Sedation for the pediatric patient. A review

Comparative Study of Intranasal Dexmedetomidine Versus Intranasal Ketamine as Premedicant in Children

Background: Pre-operative anxiety in children not only makes induction difficult but it is also associated with an increase in the requirement of analgesics, the incidence of post-operative nausea and vomiting (PONV), emergence delirium (ED), and postoperative maladaptive behavioral changes. It can be reduced effectively by pharmacological interventions. In a quest to find the ideal premedicant and non-invasive way of its administration, we decided to compare intranasal (IN) dexmedetomidine with IN ketamine as a premedicant in pediatric patients.

Aims and objectives: To compare sedation score, mask acceptance score (MAS) during induction, the incidence of ED, and other adverse events in both groups.

Material and methods: Some 60 children, between 1 and 8 years of age of either sex undergoing surgical procedures were included in this study and randomly divided into two groups (Group D and Group K). Thirty minutes prior to induction of anesthesia, patients of Group D received dexmedetomidine 1 mcg kg^-1 in 1 mL of 0.9% saline intranasally and patients of Group K received ketamine 5 mg kg^-1 in 1 mL of 0.9% saline intranasally through calibrated dropper (0.5 mL in each nostril) in a recumbent position. Incidences of sneezing or coughing after IN administration of study drugs were recorded. The subsequent sedation scores were assessed using MOASS at 15 min, then at 30 min following premedication at the time of parental separation. After shifting patients to operation theater inhalation induction was done. MAS at induction and any adverse effects were recorded.

Results: Children in Group K were found to be significantly more sedated at 30 min after administration of premedication and mask acceptance was also better (p value < 0.0001 with a confidence interval, CI=95%). But the incidence of ED and PONV was high.

Conclusion: Intranasal dexmedetomidine (1 mcg kg^-1) is clinically less effective as a premedicant in terms of sedation and mask acceptance in older children as compared to ketamine (5 mg kg^-1), but associated with fewer incidence of ED and PONV. We recommend the usage of IN dexmedetomidine in a higher dose (1.5-2 mcg kg^-1), through nebulization/atomizer for the desired level of sedation and mask acceptance.

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

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

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

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

Efficacy of midazolam as oral premedication in children in comparison to triclofos sodium

BACKGROUND AND AIMS

The perioperative behavioural studies demonstrate that children are at greater risk of experiencing turbulent anaesthetic induction and adverse behavioural sequelae. We aimed to compare the efficacy of midazolam 0.5 mg/kg with triclofos sodium 100 mg/kg as oral premedication in children undergoing elective surgery.

METHODS

In this prospective, randomised and double-blind study, sixty children posted for elective lower abdominal surgery were enrolled. The patients were randomly divided into midazolam group (Group M) and triclofos sodium group (Group T) of thirty each. Group M received oral midazolam 0.5 mg/kg 30 min before induction, and Group T received oral triclofos sodium 100 mg/kg 60 min before induction. All children were evaluated for level of sedation after premedication, behaviour at the time of separation from parents and at the time of mask placement for induction of anaesthesia. Mann-Whitney U-test was used for comparing the grade of sedation, ease of separation and acceptance of face mask.

RESULTS

Oral midazolam produced adequate sedation in children after premedication in comparison to oral triclofos (P = 0.002). Both drugs produced successful separation from parents, and the children were very cooperative during induction. No adverse effects attributable to the premedicants were seen.

CONCLUSIONS

Oral midazolam is superior to triclofos sodium as a sedative anxiolytic in paediatric population.

A prospective, randomized, double blinded comparison of intranasal dexmedetomodine vs intranasal ketamine in combination with intravenous midazolam for procedural sedation in school aged children undergoing MRI

Background:

For optimum magnetic resonance imaging (MRI) image quality and to ensure precise diagnosis, patients have to remain motionless. We studied the effects of intranasal dexmedetomidine and ketamine with intravenous midazolam for pre-procedural and procedural sedation in school aged children.

Patients and Methods:

Children were randomly allocated to one of two groups: (Group D) received intranasal dexmedetomidine 3 μg kg^–1 and (Group K) received intranasal ketamine 7 mg kg^–1. Sedation levels 10, 20 and 30 min after drug instillation were evaluated using a Modified Ramsay sedation scale. A 4-point score was used to evaluate patients when they were separated from their parents and their response to intravenous cannulation.

Results:

The two groups were comparable in terms of the child's anxiety at presentation (P = 0.245). We observed that Group K achieved faster sedation at 10 min point with P < 0.05. A comparable sedation score at 20 and 30 min were noted. The two groups were comparable regarding to the child's acceptance of nasal administration (P = 0.65). The sedation failure rate was insignificantly differ between groups (13.7% vs. 20.6% for Group D and K respectively). Heart rate and systolic blood pressure showed a significant difference between the two groups starting from the point of 20 min.

