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Romano F, Brändle G, Abplanalp-Marti O, Gualtieri R, Sahyoun C. Procedural sedation and analgesia in Swiss Pediatric Emergency Departments: a national subgroup analysis of a European cross-sectional survey. Eur J Pediatr 2024; 183:4579-4583. [PMID: 39096384 DOI: 10.1007/s00431-024-05701-5] [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: 04/25/2024] [Revised: 07/02/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024]
Abstract
This study aims to provide a national overview of procedural sedation and analgesia practices within Pediatric Emergency Departments in Switzerland, focusing on the availability of pharmacologic agents, the presence of safety protocols, the utilization of non-pharmacological interventions, and to identify specific local limitations. We conducted a detailed subgroup analysis of Swiss data from a European cross-sectional survey on emergency department pediatric Procedural Sedation and Analgesia (PSA) practice, isolating data from Swiss sites. The survey, conducted between November 2019 and March 2020, covered various aspects of procedural sedation and analgesia practices. The survey included nine Swiss sites, treating a total of 252,786 patients in 2019. Topical analgesia, inhaled equimolar nitrous oxide-oxygen mixture, and ketamine were largely available. All sites had nurse-directed triage protocols in place; however, opioid administration was included in the protocols in only 66% of sites. Only 33% of hospitals reported common use of intravenous sedation. Barriers to procedural sedation and analgesia implementation included staffing shortages (89% of sites) and lack of dedicated spaces (78%).Conclusions: Despite a broad array of pharmacological and options available in Swiss Pediatric Emergency Departments, challenges remain in standardizing practices across the country. Limited space and staffing and enhancing training on non-pharmacological interventions were identified as potential areas for improving pain and anxiety management in pediatric emergency care. This study underscores the need for national guidelines to harmonize emergency department PSA practices across Switzerland, ensuring all children have access to effective and evidence-based procedural comfort. What is Known: • Recent research, conducted in European emergency departments, suggests that in pediatric Procedural Sedation and Analgesia (PSA) resources are limited, and practice is heterogeneous What is New: • Swiss pediatric hospitals offer a wide range of pharmacological options for pain and anxiety management. However, significant barriers to PSA were identified. These include external control of intravenous sedation and insufficient integration of non-pharmacological interventions, such as child life specialists and procedural hypnosis. National guidelines are needed to harmonize PSA practices.
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Affiliation(s)
- Fabrizio Romano
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Gabriel Brändle
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland
- Division of Pediatric Emergency Medicine, Hirslanden Clinique Des Grangettes, Geneva, Switzerland
| | - Olivia Abplanalp-Marti
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Renato Gualtieri
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland.
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University, Geneva, Switzerland.
| | - Cyril Sahyoun
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland
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Sulton CD, Fletcher N, Murphy J, Gillespie S, Burger RK. Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:83-87. [PMID: 37276083 DOI: 10.1097/pec.0000000000002993] [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: 06/07/2023]
Abstract
BACKGROUND Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS. OBJECTIVE The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED. METHODS Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures. RESULTS Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group. CONCLUSIONS Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.
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Affiliation(s)
- Carmen D Sulton
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, GA
| | - Nicholas Fletcher
- Department of Orthopaedics, Center for Advanced Pediatrics, Emory University, Atlanta, GA
| | - Joshua Murphy
- Children's Physician Group - Orthopaedics, Children's Healthcare of Atlanta, Atlanta, GA
| | - Scott Gillespie
- Division of Biostatistics, Emory University School of Medicine, Atlanta, GA
| | - Rebecca K Burger
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, GA
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Wu X, Liu Y, Li B, Zhou D, Cheng T, Ma T, Yang X, Xia B. Safety of deep intravenous propofol sedation in the dental treatment of children in the outpatient department. J Dent Sci 2023; 18:1073-1078. [PMID: 37404595 PMCID: PMC10316414 DOI: 10.1016/j.jds.2022.11.013] [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: 10/30/2022] [Revised: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background/purpose Intravenous sedation with propofol in the dental treatment offers an alternative to inhalation sedation or general anesthesia. The aim of this study was to evaluate the safety and identify risk factors for intraoperative complications. Materials and methods Uncooperative children who could not complete dental treatment under non-pharmacological behavior management or mild-to-moderate sedation in the outpatient pediatric department were selected. Details and time of dental treatment; intraoperative vital signs data, including blood pressure, heart rate, respiratory rate, pulse oxygen saturation (SpO2), end-tidal carbon dioxide, and electrocardiogram; and incidence of intraoperative and postoperative complications were recorded. Results Overall, 344 children were selected, with 342 completing dental treatment. The dental treatment time was 20-155 (median, 85; interquartile range, 70-100) min. The number of treated teeth was at least 1 and at most 13 (median, 6; interquartile range, 5-8). Among 342 children, 35 (10.2%) had their treatment interrupted temporarily due to choking cough. No serious complications occurred; the incidence rate of minor complications was 47/342 (13.7%). Tachycardia was observed in 5/342 (1.5%) cases, oxygen desaturation (SpO2 < 95%) in 18, and hypoxemia (SpO2 ≤ 90%) in 25. The treatment duration was significant longer in cases with than without complications (P < 0.05), and children coughing during treatment were more likely to have complications (P < 0.05). Postoperative restlessness occurred in six children, but there was no vomiting, aspiration, or respiratory obstruction. Conclusion Decreased oxygen saturation is the most common complications. Cough during treatment and longer treatment duration were risk factors for complications.
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Affiliation(s)
- Xiaoran Wu
- Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Yun Liu
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Binghua Li
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Dan Zhou
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Tong Cheng
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Tianyu Ma
- Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Xudong Yang
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
| | - Bin Xia
- Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, National Center of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing, PR China
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Tesoro S, Gamba P, Bertozzi M, Borgogni R, Caramelli F, Cobellis G, Cortese G, Esposito C, Gargano T, Garra R, Mantovani G, Marchesini L, Mencherini S, Messina M, Neba GR, Pelizzo G, Pizzi S, Riccipetitoni G, Simonini A, Tognon C, Lima M. Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP). Surg Endosc 2022; 36:7877-7897. [PMID: 36121503 PMCID: PMC9613560 DOI: 10.1007/s00464-022-09577-0] [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] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy.
