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Couloures KG, Anderson MP, Hill CL, Chen A, Buckmaster MA. Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk. J Pediatr Intensive Care 2024; 13:201-208. [PMID: 38919693 PMCID: PMC11196135 DOI: 10.1055/s-0042-1745831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/21/2022] [Indexed: 10/18/2022] Open
Abstract
This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant β -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.
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Affiliation(s)
- Kevin G. Couloures
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
| | - Michael P. Anderson
- Department of Biostatistics, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - C. L. Hill
- Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Allshine Chen
- Department of Biostatistics, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - Mark A. Buckmaster
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Mills LA, Kuntz HM. Adverse Events in Patients Aged 90 Days or Younger Receiving Ketamine in the Emergency Department. Pediatr Emerg Care 2024:00006565-990000000-00470. [PMID: 38776429 DOI: 10.1097/pec.0000000000003218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES The aim of this study was to identify the incidence of adverse events of ketamine administration in the pediatric emergency department in patients aged 90 days or younger in order to demonstrate the safety and efficacy of administration in this patient population. METHODS An 8-year retrospective chart review of patients aged 90 days or younger who received ketamine in the pediatric emergency department was conducted. All patients who met the age criteria were included in this study. Identified routes of ketamine administration included oral, intramuscular, and intravenous. RESULTS Fourteen patients were identified who met the inclusion criteria and were included in the final analysis. The median age was 45 days old. Indications for ketamine administration included 7 cases for procedural sedation, 5 cases for RSI, and 2 cases for postintubation sedation. The average dose amount (mg/kg) of ketamine administered was 10, 4.43, and 1.59 for oral, intramuscular, and intravenous routes, respectively. Of the 14 patients, 1 patient was identified to have an adverse event to ketamine administration. A transient desaturation and bradycardic event due to laryngospasm was observed during laryngoscopy performed for RSI that was resolved with administration of anticholinergics and paralytics as well as successful intubation and ventilation. CONCLUSIONS In this study, 1 patient suffered an adverse event due to laryngospasm during intubation. In the pediatric population, the incidence of adverse events of ketamine administration has been found to be variable in the current literature, ranging from 0.71% to 7.26%. In our study, an adverse event occurred in 1 out of 14 administrations (7.1%). The incidence of adverse events associated with ketamine administration in our patients aged 90 days or less appeared to be similar to that reported in the general pediatric population.
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Erumbala G, Anzar S, Deiratany S, Blackie B, Powell C, Al Ansari K. Procedural sedation programme minimising adverse events: a 3-year experience from a tertiary paediatric emergency department. Arch Dis Child 2024; 109:88-92. [PMID: 37775146 DOI: 10.1136/archdischild-2023-326021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION A well-developed procedural sedation programme in the paediatric emergency department can minimise adverse events. We examined how adherence to current best evidence ensures safe delivery of paediatric sedation in a newly established tertiary paediatric hospital. METHODS Our sedation service uses a robust provider training and privileging system, standardised policy and procedures and rigorous data collection all within an evidence-based clinical governance process. We examined sedation data from the first 3 years of operation. RESULTS From July 2018 to May 2022, ketamine was used in 3388 of the 3405 sedations. The mean age of sedated children was 5.5 years (range 6 months to 17.8 years) and common indications were closed reduction of fractures and laceration repairs. A total of 148 (4.37%, 95% CI 3.68% to 5.06%) adverse events were documented, including 88 (2.59%, 95% CI 2.06% to 3.13%) cases of vomiting, 50 (1.48%, 95% CI 1.07% to 1.88%) cases related to airway and breathing with 40 (1.18%, 95% CI 0.82% to 1.54%) cases of oxygen desaturation, 6 (0.18%, 95% CI 0.04% to 0.32%) cases of laryngospasm, 4 (0.12%, 95% CI 0% to 0.23%) cases of apnoea. CONCLUSION This study presents a large single-centre dataset on the use of intravenous ketamine in paediatric procedural sedation. Adhering to international standards and benchmarks for provider skills and training, drug administration and monitoring facilities, with a strict clinical governance process, optimizes patient safety.
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Affiliation(s)
- Gokul Erumbala
- Department of Emergency Medicine, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Sabu Anzar
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
| | | | - Barbara Blackie
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Medical College, Weill Cornell Medcial College, Doha, Qatar
| | - Colin Powell
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Khalid Al Ansari
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Medical College, Weill Cornell Medcial College, Doha, Qatar
- Qatar University, Education City, Doha, Qatar
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Sharif S, Munshi L, Burry L, Mehta S, Gray S, Chaudhuri D, Duffett M, Siemieniuk RA, Rochwerg B. Ketamine sedation in the intensive care unit: a survey of Canadian intensivists. Can J Anaesth 2024; 71:118-126. [PMID: 37884773 DOI: 10.1007/s12630-023-02608-x] [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: 02/19/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE We sought to understand the beliefs and practices of Canadian intensivists regarding their use of ketamine as a sedative in critically ill patients and to gauge their interest in a randomized controlled trial (RCT) examining its use in the intensive care unit (ICU). METHODS We designed and validated an electronic self-administered survey examining the use of ketamine as a sedative infusion for ICU patients. We surveyed 400 physician members of the Canadian Critical Care Society (CCCS) via email between February and April 2022 and sent three reminders at two-week intervals. The survey was redistributed in January 2023 to improve the response rate. RESULTS We received 87/400 (22%) completed questionnaires. Most respondents reported they rarely use ketamine as a continuous infusion for sedation or analgesia in the ICU (52/87, 58%). Physicians reported the following conditions would make them more likely to use ketamine: asthma exacerbation (73/87, 82%), tolerance to opioids (68/87, 77%), status epilepticus (44/87, 50%), and severe acute respiratory distress syndrome (33/87, 38%). Concern for side-effects that limited respondents' use of ketamine include adverse psychotropic effects (61/87, 69%) and delirium (47/87, 53%). The majority of respondents agreed there is need for an RCT to evaluate ketamine as a sedative infusion in the ICU (62/87, 71%). CONCLUSION This survey of Canadian intensivists illustrates that use of ketamine as a continuous infusion for sedation is limited, and is at least partly driven by concerns of adverse psychotropic effects. Canadian physicians endorse the need for a trial investigating the safety and efficacy of ketamine as a sedative for critically ill patients.
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Affiliation(s)
- Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Hamilton General Hospital, 237 Barton St East, 2nd Floor McMaster Wing, Room 252, Hamilton, ON, L8L 2X2, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Sara Gray
- Division of Emergency Medicine, and the Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Network, University of Toronto, Toronto, ON, Canada
| | - Dipayan Chaudhuri
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Choi K, Yu W. The Difference in Time to Discharge Between Daytime and Nighttime Administration of Ketamine in Children. Pediatr Emerg Care 2023; 39:773-775. [PMID: 37665968 DOI: 10.1097/pec.0000000000003042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVE The objective of this study was to compare the time to discharge between daytime and nighttime ketamine administration to children undergoing primary facial repair in the emergency department (ED). METHODS This retrospective, cross-sectional study was performed in a sample of children aged younger than 18 years and requiring sedation for primary facial repair in 2019. Children who received ketamine for reasons other than facial repair were excluded. All patients were initially injected with 4 mg/kg of ketamine intramuscularly and additionally injected if sedation failed. The time of injection and awakening were recorded in the electronic medical record system by nurses in charge, and the level of wakefulness was determined with a postanesthesia discharge scoring system administered by physicians. RESULTS A total of 562 cases of ketamine administration were divided into 2 groups: daytime and nighttime. We defined daytime and nighttime as 8 a . m . and 8 p . m ./sunrise and sunset, respectively. They found that there were no significant differences between 2 groups in each standard (95% confidence interval, -4.55-4.55; P = 0.877 and 95% confidence interval, -6.41-2.41; P = 0.487, respectively). CONCLUSIONS The findings of the study suggest that the time of ketamine injection has no relationship to duration of sedation for primary facial repair in children.