Conclusion:

Intranasal dexmedetomidine 3 μg kg^–1 or ketamine 7 mg kg^–1 can be used safely and effectively to induce a state of moderate conscious sedation and to facilitate parents’ separation and IV cannulation. Addition of midazolam in a dose not sufficient alone to produce the target sedation achieved our goal of deep level of sedation suitable for MRI procedure.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

The association for behavior analysis international position statement on restraint and seclusion

A task force authorized by the Executive Council of the Association for Behavior Analysis International (ABAI) generated the statement below concerning the techniques called restraint and seclusion. Members of the task force independently reviewed the scientific literature concerning restraint and seclusion and agreed unanimously to the content of the statement. The Executive Council accepted the statement, and it was subsequently approved by a two-thirds majority vote of the general membership. It now constitutes official ABAI policy. The position statement is posted on the ABAI Web site (www.abainternational.org/ABA/statements/RestraintSeclusion.asp). The purpose of the position statement is to provide guidance to behavior analysts and other professionals interested in the position of ABAI on these controversial topics. In extreme cases, abuses of procedures erroneously used in the name of behavior analysis are not defensible. On the other hand, behavior analysts acting ethically and in good faith are provided with guidelines for sound and acceptably safe practice. To the extent that behavior-analytic positions influence public policy and law, this statement can be presented to officials and lawmakers to guide informed decision making. At the conclusion of the document, a bibliography is provided of articles and presentations considered by one or more task force members in developing the position statement.

Stratification of sedation risk--a challenge to the sedation continuum

We detail the limitations of the current paradigm of the sedation continuum - a tool ubiquitous to all sedation care settings and now a quarter century old. Definitions in this existing taxonomy are based on patient responsiveness to verbal and/or tactile stimuli, and the inherent subjectivity of this focus has both challenged the reliable assessment of adverse event risk and precluded clear delineation of sedation boundaries, e.g., what is the dividing line between moderate and deep sedation? We present the rationale to support a broadening of this sedation continuum precept to include an objective mechanism to predict the ongoing risk of serious adverse events, and then propose sequential steps for the development of such a restructured framework. This process, while ambitious, would yield a clear and consistent language to facilitate quality assurance, provide an objective framework for standardized sedationist training and credentialing, and permit inclusion into computerized decision-support algorithms to facilitate more precise sedative delivery. It is important to clearly delineate this goal now to permit design and initiation of the requisite research.

[Sedation with sevoflurane for magnetic resonance imaging in pediatrics: retrospective study of 5864 cases]

OBJECTIVE

To evaluate the use of sevoflurane for sedating pediatric patients undergoing magnetic resonance imaging studies.

MATERIAL AND METHODS

Data were extracted retrospectively from the records of 5864 pediatric patients (aged 0-18 years) who had undergone magnetic resonance imaging studies in our hospital from 1999 to 2004. Sevoflurane was usually administered at high concentrations of up to 7% on induction; after 2 minutes the concentration was reduced. The patient, breathing spontaneously, was kept sedated with a sevoflurane concentration of 1.5% to 2% in a mixture of 50% nitrous oxide and 50% oxygen.

RESULTS

Optimal sedation was achieved in 5789 (98.72%) of the cases treated. Complications included 11 episodes of vomiting, 53 cases (0.9%) of mild respiratory depression, 6 cases of severe respiratory depression on induction, and 5 cases of agitation. There were no cases of prolonged sedation.

CONCLUSION

Sevoflurane is useful for sedating pediatric patients in the setting of this study. Induction is rapid and gentle, and maintained sedation is constant, stable and homogeneous. Awakening and recovery are rapid, and the incidence of complications low.

Magnetic resonance imaging anesthesia: new challenges and techniques

PURPOSE OF REVIEW

The increasing use of magnetic resonance imaging as a diagnostic modality has led to increased demand for sedation and monitoring during the procedure. This review is to acquaint the reader with the most recent developments in magnetic resonance imaging diagnostics and to describe the evolving techniques and strategies for patient management.

RECENT FINDINGS

Many centers are meeting the challenges of increasing demand by streamlining their sedation/anesthetic protocols to achieve greater efficiency. Some have enlisted the help of nursing staff who are trained to provide sedation for certain patients. Continued experience in magnetic resonance imaging anesthesia has led to a better understanding of patient needs and decreased the number of failed procedures. The scope of magnetic resonance imaging diagnostics has expanded to include urology, otolaryngology, and neonatal evaluation. Although infants and children constitute the majority of patients, many adults also require anesthesia for magnetic resonance imaging and present their own challenges.

SUMMARY

Anesthesia and sedation during magnetic resonance imaging have a unique set of constraints. However, most of the standards of modern, safe anesthetic care can be met in this environment. The growing experience at many hospitals has demonstrated that a wide range of patients can receive safe care during magnetic resonance imaging.

Emergency endoscopy in children

Endoscopy in children has developed along with pediatric gastroenterology over the last four decades. Introduction of endoscopic techniques in adults precedes application in children, and pediatric endoscopists do fewer procedures than their adult counterparts whether routine or as an emergency. Training for pediatric endoscopists therefore needs to be thorough. This article in particular highlights developments in pediatric gastroenterology of importance to emergency procedures.

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update

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 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 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 tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for 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 people to 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 presedation level of consciousness before discharge from medical 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.

