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Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Zhuge J, Zheng D, Li X, Nie X, Liu J, Liu R. Parental preferences for the procedural sedation of children in dentistry: a discrete choice experiment. Front Pediatr 2023; 11:1132413. [PMID: 38116578 PMCID: PMC10728602 DOI: 10.3389/fped.2023.1132413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Purpose The aim of this study was to explore parental preferences for the procedural sedation of children in dentistry through a discrete choice experiment (DCE) to inform clinical decisions and oral health management. Methods Based on literature reviews, interviews with parents of pediatric dental patients, and expert consultation, six attributes, including fasting time, recovery time, sedative administration routes, adverse reactions, sedation depth and procedure cost, were incorporated into the DCE questionnaire. The DCE questionnaire collected data on parental preferences for pediatric dental sedation treatment from June to August 2022. A conditional logit model was used to analyze preference and willingness to pay (WTP) for each attribute and its level. Subgroup analyses assessing the impact of parents' dental anxiety on procedural sedation preferences were also conducted using conditional logit models. Results A total of 186 valid questionnaires were gathered. Parents' preferences for fewer adverse reactions, a milder sedation depth, lower out-of-pocket cost, shorter fasting and recovery times and administration by inhalation were significantly associated with their choice of sedation model. The conditional logit model showed that parents were most interested in treatments with no adverse reactions (0% vs. 15%) (Coef, 1.033; 95% CI, 0.833-1.233), followed by those providing minimal sedation (vs. deep sedation) (Coef, 0.609; 95% CI, 0.448-0.769). Moreover, the relative importance of adverse reactions and fasting time was higher among anxious than nonanxious parents. The study found a WTP threshold of ¥1,538 for reducing adverse reactions (15% to 0%). The WTP threshold for the best sedation procedure scenario (no fasting requirement, 10 min recovery time, administration by inhalation, 0% adverse reaction incidence and minimal sedation) was ¥3,830. Conclusion Reducing the adverse reactions and depth of sedation are predominant considerations for parents regarding procedural sedation in pediatric dentistry, followed by lower cost, shorter fasting and recovery times and inhalation sedation. Parents with dental anxiety had a stronger preference for options with a lower incidence of adverse reactions and shorter fasting time than parents without dental anxiety. This discovery is helpful for doctors and can promote collaborative decision-making among parents and doctors.
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Affiliation(s)
- Jinru Zhuge
- Department of Anesthesiology, The Affiliated Stomatology Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dongyue Zheng
- Department of Nursing, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xingwang Li
- Department of Anesthesiology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xin Nie
- Department of Stomatology, The Affiliated Stomatology Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiefan Liu
- Department of Stomatology, The Affiliated Stomatology Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruohai Liu
- Department of Anesthesiology, The Affiliated Stomatology Hospital of Wenzhou Medical University, Wenzhou, China
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Assessing procedural satisfaction in the pediatric ED: A systematic review. Am J Emerg Med 2020; 43:283-286. [PMID: 32693939 DOI: 10.1016/j.ajem.2020.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
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Orb Q, Rezaie A, Furst S, Meier JD, Park AH. Using anxiolytics in a pediatric otolaryngology clinic to avoid the operating room. Int J Pediatr Otorhinolaryngol 2019; 120:73-77. [PMID: 30772615 DOI: 10.1016/j.ijporl.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION There is increasing concern regarding the risks associated with the use of general anesthesia in pediatric patients. Many otolaryngologic procedures performed under general anesthesia can also be performed in clinic. We hypothesize that anxiolytics can aid in performing common procedures in clinic thus avoiding the need to undergo general anesthesia in the OR. METHODS We performed a retrospective review of patients undergoing inoffice procedures with anxiolytics in our pediatric otolaryngology outpatient clinic between February 2013 and January 2017. Charts were reviewed for age, past medical history, procedure type/duration, and outcome. These results were then compared to a cohort undergoing similar procedures in the OR. RESULTS A total of 34 patients underwent an in-office procedure with an anxiolytic. The success rate was 97% (33/34). The average age was 6.2 years. Six children (17%) had a known history of chromosomal abnormalities and 2 children (6%) had autism. The four most common procedures performed were cerumen impaction removal (8), flexible laryngoscopy (6), ear canal foreign body removal (5), and septal cautery (4). Performing similar procedures in the OR resulted in an average additional cost of $822. CONCLUSIONS Performing procedures with anxiolytics in a pediatric otolaryngology clinic is safe, expeditious, and cost-effective. Anxiolytics can provide an effective alternative to general anesthesia.