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Affiliation(s)
- Kang Choi
- From the Department of Emergency Medicine, Bundang Jaesaeng General Hospital, Seongnam-si, Republic of Korea
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Schep LJ, Slaughter RJ, Watts M, Mackenzie E, Gee P. The clinical toxicology of ketamine. Clin Toxicol (Phila) 2023:1-14. [PMID: 37267048 DOI: 10.1080/15563650.2023.2212125] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Ketamine is a pharmaceutical drug possessing both analgesic and anaesthetic properties. As an anaesthetic, it induces anaesthesia by producing analgesia with a state of altered consciousness while maintaining airway tone, respiratory drive, and hemodynamic stability. At lower doses, it has psychoactive properties and has gained popularity as a recreational drug. OBJECTIVES To review the epidemiology, mechanisms of toxicity, pharmacokinetics, clinical features, diagnosis and management of ketamine toxicity. METHODS Both OVID MEDLINE (January 1950-April 2023) and Web of Science (1900-April 2023) databases were searched using the term "ketamine" in combination with the keywords "pharmacokinetics", "kinetics", "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". Furthermore, bibliographies of identified articles were screened for additional relevant studies. These searches produced 5,268 non-duplicate citations; 185 articles (case reports, case series, pharmacokinetic studies, animal studies pertinent to pharmacology, and reviews) were considered relevant. Those excluded were other animal investigations, therapeutic human clinical investigations, commentaries, editorials, cases with no clinical relevance and post-mortem investigations. EPIDEMIOLOGY Following its introduction into medical practice in the early 1970s, ketamine has become a popular recreational drug. Its use has become associated with the dance culture, electronic and dubstep dance events. MECHANISM OF ACTION Ketamine acts primarily as a non-competitive antagonist on the glutamate N-methyl-D-aspartate receptor, causing the loss of responsiveness that is associated with clinical ketamine dissociative anaesthesia. PHARMACOKINETICS Absorption of ketamine is rapid though the rate of uptake and bioavailability is determined by the route of exposure. Ketamine is metabolized extensively in the liver. Initially, both isomers are metabolized to their major active metabolite, norketamine, by CYP2B6, CYP3A4 and CYP2C9 isoforms. The hydroxylation of the cyclohexan-1-one ring of norketamine to the three positional isomers of hydroxynorketamine occurs by CYP2B6 and CYP2A6. The dehydronorketamine metabolite occurs either by direct dehydrogenation from norketamine via CYP2B6 metabolism or non-enzymatic dehydration of hydroxynorketamine. Norketamine, the dehydronorketamine isomers, and hydroxynorketamine have pharmacological activity. The elimination of ketamine is primarily by the kidneys, though unchanged ketamine accounts for only a small percentage in the urine. The half-life of ketamine in humans is between 1.5 and 5 h. CLINICAL FEATURES Acute adverse effects following recreational use are diverse and can include impaired consciousness, dizziness, irrational behaviour, hallucinations, abdominal pain and vomiting. Chronic use can result in impaired verbal information processing, cystitis and cholangiopathy. DIAGNOSIS The diagnosis of acute ketamine intoxication is typically made on the basis of the patient's history, clinical features, such as vomiting, sialorrhea, or laryngospasm, along with neuropsychiatric features. Chronic effects of ketamine toxicity can result in cholangiopathy and cystitis, which can be confirmed by endoscopic retrograde cholangiopancreatography and cystoscopy, respectively. MANAGEMENT Treatment of acute clinical toxicity is predominantly supportive with empiric management of specific adverse effects. Benzodiazepines are recommended as initial treatment to reduce agitation, excess neuromuscular activity and blood pressure. Management of cystitis is multidisciplinary and multi-tiered, following a stepwise approach of pharmacotherapy and surgery. Management of cholangiopathy may require pain management and, where necessary, biliary stenting to alleviate obstructions. Chronic effects of ketamine toxicity are typically reversible, with management focusing on abstinence. CONCLUSIONS Ketamine is a dissociative drug employed predominantly in emergency medicine; it has also become popular as a recreational drug. Its recreational use can result in acute neuropsychiatric effects, whereas chronic use can result in cystitis and cholangiopathy.
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Affiliation(s)
- Leo J Schep
- Professional Practice Fellow, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | | | - Martin Watts
- Emergency Department, Southland Hospital, Invercargill, New Zealand
| | - Elliot Mackenzie
- Obstetrics and Gynaecology, Women and Childrens Health. Dunedin Public Hospital, Dunedin, New Zealand
| | - Paul Gee
- National Poisons Centre, University of Otago, Dunedin, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Zaki HA, Ibrahim T, Osman A, Elnabawy WA, Gebril A, Hamdi AH, Mohamed EH. Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis. Cureus 2023; 15:e36742. [PMID: 37123736 PMCID: PMC10132230 DOI: 10.7759/cureus.36742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Nucci A, Sforzi I, Morley-Fletcher A, Saffirio C, Bussolin L, Masi S, Weinstock P, De Luca M. Quality Improvement Initiative Using Blended In Situ Simulation Training on Procedural Sedation and Analgesia in a Pediatric Emergency Department: Better Patient Care at Lower Costs. Simul Healthc 2022; 17:299-307. [PMID: 34966127 DOI: 10.1097/sih.0000000000000626] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is evidence in the literature for high-fidelity in situ simulation training programs being an effective modality for physicians training. This quality initiative focused on implementation of the procedural sedation and analgesia (PSA) in our pediatric emergency department (PED). The primary outcomes of this study were to evaluate the impact of blended in situ simulation training (BST) program on PSA for closed forearm fracture reduction in the PED and to assess its cost-effectiveness. The secondary outcomes were to estimate this change on PSA's clinical efficacy and safety. METHODS Between 2014 and 2018, a single-center, quasi-experimental, uncontrolled before and after study on forearm fracture reduction management was conducted. To assess the impact of our BST-PSA course, both historical control and prospective analyses were performed. Statistical significance was based on Fisher exact test or Pearson χ 2 test. RESULTS Eight hundred eighty-five children met inclusion criteria. A significant difference in the number of PSAs performed in the PED, before and after BST, was found (37% vs. 85.3%, P < 0.001). Furthermore, a reduction in the number of hospitalizations for closed fracture reduction was measured (68.2% vs. 31.8%, P < 0.001). The overall cost savings from the BST-enabled increase in PSAs carried out in the PED was €370,714 ($440,838) with a return on investment of 64:1. No significant increase of PSA-related adverse events was found, and no serious adverse events occurred. CONCLUSIONS Findings provide evidence of the benefits of implementing BST to enable PSA use in the PED, with an improved patient flow and significant cost savings from avoiding unnecessary hospitalizations.
