R) x) Caregiver unable to complete study tasks due to insufficient comprehension of either English or French in the absence of a native language interpreter xi) Weight >= 65 kg (to avoid under-dosing of INM or IND) x) Not class I (healthy) or II (controlled mild to moderate disease) xii) No concomitant fracture or dislocation requiring orthopedic manipulation
Underlined terms in the criteria open these too. Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
An allergy, or another reaction of the immune system, to a substance. “Hypersensitivity to the study drug” means a known allergic reaction to it — not every side effect a medicine can have.
A reason a treatment, test or procedure should not be given to a particular person, such as an allergy, another illness or a medicine they take.
The anaesthetists’ scale of health before surgery: I is healthy, II has a mild illness that is under control, III a severe one, IV a severe illness that is a constant threat to life. V and VI are used for the critically ill and for organ donors.
Hypersensitivity
An allergy, or another reaction of the immune system, to a substance. “Hypersensitivity to the study drug” means a known allergic reaction to it — not every side effect a medicine can have.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Contraindication
A reason a treatment, test or procedure should not be given to a particular person, such as an allergy, another illness or a medicine they take.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
ASA physical status
The anaesthetists’ scale of health before surgery: I is healthy, II has a mild illness that is under control, III a severe one, IV a severe illness that is a constant threat to life. V and VI are used for the critically ill and for organ donors.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
IN dexmedetomidine 3 mcg/kg \[100 mcg/mL (max 200 mcg or 2 mL)\]
Drug: Dexmedetomidine
IN midazolam 0.4 mg/kg \[5 mg/mL (max 10 mg or 2 mL)\]
Drug: Midazolam Nasal Spray
50% N2O in 50% oxygen by face mask or on-demand system
Drug: Nitrous oxide
Intranasal dexmedetomidine 3 mcg/kg \[100 mcg/mL (max 200 mcg or 2 mL)
Also known as: Precedex
Intranasal midazolam 0.4 mg/kg \[5 mg/mL (max 10 mg or 2 mL)
Also known as: Versed
50% nitrous oxide in 50% oxygen by face mask
Also known as: Nitronox
Observational Scale of Behavioral Distress - Revised (OSBD-R)
Score ranges from 0 (no distress) to 23.5 (maximal distress) and will be scored for the time interval encompassing preparation and suturing
Time frame: During preparation, suturing, and recovery (20 minutes)
Adverse effects
Will be based on the Quebec Guidelines and Health Canada reporting standards for sedation in children and include nausea and vomiting
Time frame: From intervention to 72 hours post-discharge
Need for additional anxiolysis or sedation to facilitate repair
Need for additional anxiolysis or sedation to facilitate repair
Time frame: During suturing (10 minutes)
Need for physical restraint
Need for restraint during preparation and suturing based on the Procedural Restraint Intensity in Children (PRIC) scale. The PRIC is scored in discrete integer values from 0=no restraint to 4=extreme forceful restraint. A higher score indicates more restraint is needed.
Time frame: During preparation and suturing (10 minutes)
Late maladaptive behaviors
Late maladaptive behaviors up to an including 72 hours post discharge using the Post-Hospital Behavior Questionnaire. The scale consists of 27 items concerning sleep, eating, anxiety, etc. where each item is scored from 1-5. The minimum score is 27 and the maximum score is 135 with higher scores indicating greater severity of behaviors.
Time frame: From discharge to 72 hours post-discharge
Compliance with intervention administration
Compliance (percent of calculated IN volume given and acceptance of face mask or on-demand mouthpiece (yes/no))
Time frame: From drug administration through completion of suturing (40 minutes)
Caregiver satisfaction with anxiolysis during laceration repair
Caregiver satisfaction with anxiolysis using a 100 mm visual analog scale. A higher score indicates greater satisfaction.
Time frame: At discharge (1 minute)
Child satisfaction with anxiolysis during laceration repair
Child (7-12 years) satisfaction with anxiolysis using a 100 mm visual analog scale. A higher score indicates greater satisfaction.
Time frame: At discharge (1 minute)
Healthcare provider (physician, nurse, respiratory therapist) satisfaction with anxiolysis during laceration repair
Nurse, physician, parent, and child 7-12 years satisfaction with anxiolysis using a 100 mm visual analog scale. A higher score indicates greater satisfaction.
Time frame: During recovery (1 minute)
Number of healthcare personnel required during repair
Maximum number of healthcare personnel required at bedside during repair to provide physical restraint or patient care
Time frame: During procedure (10 minutes)
Cost of healthcare personnel required at bedside during repair
Costs of healthcare personnel based on salary per minute required at bedside during repair to provide physical restraint or patient care
Time frame: During procedure (40 minutes)
Cost of interventions
Cost of interventions based on group assignment
Time frame: During procedure (40 minutes)
Total ED length of stay
ED length of stay
Time frame: During emergency department visit (2 hours)
Duration of procedure
Duration of laceration repair
Time frame: During procedure (40 minutes)
Post-intervention length of stay
Length of stay due to anxiolytic
Time frame: From drug administration to discharge (80 minutes)
Nasal irritation
Nasal irritation due IN intervention using the FLACC scale. Measured following IN sprays
Time frame: During IN intervention administration (2 minutes)
Post-procedure length of stay
Post-procedure length of stay
Time frame: From suturing to discharge (40 minutes)
Caregiver state anxiety
Caregiver anxiety related to laceration repair using State Trait Anxiety Inventory Short version - State (STAIS5)
Time frame: Immediately prior to Phase II (preparation) (1 minute)
Plan to share: No
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Studies of the drugs tested here: Dexmedetomidine · Midazolam · Nitrous Oxide
London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's →