Efficacy of rectal midazolam for the sedation of preschool 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.

Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation

BACKGROUND

Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic.

OBJECTIVE

Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients.

METHODS

We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies.

RESULTS

A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation.

CONCLUSIONS

Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.

The efficacy of benzodiazepines as acute anxiolytics in children: A meta-analysis

OBJECTIVE

Current practice guidelines do not recommend benzodiazepines for acute management of anxiety disorders in pediatric patients. However, in procedural settings, benzodiazepines are commonly used to relieve acute preprocedural stress. This meta-analysis examines the efficacy and tolerability of benzodiazepines as short-term anxiolytics in children.

METHOD

PubMed was searched for randomized controlled trials assessing the efficacy of benzodiazepines as short-term anxiolytics in pediatric patients. Twenty-one trials involving 1,416 participants were included. A fixed effects model was used to examine the standardized mean difference of improvement in anxiety levels compared to control conditions. In stratified subgroup and meta-regression, the effect of the specific agent, dose, timing, and setting of benzodiazepine treatment was examined.

RESULTS

A significant benefit was seen for benzodiazepines compared to control (standardized mean difference = 0.71 [95% confidence interval, 0.60-0.82], k = 24, z = 12.7, P < .001). There was also funnel plot asymmetry in this meta-analysis, suggesting some evidence of publication bias. Moderator analyses found that when benzodiazepines were used in dental or nonoperating room procedures, they were more effective than when they were used in operating room procedures (test for subgroup differences Q2 = 6.34, P = .04). Tolerability analysis revealed there was no significant difference in the risk of developing irritability or behavioral changes between benzodiazepine and control groups.

CONCLUSIONS

Benzodiazepines are effective and well-tolerated when used as short-term anxiolytics in procedural settings for pediatric patients. Further research is needed to determine whether benzodiazepines are effective in pediatric anxiety disorders.

Use of sedative drugs at reducing the side effects of voiding cystourethrography in children

BACKGROUND

Imaging of the kidneys and urinary tract has a significant and critical role for diagnosis of genitourinary system diseases. Although technological progress goes toward less invasive approaches, some of the current methods are still invasive and annoying. Voiding cystourethrography (VCUG) is the best and most accurate method for diagnosis and grading of vesicoureteral reflux. VCUG is a distressful procedure that gives serious anxiety and pain in a large proportion of children and fear for parents; therefore, using effective sedative drugs with the least side effects is necessary and should be considered.

MATERIALS AND METHODS

In this review article, importance and efficacy of different drugs before catheterization VCUG be compared in the base of literature survey on EMBASE, PubMed, and Cochrane source.

RESULTS

We found that the treatment should be based on nonpharmacological and pharmacological methods; nonpharmacological treatment includes the psychological preparation before procedures as a safety precaution with little or no risk modality, as well as reassuring support. The presence of parents during painful procedures cannot alleviate children distress. Pharmacological methods include oral midazolam (0.5 mg/kg) and intranasal use (0.2 mg/kg) that had been used 10 min before the procedure can effect on anterograde amnesia and sedation without considerable effect on accuracy and grade of reflux. Nitric oxide has a shorter recovery time versus midazolam but has a potential risk for deep sedation and may interfere with the child's voiding phase.

CONCLUSION

In summary, oral midazolam of 0.5-0.6 mg/kg or 0.2 mg/kg intranasal is acceptable drug that can be used before VCUG.

Common office procedures and analgesia considerations

This article reviews common office procedures and analgesia considerations for pediatric outpatients. Layer times of onset of analgesics to coincide with procedures. Pediatric procedural distress is multimodal. Always address parent and child fear and attention, along with pain.

Safety of pediatric procedural sedation in a Canadian emergency department

OBJECTIVE

To assess the safety of pediatric procedural sedation performed by emergency physicians working within a structured sedation protocol.

METHODS

A retrospective review of all children undergoing emergency department (ED) procedural sedation during a 2-year period after the institution of a structured sedation protocol.

RESULTS

167 children underwent procedural sedation, primarily for orthopedic manipulation, wound management and foreign body removal. Of these, 82% received ketamine, 17% received fentanyl and midazolam and 1% received midazolam alone. Sedation was adequate in all but 6 patients, who required supplemental ketamine for orthopedic manipulation. Vomiting after arousal occurred in 17 children (10%), but no episodes of clinical aspiration occurred. One child became agitated during recovery and another experienced a transient visual hallucination. There were no cases of laryngospasm, apnea or cardiorespiratory compromise, and no mortality or significant morbidity occurred.