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Affiliation(s)
- Alessia Nucci
- From the Emergency Department, Simulation Program, Meyer Children's Hospital, Florence, Italy (A.N.); Emergency Department, Simulation Program, Pediatric Trauma Center, Meyer Children's Hospital, Florence, Italy (I.S., C.S.); Pediatric Simulation Program, South Shore Hospital, Faculty Simulator Program (SIMPeds), Boston Children's Hospital, Boston, Massachusetts (A.M.-F.); Trauma Center, Neuro-anesthesia and Pediatric Neuro-intensive Unit Department, Meyer Children's Hospital, Florence, Italy (L.B.); Director (Trauma Center) Emergency Department, Meyer Children's Hospital, Florence, Italy (S.M.); Department of Anesthesiology, Critical Care, and Pain Medicine, Simulator Program (SIMPeds), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (P.W.); and Simulation and Risk Management, Meyer Children's Hospital, Florence, Italy (D.L.M.)
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Kolevzon A, Levy T, Barkley S, Bedrosian-Sermone S, Davis M, Foss-Feig J, Halpern D, Keller K, Kostic A, Layton C, Lee R, Lerman B, Might M, Sandin S, Siper PM, Sloofman LG, Walker H, Zweifach J, Buxbaum JD. An open-label study evaluating the safety, behavioral, and electrophysiological outcomes of low-dose ketamine in children with ADNP syndrome. HGG ADVANCES 2022; 3:100138. [PMID: 36119806 PMCID: PMC9471202 DOI: 10.1016/j.xhgg.2022.100138] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Activity-dependent neuroprotective protein (ADNP) syndrome is a rare genetic condition associated with intellectual disability and autism spectrum disorder. Preclinical evidence suggests that low-dose ketamine may induce expression of ADNP and that neuroprotective effects of ketamine may be mediated by ADNP. The goal of the proposed research was to evaluate the safety, tolerability, and behavioral outcomes of low-dose ketamine in children with ADNP syndrome. We also sought to explore the feasibility of using electrophysiological markers of auditory steady-state response and computerized eye tracking to assess biomarker sensitivity to treatment. This study utilized a single-dose (0.5 mg/kg), open-label design, with ketamine infused intravenously over 40 min. Ten children with ADNP syndrome ages 6 to 12 years were enrolled. Ketamine was generally well tolerated, and there were no serious adverse events. The most common adverse events were elation/silliness (50%), fatigue (40%), and increased aggression (40%). Using parent-report instruments to assess treatment effects, ketamine was associated with nominally significant improvement in a wide array of domains, including social behavior, attention deficit and hyperactivity, restricted and repetitive behaviors, and sensory sensitivities, a week after administration. Results derived from clinician-rated assessments aligned with findings from the parent reports. Overall, nominal improvement was evident based on the Clinical Global Impressions - Improvement scale, in addition to clinician-based scales reflecting key domains of social communication, attention deficit and hyperactivity, restricted and repetitive behaviors, speech, thinking, and learning, activities of daily living, and sensory sensitivities. Results also highlight the potential utility of electrophysiological measurement of auditory steady-state response and eye-tracking to index change with ketamine treatment. Findings are intended to be hypothesis generating and provide preliminary support for the safety and efficacy of ketamine in ADNP syndrome in addition to identifying useful endpoints for a ketamine clinical development program. However, results must be interpreted with caution given limitations of this study, most importantly the small sample size and absence of a placebo-control group.
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Zheng Y, Xu Y, Huang B, Mai Y, Zhang Y, Zhang Z. Effective dose of propofol combined with a low-dose esketamine for gastroscopy in elderly patients: A dose finding study using dixon’s up-and-down method. Front Pharmacol 2022; 13:956392. [PMID: 36204220 PMCID: PMC9530901 DOI: 10.3389/fphar.2022.956392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/06/2022] [Indexed: 12/05/2022] Open
Abstract
Objective: This study aimed to determine the optimal dose of propofol combined with esketamine to inhibit the response to gastroscope insertion in elderly patients. Methods: This is a prospective, non-controlled, non-randomized, single-center study. Elderly patients aged 65–80 years were enrolled in the study with the American society of anesthesiologists (ASA) physical status I or II undergoing elective gastroscopy. All patients were administered propofol after an intravenous esketamine at the dosage of 0.3 mg/kg 30 s, the subsequent dose of propofol was determined by the response of the previous patient to gastroscope insertion (choking, body movement, etc.) using Dixon’s up-and-down method. The initial dose of propofol administered to the first elderly patient was 3.0 mg/kg, and the standard ratio of propofol dose in adjacent patients was 0.9. At least six crossover points were obtained before the conclusion of the study. By using Probit analysis the median effective dose (ED50), 95% effective dose (ED95), and the corresponding 95% confidence interval (CI) for propofol were determined. Results: The study continued until we obtained seven crossover points and 32 elderly patients (17 males and 15 females) were collected. The ED50 of propofol combined with esketamine inhibiting response to gastroscope insertion in elderly patients were found to be 1.479 mg/kg (95% CI 1.331–1.592 mg/kg), and ED95 was found to be 1.738 mg/kg (95% CI 1.614–2.487 mg/kg). Conclusion: According to the present study, propofol combined with 0.3 mg/kg esketamine is safe and effective for elderly patients undergoing gastroscopy. The ED50 and ED95 doses of propofol inhibiting response to gastroscope insertion in elderly patients when combined with 0.3 mg/kg esketamine were 1.479 and 1.738 mg/kg, respectively, without apparent adverse effects.
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Affiliation(s)
- Yuling Zheng
- Department of Anesthesiology, the Affiliated Shunde Hospital of Jinan University, Foshan, China
| | - Yafei Xu
- Department of Anesthesiology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Bixin Huang
- Department of Anesthesiology, the Affiliated Shunde Hospital of Jinan University, Foshan, China
| | - Ying Mai
- Department of Anesthesiology, the Affiliated Shunde Hospital of Jinan University, Foshan, China
| | - Yiwen Zhang
- Department of Anesthesiology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Zhongqi Zhang
- Department of Anesthesiology, the Affiliated Shunde Hospital of Jinan University, Foshan, China
- *Correspondence: Zhongqi Zhang,
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Lipscombe C, Akhlaghi H, Groombridge C, Bernard S, Smith K, Olaussen A. Intubation Rates following Prehospital Administration of Ketamine for Acute Agitation: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2022; 27:1016-1030. [PMID: 35913093 DOI: 10.1080/10903127.2022.2108178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Ketamine is a fast-acting, dissociative anesthetic with a favorable adverse effect profile that is effective for managing acute agitation as a chemical restraint in the prehospital and emergency department (ED) settings. However, some previously published individual studies have reported high intubation rates when ketamine was administered prehospitally. OBJECTIVE This systematic review aims to determine the rate and settings in which intubation following prehospital administration of ketamine for agitation is occurring, as well as associated indications and adverse events. METHODS We searched PubMed, Scopus, Ovid MEDLINE, Embase, CINAHL Plus, PsycINFO, the Cochrane Library, ClinicalTrials.gov, OpenGrey, Open Access Theses and Dissertation, and Google Scholar from the earliest possible date until 13/February/2022. Inclusion criteria required studies to describe agitated patients who received ketamine in the prehospital setting as a first-line drug to control acute agitation. Reference lists of appraised studies were screened for additional relevant articles. Study quality was assessed using the Newcastle-Ottawa quality assessment scale. Synthesis of results was completed via meta-analysis, and the GRADE tool was used for certainty assessment. RESULTS The search yielded 1466 unique records and abstracts, of which 50 full texts were reviewed, resulting in 18 being included in the analysis. All studies were observational in nature and 15 were from USA. There were 3476 patients in total, and the overall rate of intubation was 16% (95% confidence interval [CI] = 8%-26%). Most intubations occurred in the ED. Within the studies, the prehospital intubation rate ranged from 0% to 7.9% and the ED intubation rate ranged from 0 to 60%. The overall pooled prehospital intubation rate was 1% (95% CI = 0%-2%). The overall pooled ED intubation rate was 19% (95% CI = 11%-30%). The most common indications for intubation were for airway protection and respiratory depression/failure. CONCLUSIONS There is wide variation in intubation rates between and within studies. The majority of intubations performed following prehospital administration of ketamine for agitation took place in the ED.
