Oral transmucosal fentanyl citrate for premedication of children undergoing laceration repair

Pharmacologic Procedural Distress Management During Laceration Repair in Children: A Systematic Review

OBJECTIVES

To systematically appraise the literature on the relative effectiveness of pharmacologic procedural distress management agents for children undergoing laceration repair.

METHODS

Six databases were searched in August 2021, and the search was updated in January 2023. We included completed randomized or quasi-randomized trials involving ( a ) children younger than 15 years undergoing laceration repair in the emergency department; ( b ) randomization to at least one anxiolytic, sedative, and/or analgesic agent versus any comparator agent or placebo; ( c ) efficacy of procedural distress management measured on any scale. Secondary outcomes were pain during the procedure, administration acceptance, sedation duration, additional sedation, length of stay, and stakeholder satisfaction. Cochrane Collaboration's risk-of-bias tool assessed individual studies. Ranges and proportions summarized results where applicable.

RESULTS

Among 21 trials (n = 1621 participants), the most commonly studied anxiolytic agents were midazolam, ketamine, and N 2 O. Oral midazolam, oral ketamine, and N 2 O were found to reduce procedural distress more effectively than their comparators in 4, 3, and 2 studies, respectively. Eight studies comparing routes, doses, or volumes of administration of the same agent led to indeterminate results. Meta-analysis was not performed because of heterogeneity in comparators, routes, and outcome measures across studies.

CONCLUSIONS

Based on procedural distress reduction, this study favors oral midazolam and oral ketamine. However, this finding should be interpreted with caution because of heterogeneous comparators across studies and minor conflicting results. An optimal agent for procedural distress management cannot be recommended based on the limited evidence. Future research should seek to identify the minimal, essential measures of patient distress during pharmacologic anxiolysis and/or sedation in laceration repair to guide future trials and reviews.

Sedation and Analgesia Using Medications Delivered via the Extravascular Route in Children Undergoing Laceration Repair

OBJECTIVES

To describe the method of delivery, dosage regimens, and outcomes of sedatives and analgesics administered via the extravascular route for laceration repair in children.

METHODS

Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords "child," "midazolam," "ketamine," dexmedetomidine," "fentanyl," "nitrous oxide" (N₂O), and "laceration repair." Articles evaluating the use of extravascular sedation in children for laceration repair published in the English language between 1946 and June 2017 were included. Two authors independently screened each article for inclusion. Reports were excluded if they did not contain sufficient details on dosage regimen and outcomes.

RESULTS

A total of 16 reports representing 953 children receiving sedatives and analgesics via the extravascular route were included for analyses. A statistical analysis was not performed because of heterogeneity in dosing and types of analyses conducted. Midazolam and N₂O were the most common agents, with oral (PO) midazolam being the most common agent. Other agents that have supporting data were intranasal (IN) dexmedetomidine, IN ketamine, IN midazolam, PO diazepam, PO ketamine, transmucosal (TM) midazolam, and TM fentanyl.

CONCLUSIONS

Most of the agents administered through the extravascular route were efficacious. Selection of the agents should be based on perceived need for analgesia versus sedation, patient accessibility, and adverse drug events. Future research is needed to determine the optimal agent and route for laceration repair.

A review of transbuccal fentanyl use in the emergency department

Patients with severe, painful injuries and illnesses treated in the emergency department are commonly administered opioid medications. Intravenous administration provides the most rapid onset of pain relief and is readily titrated. Fentanyl, administered intravenously, is well documented as an effective medication for pain management in the emergency department. It is preferred in many settings due to its minimal hemodynamic effects, as compared to other commonly used opioids. However, not all patients require intravenous access. These patients are given orally administered pain medications. The oral route is effective at minimizing pain but has a much slower onset of action when compared to the intravenous route. As an alternative to the slower onset of action seen with oral opioids, this paper discusses the use of fentanyl buccal tablet for pain management in the emergency department. Fentanyl buccal tablets are readily absorbed, with a bioavailability of approximately 65%, and have a more rapid onset of action than achieved with traditional oral opioids used in the emergency department.

