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Use of ketamine by paediatricians in Italian paediatric emergency departments: a missed opportunity? Eur J Pediatr 2019; 178:587-591. [PMID: 30671694 DOI: 10.1007/s00431-019-03320-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
Procedural sedation and analgesia with ketamine are part of daily practice for children undergoing painful procedures in the paediatric emergency department (ED) of North America. A massive number of studies demonstrate ketamine's safety and efficacy in the hands of trained ED paediatricians, with few severe adverse events (SAEs) recorded. Since there are no data on ketamine's usage in Italian paediatric EDs, we created a survey to examine procedural sedation with ketamine in the EDs of the Italian PIPER (Pain in Paediatric Emergency Room) group, which includes 36 paediatric EDs providing 1.4 million paediatric visits each year. Results were reviewed using frequencies to describe responses. Thirty-two out of 36 centres replied to the questionnaire. In 6 (19%) out of 32 centres, ketamine is not used at all in the paediatric ED. In 6 centres (23%) of 26 which use ketamine, this drug is autonomously administered by the emergency paediatrician, whereas in 20 (77%) of them it is exclusively managed by the anaesthesiologist on call.Conclusion: ketamine is autonomously administered only by a small percentage of Italian emergency paediatricians. There is an increasing need for implementation of procedural sedation training and use of ketamine in the everyday practice outside the operating room in paediatric EDs. What is Known: • Ketamine is safely and efficaciously administered for children's procedural sedation and analgesia by trained emergency paediatricians in the everyday practice outside the operating room in North America. • In the Italian setting, there are no data at all concerning ketamine's usage by the emergency paediatricians for procedural sedation and pain control. What is New: • In this study emerged that ketamine is poorly administered by Italian emergency paediatricians for procedural sedation and analgesia outside the operating room. • A great deal of educational effort should be made to widen ketamine based procedural sedation availability in Italian emergency departments by spreading specific training tracks and guidelines.
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Kim D, Lee EK, Jeong JS, Gil NS, Hahm TS, Shin YH. Incidence and risk factors of unplanned intubation during pediatric sedation for MRI. J Magn Reson Imaging 2019; 49:1053-1061. [PMID: 30350443 DOI: 10.1002/jmri.26314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is often difficult for the pediatric patient to cooperate or to remain immobile during MR scans. Therefore, sedation is usually needed for children. PURPOSE To evaluate the incidence and contributing factors of unanticipated intubation during sedation for MRI scan in children. STUDY TYPE Retrospective observational study. POPULATION/SUBJECTS In all, 1165 charts were reviewed retrospectively of patients who had been sedated by anesthesiologists at a single institution from May 2015 to June 2016. ASSESSMENT Patient's demographics, the region of the MRI scan, total amount of medication, duration of sedation, and any adverse event during MRI were assessed. The adverse events during sedation including airway obstruction, apnea, desaturation, bradycardia, and hypotension were also assessed. STATISTICAL TESTS Risk factors of unplanned intubation during MRI sedation were identified by univariate and multivariate analysis. Firth's exact logistic regression was used for univariate and multivariate analysis. According to the results from multiple logistic regression, a nomogram was developed to predict the risk. RESULTS A total of 1165 children aged 7 days to 18 years with sedation used during an MRI scan during the study period showed an incidence of unexpected intubation as ~2% (n = 23, 95% confidence interval [CI]; 0.0123, 0.0295). Multivariate logistic regression revealed the following risk factors of unplanned intubation: American Society of Anesthesiologists (ASA) class III patients (odds ratio [OR] 1.212, P < 0.001), premature birth (OR 2.317, P < 0.001), and the presence of gastroesophageal reflux disease (GERD) (OR 1.474, P < 0.001) or congenital heart disease (OR 1.118, P < 0.001). DATA CONCLUSION This study identified risk factors of unplanned intubation as follows: ASA class III patients, premature birth, and the presence of GERD or congenital heart disease. The physician should screen risk factors of unexpected intubation and maintain adequate sedation during MRI scans in pediatric patients. Level of Evidence 3. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:1053-1061.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nam-Su Gil
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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The Use of Ketamine for the Management of Acute Pain in the Emergency Department. Adv Emerg Nurs J 2019; 41:111-121. [DOI: 10.1097/tme.0000000000000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mason KP, Seth N. Future of paediatric sedation: towards a unified goal of improving practice. Br J Anaesth 2019; 122:652-661. [PMID: 30916013 DOI: 10.1016/j.bja.2019.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.
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Affiliation(s)
- Keira P Mason
- Harvard Medical School, Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, USA.
| | - Neena Seth
- Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Childers R, Vilke G. Ketamine for Acute Agitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Flores-González JC, Estalella-Mendoza A, Rodríguez-Campoy P, Saldaña-Valderas M, Lechuga-Sancho AM. Topical Pharyngeal Lidocaine Reduces Respiratory Adverse Events During Upper Gastrointestinal Endoscopies Under Ketamine Sedation in Children. Paediatr Drugs 2019; 21:25-31. [PMID: 30478762 DOI: 10.1007/s40272-018-0320-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Upper gastrointestinal endoscopies (UGEs) performed under ketamine sedation may increase the risk of respiratory adverse events (RAEs) due to pharyngeal stimulation. Topical lidocaine prevents general anesthesia-induced laryngospasm. OBJECTIVE Our objective was to determine whether topical lidocaine may reduce the incidence of RAEs induced by pharyngeal stimulation in UGEs performed on children sedated with ketamine. METHODS We conducted a single-center prospective study. We included every patient admitted for an elective diagnostic UGE under ketamine sedation who received lidocaine prior to the technique. Patients requiring any other medication were excluded. Our main outcome measure was the number of desaturation episodes. We then compared these results with those obtained in an historic group who did not receive topical lidocaine, in which we registered a total of 54 desaturation episodes. RESULTS In total, 88 children (52.3% boys) were included. The median age was 7 years [interquartile range (IQR) 3-11]. The mean duration of the procedure was 6.5 ± 2.4 min, and the median initial ketamine dose was 1.76 mg/kg (IQR 1.56-2.03). The total number of desaturation episodes was 3 (3.4%), and two of these occurred prior to the introduction of the endoscope. This result represents a lower incidence than in previously reported series, and a significant decrease (p < 0.0001) with respect to the 54 RAEs registered in the historic group of 87 children. CONCLUSIONS Topical lidocaine premedication significantly reduced the incidence of RAEs in children during UGEs under ketamine sedation. Our findings should be confirmed by a double-blind randomized controlled trial.