Management of preoperative anxiety in children

Although anesthesia during surgery prevents children from recalling actual surgical events, they are subjected to stressful events while preparing for surgery. One estimate suggests that 60% of children experience significant anxiety before anesthesia induction and surgery, and literature from around the world indicates that preoperative anxiety is a global concern for health care providers. The challenge that nurses face is to better manage children's anxiety in today's fast paced ORs. This article uses case studies to show nursing strategies that can be used to help allay the fears of children at different psychosocial stages of development.

Etomidate Versus Midazolam for Procedural Sedation in Pediatric Outpatients: A Randomized Controlled Trial

STUDY OBJECTIVE

Midazolam is widely used for procedural sedation and analgesia. Etomidate has been studied mostly in adults. Our objective is to compare the efficacy of etomidate and midazolam for achieving procedural sedation and analgesia in children.

METHODS

A randomized, double-blind, emergency department and orthopedic clinic-based trial was carried out among patients aged 2 to 18 years with displaced extremity fractures. Patients were administered 1 microg/kg of fentanyl and either 0.2 mg/kg of etomidate or 0.1 mg/kg of midazolam. Adequate sedation was defined, for the purpose of this study, as a score of 4 or more on the Ramsay Sedation Scale. The primary outcome was induction and recovery time. The rates of adverse events, success of fracture reduction, and parent and physician satisfaction were also compared.

RESULTS

From April to August 2004, 100 of 128 eligible patients were enrolled (age 8.7+/-3.7 years; 50% male patients). A higher proportion of patients attained adequate sedation among those who received etomidate: 46 of 50 (92%) versus 18 of 50 (36%) (delta 56%; 95% confidence interval [CI] 38% to 69%). Time taken for induction (hazard ratio 4.9; 95% CI 2.2 to 10.9) and time taken for recovery (hazard ratio 2.8; 95% CI 1.5 to 5.1) were lower among patients who received etomidate. The rates of adverse events were similar in both groups, except for myoclonus and pain at the injection site, which was more frequent in the etomidate group.

CONCLUSION

Induction and recovery times are shorter with etomidate compared with midazolam. At the dosages used for procedural sedation and analgesia among children with displaced extremity fracture, etomidate has higher efficacy in comparison with midazolam.

Oral versus intranasal midazolam premedication for infants during echocardiographic study

Movement and anxiety during echocardiographic study may reduce the reliability and affect the quality of echocardiographic images. Thus, sedation is an essential component when it is performed in infants. This randomized, single-blinded, placebo-controlled study was undertaken to evaluate the acceptability and effectiveness of intranasal midazolam (INM) versus oral midazolam (OM) in infants during transthoracic echocardiography. Eighty patients between the ages of 6 mo and 3 y who presented for elective echocardiographic study were divided into 3 groups: the OM group received 0.4 mg/kg of injectable midazolam mixed with an equal volume of cherry juice, the INM group received 0.2 mg/kg as drops,and the control group was given oral cherry juice or intranasal serum physiologic. A blinded clinician assessed and scored the level of sedation and comfort during the procedure for each child, and a score for ease of administration was recorded by the nurse. The intranasal route was more acceptable to infants than the oral route (P<.001). No significant difference in the effects of sedation was observed between the OM group and the INM group (P=.583), but significant differences were observed between the sedated groups and the control group (P<.001). The procedure was significantly more comfortable in groups given OM and INM than in the control group (P<.001). Although no difference in sedation score was seen between the oral and nasal routes, INM was better accepted by infants than OM. Echocardiography was performed more reliably and comfortably in those given midazolam than in those in the control group.

Sedation for procedures in children: a guide for the non-anaesthetist

The aim of this review is to provide a succinct guide to sedation of children for procedures. Uncooperative children are notoriously hard to sedate and the choice of appropriate technique depends upon the intended procedure. It is too easy to exceed safe dose limits and cause airway obstruction or respiratory depression. ‘Sedationists’ must remember that safety is paramount; they must receive training and work within protocols. Published guidelines are available.

[Management of agitated, violent or psychotic patients in the emergency department: an overdue protocol for an increasing problem]

Patients with extreme agitation, delirium, violent behavior or acute psychosis are frequently evaluated in the emergency departments of general hospitals. However, the traditional infrequency of this type of situation in pediatric emergency services can lead to a certain lack of foresight and efficiency in the initial management of these patients. Because of the current known increase of psychosocial disorders in pediatric emergencies, new pharmacological treatments for juvenile psychotic processes, and particularly the lack of compliance with these treatments, as well as the earlier consumption of ever more varied illicit drugs among young people, the frequency and diversity of this kind of disorder is on the increase. The treatment of agitation, aggression and violence begins with successful management of the acute episode, followed by strategies designed to reduce the intensity and frequency of subsequent episodes. The key to safety is early intervention to prevent progression from agitation to aggression and violence. Consequently, urgent measures designed to inhibit agitation should be adopted without delay by the staff initially dealing with the patient, usually in the emergency unit. Patients with psychomotor agitation disorder (PMAD) may require emergency physical and/or chemical restraints for their own safety and that of the healthcare provider in order to prevent harmful clinical sequelae and to expedite medical evaluation to determine the cause. However, the risks of restraint measures must be weighed against the benefits in each case. This review aims to present the emergency measures to be taken in children with PMAD. The distinct etiological situations and criteria for the choice of drugs for chemical restraint in each situation, as well as the complications associated with certain drugs, are discussed. It is advisable, therefore, that health professionals become familiar with the distinct pharmacological options.

