1
|
Nilsen AS, Juel BE, Farnes N, Romundstad L, Storm JF. Behavioral effects of sub-anesthetic ketamine in a go/no-go task. JOURNAL OF PSYCHEDELIC STUDIES 2021. [DOI: 10.1556/2054.2020.00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AbstractBackground and aimsWhile psychedelic agents are known to have powerful, but largely unexplained, effects on contents of consciousness, there is an increasing interest in the potential clinical usefulness of such drugs for therapy, and legalization is discussed in some countries. Thus, it is relevant to study the effects of psychedelic compounds not only on experience, but also on behavioral performance.MethodsSeven healthy participants performed a motor response inhibition task before, during, and after sub-anesthetic doses of intravenously administered ketamine. The infusion rate was individually adjusted to produce noticeable subjective psychedelic effects.ResultsWe observed no statistically significant impact of sub-anesthetic ketamine on reaction times, omission errors, or post error slowing, relative to the preceding drug-free condition. However, we did observe significant correlations between performance impairment and self-reported, subjective altered states of consciousness, specifically experience of “anxiety” and “complex imagery.”ConclusionsConsidering the limited number of participants and large variation in strength of self-reported experiences, further studies with wider ranges of ketamine doses and behavioral tasks are needed to determine the presence and strength of potential behavioral effects.
Collapse
Affiliation(s)
- André Sevenius Nilsen
- 1Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Bjørn Erik Juel
- 1Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Nadine Farnes
- 1Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Luis Romundstad
- 2Department of Anesthesia, and Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Johan Frederik Storm
- 1Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| |
Collapse
|
2
|
Chen J, Chen Y, Zhang Q, Ma X, Mei L, Wang W, Shen J, Zhang Q, Wang L, Shen M, He K, Chen X, Yang J. Grades of hearing loss affect the presence of acoustically evoked short latency negative responses in children with large vestibular aqueduct syndrome. Int J Pediatr Otorhinolaryngol 2020; 138:110159. [PMID: 32745789 DOI: 10.1016/j.ijporl.2020.110159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We aimed to investigate the relationship between grades of hearing loss and the presence of acoustically evoked short latency negative response (ASNR) in children with large vestibular aqueduct syndrome (LVAS), so as to enhance the reference value of ASNR for the diagnosis of LVAS in children. METHODS Two hundred sixteen ears from 108 patients (aged 4-90 months) diagnosed with bilateral LVAS, with slight to profound hearing loss, were enrolled in the present study from January 2012 to December 2018. All of the cases were diagnosed with LVAS according to high-resolution computed tomography (HRCT) or magnetic resonance imaging (MRI) scans of the inner ears. The auditory brain stem response (ABR) tests were performed on these subjects with click stimulus (ck-ABR), and the ASNRs were detected based on the method recommended by previous studies. The degree of hearing loss for each ear was classified by the estimated pure-tone average (PTA) thresholds, which were calculated according to the ck-ABR thresholds. RESULTS ASNRs were present in 40.7% (88/216) ears during ck-ABR tests. Both thresholds of ABR (Z = 2.977, p = 0.003) and estimated PTA (Z = 2.977, p = 0.003) were significantly higher in the ASNR absent group than in the ASNR present group. The frequency of not profound hearing impairment (≤80 dB HL) was much higher in the ASNR present group (44/88; 50%) than in the ASNR absent group (40/128; 31.3%) (χ2 = 7.714, p = 0.005). The results of the logistic regression model, adjusted by cases' age and gender, showed that compared with those ears with profound hearing impairment (>80 dB HL), the not profound impaired ears were associated with a 2.48-fold increased odds of recording ASNR presence in the ck-ABR test [odds ratio (OR) = 2.48, 95% confidence interval (CI): 1.38-4.46, p = 0.003]. CONCLUSIONS Grades of hearing loss affect the presence of ASNR in children with LVAS, and manifesting as cases with not profound hearing impairment showed increased odds of recording ASNR in the ck-ABR test. Furthermore, more studies should be performed imperatively to determine the diagnosis value of ASNR in children with LVAS.
Collapse
Affiliation(s)
- Jianyong Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Yao Chen
- Department of Endocrinology and Genetic Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Xiaobao Ma
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Ling Mei
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Wei Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Jiali Shen
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Qin Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Lu Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Min Shen
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Kuan He
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Xiangping Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Jun Yang
- Department of Otorhinolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Shanghai Jiaotong University School of Medicine Ear Institute, Shanghai, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China.
| |
Collapse
|
3
|
Kun W, Yuen C, Tung W. A Pilot Experience of the use of Intramuscular Ketamine for Paediatric Sedation in an Accident and Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790000700304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A prospective uncontrolled clinical trial was conducted to study the effectiveness and safety of using intramuscular ketamine in Accident & Emergency department in Hong Kong. Initial dose of 4 mg/kg (followed by a supplemental dose of 2–4 mg/kg if required) intramuscular ketamine was given to 35 children (between the ages of one to fourteen) to facilitate the carrying out of painful but necessary procedures. Satisfactory or acceptable sedation was obtained in more than 97% of these children without adjuvant physical restraint or local anaesthesia. The mean onset time was 6.78 minutes and mean time to regain consciousness was 94.97 minutes. Mean length of hospital stay was 186.65 minutes. None of these children developed laryngospasm, respiratory depression or cardiovascular instability. Trivial oxygen desaturation was observed in one child secondary to hypersecretion of saliva but he responded to suction and oxygen with no adverse sequel. The incidence of hypersalivation was 8.6%. Other side effects such as emesis (23.5%), muscle spasm (11.85%) were self-limiting There was no case of upsetting reaction observed. Ketamine by intramuscular route provides a better option to facilitate painful procedures in children in Accident & Emergency department as compared with the application of physical restraint. Yet expertise and equipment for advanced airway management is necessary for the uncommon risk of airway complications.