Fentanyl for breakthrough pain: a systematic review

The purpose of this article is to systematically review the use of fentanyl as an analgesic for breakthrough pain. This article found that the oral transmucosal fentanyl (OTFC) had a quicker onset to analgesia than oral immediate-release opioids. Intranasal fentanyl (INFS) had a quicker onset to analgesia than buccal tablets, which in turn had a quicker onset to analgesia than OTFC. Patient acceptance and global rating of efficacy were greater for INFS than for buccal fentanyl. OTFC and INFS have been used effectively to reduce acute pain in children who are opioid-naive. Abuse and addiction to OTFC, fentanyl buccal tablets and INFS was low, owing to patient selection.

Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study

INTRODUCTION

The ideal analgesic agent for burns wound dressings in paediatric patients would be one that is easy to administer, well tolerated, and produces rapid onset of analgesia with a short duration of action and minimal side-effects to allow rapid resumption of activities and oral intake. We compared our current treatment of oral morphine to intranasal fentanyl in an attempt to find an agent closer to the ideal.

METHODS

A randomised double blind two-treatment crossover study comparing intranasal administration of fentanyl (INF) to orally administered morphine (OM). Children with burn injury aged up to 15 years and weighing 10-75 kg were included. Primary end-point was pain scores. Secondary end-points were time to resumption of age-appropriate activities, time to resumption of fluid intake, sedation and cooperation. Routine observations and vital signs were also recorded.

RESULTS

Twenty-four patients were studied with a median age of 4.5 years (interquartile range 1.8-9.0 years) and a median weight of 18.4 kg (interquartile range 12.9-33.2kg). Mean pain difference scores (OM-INF) ranged from -0.500 (95% CI=-1.653 to 0.653) at baseline to -0.625 (05% CI=-1.863 to 0.613) for a retrospective rating of worst pain experienced during the dressing procedure. All measurements were within a pre-defined range of equivalent efficacy. The median time to resumption of fluid intake was 108 min (range 44-175 min) with OM and 140 min (range 60-210 min) with INF. These differences were not statistically significant. Fewer patients experienced mild side-effects with INF compared to OM (n=5 versus n=10). No patients experienced depressed respirations or oxygen saturations.

SUMMARY

Intranasal fentanyl was shown to be equivalent to oral morphine in the provision of analgesia for burn wound dressing changes in this cohort of paediatric patients. It was concluded that intranasal fentanyl is a suitable analgesic agent for use in paediatric burns dressing changes either by itself or in combination with oral morphine as a top up titratable agent.

Pain management in the wilderness and operational setting

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).

Pain Management in the Prehospital Environment

Pain measurement and relief is complex and should be a priority for prehospital providers and supervisors. The literature continues to prove that we are poor pain relievers, despite the high prevalence of pain in the out-of-hospital patient population. Lack of education and research, along with agent availability, controlled substance regulation, and many myths given credence by health care providers, hinder our ability to achieve adequate pain assessment and treatment in the prehospital setting. Protocols must be established to help guide providers through proper acknowledgment, measurement, and treatment for prehospital pain. Nonpharmacologic therapies must also be taught and reinforced as important adjuncts to pain management. Finally, formation of quality improvement pain programs that evaluate patient outcomes and provider practice patterns will help EMS systems understand the pain management process and outline areas for improvement. Only through emphasis on pain education, research, protocol and program monitoring development will the quality of pain assessment and management in the prehospital setting improve.

