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Marques C, Dinis M, Machado V, Botelho J, Lopes LB. Evaluating the Quality of Systematic Reviews on Pediatric Sedation in Dentistry: An Umbrella Review. J Clin Med 2024; 13:3544. [PMID: 38930074 PMCID: PMC11205123 DOI: 10.3390/jcm13123544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Sedation is a depression of a patient's state of consciousness, induced by medications, that can reach different levels of intensity during a medical procedure. Conscious sedation produces a minimally depressed level of consciousness without impairment of the ability to maintain an open airway, of protective reflexes or of responses to verbal and physical stimulation. This umbrella review is aimed at critically assessing the available systematic reviews (SRs) and meta-analyses (MA) on sedation in children/adolescents. An electronic database search was conducted that included Pubmed-Medline, Web of Science, Cochrane, Scopus, Scielo, Embase, LILACS and TRIP and the scope of which extended until January 2023. The risk of bias (RoB) of SRs was analyzed using the Measurement Tool to Assess SRs criteria 2 (AMSTAR2). Of 998 entries, 37 SRs were included. In terms of methodological quality, eight studies were assessed as having critically low quality, four studies had low quality, nine studies had moderate quality, and sixteen were considered to be of high quality. Based on the current guidelines, the most employed drugs in pediatric dentistry for sedation are nitrous oxide and midazolam; however, the available evidence supporting their use is insufficient and of low/critically low quality. The combined technique is recommended (nitrous oxide (30-50%) + midazolam). The optimal dose of oral midazolam is 0.75 mg/kg. The level of methodological quality of SRs is expected to increase according to the results and future directions of this umbrella review.
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Affiliation(s)
| | | | | | - João Botelho
- Egas Moniz Center for Interdisciplinary Research Center (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal; (C.M.); (M.D.); (V.M.); (L.B.L.)
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Lu B, Wei L, Shi G, Du J. Nanotherapeutics for Alleviating Anesthesia-Associated Complications. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2308241. [PMID: 38342603 PMCID: PMC11022745 DOI: 10.1002/advs.202308241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/22/2023] [Indexed: 02/13/2024]
Abstract
Current management of anesthesia-associated complications falls short in terms of both efficacy and safety. Nanomaterials with versatile properties and unique nano-bio interactions hold substantial promise as therapeutics for addressing these complications. This review conducts a thorough examination of the existing nanotherapeutics and highlights the strategies for developing prospective nanomedicines to mitigate anesthetics-related toxicity. Initially, general, regional, and local anesthesia along with the commonly used anesthetics and related prevalent side effects are introduced. Furthermore, employing nanotechnology to prevent and alleviate the complications of anesthetics is systematically demonstrated from three aspects, that is, developing 1) safe nano-formulization for anesthetics; 2) nano-antidotes to sequester overdosed anesthetics and alter their pharmacokinetics; 3) nanomedicines with pharmacodynamic activities to treat anesthetics toxicity. Finally, the prospects and challenges facing the clinical translation of nanotherapeutics for anesthesia-related complications are discussed. This work provides a comprehensive roadmap for developing effective nanotherapeutics to prevent and mitigate anesthesia-associated toxicity, which can potentially revolutionize the management of anesthesia complications.
