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Lozano-Díaz D, Valdivielso Serna A, Garrido Palomo R, Arias-Arias Á, Tárraga López PJ, Martínez Gutiérrez A. Validation of the Ramsay scale for invasive procedures under deep sedation in pediatrics. Paediatr Anaesth 2021; 31:1097-1104. [PMID: 34173295 DOI: 10.1111/pan.14248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 05/23/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Ramsay scale is the most widely used scale during pediatric procedures although it has not been formally validated. OBJECTIVE To validate the Ramsay scale during invasive procedures under sedation in pediatrics. METHODS A prospective analytic study was conducted in two hospitals. All patients ≥6 months that were undergoing invasive procedures under sedation were enrolled. All were recorded, and these videos were edited and randomized. 150 videos were scored by four observers (a pediatrician, a pediatric intensive care unit nurse, an anesthetist, and an operating room nurse). All videos were scored with the Ramsay scale and University of Michigan Sedation Scale. Observers were blinded to drug administration. Construct validity was measured through Wilcoxon test paired samples after administration of sedatives. Criterion validity, intra-observer reliability, and interobserver correlation were evaluated by comparing the scores of the scales using Spearman's correlation coefficient. Interobserver agreement was measured using the intraclass correlation coefficient. To assess test-retest reliability, 50 videos were randomly selected and reevaluated. RESULTS Sixty-five patients were included. Construct validity was demonstrated through changes in the Ramsay scale scoring after administration of sedatives (p < .0001). Regarding criterion validity, the Ramsay scale had a high correlation with the UMSS (ρ = 0.621). Intra-observer agreement was ρ = 0.884. The Ramsay scale showed interobserver reliability with an intraclass correlation coefficient = 0.94 when comparing it with the University of Michigan Sedation Scale. Internal consistency was α = 0.91. Regarding applicability, in our study, it was applied in two hospitals in different areas by four professionals from distinct categories. CONCLUSIONS The Ramsay scale is valid, reliable, and applicable to monitoring sedation for invasive procedures under deep sedation in pediatrics.
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Affiliation(s)
- David Lozano-Díaz
- Department of Pediatrics, Hospital General La Mancha Centro, Ciudad Real, Spain
| | | | | | - Ángel Arias-Arias
- Research Unit, Hospital General La Mancha Centro, Ciudad Real, Spain
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Tête X, Masson Y, Donat N, Rager G, Leclerc T, Fontaine B. Mise au point sur l’utilisation du GammaOH en anesthésie–réanimation. ANESTHÉSIE & RÉANIMATION 2021. [PMCID: PMC8346353 DOI: 10.1016/j.anrea.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Michel J, Hofbeck M, Merz T, Kumpf M, Meiers A, Neunhoeffer F. Gamma-hydroxybutyrate: is it a feasible alternative to midazolam in long-term mechanically ventilated children? Curr Med Res Opin 2019; 35:1721-1726. [PMID: 31079504 DOI: 10.1080/03007995.2019.1618253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Benzodiazepines like midazolam are commonly used for long-term sedation of critically ill children requiring mechanical ventilation. Tolerance to midazolam may occur in these patients resulting in a ceiling effect with insufficient or missing sedative response to increases of midazolam infusion or bolus application. The aim of this study was to evaluate the feasibility of a drug rotation protocol replacing continuous infusion of midazolam with gamma-hydroxybutyrate (GHB) to counteract midazolam tolerance. Methods: This retrospective, observational study was conducted in a 14-bed pediatric intensive care unit of a tertiary referral center. Thirty-three mechanically ventilated children with tolerance to midazolam who received continuous infusion of GHB were included. Success of drug rotation from midazolam to GHB was defined as adequate sedation with GHB and subsequent reduction of required doses of midazolam. Results: In our cohort, drug rotation for at least 2 days could be successfully performed in 10 out of 34 children resulting in subsequent reduction of required doses of midazolam. Drug rotation to GHB failed in 24 patients due to insufficient sedation resulting in a premature termination of the protocol. In these children, dosing of midazolam could not be reduced following drug rotation. We could not identify factors which predict success or failure of drug rotation from midazolam to GHB. Conclusions: The data from our single-center study suggest that drug rotation from midazolam to GHB may be worth trying in children with midazolam tolerance during long-term sedation, but physicians should be aware of possible treatment failure.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Timo Merz