CONCLUSION

Emergency physicians using a structured sedation protocol can safely perform ED pediatric procedural sedation. Where intravenous access is not already present, intramuscular ketamine, administered in the doses described, is a safe and effective agent for pediatric sedation.

Nasal and buccal treatment of midazolam in epileptic seizures in pediatrics

Acute seizure and status epilepticus constitute major medical emergencies in children. Four to six percent of children will have at least one seizure in the first 16 years of life. Status epilepticus is a common neurological emergency in childhood and is associated with significant morbidity and mortality. The early application of antiepileptic treatment is very important. Because early treatment prevents the status epilepticus formation and shortens the duration of seizure activity. For this reason administration of anticonvulsant therapy in the prehospital setting is very important. Seizures generally begin outside the hospital, and thus parents and caregivers need simple, safe and effective treatment options to ensure early intervention. The only special preparation used for this purpose is rectal diazepam but has some disadvantages. Midazolam is a safe, short-acting benzodiazepin. It is suitable to use oral, buccal, nasal, im and iv routes. This provides a wide area for clinical applications. Recently there are many clinical studies about the usage of nasal and buccal midazolam for treatment of pediatric epileptic seizures. The nasal and buccal applications in pediatric seizures are very practical and effective. Parents and caregivers can apply easily outside the hospital.

Accuracy of temporal artery thermometry in neonatal intensive care infants

PURPOSE

To determine the accuracy of temporal artery and axillary temperatures and the discomfort level of stable neonates during temperature measurement.

SUBJECTS

Convenience sample of neonates between the ages of 32 and 40 weeks' gestation cared for in an isolette or crib.

DESIGN

A method-comparison design was used to compare different methods for noninvasive temperature monitoring (infra-red temporal artery; axillary electronic) to core body temperatures (indwelling rectal probe).

MAIN OUTCOME MEASURE

Bias and precision of test temperature devices (temporal artery; axillary).

RESULTS

Bias and precision for the temporal artery and axillary devices were 0.30 ± 0.44 and 0.28 ± 0.33, respectively. Analysis of variance found significant differences between both temporal and axillary temperatures compared to rectal temperatures (P < .01). Statistical differences were small and did not represent a clinically important difference. No statistical difference was found between temporal artery and axillary temperatures (P = .81). Increases in neonate discomfort after temperature measurement were significantly greater with axillary than increases after temporal artery temperature measurement (P = .03).

CONCLUSIONS

This study found that body temperature measured with the temporal artery thermometer was similar to temperatures obtained with an axillary thermometer in stable, afebrile neonates. The use of temporal artery thermometry appears to be an acceptable approach for noninvasive temperature measurement in neonates, which causes less discomfort in neonates.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?

OBJECTIVE

Ketamine has become the drug most favoured by emergency physicians for sedation of children in the ED. Some emergency physicians do not use ketamine for paediatric procedural sedation (PPS) because of concern about emergence delirium on recovery. The present study set out to determine the true incidence and nature of this phenomenon.

METHODS

Prospective data relating to any emergence agitation, crying, hallucinations, dreams, altered perceptions, delirium and necessary interventions were recorded in consecutive cases of ketamine PPS from March 2002 to June 2007, and analysed. Standard inclusion and exclusion criteria for the use of ketamine were followed.

RESULTS

A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure.

CONCLUSION

The belief that ketamine, in the doses used for ED PPS, causes frequent emergence delirium is flawed. A pleasant emergence phenomenon is common, but is not distressing for the child, and has no long-term (up to 30 days) negative sequelae. Rarely, there is anxiety or distress on awakening from ketamine sedation, which settles spontaneously. This should not deter emergency physicians from using ketamine for PPS.

Pharmacotherapy for anxiety disorders in children and adolescents

BACKGROUND

Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders.

OBJECTIVES

To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%).

AUTHORS' CONCLUSIONS

Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

Induction of anesthesia in a combative child; management and issues

A developmentally delayed, 13-year old autistic boy required management of multifocal cerebral and pulmonary tumors, involving several anesthetics over a 4-month period. At each anesthetic he refused premedication, displayed increasing anxiety and became more combative. With parental guidance and involvement, a variety of anesthetists tried a range of techniques to achieve induction, each ultimately resorting to the use of physical restraint. Principles essential to the care of such a child include early recognition, parental support, multi-disciplinary planning of procedures requiring general anesthesia, continuity of anesthesia care, and clear guidelines about the perioperative management of uncooperative children, including the ethical use of restraint.