| | - Mirko Bertozzi
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Fabio Caramelli
- Anesthesia and Intensive Care Unit, IRCCS Sant'Orsola Polyclinic, Bologna, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children's Hospital, Polytechnical University of Marche, Ancona, Italy
| | - Giuseppe Cortese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
| | - Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giulia Mantovani
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Laura Marchesini
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS San Matteo Polyclinic, Pavia, Italy
| | - Mario Messina
- Division of Pediatric Surgery, Santa Maria Alle Scotte Polyclinic, University of Siena, Siena, Italy
| | - Gerald Rogan Neba
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Vittore Buzzi' Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Simone Pizzi
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Alessandro Simonini
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Costanza Tognon
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Mario Lima
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
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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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Vinson AE, Peyton J, Kordun A, Staffa SJ, Cravero J. Trends in Pediatric MRI sedation/anesthesia at a tertiary medical center over time. Paediatr Anaesth 2021; 31:953-961. [PMID: 34036674 DOI: 10.1111/pan.14225] [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: 03/15/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Each year, hundreds of thousands of children require sedation/anesthesia to facilitate MRI scans. Anesthetic techniques for accomplishing sedation/anesthesia vary widely between institutions and providers, with unclear implications for patient safety. AIMS We sought to establish trends in anesthetic practice for pediatric MRI sedation/anesthesia across a 7-year period and determine rates of adverse events, considering technique used, age, and ASA physical classification status (ASA-PS). METHODS Using established data resources, we analyzed 24 052 anesthetics performed by anesthesiologists for MRI scans between 5/1/2013 and 12/31/2019 on patients less than 18 years old, focusing on medications used, trends of use, and associated adverse events. Adverse events (hypoxia, hypotension, bradycardia) were defined by deviation from age norms and accessed via the electronic anesthetic record database. The Cochran-Armitage test was used to assess trends over time in categorical data, and one-way ANOVA was used to analyze continuous data. Multivariable logistic regression analysis was implemented to determine the independent associations between anesthetic technique and adverse events while adjusting for age, ASA-PS, and weight. RESULTS The most significant trends noted were a decrease in "propofol-only" anesthetic techniques and an increase in propofol and dexmedetomidine combination techniques. Mild desaturation (80-89% SpO2 ) occurred in 4.22% of cases with more significant hypoxia much rarer (0.44% of cases having desaturation <70% SpO2 ). Bradycardia occurred in 2.39% of cases and hypotension in 1.75% of cases. Major adverse events were rare. CONCLUSIONS We provide the largest report of the nature of MRI sedation/anesthesia as practiced by anesthesiologists in a large children's hospital. We demonstrate that, even in a large system, anesthetic techniques are pliable and shift significantly over time. Our data also support a high level of safety within our system, despite a case mix likely higher in risk than those in most of the previously published studies.
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Affiliation(s)
- Amy E Vinson
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA
| | - James Peyton
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA
| | - Anna Kordun
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA
| | - Joseph Cravero
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA
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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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Sahyoun C, Cantais A, Gervaix A, Bressan S, Löllgen R, Krauss B. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. Eur J Pediatr 2021; 180:1799-1813. [PMID: 33511466 PMCID: PMC8105204 DOI: 10.1007/s00431-021-03930-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022]
Abstract
Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known: • Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures. • We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms "pediatrics," "hypnotics and sedatives," "conscious sedation," and "ambulatory surgical procedures" and the non-MeSH term "procedural sedation" and found no reports describing the current practice of pediatric PSA in Europe. What is New: • This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia. • Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.
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Affiliation(s)
- Cyril Sahyoun
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Aymeric Cantais
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Alain Gervaix
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Silvia Bressan
- Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Ruth Löllgen
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Baruch Krauss
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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Kim JY, Kim KN, Kim DW, Lim HJ, Lee BS. Effects of dexmedetomidine sedation for magnetic resonance imaging in children: a systematic review and meta-analysis. J Anesth 2021; 35:525-535. [PMID: 34002258 DOI: 10.1007/s00540-021-02946-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/07/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Pediatric sedation is commonly required to obtain high-quality images in magnetic resonance imaging (MRI). We performed a systematic review and meta-analysis to assess the effects of dexmedetomidine sedation for MRI in children. METHODS A systematic review was conducted to find all randomized controlled trials concerning dexmedetomidine sedation for MRI in children. We searched databases using the Ovid platform in the Cochrane Controlled Trials Register, MEDLINE, and EMBASE. This study was registered in the PROSPERO database: CRD42020198368. RESULTS Seven studies and 753 participants were included. Dexmedetomidine sedation showed a significantly delayed onset time [weighted mean differences (WMD) = 8.13 min, 95% confidence interval (CI) 4.64 to 11.63, I2 = 98%] and recovery time (WMD = 5.22 min, 95% CI 0.35 to 10.09, I2 = 92%) compared to propofol, ketamine, and midazolam sedation. There was no difference in quality of sedation [risk ratio (RR) = 1.25, 95% CI 0.92 to 1.69, I2 = 89%], or incidence of sedation failure (RR = 1.39, 95% CI 0.53 to 3.66, I2 = 83%) between groups. Although a significantly decreased heart rate (WMD = - 17.34 beats/minute, 95% CI - 22.42 to - 12.26, I2 = 96%) was observed, bradycardia that required treatment was not increased (RR = 8.00, 95% CI 1.02 to 62.64, I2 = 0%). Dexmedetomidine sedation had a lower incidence of desaturation events (RR = 0.42, 95% CI 0.20 to 0.86, I2 = 4%). However, there was no difference in incidence of postoperative vomiting (RR = 0.42, 95% CI 0.15 to 1.17, I2 = 17%) between groups. CONCLUSIONS Dexmedetomidine sedation provided a similar sedation quality with a reduced incidence of desaturation events. However, the delayed onset and recovery times were drawbacks. The clinical significance of bradycardia is considered to be low. GRADE assessment revealed the quality of the evidence in this meta-analysis ranged from very low to moderate.
