Anaesthetists’ peri-operative off-label use of alpha-2 adrenergic agonists in paediatric patients at a Johannesburg academic hospital: A descriptive study.

Esaias Janse van Rensburg; Laura Indiveri; Palesa  Mogane

doi:10.51168/sjhrafrica.v7i2.2534

Authors

Esaias Janse van Rensburg Department of Anaesthesiology, University of the Witwatersrand, Faculty of Health Sciences, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
Laura Indiveri Department of Anaesthesiology, Charlotte Maxeke Johannesburg Academic Hospital, 7 York Road, Parktown, Johannesburg 2193, South Africa.
Palesa Mogane Department of Anaesthesiology, Chris Hani Baragwanath Academic Hospital, 26 Chris Hani Rd, Soweto, South Africa.

DOI:

https://doi.org/10.51168/sjhrafrica.v7i2.2534

Keywords:

Clonidine, Dexmedetomidine, Alpha-2 agonists, Paediatric anaesthesia, Off-label drug use

Abstract

Background

The use of alpha (α)-2 adrenergic agonists, specifically clonidine and dexmedetomidine, has increased in paediatric anaesthesia due to their sedative and opioid-sparing properties. However, their use remains largely off-label, leading to variability in clinical practice. This study aimed to describe the peri-operative administration patterns, dosing, and safety of these agents at a high-volume South African academic hospital.

Methods

A retrospective, cross-sectional descriptive observational study was conducted at Chris Hani Baragwanath Academic Hospital (CHBAH). Clinical records of 300 children (aged 0–14 years) who received either clonidine (n = 152) or dexmedetomidine (n = 148) between April and June 2025 were analysed. Data on demographics, surgical discipline, ASA physical status, dosing, and adverse events were extracted and compared.

Results

Dexmedetomidine was preferentially used in patients with higher American Society of Anaesthesiologists classifications (ASA) and those undergoing burns surgery (p < 0.05). Clonidine was more frequently utilized in orthopaedic procedures and via the caudal route. The intravenous (IV) route was dominant (91%), with most agents administered intra-operatively as a bolus. Median IV doses were 0.77 mcg/kg for clonidine and 0.54 mcg/kg for dexmedetomidine. Side effects, including hypotension (<2%) and hypothermia (<5%), were rare and not significantly different between groups.

Conclusions

Both clonidine and dexmedetomidine are utilized frequently and safely as off-label adjuncts in this setting. While dexmedetomidine is favoured for physiologically vulnerable patients, clonidine remains a routinely used, cost-effective alternative. The local dosing practices are more conservative than international benchmarks, with minimal adverse events observed.

Recommendations

The findings of this study support the continued use of clonidine and dexmedetomidine as perioperative adjuncts in paediatric anaesthesia. Development of local institutional guidelines may assist in promoting greater consistency in practice. Regular audit of prescribing patterns and adverse events should be encouraged to support safe off-label use of α-2 adrenergic agonists in paediatric patients.

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