The management of infants and children for painless imaging

The ability of a child to remain sufficiently immobile for painless imaging depends upon their behaviour and the imaging itself. Anaesthesia allows imaging to be optimised but it is expensive, scarce and inappropriate for many situations. Fortunately, sedation and behavioural techniques are sufficiently successful for the majority of scanning, and success rates are high provided that suitable children are selected. Sedation, however, administered by non-anaesthetists, may have catastrophic complications such as airway obstruction. Current UK recommendations demand that any sedation technique has a 'wide margin of safety', but in addition to this, safety is dependent on trained, skillful and experienced staff. Magnetic resonance imaging frightens many children and special planning is necessary for sedation and anaesthesia. When planning an imaging service for children, all the management techniques should be considered in order to achieve maximum efficiency, quality and safety.

Topical adrenaline and cocaine gel for anaesthetising children's lacerations. An audit of acceptability and safety

OBJECTIVES

(1) To assess the acceptability of a gel solution of adrenaline (epinephrine) (1 in 2000) and cocaine (5%) for anaesthetising children's facial lacerations to the child, parent, and operator. (2) To assess the safety of the current protocol.

SETTING

The emergency unit of a large university hospital.

METHODS

All patients who were treated with topical adrenaline and cocaine (topAC) gel over a six month period were entered into a prospective audit (n = 75). Patient details, the nature and cause of the injury, and any treatment carried out were all recorded. The acceptability to children over 3 years of age, was assessed by the use of the Wong Baker face scale, in which 0 represents "no hurt" and 5 represents "hurts worst". The acceptability to both the parent and the operator was assessed by the use of a 0 to 9 Likert scale, where 0 represented "very acceptable" and 9 represented "not at all" acceptable.

RESULTS

(1) Children aged 3 years or older graded their pain during the procedure as having a mean value of 1.17 on the Wong Baker (0 to 5) scale. Parents graded acceptability on the Likert scale (0 to 9) with a mean score of 1.13. Operators using the same grading system, recorded a mean score of 1.75. (2) No toxic side effects were seen but the protocol was updated in line with evidence.

CONCLUSIONS

Topical adrenaline and cocaine is an effective anaesthetic for suturing children's facial lacerations and is acceptable to child, parent, and operator alike.

Magnetic resonance imaging under sedation in newborns and infants: a study of 640 cases using sevoflurane

BACKGROUND

The purpose of the present study was to show that sevoflurane is a safe and effective agent for the sedation of newborns and infants who are to undergo magnetic resonance imaging (MRI) examinations.

METHODS

The study was performed on 640 infants aged from 1 day to 12 months given sevoflurane in high concentrations--up to 7% at the 2 min induction peak. Following induction and during MRI examination, the children were maintained with spontaneous respiration and sedation levels with a sevoflurane concentration of approximately 1.5-2%, in combination with a mixture of oxygen and nitrous oxide (50% O(2)-50% N(2)O).

RESULTS

Sedation proved optimal in 97.9% of cases and complications were one case of vomiting, eight cases of minor hypoxia and two of severe hypoxia. No case of prolonged sedation or postoperative emergence agitation was observed.

CONCLUSIONS

Sevoflurane is an ideal agent for this type of diagnostic procedure in newborns and infants. We discuss the need for elaborating specific protocols for pediatric sedation and emphasize the strict observation of recommendations, which include the practical experience and up-to-date specialized training of the anesthesiologist carrying out sedation procedures in children.

Evolving treatment in a decade of pediatric burn care

BACKGROUND

Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Children's Hospital (SLCH). This study assessed the effect of these interventions on resource utilization.

METHODS

The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges.

RESULTS

Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated (+48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [-53%]). LOS declined from 10.4 +/- 8.3 days (1993) to 5.8 +/- 14.2 days (2002 [-44%; P <.05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P <.05) Average charge per patient fell 45% from 13,286 dollars (1993) to 7,372 dollars (2002), adjusted to 1993 dollars using medical care price index.

CONCLUSIONS

Over a 10-year period, the program achieved a significant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS.

Sedation and analgesia in the pediatric patient

The administration of sedation and analgesia for pediatric gastrointestinal procedures has become routine but is not standardized. For the most part, pediatric endoscopists are encouraged to use their clinical judgment to select between using intravenous (IV) sedation or general anesthesia on an individual patient basis. Commonly administered IV sedation regimens in children combine benzodiazepines with narcotics, but anesthesiologist administered propofol sedation is gaining acceptance among pediatric gastroenterologists. Guidelines for patient monitoring and new technologic advances may help to ensure patient safety for children undergoing endoscopic procedures, no matter what sedation regimen is used.

