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Dhuse J, Cash T, Elges MS, Alazraki A, Beer R, Jergel A, Goldsmith KC, Hall M, Kamat PP. Trends in analgesia-sedation of pediatric patients receiving I-131 MIBG in the pediatric intensive care unit: A report from the Pediatric Health Information System database. Pediatr Blood Cancer 2024; 71:e31205. [PMID: 39010648 DOI: 10.1002/pbc.31205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/26/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Children with neuroblastoma receiving I-131 metaiodobenzylguanidine (MIBG) therapy require sedation-analgesia for strict radiation safety precautions during MIBG infusion and clearance. We evaluated the sedation-analgesia trends of patients undergoing MIBG therapy using the Pediatric Health Information System (PHIS) database. MATERIALS AND METHODS Retrospective data from 476 patient encounters from the PHIS from 2010 to 2019. RESULTS Total 240/476 (50.45%) children evaluated were under 6 years of age. Compared to 2010, in 2018 there was a decrease in benzodiazepine infusion use (60% vs. 40%, p < .04), as well as a decrease in use of opiate infusion (35% vs. 25%, p < .001). Compared to 2010, in 2018 we report an increase in the use of ketamine (from 5% to 10%, p < .002), as well as an increase in dexmedetomidine use (0% vs. 30%, p < .001). Dexmedetomidine was the most used medication in the 0-3 years age group compared to children older than 3 years of age (14.19% vs. 5.80%, p < .001). Opiate was the most used medication in children greater than 3 years compared to the 0-3-year age group (36.23 vs. 23.87, p < .05). CONCLUSION Using PHIS data, we discovered considerable variability in the medications used for sedation in patients undergoing MIBG therapy. Although benzodiazepines and opioids were the most used agents, there was a trend toward decreasing use of benzodiazepines and opioids in these patients. Furthermore, there has been an increasing trend in the use of dexmedetomidine and ketamine.
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Affiliation(s)
- Jordann Dhuse
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas Cash
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Michael S Elges
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Adina Alazraki
- Department of Radiology, Division of Pediatric Radiology and Imaging, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachael Beer
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew Jergel
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kelly C Goldsmith
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Pradip P Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
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Yoon J, Park JO, Song H, Lee CA, Wang SJ, Park HA. Efficacy and safety of ketamine alone and ketamine-dexmedetomidine combination for sedation for brain computed tomography in paediatric patients with head injuries: A retrospective study. Emerg Med Australas 2024; 36:443-449. [PMID: 38379190 DOI: 10.1111/1742-6723.14383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 01/13/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To compare the efficacy and safety of ketamine alone with those of ketamine-dexmedetomidine combination for sedation during brain CT in paediatric patients with head injuries. METHODS We retrospectively analysed the data of paediatric patients who underwent sedation for brain CT at the ED. We included patients aged 6 months to 6 years with American Society of Anesthesiologists physical status I or II. The sedative protocol involved the administration of intramuscular (IM) ketamine 3 mg/kg (K), ketamine 2 mg/kg with dexmedetomidine 1.5 μg/kg (KD) or ketamine 1.5 mg/kg with dexmedetomidine 1.5 μg/kg (low-KD). The primary and secondary outcomes were sedation failure and adverse events, respectively. RESULTS We included 77 patients; among them, 28, 23 and 26 were in the K, KD and low-KD groups, respectively. In multivariable analysis, the combination groups (KD and low-KD groups) were significantly associated with a lower possibility of sedation failure compared to the K group (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.56). Moreover, there were no significant differences in adverse events between the groups, and the sedation-related time variables also did not significantly differ among the three groups. CONCLUSIONS Our findings indicated that a combination of IM ketamine-dexmedetomidine provides effective sedation for paediatric patients undergoing brain CT without significant adverse events. Further research is needed to investigate the potential benefits of using lower doses of ketamine in combination.
