Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory

Parental preferences for the procedural sedation of children in dentistry: a discrete choice experiment

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.

Comparison of the Quality of Recovery-15 score in patients undergoing oncoplastic breast-conserving surgery under monitored anesthesia care versus general anesthesia: a prospective quality improvement study

PURPOSE

Whether changing the institutional practice from general anesthesia (GA) to monitored anesthesia care (MAC) affects postoperative quality of recovery for oncoplastic breast-conserving surgery (BCS) is currently unknown. We designed this quasi-experimental study to evaluate a quality improvement (QI) initiative instituted in Edmonton, AB, Canada.

METHODS

We chose a prospective controlled cohort study design for this QI study, where patients underwent oncoplastic BCS under MAC in one hospital and BCS under GA at another hospital (control). A total of 125 patients undergoing surgery between May 2021 and February 2022 were enrolled. Exclusion criteria were male sex, total mastectomy, or age under 18. All other patients were included. The primary outcome was the change in Quality of Recovery-15 score at 24 hr compared with a preoperative baseline. Secondary outcomes included intra- and postoperative time profiles, perioperative analgesic and antiemetic use and length of hospital stay. Statistical analysis included a propensity score analysis to account for confounding variables.

RESULTS

Sixty-four patients received GA and 61 MAC. No enrolled patients were lost to follow up but two were excluded secondarily. No patients receiving MAC needed conversion to GA or unplanned airway management. Monitored anesthesia care was associated with superior outcomes for the primary outcome (β/SE[β], 3.31; 99.5% confidence interval, 0.45 to 6.17; P = 0.001) and most secondary outcomes, when accounting for confounding factors.

CONCLUSIONS

A care transformation initiative for patients undergoing oncoplastic BCS under MAC was associated with a higher quality recovery profile and shorter length of stay without any increase in perioperative or postoperative adverse events.

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BACKGROUND

Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult.

DISCUSSION

Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure.

CONCLUSION

There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Physician Self-Reported Practice Patterns: Midazolam for Minor Procedures in Pediatric Patients

Midazolam is frequently used as a single agent to provide minimal sedation (also called anxiolysis) when performing procedures in minor children. Published guidelines on the optimal use of intranasal (INM) and oral midazolam (POM) are lacking. The purpose of this study is to explore the self-reported physician practice related to midazolam use in facilitating minor procedures in children. We developed a survey that was approved by the Academy of Pediatrics Section on Emergency Medicine (APP-SOEM) and was then electronically distributed via its listserve. Questions were posed about the therapeutic and maximum dosing of INM and POM, consideration of Nothing-By-Mouth (NPO) status, use of cardiopulmonary monitors, as well as discharge criteria. There was a 47% (218/465) response rate. For therapeutic INM doses, 65% of responders used a dose range of 0.3 to 0.6 mg/kg, and 75% selected a maximum dose of 10 mg irrespective of the child's weight. About 20% of the responders selected a dosage range of 0.7 to 1 mg/kg for therapeutic POM dose, with 43% opting for a maximum dose of 20 mg irrespective of the child's weight. We observed a dichotomous variation in reported physician use of cardiopulmonary monitors; 42% never employ monitors, and the remainder used monitors some of the time. There was consensus on the NPO status and discharge criteria; 80% of physicians did not consider NPO status prior to midazolam use. The level of alertness was the most commonly selected discharge criterion. This nationwide survey of physicians indicates practice variation with midazolam dosing and cardiopulmonary monitor usage when performing minor procedures in children. Implementing practice guidelines, specifically for minimal sedation with mainstay agents such as midazolam, may standardize physician practice and improve overall patient care.

Paediatric procedural sedation and analgesia in a South African emergency centre: a single-centre, descriptive study

BACKGROUND

Procedural sedation and analgesia are considered a core competency in emergency medicine as patients present to the emergency centre on an unscheduled basis, often with complex complaints that necessitate emergent management. Previous evidence has consistently shown that procedural sedation and analgesia in the emergency centre in the paediatric population, even the very young, are safe if appropriate monitoring is performed and appropriate medications are used. The aim of the study was to describe the indications for procedural sedation and analgesia, the fasting status of paediatric patients undergoing procedural sedation and analgesia and the complications observed during procedural sedation and analgesia in the paediatric population at a single emergency centre in Cape Town, South Africa.