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Affiliation(s)
- Quinn Orb
- Division of Otolaryngology, Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA
| | - Aida Rezaie
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sheldon Furst
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Jeremy D Meier
- Division of Otolaryngology, Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA
| | - Albert H Park
- Division of Otolaryngology, Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA.
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Adinehmehr L, Shetabi H, Moradi Farsani D, Salehi A, Noorbakhsh M. Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial. Anesth Pain Med 2019; 9:e87415. [PMID: 31341824 PMCID: PMC6616865 DOI: 10.5812/aapm.87415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background According to the favorable effects of combination therapy to provide better sedation during phacoemulsification and lack of any studies investigating the sedative effect of etomidate, propofol, and midazolam in combination with fentanyl during the procedure. Objectives The current study aimed at comparing the sedative properties of the mentioned three combination therapies in this field. Methods The current double-blind, randomized, controlled clinical trial was conducted on patients referred for elective phacoemulsification surgery under sedation. They were randomly allocated to the three groups to receive fentanyl plus one of the following medications: Propofol, midazolam, and etomidate. Demographic characteristics, medical condition, and hemodynamic parameters before, during, and after surgery, sedation level, anesthetic complications, sedation-related adverse events, and patients' and surgeons' satisfaction were evaluated and recorded by the anesthesiologist and compared in the three studied groups. Results In the current study, out of 150 enrolled patients, 98 completed the study. Frequency of different levels of Ramsay scores was not significantly different between the groups (P = 0.41). Frequency of Ramsay scores 3 and 4 was 92%, 79.4%, and 88.2% in etomidate, midazolam and propofol groups, respectively (P = 0.32). The median recovery time was significantly higher in the midazolam group than the propofol group (P = 0.04); intergroup comparisons indicated that the patients' mean score of satisfaction in the propofol group was significantly higher than that of the etomidate group (P = 0.006). Conclusions The current study findings indicated that though the quality of sedation during phacoemulsification cataract surgery was acceptable in the three agents and the results had no significantly differences among the groups, and considering other factors including recovery time, hemodynamic evaluation, sedation-related complications, and patients' satisfication scores, it is suggested that propofol was superior to the other two agents.
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Affiliation(s)
- Leili Adinehmehr
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
- Corresponding Author: Anesthesiology Department, Al Zahra Medical Center, Isfahan University of Medical Sciences, Sofeh Blvd., Isfahan, Iran.
| | - Darioush Moradi Farsani
- Anesthesiology and Critical Care Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Salehi
- Ophthalmology Department, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
Supplemental Digital Content is available in the text.
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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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Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries. Pediatr Emerg Care 2016; 32:830-834. [PMID: 25834964 DOI: 10.1097/pec.0000000000000373] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department. METHODS Forty-four healthy children aged 7 to 18 years were included. The patients were randomly divided into 2 groups. Group 1 (24 patients) received etomidate and fentanyl, and group 2 (20 patients) received ketamine intravenously. The Ramsay Sedation Scale and American Pediatric Association discharge criteria were used to evaluate the patients. RESULTS There were 70 fractured bones and 3 joint dislocations. Except in 1 case (2.3%), all of the injuries were reducted successfully. The mean amount of drugs used to provide adequate sedation and analgesia were 0.25 mg/kg of etomidate and 1.30 μg/kg of fentanyl in group 1 and 1.25 mg/kg of ketamine in group 2. Fourteen patients (31.8%) reported adverse effects, and none required hospitalization. There was no difference between the groups in the recovery times, occurrence of adverse effects, and postsedation observation durations (P > 0.05). The mean (SD) induction time for the patients in group 1 was 4.3 (1.0) minutes, whereas it was 2.2 (1.6) minutes in group 2 (P < 0.001). CONCLUSIONS Etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures. Ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy.
