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de Rover I, Wylleman J, Dogger JJ, Bramer WM, Hoeks SE, de Graaff JC. Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis. Br J Anaesth 2023; 130:51-73. [PMID: 36283870 DOI: 10.1016/j.bja.2022.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0-8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques. METHODS Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0-8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events. RESULTS Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91-0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92-0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14-0.65); for oral pentobarbital 99% (95% CI: 0.90-1.00); for rectal thiopental 92% (95% CI: 0.85-0.96); for oral melatonin 75% (95% CI: 0.54-0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38-0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78-0.99); and for inhaled sevoflurane 98% (95% CI: 0.97-0.99). CONCLUSIONS We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.
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Affiliation(s)
- Ingeborg de Rover
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jasper Wylleman
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Anaesthesiology and Perioperative Medicine, UZ Brussel, Brussels, Belgium
| | - Jaap J Dogger
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands.
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Ahmed J, Patel W, Pullattayil AK, Razak A. Melatonin for non-operating room sedation in paediatric population: a systematic review and meta-analysis. Arch Dis Child 2022; 107:78-85. [PMID: 33785532 DOI: 10.1136/archdischild-2020-320592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/24/2021] [Accepted: 02/28/2021] [Indexed: 11/03/2022]
Abstract
CONTEXT The literature on melatonin as a sedative agent in children is limited. OBJECTIVE To conduct a systematic review of studies assessing the efficacy and safety of melatonin for non-operating room sedation in children. METHODS Medline, Embase, Cochrane Library and Cumulative Index to Nursing and Allied Health were searched until 9 April 2020 for studies using melatonin and reporting one of the prespecified outcomes of this review. Two authors independently assessed the eligibility, risk of bias and extracted the data. Studies with a similar study design, comparator and procedure were pooled using the fixed-effect model. RESULTS 25 studies (clinical trials=3, observational studies=9, descriptive studies=13) were included. Melatonin was used for electroencephalogram (EEG) (n=12), brainstem evoked response audiometry (n=8) and magnetic resonance imaging (MRI) (n=5). No significant differences were noted on meta-analysis of EEG studies comparing melatonin with sleep deprivation (SD) (relative risk (RR) 1.06 (95% CI 0.99 to 1.12)), melatonin with chloral hydrate (RR 0.97 (95% CI 0.89 to 1.05)) and melatonin alone with melatonin and SD combined (RR 1.03 (95% CI 0.97 to 1.10)) for successful procedure completion. However, significantly higher sedation failure was noted in melatonin alone compared with melatonin and SD combined (RR 1.55 (95% CI 1.02 to 2.33)) for EEG. Additionally, meta-analysis showed lower sleep latency for melatonin compared with SD (mean difference -10.21 (95% CI -11.53 to -8.89) for EEG. No major adverse events were reported with melatonin. CONCLUSION Although several studies were identified, and no serious safety concerns were noted, the evidence was not of high quality to establish melatonin's efficacy for non-operating room sedation in children.
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Affiliation(s)
- Javed Ahmed
- Neonatology, Hamad Medical Corporation, Doha, Qatar
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Princess Nourah Bint Abdulrahman University, Riyadh, Al Riyadh, Saudi Arabia
| | | | - Abdul Razak
- Division of Neonatology, Department of Pediatrics, Princess Nourah Bint Abdulrahman University, Riyadh, Al Riyadh, Saudi Arabia
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Gernhold C, Kundtner N, Steinmair M, Henkel M, Oswald J, Haid B. Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit. CHILDREN-BASEL 2021; 8:children8050424. [PMID: 34065386 PMCID: PMC8160837 DOI: 10.3390/children8050424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022]
Abstract
Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.