METHODS

A retrospective, descriptive study was conducted at Mitchells Plain Hospital, a district-level hospital situated in Mitchells Plain, Cape Town. All paediatric patients younger than 13 years of age who presented to the emergency centre and received procedural sedation and analgesia during the study period (December 2020-April 2021) were included in the study. Data was extracted from a standardised form, and simple descriptive statistics were used.

RESULTS

A total of 113 patients (69% male) were included: 13 infants (< 1 year of age), 47 young children (1-5 years of age) and 53 older children (5-13 years of age). There was only 1 (0.9%) complication documented, which was vomiting and did not require admission. The majority of patients received ketamine (96.5%). The standardised procedural sedation and analgesia form was completed in 49.1% of cases. Indications included burns debridement (11.5%), suturing (17.7%), fracture reduction (23.9%), lumbar punctures (31.9%) and others (15.0%). The indications for procedural sedation and analgesia varied between the different age groups. The majority of patients in this study did not have their fasting status documented (68.1%), and 18.6% were not appropriately fasted as per American Society of Anaesthesiology guidelines. Despite this, there was an extremely low rate of documented complications of 0.9%.

CONCLUSION

The study findings are in accordance with previous international literature reporting low complication rates. Although fasting status was unknown in the majority of patients, there was an extremely low rate of documented complications and no interventions required. Safe, timely procedural sedation and analgesia with minimal pain and unnecessary suffering can become the norm in emergency medicine practice in South Africa.

Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients

OBJECTIVES

There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS.

METHODS

We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment.

RESULTS

Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk."

CONCLUSIONS

The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.

Documentation of Procedural Sedation by Emergency Physicians

Introduction

Patients presenting to the emergency department (ED) frequently require procedural sedation and analgesia (PSA) to facilitate procedures, such as joint reduction. Proper documentation of screening demonstrates awareness of the necessity of presedation assessment. It is unknown if introducing emergency physicians (EPs) at the ED improves presedation assessment and documentation. In this study the differences in documentation of ED sedation and success rates for reduction of hip dislocations in the presence versus absence of EPs are described.

Methods

In this retrospective descriptive study, we analyzed data of patients presenting with a dislocated hip post total hip arthroplasty (THA) shortly after the introduction of EPs. The primary outcome measure was the presence of documentation of presedation assessment. Secondary outcomes were documentation of medication, vital signs, and success rate of hip reductions.

Results

In the two-year study period, 133 sedations for hip reductions were performed. Sixty-eight sedations were completed by an EP. The documentation of fasting status, airway screening, analgesia use, and vital signs was documented significantly more often when an EP was present (respectively 64.9%, 80.3%, 37.4%, and 72.7%, all P < 0.001). There was no difference in success rate of hip reductions between the groups.

Conclusion

PSA in the ED is associated with superior documentation of presedation assessment, medication, and vital signs when EPs are involved.

Regulatory Challenges to Emergency Medicine Procedural Sedation

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

Point-of-Care Ultrasound to Assess Gastric Content

Gastric ultrasound (US) is a growing modality within the point-of-care ultrasound (POCUS) field. It provides the ability to directly measure an individual patient's gastric content and has potential use as both a clinical and a research tool. Here, we review the historical development of current gastric US models and their clinical application within the field of general anesthesia, describe the US findings and technique for using POCUS to assess gastric content, and discuss the current and potential applications of gastric POCUS within the emergency department.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Future of paediatric sedation: towards a unified goal of improving practice

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

Procedural sedation and analgesia practices in the emergency centre

Introduction

Procedural sedation and analgesia allows the clinician to safely and efficiently administer sedation, analgesia, anxiolysis and sometimes amnesia to facilitate the performance of various procedures in the emergency centre. The aim of this study is to determine current sedation practices, common indications and major obstacles in selected emergency centres across Southern Gauteng, South Africa, with a view to improving future standards and practices.

Methods

This was a prospective, questionnaire based, cross-sectional interview of emergency centre managers or their designee of selected private-sector and public-sector hospitals in Southern Gauteng.