Safe and effective sedation and analgesia for bone marrow aspiration procedures in children with alfentanil, remifentanil and combinations with midazolam

BACKGROUND

Invasive procedures such as bone marrow aspiration in children may be painful and cause anxiety. We investigated the efficacy and safety of remifentanil (R) alfentanil (A), remifentanil-midazolam (RM), and alfentanil-midazolam (AM) combinations in providing analgesia and sedation for bone marrow aspiration.

METHODS

Eighty children undergoing a diagnostic bone marrow aspiration whose ages ranged from 5-16 years (mean 9.20 +/- 3.00 years) were enrolled in this study. The patients were randomly assigned to one of 4 treatment groups. Vital signs, sedation and pain scores, somatic responses (sweating and tears) were recorded before, during bone marrow aspiration and after 5 and 15 min of the procedure.

RESULTS

There were no statistical differences between sedation and the CHEOPS scores of the four groups during and after the procedures. The VAS scores were significantly higher for group A compared with groups R and RM during the procedure (P < 0.008). There were no differences between the VAS scores in group AM compared with groups R and RM (P > 0.008). There were also no statistical differences among the VAS scores of four groups after the procedure (P > 0.008). All patients had adequate sedation and analgesia. None of the patients in the study had deep sedation, hypotension, bradycardia, hypoxemia, or respiratory depression.

CONCLUSIONS

Remifentanil, alfentanil, remifentanil-midazolam, and alfentanil-midazolam combinations are effective in children and can be used safely in bone marrow aspiration which is a brief but painful procedure performed in the pediatric patient group.

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.

Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation

BACKGROUND

Paediatric procedural sedation (PPS) is a common procedure in most general EDs. Many departmental guidelines suggest mandatory fasting times for children undergoing PPS, in an attempt to decrease the incidence of postoperative vomiting and (theoretically) aspiration pneumonitis, despite there being little or no evidence in the literature to support these mandatory fasting times.

OBJECTIVES

To prospectively address the relationship between preprocedure fasting time and intraprocedure or postprocedure vomiting in children aged 1-12 years undergoing procedural sedation with intravenous ketamine in the ED.

METHODS

From January 1999 to May 2000 all children presenting to the Royal Darwin Hospital Emergency Department with a condition requiring ketamine PPS were enrolled for data collection after parental consent was obtained. Titrated intravenous ketamine was administered via protocol. Prospective ED procedural sedation data collection forms of 272 consecutive cases of titrated intravenous ketamine sedation were reviewed.

RESULTS

Fasting time was accurately recorded on 257 (95%) data collection forms. There was no intraprocedure vomiting. Overall rate of postprocedure vomiting was 13.9%. No statistically significant association between decreased fasting time and increased incidence of vomiting was found. In fact, there was a trend towards increased incidence of vomiting with increased fasting time (P = 0.08). The rate of vomiting of those children fasted 3 h or greater preprocedure (20/127 or 15.8%) was over twice the rate of those fasted less than 1 hour (2/30 or 6.6%). Incidence of vomiting was significantly associated with increasing age (P = 0.0007). No clinically evident aspiration pneumonitis occurred.

CONCLUSION

Prolonged preprocedure fasting time did not reduce the incidence of postprocedure vomiting in this case series; to the contrary there was a increased incidence of vomiting with longer fasting times (P = 0.08). There was an increase in postprocedure vomiting with increasing age of the patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Costs of sedation using oral midazolam: money, time, and parental attitudes

OBJECTIVE

Many agents suitable for pediatric outpatient sedation have been identified and compared, but less data have appeared on the effect of sedation use on Emergency Department (ED) length of stay (LOS) or visit costs. We sought to discover the relationship between one commonly used method of sedation, orally administered midazolam, and ED LOS and visit costs. Parents were then surveyed to determine their attitudes toward sedation given knowledge of these costs.