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Affiliation(s)
- Jose Carlos Flores-González
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Avda Ana de Viya 21, 11009, Cádiz, Spain. .,Institute of Research and Innovation in Biomedical Sciences (INIBiCA), Cadiz, Spain.
| | - Ana Estalella-Mendoza
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Avda Ana de Viya 21, 11009, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences (INIBiCA), Cadiz, Spain
| | - Patricia Rodríguez-Campoy
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Avda Ana de Viya 21, 11009, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences (INIBiCA), Cadiz, Spain
| | - Mónica Saldaña-Valderas
- Clinical Farmacology Unit, Puerta del Mar University Hospital, Cadiz, Spain.,Institute of Research and Innovation in Biomedical Sciences (INIBiCA), Cadiz, Spain
| | - Alfonso M Lechuga-Sancho
- Mother and Child Health, and Radiology Department, Cádiz University, Cadiz, Spain.,Institute of Research and Innovation in Biomedical Sciences (INIBiCA), Cadiz, Spain
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Toce MS, Kim H, Chung S, Krauss BS. Prolonged central apnoea after intravenous morphine administration in a 12-year-old male with a UGT1A1 loss-of-function polymorphism. Br J Clin Pharmacol 2018; 85:258-262. [PMID: 30421550 DOI: 10.1111/bcp.13779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/25/2018] [Accepted: 09/30/2018] [Indexed: 11/28/2022] Open
Abstract
ADVERSE EVENT Repeated and prolonged episodes of central apnoea and hypoxia after receiving intravenous morphine for analgesia and ketamine for sedation. DRUG IMPLICATED Intravenous morphine sulfate. THE PATIENT Previously healthy 12-year-old male with no history of sleep apnoea who presented with distal tibia and fibula fracture. EVIDENCE THAT LINKS DRUG TO EVENT Pharmacogenomic testing revealed that the patient was homozygous for the T allele at the rs887829 SNP in UGT1A1, an enzyme involved in the metabolism of morphine. This polymorphism is a loss-of-function variant, leading to impaired metabolism of morphine. MECHANISM Morphine is metabolized by UDP-glucuronosyltransferase (UGT)-2B7 and UGT1A1 to form its major metabolites morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Our patient was a poor metabolizer through UGT1A1, likely leading to increased respiratory depression as morphine has greater respiratory depressant effects compared to its metabolites. IMPLICATIONS When appropriate, physicians should enquire about prior receipt of opioids, in both the patient and family, to be better prepared for potential adverse reactions. In the patient with excessive sedation or respiratory depression to standard doses of morphine, genetic testing may be warranted, especially if there is a family or past history that supports a metabolic defect in morphine metabolism and/or excretion.
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, MA, USA
| | - Hyun Kim
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA
| | - Sarita Chung
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Baruch S Krauss
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Poonai N, Canton K, Ali S, Hendrikx S, Shah A, Miller M, Joubert G, Hartling L. Intranasal ketamine for anesthetic premedication in children: a systematic review. Pain Manag 2018; 8:495-503. [PMID: 30394192 DOI: 10.2217/pmt-2018-0039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIM In children, intravenous anesthetic premedication can be distressing. Intranasal (IN) ketamine offers a less invasive approach. MATERIALS AND METHODS We included randomized trials of IN ketamine in anesthetic premedication in children 0-19 years. We performed electronic searches of MEDLINE, EMBASE, Google Scholar, CINAHL, Cochrane Library, Web of Science, Scopus, clinical trial registries and conference proceedings. RESULTS Among the 23 trials (n = 1680) included, IN ketamine adequately sedated 220/311 (70%) for face mask application, 217/308 (70%) for caregiver separation, 200/371 (54%) for iv. insertion and 19/30 (63%) for monitor application. Vomiting was the most common adverse effect (35/1579 [2.2%]). CONCLUSION There is a need for sufficiently powered, methodologically rigorous trials, using psychometrically evaluated, objective outcome measures to meaningfully inform practice.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada.,Division of Emergency Medicine, Western University, London, Canada.,Children's Health Research Institute, London Health Sciences Centre, London, Canada
| | - Kyle Canton
- Division of Emergency Medicine, Western University, London, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.,Women & Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Shawn Hendrikx
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada
| | - Amit Shah
- Division of Emergency Medicine, Western University, London, Canada
| | - Michael Miller
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada.,Children's Health Research Institute, London Health Sciences Centre, London, Canada
| | - Gary Joubert
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada.,Division of Emergency Medicine, Western University, London, Canada.,Children's Health Research Institute, London Health Sciences Centre, London, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
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Randomized Trial of Intranasal Fentanyl Versus Intravenous Morphine for Abscess Incision and Drainage. Pediatr Emerg Care 2018; 34:607-612. [PMID: 27387971 DOI: 10.1097/pec.0000000000000810] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children. METHODS We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department. Patients received IN fentanyl (2 μg/kg; maximum, 100 μg) or IV morphine (0.1 mg/kg; maximum, 8 mg). The primary outcome, determined independently by blinded assessors, was the Observational Scale of Behavioral Distress-Revised (OSBD-R). The prestated margin of noninferiority (Δ) was 1.80. Secondary outcomes included self-reported pain, treatment failure, and patient and parental satisfaction. RESULTS We enrolled 20 children (median age, 15.4 years), 10 in each group. The difference between total OSBD-R scores was -13.45 (95% confidence interval, -24.24 to -2.67), favoring IN fentanyl.There was less self-reported pain in patients who received IN fentanyl immediately after the procedure. Four patients (40%) receiving IV morphine had treatment failures and required moderate sedation or had the procedure terminated. More patients who received IN fentanyl were satisfied with the analgesic administered compared with those who received IV morphine. CONCLUSIONS In a small sample of children aged 4 to 18 years undergoing abscess I&D, IN fentanyl was noninferior, and potentially superior, to IV morphine for reducing procedural pain and distress.
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Green SM, Roback MG, Krauss BS. The Newest Threat to Emergency Department Procedural Sedation. Ann Emerg Med 2018; 72:115-119. [DOI: 10.1016/j.annemergmed.2017.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/16/2022]
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Chang SL, Lin WL, Weng CH, Wu SJ, Tsai HJ, Wang SM, Peng CC, Chang JH. Atropine use may lead to post-operative respiratory acidosis in neonates receiving ductal ligation: A retrospective cohort study. Pediatr Neonatol 2018; 59:136-140. [PMID: 28780389 DOI: 10.1016/j.pedneo.2017.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 03/08/2017] [Accepted: 04/12/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is one of the most common cardiac conditions in preterm infants. Closure of the PDA in symptomatic patients can be achieved medically or surgically. Atropine is commonly administered in general anesthesia as a premedication in this age group but with limited evidence addressing the effect of its use. Our study examined the association of the use of atropine as a premedication in PDA ligation and the risk of post-operative respiratory complications. METHODS This retrospective cohort study included 150 newborns who have failed medical treatment for PDA and received PDA ligation during 2008-2012 in a single tertiary medical center. Ninety-two of them (61.3%) received atropine as premedication for general anesthesia while 58 (38.7%) did not. Post-operative respiratory condition, the need of cardiopulmonary resuscitation and the presence of bradycardia were measured. RESULTS Patients with atropine use were associated with increased odds of respiratory acidosis in both univariate analysis (22.9% vs 7.3%; OR = 3.785, 95% CI = 1.211-11.826, p = 0.022) and multivariate analysis (OR = 4.030, 95% CI = 1.230-13.202, p = 0.021), with an even higher odds of respiratory acidosis in patients receiving both atropine and ketamine. CONCLUSION The use of atropine as premedication in general anesthesia for neonatal PDA ligation is associated with higher risk of respiratory acidosis, which worsens with the combined use of ketamine.