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Affiliation(s)
- Carlos Lipscombe
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Hamed Akhlaghi
- Emergency Department, St Vincent's Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Psychology, Faculty of Health, Deakin University, Geelong, Australia
| | - Christopher Groombridge
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stephen Bernard
- Centre for Research and Evaluation, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Alexander Olaussen
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Victoria, Australia
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13
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Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med 2022; 80:485-496. [PMID: 35752522 DOI: 10.1016/j.annemergmed.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. METHODS Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. RESULTS We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). CONCLUSION We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.
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Affiliation(s)
- Peter Cosgrove
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatric Emergency Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK.Dr Cosgrove is currently affiliated with Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
| | - Baruch S Krauss
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Joseph P Cravero
- Department of Anesthesia, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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14
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Boriosi JP, Lasarev MR, Peters ME, Ferrazzano P, Hollman GA. Anticholinergics and serious adverse events in pediatric procedural sedation: A report of the pediatric sedation research consortiums. Paediatr Anaesth 2022; 32:665-672. [PMID: 35072305 DOI: 10.1111/pan.14403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 12/17/2021] [Accepted: 01/14/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pediatric sedation is a clinical activity with potential for serious but rare airway adverse events, particularly laryngospasm. Anticholinergic drugs, atropine and glycopyrrolate, are frequently used with the intention to improve sedation safety by virtue of their antisialagogue effects. AIMS The objective of this study is to describe the current practice of anticholinergic use in pediatric sedation and to compare the frequency of serious sedation-related adverse events in patients who received anticholinergics to those who did not. METHODS We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Patient characteristics, procedure type, sedation provider, sedatives, location of sedation, anticholinergic administered, adverse events, and airway interventions were reported. Propensity score matching and multivariable logistic regression were used to test whether any association exists between anticholinergic use and serious sedation-related adverse events. RESULTS Anticholinergics were administered in 7.1% (n = 18 707) of all cases (n = 263 883) reported between November 2011 and October 2017. When anticholinergics were used, atropine was used in 22% (n = 4111) and glycopyrrolate in 78.1% (n = 14 601) of sedations. Use of anticholinergics was more common in patients with well-described risk factors for airway adverse events: active/history of upper respiratory infection, history of reactive airway disease/asthma, and exposure to smoke. However, infants and ASA 3 patients were not associated with higher rate of anticholinergic use. Anticholinergic use was independently associated with an increase in the odds of serious adverse events, OR 1.8 (95% CI 1.6-2.1), especially airway adverse events. CONCLUSIONS In this large Pediatric Sedation Research Consortium study, we found the use of anticholinergic adjuvants independently associated with greater odds of serious adverse events, especially airway adverse events, after adjusting for well-known sedation risk factors using propensity score matching and multivariate analysis.
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Affiliation(s)
- Juan P Boriosi
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Michael R Lasarev
- Department of Biostatistics, University of Wisconsin, Madison, Wisconsin, USA
| | - Megan E Peters
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Peter Ferrazzano
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Gregory A Hollman
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
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15
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Cohen N, Test G, Pasternak Y, Singer-Harel D, Schneeweiss S, Ratnapalan S, Schuh S, Finkelstein Y. Opioids Safety in Pediatric Procedural Sedation with Ketamine. J Pediatr 2022; 243:146-151.e1. [PMID: 34921870 DOI: 10.1016/j.jpeds.2021.11.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/04/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the effects of pre- and intraprocedural opioids on adverse events in children undergoing procedural sedation with ketamine in the emergency department (ED). STUDY DESIGN We conducted a retrospective cohort study of all children aged 0-18 years who underwent procedural sedation with intravenous ketamine alone, or in combination with an opioid, at a tertiary-care pediatric ED between June 1, 2018, and August 31, 2020. We explored predictors of serious adverse events (SAEs), desaturation or respiratory intervention, and vomiting. RESULTS Of 1164 included children (694 male, 59.6%; median age 5.0 years [IQR 2.0-8.0]), 80 (6.8%) vomited, 63 (5.4%) had a desaturation or required respiratory interventions, and 6 (0.5%) had SAEs. Pre- and intraprocedural opioids were not independent predictors of sedation-related adverse events. A concurrent respiratory illness (aOR 3.73; 95% CI 1.31-10.60, P = .01), dental procedure (aOR 3.05; 95% CI 1.25-7.21, P = .01), and a greater total ketamine dose (aOR 1.75; 95% CI 1.21-2.54, P = .003) were independent predictors of desaturation or respiratory interventions. A greater total ketamine dose (aOR 1.86; 95% CI 1.16-2.98, P = .01) and older age (aOR 1.15; 95% CI 1.07-1.24, P < .001), were independent predictors of vomiting. CONCLUSIONS Pre- and intraprocedural opioids do not increase the likelihood of sedation-related adverse events. SAEs are rare during pediatric procedural sedation with ketamine in the ED.
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Affiliation(s)
- Neta Cohen
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
| | - Gidon Test
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Yehonatan Pasternak
- Division of Clinical Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Suzan Schneeweiss
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Savithiri Ratnapalan
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada; Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada; Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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16
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Burger RK, Taylor TR, Chumpitazi CE, Robinson LC, Sims MJ, Tunc EM, Mulcrone AE, Caglar D, Sulton CD, Little-Wienert K, Klein EJ, Titus MO, Jackson BF. Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines. Pediatr Emerg Care 2022; 38:162-166. [PMID: 35358144 DOI: 10.1097/pec.0000000000002568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.
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Affiliation(s)
- Rebecca K Burger
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Taryn R Taylor
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Corrie E Chumpitazi
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Lauren C Robinson
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Morgan J Sims
- Division of Emergency Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Emine M Tunc
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Amanda E Mulcrone
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Derya Caglar
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Carmen D Sulton
- From the Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Kim Little-Wienert
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Eileen J Klein
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - M Olivia Titus
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Benjamin F Jackson
- Division of Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Taiwo A, Braimah R, Ibikunle A, Adigun O, Lawal S, Ile-Ogendengbe B, Bala M, Olayinka A, Adeyemi M, Farouk M. Applicability of Ambulatory Cleft Lip Repair in North-western Nigeria: Case Series and Review of the Existing Literature. JOURNAL OF CLEFT LIP PALATE AND CRANIOFACIAL ANOMALIES 2022. [DOI: 10.4103/jclpca.jclpca_4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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18
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Moake MM, Presley BC, Hill JG, Wolf BJ, Kane ID, Busch CE, Jackson BF. Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients. Pediatr Emerg Care 2022; 38:e178-e186. [PMID: 32769837 PMCID: PMC7854775 DOI: 10.1097/pec.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Ian D Kane
- From the Department of Pediatric Emergency Medicine
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19
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Bowman CF, Pruitt B, Marx J, Thornton SL. Massive Iatrogenic Pediatric Ketamine Overdose With Serial Levels and Minimal Morbidity. Pediatr Emerg Care 2021; 37:e1711-e1713. [PMID: 30829847 DOI: 10.1097/pec.0000000000001783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Ketamine is a dissociative anesthetic commonly used for procedural sedation owing to its perceived favorable safety profile. Despite its frequent use, overdoses of ketamine are rarely reported, and no cases with serum levels of ketamine or its metabolite have previously been reported. We report a case of an iatrogenic pediatric ketamine 20 mg/kg intramuscular overdose with serial ketamine and norketamine levels that resulted in minimal toxicity.