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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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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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Abstract
As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.
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Affiliation(s)
- John W Berkenbosch
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville, Kosair Children's Hospital, 571 S. Floyd, Ste 332, Louisville, KY, 40202, USA.
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Abstract
Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.
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Affiliation(s)
- Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Su F, El-Komy MH, Hammer GB, Frymoyer A, Cohane CA, Drover DR. Population pharmacokinetics of etomidate in neonates and infants with congenital heart disease. Biopharm Drug Dispos 2015; 36:104-14. [PMID: 25377074 DOI: 10.1002/bdd.1924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/16/2014] [Accepted: 10/25/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Etomidate is a rapid-onset, short-acting hypnotic medication administered for the induction of anesthesia. It is currently approved by the Food and Drug Administration for use in older children and adults. Pharmacokinetic data to help guide dosing in neonates and infants are lacking. OBJECTIVE The aim of this study was to determine the pharmacokinetics of etomidate in neonates and infants with congenital heart disease undergoing cardiac surgery. METHODS Four neonates and 16 infants, postnatal age 0.3-11.7 months, requiring open-heart surgery received 0.3 mg/kg of etomidate administered as a single intravenous dose prior to surgery. Blood sampling for plasma etomidate concentration occurred immediately following etomidate administration until the initiation of cardiopulmonary bypass. A population pharmacokinetic approach using nonlinear mixed-effects modeling was applied to characterize etomidate pharmacokinetics. RESULTS The pharmacokinetics of etomidate was described by a two-compartment model with first-order elimination. An allometric weight-based model was applied to scale results to a 70 kg adult. Covariates including age and cardiac physiology were not found significantly to impact etomidate pharmacokinetics. The study population was found to have a central and intercompartmental clearance of 0.624 l/min/70 kg and 0.44 l/min/70 kg, respectively; central and peripheral distribution volume of 9.47 l/70 kgand 22.8 l/70 kg, respectively. Inter-individual variability was 94-142% for all parameters and the residual variability was 29%. CONCLUSIONS The clearance of etomidate is lower in neonates and infants with congenital heart disease compared with published values for older children without congenital heart disease. In addition, etomidate pharmacokinetics is highly variable in this pediatric cardiac population.
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Affiliation(s)
- Felice Su
- Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
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Abstract
A spectrum of conditions requires sedation and analgesia in pediatric population. Ineffective treatment of pain may result in physiological and behavioral responses that can adversely affect the developing nociceptive system. The recognition of pain in children can be facilitated by different pain scales. This article reviews the procedural sedation and analgesia (PSA) practices in children along with pharmacology of the drugs used for this purpose.
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Affiliation(s)
- Charu Mahajan
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hari Hara Dash
- Department of Anesthesiology, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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ERDOES G, BASCIANI RM, EBERLE B. Etomidate--a review of robust evidence for its use in various clinical scenarios. Acta Anaesthesiol Scand 2014; 58:380-9. [PMID: 24588359 DOI: 10.1111/aas.12289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 02/02/2023]
Abstract
Etomidate is an intravenous hypnotic with a favourable clinical profile in haemodynamic high-risk scenarios. Currently, there is an active debate about the clinical significance of the drug's side effects and its overall risk-benefit ratio. Etomidate-induced transient adrenocortical suppression is well documented and has been associated with increased mortality in sepsis. In surgical patients at risk of hypotensive complications, however, a review of current literature provides no robust evidence to contraindicate a single-bolus etomidate induction. Large randomised controlled trials as well as additional observational data are required to compare safety of etomidate and its alternatives.