Results

Overall, 17 hospitals completed the interview, nine (53%) public-sector and eight (47%) private-sector hospitals, with 36% of hospitals being aligned to an academic institute. All hospitals performed procedural sedation in their emergency centre. Forty seven percent of managers had between ten and 19 years of clinical experience post internship. Although eleven (64.7%) managers achieved a postgraduate qualification in emergency medicine, only seven (41%) were accredited with a Fellowship of the College of Emergency Medicine (FCEM) qualification and only three (17.7%) centres employed three or more specialists. The majority of centres (52.3%) performed between ten and 30 procedures per month requiring sedation. Staff training in the practice of procedural sedation was mostly obtained internally (52.9%), from in-house seniors. Essential drugs, procedure monitors, resuscitation equipment and protocols were all available in 70.6% of centres.

Conclusion

Although the safe practice and awareness of procedural sedation and analgesia in both public-sector and private-sector emergency centres in Southern Gauteng appears to be on the increase, there is still a need to enhance practitioner training and promote awareness of current local and international trends, protocols and recommendations.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review

Background

Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.

Methods

We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.

Results

Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.

Conclusions

This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

Procedural sedation of elderly patients by emergency physicians: a safety analysis of 740 patients

BACKGROUND

The elderly are perceived as a high-risk group for procedural sedation. Concern exists regarding the safety of sedation of this patient group by emergency physicians, particularly when using propofol.

METHODS

We analysed prospectively collected data on patients aged 75 yr or older undergoing sedation between October 2006 and March 2017 in the emergency department of a single centre. We used the World Society of Intravenous Anaesthesia International Sedation Task Force adverse event tool, stratifying identified adverse events according to consensus agreement.

RESULTS

Of 740 consecutive patients (median age 84 yr), 571 patients received propofol, 142 morphine and midazolam, and 27 other agents. We identified 19 sentinel events: 2 cases of hypoxia, 10 of apnoea (without hypoxaemia), 5 of hypotension, and 2 of both hypoxaemia and hypotension. We also identified 30 moderate, 41 minor, and 7 minimal risk adverse events. There were no adverse outcomes.

CONCLUSIONS

We observed safe sedation practice in this high-risk group of patients in this department. A sentinel adverse event rate of 2.6% including a hypoxaemia rate of 0.5%, with no adverse outcomes sets a benchmark for elderly sedation. We recommend quality pre-oxygenation, an initial propofol bolus of no more than 0.5 mg kg^-1, and a robust training and governance framework.

A comparison of ketamine + midazolam to propofol for procedural sedation for lumbar puncture in pediatric oncology by nonanesthesiologists-a randomized comparative trial

BACKGROUND

Both ketamine-midazolam and propofol are frequently used in pediatric oncology units for procedural sedation. However, there are no prospective, randomized comparative trials (RCT) comparing the two groups when the procedure is performed by nonanesthesiologists.

OBJECTIVE

To compare ketamine + midazolam (group A) and propofol (group B) as sedative agents for intrathecal chemotherapy with regard to efficacy, side effects, time to induction, time to recovery, and smoothness of recovery.

METHODS

A partially-blinded RCT was conducted between August 2015 and March 2017 after gaining institutional ethics committee approval. Children aged 1-12 years requiring intravenous sedation for intrathecal chemotherapy were included. Patients were allocated to two treatment arms using computer-generated randomization tables, after obtaining written consent. The initial doses used were: ketamine 2 mg/kg, midazolam 0.2 mg/kg, and propofol 2.5 mg/kg, as per standard recommendations. The patient, parents, and person analyzing the data were blinded. Time to sedation, dose required, depth of sedation, vital parameters, time and smoothness of recovery, and emergence phenomena were documented.

RESULTS

We enrolled 152 patients (76 each in group A and B). Nine patients had a failure of sedation (all in group B). Mean time to sedation and recovery was shorter in group B (P < 0.001). Transient drop in saturation was more frequent in group B, without statistical significance (P = 0.174). Mean depth of sedation was greater in group A (P < 0.001). Emergence symptoms were more frequently experienced in group A (P < 0.001).

CONCLUSIONS

Ketamine-midazolam combination is safer and more effective. Propofol is faster in onset and recovery, and has smoother emergence with poor efficacy at recommended initial doses.

Shortened preprocedural fasting in the pediatric emergency department

BACKGROUND

There is no evidence of an association between fasting time and the incidence of adverse events during procedural sedation and analgesia. Pediatric and adult emergency medicine guidelines support avoiding delaying procedures based on fasting time. General pediatric guidelines outside emergent care settings continue to be vague and do not support a set fasting period for urgent and emergent procedures.