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Affiliation(s)
- Connor F Bowman
- From the University of Kansas Health System Poison Control Center
| | - Brandon Pruitt
- Department of Emergency Medicine, University of Kansas Health System, Kansas City, KS
| | - Jared Marx
- Department of Emergency Medicine, University of Nebraska School of Medicine, Omaha, NE
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20
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Mace SE, Ulintz A, Peterson B, Nowacki AS, Worley J, Zamborsky S. Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department. Pediatr Emerg Care 2021; 37:e500-e506. [PMID: 34463665 DOI: 10.1097/pec.0000000000002513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). METHODS Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. RESULTS Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. CONCLUSIONS Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.
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Affiliation(s)
| | - Alexander Ulintz
- From the Department of Emergency Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | | | | | - Jasmine Worley
- Ross University School of Medicine, Bridgetown, Barbados
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21
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Lee JY, Choi SJ, Park JS, Lee JS, Ryu JM, Yum MS. Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018. J Korean Med Sci 2021; 36:e213. [PMID: 34427061 PMCID: PMC8382566 DOI: 10.3346/jkms.2021.36.e213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.
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Affiliation(s)
- Jeong Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jun Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Sung Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi Sun Yum
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Matsuura K, Tsuchida J, Ando S, Sozu T. Matrix decomposition in meta-analysis for extraction of adverse event pattern and patient-level safety profile. Pharm Stat 2021; 20:806-819. [PMID: 33675157 PMCID: PMC8359197 DOI: 10.1002/pst.2109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/08/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
The purpose of assessing adverse events (AEs) in clinical studies is to evaluate what AE patterns are likely to occur during treatment. In contrast, it is difficult to specify which of these patterns occurs in each patient. To tackle this challenging issue, we constructed a new statistical model including nonnegative matrix factorization by incorporating background knowledge of AE-specific structures such as severity and drug mechanism of action. The model uses a meta-analysis framework for integrating data from multiple clinical studies because insufficient information is derived from a single trial. We demonstrated the proposed method by applying it to real data consisting of three Phase III studies, two mechanisms of action, five anticancer treatments, 3317 patients, 848 AE types, and 99,546 AEs. The extracted typical treatment-specific AE patterns coincided with medical knowledge. We also demonstrated patient-level safety profiles using the data of AEs that were observed by the end of the second cycle.
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Affiliation(s)
- Kentaro Matsuura
- Department of Management Science, Graduate School of EngineeringTokyo University of ScienceTokyoJapan
| | - Jun Tsuchida
- Department of Information and Computer Technology, Faculty of EngineeringTokyo University of ScienceTokyoJapan
| | - Shuji Ando
- Department of Information and Computer Technology, Faculty of EngineeringTokyo University of ScienceTokyoJapan
| | - Takashi Sozu
- Department of Information and Computer Technology, Faculty of EngineeringTokyo University of ScienceTokyoJapan
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Maqueda B, Rousseau L. Refractory Severe Laryngospam During Rapid Sequence Induction: A Case Report. A A Pract 2021; 15:e01489. [PMID: 34166265 DOI: 10.1213/xaa.0000000000001489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Laryngospasm is a rare cause of upper-airway obstruction in adults. It most commonly occurs during light anesthesia. We report a case of severe laryngospasm following rapid sequence induction in an adult requiring an emergency neurosurgical procedure. Laryngospasm occurred despite deep anesthesia with ketamine and neuromuscular blockade with succinylcholine. Several intubation attempts failed. Therefore, 2 hypotheses are considered: succinylcholine resistance and ketamine-induced laryngospasm. To our knowledge, this is the first description of laryngospasm occurring despite deep anesthesia and neuromuscular blockade. An idiosyncratic effect of ketamine may be involved, although this phenomenon has not yet been studied.
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Affiliation(s)
- Bastien Maqueda
- From the Department of Anesthesiology, Liège University Hospital, Sart Tilman, Liège, Belgium
| | - Ludovic Rousseau
- Department of Anesthesiology, Pasteur II Hospital, Nice University Hospital, Cedex 1, France
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:dic-2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
Background One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. Methods Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors’ personal collections of literature were reviewed. The terms “palliative care”, “ketamine”, “neuropathic pain”, “procedural pain”, “status epilepticus”, “refractory pain” and “child”, adding “age: birth–18 years” on a further filter were used for the search. Discussion The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. Conclusion Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Lee JR, Lee JH, Lee HM, Kim N, Kim MH. Independent risk factors for adverse events associated with propofol-based pediatric sedation performed by anesthesiologists in the radiology suite: a prospective observational study. Eur J Pediatr 2021; 180:1413-1422. [PMID: 33386997 DOI: 10.1007/s00431-020-03916-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
This study aimed to identify the types and frequencies of adverse events, as well as the risk factors for respiratory complications related to pediatric sedation. This single-center, prospective, observational study was conducted in a radiology suite at a tertiary university hospital for 2 years. Patients aged under 18 years, who underwent sedation solely by anesthesiologists for computed tomography or magnetic resonance imaging scans, were eligible for inclusion. Univariate and multivariate logistic regression analyses were carried out to identify the risk factors of adverse events, including respiratory complications, related to the propofol-based sedation. We further performed a sensitivity test with 1-to-5 propensity score matching analysis to assess the robustness of our findings. Among 2569 children, 3.9% experienced respiratory problems related to the sedation. After 1-to-5 propensity matching analysis, cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of adverse respiratory events.Conclusions: Our protocol for pediatric sedation demonstrates a high success rate and low likelihood of fatal complications, but proactive management prior to propofol-based sedation is critical to prevent adverse respiratory events in children. What is Known: • Propofol-based pediatric sedation is associated with adverse events necessarily even though performed by professional anesthesiologists solely. What is New: • Cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of respiratory adverse events. • Proactive management prior to sedation is critical to preventing adverse respiratory events for pediatrics.
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Affiliation(s)
- Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Jae Hoon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Hye-Mi Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Nayeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, South Korea
| | - Myoung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, South Korea.