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Affiliation(s)
- Ji Yoon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 04763, Republic of Korea
| | - Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 04763, Republic of Korea.
| | - Dong Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 04763, Republic of Korea
| | - Hyun Jin Lim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 04763, Republic of Korea
| | - Bong Soo Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 04763, Republic of Korea
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Mason KP, Park RS, Sullivan CA, Lukovits K, Halpin EM, Imbrescia ST, Cavanaugh D, Prescilla R, Fox VL. The synergistic effect of dexmedetomidine on propofol for paediatric deep sedation: A randomised trial. Eur J Anaesthesiol 2021; 38:541-547. [PMID: 33009191 DOI: 10.1097/eja.0000000000001350] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Propofol and dexmedetomidine are used separately, and sometimes together, for paediatric deep sedation. Although their combination has been described in adults, the effect of dexmedetomidine as a potential synergist in children has not been studied before. OBJECTIVES The primary objective was to compare the propofol requirements of children who receive propofol alone with those who receive it in combination with dexmedetomidine for deep sedation for upper and lower endoscopic gastrointestinal procedures. DESIGN This was a prospective, open-label, randomised study comparing patients who received propofol alone (group P) with those who received dexmedetomidine and propofol (group DP). The depth of sedation was titrated to a target bispectral (BIS) index. SETTING A Gastroenterology Procedure Unit at a single, tertiary care academic medical centre from April 2018 until December 2019. PATIENTS Eligible patients were scheduled for upper endoscopy, lower endoscopy or both. A total of 39 patients were enrolled (20 DP) and (19 P). INTERVENTIONS Patients in Group DP received dexmedetomidine 0.5 μg kg-1 administered over 1 min followed by an infusion of 0.15 μg kg-1 h-1. In both groups, intravenous propofol was given in bolus increments titrated to a BIS index of 40 to 50 and then a continuous infusion of propofol to maintain BIS at 40 to 50. MAIN OUTCOME MEASURES The primary outcome measure was propofol requirement in each group. Secondary outcome measures were time to achieve the targeted sedation depth, time to achieve an Aldrete recovery score of 9, duration of sedation, mean BIS values, adverse events, 'PAED' scores and time to discharge from the postanaesthesia care unit (PACU). RESULTS The median (range) total dose of propofol was 0.23 (0.10 to 0.50) mg kg-1 min-1 in group DP and 0.40 (0.20 to 0.50) mg kg-1 min-1 in group P (P = 0.0004). Time of discharge from the PACU was 60 (20 to 121) min in group DP and 63 (46 to 91) min in group P (P = 0.0409). CONCLUSION The combination of dexmedetomidine and propofol for paediatric procedural sedation achieved a significant reduction in median propofol dose and a slightly shorter median time to discharge from PACU. Large-scale studies may determine whether this reduction decreases the risk of significant adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02952222.
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Affiliation(s)
- Keira P Mason
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston (KPM, RSP, CAS), Special Care Nursery, Winchester Hospital,Winchester (EMH), Department of Experimental Therapeutics/Interventional Trials, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston (STI), Boston Biostatistical Consulting, North Reading (DC), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (KL, RP) and Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA (VLF)
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Sulton CD, Burger RK, Figueroa J, Taylor TR. Evaluation of pediatric procedural sedation education in pediatric emergency medicine fellowships. Medicine (Baltimore) 2021; 100:e24690. [PMID: 33578603 PMCID: PMC10545226 DOI: 10.1097/md.0000000000024690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/09/2020] [Accepted: 01/20/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills.
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Affiliation(s)
- Carmen D. Sulton
- Division of Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta
| | - Rebecca K. Burger
- Division of Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta
| | - Janet Figueroa
- Department of Pediatrics, Pediatrics Biostatics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Taryn R. Taylor
- Division of Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta
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Evans M, Thompson T, Hsu C, Spray B, Edwards L, Grigorian A, Dalabih A. Pediatric Deep Sedation for Ophthalmology Procedures in an Outpatient Setting, Risk Evaluation. Anesth Essays Res 2021; 15:301-305. [PMID: 35320958 PMCID: PMC8936870 DOI: 10.4103/aer.aer_134_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Pediatric deep sedation (PDS) performed by a dedicated pediatric sedation service has been found to be safe, convenient, and efficient for minor procedures. Major complications such as cardiopulmonary resuscitation, intubation, and death are rare. However, minor complications such as desaturation, apnea, suctioning, or laryngospasm can occur infrequently. To date, little data exist evaluating PDS use for minor ophthalmology procedures. Aims: The aim of this study was to evaluate the incidence of complications for subjects receiving PDS for minor ophthalmology procedures. Setting: Pediatric children's hospital sedation service. Materials and Methods: This was a review of a prospectively collected database between 2018 and 2020. A hundred and thirty-four subjects aged 0–18 years, who underwent PDS for minor ophthalmology procedures, were compared to 1119 subjects who received PDS for other procedures (e.g., lumbar puncture, bone marrow aspirate/biopsy, and Botox). Statistical Analysis: SAS software, version 9.4, was used to determine variables associated with deep sedation that were predictive of complications. A multiple logistic regression procedure was conducted. Statistical significance was set at the 0.05 level. Results: Subjects receiving PDS for ophthalmology procedures had a higher rate of minor complications than the control group (n = 18, 13.4%, vs. n = 58, 5.7%; P < 0001). No major complications occurred in any of the studied subjects. The ophthalmology group had a higher rate of bag-mask ventilation, airway positioning, and suctioning. Conclusions: Ophthalmology procedures using PDS have a greater occurrence of minor complications compared to other painful procedures. No major complications were noted in either group, providing evidence that PDS can be performed safely for ophthalmology procedures using the sedation team model.
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Jung SM. Drug selection for sedation and general anesthesia in children undergoing ambulatory magnetic resonance imaging. Yeungnam Univ J Med 2020; 37:159-168. [PMID: 32299181 PMCID: PMC7384916 DOI: 10.12701/yujm.2020.00171] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 12/23/2022] Open
Abstract
The demand for drug-induced sedation for magnetic resonance imaging (MRI) scans have substantially increased in response to increases in MRI utilization and growing interest in anxiety in children. Understanding the pharmacologic options for deep sedation and general anesthesia in an MRI environment is essential to achieve immobility for the successful completion of the procedure and ensure rapid and safe discharge of children undergoing ambulatory MRI. For painless diagnostic MRI, a single sedative/anesthetic agent without analgesia is safer than a combination of multiple sedatives. The traditional drugs, such as chloral hydrate, pentobarbital, midazolam, and ketamine, are still used due to the ease of administration despite low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, and propofol, with high effectiveness and rapid recovery, are preferred for children undergoing ambulatory MRI. General anesthesia using propofol or sevoflurane can also provide predictable rapid time to readiness and scan times in infant or children with comorbidities. The selection of appropriate drugs as well as sufficient monitoring equipment are vital for effective and safe sedation and anesthesia for ambulatory pediatric MRI.