High-dose rectal midazolam for pediatric procedures: a randomized trial of sedative efficacy and agitation

OBJECTIVES

To compare 2 doses of rectal midazolam, used for pediatric emergency department sedation, with regard to sedative efficacy and frequency of paradoxical agitation.

METHODS

Children <or=48 months old undergoing cutaneous procedures received midazolam by rectum, randomized in double-blind fashion to standard (0.5 mg/kg, SDM) or high (1 mg/kg, HDM) doses. Behaviors were scored on a 5-point sedation scale before and during procedures. Proportions manifesting successful sedation and postprocedure agitation were compared between the 2 doses.

RESULTS

Sixty-five patients (32 SDM, 33 HDM) underwent sedated procedures (repair of lacerations, 97%). Behavior scores improved for both groups following medication administration and at best sedation during procedure. HDM produced better sedation at time of first suture (successful sedation: 70%, SDM vs. 91%, HDM; intergroup difference = 21%; 95% confidence interval [CI] = 2, 41) and at best point during the procedure (72%, SDM vs. 97%, HDM; Delta = 25%; 95% CI = 8, 43). However, sedative efficacy declined such that only 50% and 73% of the SDM and HDM groups, respectively, had successful sedation at the worst point during the procedures. Postprocedure agitation occurred in 17% of patients (6%, SDM vs. 27%, HDM; Delta = 21%; 95% CI = 3, 39).

CONCLUSIONS

Rectal midazolam improved sedation scores over preprocedure levels and was more effective with a dose of 1 mg/kg than with 0.5 mg/kg. However, inadequate sedation in 27-50% of patients and prolonged agitation in 27% of patients at higher doses counter the advantages of rectal midazolam.

Use of intramuscular ketamine for endoscopy sedation in children

OBJECTIVE

To report the experience of the use of intramuscular (IM) ketamine for endoscopy sedation in children.

METHODOLOGY

Children over 6 months of age scheduled for elective endoscopy - esophagogastroduodenoscopy (EGD), bronchoscopy and nasopharyngolaryngoscopy (NPL) were enrolled for (2 mg/kg to 3 mg/kg) intramuscular ketamine sedation. A repeated dose of 2 mg/kg intramuscular ketamine was administered to those who failed the first sedation. Alternative sedation (intravenous midazolam and fentanyl) was given to children who failed ketamine sedation twice. Sedation was regarded as successful if the procedure was completed by endoscopist with a single dose of ketamine.

RESULTS

Sixty children were enrolled for the study. Overall success rate in our patients was 78.3%. Failure rate in infants was 50%, i.e. 4 out of 8. For children aged 1-7, the failure rate was 32%. Failure rate dropped markedly to 6.7% for those older than 7 years of age, and it showed significant difference when compared with the other two groups. Two cases of laryngospasm were experienced in the present study.

CONCLUSION

Intramuscular ketamine is an effective medication for sedation in endoscopy undertaken in children over age 7 years, but it should be avoided with children under age 7 because of the high failure rate.

Comparison of oral pentobarbital sodium (nembutal) and oral chloral hydrate for sedation of infants during radiologic imaging: preliminary results

OBJECTIVE

The purpose of this study was to compare the safety and efficacy of oral cherry-flavored pentobarbital sodium (Nembutal) and oral chloral hydrate to sedate infants undergoing radiologic imaging.

SUBJECTS AND METHODS

We prospectively recorded data for all infants sedated with oral cherry-flavored pentobarbital sodium and oral chloral hydrate for imaging examinations between January 1997 and August 1999. The parameters recorded were each patient's age, weight, and American Society of Anesthesiologists classification; the time required to sedate; the total length of sedation time; the time required to discharge from the recovery room; and adverse events. The two-sample Student's t test and Fisher's exact test were used for statistical analysis.

RESULTS

Oral pentobarbital sodium was administered to 317 infants. These infants had a mean age +/- SD of 6.9 +/- 3.1 months and a mean weight of 7.8 +/- 4.8 kg; they received a median dose of 4 mg/kg of body weight. Oral chloral hydrate was administered to 358 infants. These infants had a mean age of 5.9 +/- 3.3 months and a mean weight of 7.3 +/- 4.9 kg; they received a median dose of 50 mg/kg of body weight. The mean time required to sedate was 19 +/- 14 min for infants receiving oral pentobarbital sodium and 16 +/- 11 min for infants receiving oral chloral hydrate (p = 0.02); the mean time required to discharge was 100 +/- 35 min for infants in the oral pentobarbital sodium group and 103 +/- 36 min for infants in the oral chloral hydrate group (p = 0.31); the mean length of sedation was 81 +/- 34 min for the oral pentobarbital sodium group and 86 +/- 36 min for the oral chloral hydrate group (p = 0.07); and median American Society of Anesthesiologists classification for both groups was P1. Oral pentobarbital sodium was inadequate for sedation in one patient (0.3%) and chloral hydrate was inadequate for sedation in another (0.3%) (p = 1.00). Adverse events were recorded for five patients (1.6%) in the oral pentobarbital sodium group and for six patients (1.7%) in the chloral hydrate group (p = 0.99).