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Affiliation(s)
- Bin Lu
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
| | - Ling Wei
- Shanxi Bethune Hospital Center Surgery DepartmentShanxi Academy of Medical SciencesTongji Shanxi HospitalThird Hospital of Shanxi Medical UniversityTaiyuan030032China
| | - Gaoxiang Shi
- Department of AnesthesiologyThird Hospital of Shanxi Medical UniversityShanxi Bethune HospitalShanxi Academy of Medical SciencesTongji Shanxi HospitalTaiyuan030032China
| | - Jiangfeng Du
- Key Laboratory of Cellular Physiology at Shanxi Medical UniversityMinistry of EducationTaiyuanShanxi Province030001China
- Department of Medical ImagingShanxi Key Laboratory of Intelligent Imaging and NanomedicineFirst Hospital of Shanxi Medical UniversityTaiyuanShanxi Province030001China
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Peck J, Brown J, Fierstein JL, Nguyen ATH, Amankwah EK, Rehman M, Wilsey M. Comparison of general endotracheal anesthesia versus sedation without endotracheal intubation during initial percutaneous endoscopic gastrostomy insertion for infants: A retrospective cohort study. Paediatr Anaesth 2022; 32:1310-1319. [PMID: 35924407 DOI: 10.1111/pan.14539] [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: 12/15/2020] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Critical airway incidents are a major cause of morbidity and mortality during anesthesia. Delayed management of airway obstruction quickly leads to severe complications due to the reduced apnea tolerance in infants and neonates. The decision of whether to intubate the trachea during anesthesia is therefore of great importance, particularly as an increasing number of procedures are performed outside of the operating room. AIM In this retrospective cohort study, we evaluated airway management for infants below 6 months of age undergoing percutaneous endoscopic gastrostomy insertion. We compared demographic, procedural, and health outcome-related data for infants undergoing percutaneous endoscopic gastrostomy insertion under general endotracheal anesthesia (n = 105) to those receiving monitored anesthesia care (n = 44) without endotracheal intubation. METHODS A retrospective chart review was completed for all infants <6 months of age who underwent percutaneous endoscopic gastrostomy insertion in our institution's endoscopy suite between January 2002 and January 2017. Descriptive statistics summarized numeric variables using medians and corresponding ranges (minimum-maximum), and categorical variables using frequencies and percentages. Differences in study outcomes between patients undergoing general anesthesia or monitored anesthesia care were evaluated with univariate quantile or Firth logistic regression for numerical and categorical outcomes, respectively. Results are presented as β [95% confidence interval] or odds ratio [95% confidence interval] along with corresponding p-values. RESULTS Both groups were similar in distribution of age, race, and gender. However, patients selected for general anesthesia had lower median body weights (3.9 kg [range: 2.0-6.7] vs. 4.4 kg [range: 2.6-6.9]), higher percentages of cardiac (95.2% vs. 84.1%), and/or neurologic comorbidities (74.3% vs. 56.8%) and were more frequently given American Society of Anesthesiologists level IV classifications (41.9% vs. 29.6%) indicating that these infants may have had more severe disease than patients selected for monitored anesthesia care. Three monitored-anesthesia-care patients required intraoperative conversion to general anesthesia. General anesthesia patients experienced greater odds of intraoperative hypoxemia (45.2% vs. 29.0%; odds ratio: 2.0 [0.9-4.3], p-value: .09) and required postoperative airway intervention more frequently than monitored-anesthesia-care patients (13.03% vs. 2.3%; odds ratio: 4.6 [0.8-25.6], p-value: .08). Procedure times were identical in both groups (6 min), but general anesthesia resulted in longer median anesthesia times (44 min [range: 22-292] vs. 12 min [range:19-136]; β:13 [95% 6.9-19.1], p-value: < .001). CONCLUSION Study results suggest that providers selected general anesthesia over monitored anesthesia care for infants and neonates with low body weights, cardiac comorbidities, and neurologic comorbidities. Increased rates of airway intervention, and increased length of stay may be at least partially related to more severe patient comorbidity, as indicated by higher American Society of Anesthesiologists classifications. However, due to the exploratory nature of these analyses, further confirmatory studies are needed to evaluate the impact of airway selection during PEG on postoperative patient outcomes.