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Affiliation(s)
- Sung Mee Jung
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Pediatric Procedural Sedation in the Emergency Setting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2735. [PMID: 32440407 PMCID: PMC7209886 DOI: 10.1097/gox.0000000000002735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/03/2020] [Indexed: 11/26/2022]
Abstract
Background Pediatric emergency department (ED) visits are common. Many are due to injury, which require procedural treatments with sedation. There are many well researched independent predictors of adverse events for pediatric procedural sedation. The duration of sedation as a predictor of adverse events has not been well studied. This study aims to determine the complication rate and severity of procedural sedation as well as determine if the duration of sedation is correlated with an increased risk of complications. Methods After Institutional Review Board approval, a retrospective study was performed on all patients seen at Helen Devos Children's ED who received sedation from August 1, 2011, to August 15, 2016. Study variables included age, weight, type of procedure, American Society of Anesthesiologist (ASA) physical status class, Mallampati score, comorbidities, sedation medication, sedation time, and complication. A logistic regression was performed assessing risk factors for complications. Statistical significance was assessed at P < 0.05. Results There were 1,814 patients included in the study. Median sedation time was 20 minutes. There were 70 (3.9%) total complications. Controlling for age, weight, comorbidities, ASA class, Mallampati score, and total sedation medication, sedation time was a significant predictor of a complication (odds ratio: 1.021; 95% CI, 1.004-1.039). Conclusions Pediatric patients can safely undergo procedural sedation in the ED. This study demonstrates a high safety profile for long procedural sedations with slight increases in risk as sedation time increases. There is no identifiable time where the duration of sedation significantly increases the risk of complication.
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Shimizu H, Homma Y, Norii T. Incidence of adverse events among elderly vs non-elderly patients during procedural sedation and analgesia with propofol. Am J Emerg Med 2020; 44:411-414. [PMID: 32409101 DOI: 10.1016/j.ajem.2020.04.094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Hiroyasu Shimizu
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan.
| | - Yosuke Homma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan
| | - Tatsuya Norii
- Department of Emergency Medicine, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
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Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics 2020; 145:peds.2019-3559. [PMID: 32332053 DOI: 10.1542/peds.2019-3559] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.
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Affiliation(s)
| | | | - Harold K Simon
- Departments of Pediatrics and.,Emergency Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anne Stormorken
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Michael Mallory
- Pediatric Emergency Medicine Associates, Scottish Rite Hospital, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Corrie E Chumpitazi
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Joseph P Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts
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Comparison of drugs used for intubation of pediatric trauma patients. J Pediatr Surg 2020; 55:926-929. [PMID: 32067810 DOI: 10.1016/j.jpedsurg.2020.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. METHODS A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. RESULTS Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. CONCLUSION Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. TYPE OF STUDY Retrospective. LEVEL OF EVIDENCE IV.
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Sedatives used in children to obtain head CT in the emergency department. Am J Emerg Med 2020; 44:198-202. [PMID: 32107128 DOI: 10.1016/j.ajem.2020.02.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/17/2020] [Accepted: 02/18/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Children in the emergency department who require computerized tomography (CT) of the head often are given sedative medications to facilitate completion of the study with adequate imaging. A prior study found the two most common medications used to obtain head CT in children were pentobarbital and chloral hydrate; however, these medications have become less popular. We hypothesized that there was variability in medication choice amongst providers in the emergency department and there has been a change in the preferred sedatives used in the last decade. METHODS We conducted a retrospective multicenter cross-sectional study of children 0-18 years old who received a medication with sedative properties and underwent head CT while in the emergency department from 2007 to 2018, using the Pediatric Health Information System (PHIS) database. The primary outcome measure was the frequency of administration of drugs within an individual sedative class. RESULTS We analyzed 24,418 patient encounters, of whom 53% received an opioid and 41% received a benzodiazepine. There were statistically significant decreases in the use of barbiturates, chloral hydrate, anti-emetic sedatives, and opioids, while increases in barbiturate combination drugs, benzodiazepines and dexmedetomidine were observed over the study period. The majority of medications were administered parenterally. CONCLUSION There is wide variability in sedatives used in children to obtain head CT and the preferred drugs have shifted over the last decade.
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Sauer H, Lobenhofer M, Abdul-Khaliq H. Analgosedation for diagnostic and interventional procedures: a countrywide survey of pediatric centers in Germany. Ital J Pediatr 2020; 46:14. [PMID: 32014023 PMCID: PMC6998146 DOI: 10.1186/s13052-020-0783-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/29/2020] [Indexed: 11/15/2022] Open
Abstract
Background As more and more diagnostic and interventional options are becoming available for use in pediatric patients, techniques of procedural sedation analgesia (PSA) are being administered in considerably growing numbers as well. Aims The objective of this research effort was to conduct the first countrywide survey on the status quo of sedation analgesia as delivered to children and adolescents in Germany. Methods We dispatched letters to all pediatric hospital settings in Germany (n = 305), including a questionnaire that had been developed with existing guidelines taken into account. Its items were designed to elucidate the current practice of PSA throughout these pediatric centers regarding (a) organizational structures and (b) standards of medication and staffing. Results A total of 138 centers returned the questionnaire, hence the response rate was 45.2%. Numerous centers had implemented adequate structures and staffing standards. Deficits were nevertheless identified, most notably in terms of on-location equipment and staff provided to deliver sedations. Essential items of equipment were not provided in up to 26.8% of centers. Adequate staffing was not provided in up to 44.2% of centers, depending on the diagnostic or interventional procedures for which the PSA was delivered. The most widely used sedative agents were midazolam, ketamine/esketamine, and propofol. Conclusions Adequate care structures for the management of procedural sedation analgesia have been implemented by many pediatric centers in Germany. On the downside, these findings also reveal deficits that will take efforts to be eliminated.
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Affiliation(s)
- Harald Sauer
- Department of Pediatric Cardiology, University Hospital of Saarland, Kirrberger Strasse, Building 9, 66421, Homburg (Saar), Germany.
| | - Marie Lobenhofer
- Department of Gynecology, St. Theresa Hospital Nuremberg, Nuremberg, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, University Hospital of Saarland, Kirrberger Strasse, Building 9, 66421, Homburg (Saar), Germany
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Green SM, Roback MG, Krauss BS, Miner JR, Schneider S, Kivela PD, Nelson LS, Chumpitazi CE, Fisher JD, Gesek D, Jackson B, Kamat P, Kowalenko T, Lewis B, Papo M, Phillips D, Ruff S, Runde D, Tobin T, Vafaie N, Vargo J, Walser E, Yealy DM, O'Connor RE. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med 2020; 73:e51-e65. [PMID: 31029297 DOI: 10.1016/j.annemergmed.2019.02.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Indexed: 11/15/2022]
Abstract
The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.