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Affiliation(s)
- Jaeyeon Yoon
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Ju Ok Park
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Hyeonyoung Song
- Data Center, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Choung A Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Soon-Joo Wang
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
| | - Hang A Park
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
- Department of Epidemiology, School of Public Health, Seoul National University, Seoul, South Korea
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Goldstein M, Jergel A, Karpen S, He Z, Austin TM, Hall M, Deep A, Gilbertson L, Kamat P. Trends in sedation-analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database. Pediatr Transplant 2024; 28:e14660. [PMID: 38017659 DOI: 10.1111/petr.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/26/2023] [Accepted: 11/16/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Children admitted to the pediatric intensive care unit (PICU), after liver transplantation, frequently require analgesia and sedation in the immediate postoperative period. Our objective was to assess trends and variations in sedation and analgesia used in this cohort. METHODS Multicenter retrospective cohort study using the Pediatric Health Information System from 2012 to 2022. RESULTS During the study period, 3963 patients with liver transplantation were admitted to the PICU from 32 US children's hospitals with a median age of 2 years [IQR: 0.00, 10.00]. 54 percent of patients received mechanical ventilation (MV). Compared with patients without MV, those with MV were more likely to receive morphine (57% vs 49%, p < .001), fentanyl (57% vs 44%), midazolam (45% vs 31%), lorazepam (39% vs. 24%), dexmedetomidine (38% vs 30%), and ketamine (25% vs 12%), all p < .001. Vasopressor usage was also higher in MV patients (22% vs. 35%, p < .001). During the study period, there was an increasing trend in the utilization of dexmedetomidine and ketamine, but the use of benzodiazepine decreased (p < .001). CONCLUSION About 50% of patients who undergo liver transplant are placed on MV in the PICU postoperatively and receive a greater amount of benzodiazepines in comparison with those without MV. The overall utilization of dexmedetomidine and ketamine was more frequent, whereas the administration of benzodiazepines was less during the study period. Pediatric intensivists have a distinctive opportunity to collaborate with the liver transplant team to develop comprehensive guidelines for sedation and analgesia, aimed at enhancing the quality of care provided to these patients.
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Affiliation(s)
- Matthew Goldstein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Andrew Jergel
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saul Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zhulin He
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas M Austin
- Department of Anesthesiology, Shands Children's Hospital, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Akash Deep
- Paediatric Intensive Care Unit (PICU), King's College Hospital, London, UK
| | - Laura Gilbertson
- Department of Anesthesiology and Pain Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pradip Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
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Baumgartner K, Groff V, Yaeger LH, Fuller BM. The use of dexmedetomidine in the emergency department: A systematic review. Acad Emerg Med 2023; 30:196-208. [PMID: 36448276 DOI: 10.1111/acem.14636] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Dexmedetomidine (DEX), a centrally acting alpha-2 agonist, is increasingly used for sedation in multiple clinical settings. Evidence from the intensive care unit and operative settings suggests DEX may have significant advantages over traditional GABAergic sedatives such as benzodiazepines. There has been limited research on the use of DEX in the emergency department (ED). METHODS We performed a systematic review of the medical literature to identify all published evidence regarding the use of DEX in the ED. We included randomized and nonrandomized studies and studies reporting any use of DEX in the ED, even when it was not the primary focus of the study. Two authors reviewed studies for inclusion, and a single author assessed studies for quality and risk of bias and abstracted data. RESULTS We identified 35 studies meeting inclusion criteria, including 11 randomized controlled trials, 13 cohort and other nonrandomized studies, and 11 case reports and case series. Significant heterogeneity in interventions, comparators, indications, and outcomes precluded data pooling and meta-analysis. We found modest evidence that DEX was efficacious in facilitating medical imaging and mixed and limited evidence regarding its efficacy for procedural sedation and sedation of nonintubated medical and psychiatric patients. Our results suggested that DEX is associated with bradycardia and hypotension, which are generally transient and infrequently require medical intervention. CONCLUSIONS A limited body of generally poor- to moderate-quality evidence suggests that the use of DEX may be efficacious in certain clinical scenarios in the ED and that DEX use in the ED is likely safe. Further high-quality research into DEX use in the ED setting is needed, with a particular focus on clear and consistent selection of indications, identification of clear and clinically relevant primary outcomes, and careful assessment of the clinical implications of the hemodynamic effects of DEX therapy.