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Affiliation(s)
- Szu-Ling Chang
- Department of Anesthesia, MacKay Memorial Hospital, Taipei 10449, Taiwan; Department of Anesthesia, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang-Ming University, Taipei 11267, Taiwan
| | - Wen-Li Lin
- Department of Pediatrics, MacKay Children's Hospital, Taipei 10449, Taiwan; Department of Health Policy and Management, Harvard University School of Public Health, Boston, MA 02115, USA
| | - Chien-Hsiang Weng
- NH Dartmouth Family Medicine, Concord Hospital, Concord, NH 03301, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Shye-Jao Wu
- Division of Cardiovascular Surgery, Department of Surgery, MacKay Memorial Hospital, Taipei 10449, Taiwan
| | - Hsin-Jung Tsai
- Department of Anesthesia, MacKay Memorial Hospital, Taipei 10449, Taiwan
| | - Shwu-Meei Wang
- Department of Pediatrics, MacKay Children's Hospital, Taipei 10449, Taiwan
| | - Chun-Chih Peng
- Department of Pediatrics, MacKay Children's Hospital, Taipei 10449, Taiwan
| | - Jui-Hsing Chang
- Department of Pediatrics, MacKay Children's Hospital, Taipei 10449, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City 252, Taiwan.
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Wiik AV, Patel P, Bovis J, Cowper A, Pastides PS, Hulme A, Evans S, Stewart C. Use of ketamine sedation for the management of displaced paediatric forearm fractures. World J Orthop 2018; 9:50-57. [PMID: 29564214 PMCID: PMC5859200 DOI: 10.5312/wjo.v9.i3.50] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/04/2018] [Accepted: 02/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.
METHODS Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.
RESULTS During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.
CONCLUSION Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.
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Affiliation(s)
- Anatole Vilhelm Wiik
- Department of Surgery and Cancer, Charing Cross Hospital, London W6 8RF, United Kingdom
| | - Poonam Patel
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
| | - Joanna Bovis
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Adele Cowper
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
| | - Philip Socrates Pastides
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Alison Hulme
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Stuart Evans
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Charles Stewart
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
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Iyer MS, Pitetti RD, Vitale M. Higher Mallampati Scores Are Not Associated with More Adverse Events During Pediatric Procedural Sedation and Analgesia. West J Emerg Med 2018; 19:430-436. [PMID: 29560077 PMCID: PMC5851522 DOI: 10.5811/westjem.2017.11.35913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/29/2017] [Accepted: 11/15/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Procedural sedation and analgesia (PSA) is used by non-anesthesiologists (NAs) outside of the operating room for several types of procedures. Adverse events during pediatric PSA that pose the most risk to patient safety involve airway compromise. Higher Mallampati scores may indirectly indicate children at risk for airway compromise. Medical governing bodies have proposed guidelines for PSA performed by NAs, but these recommendations rarely suggest using Mallampati scores in pre-PSA evaluations. Our objective was to compare rates of adverse events during pediatric PSA in children with Mallampati scores of III/IV vs. scores of Mallampati I/II. Methods This was a prospective, observational study. Children 18 years of age and under who presented to the pediatric emergency department (PED) and required PSA were enrolled. We obtained Mallampati scores as part of pre-PSA assessments. We defined adverse events as oxygen desaturation < 90%, apnea, laryngospasm, bag-valve-mask ventilation performed, repositioning of patient, emesis, and "other." We used chi-square analysis to compare rates of adverse events between groups. Results We enrolled 575 patients. The median age of the patients was 6.0 years (interquartile range = 3.1,9.9). The primary reasons for PSA was fracture reduction (n=265, 46.1%). Most sedations involved the use of ketamine (n= 568, 98.8%). Patients with Mallampati scores of III/IV were more likely to need repositioning compared to those with Mallampati scores of I/II (p=0.049). Overall, patients with Mallampati III/IV scores did not experience a higher proportion of adverse events compared to those with Mallampati scores of I/II. The relative risk of any adverse event in patients with Mallampati scores of III/IV (40 [23.8%]) compared to patients with Mallampati scores of I/II (53 [18.3%]) was 1.3 (95% confidence interval [0.91-1.87]). Conclusion Patients with Mallampati scores of III/IV vs. Mallampati scores of I/II are not at an increased risk of adverse events during pediatric PSA. However, patients with Mallampati III/IV scores showed an increased need for repositioning, suggesting that the sedating physician should be vigilant when performing PSA in children with higher Mallampati scores.
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Affiliation(s)
- Maya S Iyer
- The Ohio State University College of Medicine/Nationwide Children's Hospital, Department of Pediatrics, Section of Emergency Medicine, Columbus, Ohio
| | - Raymond D Pitetti
- Children's Hospital of Pittsburgh of UPMC, Department of Pediatrics, Division of Pediatric Emergency Medicine, Pittsburgh, Pennsylvania
| | - Melissa Vitale
- Children's Hospital of Pittsburgh of UPMC, Department of Pediatrics, Division of Pediatric Emergency Medicine, Pittsburgh, Pennsylvania
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Azizkhani R, Bahadori A, Shariati M, Golshani K, Ahmadi O, Masoumi B. Ketamine versus Ketamine / magnesium Sulfate for Procedural Sedation and Analgesia in the Emergency Department: A Randomized Clinical Trial. Adv Biomed Res 2018; 7:19. [PMID: 29456990 PMCID: PMC5812085 DOI: 10.4103/abr.abr_143_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The present study was designed to evaluate the effectiveness of magnesium sulfate (MgSO4) in procedural sedation and analgesia (PSA) when combined with ketamine in patients with fractures in emergency departments and required short and painful emergency procedures. MATERIALS AND METHODS In this study, 100 patients with fractures and dislocations who were presented to the emergency departments and required PSA for short and painful emergency procedures were randomly allocated to groups of ketamine plus MgSO4 or ketamine alone. Train of four (TOF) stimulation pattern was assessed using nerve stimulator machine and compared between groups. RESULTS The mean age of studied patients was 46.9 ± 9.3 years old. 48% were male and 52% were female. No significant differences were noted between groups in demographic variables. The status of TOF, 2 min after the injection of ketamine (1.5 mg/kg), in both groups was similar. After the injection of the second dose of ketamine (1 mg/kg) the status of TOF in four patients in ketamine plus MgSO4 (0.45 mg/kg) group changed, it was three quarters but in ketamine group, the status of TOF in all patients was four quarters. The difference between groups was not statistically significant (P = 0.12). CONCLUSION The findings revealed that for muscle relaxation during medical procedures in the emergency department, ketamine in combination with MgSO4 with this dose was not effective for muscle relaxation during procedures.
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Affiliation(s)
- Reza Azizkhani
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Bahadori
- Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Shariati
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keyhan Golshani
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Wedmore IS, Butler FK. Battlefield Analgesia in Tactical Combat Casualty Care. Wilderness Environ Med 2018; 28:S109-S116. [PMID: 28601204 DOI: 10.1016/j.wem.2017.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.
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Affiliation(s)
- Ian S Wedmore
- Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler).
| | - Frank K Butler
- Madigan Army Medical Center, Tacoma, Washington (Dr Wedmore) and the Joint Trauma System, San Antonio, TX (Dr Butler)
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Sheth MK, Brand A, Halterman J. Ketamine-induced Changes in Blood Pressure and Heart Rate in Pre-hospital Intubated Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.21467/ajgr.3.1.20-33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sedation and analgesia for procedures in the pediatric emergency room. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ramalho CE, Bretas PMC, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J) 2017; 93 Suppl 1:2-18. [PMID: 28945987 DOI: 10.1016/j.jped.2017.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. DATA SOURCES Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. DATA SYNTHESIS Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. CONCLUSIONS The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.
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Affiliation(s)
- Carlos Eduardo Ramalho
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Pedro Messeder Caldeira Bretas
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil.