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Kuypers MI, Klijn A, Mullaart-Jansen NE, Plötz FB. Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands. World J Emerg Med 2020; 11:69-73. [PMID: 32076470 DOI: 10.5847/wjem.j.1920-8642.2020.02.001] [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] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians. METHODS We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire. RESULTS The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients. CONCLUSION The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.
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Affiliation(s)
| | - Adinda Klijn
- Emergency Department, Dijklanderziekenhuis, Hoorn, the Netherlands
| | | | - Frans B Plötz
- Department of Pediatrics, Tergooi Hospital, Blaricum, the Netherlands
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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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Barnes BC, Kamat PP, McCracken CM, Santore MT, Mallory MD, Simon HK, Sulton CD. Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center. J Emerg Med 2019; 57:429-436. [PMID: 31591076 DOI: 10.1016/j.jemermed.2019.06.048] [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: 05/02/2019] [Revised: 06/21/2019] [Accepted: 06/29/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS. OBJECTIVE To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization. METHODS Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded. RESULTS A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed. CONCLUSION Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.
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Affiliation(s)
- Brandi C Barnes
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Pradip P Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Courtney M McCracken
- Division of Biostatistics, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew T Santore
- Department of Pediatrics, Division of Pediatric Surgery, Department of Pediatric Trauma, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael D Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia
| | - Harold K Simon
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Carmen Denease Sulton
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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Sauer H, Bertram H, Dietl M, Haas N. Analgosedierung bei kinderkardiologischen Patienten. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0744-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sauer H, Gruenzinger L, Pfeifer J, Graeber S, Abdul-Khaliq H. Propofol Versus 4-hydroxybutyric Acid in Pediatric Cardiac Catheterizations. Open Med (Wars) 2019; 14:416-425. [PMID: 31198855 PMCID: PMC6555241 DOI: 10.1515/med-2019-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/23/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction Pediatric patients require deep sedation at least for cardiac catheterizations (CCs). Usually, we perform these CCs applying propofol, but we have seen several side effects of this sedative. We have had good experience with 4-hydroxybutyric acid for other sedations. To optimize our standardized CC procedure, we initiated a prospective, randomized trial to compare the two substances. Methods We analyzed our sedation protocols of all CCs within a period of 12 months. In addition to the primary endpoints, the feasibility of the CCs and the occurrence of severe complications, several other parameters were included in the analysis (vital parameters, blood gas analysis, intervention measures). The protocols were blinded for the first part of the evaluation. Results During the 12-month-period, 36 patients were included in each group. The propofol group showed lower blood pressure values towards the end of the sedations, while the blood gas analyses revealed lower pH levels and higher pCO2 values. The complication rate was low in both groups. Conclusion Both procedures are suited for the safe performance of deep sedations for CCs. The application of 4-hydroxybutyric acid seems to have a few advantages with regard to spontaneous breathing, gas exchange, stability of cardiocirculatory parameters and sedation quality.
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Affiliation(s)
- Harald Sauer
- Clinic for Pediatric Cardiology, University Hospital of Saarland, Kirrberger Strasse, 66421Homburg, Germany
- Tel.: ++49 (0) 6841 – 16 – 28374, FAX: ++49 (0) 6841 – 16 – 28452
| | - Laura Gruenzinger
- Clinic for Dermatology – Lippe Hospital Detmold, Roentgenstrasse 18, 32756Detmold, Germany
| | - Jochen Pfeifer
- Clinic for Pediatric Cardiology – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
| | - Stefan Graeber
- Institute of Medical Biometry, Epidemiology and Medical Computer Science – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
| | - Hashim Abdul-Khaliq
- Clinic for Pediatric Cardiology – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
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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: 130] [Impact Index Per Article: 26.0] [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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Schultz ML, Niescierenko M. Guidance for Implementing Pediatric Procedural Sedation in Resource-Limited Settings. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Boriosi JP, Zhao Q, Preston A, Hollman GA. The utility of the pretracheal stethoscope in detecting ventilatory abnormalities during propofol sedation in children. Paediatr Anaesth 2019; 29:604-610. [PMID: 30801831 DOI: 10.1111/pan.13616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Monitoring of ventilation with capnography or a stethoscope is recommended because the detection of ventilatory abnormalities can be significantly delayed by the use of pulse oximetry alone in patients receiving supplemental oxygen. The aim of this study was to evaluate the diagnostic performance of the pretracheal stethoscope with pulse oximetry and capnography in detecting adverse respiratory events during propofol sedation in nonintubated children. We hypothesized that use of the pretracheal stethoscope would facilitate earlier detection of adverse respiratory events. METHODS This was a prospective observational study of children undergoing procedural sedation at a pediatric sedation program. A pretracheal stethoscope, pulse oximetry, and nasal capnography were attached at the discretion of the sedation nurse and provider to monitor ventilation. RESULTS We enrolled 104 patient encounters (mean recorded time, SD 8.3 ± 5.3 minutes) from February, 2015 to March, 2017. The pretracheal stethoscope was the first monitor to detect adverse events in 64% (25/39) of patients compared to 18% (7/39) for capnography and 15% (6/39) for pulse oximetry. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation. The positive predictive value for detecting a true ventilation abnormality and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 100% (90%-100%), 18% (10%-31%), and 27% (18%-38%), respectively. The negative predictive value and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 88% (82%-92%), 68% (59%-75%), and 70% (61%-78%), respectively. Limitations are short observation time, nonstandardized application of respiratory monitors, and too much focus on auscultation. CONCLUSION A pretracheal stethoscope in conjunction with capnography and pulse oximetry detects most sedation-related adverse events first. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation.
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Affiliation(s)
- Juan P Boriosi
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin
| | - Qianqian Zhao
- Department of Biostatistics, University of Wisconsin, Madison, Wisconsin
| | - Ashley Preston
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin
| | - Gregory A Hollman
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin
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Reibling ET, Green SM, Phan T, Lopez-Gusman E, Fierro L, Davis A, Sugarman T, Futernick M. Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey. Acad Emerg Med 2019; 26:539-548. [PMID: 30240039 DOI: 10.1111/acem.13619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/04/2018] [Accepted: 09/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California. METHODS We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact. RESULTS We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. CONCLUSIONS In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.