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Affiliation(s)
- Christa Gernhold
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
- Correspondence:
| | - Nina Kundtner
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Martin Steinmair
- Department of Nuclear Medicine, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria;
| | - Martin Henkel
- Department of Paediatrics, Hospital of the Sisters of Charity Seilerstätte 4, 4020 Linz, Austria;
| | - Josef Oswald
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Bernhard Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
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Pozzi M, Galbiati S, Locatelli F, Carnovale C, Radice S, Strazzer S, Clementi E. Drug Use in Pediatric Patients Admitted to Rehabilitation For Severe Acquired Brain Injury: Analysis of the Associations With Rehabilitation Outcomes. Paediatr Drugs 2021; 23:75-86. [PMID: 33230677 DOI: 10.1007/s40272-020-00429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with severe acquired brain injuries require drug therapies in intensive care for life support and injury treatment. Patients who then access rehabilitation usually maintain their drug treatments long term, with a potential influence on the rehabilitation course. Whereas drug effects have been reported for specific drugs and clinical issues in adults, comprehensive data on pediatric patients with traumatic and non-traumatic injuries are scant. OBJECTIVES The aims of this study were to describe the therapeutic classes and groups of drugs prescribed to pediatric inpatients recovering from severe acquired brain injury when they enter rehabilitation; to assess whether clinical variables may determine the use of drug classes; and to assess whether the use of drug classes may be associated with differences in rehabilitation outcomes. METHODS We carried out a retrospective chart review, following a previous study on the clinical-epidemiological characteristics of our patients. We collected information on drug therapies present at admittance to rehabilitation and analyzed their distribution according to therapeutic classes and groups. We verified the associations of drug groups with clinical variables (putatively antecedents to drug use) and with rehabilitation outcomes (putatively resultant of drug use and of clinical variables) in regression models. The clinical variables considered were injury etiology, Glasgow Outcome Score (GOS) at admittance to rehabilitation, sex, age at injury, plus two aggregate factors resulting from the previous work, 'neurological dysfunction' regarding the use of devices and 'injury severity' regarding the neurological status. The rehabilitation outcomes used were death after rehabilitation, persistence of a vegetative/minimally conscious state, coma duration, duration of the rehabilitation stay, rehabilitation efficiency (GOS at discharge minus GOS at admittance, divided by the length of rehabilitation stay). RESULTS We described the distribution of drug classes and groups among pediatric patients with severe acquired brain injuries. Regarding the associations between drug classes and clinical variables, we found greater use of cardiovascular agents with higher patient age, 'neurological dysfunction' score, and with an etiology of hypoxic brain injury. The use of antithrombotic agents was greater with higher patient age and 'neurological dysfunction' score. Glucocorticoid use was greater with higher GOS at admittance and with several etiologies: brain tumor, infective encephalitis, and autoimmune encephalitis. Regarding drug classes and rehabilitation outcomes, we found that the use of cardiovascular drugs was associated with increased occurrence of death after rehabilitation. The use of antispastic drugs was associated with a more frequent permanence in vegetative/minimally conscious states. The use of antispastic drugs and melatonin was associated with longer coma duration. The use of glucocorticoid drugs was associated with decreased rehabilitation efficiency. CONCLUSIONS We provided a description of drug use in pediatric rehabilitation after severe acquired brain injuries, which was lacking in the literature. Prospective studies should verify our associative observations regarding clinical variables, drugs use, and outcomes, to assess causality.
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Affiliation(s)
- Marco Pozzi
- U.O. Gravi Cerebrolesioni Acquisite NR3, Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Sara Galbiati
- U.O. Gravi Cerebrolesioni Acquisite NR3, Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Federica Locatelli
- U.O. Gravi Cerebrolesioni Acquisite NR3, Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, Luigi Sacco" University Hospital, Università di Milano, 20157, Milan, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, Luigi Sacco" University Hospital, Università di Milano, 20157, Milan, Italy
| | - Sandra Strazzer
- U.O. Gravi Cerebrolesioni Acquisite NR3, Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.