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McKinley K, Panakos P, Yousef D. Characterization of ketamine usage in a large tertiary-care emergency department. Am J Emerg Med 2021; 47:149-153. [PMID: 33812331 DOI: 10.1016/j.ajem.2021.03.074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Ketamine is a phencyclidine derivative first used in clinical practice in the 1970's. Specifically within the emergency department (ED), ketamine is utilized for a wide variety of indications including but not limited to procedural sedation, rapid sequence intubation, agitation, and pain. As providers continue to utilize ketamine more frequently and for additional indications, additional data describing its safety and efficacy in the ED setting is warranted. OBJECTIVES To describe current trends in ketamine usage within a large tertiary-care Emergency Department. METHODS All patients receiving intravenous (IV) or intramuscular (IM) ketamine within the Emergency Department between January 1, 2019 and December 31, 2019 were eligible for study inclusion. Patients were excluded from the study if they were less than 18 years of age, pregnant, or incarcerated. Data was collected using a report of ketamine removal from the ED automatic dispensing cabinets, with administration confirmed by electronic medical record review. RESULTS During the study period, 170 patients received 195 doses of ketamine for the indications of agitation, procedural sedation, rapid sequence intubation, pain, sedation, seizure, status asthmaticus, and unknown. Patients were mostly male (74%) with a mean age of 45 years (range 20-97 years). The most common indications for ketamine administration were agitation and procedural sedation. For agitation, ketamine was utilized as first line therapy in 45% of patients. Seventy-seven percent of these patients did not require an additional sedative agent up to 60 min after ketamine administration. Procedural sedations were most commonly orthopedic reductions, and ketamine was given more frequently in combination with propofol than as monotherapy. Five percent of patients had an adverse event documented in the electronic medical record, with a single incidence of ketamine induced laryngospasm requiring intubation. CONCLUSION This descriptive review supports the versatility, safety, and efficacy of ketamine use within a large, tertiary-care, academic emergency department. Larger, prospective studies are warranted to draw further conclusions regarding ideal ketamine utilization within the emergency department.
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Affiliation(s)
- Kelly McKinley
- Jackson Memorial Hospital Department of Pharmacy, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
| | - Patricia Panakos
- Jackson Memorial Hospital Emergency Department, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
| | - Daniel Yousef
- Jackson Memorial Hospital Department of Pharmacy, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
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Jamal D, Powell C. Paediatric procedural sedation in the emergency department: is ketamine safe? Arch Dis Child Educ Pract Ed 2021; 106:120-124. [PMID: 32522748 DOI: 10.1136/archdischild-2019-318610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Dried Jamal
- Pediatric Emergency, Sidra Medical and Research Center, Doha, Qatar
| | - Colin Powell
- Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar .,Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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Schlegelmilch M, Roback MG, Bhatt M. Impact of young age on outcomes of emergency department procedural sedation. Am J Emerg Med 2021; 46:116-120. [PMID: 33744747 DOI: 10.1016/j.ajem.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Relatively little is known about outcomes of procedural sedation in very young children. Our objective was to examine the association between procedural sedation in young children (≤ 2 years) and the incidence of sedation-related adverse events. METHODS This is a secondary analysis of a prospective cohort study of children 0 to 18 years undergoing parenteral procedural sedation in six Canadian pediatric emergency departments (ED). The primary risk factor was age ≤ 2 years. Secondary risk factors were sex, procedure type, pre-procedure and sedation medications. The outcomes examined were: serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting. RESULTS Of the 6295 patients included, 946 (15%) were ≤2 years. Children 13-24 months comprised 90% of the young age group. Children ≤ 2 years were sedated most commonly for laceration repair (n = 450; 47.6%), while orthopedic reduction was most common in children > 2 (n = 3983; 74.5%). Ketamine was the most common medication in both groups, but was used more frequently in children ≤ 2 years (80.9% vs 58.9%; p < 0.001). There was no difference in the odds of SAE (OR 0.83, 95% Confidence Interval (CI) 0.4 to 1.9), significant intervention (OR 0.82, 95% CI 0.4 to 1.7) or oxygen desaturation (OR 0.95, 95% CI 0.7 to 1.3) between age groups, however children ≤ 2 years vomited less frequently (OR 0.24, 95% CI 0.1 to 0.6). CONCLUSIONS Young age, specifically between 13 and 24 months, was not associated with a significant difference in the incidence of adverse events.
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Affiliation(s)
- Michael Schlegelmilch
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.
| | - Mark G Roback
- Department of Pediatrics, University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, USA.
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.
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Abstract
Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.
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SASA paediatric guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in children: 2021–2026. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.4.s2.2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Clark NA, Richardson T, Schuster JE, Parthiban A, Puls HT. Variations in Sedated Echocardiography and Association With Repeat Echocardiography in Nonrefractory Kawasaki Disease. Hosp Pediatr 2020; 11:36-43. [PMID: 33288673 DOI: 10.1542/hpeds.2020-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Echocardiography performed under sedation allows for better coronary artery visualization in children with Kawasaki disease. We sought to describe hospital-level variability in the percentage of sedated echocardiography (SE) among children with nonrefractory Kawasaki disease (NRKD) and then test its association with repeat echocardiography, length of stay (LOS), and costs. METHODS We identified children in the Pediatric Health Information System <36 months of age hospitalized with NRKD from March 2010 to February 2017. Hospital-level percentage of SE was the primary outcome. Secondary outcomes were repeat echocardiography during the same hospitalization, LOS, and costs. We used χ2 and Wilcoxon rank tests to compare differences in repeat echocardiography between SE and nonsedated echocardiography. Pearson correlation was used to test associations between SE and repeat echocardiography, LOS, and costs. RESULTS There were 2887 NRKD hospitalizations from 40 children's hospitals. Initial SE varied from 0.0% to 87.0% (median 5.9%; interquartile range 1.4%-21.1%). Of initial echocardiographies, 22.4% were sedated and 10.1% of all hospitalizations had a repeat echocardiography. Use of SE at the hospital level was associated with a lower likelihood for repeat echocardiography (r = -0.32; 95% confidence interval -0.58 to -0.01; P = .042). Absolute risk reduction was 3.5% and the number needed to sedate was 29. Initial SE was not associated with LOS or hospital-level costs but was associated with increased patient-level costs. CONCLUSIONS Significant variation exists in the use of SE for children <36 months of age with NRKD at children's hospitals. Our results suggest that determination of SE should not be driven by concern for repeat echocardiography or LOS considerations.
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Affiliation(s)
| | - Troy Richardson
- Divisions of Hospital Medicine.,Children's Hospital Association, Lenexa, Kansas
| | | | - Anitha Parthiban
- Cardiology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; and
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Friedman MS, Saloum D, Haaland A, Drapkin J, Likourezos A, Strayer RJ. Description of Adverse Events in a Cohort of Dance Festival Attendees with Stimulant-Induced Severe Agitation Treated with Dissociative-Dose Ketamine. PREHOSP EMERG CARE 2020; 25:761-767. [DOI: 10.1080/10903127.2020.1837311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wink LK, Reisinger DL, Horn P, Shaffer RC, O’Brien K, Schmitt L, Dominick KR, Pedapati EV, Erickson CA. Brief Report: Intranasal Ketamine in Adolescents and Young Adults with Autism Spectrum Disorder—Initial Results of a Randomized, Controlled, Crossover, Pilot Study. J Autism Dev Disord 2020; 51:1392-1399. [DOI: 10.1007/s10803-020-04542-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kitch BB. Out-of-hospital ketamine: review of a growing trend in patient care. J Am Coll Emerg Physicians Open 2020; 1:183-189. [PMID: 33000033 PMCID: PMC7493477 DOI: 10.1002/emp2.12023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/31/2019] [Accepted: 01/21/2020] [Indexed: 11/18/2022] Open
Abstract
Ketamine is a unique medication with a long history of use in the emergency department. Out-of-hospital indications for ketamine have been explored and are currently expanding in some systems. This article provides background on ketamine history and pharmacology, its use in the hospital environment and possible applications for emergency medical services usage of this medication. Contraindications and adverse reactions are discussed to provide education on the nuances of ketamine administration and mitigation strategies. Out-of-hospital indications for ketamine are discussed including airway management, rapid sequence induction, analgesia, sedation, and treatment of excited delirium.