Collapse
Affiliation(s)
- Wm Kun
- Kwong Wah Hospital, Department of Accident and Emergency, 25 Waterloo Road, Kowloon, Hong Kong
| | | | | |
Collapse
|
4
|
Lo TCT, Yeung ST, Lee S, Skavinski K, Liao S. Reduction of central neuropathic pain with ketamine infusion in a patient with Ehlers-Danlos syndrome: a case report. J Pain Res 2016; 9:683-687. [PMID: 27695362 PMCID: PMC5029839 DOI: 10.2147/jpr.s110261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Ehlers–Danlos syndrome frequently causes acute and chronic pain because of joint subluxations and dislocations secondary to hypermobility. Current treatments for pain related to Ehlers–Danlos syndrome and central pain syndrome are inadequate. This case report discusses the therapeutic use of ketamine intravenous infusion as an alternative. Case report A 27-year-old Caucasian female with a history of Ehlers–Danlos syndrome and spinal cord ischemic myelopathy resulting in central pain syndrome, presented with severe generalized body pain refractory to multiple pharmacological interventions. After a 7-day course of ketamine intravenous infusion under controlled generalized sedation in the intensive care unit, the patient reported a dramatic reduction in pain levels from 7–8 out of 10 to 0–3 out of 10 on a numeric rating scale and had a significant functional improvement. The patient tolerated a reduction in her pain medication regimen, which originally included opioids, gabapentin, pregabalin, tricyclic antidepressants, and nonsteroidal anti-inflammatory drugs. Conclusion Ketamine infusion treatment has been used in various pain syndromes, including central neuropathic pain, ischemic pain, and regional pain syndrome. Reports have suggested that ketamine modulates pain by the regression of N-methyl-D-aspartate receptor to a resting state. As such, propagation of nociceptive signal to brain is interrupted allowing for the restoration of physiological balance between pain inhibition and facilitation. The present report shows that this treatment option can be used in patients with refractory central pain syndrome in the setting of spinal cord myelopathy secondary to Ehlers–Danlos syndrome. In addition, as seen in this case, this protocol can potentially decrease the chronic use of pain medication, such as opioids.
Collapse
Affiliation(s)
- Tony Chung Tung Lo
- Department of Physical Medicine and Rehabilitation, University of California Irvine, Orange, CA
| | - Stephen Tung Yeung
- Department of Immunology, University of Connecticut School of Medicine, Farmington, CT
| | - Sujin Lee
- Department of Physical Medicine and Rehabilitation, University of California Irvine, Orange, CA
| | - Kira Skavinski
- Department of Palliative Medicine, University of California San Diego, La Jolla
| | - Solomon Liao
- Department of Palliative Medicine, University of California Irvine, Orange, CA, USA
| |
Collapse
|
5
|
Kohi MP, Fidelman N, Behr S, Taylor AG, Kolli K, Conrad M, Hwang G, Weinstein S. Periprocedural Patient Care. Radiographics 2016; 35:1766-78. [PMID: 26466184 DOI: 10.1148/rg.2015150038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Periprocedural care of patients who undergo image-guided interventions is a task of monumental importance. As physicians who perform procedures, radiologists rely on their noninterpretive skills to optimize patient care. At the center of periprocedural care is proper patient identification. It is imperative to perform the indicated procedure for the correct patient. It is also of great importance to discuss with the patient the nature of the procedure. This conversation should include the indications, risks, benefits, alternatives, and potential complications of the procedure. Once the patient agrees to the procedure and grants informed consent, it is imperative to stop and confirm that the correct procedure is being performed on the correct patient. This universal time-out policy helps decrease errors and improves patient care. To optimize our interpretative and procedural skills, it may be necessary to provide the patient with sedation or anesthesia. However, it is important to understand the continuum of sedation and be able to appropriately monitor the patient and manage the sedation in these patients. To minimize the risks of infection, periprocedural care of patients relies on aseptic or, at times, sterile techniques. Before the procedure, it is important to evaluate the patient's coagulation parameters and bleeding risks and correct the coagulopathy, if needed. During the procedure, the patient's blood pressure and at times the patient's glucose levels will also require monitoring and management. After the procedure, patients must be observed in a recovery unit and deemed safe for discharge. The fundamental components of periprocedural care necessary to enhance patient safety, satisfaction, and care are reviewed to familiarize the reader with the important noninterpretive skills necessary to optimize periprocedural care.
Collapse
Affiliation(s)
- Maureen P Kohi
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Nicholas Fidelman
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Spencer Behr
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Andrew G Taylor
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Kanti Kolli
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Miles Conrad
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Gloria Hwang
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| | - Stefanie Weinstein
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 505 Parnassus Ave, M-361, San Francisco, CA 94143 (M.P.K., N.F., S.B., A.G.T., K.K., M.C., S.W.); and Department of Radiology, Stanford University Medical Center, Palo Alto, Calif (G.H.)
| |
Collapse
|
6
|
|
7
|
Oktay C, Eray O, Cete Y, Bozan H. Ketamine is still safe without concurrent midazolam and atropine for pediatric procedures in the emergency department. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/1568569054729517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
8
|
Abstract
Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.
Collapse
|
9
|
Abstract
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.