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Affiliation(s)
- Jacquelin Peck
- Department of Anesthesia, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Jerry Brown
- Office of Medical Education, University of South Florida, Tampa, Florida, USA
| | - Jamie L Fierstein
- Epidemiology and Biostatistics, Johns Hopkins All Children's Clinical and Translational Research Institute, Saint Petersburg, Florida, USA
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics, Johns Hopkins All Children's Clinical and Translational Research Institute, Saint Petersburg, Florida, USA
| | - Ernest K Amankwah
- Epidemiology and Biostatistics, Johns Hopkins All Children's Clinical and Translational Research Institute, Saint Petersburg, Florida, USA
| | - Mohamed Rehman
- Department of Pediatric Anesthesia, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Michael Wilsey
- Department of Pediatric Gastroenterology, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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Monsereenusorn C, Malaithong W, Lertvivatpong N, Photia A, Rujkijyanont P, Traivaree C. The efficacy and safety of midazolam with fentanyl versus midazolam with ketamine for bedside invasive procedural sedation in pediatric oncology patients: A randomized, double-blinded, crossover trial. Pediatr Hematol Oncol 2022; 39:681-696. [PMID: 36239702 DOI: 10.1080/08880018.2022.2055685] [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] [Indexed: 10/18/2022]
Abstract
Children with cancer often require sedation before undergoing invasive procedures. Fentanyl, ketamine, and midazolam are effective drugs widely used for procedural sedation. This study aimed to investigate the efficacy and safety of midazolam-fentanyl (M-F) compared with midazolam-ketamine (M-K) for bedside procedural sedation among pediatric oncology patients. A randomized, double-blinded, crossover trial was conducted among children with cancer requiring procedural sedation for invasive procedures. Patients were randomly assigned either intravenous M-F or M-K and subsequently received the alternate regimens following the crossover design of the study. The efficacy and safety of the sedations including sedation time intervals, nausea score, vomiting episodes, pain score, adverse effects, and parent's satisfaction were evaluated. In all, 58 patients with 116 procedural sedations were enrolled. M-K provided a shorter induction time (0:58 vs. 1:23 min) (p = 0.005), but longer sedation (9:02 vs. 5:50 min) (p = 0.019) and emergence time (4:26 vs. 0:56 min) (p = 0.011) compared with M-F. Sedation routes affected the sedation time intervals. Patients had higher rates of vomiting (0, range 0-8 vs. 0, range 0-2) (p = 0.033) but experienced less pain (0 vs. 2) (p = 0.008) in the M-K group. Overall satisfaction and other adverse effects were comparable among both sedation regimens. Combined sedative drugs are recommended to improve the effectiveness of bedside procedural sedation. M-K provided shorter induction, but longer sedation and emergence time compared with M-F. These findings correlated with sedative routes. Patients receiving M-K experienced a higher rate of vomiting, but less painfulness compared with M-F. Overall satisfaction and tolerable side effects were comparable among both sedative regimens.
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Affiliation(s)
- Chalinee Monsereenusorn
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Wanwipha Malaithong
- Department of Anesthesiology, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Nawachai Lertvivatpong
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Apichat Photia
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Piya Rujkijyanont
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chanchai Traivaree
- Division of Hematology/Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
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Gao PF, Li SY, Li Y, Zhao L, Luo Q, Ji Y. The comparison of ketamine-dexmedetomidine (ketadex) and ketamine-propofol (ketofol) for procedural sedation in pediatric patients: A meta-analysis of randomized controlled trials. Heliyon 2022; 8:e11166. [PMID: 36303919 PMCID: PMC9593188 DOI: 10.1016/j.heliyon.2022.e11166] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/22/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The combination of different agents used for procedural sedation allows a greater range of desirable effects while minimizing side effects. The ketamine-dexmedetomidine combination (ketadex) and ketamine-propofol combination (ketofol) are successful examples. The purpose of this meta-analysis was to compare the safety and efficacy of ketadex with ketofol used for procedural sedation in pediatric patients. Methods We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from inception to June 2022. Studies were independently evaluated for inclusion criteria and exclusion criteria by two reviewers. Outcome measures for safety comparison were the incidence of hypotension, bradycardia, respiratory depression, nausea, vomiting, and agitation; Outcome measure for efficacy comparison was clinicians' satisfaction. In addition, we compared the recovery time of ketadex and ketofol. Results Nine studies were included in this meta-analysis. Compared with ketofol, ketadex sedation in pediatric patients had lower risk of respiratory depression (RR: 0.51, 95% CI: 0.34–0.76, P = 0.0009). However, ketadex displayed significant effect on recovery time (MD: 8.38 min, 95% CI: 7.55–9.22 min, P < 0.00001). Ketadex had similar incidence of hypotension (RR: 0.95, 95% CI: 0.33–2.67, P = 0.92) and bradycardia (RR: 1.80, 95% CI: 0.64–5.06, P = 0.26) compared to those with ketofol. Clinicians' satisfaction rate of ketadex and ketofol were both high (RR: 0.93, 95% CI: 0.69–1.25, P = 0.62). Also, no significant difference was observed between ketadex and ketofol on the incidence of nausea, vomiting, and agitation. Conclusions Both ketadex and ketofol can provide effective sedation and maintain stable hemodynamics. In consideration of good safety profile in respiratory problems, we suggest ketadex is a better option for procedural sedation in pediatric patients.