| | - Emilio Clementi
- U.O. Gravi Cerebrolesioni Acquisite NR3, Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.,Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, Luigi Sacco" University Hospital, Università di Milano, 20157, Milan, Italy
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Efficiency of Melatonin as a Sedative for Auditory Brainstem Response in Children. Audiol Res 2020; 10:50-54. [PMID: 33202546 PMCID: PMC7768538 DOI: 10.3390/audiolres10020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/09/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction-Although auditory brainstem response (ABR) testing is among the most frequently used investigations in pediatric audiology and it often requires sedation or general anesthesia. In recent years, melatonin has been successfully used as an alternative way of inducing sleep, particularly in children undergoing magnetic resonance imaging (MRI) or electroencephalography (EEG). Purpose-To assess the effectiveness of orally administered melatonin as an alternative to sedation or general anesthesia during ABR testing. Method-In total, 33 children with suspected hearing loss underwent ABR tests in melatonin-induced sleep. Each patient received an initial dose of 5 mg, which was re-administered in case of failure to obtain sleep. Click-induced ABR tests were performed on both ears. Results-ABR tests were successfully performed in 72.7% of the patients. The average total length of time needed to obtain sleep and complete the ABR testing was 45 min. There was no significant difference between the patients who completed the examination and those who did not in terms of age or psychomotor development. There was a statistically significant association between receiving a maintenance dose and successful completion of the test (p < 0.001). There was also a significant connection between the degree of hearing loss and the success rate of the ABR tests (p < 0.001). Conclusions-Melatonin-induced sleep is a good and safer alternative to anesthesia to perform ABR testing in young children. It is easily administered, tolerated by the patients, and accepted by parents.
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Barbosa-Méndez S, Salazar-Juarez A. Melatonin does not produce sedation in rats: A chronobiological study. Chronobiol Int 2019; 37:353-374. [DOI: 10.1080/07420528.2019.1702554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Susana Barbosa-Méndez
- Molecular Neurobiology and Neurochemistry of Addiction, Ramón de la Fuente Muñiz National Institute of Psychiatry, Ciudad de México, México
| | - Alberto Salazar-Juarez
- Molecular Neurobiology and Neurochemistry of Addiction, Ramón de la Fuente Muñiz National Institute of Psychiatry, Ciudad de México, México
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Picone S, Ariganello P, Mondì V, Di Palma F, Martini L, Marziali S, Fariello G, Paolillo P. A solution based on melatonin, tryptophan, and vitamin B6 (Melamil Tripto©) for sedation in newborns during brain MRI. Ital J Pediatr 2019; 45:122. [PMID: 31547831 PMCID: PMC6757392 DOI: 10.1186/s13052-019-0714-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Melatonin has been studied and used for several years as a sleep-wake cycle modulator in patients with sleep disorders. Experimental evidence has demonstrated the multiple neuroprotective benefits of this indoleamine secreted by the pineal gland. Melatonin is also used in neurological investigations, for its ability to induce sleep in children. In fact, it favors falling asleep during electroencephalogram, Magnetic Resonance Imaging (MRI), and during brainstem auditory evoked potentials. Previous studies are focused on infants and children. No investigation have been performed in neonates, before or during instrumental assessments. MATERIAL AND METHODS One hundred ten newborns (term and preterm) undergoing brain MRI were enrolled in the study. Thirty minutes before the planned time for the examination, we administered a single dose solution of melatonin- tryptophan-vitamin B6. Twenty minutes after the initial administration of 2 mg, a second dose of 1 mg was administered, if the baby was still awake. If after further 15 min the baby was still not sleeping, an additional dose of 1 mg was administered. RESULTS In 106 patients we obtained adequate sedation without adverse events, allowing us to perform an adequate quality MRI, with a median time of 25 min to reach sleeping. Only in three patients MRI could not be performed. In patients having a large weight, higher doses of melatonin were necessary to reach sleeping. Considering the pro kg dose of melatonin, the average dose that induced sleepiness in neonates was 0,64 ± 0.16 mg/Kg. CONCLUSION A solution based on Melatonin- tryptophan-vitamin B6 can be a helpful sedative to administer to neonates undergoing brain MRI, avoiding the use of anesthetics and achieving adequate assessments.
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Affiliation(s)
- S Picone
- Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Via Casilina 1069, 00169, Rome, Italy.
| | - P Ariganello
- Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Via Casilina 1069, 00169, Rome, Italy
| | - V Mondì
- Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Via Casilina 1069, 00169, Rome, Italy
| | - F Di Palma
- Medical School, La Sapienza University, Piazzale Aldo Moro 5, Rome, Italy
| | - L Martini
- Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Via Casilina 1069, 00169, Rome, Italy
| | - S Marziali
- Department of Neuroradiology, Policlinico Casilino General Hospital, Via Casilina, 1069, Rome, Italy
| | - G Fariello
- Department of Neuroradiology, Policlinico Casilino General Hospital, Via Casilina, 1069, Rome, Italy
| | - P Paolillo
- Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Via Casilina 1069, 00169, Rome, Italy
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