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Affiliation(s)
- Ellen T Reibling
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA
| | - Steven M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA
| | - Tammy Phan
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA
| | - Elena Lopez-Gusman
- California Chapter of the American College of Emergency Physicians, Sacramento, CA
| | - Lizveth Fierro
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA
| | - Andrew Davis
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA
| | - Thomas Sugarman
- Department of Emergency Medicine, Sutter Delta Medical Center, Antioch, CA
| | - Marc Futernick
- Department of Emergency Medicine, California Hospital Med Center, Los Angeles, CA
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31
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Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med 2019; 73:470-480. [DOI: 10.1016/j.annemergmed.2018.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
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Kamat PP, Kudchadkar SR, Simon HK. Sedative and Anesthetic Neurotoxicity in Infants and Young Children: Not Just an Operating Room Concern. J Pediatr 2019; 204:285-290. [PMID: 30270160 DOI: 10.1016/j.jpeds.2018.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/15/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Pradip P Kamat
- Department of Pediatrics, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA; Children's Sedation Services at Egleston, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
| | - Harold K Simon
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
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33
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Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth 2018; 118:344-354. [PMID: 28186265 DOI: 10.1093/bja/aex004] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - B S Krauss
- Division of Emergency Medicine, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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34
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Shavit I, Shavit D, Feldman O, Samuel N, Ilivitzki A, Cohen DM. Emergency Physician-Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series. J Emerg Med 2018; 56:29-35. [PMID: 30389283 DOI: 10.1016/j.jemermed.2018.09.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/04/2018] [Accepted: 09/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation. OBJECTIVE The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI). METHODS We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse. RESULTS Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6-20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79-104 min), 10.5 min (IQR, 9-12 min), 21 min (IQR, 20-30 min), 25 min (IQR, 23-30 min), and 108 min (IQR, 82-161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation. CONCLUSIONS The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician-administered sedation for PRI.
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Affiliation(s)
- Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Danielle Shavit
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Oren Feldman
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Nir Samuel
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Anat Ilivitzki
- Pediatric Imaging Unit, Rambam Health Care Campus, Haifa, Israel
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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35
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Green SM, Roback MG, Krauss BS. The Newest Threat to Emergency Department Procedural Sedation. Ann Emerg Med 2018; 72:115-119. [DOI: 10.1016/j.annemergmed.2017.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Indexed: 11/16/2022]
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36
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Scherrer PD, Rogers AP, Kamat PP. Shifting the Paradigm: The Quiet Revolution of Pediatric Procedural Sedation Practice. Hosp Pediatr 2018; 8:372-374. [PMID: 29844023 DOI: 10.1542/hpeds.2018-0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Patricia D Scherrer
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia; and
| | - Amber P Rogers
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Pradip P Kamat
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia; and
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37
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Low-Dose Propofol for Pediatric Migraine: A Prospective, Randomized Controlled Trial. J Emerg Med 2018; 54:600-606. [DOI: 10.1016/j.jemermed.2018.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/03/2018] [Accepted: 01/06/2018] [Indexed: 11/19/2022]
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38
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Kamat PP, Karaga MK, Wisniewski BL, McCracken CE, Simon HK, Sidhu R, Grunwell JR. Outpatient Procedural Sedation of Patients With Autism Spectrum Disorders for Magnetic Resonance Imaging of the Brain Using Propofol. J Child Neurol 2018; 33:313-319. [PMID: 29439610 DOI: 10.1177/0883073817753908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To quantify the number of personnel, time to induce and complete sedation using propofol for outpatient magnetic resonance imaging (MRI) of the brain, and the frequency of serious adverse events (SAEs) in children with autism spectrum disorder (ASD) compared with children without ASD. RESULTS Baseline characteristics were the same between both groups. Overall sedation success was 99%. Although most children were sedated with ≤3 providers, 10% with ASD needed ≥4 providers (P = .005). The duration of sedation was less for the ASD group compared with the non-ASD group (49 minutes vs 56 minutes, P = .005). There was no difference in SAE frequency between groups (ASD 14% vs non-ASD 16%, P = .57). CONCLUSION Children with ASD can be sedated for brain MRI using propofol with no increased frequency of SAEs compared with children without ASD. Sedation teams should anticipate that 10% of children with ASD may need additional personnel before propofol induction.
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Affiliation(s)
- Pradip P Kamat
- 1 Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,2 Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Marie K Karaga
- 1 Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | | | - Courtney E McCracken
- 3 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Harold K Simon
- 1 Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,4 Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Reet Sidhu
- 5 Division of Pediatric Neurology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Jocelyn R Grunwell
- 3 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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39
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Miller AF, Monuteaux MC, Bourgeois FT, Fleegler EW. Variation in Pediatric Procedural Sedations Across Children's Hospital Emergency Departments. Hosp Pediatr 2018; 8:36-43. [PMID: 29233853 DOI: 10.1542/hpeds.2017-0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Describe the trends in pediatric sedation use over time and determine variation in use of procedural sedation across children's hospital emergency departments (EDs). METHODS We analyzed ED data from 35 hospitals within the Pediatric Health Information System for patients <19 years old who received sedation medications and were discharged from 2009 to 2014. Patients with chronic comorbidities or undergoing intubation were excluded. We determined frequency and trends in use of sedation and compared these between EDs. Descriptive statistics with appropriate weighting were used. RESULTS Of the 1 448 011 patients potentially requiring sedation who presented to the ED, 99 951 (7.9%) underwent procedural sedation. Medication usage in 2014 included ketamine (73.7%), fentanyl and midazolam (15.9%), ketofol (7.3%), and propofol (2.7%). Use of fentanyl and midazolam increased, whereas use of ketamine, pentobarbital, etomidate, chloral hydrate, and methohexital decreased over time. Significant variation exists in the use of sedation across hospitals; in 2014, the sedation rate ranged 0.2% to 32.0%, with a median of 8.0%. The diagnosis with the largest variation in procedural sedation use was dislocation, with sedation rates ranging from 2% to 35%. CONCLUSIONS There is significant variability across pediatric EDs in the use of procedural sedation, suggesting sedations may be performed too often or too little in some hospitals.