OBJECTIVE

To describe shortened preprocedural fasting and vomiting event rates during the implementation of a shortened fasting protocol.

METHODS

This was a prospective study of patients undergoing procedural sedation and analgesia (PSA) in an urban, tertiary care children's hospital emergency center from March 2010-February 2012. All consecutive patients had documentation of preprocedural fasting time and adverse events recorded on a standardized data collection form.

RESULTS

PSA occurred in 2426 patients with fasting data available for 2188 (90.2%); 1472 were fasted ≥6 h for solids and 716 patients were in the shortened fasting group (<6 h). There is no evidence of an association between emesis at any time and shortened fasting time unadjusted (OR = 1.18 (95% CI 0.75-1.84) or adjusted for known risk factors including age >12 years, initial ketamine dose >2.5 mg/kg or total dose >5.0 mg/kg (OR = 1.14 (95% CI 0.74-1.75).

CONCLUSION

Analysis of a large prospective cohort study failed to find evidence of an association between emesis and shortened fasting time upon implementation of a shortened fasting protocol for procedural sedation and analgesia.

Protocol for a double blind, randomised placebo-controlled trial using ondansetron to reduce vomiting in children receiving intranasal fentanyl and inhaled nitrous oxide for procedural sedation in the emergency department (the FON trial)

INTRODUCTION

Intranasal fentanyl and nitrous oxide (N₂O) can be combined to create a non-parenteral procedural sedation regimen for children in the paediatric emergency department. This combination of intranasal fentanyl and N₂O provides effective pain relief for more painful procedures, but is associated with a higher incidence of vomiting than N₂O alone. Our aim is to assess whether ondansetron used preventatively reduces the incidence of vomiting associated with intranasal fentanyl and N₂O for procedural sedation compared with placebo.

METHODS AND ANALYSIS

This study is a double blind, randomised placebo-controlled superiority trial. This is a single-centre trial of 442 children aged 3-18 years presenting to a tertiary care Paediatric Emergency Department at the Royal Children's Hospital (RCH), Melbourne, Australia, requiring procedural sedation with intranasal fentanyl and N₂O. After written consent, eligible participants are randomised to receive ondansetron or placebo along with intranasal fentanyl, 30-60 min prior to N₂O administration. The primary outcome is vomiting during or up to 1 hour after procedural sedation. Secondary outcomes include: number of vomits and retching during procedural sedation, vomiting 1-24 hours after procedural sedation, procedural sedation duration and associated adverse events, procedure abandonment, parental satisfaction and the value parents place on the prevention of vomiting. This trial will allow refinement of a non-parenteral sedation regimen for children requiring painful procedures.

ETHICS AND DISSEMINATION

This study has ethics approval at the RCH, Melbourne, protocol number 36174. The results from this trial will be submitted to conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12616001213437).

Anesthesia for a Patient With Excessive Supragastric Belching

Excessive supragastric belching is rarely described in the anesthesia literature. Anesthesia planning of a 26-year-old patient with excessive supragastric belching, history of superior mesenteric artery syndrome (SMAS), and dental anxiety requires preoperative assessment. This case report outlines the anesthetic considerations and the management to facilitate comprehensive dentistry. Key anesthetic considerations include anxiolysis, aspiration risk reduction, total intravenous anesthesia (TIVA), and postoperative nausea and vomiting (PONV) prophylaxis.

Classification of hospital admissions into emergency and elective care: a machine learning approach

Rising admissions from emergency departments (EDs) to hospitals are a primary concern for many healthcare systems. The issue of how to differentiate urgent admissions from non-urgent or even elective admissions is crucial. We aim to develop a model for classifying inpatient admissions based on a patient's primary diagnosis as either emergency care or elective care and predicting urgency as a numerical value. We use supervised machine learning techniques and train the model with physician-expert judgments. Our model is accurate (96%) and has a high area under the ROC curve (>.99). We provide the first comprehensive classification and urgency categorization for inpatient emergency and elective care. This model assigns urgency values to every relevant diagnosis in the ICD catalog, and these values are easily applicable to existing hospital data. Our findings may provide a basis for policy makers to create incentives for hospitals to reduce the number of inappropriate ED admissions.

[Preparation of sedation-analgesia procedures in spanish paediatric emergency departments: A descriptive study]

INTRODUCTION

The objective of this study was to describe the current practice regarding the preparation of the sedation-analgesia (SA) procedures performed in the paediatric emergency centres in Spain.