Collapse
Affiliation(s)
- Fernando Soto
- Pediatric Emergency Medicine Section, University of Puerto Rico School of Medicine, PO Box 29207, San Juan, PR 00929, USA.
| | | | | |
Collapse
|
10
|
Abstract
OBJECTIVE Ketamine is used intramuscularly or intravenously as a sedative when repairing the skin lacerations of children in many emergency departments (EDs). Nitrous oxide (N(2)O) has the advantages of being a sedative agent that does not require a painful injection and that offers shallower levels of sedation and a rapid recovery of mental state. We evaluated the clinical usefulness of N(2)O compared with intravenous ketamine when used for the repair of lacerations in children in the ED. METHODS From January to December 2009, we performed a prospective, randomized study at a single academic ED enrolling pediatric patients aged 3 to 10 years who needed primary repair of a laceration wound. The primary outcome was recovery time, which was defined as the time from completion of procedure to recovery of mental state. Other outcomes were sedation depth, pain scale, adverse effects, and satisfaction with sedation. RESULTS There were 32 children who were randomly assigned. Recovery times were shorter in the N(2)O group compared with those in the ketamine group (median [interquartile range (IQR)], 0.0 minutes, [0.0-4.0 minutes] vs 21.5 minutes [12.5-37.5 minutes], P < 0.05). Sedation levels were deeper in the ketamine group than in the N2O group, but pain scales were comparable between groups. No difference was observed in the satisfaction scores by physicians, parents, or nurses. CONCLUSIONS Nitrous oxide inhalation was preferable to injectable ketamine for pediatric patients because it is safe, allows for a faster recovery, maintains sufficient sedation time, and does not induce unnecessarily deep sedation.
Collapse
|
11
|
Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. J Trauma Acute Care Surg 2012. [DOI: 10.1097/ta.0b013e3182754674] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
12
|
Meredith JR, O'Keefe KP, Galwankar S. Pediatric procedural sedation and analgesia. J Emerg Trauma Shock 2011; 1:88-96. [PMID: 19561987 PMCID: PMC2700614 DOI: 10.4103/0974-2700.43189] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 08/21/2008] [Indexed: 12/11/2022] Open
Abstract
Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.
Collapse
|
13
|
Affiliation(s)
- Héctor M Alonso-Serra
- Emergency Medicine Unit and Office of Emergency Management, San Juan Veterans Administration Medical Center, San Juan, Puerto Rico
| | | |
Collapse
|
14
|
Abstract
Although the recognition of hypoxemia is greatly enhanced through the proper and informed use of the pulse oximeter, the device can never be relied on to take the place of the clinician at the bedside who makes sure that the data provided matches the clinical picture with which he or she is presented.
Collapse
|
15
|
Abstract
Objective The purpose of this study was to prospectively characterize the safety and effectiveness of moderate sedation/analgesia for performing radiologic non-vascular abdominal intervention. Materials and Methods During a 3-month period, a total of 63 adult patients with a mean age of 64 years (range: 27-82) underwent moderate sedation for 72 radiologic non-vascular interventional procedures. A combination of fentanyl citrate and midazolam hydrochloride, based on the patient's body weight, was intravenously administered until the patient was drowsy and tranquil. The adverse events associated with this moderate sedation were assessed. The visual analog scale format was used to measure the subjective feelings of the patient's pre-procedural anxiety and intraprocedural pain. Results The mean total dose per kilogram of body weight of fentanyl used in PTBD was 1.148 µg, it was 1.157 µg for PTGBD, 1 µg for AD, 1 µg for PCN, 1.641 µg for TDC, 1 µg for DJS, 2 µg for BS, 1 µg for GS and 2 µg for RFA. The mean total dose per kilogram of body weight of midazolam was 0.035 mg in PTBD, PTGBD, AD, PCN, DJS, GS and RFA, 0.039 mg in TDC, and 0.043 mg in BS. A temporary reduction of systolic blood pressure to less than 80 mmHg was observed during 5 procedures (6.9%), whereas a temporary elevation of systolic blood pressure above 150 mmHg was observed during 10 procedures (13.8%). A reduction of arterial oxygen saturation to less than 90% was observed during 14 procedures (19.4%). None of the patients required pharmacologic reversal agents or cardiopulmonary resuscitation. The mean anxiety score recorded before all procedures was 5.2 (distressing). The mean pain score during the procedure, which was recorded after all procedures, was 2.9 (mild). Conclusion Moderate sedation allows performance of safe and effective radiologic non-vascular intervention, and it is also easy for an interventional radiologist to use. The patients should be continuously monitored to check their vital signs and arterial oxygen saturation during the procedures.
Collapse
Affiliation(s)
- Tae-Hoon Kim
- Department of Radiology, Dankook University Hospital, Chungnam, Korea.