Comparison of meperidine plus midazolam and fentanyl plus midazolam in procedural sedation: a double-blind, randomized controlled trial

This double-blind, randomized, prospective study was conducted to compare the analgesic and sedative efficacy of fentanyl and meperidine in orthopedic closed reduction of fractures and dislocations undertaken in the emergency department. Seventy consecutive adult patients with fractures or dislocations suitable for reduction were randomized to receive fentanyl (1 mcg/kg; n = 36) or meperidine (0.5 mg/kg; n = 34) in combination with midazolam (0.02 mg/kg). Vital signs and alertness scale scores of the patients were monitored. The Visual Analog Scale (VAS) was used to determine the degree of pain. There was no statistically significant difference between the VAS mean scores of the fentanyl and meperidine groups (t test, P = .772). The need for additional analgesic drugs was significantly more frequent in patients receiving meperidine (P = .018). No adverse events, such as hypotension or respiratory depression, were noted. Euphoria occurred in one patient in the fentanyl group. Although dose requirements differ, fentanyl and meperidine provide effective and reliable analgesia in closed reduction of fractures and dislocations.

A novel pain management strategy for combat casualty care

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.

Oral premedication with fentanyl may be a safe and effective alternative to oral midazolam

BACKGROUND AND OBJECTIVE

Although midazolam is commonly given orally to infants and small children for premedication, the taste is sometimes unacceptable even when mixed with syrup. We tested the efficacy and safety of oral fentanyl compared with oral midazolam in a randomized open-label study.

METHODS

Fifty-one children, aged 12-107 months and weighing 10-25 kg, were randomly assigned to fentanyl or midazolam treatment groups. Midazolam (5 mg) or fentanyl (0.1 mg) was given orally from a small bottle with a small orifice 30 min before transfer to the preoperative holding room. The excitation-sedation conditions of the patients were assessed before and after general anaesthesia.

RESULTS

The preoperative scores did not differ significantly between the two groups. No major complications were observed in either group. Postoperative vomiting occurred in 5 of 27 (18.5%) patients treated with oral fentanyl and in none of 24 of those treated with midazolam.

CONCLUSIONS

Oral administration of fentanyl 30 min before entrance to the holding room for an operation from a bottle with a small orifice is a premedication option for children between 1 and 8 yr of age.

Procedural sedation and analgesia for children in the emergency department

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.

A randomized, clinical trial of oral midazolam plus placebo versus oral midazolam plus oral transmucosal fentanyl for sedation during laceration repair

OBJECTIVE

To determine whether a combination of oral transmucosal fentanyl (Fentanyl Oralet, Abbott Laboratories, North Chicago, IL) plus oral midazolam has an acceptable safety profile and is more effective than oral midazolam alone for sedation during laceration repair in a pediatric emergency department (ED).

METHODS

Randomized, double-blind, placebo-controlled, clinical trial. Patients between 2 and 8 years of age who weighed >10 kg and presented to the ED with a laceration in need of repair under sedation were eligible for inclusion. All patients received oral midazolam (0.5 mg/kg; maximum dose 10 mg) and either fentanyl (5-10 microg/kg) or placebo in oralet form. Data collected every 5 minutes included the following: heart rate, oxygen saturation, respiratory rate, pain as measured on a Children's Hospital of Eastern Ontario Pain Score (CHEOPS) scale (range: 4-13), and an activity scale (range: 1-5). Effectiveness of sedation was measured by CHEOPS and activity scores compared between the treatment groups.

RESULTS

Fifty-one patients were randomized to receive oral midazolam plus fentanyl (N = 28) or oral midazolam plus placebo (N = 23). Age, weight, gender, or baseline pain and activity scores did not differ between the 2 groups. Seven patients in the fentanyl group vomited compared with 0 patients in the placebo group. Three patients in the fentanyl group and no patients in the placebo group had brief oxygen saturation below 93% on room air. The mean pain score within 5 minutes of the start of the procedure did not differ between the 2 groups (fentanyl group, 9.4 versus placebo group, 8.8). Mean activity scores within 5 minutes of the start of the procedure were also similar (fentanyl group, 4.3 versus placebo group, 4.3).

CONCLUSIONS

The addition of oral transmucosal fentanyl to oral midazolam did not improve pain or activity scores in pediatric patients given sedation for laceration repair. Patients who received Fentanyl Oralet suffered significantly more side effects despite the relatively low doses administered in this study. Oral transmucosal fentanyl should not be used for procedural sedation in the ED.