CONCLUSION

Oral pentobarbital sodium is as safe and efficacious as oral chloral hydrate for sedating infants.

Children with suspected craniosynostosis: a cost-effectiveness analysis of diagnostic strategies

OBJECTIVE

Our purpose was to evaluate the clinical and economic impact of three evaluation strategies in children at different risks of craniosynostosis.

MATERIALS AND METHODS

A decision-analytic and cost-effectiveness model was constructed to compare three evaluation in strategies in children with suspected synostosis: no imaging, radiography (if abnormal, followed by three-dimensional CT [3D CT]), and 3D CT. Three risk groups were analyzed on the basis of the prevalence (pretest probability) of disease: low (completly healthy children; prevalence, 34/100,000), intermediate (healthy children with head deformity; prevalence, 1/115), and high risk (children with syndromic craniofacial disorders [i.e., Crouzon's syndrome or Apert's syndrome]; prevalence, 9-10/10). Test performance (sensitivity and specificity) of the evaluation strategies was obtained from the literature. Costs (not charge) estimates were obtained from the hospital cost-accounting database and from the Medicaid fee schedule.

RESULTS

In the low-risk group, the radiographic and 3D CT strategies resulted in a cost per quality-adjusted life year (QALY) gained of more than $560,000. In the intermediate-risk group, the radiographic strategy resulted in a cost per QALY gained of $54,600. Three-dimensional CT was more effective than the two other strategies but at a higher cost-hence, with a cost per QALY gained of $374,200. In the high-risk group, 3D CT was the most effective strategy with a cost per QALY gained of $33,800. Less experienced radiologists and poor-quality studies increased the evaluation cost per QALY gained for all of the risk groups because of decreased effectiveness.

CONCLUSION

Radiologic screening of completely healthy children (low risk) for synostosis is not warranted because of the high cost per QALY gained of the radiographic and 3D CT strategies. In healthy children with head deformity (intermediate risk), the radiographic strategy had a reasonable cost per QALY gained. Three-dimensional CT was more effective but had a high cost per QALY gained. In children with syndromic craniofacial disorders (high risk), 3D CT was the most effective strategy and had a reasonable cost per QALY gained. Selection of children with suspected craniosynostosis based on their risk group and use of the most appropriate evaluation strategy could maximize clinical and economic outcomes for these patients.

Nitrous oxide-oxygen or oral midazolam for pediatric outpatient sedation

OBJECTIVE

A total of 1112 pediatric outpatient sedations, by either nitrous oxide-oxygen inhalation (N2O) or oral midazolam, administered over a 10-year period were reviewed. Patient responses and outcomes were evaluated to ascertain the safety of these sedation techniques.

STUDY DESIGN

A total of 819 patients were included in this study. Patient health status, age, weight, behavior, treatment rendered, and length of treatment were recorded. Vital signs (heart rate, blood pressure, oxygen saturation) were recorded for the N2O group. Complications and successful completion of treatment were also noted.

RESULTS

Both the N2O and midazolam groups demonstrated a low complication rate with a high rate of successful completion of treatment. Patients receiving N2O were somewhat older on average and underwent a greater number of surgical procedures than patients in the midazolam group. Vital signs recorded in the N2O group were observed to remain stable throughout treatment.

CONCLUSIONS

The use of either oral midazolam or nitrous oxide-oxygen as single agents provides safe and effective conscious sedation in the pediatric outpatient population.

Newborns with suspected occult spinal dysraphism: a cost-effectiveness analysis of diagnostic strategies

OBJECTIVE

To assess the clinical and economic consequences of different diagnostic strategies in newborns with suspected occult spinal dysraphism.

METHODS

A decision-analytic model was constructed to project the cost and health outcomes of magnetic resonance imaging (MRI), ultrasound (US), plain radiographs, and no imaging in newborns with suspected occult spinal dysraphism. Morbidity and mortality rates of early versus late diagnosis of dysraphism and the sensitivity and specificity of MRI, US, and plain radiographs were obtained from the literature. Cost estimates were obtained from a hospital cost accounting database and from the Medicaid fee schedule.

RESULTS

We found that the choice of imaging strategy depends on the underlying risk of occult spinal dysraphism. In low-risk children with intergluteal dimple or newborns of diabetic mothers (pretest probability: 0.3%-0.34%), US was the most effective strategy with an incremental cost-effectiveness ratio of $55 100 per quality-adjusted life year gained. For children with lumbosacral dimples, who have a higher pretest probability of 3.8%, US was less costly and more effective than the other 3 strategies considered. In intermediate-risk newborns with low anorectal malformation (pretest probability: 27%), US was more effective and less costly than radiographs and no imaging. However, MRI was more effective than US at an incremental cost-effectiveness of $1000 per quality-adjusted life year gained. In the high-risk group that included high anorectal malformation, cloacal malformation, and exstrophy (pretest probability: 44%-46%), MRI was actually cost-saving when compared with the other diagnostic strategies. For the intermediate-risk group, we found our analysis to be sensitive to the costs and diagnostic performances (sensitivity and specificity) of MRI and US. Lower MRI cost or greater MRI diagnostic performance improved the cost-effectiveness of the MRI strategy, whereas lower US cost or greater US diagnostic performance worsened the cost-effectiveness of the MRI strategy. Therefore, individual or institutional expertise with a specific diagnostic modality (MRI versus US) may influence the optimal diagnostic strategy.