METHODS

All ED patients under 10 years of age seen in a pediatric ED during April and May of 1996 for repair of lacerations <2.5 cm in length were identified via retrospective chart review. Children were excluded if they had other significant injuries, received sedatives other than oral midazolam, or were repaired by non-ED physicians. Preliminary cost and LOS data from this review was used to create a parental survey measuring attitudes toward the costs of an unnamed form of sedation (not mentioning oral midazolam). A convenience sample of parents in an ED waiting room were asked if they would want sedation administered to a child needing sutures if this increased the visit cost by $100 and/or increased LOS by 30 minutes. Parents were then asked to re-answer these questions assuming that the sedation medication was effective only 50% of the time.

RESULTS

Of 120 patients meeting entry criteria, 57 (48%) received oral midazolam. Children sedated with this agent were significantly younger (3.6 vs. 4.6 years, P = 0.015), had more layered repairs (30% vs. 14%, P = 0.047), and more facial lacerations (84% vs. 63%, P = 0.01) when compared with nonsedated patients. Mean LOS for patients with simple lacerations receiving oral midazolam increased by 17.1 minutes (P = 0.03) compared with nonsedated children; for layered repairs, the mean increase was 30.9 minutes (P<0.05). The use of oral midazolam did not effect physician charges, but did significantly increase mean combined nurse/hospital charges and total charges by 73 to 87 dollars, depending on laceration type (P<0.001 all cases). Of 81 parents surveyed, 81% said that they would be willing to wait 30 extra minutes for sedation to be used; this figure fell to 73% if sedation was effective 50% of the time. Seventy-five percent of parents were willing to pay $100 extra for sedation; 67% if sedation was effective only half the time. Willingness to endure a longer LOS or pay increased charges was not associated with parental sex or insurance status.

CONCLUSION

The use of oral midazolam significantly increases ED visit LOS and cost. This information is important to review with parents when discussing sedation options. Up to one third of parents surveyed would not want to wait extra time or pay extra money for sedation to be administered, especially if the efficacy of the chosen method was not assured.

Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial

OBJECTIVE

The comparative safety and efficacy of chloral hydrate and midazolam for sedation of children has not been adequately studied.

METHODS

In a double-blind randomized trial, at a single university hospital, we enrolled 40 children, ages 2 months to 8 years, in an out-patient neuroimaging study. Children judged to require sedation were enrolled during a 14-month period ending August 1995. They received identically appearing liquids of equal volume of either chloral hydrate (75 mg/kg, maximum 2 g) or midazolam (0.5 mg/kg, maximum 10 mg) by mouth. Children were monitored for changes in arterial blood pressure, oxygen saturation, pulse, respiration and anxiety. Efficacy was judged by evaluating the child's ability to complete the intended scan. Supplemental dosing was administered to children who were judged inadequately sedated 30 minutes after the initial medication.

RESULTS

Interim analysis demonstrated a significant sedation failure rate. Of 40 enrolled children, 33 completed the protocol. Efficacy was significantly improved for the chloral hydrate group for both ability to perform the scan, chloral hydrate = 11/11 (100%, 95% CI = 72-100) vs. midazolam = 11/22 (50%, 95% CI = 29-71), and the need for supplementary dosing, chloral hydrate = 1/11 (9%, 95% CI = 0-26) vs midazolam = 12/22 (55%, 95% CI = 34-76), P<0.05. Mean duration of sedation was not significantly different. No physiological deterioration occurred and no oxygen administration was required.

CONCLUSIONS

We conclude that, in these doses, oral chloral hydrate may provide more effective sedation than midazolam for brief neuroimaging studies in young children.

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.

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.

Clinical pharmacology of midazolam in infants and children

Midazolam is a parenteral benzodiazepine with sedative, amnesic, anxiolytic, muscle relaxant and anticonvulsant properties. The drug exerts its clinical effect by binding to a receptor complex which facilitates the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Midazolam has a faster onset and shorter duration of action than other benzodiazepines such as diazepam and lorazepam. The most serious adverse events associated with midazolam in children include hypoventilation, decreased oxygen saturation, apnoea and hypotension. It is water soluble in the commercially prepared formulation but becomes lipid soluble at physiological pH and can then cross the blood brain barrier. It is metabolised in the liver by the cytochrome P450 system, and its chief metabolite is 1-hydroxymethyl midazolam. The latter is conjugated to the glucuronide form, and it has only minimal biological activity. Midazolam is excreted primarily by the kidney. Its half-life in children over 12 months is reported to be 0.8 to 1.8 hours, with a clearance of 4.7 to 19.7 ml/min/kg. Doses given to children must be calculated on a mg/kg basis. For children 6 months to 5 years of age the initial dose is 0.05 to 0.1 mg/kg. A total dose up to 0.6 mg/kg titrated slowly may be necessary to achieve the desired endpoint. For children 6 to 12 years of age the initial dose is 0.025 to 0.05 mg/kg with a total dose up to 0.4 mg/kg to achieve the desired end-point.