Sedation and analgesia in pediatric patients for procedures outside the operating room

Sedation and analgesia in pediatric patients for procedures outside the operating room are becoming more frequent as health care is being driven to be more cost effective and "efficient." Although anesthesiologists may not be directly involved in sedation or analgesia outside of the operating room, there is a high likelihood that they will be asked by their institutions to be integrally involved in creating and supervising sedation policy given that the American Society of Anesthesiologists and the Joint Commission on Accreditation of Healthcare Organizations consider sedation and analgesia as part of a continuum ranging from minimal sedation to moderate sedation and analgesia, deep sedation and analgesia, and, finally, general anesthesia. Further, anesthesiologists will be asked to define, teach, and credential nonanesthesiology practitioners who perform deep sedation because these practitioners are now required to be qualified to "rescue from general anesthesia."

Noninvasive drug delivery

Advances in biopharmaceutical technology have spawned new drug delivery devices and mechanisms. Noninvasive methods, including iontophoresis and transmucosal drug delivery, have improved treatment of certain patient population. Their use is discussed in the following paper.

A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care

Analgesia for pediatric burn wound care in the outpatient clinic is constrained by time, personnel, and/or monitoring capabilities, yet may improve patient satisfaction and comfort, clinic efficiency, and patient throughput. The ideal analgesic in this increasingly common setting should be palatable, provide potent, rapid, and brief analgesia, and require minimal appropriate monitoring. Using a placebo-controlled, double-blind design we compared oral transmucosal fentanyl citrate (OTFC, approximately 10 microg/kg) and oral oxycodone (0.2 mg/kg) in 22 pediatric outpatient wound care procedures (ages 5-14 years). Pulse oximetry, vital signs, side effects, patient pain scores, and observer scores for cooperation, anxiety, and sedation were recorded. OTFC and oral oxycodone resulted in similar outcome measures and vital signs, and no significant side effects. The taste of OTFC was preferred. We conclude that OTFC and oral oxycodone are safe and effective analgesics in the setting of monitored outpatient wound care in children, and that OTFC offers the advantage of improved palatability.

Pharmacological management of pain and anxiety during emergency procedures in children

Painful procedures are frequently required during treatment of children in the emergency department and are very stressful for the children, their parents and healthcare providers. Pharmacological methods to safely provide almost painless local anaesthesia, analgesia and anxiolysis have been increasingly studied in children. With knowledge of these methods, and patience, the emergency care provider can greatly reduce the distress often associated with emergency care of children. Topical local anaesthetics such as LET [lidocaine (lignocaine), epinephrine (adrenaline), tetracaine] or buffered lidocaine injected through the wound with fine needles can almost painlessly anaesthetise lacerations for suturing. Topical creams such as lidocaine/ prilocaine (EMLA) or tetracaine, iontophoresed lidocaine, or buffered lidocaine subcutaneously injected with fine needles can make intravenous catheter placement virtually 'painless'. When anxiety is significant, and mild to moderate analgesia/ anxiolysis/amnesia is needed, nitrous oxide can be administered if the proper delivery devices are available. Alternatively, when intensely painful fracture reduction, burn debridement, or abscess drainage is necessary, well tolerated and effective deep sedation can be achieved with careful use of midazolam and either ketamine or fentanyl.

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.

Pharmacology of emergency department pain management and conscious sedation

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.

Systemic analgesia and sedation in managing orthopedic emergencies

Many potent agents have become available in the emergency department for providing systemic analgesia and sedation for painful orthopedic procedures. This article details the pharmacology and principles of systemic analgesia and sedation, which will help the emergency physician provide maximal patient comfort with minimal complications during painful procedures. The use of an appropriate agent in these situations will optimize the outcome of the procedure itself and result in greater patient satisfaction.