MATERIAL AND METHODS

A multicentre, observational and prospective analytical study was carried out on the SA procedures that were performed on children under 18 years-old in 18 paediatric emergency departments between February 2015 and January 2016.

RESULTS

A total of 658 SA procedures were registered in 18 hospitals of Spain, most of them to children older than 24 months. The type of the procedure was: simple analgesia in 57 (8.6%), sedation in 44 (6.7%), SA for a not very painful procedure in 275 (41.8%), and SA for a very painful procedure in 282 (42.9%). Informed consent was requested in 98.6% of the cases. The written form was more frequently preferred in the group of patients that received SA for a very painful procedure (76.6%) in comparison to a painful procedure or to simple analgesia (62.9% and 54.4%, respectively, P<.001). The staff that most frequently performed the SA procedures were the paediatricians of the emergency departments (64.3%), followed by Paediatrics Residents (30.7%). The most frequent reasons for the SA were traumatological (35.9%) and surgical (28.4%). Fasting was observed in 81% of the cases. More than two-thirds (67.3%, n=480) children were monitored, the majority (95.8%) of them using pulse oximetry. The pharmacological strategy used was the administration of one drug in 443 (67.3%) of the cases, mostly nitrous oxide, and a combination of drugs in 215 (32.7%), especially midazolam/ketamine (46.9%).

CONCLUSION

The majority of the SA procedures analysed in this study have been carried out correctly and prepared in accordance with the current guidelines.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Paediatric procedural sedation within the emergency department

Procedural sedation and analgesia in children requires the use of non-pharmacological and pharmacological approaches to facilitate the management of painful procedures. The development of skills in such techniques has mirrored the development of paediatric emergency medicine as a subspecialty. Governance, education and credentialing must facilitate safe sedation practice, using a structured approach, as sedating children in the busy environment of an emergency department is not without risk. Emergency clinicians, patients and caregivers all have a role to play in developing a safe, effective sedation plan.

Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room

Background

Studies that have attempted to define the incidence of aspiration or pulmonary complications during sedation/anesthesia of children with respect to nil per os (NPO) status or other factors are difficult because of the relatively infrequent rate of these complications.

Methods

The Pediatric Sedation Research Consortium consists of 42 participating institutions with elective sedation services that submit consecutive patient encounter information to a central database. The authors evaluated aspiration episodes and a combined outcome of major adverse events (defined as aspiration, death, cardiac arrest, or unplanned hospital admission) with respect to NPO status, American Society of Anesthesiologists physical status, age, propofol use, procedure types, and urgency of the procedure.

Results

A total of 139,142 procedural sedation/anesthesia encounters were collected between September 2, 2007 and November 9, 2011. There were 0 deaths, 10 aspirations, and 75 major complications. NPO status was known for 107,947 patients, of whom 25,401 (23.5 %) were not NPO. Aspiration occurred in 8 of 82,546 (0.97 events per 10,000) versus 2 of 25,401 (0.79 events per 10,000) patients who were NPO and not NPO, respectively (odds ratio, 0.81; 95% CI, 0.08 to 4.08; P = 0.79). Major complications occurred in 46 of 82,546 (5.57 events per 10,000) versus 15 of 25,401 (5.91 events per 10,000) (odds ratio, 1.06; 95% CI, 0.55 to 1.93; P = 0.88). Multivariate adjustment did not appreciably impact the effect of NPO status.

Conclusions

The analysis suggests that aspiration is uncommon. NPO status for liquids and solids is not an independent predictor of major complications or aspiration in this sedation/anesthesia data set.

Propofol Increases Host Susceptibility to Microbial Infection by Reducing Subpopulations of Mature Immune Effector Cells at Sites of Infection