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Affiliation(s)
- Bryan B. Kitch
- Department of Emergency MedicineEast Carolina UniversityGreenvilleNorth Carolina
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Wiersma AJ, Bernier B, Leonard J, Faulk D, DiStefano M, Wathen J. Ketamine Sedation and Hypoxia: A Quality Improvement Project to Reduce Respiratory Events Receiving Intervention. J Emerg Med 2020; 58:864-873. [PMID: 32284229 DOI: 10.1016/j.jemermed.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/05/2020] [Accepted: 03/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally. OBJECTIVE A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs. METHODS Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay. RESULTS REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation. CONCLUSIONS Using QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.
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Affiliation(s)
- Alexandria J Wiersma
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado, School of Medicine, Aurora, Colorado
| | - Benjamin Bernier
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Jan Leonard
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado, School of Medicine, Aurora, Colorado
| | - Debra Faulk
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado, School of Medicine, Aurora, Colorado
| | - Michael DiStefano
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado, School of Medicine, Aurora, Colorado
| | - Joseph Wathen
- Department of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado, School of Medicine, Aurora, Colorado
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Paediatric procedural sedation and analgesia by emergency physicians in a country with a recent establishment of emergency medicine. Eur J Emerg Med 2019; 26:168-173. [PMID: 29240569 DOI: 10.1097/mej.0000000000000524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Paediatric patients receive less procedural sedation and analgesia (PSA) in the emergency department compared with adults, especially in countries where emergency medicine is at an early stage of development. The objectives of this study were to evaluate the adverse events and efficacy of paediatric PSA in a country with a recent establishment of emergency medicine and to describe which factors aided implementation. METHODS This is a prospective, multicentre, observational study of paediatric patients undergoing PSA by the first trained emergency physicians (EPs) in The Netherlands. A standardized data collection form was used at all participating hospitals to collect data on adverse events, amnesia, pain scores, and procedure completion. A survey was used to interpret which factors had aided PSA implementation. RESULTS We recorded 351 paediatric PSA. The mean age was 9.5 years (95% confidence interval: 9.1-10.0). Esketamine was most frequently used (42.4%), followed by propofol (34.7%). The adverse event rate was low (3.0%). Amnesia was present in 86.8%. The median pain score was 2 (out of 10) for patients without amnesia. Procedures were successfully completed in 93.9% of the cases. CONCLUSION Paediatric PSA provided by the first EPs in The Netherlands showed appropriate levels of sedation and analgesia with a high rate of procedure completion and a low rate of adverse events. Our paper suggests that EPs provided with a proper infrastructure of mentorship, training and guidelines can implement effective paediatric PSA.
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Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2019; 75:374-385. [PMID: 31792941 PMCID: PMC7064977 DOI: 10.1111/anae.14892] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - P L Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M G Roback
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - G Andolfatto
- University of British, Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, BC, Canada
| | - F E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Vic., Australia
| | - E Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - L R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania-Goias, Brazil
| | - A Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, the Netherlands
| | - D W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - B S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - V M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - E Alcaino
- Department of Paediatric Dentistry, University of Sydney, Westmead Centre for Oral Health, Sydney, NSW, Australia
| | - P S Costa
- Department of Pediatrics, Federal University of Goias, Goiania-Goias, Brazil
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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Incidence and risk factors for adverse events during monitored anaesthesia care for gastrointestinal endoscopy in children: A prospective observational study. Eur J Anaesthesiol 2019; 36:390-399. [PMID: 30950900 DOI: 10.1097/eja.0000000000000995] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN An observational study. SETTING Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS Mean ± SD age of the children was 8.5 ± 4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. CONCLUSION The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. TRIAL REGISTRATION ISRCTN70362666.
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Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters. J Clin Med 2019; 8:jcm8122087. [PMID: 31805686 PMCID: PMC6947169 DOI: 10.3390/jcm8122087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/28/2022] Open
Abstract
Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for <60 s is the most prevalent adverse event with a rate of 7.8 per 10,000, followed by airway obstruction at a rate of 5.42 per 10,000. Apnea occurred at a rate of 4.75 per 10,000. Significant predictors of adverse events are ≥ ASA score III (p = 0.0003), procedure time (6:00 pm–12:00 am: p < 0.0001, 12:00–6:00 am: p = 0.0003), and non-hospital location (p < 0.0001). The AE sedation reporting tool has demonstrated that the majority of adverse events in children and adults who receive procedural sedation from multi-specialists internationally required minor interventions and had outcomes of minor risk.
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Masaracchia MM, Sites BD, Lee J, Thomas JJ, Fernandez PG. Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: An observational analysis. Acta Anaesthesiol Scand 2019; 63:1225-1230. [PMID: 31313291 DOI: 10.1111/aas.13429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/01/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Guidelines issued by the American Society of Regional Anesthesia and Pain Medicine suggest that ketamine infusions for acute pain management are advantageous as a primary treatment or as an opioid adjunct. Despite significant data regarding its use in adult patients, there remains a paucity of information related to its quality and side effect profile in pediatrics and how it can be effectively used. We aimed to summarize our practice of utilizing ketamine for pediatric pain management in non-critical care settings. METHODS Patients aged 0-21 years receiving low-dose ketamine infusions (≤0.3 mg/kg/hour) in inpatient care units over five years were retrospectively analyzed. Demographics, specific quality metrics, and side effects were quantified. RESULTS About 172 patients received 270 subhypnotic ketamine infusions. The median duration of the infusions was 63.8 hours and 0.2 mg/kg/hour for the highest dose. The primary indication for ketamine was chronic pain exacerbation (83.3%). Despite similar opioid consumption, there was a significant reduction in mean verbal pain scores before (8.9 ± 1.9, P < .001) and after ketamine (6.5 ± 2.7, P < .001) use. Although there were 52 incidences of some side effect (neurologic excitability [10.4%]; over-sedation [7.4%]; rapid response team alerts [1.1%]), none resulted in termination of the infusion or escalations in care. CONCLUSION Ketamine can effectively be used as part of a multimodal analgesic regimen in pediatric patients in non-critical care settings. Our five-year experience using low-dose ketamine infusions highlights an acceptable side effect profile, with no attributable escalations in care or serious adverse events.
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Affiliation(s)
- Melissa M. Masaracchia
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
| | - Brian D. Sites
- Department of Anesthesiology Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Justin Lee
- University of Colorado School of Medicine Aurora Colorado
| | - James J. Thomas
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
| | - Patrick G. Fernandez
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
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Trevisan M, Romano S, Barbi E, Bruno I, Murru FM, Cozzi G. Intranasal dexmedetomidine and intravenous ketamine for procedural sedation in a child with alpha-mannosidosis: a magic bullet? Ital J Pediatr 2019; 45:119. [PMID: 31481093 PMCID: PMC6720406 DOI: 10.1186/s13052-019-0711-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/22/2019] [Indexed: 02/04/2023] Open
Abstract
Background Procedural sedation is increasingly needed in pediatrics. Although different drugs or drugs association are available, which is the safest and most efficient has yet to be defined, especially in syndromic children with increased sedation-related risk factors. Case report we report the case of a five-year-old child affected by alpha-mannosidosis who required procedural sedation for an MRI scan and a lumbar puncture. We administered intranasal dexmedetomidine (4 μg/kg) 45 min before intravenous cannulation, followed by one bolus of ketamine (1 mg/kg) for each procedure. The patient maintained spontaneous breathing and no desaturation or any complication occurred. Conclusion intranasal dexmedetomidine and intravenous ketamine could be a feasible option for MRI and lumbar puncture in children with alpha-mannosidosis needing sedation.
