Dexmedetomidine as a bridge for the agitated adolescent waiting for a psychiatric bed

Design

single-centre retrospective case series over 16 months, no comparator

Population

20 adolescents aged 12–17 with severe agitation awaiting psychiatric care; median age 15 years

Primary outcome

need for additional sedation despite dexmedetomidine infusion

Effect

9 of 20 (45%, 95% CI 26–66) needed additional sedation; median infusion 21 hours at median maximum 1.6 mcg/kg/h; 5 transferred to paediatric intensive care

Severely agitated adolescents boarding in emergency departments awaiting psychiatric admission often receive repeated boluses of antipsychotics and benzodiazepines over many hours, with the accumulating sedation and airway risk that implies. This retrospective series from one Italian department describes an alternative: 20 adolescents aged 12 to 17, over 16 months, given a dexmedetomidine infusion as bridge sedation.

Median age was 15, median infusion duration 21 hours and median maximum dose 1.6 mcg/kg per hour. Nine of the 20 (45%, 95% CI 26–66) still required additional sedation during the infusion. One patient desaturated, which responded to repositioning and supplemental oxygen. Five were transferred to paediatric intensive care because they needed multiple sedatives.

This is twenty patients, retrospective, with no comparison group and a self-selected cohort. It establishes that the approach is feasible in a department set up to monitor it, and nothing more. A 21-hour infusion in an adolescent requires continuous monitoring, a staffed space and a team comfortable with the drug — three things most emergency departments boarding psychiatric patients do not have, which is precisely why those patients are boarding.

• Feasibility in a specialist centre, not evidence of superiority over standard bolus sedation.
• Continuous cardiorespiratory monitoring is mandatory — bradycardia and hypotension are the expected effects, and one patient here desaturated.
• Nearly half still needed additional sedation, so plan the escalation pathway before starting rather than during.
• A quarter of the cohort went to paediatric intensive care; know in advance where that patient goes.
• Address the underlying problem too: the infusion exists because the psychiatric bed does not.

Why it matters

Adolescents are being sedated in corridors for many hours with no protocol, and this is the first description of a planned alternative.

Don't overread it

Twenty patients, retrospective, with no control group — this shows the approach is possible, not that it is better or safe at scale.

The statistics, in plain English

With 20 patients, the 45% requiring additional sedation carries a confidence interval from 26% to 66% — the true proportion could be a quarter or two-thirds. The single desaturation means the observed rate is 5%, but one event in twenty patients bounds the real rate loosely, up to around 25%. Nothing here is compared with anything, so the adverse event rates cannot be read as better or worse than repeated bolus sedation.

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