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Affiliation(s)
- G. ERDOES
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - R. M. BASCIANI
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
| | - B. EBERLE
- Department of Anaesthesiology and PainTherapy; University Hospital Bern; Bern Switzerland
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Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med 2014; 63:247-58.e18. [DOI: 10.1016/j.annemergmed.2013.10.015] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mandt MJ, Roback MG, Bajaj L, Galinkin JL, Gao D, Wathen JE. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care 2012; 28:898-904. [PMID: 22929142 DOI: 10.1097/pec.0b013e318267c768] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children. METHODS This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 μg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion. RESULTS Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes. CONCLUSIONS For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.
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Affiliation(s)
- Maria J Mandt
- Department of Pediatrics, Section of Emergency Medicine, The Children's Hospital, University of Colorado Denver Health Science Center, Aurora, CO 80045, USA.
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Denny MA, Manson R, Della-Giustina D. Propofol and Etomidate are Safe for Deep Sedation in the Emergency Department. West J Emerg Med 2012; 12:399-403. [PMID: 22224127 PMCID: PMC3236171 DOI: 10.5811/westjem.2011.5.2099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 12/23/2010] [Accepted: 05/02/2011] [Indexed: 11/11/2022] Open
Abstract
This study describes deep sedations performed for painful procedures completed in the emergency department at an academic tertiary care hospital during an 18-month period. One hundred consecutive cases were retrospectively reviewed to describe indications, complications, procedural lengths, medication dosing, and safety of these sedations. Propofol and etomidate were the preferred agents. We found that there were relatively few complications (10%), with only 2 of these (2%) being major complications. All complications were brief and did not adversely affect patient outcomes. This data further demonstrate the safety profile of deep sedation medications in the hands of emergency physicians trained in sedation and advanced airway techniques.
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Affiliation(s)
- Mark A Denny
- Diley Ridge Medical Center, Canal Winchester, Ohio
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Heng Vong C, Bajard A, Thiesse P, Bouffet E, Seban H, Marec Bérard P. Deep sedation in pediatric imaging: efficacy and safety of intravenous chlorpromazine. Pediatr Radiol 2012; 42:552-61. [PMID: 22246411 DOI: 10.1007/s00247-011-2310-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 09/22/2011] [Accepted: 09/26/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The quality of MRI and CT depends largely on immobility of the patient during the procedure, which is often difficult to achieve without sedation in children below the age of 6 years. OBJECTIVE To assess the efficacy and safety of intravenous chlorpromazine sedation for repeated imaging in young children treated for cancer. MATERIALS AND METHODS From July 2003 to January 2007, information on children younger than 6 years of age having MRI or CT was prospectively collected. Forty-five minutes before the scan, a 10-min infusion of chlorpromazine 0.5 mg/kg was administered and managed by non-anesthetic staff. Patient monitoring included continuous measurement of pulse, respiration, oxygen saturation and arterial blood pressure. Procedure-related parameters and adverse events were documented. Sedation was considered successful when the procedure was completed and at least 95% of images were usable. RESULTS One-hundred-one procedures (82 MRI, 19 CT) were evaluated in 62 children, 3-74 months old. Adequate sedation was achieved in 96% of cases, with mean induction time, 22 min; mean duration of sleep, 72 min, and mean duration of procedure, 33 min. Mean time spent in the radiology unit was 104 min. Ninety-six percent of imaging procedures were successfully completed. No cardiac, respiratory, neurological or allergic complication occurred. CONCLUSION Intravenous chlorpromazine is safe and effective for procedural sedation in young children with cancer undergoing MRI and CT.