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Affiliation(s)
- Matteo Trevisan
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Sara Romano
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.,Department of Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Irene Bruno
- Department of Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Flora Maria Murru
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy. Via dell'Istria 65/1, 34131, Trieste, Italy
| | - Giorgio Cozzi
- Pediatric Emergency Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - Trieste, Italy. Via dell'Istria 65/1, 34131, Trieste, Italy
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Häske D, Böttiger BW, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Schempf B, Wafaisade A, Bernhard M. Analgesie bei Traumapatienten in der Notfallmedizin. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00629-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Rectal ketamine during paediatric burn wound dressing procedures: a randomised dose-finding study. Burns 2019; 45:1081-1088. [DOI: 10.1016/j.burns.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/16/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022]
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Zielinska M, Bartkowska-Sniatkowska A, Becke K, Höhne C, Najafi N, Schaffrath E, Simic D, Vittinghoff M, Veyckemans F, Morton N. Safe pediatric procedural sedation and analgesia by anesthesiologists for elective procedures: A clinical practice statement from the European Society for Paediatric Anaesthesiology. Paediatr Anaesth 2019; 29:583-590. [PMID: 30793427 DOI: 10.1111/pan.13615] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 01/29/2019] [Accepted: 02/16/2019] [Indexed: 12/21/2022]
Abstract
The growing number of medical procedures performed in children that require cooperation of patients, lack of movement, anxiolysis or/and analgesia triggers the increased need for procedural sedation. This document presents the consensus statement of the European Society for Paediatric Anaesthesiology about the principles connected with the safe management of procedural sedation and analgesia (PSA) by anaesthesiologists for elective procedures in children. It does not aim to provide a legal statement on how and by whom PSA should be performed. The document highlights that any staff taking part in sedation of children must be appropriately trained with the required competencies and must be able to demonstrate regularly that they have maintained their knowledge, skills and clinical experience. The main goal of creating this document was to reflect the opinions of the community of the paediatric anaesthesiologists in Europe regarding how PSA for paediatric patients should be organized to make it safe.
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Affiliation(s)
- Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Alicja Bartkowska-Sniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Karin Becke
- Department of Anaesthesiology, Paediatric Anaesthesiology and Intensive Care Medicine, Cnopf Childrens Hospital, Hospital Hallerwiese, Nürnberg, Germany
| | - Claudia Höhne
- Department of Anaesthesiology, Intensive Medicine and Pain Medicine, DRK Hospitals Berlin, Koepnick, Berlin, Germany
| | - Nadia Najafi
- Department of Anaesthesia and Perioperative Medicine, University Hospital Brussel, Free University of Brussels, Brussels, Belgium
| | - Eva Schaffrath
- Department of Anesthesiology, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Dusica Simic
- Department of Pediatric Anesthesia and Intensive Care, University Children`s Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Maria Vittinghoff
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Francis Veyckemans
- Section of Paediatric Anaesthesia, Hospital Jeanne de Flandre, Lille, France
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Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department. Pediatr Qual Saf 2019; 4:e135. [PMID: 30937415 PMCID: PMC6426494 DOI: 10.1097/pq9.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 12/21/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation. Methods Pediatric emergency medicine fellows at a children's hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys. Results Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline). Conclusions A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.
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Use of ketamine by paediatricians in Italian paediatric emergency departments: a missed opportunity? Eur J Pediatr 2019; 178:587-591. [PMID: 30671694 DOI: 10.1007/s00431-019-03320-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
Procedural sedation and analgesia with ketamine are part of daily practice for children undergoing painful procedures in the paediatric emergency department (ED) of North America. A massive number of studies demonstrate ketamine's safety and efficacy in the hands of trained ED paediatricians, with few severe adverse events (SAEs) recorded. Since there are no data on ketamine's usage in Italian paediatric EDs, we created a survey to examine procedural sedation with ketamine in the EDs of the Italian PIPER (Pain in Paediatric Emergency Room) group, which includes 36 paediatric EDs providing 1.4 million paediatric visits each year. Results were reviewed using frequencies to describe responses. Thirty-two out of 36 centres replied to the questionnaire. In 6 (19%) out of 32 centres, ketamine is not used at all in the paediatric ED. In 6 centres (23%) of 26 which use ketamine, this drug is autonomously administered by the emergency paediatrician, whereas in 20 (77%) of them it is exclusively managed by the anaesthesiologist on call.Conclusion: ketamine is autonomously administered only by a small percentage of Italian emergency paediatricians. There is an increasing need for implementation of procedural sedation training and use of ketamine in the everyday practice outside the operating room in paediatric EDs. What is Known: • Ketamine is safely and efficaciously administered for children's procedural sedation and analgesia by trained emergency paediatricians in the everyday practice outside the operating room in North America. • In the Italian setting, there are no data at all concerning ketamine's usage by the emergency paediatricians for procedural sedation and pain control. What is New: • In this study emerged that ketamine is poorly administered by Italian emergency paediatricians for procedural sedation and analgesia outside the operating room. • A great deal of educational effort should be made to widen ketamine based procedural sedation availability in Italian emergency departments by spreading specific training tracks and guidelines.
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Kim D, Lee EK, Jeong JS, Gil NS, Hahm TS, Shin YH. Incidence and risk factors of unplanned intubation during pediatric sedation for MRI. J Magn Reson Imaging 2019; 49:1053-1061. [PMID: 30350443 DOI: 10.1002/jmri.26314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is often difficult for the pediatric patient to cooperate or to remain immobile during MR scans. Therefore, sedation is usually needed for children. PURPOSE To evaluate the incidence and contributing factors of unanticipated intubation during sedation for MRI scan in children. STUDY TYPE Retrospective observational study. POPULATION/SUBJECTS In all, 1165 charts were reviewed retrospectively of patients who had been sedated by anesthesiologists at a single institution from May 2015 to June 2016. ASSESSMENT Patient's demographics, the region of the MRI scan, total amount of medication, duration of sedation, and any adverse event during MRI were assessed. The adverse events during sedation including airway obstruction, apnea, desaturation, bradycardia, and hypotension were also assessed. STATISTICAL TESTS Risk factors of unplanned intubation during MRI sedation were identified by univariate and multivariate analysis. Firth's exact logistic regression was used for univariate and multivariate analysis. According to the results from multiple logistic regression, a nomogram was developed to predict the risk. RESULTS A total of 1165 children aged 7 days to 18 years with sedation used during an MRI scan during the study period showed an incidence of unexpected intubation as ~2% (n = 23, 95% confidence interval [CI]; 0.0123, 0.0295). Multivariate logistic regression revealed the following risk factors of unplanned intubation: American Society of Anesthesiologists (ASA) class III patients (odds ratio [OR] 1.212, P < 0.001), premature birth (OR 2.317, P < 0.001), and the presence of gastroesophageal reflux disease (GERD) (OR 1.474, P < 0.001) or congenital heart disease (OR 1.118, P < 0.001). DATA CONCLUSION This study identified risk factors of unplanned intubation as follows: ASA class III patients, premature birth, and the presence of GERD or congenital heart disease. The physician should screen risk factors of unexpected intubation and maintain adequate sedation during MRI scans in pediatric patients. Level of Evidence 3. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:1053-1061.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nam-Su Gil
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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The Use of Ketamine for the Management of Acute Pain in the Emergency Department. Adv Emerg Nurs J 2019; 41:111-121. [DOI: 10.1097/tme.0000000000000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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