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Burke TF, Suarez S, Sessler DI, Senay A, Yusufali T, Masaki C, Guha M, Rogo D, Jani P, Nelson BD, Rogo K. Safety and Feasibility of a Ketamine Package to Support Emergency and Essential Surgery in Kenya when No Anesthetist is Available: An Analysis of 1216 Consecutive Operative Procedures. World J Surg 2017; 41:2990-2997. [DOI: 10.1007/s00268-017-4312-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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71
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Burstein B, Paquin R. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation. Am J Emerg Med 2017; 35:1391-1395. [DOI: 10.1016/j.ajem.2017.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 11/25/2022] Open
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Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr 2017; 171:957-964. [PMID: 28828486 PMCID: PMC5710624 DOI: 10.1001/jamapediatrics.2017.2135] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes. OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis. EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTS Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCE The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Departments of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J. Farion
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne Beno
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - C. Michelle McTimoney
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada,Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Nadia Sourial
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark G. Roback
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis,Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
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Neufeld M, Spence D, Water T. Working in the dark: a hermeneutic inquiry into health professionals' stories of ketamine sedation with children. Contemp Nurse 2017; 53:545-557. [PMID: 28786744 DOI: 10.1080/10376178.2017.1362956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Physiological risks of ketamine have been well researched, yet for health professionals (HPs) undertaking paediatric ketamine sedation, questions of benefit and harm remain. RESEARCH QUESTION What are health care professionals' experiences of undertaking ketamine sedation with children? METHODOLOGY Hermeneutic narrative. METHODS The study comprised hermeneutic narrative analysis of stories from seven HPs in nursing, medicine, paramedicine, and play therapy. FINDINGS The theme, "seeking to control and protect" reveals the chaotic nature of paediatric emergency work and how ketamine can deliver control. The second theme "working in the dark" acknowledges that HPs try to balance perceived benefit and harm, adopting "dream-seeding" in an attempt to mitigate potentially negative psychotropic events. CONCLUSION The study recommends further research into children's experiences of ketamine sedation and the use of dream-seeding to mitigate negative emergence phenomena. It also recommends education for clinicians to increase awareness of the potential for non-physiological risk and harm.
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Affiliation(s)
- Michael Neufeld
- a Department of Nursing, School of Clinical Science , Auckland University of Technology , Private Bag 92006, Auckland 1142 , New Zealand
| | - Deborah Spence
- a Department of Nursing, School of Clinical Science , Auckland University of Technology , Private Bag 92006, Auckland 1142 , New Zealand
| | - Tineke Water
- a Department of Nursing, School of Clinical Science , Auckland University of Technology , Private Bag 92006, Auckland 1142 , New Zealand
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Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med 2017. [PMID: 28650904 PMCID: PMC6287759 DOI: 10.1097/pcc.0000000000001246] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. DESIGN Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. SETTING Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. PATIENTS Children from birth to less than or equal to 21 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. CONCLUSIONS Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.
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75
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Stevic M, Ristic N, Budic I, Ladjevic N, Trifunovic B, Rakic I, Majstorovic M, Burazor I, Simic D. Comparison of ketamine and ketofol for deep sedation and analgesia in children undergoing laser procedure. Lasers Med Sci 2017; 32:1525-1533. [DOI: 10.1007/s10103-017-2275-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 06/22/2017] [Indexed: 11/28/2022]
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Young JR, Sawe HR, Mfinanga JA, Nshom E, Helm E, Moore CG, Runyon MS, Reynolds SL. Subdissociative intranasal ketamine plus standard pain therapy versus standard pain therapy in the treatment of paediatric sickle cell disease vaso-occlusive crises in resource-limited settings: study protocol for a randomised controlled trial. BMJ Open 2017; 7:e017190. [PMID: 28698351 PMCID: PMC5541700 DOI: 10.1136/bmjopen-2017-017190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pediatric sickle cell disease, highly prevalent in sub-Saharan Africa, carries great morbidity and mortality risk. Limited resources and monitoring make management of acute vaso-occlusive crises challenging. This study aims to evaluate the efficacy and safety of subdissociative intranasal ketamine as a cheap, readily available and easily administered adjunct to standard pain therapy. We hypothesise that subdissociative, intranasal ketamine may significantly augment current approaches to pain management in resource-limited settings in a safe and cost-effective manner. METHODS AND ANALYSIS This is a multicentred, randomised, double-blind, placebo-controlled trial enrolling children 4-16 years of age with sickle cell disease and painful vaso-occlusive pain crises. Study sites include two sub-Saharan teaching and referral hospitals with acute intake areas. All patients receive standard analgesic therapy during evaluation. Patients randomised to the treatment arm receive 1 mg/kg intranasal ketamine at onset of therapy, while placebo arm participants receive volume-matched intranasal normal saline. All participants and clinical staff are blinded to the treatment allocation. Data will be analysed on an intention-to-treat basis. Primary endpoints are changes in self-report pain scales (Faces Pain Scale-Revised) at 30, 60 and 120 minutes and rates of adverse events. Secondary endpoints include hospital length of stay, total analgesia use and quality of life assessment 2-3 weeks postintervention. ETHICS AND DISSEMINATION The research methods for this study have been approved by the Cameroon Baptist Convention Health Board Institutional Review Board (IRB2015-07), the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol. IX/2299), Muhimbili National Hospital IRB (MNH/IRB/I/2015/14) and the Tanzanian Food and Drugs Authority (TFDA0015/CTR/0015/9). Data reports will be provided to the Data and Safety Monitoring Board (DSMB) periodically throughout the study as well as all reports of adverse events. All protocol amendments will also be reviewed by the DSMB. Study results, regardless of direction or amplitude, will be submitted for publication in relevant peer-reviewed journals. TRIAL REGISTRATION ClinicalTrials.Gov, NCT02573714. Date of registration: 8 October 2015. Pre-results.
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Affiliation(s)
- James R Young
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hendry Robert Sawe
- Deparment of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Juma A Mfinanga
- Department of Emergency Medicine, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Ernest Nshom
- Department of Internal Medicine, CIMS, Mbingo Baptist Hospital, Cameroon Baptist Convention, Mbingo, Cameroon
| | - Ethan Helm
- Department of Pediatrics, Mbingo Baptist Hospital, Cameroon Baptist Convention, Mbingo, Cameroon
| | - Charity G Moore
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Michael S Runyon
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Stacy L Reynolds
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
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Mallory MD, Travers C, McCracken CE, Hertzog J, Cravero JP. Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation. Pediatrics 2017; 140:peds.2017-0009. [PMID: 28759404 DOI: 10.1542/peds.2017-0009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Upper respiratory infections (URIs) are associated with airway adverse events (AAEs) during general anesthesia. There have been no large studies examining the relationship between URIs and AAEs during pediatric procedural sedation. We hypothesized that there would be a relationship between URI status and AAEs in pediatric procedural sedation. METHODS We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Specific questions regarding URI status were added to the database to facilitate our analysis. Characteristics of patients, procedure types, adjunctive medications, adverse events, and airway interventions (AIs) were reported. We performed bivariate analysis of adverse events and URI status, then used a multivariable logistic regression model to assess the relationship between URI status and adverse events. We examined the secondary outcome of AI similarly. RESULTS Of the 105 728 sedations entered into the Pediatric Sedation Research Consortium database during the study period, we were able to use 83 491 for analysis. Controlling for multiple patient, drug, and procedure characteristics, recent and current URI were associated with increased frequency of AAEs. In general, the frequency of AAEs and AIs increased from recent URI, to current URI-clear secretions to current URI-thick secretions. We did not find a relationship between URI status and non-AAEs. CONCLUSIONS URI status is associated with a statistically significant increase in frequency of AAEs and AI during pediatric procedural sedation for the population sedated by our consortium. Although URI status merits consideration in determining potential risk for sedation, rates of some AAEs and AIs remained low regardless of URI status.