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Anna Meiers
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
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Sauer H, Gruenzinger L, Pfeifer J, Graeber S, Abdul-Khaliq H. Propofol Versus 4-hydroxybutyric Acid in Pediatric Cardiac Catheterizations. Open Med (Wars) 2019; 14:416-425. [PMID: 31198855 PMCID: PMC6555241 DOI: 10.1515/med-2019-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/23/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction Pediatric patients require deep sedation at least for cardiac catheterizations (CCs). Usually, we perform these CCs applying propofol, but we have seen several side effects of this sedative. We have had good experience with 4-hydroxybutyric acid for other sedations. To optimize our standardized CC procedure, we initiated a prospective, randomized trial to compare the two substances. Methods We analyzed our sedation protocols of all CCs within a period of 12 months. In addition to the primary endpoints, the feasibility of the CCs and the occurrence of severe complications, several other parameters were included in the analysis (vital parameters, blood gas analysis, intervention measures). The protocols were blinded for the first part of the evaluation. Results During the 12-month-period, 36 patients were included in each group. The propofol group showed lower blood pressure values towards the end of the sedations, while the blood gas analyses revealed lower pH levels and higher pCO2 values. The complication rate was low in both groups. Conclusion Both procedures are suited for the safe performance of deep sedations for CCs. The application of 4-hydroxybutyric acid seems to have a few advantages with regard to spontaneous breathing, gas exchange, stability of cardiocirculatory parameters and sedation quality.
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Affiliation(s)
- Harald Sauer
- Clinic for Pediatric Cardiology, University Hospital of Saarland, Kirrberger Strasse, 66421Homburg, Germany
- Tel.: ++49 (0) 6841 – 16 – 28374, FAX: ++49 (0) 6841 – 16 – 28452
| | - Laura Gruenzinger
- Clinic for Dermatology – Lippe Hospital Detmold, Roentgenstrasse 18, 32756Detmold, Germany
| | - Jochen Pfeifer
- Clinic for Pediatric Cardiology – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
| | - Stefan Graeber
- Institute of Medical Biometry, Epidemiology and Medical Computer Science – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
| | - Hashim Abdul-Khaliq
- Clinic for Pediatric Cardiology – University Hospital of Saarland, Kirrberger Strasse, 66421Homburg (Saar), Germany
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Antelmi E, Plazzi G, Pizza F, Vandi S, Aricò D, Ferri R. Impact of acute administration of sodium oxybate on heart rate variability in children with type 1 narcolepsy. Sleep Med 2018; 47:1-6. [PMID: 29880141 DOI: 10.1016/j.sleep.2018.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/08/2018] [Accepted: 03/12/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Currently, cardiovascular measurements in children affected with type 1 narcolepsy (NT1) have never been investigated, and neither have their modulation by the administration of sodium oxybate (SO). METHODS Twelve drug-naïve NT1 children (four males, eight females) with a mean age of 11 ± 3.16 years underwent a nocturnal polysomnography, at baseline and during the first night of SO administration. Data were contrasted with those recorded in 23 age-matched healthy controls. Heart rate variability (HRV) analysis was performed by analyzing the electrocardiogram signal for automatic detection of R waves with a computer program calculating a series of standard time-domain measures and obtaining spectral parameters, by means of a Fast-Fourier Transform. RESULTS In sleep stages N2 and N3, NT1 children showed increased power in the low-frequency (LF) and very-LF (VLF) ranges, when compared to controls. In addition, HRV (as measured by time domain parameters) during all sleep stages tended to be slightly higher in patients when compared to controls. Treatment with SO did not change significantly any parameter, but an overall trend to mildly decreased HRV that reached a significant value only during R sleep. CONCLUSIONS HRV during all sleep stages tended to be slightly higher in young patients when compared to controls, confirming the presence of a slight sympathovagal system imbalance even in NT1 children. SO tends to decrease these values especially during REM sleep and in that regard, further studies supporting these preliminary findings and considering the long-term effects of SO on heart rate parameters are warranted.
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Affiliation(s)
- Elena Antelmi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy.
