Comparison of oral transmucosal fentanyl citrate and an oral solution of meperidine, diazepam, and atropine for premedication in children

Pain Management and Conscious Sedation for the Pediatric Patient

Pain management in children was previously ignored primarily because of myths and misconceptions about childhood pain. Undertreatment of pain was once a common and accepted practice. However, in recent years, with increased knowledge and understanding coupled with improved pain assessment tools, health care providers are more conscious about providing adequate and safe analgesia to children. Because of the differences in patient response to various pharmacological agents, it is important to understand the pharmacokinetic and pharmacodynamic differences of the various agents. Choices of pain management should be individualized, and adjustments should be made based on the patient's clinical condition. Conscious sedation before diagnostic and therapeutic procedures should be approached with caution. Deaths and complications related to conscious sedation therapy have prompted the development of guidelines for safer and more effective pharmacological interventions. The recently published guidelines include recommendations for skilled personnel, continuous monitoring, appropriate use of drugs, and ability to manage unforeseen complications. Selection of the most appropriate sedatives should take into consideration the type of procedure, the patient's clinical condition, and the desired level and duration of consciousness. Similar to pain management, individualization is crucial. This article will discuss the principles of pain management and conscious sedation in children. Facts and scientific findings will be presented to discredit the myths and misconceptions often associated with pediatric pain. Various pain assessment tools will be summarized. The newly published sedation guidelines set forth by the American Academy of Pediatrics Committee on Drugs will be briefly discussed. Furthermore, commonly used agents will be reviewed. Copyright © 1996 by W.B. Saunders Company

Oral transmucosal fentanyl citrate for cancer breakthrough pain: a review

PURPOSE/OBJECTIVES

To review the dose titration, efficacy, and safety of oral transmucosal fentanyl citrate (OTFC).

DATA SOURCES

Phase I and II clinical trial abstracts and evidence-based review articles.

DATA SYNTHESIS

OTFC has an onset, peak, and duration of action similar to that of an IV dose of an opioid and has been demonstrated to be effective and well tolerated for the management of breakthrough pain in patients with cancer.

CONCLUSIONS

Studies of OTFC demonstrate that it is easy to use,noninvasive, effective, safe, and acceptable to patients, caregivers, and healthcare providers. However, OTFC is expensive and approved for use only in opioid-tolerant patients with cancer.

IMPLICATIONS FOR NURSING

Breakthrough pain in patients with cancer is a common problem with characteristics that make it difficult to treat. Oncology nurses should familiarize themselves with OTFC's unique characteristics to be able to best help patients manage their therapy.

Fentanyl

Fentanyl, a potent lipid-soluble opioid which was first synthesized more than 40 years ago, is still the most popular opioid used in the perioperative period throughout the world. Fentanyl's introduction, versatility, and popularity have resulted in its use in many acute and chronic pain conditions and a multitude of novel delivery systems in the last two decades. In spite of the development of more potent, safer, faster onset, and both shorter and longer lasting alternative opioids, fentanyl remains the mainstay of anesthesiologists and Certified Registered Nurse Anesthetists in the perioperative period, and for many pain physicians throughout the world.

A comparison of oral transmucosal fentanyl and oral midazolam for premedication in children

Oral transmucosal fentanyl citrate (OTF) was compared with midazolam as a premedicant in a prospective, randomised, placebo-controlled, double-blind trial. Eighty children (ASA grade 1 or 2, aged 3-9 years) who presented for tonsillectomy were randomly allocated to receive either 2.5 ml OTF (15-20 microg.kg(-1)) in a lollipop format and 0.5 ml.kg(-1) placebo syrup, or midazolam syrup (0.5 mg.kg(-1)) and a placebo lollipop (2.5 ml). The acceptability of sedation, anxiety and compliance with anaesthetic induction were assessed. The children were given an 'emergence' score for their recovery. Analgesia requirements, the incidence of vomiting, itching and any behavioural changes were assessed for 6 h postoperatively. Oral transmucosal fentanyl citrate was as effective as midazolam in aiding compliance with anaesthesia, but is significantly better in its appeal to children (p < 0.001) and emergence (p < 0.001) characteristics. In conclusion, OTF may be particularly useful as a premedicant in paediatric practice.