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Affiliation(s)
- Michael D Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia;
| | - Curtis Travers
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - James Hertzog
- Department of Pediatrics, Division of Critical Care Medicine, Nemours Alfred I. DuPont Hospital for Children, Wilmington, Delaware; and
| | - Joseph P Cravero
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard University, Boston, Massachusetts
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Rocha A, Hart N, Trujillo KA. Differences between adolescents and adults in the acute effects of PCP and ketamine and in sensitization following intermittent administration. Pharmacol Biochem Behav 2017; 157:24-34. [PMID: 28442368 DOI: 10.1016/j.pbb.2017.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/12/2017] [Accepted: 04/14/2017] [Indexed: 01/08/2023]
Abstract
Adolescence is a phase of development during which many physiological and behavioral changes occur, including increased novelty seeking and risk taking. In humans, this is reflected in experimentation with drugs. Research demonstrates that drug use that begins during adolescence is more likely to lead to addiction than drug use that begins later in life. Despite this, relatively little is known of the effects of drugs in adolescence, and differences in response between adolescents and adults. PCP and ketamine are popular club drugs, both possessing rewarding properties that could lead to escalating use. Drug sensitization (or reverse tolerance), which refers to an increase in an effect of a drug following repeated use, has been linked with the development of drug cravings that is a hallmark of addiction. The current work investigated the acute response and the development of sensitization to PCP and ketamine in adolescent and adult rats. Periadolescent Sprague-Dawley rats (30days or 38days of age), and young adults (60days of age) received PCP (6mg/kg IP) or ketamine (20mg/kg IP) once every three days, for a total of five drug injections. Adolescents and adults showed a stimulant response to the first injection of either drug, however the response was considerably greater in the youngest adolescents and lowest in the adults. With repeated administration, adults showed a robust escalation in activity that was indicative of the development of sensitization. Adolescents showed a flatter trajectory, with similar high levels of activity following an acute treatment and after five drug treatments. The results demonstrate important distinctions between adolescents and adults in the acute and repeated effects of PCP and ketamine.
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Affiliation(s)
- Angelica Rocha
- Office for Training Research, and Education in the Sciences, California State University San Marcos, CA 92096, USA
| | - Nigel Hart
- Office for Training Research, and Education in the Sciences, California State University San Marcos, CA 92096, USA
| | - Keith A Trujillo
- Office for Training Research, and Education in the Sciences, California State University San Marcos, CA 92096, USA; Department of Psychology, California State University San Marcos, CA 92096, USA.
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Poonai N, Canton K, Ali S, Hendrikx S, Shah A, Miller M, Joubert G, Rieder M, Hartling L. Intranasal ketamine for procedural sedation and analgesia in children: A systematic review. PLoS One 2017; 12:e0173253. [PMID: 28319161 PMCID: PMC5358746 DOI: 10.1371/journal.pone.0173253] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/04/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Ketamine is commonly used for procedural sedation and analgesia (PSA) in children. Evidence suggests it can be administered intranasally (IN). We sought to review the evidence for IN ketamine for PSA in children. METHODS We performed a systematic review of randomized trials of IN ketamine in PSA that reported any sedation-related outcome in children 0 to 19 years. Trials were identified through electronic searches of MEDLINE (1946-2016), EMBASE (1947-2016), Google Scholar (2016), CINAHL (1981-2016), The Cochrane Library (2016), Web of Science (2016), Scopus (2016), clinical trial registries, and conference proceedings (2000-2016) without language restrictions. The methodological qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, respectively. RESULTS The review included 7 studies (n = 264) of children ranging from 0 to 14 years. Heterogeneity in study design precluded meta-analysis. Most studies were associated with a low or unclear risk of bias and outcome-specific ratings for quality of evidence were low or very low. In four of seven studies, IN ketamine provided superior sedation to comparators and resulted in adequate sedation for 148/175 (85%) of participants. Vomiting was the most common adverse effect; reported by 9/91 (10%) of participants. CONCLUSIONS IN ketamine administration is well tolerated and without serious adverse effects. Although most participants were deemed adequately sedated with IN ketamine, effectiveness of sedation with respect to superiority over comparators was inconsistent, precluding a recommendation for PSA in children.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Kyle Canton
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Shawn Hendrikx
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Amit Shah
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Michael Miller
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Gary Joubert
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Michael Rieder
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta
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Kraus C, Rabl U, Vanicek T, Carlberg L, Popovic A, Spies M, Bartova L, Gryglewski G, Papageorgiou K, Lanzenberger R, Willeit M, Winkler D, Rybakowski JK, Kasper S. Administration of ketamine for unipolar and bipolar depression. Int J Psychiatry Clin Pract 2017; 21:2-12. [PMID: 28097909 DOI: 10.1080/13651501.2016.1254802] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Clinical trials demonstrated that ketamine exhibits rapid antidepressant efficacy when administered in subanaesthetic dosages. We reviewed currently available literature investigating efficacy, response rates and safety profile. METHODS Twelve studies investigating unipolar, seven on bipolar depression were included after search in medline, scopus and web of science. RESULTS Randomized, placebo-controlled or open-label trials reported antidepressant response rates after 24 h on primary outcome measures at 61%. The average reduction of Hamilton Depression Rating Scale (HAM-D) was 10.9 points, Beck Depression Inventory (BDI) 15.7 points and Montgomery-Asberg Depression Rating Scale (MADRS) 20.8 points. Ketamine was always superior to placebo. Most common side effects were dizziness, blurred vision, restlessness, nausea/vomiting and headache, which were all reversible. Relapse rates ranged between 60% and 92%. To provide best practice-based information to patients, a consent-form for application and modification in local language is included. CONCLUSIONS Ketamine constitutes a novel, rapid and efficacious treatment option for patients suffering from treatment resistant depression and exhibits rapid and significant anti-suicidal effects. New administration routes might serve as alternative to intravenous regimes for potential usage in outpatient settings. However, long-term side effects are not known and short duration of antidepressant response need ways to prolong ketamine's efficacy.