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Affiliation(s)
- Andrew F Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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40
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Ionizing radiation from computed tomography versus anesthesia for magnetic resonance imaging in infants and children: patient safety considerations. Pediatr Radiol 2018; 48:21-30. [PMID: 29181580 DOI: 10.1007/s00247-017-4023-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/19/2017] [Accepted: 10/30/2017] [Indexed: 12/20/2022]
Abstract
In the context of health care, risk assessment is the identification, evaluation and estimation of risk related to a particular clinical situation or intervention compared to accepted medical practice standards. The goal of risk assessment is to determine an acceptable level of risk for a given clinical treatment or intervention in association with the provided clinical circumstances for a patient or group of patients. In spite of the inherent challenges related to risk assessment in pediatric cross-sectional imaging, the potential risks of ionizing radiation and sedation/anesthesia in the pediatric population are thought to be quite small. Nevertheless both issues continue to be topics of discussion concerning risk and generate significant anxiety and concern for patients, parents and practicing pediatricians. Recent advances in CT technology allow for more rapid imaging with substantially lower radiation exposures, obviating the need for anesthesia for many indications and potentially mitigating concerns related to radiation exposure. In this review, we compare and contrast the potential risks of CT without anesthesia against the potential risks of MRI with anesthesia, and discuss the implications of this analysis on exam selection, providing specific examples related to neuroblastoma surveillance imaging.
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41
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Sedation and analgesia for procedures in the pediatric emergency room. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ramalho CE, Bretas PMC, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J) 2017; 93 Suppl 1:2-18. [PMID: 28945987 DOI: 10.1016/j.jped.2017.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. DATA SOURCES Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. DATA SYNTHESIS Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. CONCLUSIONS The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.
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Affiliation(s)
- Carlos Eduardo Ramalho
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Pedro Messeder Caldeira Bretas
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil.
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Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med 2017. [PMID: 28650904 PMCID: PMC6287759 DOI: 10.1097/pcc.0000000000001246] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. DESIGN Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. SETTING Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. PATIENTS Children from birth to less than or equal to 21 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. CONCLUSIONS Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.
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Mallory MD, Travers C, McCracken CE, Hertzog J, Cravero JP. Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation. Pediatrics 2017; 140:peds.2017-0009. [PMID: 28759404 DOI: 10.1542/peds.2017-0009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Upper respiratory infections (URIs) are associated with airway adverse events (AAEs) during general anesthesia. There have been no large studies examining the relationship between URIs and AAEs during pediatric procedural sedation. We hypothesized that there would be a relationship between URI status and AAEs in pediatric procedural sedation. METHODS We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Specific questions regarding URI status were added to the database to facilitate our analysis. Characteristics of patients, procedure types, adjunctive medications, adverse events, and airway interventions (AIs) were reported. We performed bivariate analysis of adverse events and URI status, then used a multivariable logistic regression model to assess the relationship between URI status and adverse events. We examined the secondary outcome of AI similarly. RESULTS Of the 105 728 sedations entered into the Pediatric Sedation Research Consortium database during the study period, we were able to use 83 491 for analysis. Controlling for multiple patient, drug, and procedure characteristics, recent and current URI were associated with increased frequency of AAEs. In general, the frequency of AAEs and AIs increased from recent URI, to current URI-clear secretions to current URI-thick secretions. We did not find a relationship between URI status and non-AAEs. CONCLUSIONS URI status is associated with a statistically significant increase in frequency of AAEs and AI during pediatric procedural sedation for the population sedated by our consortium. Although URI status merits consideration in determining potential risk for sedation, rates of some AAEs and AIs remained low regardless of URI status.
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Affiliation(s)
- Michael D Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia;
| | - Curtis Travers
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - James Hertzog
- Department of Pediatrics, Division of Critical Care Medicine, Nemours Alfred I. DuPont Hospital for Children, Wilmington, Delaware; and
| | - Joseph P Cravero
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard University, Boston, Massachusetts
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Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol 2017; 47:974-983. [PMID: 28488002 DOI: 10.1007/s00247-017-3844-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/24/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.
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Wall BF, Magee K, Campbell SG, Zed PJ. Capnography versus standard monitoring for emergency department procedural sedation and analgesia. Cochrane Database Syst Rev 2017; 3:CD010698. [PMID: 28334427 PMCID: PMC6353146 DOI: 10.1002/14651858.cd010698.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting. OBJECTIVES To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015. SELECTION CRITERIA We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA. DATA COLLECTION AND ANALYSIS Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models. MAIN RESULTS We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time. AUTHORS' CONCLUSIONS There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.
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Affiliation(s)
- Brian F Wall
- North York General HospitalDepartment of Emergency Medicine4001 Leslie StTorontoOntarioCanadaM2K 1E1
- St. Michael’s HospitalDepartment of Emergency Medicine30 Bond StreetTorontoOntarioCanadaM5B 1W8
| | - Kirk Magee
- Dalhousie UniversityDepartment of Emergency MedicineQueen Elizabeth II Health Sciences Centre, Halifax Infirmary1796 Summer StreetHalifaxNSCanadaB3H 3A7
| | - Samuel G Campbell
- Dalhousie UniversityDepartment of Emergency MedicineQueen Elizabeth II Health Sciences Centre, Halifax Infirmary1796 Summer StreetHalifaxNSCanadaB3H 3A7
| | - Peter J Zed
- The University of British ColumbiaFaculty of Pharmaceutical Sciences2146 East MallVancouverBCCanadaV6T 1Z3
- The University of British ColumbiaDepartment of Emergency MedicineVancouverCanada
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Jones NE, Kelleman MS, Simon HK, Stockwell JA, McCracken C, Mallory MD, Kamat PP. Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service. Am J Emerg Med 2017; 35:1101-1105. [PMID: 28330689 DOI: 10.1016/j.ajem.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. OBJECTIVE Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. METHODS Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. RESULTS Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2-7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9-2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0-6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28-57). CONCLUSION Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.
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Affiliation(s)
- Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Harold K Simon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Jana A Stockwell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael D Mallory
- Pediatric Emergency Medicine Associates, Atlanta, GA, United States.