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Chéron G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for the child under spontaneous ventilation?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:369-76. [PMID: 22464837 DOI: 10.1016/j.annfar.2012.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Chéron
- Département des urgences pédiatriques, université Paris Descartes Paris-V, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Kost S, Roy A. Procedural Sedation and Analgesia in the Pediatric Emergency Department: A Review of Sedative Pharmacology. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Bhatt M, Currie GR, Auld MC, Johnson DW. Current practice and tolerance for risk in performing procedural sedation and analgesia on children who have not met fasting guidelines: a Canadian survey using a stated preference discrete choice experiment. Acad Emerg Med 2010; 17:1207-15. [PMID: 21175519 DOI: 10.1111/j.1553-2712.2010.00922.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objectives were to explore the tolerance of pediatric emergency medicine (PEM) physicians for risk in choosing when to perform procedural sedation and analgesia (PSA) and to describe adherence to preprocedural fasting guidelines and factors affecting the physicians' decisions. METHODS A survey of Canadian PEM physicians who perform PSA was conducted. Respondents were asked about their PSA practices. Risk tolerance was assessed using an economics-based stated preference elicitation method called a discrete choice experiment (DCE). Using a hypothetical clinical situation of a healthy child needing PSA, three fasting scenarios (ingestion of full meal < 2 hours ago, full meal between 2 and 4 hours ago, liquids less than 1 hour ago) were created. For each fasting scenario, 16-choice questions with varying numeric risks of major and minor adverse events were presented and respondents were asked whether they would administer PSA now or wait for guidelines to be met. In this exploratory study, choice data were analyzed using multivariate regression analysis, and preliminary inferential statistics are presented. RESULTS A total of 114 (63.6%) completed surveys were returned. Respondents were 54% male, were in practice for a median of 6-10 years, and reported following fasting guidelines 53% of the time. Most had institutional fasting policies (70%), used ketamine (in 78% of PSA by 95% of users), and identified patient variables (prolonged pain, parental concern) as more important than environmental variables (patient flow, use of resources) in deciding when to administer PSA. Both major and minor risks of adverse events affected the choice of whether to do immediate PSA or wait until fasting guidelines were met. A 0.1-percentage-point increase in the probability of a major adverse event reduced physician likelihood of performing immediate PSA before meeting fasting guidelines by 17.6 percentage points. In comparison, a 10-percentage-point increase in the probability of a minor adverse event reduced physician likelihood of performing immediate PSA by 17.2%. Respondents were less likely to perform PSA immediately if a child had a full meal < 2 hours ago versus 2-4 hours ago or liquids < 1 hour ago. Sex, highest level of postgraduate training, frequency of performing PSA, and experience with a prior adverse event did not affect the choice to do immediate PSA. Years in practice affected the decision, with those in practice for 6-10 years more likely to perform immediate PSA than those in practice for shorter or longer. Those who reported having an institutional fasting policy were less likely to perform immediate PSA. CONCLUSIONS These results suggest that fasting guidelines are not strictly adhered to in Canadian pediatric emergency departments (EDs) currently, and there is some willingness of physicians to change their sedation practice in light of evidence from hypothetical surveillance data about risks. On the other hand, some physicians suggest that they will follow guidelines regardless of how low the estimated risk is from surveillance data. An understanding of how physicians respond to evidence about small risks and how the information is best understood by this population is interesting for knowledge translation if evidence-based practice guidelines for procedural sedation in the ED are developed in the future.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Montreal Children's Hospital McGill University, Quebec, Canada.
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Ketamine/midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions. Pediatr Emerg Care 2010; 26:408-12. [PMID: 20502386 DOI: 10.1097/pec.0b013e3181e057cd] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidate's safety and efficacy in pediatric procedural sedation. OBJECTIVE The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED. METHODS Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation. RESULTS Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group. CONCLUSIONS This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.