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Burger RK, Taylor TR, Chumpitazi CE, Robinson LC, Sims MJ, Tunc EM, Mulcrone AE, Caglar D, Sulton CD, Little-Wienert K, Klein EJ, Titus MO, Jackson BF. Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines. Pediatr Emerg Care 2022; 38:162-166. [PMID: 35358144 DOI: 10.1097/pec.0000000000002568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.
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Affiliation(s)
- Rebecca K Burger
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Taryn R Taylor
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Corrie E Chumpitazi
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Lauren C Robinson
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Morgan J Sims
- Division of Emergency Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Emine M Tunc
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Amanda E Mulcrone
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Derya Caglar
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Carmen D Sulton
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Kim Little-Wienert
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Eileen J Klein
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - M Olivia Titus
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Benjamin F Jackson
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Zhang Y, Ou C, Bai X, Lai J, Huang W, Ouyang H. Efficacy and safety of the combination of propofol and S(+)-ketamine for procedural sedation in pediatric patients undergoing totally implantable venous access port implantation: A prospective randomized controlled study. Front Pediatr 2022; 10:974917. [PMID: 36061400 PMCID: PMC9428347 DOI: 10.3389/fped.2022.974917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Totally implantable venous access port (TIVAP) implantation is usually performed under general anesthesia with endotracheal intubation in children. Procedural sedation without endotracheal intubation has been applied to minor pediatric surgeries like central venous catheter insertion. To explore a more efficient and less invasive anesthesia mode to implant TIVAPs for children, we aimed to evaluate the efficacy and safety of procedural sedation using propofol and S(+)-ketamine compared with general anesthesia. METHODS Sixty-six patients aged 6 months to 10 years undergoing TIVAP implantation were randomly allocated to two groups. Patients under procedural sedation [S(+)-ketamine-propofol (sketofol) group] were given target-controlled infusion of propofol 4 μg/ml using the Paedfusor model and S(+)-ketamine 0.5 mg/kg as induction, and had target-controlled infusion of propofol 3-4 μg/ml as maintenance. Patients in sketofol group received medium-flow oxygen inhalation through facemasks during surgery. Patients under general anesthesia (control group) were given propofol 2 mg/kg, cisatracurium 0.2 mg/kg, fentanyl 3 μg/kg as induction, and sevoflurane 0.8 minimum alveolar concentration as maintenance after endotracheal intubation. Primary outcome was the postoperative emergence agitation evaluated 5 min after awakening. RESULTS Postoperative emergence agitation evaluated 5 min after awakening was lower in sketofol group versus control group [1.0 (0.5, 1.0) vs. 3.0 (2.0, 4.0); median difference (95% CI): 2.0 (1.0, 2.0); P < 0.001]. Time to awakening was significantly lower in sketofol group versus control group [15.0 (5.0, 23.0) vs. 26.0 (20.5, 37.5); median difference (95% CI): 11.0 (7.0, 19.0); P < 0.001], as well as time to discharge from post anesthesia care unit [35.0 (24.0, 45.0) vs. 45.0 (37.5, 59.5); median difference (95% CI): 10.0 (10.0, 23.0); P < 0.001]. Postoperative complications or adverse events were not reported in sketofol group. CONCLUSIONS Compared to general anesthesia with endotracheal intubation, procedural sedation using propofol and S(+)-ketamine improves the postoperative emergence agitation right after the recovery of consciousness, and has advantage in shortening anesthetic recovery time for pediatric patients undergoing TIVAP implantation.