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.

Comparison of routes of flumazenil administration to reverse midazolam-induced respiratory depression in a canine model

OBJECTIVE

To determine whether flumazenil, a drug used to reverse benzodiazepine-induced respiratory depression and approved only for i.v. use, is effective by alternative routes.

METHODS

A randomized, controlled, nonblinded, crossover canine trial was performed to evaluate reversal of midazolam-induced respiratory depression by flumazenil when administered by alternative routes. Mongrel dogs were sedated with thiopental 19 mg/kg i.v., then tracheally intubated. With the dogs spontaneously breathing, tidal volume, end-tidal CO2, and O2 saturation were observed until a stable baseline was achieved. Incremental doses of midazolam were administered until respiratory depression (30% decline in tidal volume, 10% decrease in O2 saturation, and 15% increase in end-tidal CO2) occurred. Flumazenil was administered by a randomly selected route [0.2 mg followed 1 minute later by 0.3 mg i.v., sublingual (s.l.) or intramuscular (i.m.); or 1 mg followed 1 minute later by 1.5 mg per rectum (PR)]. Time to return to baseline respiratory functions was recorded ("time to reversal"). Each of 10 dogs was studied using all 4 routes of flumazenil administration with a washout period of at least 7 days. An additional dog served as a control (no flumazenil).

RESULTS

The control time to reversal was 1,620 seconds. The i.v. route was significantly faster (mean 120 +/- 24.5 sec) than the other 3 routes (p < 0.005). The SL route was the second fastest (mean 262 +/- 94.5 sec), the IM route was the third fastest (mean 310 +/- 133.7 sec) and the PR route was the s;owest (mean 342 +/- 84.4 sec). The SL, IM, and PR routes did not differ significantly from one another.

CONCLUSIONS

Flumazenil administered by all 4 routes reversed midazolam-induced respiratory depression in a dog model. For the selected dosages used, the i.v. route was significantly faster than all 3 other routes, and SL was the second fastest.

Midazolam: a review of therapeutic uses and toxicity

Midazolam is a familiar agent commonly used in the emergency department to provide sedation prior to procedures such as laceration repair and reduction of dislocations. Midazolam is also effective in the treatment of generalized seizures, status epilepticus, and behavioral emergencies, particularly when intravenous access is not available. Midazolam is often employed as an induction agent for rapid sequence endotracheal intubation. Midazolam has a rapid onset of action following intravenous, intramuscular, oral, nasal, and rectal administration. Only 50% of an orally administered dose reaches the systemic circulation due to extensive first-pass metabolism. Midazolam is metabolized by the cytochrome P450 enzyme system to several metabolites including an active metabolite, alpha-hydroxymidazolam. Cytochrome P450 inhibitors such as cimetidine can profoundly reduce the metabolism of midazolam. Midazolam has a half-life of approximately 1 h, but this half-life may be prolonged in patients with renal or hepatic dysfunction. Midazolam has been associated with respiratory depression and cardiac arrest when used in combination with an opioid, particularly in the elderly, although all ages are at risk for respiratory depression. Midazolam is relatively free of side effects when used alone and offers several advantages over traditional pharmacological agents such as chloral hydrate and the combination of meperidine, chlorpromazine, and promethazine. Hiccups, cough, nausea, and vomiting are the most commonly reported adverse effects. Many of the adverse effects associated with midazolam can be reversed rapidly by the administration of flumazenil, a competitive benzodiazepine receptor antagonist. Midazolam is a safe and effective agent for providing sedation in the emergency department.

Pediatrics. A potpourri of clinical pearls

A pediatric focus in the emergency department requires an understanding of age-specific parameters of assessment and management. Differential considerations are unique in the pediatric patient reflecting both congenital and acquired conditions. Respiratory problems, meningitis, seizures, and child abuse require careful assessment and aggressive intervention. When approaching the ill child, attention must be directed toward reducing anxiety and pain in the patient.

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.