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Affiliation(s)
- Christoph Kraus
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Ulrich Rabl
- b Department of Adult Psychiatry , Poznan University of Medical Sciences , Poznan , Poland
| | - Thomas Vanicek
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Laura Carlberg
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Ana Popovic
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Marie Spies
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Lucie Bartova
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Gregor Gryglewski
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Rupert Lanzenberger
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Matthäus Willeit
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Dietmar Winkler
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Janusz K Rybakowski
- b Department of Adult Psychiatry , Poznan University of Medical Sciences , Poznan , Poland
| | - Siegfried Kasper
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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81
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Flores-González JC, Lechuga-Sancho AM, Saldaña Valderas M, Jimenez Gomez G, Cruzado García MD, Pérez Aragón C, Blanca García JA. Respiratory adverse events during upper digestive endoscopies in children under ketamine sedation. Minerva Pediatr (Torino) 2017; 73:15-21. [PMID: 28176512 DOI: 10.23736/s2724-5276.16.04758-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There is no evidence of the need for oxygen supplementation during upper digestive endoscopies under ketamine sedation in children, and the latest recommendations specifically state that it is not mandatory for the procedure. The aim of our study is to assess the incidence of respiratory adverse events during upper digestive endoscopies in children under Ketamine sedation when performed without oxygen supplementation, in accordance with the latest recommendations. METHODS Eighty-eight children undergoing ketamine sedation for programmed upper digestive endoscopy at our Pediatric Intensive Care Unit were included. Patients needing other sedative agents different from ketamine were excluded. No patients received previous oxygen therapy. Suction equipment, oxygen, a bag-valve-mask, and age-appropriate equipment for advanced airway management were immediately available. The primary outcome measure was the incidence of desaturation episodes (i.e. FiO<inf>2</inf> below 90% requiring an intervention). RESULTS Fifty-five patients (62.5%) presented a desaturation episode during the procedure. Most desaturation episodes occurred during the endoscope introduction (78.2%), and 5 episodes were previous to the endoscope introduction (minute 0). Around sixty percent of patients (58.9%) required oxygen therapy and four patients required bag-mask ventilation. Once oxygen therapy was initiated, 34 patients (70.5%) required it during the complete procedure or part of it. CONCLUSIONS Desaturation episodes occur frequently early on in the procedure. Our data suggest that the role of oxygen supplementation prior to, and during upper digestive endoscopies under ketamine sedation in children should be thoroughly assessed for future recommendations.
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Affiliation(s)
| | - Alfonso M Lechuga-Sancho
- Department of Mother and Child Health, University of Cadiz, Cadiz, Spain.,Department of Radiology, University of Cadiz, Cadiz, Spain
| | | | | | | | - Cristina Pérez Aragón
- Unit of Pediatric Gastroenterology, Puerta del Mar University Hospital, Cadiz, Spain
| | - Jose A Blanca García
- Unit of Pediatric Gastroenterology, Puerta del Mar University Hospital, Cadiz, Spain
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82
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Gaffar S, Eskander JP, Beakley BD, McClure BP, Amenta P, Pierre N. A case of central diabetes insipidus after ketamine infusion during an external to internal carotid artery bypass. J Clin Anesth 2017; 36:72-75. [DOI: 10.1016/j.jclinane.2016.09.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 08/30/2016] [Accepted: 09/13/2016] [Indexed: 11/27/2022]
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Suryaprakash S, Tham LP. Predictors of emesis in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department. Singapore Med J 2016; 58:660-665. [PMID: 27933328 DOI: 10.11622/smedj.2016187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Emesis is one of the most common adverse events associated with ketamine sedation. However, its predictors have not been clearly studied among Asian children. This study aimed to determine the incidence and predictors of emesis in children undergoing intramuscular (IM) ketamine sedation in an emergency department (ED) in Singapore and to identify high-risk groups, so that antiemetics may be administered prophylactically. METHODS In a prospective observational study, all children requiring procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 January 2015 were included. All cases of emesis following ketamine sedation were prospectively documented. Univariate and multivariate logistic regression analyses were performed to identify the predictors of emesis. RESULTS 2,502 sedations were performed using IM ketamine in the ED during the study period. Overall incidence of emesis associated with IM ketamine sedation was 8.4%. Children aged ≥ 8 years were significantly associated with increased risk of emesis (odds ratio 4.636, 95% confidence interval 3.271-6.570; p < 0.001), with an emesis rate of 19.6%. Other variables such as initial dose (3 mg/kg vs. 4 mg/kg), total dosage (including top-ups), type and site of procedure, gender and ethnicity were not significant predictors. The number needed to treat for antiemetics in children aged ≥ 8 years was five. CONCLUSION Age is a significant predictor of emesis. We recommend conducting a randomised controlled trial to compare the effects of prophylactic oral ondansetron in patients stratified into the age groups of ≥ 8 years and < 8 years.
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Affiliation(s)
| | - Lai Peng Tham
- Duke-NUS Medical School, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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84
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Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med 2016; 17:1109-1116. [PMID: 27505716 PMCID: PMC5138082 DOI: 10.1097/pcc.0000000000000920] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events. DESIGN Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium. SETTING Sedation services from academic, community, free-standing children's hospitals and pediatric wards within general hospitals. PATIENTS Children from birth to 21 years old or younger. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92-7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60-1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm. CONCLUSIONS This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.
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Simulation and Web-based learning increases utilization of Bier block for forearm fracture reduction in the pediatric emergency department. CAN J EMERG MED 2016; 19:434-440. [PMID: 27866507 DOI: 10.1017/cem.2016.392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Bier block (BB) is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet remains infrequently used in the pediatric emergency department (PED). No standardized methods of BB training have previously been described. The objective of this study was to determine whether a multimodal instructional course increases comfort with BB and translates to increased use of this technique. METHODS A novel interdisciplinary simulation and Web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre-/post-training, and at 2 and 6 months regarding their comfort with BB. In parallel, we prospectively assessed the clinical use of BB for children ages 6 to 18 years requiring closed reduction of forearm fractures during the 24-month post-course period. RESULTS Course participation included 26 physicians and 12 nurses. Survey response rate was 100%. Course participation increased both comfort (10% pre-training v. 89% post-training, p<0.001) and the willingness to use BB (51% pre-training v. 95% post-training, p<0.001), an effect sustained at 6 months post-course (66% and 92%, respectively, p<0.001 for both). In clinical practice, there were no BBs performed prior to course administration. We observed a consistent and sustained increase in clinical use among the BB-trained physicians, with 37% of all forearm reductions performed using BB at 24 months post-course completion. CONCLUSIONS A novel combined simulation and Web-based training course increased comfort and willingness to use BB and was associated with increased use of this technique for forearm fracture reduction in the PED.
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Burmon C, Adamakos F, Filardo M, Motov S. Acute pulmonary edema associated with ketamine-induced hypertension during procedural sedation in the ED. Am J Emerg Med 2016; 35:522.e1-522.e4. [PMID: 28277252 DOI: 10.1016/j.ajem.2016.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/05/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Caroline Burmon
- Emergency Department, Maimonides Medical Center, Brooklyn, NY.
| | - Frosso Adamakos
- Emergency Department, Maimonides Medical Center, Brooklyn, NY
| | | | - Sergey Motov
- Emergency Department, Maimonides Medical Center, Brooklyn, NY
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Arpaci AH, Isik B. Pediatric tooth extractions under sedoanalgesia. Pak J Med Sci 2016; 32:1291-1295. [PMID: 27882039 PMCID: PMC5103151 DOI: 10.12669/pjms.325.10643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/20/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The present study aims to evaluate intravenous ketamine and inhalation sedation in children, their unwanted side-effects and surgeon satisfaction. METHODS In this study, data of 922 children aged between 1-18 who underwent tooth extraction under sedoanalgesia in our department between September 2015-January 2016 were gathered and anesthesia approaches, unwanted side effects and surgical satisfaction was investigated. Postoperative recovery emergence agitation or delirium was evaluated with Watcha Behavior Scale (WBS). RESULTS Patients were grouped and compared according to acceptance of intravenous line placement (Group-1) or not (Group- 2). Group 1 received intravenous ketamine anesthesia (n=822), Group 2 received inhalation anesthesia with sevoflurane (n=100). Number of patients, age, weight and gender was significantly different in two groups. When side effects were investigated nausea was observed in 30 patients (3.6%), skin rashes were observed in 26 patients (3.2%) in Group-1 while skin rashes were observed in one patient (1%) in Group 2. 95% of surgeons reported intravenous anesthesia, 18% of surgeons reported inhalation anesthesia to be the anesthesia of choice. Emergence of postoperative recovery agitation (WBS≥3) was observed more frequent in Group 2 (p<0.05) than Group 1. CONCLUSION Ketamine, which has analgesic, hypnotic and amnestic effects and which does not alter pharyngeal and laryngeal reflexes thus minimizes aspiration possibility, is a safe and effective anesthetic agent for tooth extractions of the pediatric population under sedoanalgesia.