CONCLUSIONS

In newborns with suspected occult dysraphism, appropriate selection of patients and diagnostic strategy may increase quality-adjusted life expectancy and decrease cost of medical work-up.

Thoracic CT technique in children

Computed tomography (CT) is a powerful tool for imaging the different structures of the child's thorax. Pediatric thoracic CT technique should provide images that allow confident diagnosis at the lowest risk to the patient. New data has increased our understanding of the risk of low-dose radiation. Understanding the technical aspects of CT scanning allows the CT scanner to be optimized for the best combination of image quality and radiation dose. Developments in CT scanning, including multidetector scanners and vascular imaging techniques, are changing the way CT scanning is used. The many imaging options available to the thoracic radiologist require a complex set of decisions when establishing CT protocols and when selecting techniques for different clinical indications. This article presents information on radiation risk and provides an overview of the broad range of factors used when performing pediatric thoracic CT.

Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies

OBJECTIVE

To assess the clinical and economic consequences of 3 diagnostic strategies-magnetic resonance imaging (MRI), computed tomography followed by MRI for positive results (CT-MRI), and no neuroimaging with close clinical follow-up-in the evaluation of children with headache suspected of having a brain tumor. Three risk groups based on clinical variables were evaluated.

MATERIALS AND METHODS

A decision-analytic Markov model and cost-effectiveness analysis was performed incorporating the risk group prior probability, MRI and CT sensitivity and specificity, tumor survival, progression rates, and cost per strategy. Outcomes were based on quality-adjusted life year (QALY) gained and incremental cost per QALY gained.

RESULTS

For low-risk children with chronic nonmigraine headaches of >6 months' duration as the sole symptom (prior probability of brain tumor 0.01%), no neuroimaging with close clinical follow-up was less costly and more effective than the 2 neuroimaging strategies. For the intermediate-risk children with migraine headache and normal neurologic examination (prior probability of brain tumor 0.4%), CT-MRI was the most effective strategy but cost >$1 million per QALY gained compared with no neuroimaging. For high-risk children with headache of <6 months' duration and other clinical predictors of a brain tumor such as an abnormal neurologic examination (prior probability of brain tumor 4%), the most effective strategy was MRI, with cost-effectiveness ratio of $113 800 per QALY gained compared with no imaging.

CONCLUSION

Our analysis suggests that MRI maximizes QALY gained at a reasonable cost-effectiveness ratio in children with headache at high risk of having a brain tumor. Conversely, the strategy of no imaging with close clinical follow-up is cost saving in low-risk children. Although the CT-MRI strategy maximizes QALY gained in the intermediate-risk patients, its additional cost per QALY gained is high. In children with headache, appropriate selection of patients and diagnostic strategy may maximize quality-adjusted life expectancy and decrease costs of medical workup.

Anxiolysis with oral midazolam in pediatric patients undergoing dermatologic surgical procedures

BACKGROUND

Pediatric patients undergoing dermatologic surgical procedures often experience high levels of anxiety. Oral midazolam is a short-acting benzodiazepine that can ameliorate procedure-related anxiety.

OBJECTIVE

Our purpose was to determine the safety and efficacy of oral midazolam as an adjuvant anxiolytic agent for pediatric patients undergoing dermatologic surgical procedures.

METHODS

A prospective series of pediatric patients undergoing dermatologic surgical procedures who received oral midazolam were monitored, and efficacy and complications were recorded.

RESULTS

Oral midazolam provided good to excellent anxiolytic effects in most pediatric patients undergoing painful dermatologic surgical procedures. Because midazolam does not provide analgesic effects, local anesthesia is necessary. Complications were uncommon and minor.

CONCLUSION

Oral midazolam is an effective anxiolytic agent in pediatric patients undergoing dermatologic surgical procedures.

Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation

OBJECTIVES

This study compared intranasal midazolam (INM) with a combination of intravenous ketamine and intravenous midazolam (IVKM) for sedation of children requiring minor procedures in the emergency department.

METHOD

A single blinded randomised clinical trial was conducted in the emergency department of a major urban paediatric hospital. Subjects requiring sedation for minor procedures were randomised to receive either INM (0.4 mg/kg) or intravenous ketamine (1 mg/kg) plus intravenous midazolam (0.1 mg/kg). Physiological variables and two independent measures of sedation (Sedation Score and Visual Analogue Sedation Scale) were recorded before sedation and at regular intervals during the procedure and recovery period. Times to adequate level of sedation and to discharge were compared.