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Affiliation(s)
- Yingjun Zhang
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chaopeng Ou
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaohui Bai
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jielan Lai
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wan Huang
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Handong Ouyang
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
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Guo P, Ran Y, Ao X, Zou Q, Tan L. Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:3160154. [PMID: 34976104 PMCID: PMC8718282 DOI: 10.1155/2021/3160154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/16/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia. METHODS We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia. RESULTS In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol. CONCLUSIONS The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.
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Affiliation(s)
- Pengfei Guo
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - YingChun Ran
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Xiaoxiao Ao
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Qing Zou
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Liping Tan
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
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Yuan C, Wang C, Wu J, Gao N, Li K, Li Y, Huang X, Huang W, Hu Z. Continuous infusion of lidocaine in pediatric colonoscopy: A randomized double-blind placebo-controlled study. Saudi J Gastroenterol 2021; 28:54-59. [PMID: 34806658 PMCID: PMC8919925 DOI: 10.4103/sjg.sjg_275_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Propofol is commonly used for providing procedural sedation during pediatric colonoscopy. Intravenous (i.v.) lidocaine can mitigate visceral pain and reduce propofol requirements during surgery. The aim of this study is to investigate the effect of i.v. lidocaine on perioperative propofol and sufentanil dose, pulse oxygen saturation, postoperative pain score, and recovery time during pediatric colonoscopy. METHODS We designed a randomized, double-blind, placebo-controlled study and enrolled 40 children aged from 3 to 10 years who underwent colonoscopy. After titration of propofol to achieve unconsciousness, the patients were given i.v. lidocaine (1.5 mg/kg later 2 mg/kg/hour) or the same volume of saline. Sedation was standardized and combined propofol with sufentanil. The primary outcome variables were intraoperative propofol and sufentanil requirements, and the number of oxygen desaturation episodes. Secondary outcome variables were recovery time after colonoscopy and post-colonoscopy pain. RESULTS Lidocaine infusion resulted in a significant reduction in propofol requirements: (median (quartile) 1.8 (1.5-2.0) vs. 3.0 (2.8-3.3) mg/kg respectively; P < 0.001) and sufentanil requirements: (median (quartile) 0.06 (0.05-0.08) vs. 0.1 (0.1-0.1) μg/kg respectively; P < 0.001). The number of subjects who experienced oxygen desaturation below 95% in the lidocaine group was also significantly less than that in the control group: 1 vs. 6 (P = 0.04). The mean (SD) recovery time was significantly shorter in the lidocaine group: (19.2 (2.6) vs. 13.3 (2.6) min respectively; P < 0.001). There was no significant difference in post-colonoscopy pain. CONCLUSION Continuous infusion of lidocaine resulted in reduction of propofol and sufentanil requirements, recovery time, and risk of hypoxemia during pediatric colonoscopy.
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Affiliation(s)
- Chao Yuan
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Chengli Wang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China
| | - Jiayao Wu
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Ningyang Gao
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Kunwei Li
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Yongle Li
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Xizhao Huang
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Wei Huang
- Department of Anesthesiology, Guangdong Women and Children Hospital, China
| | - Zurong Hu
- Department of Anesthesiology, Guangdong Women and Children Hospital, China,Address for correspondence: Dr. Zurong Hu, Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China, No. 13 Guangyuan West Road, Guangzhou, 510010, China. E-mail:
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Li HP, Liu KP, Yao L. Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis. Am J Emerg Med 2021; 50:442-448. [PMID: 34492589 DOI: 10.1016/j.ajem.2021.08.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication. METHODS Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events. RESULTS 15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2, 14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia. CONCLUSIONS DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia.
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Affiliation(s)
- Hong-Pei Li
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Kun-Peng Liu
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China.