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Debora Aricò
- Sleep Research Centre, Department of Neurology I.C., Oasi Institute IRCCS, Troina, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Department of Neurology I.C., Oasi Institute IRCCS, Troina, Italy
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Liu B, Cai J, Xu Y, Peng X, Zheng H, Huang K, Yang J. Three-dimensional magnetic resonance cholangiopancreatography for the diagnosis of biliary atresia in infants and neonates. PLoS One 2014; 9:e88268. [PMID: 24505457 PMCID: PMC3914942 DOI: 10.1371/journal.pone.0088268] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 01/08/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Magnetic resonance cholangiopancreatography (MRCP) is widely accepted for visualization of the biliary system. However, the sensitivity and specificity of MRCP for the diagnosis of biliary atresia (BA) are still not fully elucidated. This study aimed to investigate the diagnostic value of three-dimensional MRCP (3D-MRCP) for BA in a large cohort of cholestatic infants and neonates. METHODS One hundred ninety patients with infant jaundice underwent 3D-MRCP and one or more of the following: (1) intraoperative cholangiography, (2) laparoscopic exploration and pathological examination, or/and (3) clinical therapy. Statistical analyses were performed to determine the diagnostic accuracy of 3D-MRCP for BA. RESULTS Our study demonstrated that 158 of 190 patients were interpreted as having BA by 3D-MRCP; of those, 103 patients were confirmed as having BA, whereas 55 patients did not have BA. Of the 32 patients interpreted as non-BA cases by 3D-MRCP, one patient was misdiagnosed. The diagnostic accuracy for 3D-MRCP was 70.53% (134 of 190), the sensitivity was 99.04% (103 of 104), the specificity was 36.05% (31 of 86), the negative predictive value was 96.88% (31 of 32), the positive predictive value was 65.19% (103 of 158), the positive likelihood ratio was 2.7473, the negative likelihood ratio was 0.0267, and the Youden index was 0.3509. CONCLUSIONS The sensitivity of 3D-MRCP in diagnosing BA was excellent, but the specificity was not as high as described in previous reports. 3D-MRCP can be an effective screening method but should be combined with other modalities to identify BA and distinguish it from other causes of infant jaundice.
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Affiliation(s)
- Bo Liu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jinhua Cai
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ye Xu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xuehua Peng
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Helin Zheng
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kaiping Huang
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Yang
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
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Viallard ML, Suc A, De Broca A, Bétrémieux P, Hubert P, Parat S, Chabernaud JL, Canouï P, Porée N, Wood C, Mazouz W, Blanchet V, Aubry R. Modalités pratiques d’une sédation en phase terminale ou en fin de vie en pédiatrie : prise de décision, mise en œuvre et surveillance. MEDECINE PALLIATIVE 2010. [DOI: 10.1016/j.medpal.2010.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Klein M, Remi J, Pfister H, Straube A, Rupprecht T, Weckbach S, Pfefferkorn T. Mimicking of Cerebral Herniation Through γ-Hydroxybutyric Acid Therapy. Am J Crit Care 2008. [DOI: 10.4037/ajcc2008.17.6.593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Besides being a treatment option for narcolepsy, γ-hydroxybutyrate is used as an adjuvant during anesthesia in Europe. In addition, it is illegally used as a recreational drug. Fixed and dilated, asymmetric pupils developed in 2 patients during continuous therapy with intravenous γ-hydroxybutyrate, which was added to the long-term anesthetics fentanyl and midazolam. Cerebral herniation as an alternative cause for the pupillary changes was ruled out by using continuous intracranial pressure monitoring and computed tomography. In both patients, the pupillary abnormalities resolved after discontinuation of γ-hydroxybutyrate. Thus, fixed and dilated pupils that are asymmetric seem to be an important side effect of γ-hydroxybutyrate therapy that may mimic cerebral herniation in deeply anesthetized patients.