The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department

Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines

Procedural sedation and analgesia are core skills in emergency medicine. Various specialty societies have developed guidelines for procedural sedation, each reflecting the perspective of the specialty group. Emergency practitioners are most likely to embrace guidelines developed by people who understand emergency department (ED) skills, procedures, conditions, and case mix. Recognizing this, the Canadian Association of Emergency Physicians (CAEP) determined the need to establish guidelines for procedural sedation in the ED. In March, 1996, a national emergency medicine (EM) working committee, representing adult and pediatric emergency physicians, was established. This committee teleconferenced with representatives of the Canadian Anesthetic Society (CAS) to identify problems, perspectives, and controversial issues, and to define a process for guideline development. The EM committee subsequently reviewed existing literature, determined levels of evidence, and developed the document, which evolved based on feedback from the CAS and CAEP Standards Committees. The final version was approved by the CAEP Standards Committee and the CAEP Board of Directors, then submitted for peer review. These guidelines discuss the goals, definitions, and principles of ED sedation, and make recommendations for pre-sedation preparation, patient fasting, physician skills, equipment and monitoring requirements, and post-sedation care. The guidelines are aimed at non-anesthesiologists practicing part-time or full-time emergency medicine. They are applicable to ED patients receiving parenteral analgesia or sedation for painful or anxiety-provoking procedures. They are intended to increase the safety of procedural sedation in the ED.

Oral transmucosal fentanyl citrate as an anaesthetic premedication when dosed to an opioid effect vs total opioid consumption

Thirty min prior to anaesthetic induction for surgery, children aged 4-12 years old were given a 10 micrograms.kg-1 oral transmucosal fentanyl citrate (OTFC) and were instructed to suck the OTFC until pruritus appeared (Group 2) or until the entire dose was consumed (Group 1). Sedation, apprehension and cooperation scores were rated, and vital signs including oxygen saturation were monitored until anaesthetic induction. The results showed that pruritus was present in 76% of children; however; in all but one child, it occurred after the OTFC had been completely consumed. There were no significant changes in oxygen saturation, but respiratory rate decreased from 19.6 +/- 1.7 to 18.4 +/- 1.3. Activity decreased significantly; however, cooperation and apprehension did not change. The conclusion was that pruritus cannot be used as an endpoint for OTFC effectiveness; however, OTFC dosed at 10 micrograms.kg-1 is effective in providing sedation without causing clinically significant changes in vital signs or oxygen saturation.

The pediatric sedation unit: a mechanism for pediatric sedation

OBJECTIVES

We have created a pediatric sedation unit (PSU) in response to the need for uniform, safe, and appropriately monitored sedation and/or analgesia for children undergoing invasive and noninvasive studies or procedures in a large tertiary care medical center. The operational characteristics of the PSU are described in this report, as is our clinical experience in the first 8 months of operation.

METHODS

A retrospective review of quality assurance data was performed. These data included patient demographics and chronic medical diagnoses, procedure, or study performed; sedative or analgesic medication given; complications (defined prospectively); and sedation and monitoring time. Patient-specific medical records related to the procedure and sedation were reviewed if a complication was noted in the quality assurance data.

RESULTS

Briefly, the PSU was staffed with an intensivist and pediatric intensive care unit nurses. Patients were admitted to the PSU and assessed medically for risk factors during sedation. Continuous heart rate, respiratory rate, and pulse oximetry monitoring were used, and blood pressure was determined every 5 minutes. After sedation and stabilization, with monitoring continued, the patient was transported to the site to undergo the procedure or study. The pediatric intensive care unit nurse remained with the patient at all times. All necessary emergency equipment was transported with the patient. After the procedure or study was completed, the patient was returned to the PSU for recovery to predetermined parameters. We were able to analyze 458 episodes of sedation for this review. Procedures and studies included radiologic examinations, cardiac catheterization, orthopedic manipulations, solid organ and bone marrow biopsy, gastrointestinal endoscopy, bronchoscopy, evoked potential measurements, and others. Patients were 2 weeks to 32 years of age. The average time from initiation of sedation to last dose of medication administered was 84 minutes. The average time from initiation of sedation to full recovery was 120 minutes. Sedative and analgesia medications use was not standardized; however, the majority of children needing sedation received propofol or midazolam. For patients requiring analgesia, ketamine or fentanyl was added. In 79 of 458 (12%) sedation episodes, complications were documented. Mild hypotension (4.4%), pulse oximetry <93% (2.6%), apnea (1.5%), and transient airway obstruction (1.3%) were the most common complications noted. Cancellation of 11 (2.4%) procedures was attributable to complications. No long-term morbidity or mortality was seen.

