Abstract

Background: Pediatric adenotonsillectomy is frequently complicated by intense postoperative pain, emergence agitation (EA), and postoperative nausea and vomiting (PONV). Opioid-based regimens exacerbate these challenges through dose-dependent respiratory depression, presenting a critical risk for children with obstructive sleep apnea (OSA).

Objectives: This narrative review evaluates the clinical utility, pharmacology, and dosing strategies of dexmedetomidine as a core component of multimodal, opioid-sparing anesthesia in pediatric adenotonsillectomy.

Methods: A targeted literature search was conducted across PubMed, Cochrane Library, and Google Scholar, identifying 46 relevant peer-reviewed studies focusing on dexmedetomidine’s efficacy, safety, and clinical outcomes in this surgical cohort.

Results: Synthesized evidence demonstrates that intraoperative dexmedetomidine, administered either intravenously or intranasally, significantly reduces perioperative opioid consumption and stabilizes hemodynamics. Crucially, it mitigates the incidence of EA and PONV without causing respiratory depression – a vital safety advantage for OSA patients who exhibit a three-fold higher susceptibility to opioid-related airway complications. While a minor prolongation of emergence times may occur, the overall recovery quality is superior to conventional regimens utilizing midazolam or fentanyl. Emerging data also support the synergistic integration of dexmedetomidine with adjuncts such as intravenous (IV) lidocaine or esketamine to further optimize the post-operative course (Table I).

Conclusion: Dexmedetomidine facilitates a reliable shift toward safer, opioid-sparing pediatric anesthesia. Its integration into protocol-driven multimodal pathways provides a superior safety-efficacy balance, particularly for high-risk cohorts, though further large-scale trials remain warranted to standardize dosing regimens across diverse pediatric populations.