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Is it safe to use propofol in the emergency department? A randomized controlled trial to compare propofol and midazolam. Int J Emerg Med 2010; 3:105-13. [PMID: 20606819 PMCID: PMC2885259 DOI: 10.1007/s12245-010-0162-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 01/14/2010] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND This study examined the safety and effectiveness of the procedural sedation analgesia (PSA) technique carried out in the emergency department (ED) of a university hospital over a period of 1 year. The research was done to compare the effectiveness and efficacy of moderate sedation of fentanyl combined with either midazolam or propofol for any brief, intense procedure in the ED setting. AIMS The objectives were to observe the occurrence of adverse events in subjects undergoing PSA for intense and painful procedures in the emergency department and to implement the use of capnography as a method of monitoring the patients when they were under PSA. METHODS Forty patients were selected for this study. They were randomly divided into two equal groups using the computer-generated random permuted blocks of four patients. Twenty patients were grouped together as group A and the remaining 20 patients as group B. Drugs used were single blinded to prevent any bias. Drug A was propofol and fentanyl, while drug B was midazolam and fentanyl. The procedures involved included orthopedic manipulation such as reduction of fractures, reduction of dislocated joints, abscess drainage, wound debridement, laceration wound repair and cardioversion. All of the subjects were monitored for their vital signs and end tidal carbon dioxide level every 10 min till the PSA was completed. The duration of stay in the ED was documented when the subjects had completed the procedure and were released from the department. RESULT Of the study population, 75.6% were males. The mean age was 37.8 years (95% CI 33.2, 39.8). None of the patients developed any major complications while under PSA. The vital signs pre-, intra- and post-procedure were not significantly different in either the propofol or mizadolam groups (p value >0.05). CONCLUSION This study had proven that there was no difference in adverse event occurrence between the studied drugs during PSA. Propofol can be recommended for use in PSA if the operator is well trained and familiar with the drug.
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Nestor NB, Burton JH. ED use of etomidate for rapid sequence induction. Am J Emerg Med 2008; 26:946-50. [DOI: 10.1016/j.ajem.2007.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 12/04/2007] [Accepted: 12/05/2007] [Indexed: 11/15/2022] Open
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Heid F, Gerth M, Roth W, Hessmann M, Werner C. [Procedural analgesia : concepts and practice]. Chirurg 2008; 79:738-44. [PMID: 18347762 DOI: 10.1007/s00104-008-1507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The effect of severe pain and its hazardous stress-related cardiocirculatory consequences have been well documented for the perisurgical setting. Independently of surgical intervention however, even short and simple measures (e.g. thorax drain removal, repositioning a limb fracture) and longer diagnostic procedures such as MRI are potentially very painful or stressful to the patient. Though longer diagnostic procedures are frequently supported by systemic medication, short interventions regularly lack this aspect. Specific challenges result from the need to counteract sometimes great changes in pain intensity. Moreover procedural analgesia represents a multidisciplinary measure not restricted to anaesthesiology, as most of these measures are performed without anaesthesia. To avoid endangering the patient, the choice of drugs and patient monitoring have to meet certain professional and technical standards. Competence in respiratory management is of paramount importance. This paper outlines these requirements and serves as an orientation outside the anaesthesiological speciality.
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Affiliation(s)
- F Heid
- Klinik für Anästhesiologie, Johannes Gutenberg-Universität, Langenbeckstrasse 1, 55131, Mainz, Deutschland.