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
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Veselis R, Kelhoffer E, Mehta M, Root JC, Robinson F, Mason KP. Propofol sedation in children: sleep trumps amnesia. Sleep Med 2016; 27-28:115-120. [PMID: 27938911 DOI: 10.1016/j.sleep.2016.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/31/2016] [Accepted: 10/04/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Detailed assessments of the effects of propofol on memory in children are lacking. We assessed the feasibility of measuring memory during propofol infusion, as commonly performed in sedation for MRI scanning. In addition, we determined the onset of memory loss in relation to the onset of sedation measured by verbal responsiveness. MATERIALS AND METHODS Children scheduled for sedation for MRI received a 10-min infusion of propofol (3 mg/kg) as they viewed and named 100 simple line drawings, one shown every five seconds, until they were no longer responsive (encoding). A control group receiving no sedation for MRI underwent similar tasks. Sedation was measured as any verbal response, regardless of correctness. After recovery from sedation, recognition memory was tested, with correct yes/no recognitions matched to sedation responses during encoding (subsequent memory paradigm). RESULTS Of the 48 children who received propofol, 30 could complete all study tasks (6.2 ± 1.6 years, 16 males). Individual responses could be modeled in all 30 children. On average, there was a 50% probability of no verbal response 3.1 min after the start of infusion, with 50% memory loss at 2.7 min. Children receiving propofol recognized 65 ± 16% of the pictures seen, whereas the control group recognized 93 ± 5%. CONCLUSION Measurement of memory and sedation is possible in verbal children receiving propofol by infusion in a clinical setting. Despite propofol being an amnestic agent, there was little or no amnestic effect of propofol while the child was verbally responsive. It is important for sedation providers to realize that propofol sedation does not always produce amnesia while the child is responsive. CLINICALTRIALS. GOV NUMBER NCT02278003.
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Affiliation(s)
- Robert Veselis
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | - Eric Kelhoffer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | - Meghana Mehta
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
| | - James C Root
- Neurocognitive Research Lab, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Psychology in Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | | | - Keira P Mason
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States.
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Sulton C, McCracken C, Simon HK, Hebbar K, Reynolds J, Cravero J, Mallory M, Kamat P. Pediatric Procedural Sedation Using Dexmedetomidine: A Report From the Pediatric Sedation Research Consortium. Hosp Pediatr 2016; 6:536-544. [PMID: 27516413 DOI: 10.1542/hpeds.2015-0280] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Dexmedetomidine (DEX) is widely used in pediatric procedural sedation (PPS) by a variety of pediatric subspecialists. The objective of our study was to describe the overall rates of adverse events and serious adverse events (SAEs) when DEX is used by various pediatric subspecialists. METHODS Patients from the Pediatric Sedation Research Consortium (PSRC) database were retrospectively reviewed and children that received DEX as their primary sedation agent for elective PPS were identified. Demographic and clinical data, provider subspecialty, and sedation-related complications were abstracted. SAEs were defined as death, cardiac arrest, upper airway obstruction, laryngospasm, emergent airway intervention, unplanned hospital admission/increased level of care, aspiration, or emergency anesthesia consult. Event rates and 95% confidence intervals (CIs) were calculated. RESULTS During the study period, 13 072 children were sedated using DEX, accounting for 5.3% of all sedation cases entered into the PSRC. Of the sedated patients, 73% were American Society of Anesthesiologists Physical Status class 1 or 2. The pediatric providers responsible for patients sedated with DEX were anesthesiologists (35%), intensivists (34%), emergency medicine physicians (12.7%), hospitalists (1.1%), and others (17%). The overall AE rate was 466/13 072 (3.6%, 95% CI 3.3% to 3.9%). The overall SAE rate was 45/13 072 (0.34%, 95% CI 0.19% to 0.037%). Airway obstruction was the most common SAE: 35/13 072 (0.27%, 95% CI 0.19% to 0.37%). Sedations were successful in 99.7% of cases. CONCLUSIONS We report the largest series of PPS using DEX outside the operating room. Within the PSRC, PPS performed using DEX has a very high success rate and is unlikely to yield a high rate of SAEs.
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Affiliation(s)
| | | | - Harold K Simon
- Department of Pediatrics, and Divisions of Pediatric Emergency Medicine and
| | - Kiran Hebbar
- Department of Pediatrics, and Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jason Reynolds
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | - Joseph Cravero
- Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts; and
| | - Michael Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Pradip Kamat
- Department of Pediatrics, and Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia;
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Sauter TC, Hautz WE, Hostettler S, Brodmann-Maeder M, Martinolli L, Lehmann B, Exadaktylos AK, Haider DG. Interprofessional and interdisciplinary simulation-based training leads to safe sedation procedures in the emergency department. Scand J Trauma Resusc Emerg Med 2016; 24:97. [PMID: 27485431 PMCID: PMC4970284 DOI: 10.1186/s13049-016-0291-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
Background Sedation is a procedure required for many interventions in the Emergency department (ED) such as reductions, surgical procedures or cardioversions. However, especially under emergency conditions with high risk patients and rapidly changing interdisciplinary and interprofessional teams, the procedure caries important risks. It is thus vital but difficult to implement a standard operating procedure for sedation procedures in any ED. Reports on both, implementation strategies as well as their success are currently lacking. This study describes the development, implementation and clinical evaluation of an interprofessional and interdisciplinary simulation-based sedation training concept. Methods All physicians and nurses with specialised training in emergency medicine at the Berne University Department of Emergency Medicine participated in a mandatory interdisciplinary and interprofessional simulation-based sedation training. The curriculum consisted of an individual self-learning module, an airway skill training course, three simulation-based team training cases, and a final practical learning course in the operating theatre. Before and after each training session, self-efficacy, awareness of emergency procedures, knowledge of sedation medication and crisis resource management were assessed with a questionnaire. Changes in these measures were compared via paired tests, separately for groups formed based on experience and profession. To assess the clinical effect of training, we collected patient and team satisfaction as well as duration and complications for all sedations in the ED within the year after implementation. We further compared time to beginning of procedure, time for duration of procedure and time until discharge after implementation with the one year period before the implementation. Cohen’s d was calculated as effect size for all statistically significant tests. Results Fifty staff members (26 nurses and 24 physicians) participated in the training. In all subgroups, there is a significant increase in self-efficacy and knowledge with high effect size (dz = 1.8). The learning is independent of profession and experience level. In the clinical evaluation after implementation, we found no major complications among the sedations performed. Time to procedure significantly improved after the introduction of the training (d = 0.88). Discussion Learning is independent of previous working experience and equally effective in raising the self-efficacy and knowledge in all professional groups. Clinical outcome evaluation confirms the concepts safety and feasibility. Conclusion An interprofessional and interdisciplinary simulation-based sedation training is an efficient way to implement a conscious sedation concept in an ED.
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Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Simone Hostettler
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Monika Brodmann-Maeder
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Luca Martinolli
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Dominik G Haider
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
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