TOPLINE

Intranasal dexmedetomidine and inhaled nitrous oxide provided comparable immediate pain control during intra-articular corticosteroid injection (IACI) in children with juvenile idiopathic arthritis (JIA). However, nitrous oxide resulted in better overall patient experience and became a preferred sedation option for future procedures.

METHODOLOGY

• Researchers conducted a randomised crossover clinical trial to compare the efficacy and safety of intranasal dexmedetomidine with those of inhaled nitrous oxide for procedural sedation during IACI in children with JIA.
• They enrolled 68 children aged 2.2-16.3 years with JIA who had one to five inflamed joints requiring IACI at a paediatric rheumatology outpatient clinic in Finland between February 2017 and December 2023; 43 patients received both sedatives across two treatment visits.
• Participants were randomly assigned to receive either intranasal dexmedetomidine (initial dose, 4 µg/kg; after the first four patients, the initial dose was reduced to 2 µg/kg due to profound and prolonged sedation) or inhaled 50% nitrous oxide at the first visit, with crossover to the alternate sedative at a subsequent visit if needed. All patients received standardised co-analgesics before IACI regardless of sedative assignment.
• The primary outcome was patient-reported pain assessed using the visual analog scale immediately after recovery from each sedation intervention. Secondary outcomes included pain ratings from parents, assisting nurses, and paediatric rheumatologists; sedation level; and safety.

TAKEAWAY

• The severity of patient-reported pain immediately after the procedure was similar between dexmedetomidine and nitrous oxide groups (mean difference, 0.2; P = .65). Pain scores were lower during the second treatment visit (mean difference, -1.2; P = .02).
• At the 1- to 3-month follow-up, patients and parents recalled less pain and reported higher satisfaction with nitrous oxide than with dexmedetomidine (P < .05 for both).
• Compared with nitrous oxide, dexmedetomidine produced deeper and longer-lasting sedation, with 13% vs 98% of patients experiencing deep sedation, and was associated with greater reductions in the heart rate and blood pressure (P < .001 for both).
• Adverse events were more common with dexmedetomidine than with nitrous oxide (11 vs 2 events) and included hypotension, bradycardia, and asymptomatic second-degree atrioventricular block; 69% of patients preferred nitrous oxide for future sedation at follow-up.

IN PRACTICE

"As dexmedetomidine is contraindicated in patients with second- or third-degree AV [atrioventricular] block, and one transient AV conduction delay was observed in our study, we suggest that routine ECG monitoring should be performed before and during DEX [dexmedetomidine] sedation," the authors wrote.

SOURCE

This study was led by Miikka Tervonen, Oulu University Hospital, Oulu, Finland. It was published online on July 21, 2026, in the European Journal of Pediatrics.

LIMITATIONS

The open-label design reflected real-life clinical practice but limited blinding. The relatively small sample size precluded subgroup analyses by age or joint size. The reduction of the dexmedetomidine dose during the trial may have reduced its analgesic efficacy and contributed to the lack of differences between the two treatment groups.

DISCLOSURES

This study was supported by research grants from the Finnish Foundation for Pediatric Research and Stiftelsen Alma och K.A. Snellman Foundation. The authors declared having no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.