CONCLUSIONS

Many children require sedation or analgesia during procedures or studies. Safe sedation is best ensured by appropriate presedation risk assessment and with monitoring by a care provider trained in resuscitative measures who is not involved in performing the procedure itself. Uniformity of care in a large institution is a standard met by the creation of a centralized service, with active input from the department of anesthesiology. We present the PSU as a model for achieving these goals.

A rational approach to the outpatient management of lacerations in pediatric patients

Lacerations are a frequent reason for pediatric health care visits. Many are referred to EDs or to surgical specialists but may be treated by the pediatrician who has the time and interest in maintaining wound care skills. Although skin closure is often viewed as the primary event in wound care, local anesthesia and wound toilet are equally important aspects in which expertise is often undervalued. On occasion, patient anxiety and resistance complicates wound care, and a variety of sedative techniques facilitates completion of procedures that otherwise would require general anesthesia. Adherence to basic principles and the occasional use of innovations in wound care enable the clinician to bring about optimal outcomes.

Oral midazolam for conscious sedation of children during minor procedures

OBJECTIVE

To compare the safety and efficacy of two doses of oral midazolam, and to assess the drug induced amnesia obtained, when used for conscious sedation of children undergoing minor procedures in the accident and emergency (A&E) setting.

METHODS

A two stage trial was completed: an initial prospective, double blinded, randomised trial comparing 0.2 mg/kg midazolam suspension with 0.5 mg/kg, followed by further data collection on the higher dose. Children whom staff and parents felt required sedation for accurate and humane completion of minor procedures were selected. Anxiety was measured using physiological parameters, a behavioural anxiety score, a parental visual analogue scale, and a telephone questionnaire at 2-7 days after the procedure.

RESULTS

Fifty patients in total were recruited. Randomisation between two doses ceased after 20 patients since staff, despite being "blinded", perceived there to be a wide variation in response to midazolam and attributed that to the difference in doses. On breaking the code these suspicions were partly supported. Due to reluctance to continue with the lower dose all children subsequently received 0.5 mg/kg. At this higher dose oral midazolam had an onset of action of 15 minutes and was effective in 76% of children (as measured by anxiety score and/or subsequent amnesia). Amnesia was reported in 66% of children. There were no adverse side effects except paradoxical hyperagitation in three (6%); this did not require any specific treatment. General anaesthesia was avoided in at least eight children in whom the procedure would not have been attempted without midazolam. Altogether 90% of parents said they would like it to be used again should similar circumstances arise.

CONCLUSIONS

At 0.5 mg/kg oral midazolam appears safe and is effective in sedating most children for minor procedures. Its use should be considered by all A&E departments dealing with children.

A Review of Oral Transmucosal Fentanyl Citrate: Potent, Rapid and Noninvasive Opioid Analgesia

The physiochemical characteristics of the potent synthetic opioid agonist fentanyl make it ideal for noninvasive transmucosal delivery. Studies of oral transmucosal fentanyl citrate (OTFC), a candied matrix formulation administered orally as a palatable lozenge on a stick, have investigated and determined this analgesic's pharmacokinetics and pharmacodynamics in a number of clinical settings, including premedication before surgery, acute analgesia for painful medical procedures, and, most recently, for the control of breakthrough cancer pain. The onset to meaningful pain relief in patients with acute pain from surgery or breakthrough pain from cancer is between 5 and 10 minutes after initiating OTFC use, equivalent to intravenous morphine. Analgesic dose equivalency studies suggest that OTFC is, on average, about 10 times more potent than morphine, although, in randomized, controlled, and blinded studies, many patients who were using relatively high doses of opioid anlagesics on an around the- clock schedule for control of cancer pain reported that even a low dose of OTFC (i.e., 200 microg) provided adequate relief from breakthrough pain. Side effects from OTFC are similar in character and frequency to other opioids, including sedation, nausea, and pruritus. These effects appear to wane rapidly with repeated use of this medication. To date there have been no reported serious adverse events in any of the population groups studied or treated with OTFC.