| |
Collapse
|
16
|
Gozal D, Goldin E, Shafran-Tikva S, Tal D, Wengrower D. Leigh syndrome: anesthetic management in complicated endoscopic procedures. Paediatr Anaesth 2006; 16:38-42. [PMID: 16409527 DOI: 10.1111/j.1460-9592.2005.01678.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Leigh's syndrome, a disorder of infancy and childhood, is characterized by gray matter degeneration and focal brainstem necrosis. It presents with special clinical features such as developmental delay, nervous system dysfunction, respiratory abnormalities, and hypertrophic cardiomyopathy that can be a real challenge to the anesthesiologist. Anesthesia or sedation has rarely been reported in patients with Leigh disease. We report our experience in sedating five children with Leigh syndrome in seven procedures undertaken in the endoscopy suite (outside the operating room). METHODS Five children with Leigh disease, three girls and two boys, have been referred to us for percutaneous endoscopic gastrostomy (PEG) insertion and or replacement (a total of seven procedures). The average age was 2.6 years with a range of 4 months to 6 years. Informed consent was obtained from the patient's parents or guardian. An anesthesia machine, scavenging system, O(2) source and routine monitoring were available. Sedation was accomplished with propofol intravenous (i.v.) (0.5-1 mg x kg(-1)) maintained with a propofol infusion (50-100 microg x kg(-1) x min(-1)). The spontaneously breathing patients received oxygen through an oxygen facemask during the procedure and afterwards recovery was managed in the gastroenterology unit. RESULTS All the children underwent the procedure without complications. One patient developed transient desaturation (SpO(2) 80%) for a few seconds. Body temperature, heart rate, arterial blood pressure, O(2) saturation and endtidal CO(2) were stable during the endoscopies. No special post-procedure management was required; the patients woke up at the end of the endoscopy and were able to drink and eat as usual. CONCLUSIONS This rare mitochondrial disease presents unique management problems to the anesthesiologist when using general anesthesia. Our patients were managed appropriately before endoscopy and underwent the procedure under deep sedation. No complications occurred. We concluded that deep sedation in the endoscopy suite was safe in this small series of patients with this rare disease.
Collapse
Affiliation(s)
- David Gozal
- Department of Pediatric Sedation Service, Anesthesiology, Hadassah University Hospital, Jerusalem, Israel
| | | | | | | | | |
Collapse
|
17
|
Affiliation(s)
- Hakan Topacoglu
- Dokuz Eylül University School of Medicine, Department of Emergency Medicine, Izmir, Turkey.
| | | | | | | |
Collapse
|
18
|
Sharieff GQ, Benjamin L, Mace S, Sacchetti A. Emergency physicians and the care of children. Am J Emerg Med 2005; 23:890-3. [PMID: 16291446 DOI: 10.1016/j.ajem.2005.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 07/11/2005] [Indexed: 10/25/2022] Open
Abstract
The care of children is an integral aspect of emergency medicine. This article reviews the many important contributions that emergency physicians have made in advancing the acute care of children.
Collapse
Affiliation(s)
- Ghazala Q Sharieff
- Emergency Department, Children's Hospital and Health Center/University of California, San Diego, CA 92011, USA
| | | | | | | |
Collapse
|
19
|
Sury MRJ, Harker H, Begent J, Chong WK. The management of infants and children for painless imaging. Clin Radiol 2005; 60:731-41. [PMID: 15978882 DOI: 10.1016/j.crad.2005.02.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 02/15/2005] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- M R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK.
| | | | | | | |
Collapse
|
20
|
Wedmore IS, Johnson T, Czarnik J, Hendrix S. Pain management in the wilderness and operational setting. Emerg Med Clin North Am 2005; 23:585-601, xi-xii. [PMID: 15829399 DOI: 10.1016/j.emc.2004.12.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The wilderness and operational setting places unique constraints on one's ability to treat pain. In this article we will discuss methods for treating pain both in the wilderness and operational setting. By operational we mean the austere deployed military setting, to include both noncombat and combat operations. The authors combined experience with wartime trauma pain management consists of experience in Operation "Just Cause" (Panama Invasion), Operation "Desert Storm" (Persian Gulf War), Operation "Uphold Democracy" (Haiti liberation), Operation "Enduring Freedom" (Afghanistan conflict), and Operation "Iraqi Freedom" (Iraq conflict).
Collapse
Affiliation(s)
- Ian S Wedmore
- University of Washington School of Medicine, Madigan Army Medical Center, Ft. Lewis, WA 98431, USA.
| | | | | | | |
Collapse
|
21
|
Abstract
Over the past 25 years, pediatric emergency medicine research and literature have progressively augmented our knowledge of safe and effective pediatric pain management strategies. Yet there is still much more we need to do to understand the painful experiences of children, and to develop optimal safe ways of addressing their needs within the context of a busy pediatric emergency department (ED). In this article, the authors review the history of ED pediatric pain management and sedation, discuss special considerations in pediatric pain assessment and management, review various pharmacologic and nonpharmacologic methods of alleviating pain and anxiety, and present ideas to improve the culture of the pediatric ED, so that it can achieve the goal of becoming pain-free.
Collapse
Affiliation(s)
- Beverly H Bauman
- Department of Emergency Medicine, Oregon Health & Sciences University, CDW-EM, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | | |
Collapse
|
22
|
Miller MA, Levy P, Patel MM. Procedural Sedation and Analgesia in the Emergency Department: What Are the Risks? Emerg Med Clin North Am 2005; 23:551-72. [PMID: 15829397 DOI: 10.1016/j.emc.2004.12.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The practitioner of emergency medicine is routinely faced with patients in need of emergent procedures and pain control and sedation. Our challenge is to make our patients' experiences as painless and as safe as possible, while maximizing our ability to perform the procedure at hand; this is not always an easy task given the propensity of each human body to react differently to interventions and stimuli. We can best meet this challenge by understanding how our patients and pharmaceutical agents intermingle in the risk-benefit equation we formulate before starting our "experiment." Coupling this information with fundamentally sound patient care and monitoring will minimize bad experiences with PSA for both the patient and practitioner.