Anesthetics are known to modulate host immune responses, but separating the variables of surgery from anesthesia when analyzing hospital acquired infections is often difficult. Here, the bacterial pathogen Listeria monocytogenes (Lm) was used to assess the impact of the common anesthetic propofol on host susceptibility to infection. Brief sedation of mice with physiologically relevant concentrations of propofol increased bacterial burdens in target organs by more than 10,000-fold relative to infected control animals. The adverse effects of propofol sedation on immune clearance of Lm persisted after recovery from sedation, as animals given the drug remained susceptible to infection for days following anesthesia. In contrast to propofol, sedation with alternative anesthetics such as ketamine/xylazine or pentobarbital did not increase susceptibility to systemic Lm infection. Propofol altered systemic cytokine and chemokine expression during infection, and prevented effective bacterial clearance by inhibiting the recruitment and/or activity of immune effector cells at sites of infection. Propofol exposure induced a marked reduction in marginal zone macrophages in the spleens of Lm infected mice, resulting in bacterial dissemination into deep tissue. Propofol also significantly increased mouse kidney abscess formation following infection with the common nosocomial pathogen Staphylococcus aureus. Taken together, these data indicate that even brief exposure to propofol severely compromises host resistance to microbial infection for days after recovery from sedation.

Procedural sedation and analgesia in the emergency department

Procedural sedation and analgesia (PSA) is a core part of modern emergency department (ED) care allowing the rapid provision of important procedures. The safe delivery of a PSA service requires an appropriately staffed and equipped environment backed up by an ongoing system of training, audit and review. Topics covered in this review include: the evidence relating to the agents used; patient care before, during and after the procedure; the outcomes of ED PSA; and, the special considerations relating to PSA in children.

Laryngospasm With Apparent Aspiration During Sedation With Nitrous Oxide

Nitrous oxide and oxygen mixture has become increasingly popular for the procedural sedation and analgesia of children in the emergency department. In general, nitrous oxide is regarded as a very safe agent according to large case series. We report a case of single-agent nitrous oxide sedation of a child, complicated by laryngospasm and radiographically confirmed bilateral upper lobe pulmonary opacities. Although rarely reported with parenteral sedative agents, laryngospasm and apparent aspiration has not been previously reported in isolated nitrous oxide sedation. This case highlights that, similar to other sedative agents, nitrous oxide administration also needs to be conducted by staff and in settings in which airway emergencies can be appropriately managed.

Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging

This prospective observational pilot study evaluated the aerosolized intranasal route for dexmedetomidine as a safe, effective, and efficient option for infant and pediatric sedation for computed tomography imaging. The mean time to sedation was 13.4 minutes, with excellent image quality, no failed sedations, or significant adverse events.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov: NCT01900405.

Pediatric sedation

Pediatric sedation is an evolving field performed by an extensive list of specialties. Well-defined sedation systems within pediatric facilities are paramount to providing consistent, safe sedation. Pediatric sedation providers should be trained in the principles and practice of sedation, which include patient selection, pre-sedation assessment to determine risks during sedation, selection of optimal sedation medication, monitoring requirements, and post-sedation care. Training, credentialing, and continuing sedation education must be incorporated into sedation systems to verify and monitor the practice of safe sedation. Pediatric hospitalists represent a group of providers with extensive pediatric knowledge and skills who can safely provide pediatric sedation.

Does ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective, randomised, open, controlled study

AIM

Ketamine is one of the most commonly used sedatives for facilitating painful procedures for paediatric patients in the emergency department (ED). However, the use of ketamine is associated with a common, though not serious, adverse event usually called ketamine-associated vomiting (KAV). The purpose of this study is to evaluate the anti-emetic effect of adjunctive ondansetron in paediatric patients receiving ketamine sedation in the ED.

METHODS

We conducted a prospective, randomised, open, controlled study in children from 1 to 18 years of age who had undergone intramuscular ketamine sedation in the ED. The patients were randomised into two groups: a ketamine-only group and a ketamine/ondansetron group. The patients in the first group received ketamine alone, while those in the second group received ketamine with oral ondansetron. The incidence of KAV was estimated in the ED and after discharge, and the time to resumption of a normal diet was measured after sedation.

RESULTS

A total of 237 patients were analysed. The incidence of KAV was 29.7% in the ketamine-only group and 25.2% in the ketamine/ondansetron group (P = 0.47). After administration of ketamine, the mean time to resumption of a normal diet was 8 h 54 min in the ketamine-only group and 8 h 39 min in the ketamine/ondansetron group (P = 0.67).

CONCLUSIONS

A relatively high rate of KAV (29.7%) was observed, and the time to resumption of a normal diet after ketamine sedation was rather long. It turned out that, however, the adjunctive administration of ondansetron did not effectively reduce the incidence of KAV.