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11
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. METHODS Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors' personal collections of literature were reviewed. The terms "palliative care", "ketamine", "neuropathic pain", "procedural pain", "status epilepticus", "refractory pain" and "child", adding "age: birth-18 years" on a further filter were used for the search. DISCUSSION The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. CONCLUSION Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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12
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Hayes JA, Aljuhani T, De Oliveira K, Johnston BC. Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:979-992. [PMID: 32665470 DOI: 10.1213/ane.0000000000004967] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Drugs such as propofol and ketamine are used alone or in combination to provide sedation for medical procedures in children. The purpose of this systematic review was to compare the safety and effectiveness of propofol and ketamine to other drug regimens. METHODS We searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Web of Science, and the grey literature (meta-Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar) for randomized controlled studies comparing intravenous propofol and ketamine to any other single or combination drug regimen administered to children undergoing diagnostic or therapeutic procedures. Meta-analyses were performed for primary (hemodynamic and respiratory adverse events) and secondary outcomes using RevMan 5.3. We assessed the risk of bias and the certainty (quality) evidence for all outcomes using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS Twenty-nine studies were included for analysis. Based on low-to-moderate quality evidence, we concluded that the use of propofol and ketamine may result in a slight-to-small reduction in the risk of hypotension, bradycardia, and apnea, and a slight increase in the risk of tachycardia, hypertension, and other respiratory adverse events, such as cough or laryngospasm. The ratio of propofol to ketamine and comparator drug regimen subgroups effects were important for desaturation and some secondary outcomes. CONCLUSIONS The use of propofol and ketamine had a minimal effect on the incidence of adverse events and other secondary outcomes. Large-scale studies are required to more accurately estimate adverse event rates and the effects of propofol and ketamine on patient-important outcomes.
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Affiliation(s)
- Jason A Hayes
- From the Department of Anesthesia and Pain Medicine, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Talal Aljuhani
- Pediatric Anesthesia Department, King Abdullah Specialized Children Hospital (KASCH), Riyadh, Saudi Arabia
| | - Kyle De Oliveira
- From the Department of Anesthesia and Pain Medicine, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bradley C Johnston
- Department of Nutrition, Texas A&M University, College Station, Texas.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Jamal D, Powell C. Paediatric procedural sedation in the emergency department: is ketamine safe? Arch Dis Child Educ Pract Ed 2021; 106:120-124. [PMID: 32522748 DOI: 10.1136/archdischild-2019-318610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Dried Jamal
- Pediatric Emergency, Sidra Medical and Research Center, Doha, Qatar
| | - Colin Powell
- Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar .,Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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Li B, Zhang R, Huang Y, Zhang K, Wat CY, Bai J, Zhang M, Zheng J. Moderate and deep sedation for non-invasive paediatric procedures in tertiary maternity and children’s hospitals in China: a questionnaire survey from China. BMC Health Serv Res 2020; 20:28. [PMID: 31914990 PMCID: PMC6951005 DOI: 10.1186/s12913-019-4885-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background Moderate and deep sedation are well-established techniques in many developed countries, and several guidelines have been published. However, they have received attention in China only in recent years. The aim of this study is to investigate current paediatric sedation practices in tertiary children’s hospitals and tertiary maternity and children hospitals in China. Methods All tertiary children’s hospitals and tertiary maternity and children hospitals registered with the National Health Commission of the People’s Republic of China were invited to participate in an electronic survey, which included information on the sedation caseload, facility availability, staff structure, clinical skill requirements for sedation providers, fasting guidelines, patient-monitoring practices, and choice of sedatives. Results Fifty-eight of the 63 hospitals that completed the survey (92.1%) provided moderate and deep sedation. Dedicated sedation rooms and post-sedation recovery rooms were found in 14 (24.1%) and 19 (32.8%) hospitals, respectively. Sedation for non-invasive procedures was primarily performed by anaesthesiologists (69.0%); however, 75.9% of the sedation providers had not received paediatric basic or advanced life-support training. Children were asked to fast from clear liquids for at least 2 h in 44.8% of hospitals and up to 6 h in 5.2% of hospitals; they were asked to fast from solid food/milk for at least 4 h in 27.6% of hospitals and more than 8 h in 1.7% of hospitals. The most commonly used sedative in all groups was chloral hydrate. For rescue, propofol was the most widely used sedative, particularly for children older than 4 years. Conclusions Moderate and deep sedation practices vary widely in tertiary children’s hospitals and tertiary maternity and children hospitals in China. Optimised practices should be established to improve the quality of moderate and deep sedation.
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