Alternative routes of drug administration--advantages and disadvantages (subject review). American Academy of Pediatrics. Committee on Drugs

During the past 20 years, advances in drug formulations and innovative routes of administration have been made. Our understanding of drug transport across tissues has increased. These changes have often resulted in improved patient adherence to the therapeutic regimen and pharmacologic response. The administration of drugs by transdermal or transmucosal routes offers the advantage of being relatively painless.12 Also, the potential for greater flexibility in a variety of clinical situations exists, often precluding the need to establish intravenous access, which is a particular benefit for children.

This statement focuses on the advantages and disadvantages of alternative routes of drug administration. Issues of particular importance in the care of pediatric patients, especially factors that could lead to drug-related toxicity or adverse responses, are emphasized.

Advanced and controlled drug delivery systems in clinical disease management

Advanced and controlled drug delivery systems are important for clinical disease management. In this review the most important new systems which have reached clinical application are highlighted. Microbiologically controlled drug delivery is important for gastrointestinal diseases like ulcerative colitis and distally localized Crohn's disease. In cardiology the more classic controlled release systems have improved patient compliance and decreased side effects. In the treatment of intractable pain the spinal and transdermal route is well documented. In neurology the flattened peak-through levels of antiepileptic drugs and anti Parkinson's drugs represents a more predictable kinetic profile. Tracheal delivery of corticosteroids and sympaticomimetics in asthma and Chronic Obstructive Pulmonary Disease is fully accepted in clinical practice: delivery by this route results in better efficacy and a better safety profile. In gynaecology the delivery of pulsatile hormones (LHRH) is used for pregnancy induction, while transdermal oestrogens are promising in the prevention of osteoporosis. In surgical practice the use of antibiotic impregnated bone cement and antibiotic impregnated biodegradable collagens is well established. To prevent infections intravascular catheters coated with heparin or antibiotics are used. In ophthalmology the Ocusert systems provide a controlled release of different drugs in the eye. Most spectacular is the clinical introduction of the first liposomal drugs; amfotericine B and daunorubicine. Liposomal formulations of these drugs have enhanced activity and decreased toxicity compared to conventional formulations.

Comparative review of the adverse effects of sedatives used in children undergoing outpatient procedures

Children often fear medical procedures and interventions. Sedative agents enhance the care of these children who undergo outpatient procedures by decreasing anxiety, increasing cooperativity, and providing amnesia. Although higher dosages and intravenous administration of sedatives often produce improved sedation, adverse effects and complications are more frequent. The goals of therapeutic efficacy and safety must be balanced in all patients. The presence or anticipation of anxiety and pain helps in deciding whether to use a sedative alone, or a regimen also providing analgesia. The patient's clinical cardiorespiratory or neurological status, other relative contraindications, the duration of the intended procedure, and the presence or absence of an intravenous line will help in choosing specific drugs. Drug complications are a common cause of adverse events in patients. The combination of a sedative and analgesic, especially a benzodiazepine and an opioid given intravenously, is associated with a higher risk of serious complications. The practitioner responsible for the administration of a sedative to a child must be competent in its use and have the ability to detect and manage complications. Patients who are deeply sedated should be continuously monitored and observed by an individual dedicated to this task. Vital signs and oxygen saturation should be documented at frequent intervals and the patient should be appropriately monitored until discharge criteria have been met. The risk of serious complications with these agents may be reduced with vigorous monitoring and a judicious choice of dosage.