Efficacy of simethicone and N-acetylcysteine as premedication in improving visibility during upper endoscopy

BACKGROUND

Simethicone and N-acetylcysteine have been widely used in improving endoscopic visibility. However, the optimal dose, volume, and dosing time for the premedication regimen are still unclear.

AIM

Our aim was to assess the efficacy of premedication in improving endoscopic visibility and determine the contributions of dose, volume, and premedication time.

METHODS

A total of 1849 patients were prospectively treated in three groups: group A: 100-mg simethicone suspension in 5 mL water; group B: 100-mg simethicone suspension in 100 mL water; and group C: 100-mg simethicone suspension in 100 mL water containing 200 mg N-acetylcysteine. Mucosa visibility was assessed at seven sites of upper gastrointestinal tract. The sum of scores was considered as total mucosal visibility score (TMVS).

RESULTS

The upper body of stomach had the worst visibility score for all groups. TMVS of groups B and C were significantly lower than those of group A. Group C had a significantly fewer patients requiring endoscopic flushing than groups A and B. The TMVS for groups B and C were significantly lower than for group A within 30 min of beginning premedication. Beyond 30 min of premedication, there was no significant difference in the TMVS among groups.

CONCLUSIONS

Premedication using 100 mg simethicone in 100 mL of water improves endoscopic visibility. Addition of N-acetylcysteine to simethicone in 100 mL of water reduces the need for endoscopic flushing. For patients unable to tolerate a large fluid volume, a 5-mL simethicone suspension administered more than 30 min prior to upper endoscopy is suggested.

An update on pediatric hospital-based sedation

PURPOSE OF REVIEW

The need for sedation for procedures performed outside the operating room has increased dramatically, and pediatric procedural sedation (PPS) is increasingly performed by practitioners who are not anesthesiologists. With 'sedationists' emerging from various specialties, there are differences in practice and guidelines with regards to presedation assessment, targeted depths of sedation, monitoring requirements, and the training required. Our aim is to identify some of the recent advances in PPS and to describe progress towards greater standardization of practice.

RECENT FINDINGS

Several studies report attempts to optimize the efficacy of specific pharmaceuticals used in PPS. Ketamine, a dissociative agent, functions uniquely and requires its own sedation practice guidelines. Utilizing less invasive administration of sedation via transmucosal and inhaled routes is gaining popularity. Additionally, replacing subjective measurement of depths of the sedation continuum and the nonstandardized definitions of adverse events with alternatives based on physiological parameters and/or required rescue interventions is underway. Finally, the use of presedation family-centered counseling and adjuncts that provide visual and auditory distraction are enhancing pharmaceutical methods.

SUMMARY

Further multispecialty collaboration and formation of greater consensus with regards to sedation practice are essential to the development of universal guidelines that optimize patient care.

Emergency department diagnosis and treatment of traumatic hip dislocations in children under the age of 7 years: a 10-year review

BACKGROUND AND AIMS

Traumatic hip dislocations (THD) are uncommon in children. They constitute true emergencies because unrecognised THD leads to avascular necrosis (AVN) of the femoral head. This review presents the evidence for best practice for the diagnosis and treatment of THD in the emergency department (ED) of children under the age of 7 years.

METHODS

Searches for the period 2002-2012 were performed in PubMED, Cochrane database, EMBASE, Google Scholar and hand search.

RESULTS

Twenty-five case reports and case series articles were identified, 53 described children with acute and 23 with neglected THD. Overall, 42 (55%) were male and 73 (96%) sustained a posterior dislocation. Forty-eight (63%) had THD following a low-energy trauma. Eight (11%) reported associated injuries. Twenty-one (39.6%) acute dislocations were reduced in the ED without complications. AVN was identified in 3 (5.7%) children, who underwent reduction ≥10 h after dislocation. Redislocation occurred in 3 (5.7%) children and coxa magna developed in 5 (9.4%). Long-term functional outcome of 42 patients resulted in full recovery, and it was fair to good in 3 (including 2 children with AVN). All neglected cases (≥4 weeks from trauma) needed open reduction in the operating room (OR). AVN was identified in 11 children (47.8%). Hip function was completely recovered in 16 (70%) patients.

CONCLUSIONS

THD in this age group mainly occurs with low-energy trauma and leads to posterior dislocations. Urgent closed reduction of acute cases are done in the OR, or the ED. ED reduction appears to be safe. Neglected THDs need open reduction.

Sedation and analgesia for the pediatric trauma patients

The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.