Collapse
Affiliation(s)
- Michael A Miller
- Department of Emergency Medicine, Darnall Army Community Hospital, 36000 Darnall Loop, Box 32, Ft. Hood, TX 76544, USA.
| | | | | |
Collapse
|
23
|
Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2005. [PMID: 15520705 DOI: 10.1016/j.annemergmed.2004.06.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.
Collapse
Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA 92354, USA.
| | | |
Collapse
|
24
|
Abstract
BACKGROUND Stillness during natural sleep after feeding may not be sufficient for successful magnetic resonance imaging (MRI) in small infants less than 5 kg. Sedation, using an oral agent, is often successful although the timing and depth of sedation is variable. In contrast anesthesia is always effective but is invasive and is associated with postanesthesia apnea and bradycardia in preterm and ex-preterm infants. We are developing an alternative technique involving insufflation of sevoflurane and present our initial experience. METHODS Infants presenting for MRI were sedated by nasal insufflation of sevoflurane carried by 2 l.min(-1) oxygen. We recorded the sevoflurane administered, timing of sedation and scanning, conscious level, oxygen saturations, and recovery profile. RESULTS Of the 13 infants studied (median postconceptional age: 46 weeks, range: 40-70 weeks; median weight: 4.4 kg, range: 3.3-6.5 kg), sevoflurane caused sleep and enabled successful imaging in 12. Six infants fell asleep within 10 min and the median maximum sevoflurane vaporizer setting for successful sedation was 4% (range: 4-8%). Before scanning, 10 infants remained easily roused by touch and two became unresponsive; one desaturated to 85% and required repositioning of the head to maintain a clear airway. Immediately after scanning all infants were easily roused by touch. CONCLUSIONS Sedation by insufflation of sevoflurane in small infants is a simple and practical alternative technique for painless imaging such as MRI; further experience is necessary to determine its limitations.
Collapse
Affiliation(s)
- Michael R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK.
| | | | | |
Collapse
|
25
|
Abstract
STUDY OBJECTIVE To determine the frequency of analgesic use in children (5 to 17 years inclusive) who present to a pediatric emergency department with acute abdominal pain. METHODS A retrospective medical record review of patients presenting to a children's hospital over a 1-year period with a chief complaint of abdominal pain and subsequently referred to the pediatric surgical service. The records were reviewed to determine emergency department analgesic use, patient disposition, and laparotomy rate. RESULTS Two hundred ninety patients met our inclusion criteria. Of the patients seen initially by emergency physicians, 14.3% received analgesics, while those seen directly by the surgical service received analgesia 15.4% of the time. The laparotomy rate for the 290 patients was 46.6%. CONCLUSIONS Analgesic use in children who present to the emergency department with acute abdominal pain and require a surgical consultation was very low, although half required a laparotomy. Prospective studies are needed to determine the efficacy and safety of analgesic use in this setting.
Collapse
Affiliation(s)
- Robert S Green
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | | | | | | |
Collapse
|
26
|
Kotwal RS, O'Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain management strategy for combat casualty care. Ann Emerg Med 2004; 44:121-7. [PMID: 15278083 DOI: 10.1016/j.annemergmed.2004.03.025] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE Pain control in trauma patients should be an integral part of the continuum of care, beginning at the scene with out-of-hospital trauma management, sustained through the evacuation process, and optimized during hospitalization. This study evaluates the effectiveness of a novel application of a pain control medication, currently indicated for the management of chronic and breakthrough cancer pain, in the reduction of acute pain for wounded Special Operations soldiers in an austere combat environment. METHODS Doses (1,600 microg) of oral transmucosal fentanyl citrate were administered by medical personnel during missions executed in support of Operation Iraqi Freedom from March 3, 2003, to May 3, 2003. Hemodynamically stable casualties presenting with isolated, uncomplicated orthopedic injuries or extremity wounds who would not have otherwise required an intravenous catheter were eligible for treatment and evaluation. Pretreatment, 15-minute posttreatment, and 5-hour posttreatment pain intensities were quantified by the verbal 0-to-10 numeric rating scale. RESULTS A total of 22 patients, aged 21 to 37 years, met the study criterion. The mean difference in verbal pain scores (5.77; 95% confidence interval [CI] 5.18 to 6.37) was found to be statistically significant between the mean pain rating at 0 minutes and the rating at 15 minutes. However, the mean difference (0.39; 95% CI -0.18 to 0.96) was not statistically significant between 15 minutes and 5 hours, indicating the sustained action of the intervention without the need for redosing. One patient experienced an episode of hypoventilation that resolved readily with administration of naloxone. Other documented adverse effects were minor and included pruritus (22.7%), nausea (13.6%), emesis (9.1%), and lightheadedness (9.1%). CONCLUSION Oral transmucosal fentanyl citrate can provide an alternative means of delivering effective, rapid-onset, and noninvasive pain management in an out-of-hospital, combat, or austere environment.
Collapse
Affiliation(s)
- Russ S Kotwal
- Department of Preventive Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Abstract
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.