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Hertzog JH, Havidich JE. Non-anesthesiologist-provided pediatric procedural sedation: an update. Curr Opin Anaesthesiol 2007; 20:365-72. [PMID: 17620847 DOI: 10.1097/aco.0b013e32825a6a0a] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review evaluates the past year's literature on the provision of pediatric procedural sedation outside of the operating room, especially as performed by non-anesthesiologist healthcare providers. RECENT FINDINGS Research on pediatric procedural sedation practice continues to be limited by small case series and single institution study design. However, some exciting developments have occurred. Recent guideline revisions and safety initiatives are reported that impact positively on practice. Efforts to analyze the elements of sedation systems that result in greater safety, efficiency, and patient satisfaction are increasing, including evaluations of tiered systems utilizing the skills of various healthcare providers. Dexmedetomidine and etomidate are the subjects of investigation on their utility for procedural sedation. A multicentered study, adequately powered to provide meaningful evaluation of adverse events, has been completed and provides valuable insight on pediatric procedural sedation as practiced by a variety of healthcare providers. SUMMARY Pediatric procedural sedation practice as performed by non-anesthesiologists continues to grow. Ongoing efforts to understand the elements of sedation systems that lead to best practice, with the subsequent development of uniform practice approaches, are essential. A collaborative relationship between anesthesiologists and non-anesthesiologist providers of procedural sedation is essential for meeting common goals.
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Affiliation(s)
- James H Hertzog
- Department of Anesthesiology and Critical Care Medicine, Alfred I duPont Hospital for Children, Wilmington, DE, USA.
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Etomidate versus pentobarbital for computed tomography sedations: report from the Pediatric Sedation Research Consortium. Pediatr Emerg Care 2007; 23:690-5. [PMID: 18090099 DOI: 10.1097/pec.0b013e3181558d5c] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare efficacy, sedation duration, and adverse events after administration of etomidate or pentobarbital for diagnostic computed tomography (CT) scans. METHODS A cohort of children sedated for CT scans between July 2004 and October 2005 was identified from a prospectively generated Pediatric Sedation Research Consortium database. The 24 Pediatric Sedation Research Consortium institutions prospectively record consecutive sedation data and adverse events on a Web-based tool. This study included all patients of American Society for Anesthesiologists (ASA) class I or II, between 6 months and 6 years old, sedated with etomidate or with intravenous pentobarbital with or without midazolam. Outcomes included sedation efficacy, duration (time from drug administration until cessation of monitoring), and complication rate. RESULTS Of 3397 pediatric sedations for CT scans, 2587 met age and ASA criteria. Etomidate was administered by pediatric emergency physicians as the sole sedative for 446 sedation service cases; pentobarbital with or without midazolam was used in 396 sedations by a variety of providers. Sedation was "not ideal" for 11 pentobarbital sedations and 1 etomidate sedation. Median etomidate dose was 0.33 mg/kg (intraquartile rank, 0.30-0.44 mg/kg); median pentobarbital dose was 4 mg/kg (intraquartile rank, 3.2-4.8 mg/kg). Mean etomidate sedation (34 minutes; 95% confidence interval [CI], 32-36 minutes) was shorter than pentobarbital (144 minutes; 95% CI, 139-150 minutes). Etomidate patients were younger (24 vs. 29 months), whereas pentobarbital patients were more often of ASA class II (52% vs. 34%), both P < 0.001. Adverse events were more common with pentobarbital (4.5% vs. 0.9%; relative risk, 3.38%; 95% CI, 1.28%-9.45%). One etomidate and 2 pentobarbital patients experienced apnea. CONCLUSIONS Etomidate as given by emergency physicians was more effective and efficient than pentobarbital, with rare adverse events.
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Burton JH, Green SM. In reply. Ann Emerg Med 2007. [DOI: 10.1016/j.annemergmed.2007.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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McConachie I. Etomidate Controversies in Emergency Medicine. Ann Emerg Med 2007; 50:200-1; author reply 201-2. [PMID: 17643856 DOI: 10.1016/j.annemergmed.2006.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 12/19/2006] [Accepted: 12/19/2006] [Indexed: 10/23/2022]
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Green SM. Research Advances in Procedural Sedation and Analgesia. Ann Emerg Med 2007; 49:31-6. [PMID: 17083997 DOI: 10.1016/j.annemergmed.2006.09.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 09/11/2006] [Accepted: 09/20/2006] [Indexed: 11/18/2022]
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