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Affiliation(s)
- Ayse Hande Arpaci
- Dr. Ayse Hande Arpaci, MD. Assistant Professor, Anaesthesiology Reanimation Specialist Oral & Maxillofacial Department, Faculty of Dentistry, Ankara University, Besevler, Ankara, Turkey
| | - Berrin Isik
- Dr. Berrin Isik, MD. Professor, Anaesthesiology Reanimation Specialist, Faculty of Medicine Dept. of Anesthesiology and Reanimation, Gazi University, Besevler, Ankara, Turkey
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Salen P, Grossman M, Grossman M, Milazzo A, Stoltzfus J. A comparison of ketamine versus etomidate for procedural sedation for the reduction of large joint dislocations. Int J Crit Illn Inj Sci 2016; 6:79-84. [PMID: 27308256 PMCID: PMC4901832 DOI: 10.4103/2229-5151.183022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Study Objectives: Ketamine and etomidate are used for procedural sedation (PS) to facilitate the performance of painful procedures. We hypothesized that ketamine produces adequate and comparable sedation conditions for dislocated large joint reduction when compared to etomidate and results in fewer adverse events. Methods: This Institutional Review Board approved prospective trial compared a convenience sample of subjects, who were randomized to receive either ketamine or etomidate for PS to facilitate reduction of large joint dislocations. Following informed consent, subjects were assigned via a computer-generated algorithm to receive either etomidate (0.1 mg/kg) or ketamine (0.5 mg/kg) intravenously; if PS was not sufficient, subjects received repeat doses of etomidate or ketamine until adequate PS was achieved. The protocol's primary endpoint was a successful reduction of dislocated, large joints. Secondary endpoints included alteration in blood pressure, vomiting, recovery agitation, hypersalivation, laryngospasm, myoclonus, hypoxia, airway assistance with chin lift or jaw thrust, bag-valve-mask ventilation, endotracheal intubation, utilization of additional doses of ketamine or etomidate, and recovery time from sedation. Results: Total enrollment was eighty subjects, 46 in the ketamine cohort and 34 in the etomidate cohort. The two PS groups were comparable in terms of gender, age, and weight. There was no significant difference in the primary endpoint of large joint dislocation reduction between the ketamine and etomidate cohorts (46/46, 100%; 32/34, 94.1%; P – 0.1). Shoulder, hip, and ankle joints account for the majority of joint reductions in this trial. Titration of PS was necessary for almost half of each cohort as evidenced by the utilization of additional dosages of the sedative agents: ketamine (22/46, 47.8%) and etomidate (14/34, 41.2%; P – 0.56). Among secondary outcome variables, significant differences between ketamine and etomidate cohorts were myoclonus (1/46, 2.2%, 15/33, 45.5%; P – 0.0001), assisted ventilation with airway manipulation (3/45, 6.7%; 9/33, 27.3%; P – 0.01), and pulsoximetry desaturation < 90% (0/46; 7/34, 20.6%; P – 0.002). There was no significant difference in recovery time from PS between the ketamine and etomidate cohorts (11 min vs. 10 min; P – 0.69). Conclusion: Ketamine produces PS conditions for successful large joint dislocation reduction that are adequate and comparable to etomidate. The increased likelihood of myoclonus, of the requirement for airway assistance, and of hypoxia observed with etomidate suggest potential benefits with the utilization of ketamine for PS for dislocated large joint reduction.
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Affiliation(s)
- Philip Salen
- Department of Emergency Medicine, St. Luke's University Hospital, Bethlehem, PA 18015, USA
| | - Michelle Grossman
- Department of General Surgery and Emergency Medicine, Southside Hospital, North Shore-LIJ Hospital Network, NY 11706, USA
| | - Michael Grossman
- Department of General Surgery and Emergency Medicine, Southside Hospital, North Shore-LIJ Hospital Network, NY 11706, USA
| | - Anthony Milazzo
- Department of Emergency Medicine, St. Luke's University Hospital, Bethlehem, PA 18015, USA
| | - Jill Stoltzfus
- Department of Emergency Medicine, St. Luke's University Hospital, Bethlehem, PA 18015, USA
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Hartling L, Milne A, Foisy M, Lang ES, Sinclair D, Klassen TP, Evered L. What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews. Acad Emerg Med 2016; 23:519-30. [PMID: 26858095 PMCID: PMC5021163 DOI: 10.1111/acem.12938] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings. METHODS We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED. RESULTS Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention). CONCLUSIONS This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.
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Affiliation(s)
- Lisa Hartling
- Alberta Research Centre for Health EvidenceDepartment of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Andrea Milne
- Alberta Research Centre for Health EvidenceDepartment of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Michelle Foisy
- Alberta Research Centre for Health EvidenceDepartment of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Eddy S. Lang
- Department of Emergency MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Douglas Sinclair
- Department of Emergency MedicineSt. Michaels HospitalUniversity of TorontoTorontoOntarioCanada
| | - Terry P. Klassen
- Department of PediatricsUniversity of Manitoba and Child Health Research Institute of ManitobaWinnipegManitobaCanada
| | - Lisa Evered
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
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Gómez-Ríos MÁ, Freire-Vila E, Kuczkowski KM, Pensado-Castiñeiras A. Comparison of sevoflurane administered through a face mask versus rectal thiopental sodium in children undergoing magnetic resonance imaging. J Matern Fetal Neonatal Med 2016; 30:437-441. [PMID: 27053335 DOI: 10.1080/14767058.2016.1174994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Sevoflurane (S) and thiopental sodium (T) are commonly used to produce sedation for routine MRI procedures. However, to date there have been no comparative studies evaluating both techniques. We herein present the firt study comparing S and T techniques for pediatric sedation in MRI procedures. MATERIALS AND METHODS 21 children, aged from 3 months to 6 years, scheduled for MRI were randomly assigned to either S or T group. Sedation performed under spontaneous respiration was induced with inspired 1-8% S in oxigen by face mask connected to a Mapleson C circuit or T (25 mg/kg) administered in distal rectum by cannula. The observed parameters included: time for induction, MRI time, first movement activity postprocedure and recovery time; MRI pauses from patient movement; technique failure, quality of the study, emergence agitation, critical events; and parental and radiologist satisfaction. RESULTS S compared with T showed significantly shorter anesthesia induction time (1.93 ± 0.7 versus 13.5 ± 2.6 min), first movement time (3.38 ± 1.2 versus 5.9 ± 2.1 min), recovery time (6.8 ± 1.6 versus 10.14 ± 3.3 min), and discharge MRI time (27.83 ± 5.1 versus 47.5 ± 8.7 min). There were fewer pauses during MRI from patient movement in S versus T (0 versus 3). The radiologists reported good quality and satisfaction scores in both groups. There were less behavioral disturbances in T group compared with S group (1 versus 3). There were no critical events in either group. There were no differences in parental satisfaction in both groups. CONCLUSIONS Sevoflurane shortens the induction and recovery time, enabling earlier discharge. Sevoflurane and rectal thiopental sodium protocols are safe and effective, providing adequate conditions for MRI in pediatric outpatients, although rectal thiopental is more unpredictable.