Collapse
Affiliation(s)
- Jenifer R Lightdale
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
28
|
Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004; 20:228-32. [PMID: 15057177 DOI: 10.1097/01.pec.0000121242.99242.e0] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if there are actual differences between pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians in the management of pain in pediatric patients with fractured extremities. METHOD Retrospective chart review of children seen with a forearm or lower extremity fracture over a 2-year period at 3 emergency departments (1 staffed by PEM physicians and 2 staffed by GEM physicians). A severe fracture was defined as a closed fracture with the presence of angulation or displacement. Procedural sedation was defined as the administration of medicine (sedative, analgesic, or dissociative anesthetic) at the time of reduction and/or immobilization of a fracture. RESULTS Of the 718 charts reviewed, PEM physicians managed 428 patients, and GEM physicians managed 290 patients. There were no significant differences between the patients managed by PEM physicians and GEM physicians with regard to age, sex, site of fracture, and proportion of severe fractures. There were no differences in the administration of analgesic-related medicines between PEM physicians and GEM physicians in the management of all fractures [40% (95% CI 35-45%) vs. 43% (95% CI 37-49%)] or severe fractures [58% (95% CI 51-64%) vs. 66% (95% CI 58-73%)]. In the management of all fractures, procedural sedation was used by PEM physicians in 100 [23% (95% CI 19-27%)] patients and by GEM physicians in 52 [18% (95% CI 14-23%)] patients. When procedural sedation was used, PEM physicians were more likely to use a sedative agent than GEM physicians [94% (95% CI 88-97%) vs. 46% (95% CI 33-59%)], fentanyl as opposed to morphine or meperidine [62% (95% CI 52-71%) vs. 19% (95% CI 33-59%)] and a combination of sedative and analgesic [90% (95% CI 83-94%) vs. 44% (95% CI 31-57%)]. For all fractures, GEM physicians documented recommending pain medications on discharge more often than PEM physicians [66% (95% CI 60-71%) vs. 45% (95% CI 40-50%)], and they prescribed significantly more prescription analgesics than PEM physicians [13% (95% CI 10-17%) vs. 2% (95% CI 1-4%)]. CONCLUSIONS In our study, most children with an extremity fracture and greater than one-third of children with a severe fracture did not receive pain medications in the emergency department. Overall, both PEM physicians and GEM physicians have similar practices of analgesic administration for fracture reduction, with a notable exception in the types of agents used during procedural sedation. GEM physicians documented discharge pain medications and prescribed prescription analgesics more often than PEM physicians.
Collapse
Affiliation(s)
- Lynn Babcock Cimpello
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, USA.
| | | | | |
Collapse
|
29
|
Waseem M, Ryan M. Parental presence during invasive procedures in children: what is the physician's perspective? South Med J 2003; 96:884-7. [PMID: 14513985 DOI: 10.1097/01.smj.0000087283.17069.98] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Invasive procedures may be frightening and painful experiences for children and their parents. Many parents prefer to be present when procedures are performed in their children. Allowing parents to be present during procedures decreases procedure-related anxiety. Few if any studies have addressed the physician's perspective on this issue. We conducted a simple observation survey to examine this question. METHODS We sent three-part questionnaires to the directors of 80 emergency departments with pediatric and/or emergency medicine (EM) residencies or pediatric EM fellowship training programs. The questionnaires asked whether physicians allowed parents to be present during medical procedures, as well as their opinions regarding parental presence and the effect it had on them as physicians. RESULTS The response rate was 77% (n = 62). More than 87% of physicians stated that they allow parents to be present during simple procedures (eg, venipuncture), but they indicated that they are more reluctant to do so during more invasive procedures (eg, major resuscitation scenario; 22%). Physicians' training also may influence their level of comfort and their decision making in such situations. CONCLUSION Most physicians stated that they allow parental presence during simple procedures. Physicians were more reluctant to allow parents to be present during complex procedures. EM and pediatric emergency medical training increased the physicians' level of comfort.
Collapse
Affiliation(s)
- Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY 10451, USA.
| | | |
Collapse
|
30
|
Abstract
Administration of sedation and analgesia in the interventional radiology suite is often necessary during painful diagnostic and therapeutic procedures. Although sedative and analgesic agents are generally safe, catastrophic complications related to their use can occur, often as a result of incorrect drug administration or inadequate patient monitoring. The incidence of adverse outcomes related to provision of sedation and analgesia can be reduced with improved understanding of the pharmacology of these medications, by providing adequate monitoring to sedated patients, by recognizing patients who are at increased risk of experiencing an adverse drug reaction, and by early and appropriate management of complications.
Collapse
Affiliation(s)
- Michael L Martin
- Department of Radiology, University of British Columbia, UBC Hospital, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5.
| | | |
Collapse
|
31
|
Sacchetti A, Turco T, Carraccio C, Hasher W, Cho D, Gerardi M. Procedural sedation for children with special health care needs. Pediatr Emerg Care 2003; 19:231-9. [PMID: 12972819 DOI: 10.1097/01.pec.0000086232.54586.ce] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with special health care needs represent a growing percentage of pediatric patients treated in all emergency departments. Substantial literature exists concerning the medical treatment of these patients, but there is little written describing the management of procedural sedation or analgesia in this population. This article examines the unique anatomic and physiologic implications of procedural sedation or analgesia management in children with special health care needs.
Collapse
Affiliation(s)
- Alfred Sacchetti
- Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ 08103, USA.
| | | | | | | | | | | |
Collapse
|
32
|
|
33
|
|
34
|
Flood RG, Krauss B. Procedural sedation and analgesia for children in the emergency department. Emerg Med Clin North Am 2003; 21:121-39. [PMID: 12630735 DOI: 10.1016/s0733-8627(02)00084-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PSA for children continues to be an integral part of the practice of emergency medicine. The advancement of knowledge for all health care professionals must continue so that pain and anxiety in children may be minimized during their visits to EDs.