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Affiliation(s)
- M. Klein
- M. Klein, J. Remi and T. A. Rupprecht are residents, H. W. Pfister and A. Straube are professors, and T. Pfefferkorn is a fellow in the Department of Neurology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany. S. Weckbach is a resident in the Department of Radiology, Klinikum Großhadern, Ludwig-Maximilian University
| | - J. Remi
- M. Klein, J. Remi and T. A. Rupprecht are residents, H. W. Pfister and A. Straube are professors, and T. Pfefferkorn is a fellow in the Department of Neurology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany. S. Weckbach is a resident in the Department of Radiology, Klinikum Großhadern, Ludwig-Maximilian University
| | | | - A. Straube
- M. Klein, J. Remi and T. A. Rupprecht are residents, H. W. Pfister and A. Straube are professors, and T. Pfefferkorn is a fellow in the Department of Neurology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany. S. Weckbach is a resident in the Department of Radiology, Klinikum Großhadern, Ludwig-Maximilian University
| | | | - S. Weckbach
- M. Klein, J. Remi and T. A. Rupprecht are residents, H. W. Pfister and A. Straube are professors, and T. Pfefferkorn is a fellow in the Department of Neurology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany. S. Weckbach is a resident in the Department of Radiology, Klinikum Großhadern, Ludwig-Maximilian University
| | - T. Pfefferkorn
- M. Klein, J. Remi and T. A. Rupprecht are residents, H. W. Pfister and A. Straube are professors, and T. Pfefferkorn is a fellow in the Department of Neurology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany. S. Weckbach is a resident in the Department of Radiology, Klinikum Großhadern, Ludwig-Maximilian University
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Meyer S, Grundmann U, Gottschling S, Kleinschmidt S, Gortner L. Sedation and analgesia for brief diagnostic and therapeutic procedures in children. Eur J Pediatr 2007; 166:291-302. [PMID: 17205245 DOI: 10.1007/s00431-006-0356-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 10/24/2006] [Indexed: 02/07/2023]
Abstract
The number of diagnostic and therapeutic procedures done outside of the operating room and the intensive care unit has increased substantially in recent years. In parallel, the management of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures has developed considerably in the past two decades. The primary goal of procedural sedation and analgesia is the safe and efficacious control of emotional distress and pain. The availability of non-invasive monitoring, short-acting opioids and sedatives has broadened the possibilities of sedation and analgesia in children in diverse settings. While most of these procedures themselves pose little risk to the child, the administration of sedation or analgesia may add substantial risk to the patient. This article reviews the current status of sedation and analgesia for invasive and non-invasive procedures in children providing an evidence-based approach to several topics of importance, including patient assessment, personnel requirements, equipment, monitoring, and drugs.
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Affiliation(s)
- Sascha Meyer
- Department of Neonatology and Paediatric Intensive Care Medicine, University Children's Hospital of Saarland, Building 9, 66421, Homburg, Germany.
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Cengiz M, Baysal Z, Ganidagli S. Oral sedation with midazolam and diphenhydramine compared with midazolam alone in children undergoing magnetic resonance imaging. Paediatr Anaesth 2006; 16:621-6. [PMID: 16719877 DOI: 10.1111/j.1460-9592.2005.01820.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to compare the safety and efficacy of oral midazolam and midazolam-diphenhydramine combination to sedate children undergoing magnetic resonance imaging (MRI). METHODS We performed a prospective randomized double-blind study in 96 children who were randomly allocated into two groups. Group D received oral diphenhydramine (1.25 mg x kg(-1)) with midazolam (0.5 mg x kg(-1)), and Group P received oral placebo with midazolam (0.5 mg x kg(-1)) alone. Sedation scores, onset and duration of sleep were evaluated. Adverse effects, including hypoxemia, failed sedation, and the return of baseline activity, were documented. RESULTS Diphenhydramine facilitated an earlier onset of midazolam sedation (P < 0.01), and higher sedation scores (P < 0.01). In children who received midazolam alone, 20 (41%) were inadequately sedated, compared with 9 (18%) children who received midazolam and diphenhydramine combination (P < 0.01). Time to complete recovery was not significantly different between the two groups. CONCLUSIONS Our study indicates that the combination of oral diphenhydramine with oral midazolam resulted in safe and effective sedation for children undergoing MRI. The use of this combination might be more advantageous compared with midazolam alone, resulting in less sedation failure during MRI.
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Affiliation(s)
- Mustafa Cengiz
- Department of Anaesthesiology and Reanimation, Medical School, Harran University, Sanliurfa, Turkey.
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Affiliation(s)
- O Carter Snead
- Department of Pediatrics, University of Toronto, and the Division of Neurology and the Brain and Behavior Research Program, Hospital for Sick Children, Toronto, ON, Canada
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