Intranasal Dexmedetomidine for Procedural Pain Management in Elderly Adults in Palliative Care Setting: a Cross Over, Superiority, Double-blind, Controlled and Randomized Clinical Trial

Although necessary for patient wellbeing, nursing care procedures potentially produce discomfort, that should be addressed before the procedures begin. In palliative care setting, daily procedures include mobilisation, hygiene care, wound dressing changes, etc. Non-invasive and simple nursing care procedures may cause anxiety and pain that can lead to a refusal of care or an increased distress. The data on procedural pain prevalence are almost only available in pediatrics and are scarce in palliative care and geriatric population. However, the SPdol french study, conducted on elderly people with palliative situations, showed that 85% of procedural pain was related to daily hygiene and comfort care. Results indicate also that in 42%, this type of care remained painful despite preventive pharmacologic measures as opioids administration. Intensity of procedural pain associated with daily and hygiene care is expected to be moderate to severe and not related to presence or absence of pain before initiation of the procedure but to bad prognostic.

In the context of chronic health problems, comfort management pharmacological interventions to achieve analgesia, slight or conscious sedation during nursing care procedures must ideally combine the following properties:

• Rapid recovery and excellent cardiovascular and respiratory security profile;
• Be administrable in the regular place of care of the patient;
• Minimal requirement for medical surveillance in terms of time, equipment and staff;
• Reproducible inset and outset of the analgesic and anxiolytic effect;
• Easy to titrate;
• Convenient, little or non-invasive and administration route as painless as possible.

Dexmedetomidine is allowed in Switzerland for intravenous (IV) medication in the intensive care unit in the adult patient. It is indicated to obtain a level of sedation no deeper than that allowing a response to a verbal stimulus. Its active molecule, Dexmedetomidine (Dex) is a selective and powerful agonist of α2-adrenoreceptors (AR). This drug has come to be of growing interest in anesthesia and sedation field these last years in literature. Its pharmacological actions on the central nervous system consist in sedative, anesthetic, anxiolytic, analgesic action with good cardiovascular, respiratory and neuropsychic tolerance profile. The main possible secondary effect with IV Dex is bradycardia, due to decreased circulating epinephrine and norepinephrine levels observed with this drug.

Intranasal (IN) administration is an easy-to-use and more efficient alternative than placebo or other sedatives (Midazolam, Ketamine, Chloral) for the sedation of sensitive or less collaborative populations as children and young adults.