Collapse
Affiliation(s)
- Robert G Flood
- Division of Emergency Medicine, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | | |
Collapse
|
35
|
Abstract
OBJECTIVES Familial dysautonomia is a rare genetic disorder that affects the development of the central nervous system, causing GI dysfunction. Because of an improved prognosis, elective surgical procedures are more common and present a unique problem to the anesthesiologist. All patients reported in the literature underwent these interventions under general anesthesia in the operating theater. We report our preliminary experience with deep sedation in the endoscopy room in patients with this rare syndrome. METHODS Four girls (7-16 yr old) underwent percutaneous endoscopic gastrostomy insertion and/or endoscopic retrograde cholangiopancreaticography. Preprocedure management consisted of adequate hydration and anxiolysis. Intraprocedure management consisted of stabilization of an erratic autonomic nervous system. Midazolam (0.1-0.2 mg/ kg) was administered i.v. before the procedure. Deep sedation was accomplished with propofol i.v. (0.5-1 mg/kg) and maintained with a propofol drip (50-100 microg/kg/min). Recovery was managed in the gastroenterology unit of our facility. RESULTS Body temperature, ventilation, heart rate, blood pressure, oxygen saturation, and end-tidal CO2 were stable during the endoscopies. The patients regained consciousness at the end of the endoscopy and were able to drink or to eat as normal. Pain that could precipitate a crisis was present in two patients and was successfully treated with a simple analgesic. No other complications occurred. CONCLUSION This rare genetic disorder presents unique management problems to the anesthesiologist, resulting in morbidity and mortality when general anesthesia is used. Our patients received appropriate management before endoscopy, and we performed the procedure under deep sedation. No complications occurred. We are thus confident that deep sedation in the endoscopy suite is safe in this rare syndrome.
Collapse
Affiliation(s)
- Dov Wengrower
- Department of Gastroenterology, Hadassah University Hospital, Jerusalem, Israel
| | | | | |
Collapse
|
36
|
Hulland SA, Freilich MM, Sàndor GKB. Nitrous oxide-oxygen or oral midazolam for pediatric outpatient sedation. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2002; 93:643-6. [PMID: 12142869 DOI: 10.1067/moe.2002.124763] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
Collapse
|
37
|
Hostetler MA, Auinger P, Szilagyi PG. Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997. Am J Emerg Med 2002; 20:139-43. [PMID: 11992329 DOI: 10.1053/ajem.2002.33002] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
This article describes parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 yrs), race, sex, insurance, type of hospital, urgency of visit, and ICD-9 (International Classification of Diseases, 9th revision) diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African-American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval [CI] 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.
Collapse
Affiliation(s)
- Mark A Hostetler
- Department of Pediatrics, Division of Emergency Medicine, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | | | | |
Collapse
|
38
|
|
39
|
Maurice SC, O'Donnell JJ, Beattie TF. Emergency analgesia in the paediatric population. Part II Pharmacological methods of pain relief. Emerg Med J 2002; 19:101-5. [PMID: 11904252 PMCID: PMC1725800 DOI: 10.1136/emj.19.2.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- S C Maurice
- Accident and Emergency Department, Wythenshawe Hospital, Manchester, UK.
| | | | | |
Collapse
|
40
|
Hostetler MA, Auinger P, Szilagyi PG. Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997. Am J Emerg Med 2002; 20:83-7. [PMID: 11880868 DOI: 10.1053/ajem.2002.31578] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The objective of the study was to describe parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 years), race, gender, insurance, type of hospital, urgency of visit, and ICD-9 diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.
Collapse
Affiliation(s)
- Mark A Hostetler
- Department of Pediatrics, Division of Emergency Medicine, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | | | | |
Collapse
|
41
|
Abstract
The ability to provide safe, effective procedural sedation and analgesia is a necessary skill for physicians caring for the acutely ill or injured pediatric patient. They physician should be familiar with the agent(s) chosen, including dosage, duration, adverse effects, and contraindications. The choice of agent and regimen should be individualized for the patient and situation. Successful outcomes depend on performing careful pre- and post-sedation evaluations, following appropriate monitoring and equipment guidelines, and having the knowledge and skills to manage any adverse cardiorespiratory event.
Collapse
Affiliation(s)
- Elliot Rodriguez
- Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, New York, USA.
| | | |
Collapse
|
42
|
Krauss B. Managing acute pain and anxiety in children undergoing procedures in the emergency department. EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:293-304. [PMID: 11554860 DOI: 10.1046/j.1035-6851.2001.00232.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- B Krauss
- Department of Paediatrics, Harvard Medical School and the Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts 02115, United States of America.
| |
Collapse
|
43
|
Green SM, Denmark TK, Cline J, Roghair C, Abd Allah S, Rothrock SG. Ketamine sedation for pediatric critical care procedures. Pediatr Emerg Care 2001; 17:244-8. [PMID: 11493822 DOI: 10.1097/00006565-200108000-00004] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe our experience using ketamine sedation to facilitate pediatric critical care procedures, and to document the safety profile of ketamine in this setting. DESIGN Retrospective consecutive case series. SETTING Pediatric intensive care unit of a tertiary children's hospital. PATIENTS Children receiving ketamine for procedural sedation over a 5-year period. INTERVENTIONS We reviewed patient records to determine indication, dosing, adverse events, inadequate sedation, and recovery time for each sedation. OUTCOME MEASURES Descriptive features of sedation including adverse events. RESULTS During the study period, children in our pediatric intensive care unit received ketamine at total of 442 times to facilitate a wide variety of critical care procedures, most commonly central line placement, esophagogastroduodenoscopy, and wound debridement. Most study children had substantial underlying illness (ASA > or = 3 in 88%; ASA > or = 4 in 39%). Inadequate sedation was noted in only nine (2%) procedures. Adverse effects included transient laryngospasm (n = 9), transient partial airway obstruction (n = 5), apnea with bradycardia (n = 1), emesis during the procedure (n = 2), emesis during recovery (n = 9), mild recovery agitation (n = 10), moderate-to-severe recovery agitation (n = 1), and excessive salivation (n = 4). There were no adverse outcomes attributable to ketamine. CONCLUSION Pediatric intensivists skilled in ketamine administration can safely and effectively administer this drug to facilitate critical care procedures. Despite the ill nature of our patient sample, adverse effects were uncommon.