RESULTS

Fifty three patients were enrolled over a 10 month period. Sedation was sufficient to complete the procedures in all children receiving IVKM and in 24 of the 26 receiving INM. Onset of sedation was an average of 5.3 minutes quicker with IVKM than with INM (95%CI 3.2, 7.4 minutes, p<0.001). Children given INM were discharged an average of 19 minutes earlier than those given IVKM (95%CI 4, 33 minutes, p=0.02). Mean Sedation Scores and Visual Analogue Sedation Scale scores for the 30 minutes after drug administration were significantly better in children given IVKM compared with INM (2.4 and 1.8 versus 3.5 and 3.8, respectively). Both doctors and parents were more satisfied with sedation by intravenous ketamine and midazolam.

CONCLUSIONS

Intravenous ketamine plus midazolam used in an appropriate setting by experienced personnel provides an excellent means of achieving sedation suitable for most non-painful minor procedures for children in the emergency department. This combination is superior to INM in terms of speed of onset and consistency of effect. INM delivered via aerosol spray has a more variable effect but may still be adequate for the completion of many of these procedures.

Sedation/Analgesia for diagnostic and therapeutic procedures in children

Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.

Conscious sedation of pediatric patients with combination oral benzodiazepines and inhaled nitrous oxide

BACKGROUND

Pediatric patients undergoing surgical procedures may experience considerable anxiety. Use of conscious sedation may be helpful in managing mild to moderate anxiety.

OBJECTIVE

To assess the effectiveness of combination oral benzodiazepines and inhaled nitrous oxide conscious sedation in pediatric surgical patients.

METHODS

Eleven episodes of conscious sedation in eight pediatric patients were prospectively monitored, with recording of indications, patient characteristics, clinical scenarios, surgical procedure, sedative regimen, quality of sedation, and complications. Extensive training in conscious sedation had been obtained, and emergency preparedness was at a high level.

RESULTS

Combination oral benzodiazepines and inhaled nitrous oxide produced good to excellent results in all patients but one. Complications were uncommon and mild. No emergency intervention was necessary.

CONCLUSION

Monitored use of a combination of oral benzodiazepine and low to moderate concentrations of inhaled nitrous oxide can provide safe and effective conscious sedation in pediatric patients. Training in conscious sedation and emergency preparedness are essential.

Adverse sedation events in pediatrics: a critical incident analysis of contributing factors

OBJECTIVE

Factors that contribute to adverse sedation events in children undergoing procedures were examined using the technique of critical incident analysis.

METHODOLOGY

We developed a database that consists of descriptions of adverse sedation events derived from the Food and Drug Administration's adverse drug event reporting system, from the US Pharmacopeia, and from a survey of pediatric specialists. One hundred eighteen reports were reviewed for factors that may have contributed to the adverse sedation event. The outcome, ranging in severity from death to no harm, was noted. Individual reports were first examined separately by 4 physicians trained in pediatric anesthesiology, pediatric critical care medicine, or pediatric emergency medicine. Only reports for which all 4 reviewers agreed on the contributing factors and outcome were included in the final analysis.

RESULTS

Of the 95 incidents with consensus agreement on the contributing factors, 51 resulted in death, 9 in permanent neurologic injury, 21 in prolonged hospitalization without injury, and in 14 there was no harm. Patients receiving sedation in nonhospital-based settings compared with hospital-based settings were older and healthier. The venue of sedation was not associated with the incidence of presenting respiratory events (eg, desaturation, apnea, laryngospasm, approximately 80% in each venue) but more cardiac arrests occurred as the second (53.6% vs 14%) and third events (25% vs 7%) in nonhospital-based facilities. Inadequate resuscitation was rated as being a determinant of adverse outcome more frequently in nonhospital-based events (57.1% vs 2.3%). Death and permanent neurologic injury occurred more frequently in nonhospital-based facilities (92.8% vs 37.2%). Successful outcome (prolonged hospitalization without injury or no harm) was associated with the use of pulse oximetry compared with a lack of any documented monitoring that was associated with unsuccessful outcome (death or permanent neurologic injury). In addition, pulse oximetry monitoring of patients sedated in hospitals was uniformly associated with successful outcomes whereas in the nonhospital-based venue, 4 out of 5 suffered adverse outcomes. Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient.

CONCLUSIONS

This study-a critical incident analysis-identifies several features associated with adverse sedation events and poor outcome. There were differences in outcomes for venue: adverse outcomes (permanent neurologic injury or death) occurred more frequently in a nonhospital-based facility, whereas successful outcomes (prolonged hospitalization or no harm) occurred more frequently in a hospital-based setting. Inadequate resuscitation was more often associated with a nonhospital-based setting. Inadequate and inconsistent physiologic monitoring (particularly failure to use or respond appropriately to pulse oximetry) was another major factor contributing to poor outcome in all venues. Other issues rated by the reviewers were: inadequate presedation medical evaluation, lack of an independent observer, medication errors, and inadequate recovery procedures. Uniform, specialty-independent guidelines for monitoring children during and after sedation are essential. Age and size-appropriate equipment and medications for resuscitation should be immediately available regardless of the location where the child is sedated. All health care providers who sedate children, regardless of practice venue, should have advanced airway assessment and management training and be skilled in the resuscitation of infants and children so that they can successfully rescue their patient should an adverse sedation event occur.