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Affiliation(s)
- Manuel Ángel Gómez-Ríos
- a Department of Anesthesia and Perioperative Medicine , Complejo Hospitalario Universitario de A Coruña , A Coruña, Galicia , Spain and.,b Head of the Anesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coruña (INIBIC) , A Coruña , Spain
| | - Enrique Freire-Vila
- a Department of Anesthesia and Perioperative Medicine , Complejo Hospitalario Universitario de A Coruña , A Coruña, Galicia , Spain and
| | - Krzysztof M Kuczkowski
- a Department of Anesthesia and Perioperative Medicine , Complejo Hospitalario Universitario de A Coruña , A Coruña, Galicia , Spain and
| | - Alberto Pensado-Castiñeiras
- a Department of Anesthesia and Perioperative Medicine , Complejo Hospitalario Universitario de A Coruña , A Coruña, Galicia , Spain and
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93
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Kannikeswaran N, Lieh-Lai M, Malian M, Wang B, Farooqi A, Roback MG. Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial. Am J Emerg Med 2016; 34:1347-53. [PMID: 27216835 DOI: 10.1016/j.ajem.2016.03.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED). METHODS We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events. RESULTS A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%). CONCLUSIONS Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.
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Affiliation(s)
- Nirupama Kannikeswaran
- Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI 48201.
| | - Mary Lieh-Lai
- Wayne State University School of Medicine, Chicago, IL 60654; Accreditation Council for Graduate Medical Education, Chicago, IL 60654
| | - Monica Malian
- Department of Pharmacy Services, Children's Hospital of Michigan, Detroit, MI 48201
| | - Bo Wang
- Wayne State University School of Medicine, Detroit, MI 48201
| | - Ahmad Farooqi
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201
| | - Mark G Roback
- University of Minnesota Medical School, Minneapolis, MN 55455
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94
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Green S, Mason K, Krauss B. Ketamine and propofol sedation by emergency medicine specialists: mainstream or menace? Br J Anaesth 2016; 116:449-51. [DOI: 10.1093/bja/aew048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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95
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Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S21-35. [DOI: 10.1097/aco.0000000000000316] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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96
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Havidich JE, Beach M, Dierdorf SF, Onega T, Suresh G, Cravero JP. Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk. Pediatrics 2016; 137:e20150463. [PMID: 26917674 PMCID: PMC9923625 DOI: 10.1542/peds.2015-0463] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Preterm and former preterm children frequently require sedation/anesthesia for diagnostic and therapeutic procedures. Our objective was to determine the age at which children who are born <37 weeks gestational age are no longer at increased risk for sedation/anesthesia adverse events. Our secondary objective was to describe the nature and incidence of adverse events. METHODS This is a prospective observational study of children receiving sedation/anesthesia for diagnostic and/or therapeutic procedures outside of the operating room by the Pediatric Sedation Research Consortium. A total of 57,227 patients 0 to 22 years of age were eligible for this study. All adverse events and descriptive terms were predefined. Logistic regression and locally weighted scatterplot regression were used for analysis. RESULTS Preterm and former preterm children had higher adverse event rates (14.7% vs 8.5%) compared with children born at term. Our analysis revealed a biphasic pattern for the development of adverse sedation/anesthesia events. Airway and respiratory adverse events were most commonly reported. MRI scans were the most commonly performed procedures in both categories of patients. CONCLUSIONS Patients born preterm are nearly twice as likely to develop sedation/anesthesia adverse events, and this risk continues up to 23 years of age. We recommend obtaining birth history during the formulation of an anesthetic/sedation plan, with heightened awareness that preterm and former preterm children may be at increased risk. Further prospective studies focusing on the etiology and prevention of adverse events in former preterm patients are warranted.
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Affiliation(s)
- Jeana E. Havidich
- The Dartmouth Institute, Lebanon, New Hampshire;,Address correspondence to Jeana E. Havidich, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756. E-mail:
| | | | | | - Tracy Onega
- The Dartmouth Institute, Lebanon, New Hampshire
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97
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Threats to safety during sedation outside of the operating room and the death of Michael Jackson. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S36-47. [DOI: 10.1097/aco.0000000000000318] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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98
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Kidd LR, Lyons SC, Lloyd G. Paediatric procedural sedation using ketamine in a UK emergency department: a 7 year review of practice. Br J Anaesth 2016; 116:518-23. [PMID: 26893406 DOI: 10.1093/bja/aev555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ketamine is growing in popularity for procedural sedation in the paediatric population, yet safety concerns remain. We performed a retrospective review of practice and outcomes of paediatric ketamine sedation using the World SIVA International Sedation Task Force reporting tool. METHODS A retrospective inspection of the dedicated emergency department electronic sedation database and subsequent note and sedation chart review was performed for all paediatric sedations throughout a 7 yr period from September 2006. All adverse events were stratified. RESULTS During the study period, procedural sedation was provided for a total of 243 children, of whom 215 were sedated with ketamine, most commonly for wound management (n=131). The median patient age was 4 yr (14 months to 15 yr), and 63.7% were male. Of the total, 76.7% were discharged home either directly (n=101) or after brief observation (n=64). One patient required subsequent general anaesthesia after a failed sedation with paradoxical agitation. Of the total, 9.8% of patients had an adverse event, the most severe risk stratification being 'minor risk'. All interventions were 'minimal risk'. There were no 'sentinel risk' outcomes. CONCLUSIONS These data support the ongoing use of ketamine for paediatric procedural sedation in the emergency department by emergency physicians. Relatively high resource requirements mean that ensuring adequate numbers of procedures may prove challenging.
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Affiliation(s)
- L R Kidd
- Department of Anaesthetics, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW
| | - S C Lyons
- Department of Anaesthetics, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW
| | - G Lloyd
- Emergency Department, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
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99
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Krieser D, Kochar A. Paediatric procedural sedation within the emergency department. J Paediatr Child Health 2016; 52:197-203. [PMID: 27062624 DOI: 10.1111/jpc.13081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/11/2015] [Accepted: 11/25/2015] [Indexed: 11/30/2022]
Abstract
Procedural sedation and analgesia in children requires the use of non-pharmacological and pharmacological approaches to facilitate the management of painful procedures. The development of skills in such techniques has mirrored the development of paediatric emergency medicine as a subspecialty. Governance, education and credentialing must facilitate safe sedation practice, using a structured approach, as sedating children in the busy environment of an emergency department is not without risk. Emergency clinicians, patients and caregivers all have a role to play in developing a safe, effective sedation plan.
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Affiliation(s)
- David Krieser
- Department of Emergency Medicine, Sunshine Hospital.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria
| | - Amit Kochar
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria.,Department of Emergency Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
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100
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Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, Miner JR, Hess EP. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:119-34. [PMID: 26801209 PMCID: PMC4755157 DOI: 10.1111/acem.12875] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/27/2015] [Accepted: 08/27/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED). METHODS Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs). RESULTS The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately. CONCLUSIONS Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.
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Affiliation(s)
- M. Fernanda Bellolio
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | - Patricia Barrionuevo
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | - M. Hassan Murad
- Division of Preventive, Occupational, and Aerospace MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
| | | | | | - James R. Miner
- Department of Emergency MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMN
| | - Erik P. Hess
- Department of Emergency MedicineMayo ClinicRochesterMN
- Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMN
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