Collapse
Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center & Children's Hospital, Loma Linda, California 92354, USA.
| | | | | | | | | | | |
Collapse
|
44
|
Otley CC, Nguyen TH, Phillips PK. Anxiolysis with oral midazolam in pediatric patients undergoing dermatologic surgical procedures. J Am Acad Dermatol 2001; 45:105-8. [PMID: 11423842 DOI: 10.1067/mjd.2001.114591] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- C C Otley
- Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
| | | | | |
Collapse
|
45
|
Krauss B. Management of acute pain and anxiety in children undergoing procedures in the emergency department. Pediatr Emerg Care 2001; 17:115-22; quiz 123-5. [PMID: 11334092 DOI: 10.1097/00006565-200104000-00010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- B Krauss
- Department of Pediatrics, Harvard Medical School, Children's Hospital, Boston, Massachusetts 02115, USA.
| |
Collapse
|
46
|
Acworth JP, Purdie D, Clark RC. Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation. Emerg Med J 2001; 18:39-45. [PMID: 11310461 PMCID: PMC1725505 DOI: 10.1136/emj.18.1.39] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
Collapse
Affiliation(s)
- J P Acworth
- Department of Emergency Medicine, Royal Children's Hospital, Herston, Brisbane, Australia.
| | | | | |
Collapse
|
47
|
Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG. Ketamine sedation for pediatric gastroenterology procedures. J Pediatr Gastroenterol Nutr 2001; 32:26-33. [PMID: 11176320 DOI: 10.1097/00005176-200101000-00010] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD). METHODS The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD. RESULTS During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intravenous route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists (ASA] class > or =3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (< or =6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness. CONCLUSION Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.
Collapse
Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, California, USA.
| | | | | | | | | |
Collapse
|
48
|
|
49
|
Abstract
OBJECTIVE To measure changes in end-tidal carbon dioxide levels (ETCO2) during sedation/analgesia in pediatric patients and to describe ETCO2 changes associated with different sedation strategies. METHODS This was a prospective, observational patient series in an urban pediatric emergency department (PED). Participants included 106 children with a mean age of 6.8 years. (range 1.2-16.6 years). Sedation/analgesia was given for fracture reduction (55%), laceration repair (37%), abscess incision and drainage (4%), and lumbar puncture (LP) (4%). Medications included fentanyl, morphine, ketamine, and midazolam. Continuous ETCO2 waveforms were recorded via a Capnogard ETCO2 Monitor. Oxygen saturation was recorded using a Nelcor N-200 pulse oximeter. Recording began prior to sedation and continued until the patient was awake or when it was necessary to remove the patient from the monitor for further medical care. Each record was analyzed for peak ETCO2 and averaged over five consecutive breaths, before and after the administration of medications. The main outcome measure was the change in ETCO2 levels. RESULTS The mean increase in ETCO2 was 6.7 mmHg (P is included in, 0.00001; range: +0.16 to +22.3). ETCO2 increased by 3.2 mmHg (95% CI = 2.2-4.2) for midazolam alone, 5.4 mmHg (95% CI = 4.5-6.4) for midazolam and ketamine, and 8.8 mmHg (95% CI = 7.4-10.2) for midazolam and opiate. Two patients had transient SpO2 desaturations below 93%, which corrected with stimulation. CONCLUSIONS Commonly used agents for pediatric sedation result in significant increases in ETCO2. ETCO2 is a useful adjunct in assessing ventilation and may serve as an objective research tool for assessing different sedation strategies.
Collapse
Affiliation(s)
- K K McQuillen
- Hasbro Children's Hospital, Department of Pediatrics, Brown University, Providence, Rhode Island, USA.
| | | |
Collapse
|
50
|
Blackburn P, Vissers R. Pharmacology of emergency department pain management and conscious sedation. Emerg Med Clin North Am 2000; 18:803-27. [PMID: 11130940 DOI: 10.1016/s0733-8627(05)70160-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The endpoints of sedation and analgesia have been more difficult than traditional physiologic parameters to measure adequately. Several clinical scoring systems have been developed in an attempt to provide more consistent and objective assessments of sedation, but the few that have been validated are cumbersome to use in the clinical setting and cannot accurately determine subtle changes in the level of sedation. Recent developments in EEG monitoring, particularly one using bispectral (BIS) analysis of the EEG signal obtained through a noninvasive forehead "lead," are promising. BIS monitoring has been used as a reliable measure of depth of midazolam-induced sedation during general anesthesia. Anesthesiologists have used this technology to prevent awareness during paralysis. One recently completed but as yet unpublished study in the ED demonstrated a high correlation with traditional sedation scales and found the device easy to use (UNC Hospitals Department of Emergency Medicine, personal communication, 1999). It is anticipated that with BIS monitoring, in combination with titratable, short-acting agents, appropriate levels of sedation can be more easily achieved while minimizing associated complications and duration of ED stay.
Collapse
Affiliation(s)
- P Blackburn
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona, USA
| | | |
Collapse
|