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Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica Groff
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lauren H Yaeger
- Becker Medical Library, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Lebrat M, Bouattour Y, Gaudet C, Yessaad M, Jouannet M, Wasiak M, Dhifallah I, Beyssac E, Garrait G, Chennell P, Sautou V. Development and Stability of a New Formulation of Pentobarbital Suppositories for Paediatric Procedural Sedation. Pharmaceutics 2023; 15:pharmaceutics15030755. [PMID: 36986615 PMCID: PMC10055724 DOI: 10.3390/pharmaceutics15030755] [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: 11/14/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 03/30/2023] Open
Abstract
Pentobarbital is a drug of choice to limit motion in children during paediatric procedural sedations (PPSs). However, despite the rectal route being preferred for infants and children, no pentobarbital suppositories are marketed, and therefore they must be prepared by compounding pharmacies. In this study, two suppository formulations of 30, 40, 50, and 60 mg of pentobarbital sodium were developed using hard-fat Witepsol® W25 either alone (formulation F1) or with oleic acid (formulation F2). The two formulations were subjected to the following tests described in the European Pharmacopoeia: uniformity of dosage units, softening time, resistance to rupture, and disintegration time. The stability of both formulations was also investigated for 41 weeks of storage at 5 ± 3 °C using a stability-indicating liquid chromatography method to quantify pentobarbital sodium and research breakdown product (BP). Although both formulae were compliant to uniformity of dosage, the results were in favour of a faster disintegration of F2 compared to F1 (-63%). On the other hand, F1 was found to be stable after 41 weeks of storage unlike F2 for which several new peaks were detected during the chromatographic analysis, suggesting a shorter stability of only 28 weeks. Both formulae still need to be clinically investigated to confirm their safety and efficiency for PPS.
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Affiliation(s)
- Matthieu Lebrat
- CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
| | - Yassine Bouattour
- Université Clermont Auvergne, CHU Clermont Ferrand, Clermont Auvergne INP, CNRS, ICCF, F-63000 Clermont-Ferrand, France
| | - Coralie Gaudet
- CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
| | - Mouloud Yessaad
- CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
| | - Mireille Jouannet
- CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
| | - Mathieu Wasiak
- CHU Clermont-Ferrand, Pôle Pharmacie, F-63003 Clermont-Ferrand, France
| | - Imen Dhifallah
- Université Clermont-Auvergne, UFR Pharmacie, UMR MEDIS, F-63001 Clermont-Ferrand, France
| | - Eric Beyssac
- Université Clermont-Auvergne, UFR Pharmacie, UMR MEDIS, F-63001 Clermont-Ferrand, France
| | - Ghislain Garrait
- Université Clermont-Auvergne, UFR Pharmacie, UMR MEDIS, F-63001 Clermont-Ferrand, France
| | - Philip Chennell
- Université Clermont Auvergne, CHU Clermont Ferrand, Clermont Auvergne INP, CNRS, ICCF, F-63000 Clermont-Ferrand, France
| | - Valérie Sautou
- Université Clermont Auvergne, CHU Clermont Ferrand, Clermont Auvergne INP, CNRS, ICCF, F-63000 Clermont-Ferrand, France
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Lee JY, Choi SJ, Park JS, Lee JS, Ryu JM, Yum MS. Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018. J Korean Med Sci 2021; 36:e213. [PMID: 34427061 PMCID: PMC8382566 DOI: 10.3346/jkms.2021.36.e213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.
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Affiliation(s)
- Jeong Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jun Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Sung Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi Sun Yum
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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