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.

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.

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.

Effects of anesthetic technique on side effects associated with fentanyl Oralet premedication

STUDY OBJECTIVES

To evaluate the efficacy of 5 to 10 micrograms/kg of oral transmucosal fentanyl citrate (OTFC) as an anesthetic premedication, and to determine whether propofol induction reduces postoperative nausea and vomiting (PONV) in pediatric patients premedicated with OTFC undergoing outpatient surgery.

DESIGN

Prospective, randomized, double-blinded study.

SETTINGS

University of Michigan Health Care Systems and University of Arizona.

PARTICIPANTS

62 ASA physical status I and II children aged 4 to 14 years (8.9 +/- 0.5 years).

INTERVENTIONS

Subjects were randomly assigned to one of four groups: (1) OTFC premedication and halothane induction; (2) OTFC premedication and propofol induction; (3) placebo premedication and halothane induction; and (4) placebo premedication and propofol induction. OTFC or placebo was administered 30 minutes prior to induction, and activity (sedation), apprehension, and cooperation scores were recorded before, at 15 and 30 minutes after study drug, and on induction. All perioperative adverse events were recorded.

MEASUREMENTS AND MAIN RESULTS

Children who received OTFC became drowsier and had a significant change from baseline in combined activity, apprehension, and cooperation scores, whereas those who received placebo became less cooperative at induction. Patients who received OTFC experienced more adverse events overall (p < 0.001) than patients who received placebo. Additionally, OTFC patients experienced more vomiting (p < 0.001) and pruritus (p = 0.049) than controls. The incidence of PONV in patients who received OTFC and halothane induction was 50%, compared to 30% in patients receiving OTFC and a propofol induction (p = NS).

CONCLUSIONS

OTFC in doses of 5 to 10 micrograms/kg was effective in producing sedation and facilitating cooperation with induction; however, it was associated with significant PONV in our study. Although propofol induction did not significantly reduce PONV in our study, further study with a larger sample, and with propofol as the sole anesthetic, may be warranted.

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.

The safety and efficacy of oral transmucosal fentanyl citrate for preoperative sedation in young children

Oral transmucosal fentanyl citrate (OTFC) is a labeled preoperative pediatric sedative. Doses greater than 15 micrograms/kg are associated with a high incidence of post-operative nausea and vomiting and occasional respiratory depression. We studied the safety and efficacy of OTFC in children 6 yr old and younger at a dose of 15 micrograms/kg. Nineteen patients undergoing surgery associated with postoperative pain were randomized to receive OTFC/intravenous (IV) saline or placebo lozenge/IV fentanyl. After 45 min, patients receiving OTFC became more sedated than the placebo group, but there were no differences in cooperation, apprehension, parental separation, or induction cooperation scores. Preoperatively, neither respiratory depression nor oxygen desaturation occurred. Nine of 10 OTFC patients developed mild pruritus, and three of 10 OTFC patients vomited preoperatively; neither complication occurred in the placebo group. (The high incidence of preoperative vomiting led to the termination of the protocol before the anticipated enrollment of 40 patients.) General anesthesia was induced via a mask, followed by a propofol infusion. Spo2 and respiratory rate were monitored, and sedation, apprehension, cooperation, ease of parental separation, and induction cooperation were scored. One OTFC patient developed rigidity during induction. Emergence and recovery were not delayed by OTFC despite a 50% incidence of postoperative vomiting. We do not recommend the use of OTFC in a 15 micrograms/kg dose as a routine preoperative sedative in children 6 yr old and younger.

Oral transmucosal fentanyl citrate for preanaesthetic medication of paediatric cardiac surgery patients

The safety and efficacy of oral transmucosal fentanyl citrate (OTFC) as a preanaesthetic medication were evaluated in 42 children aged two to twelve years scheduled to undergo general anaesthesia for open cardiac surgery. Patients were randomly assigned to receive either a placebo lozenge or a lozenge of 15-20 micrograms.kg-1) OTFC 45 min preoperatively and were managed in a double-blinded manner. Heart rate, respiratory rate (RR), blood pressure, and digital pulse oximetry (SpO2) were monitored throughout the study. Scoring systems were utilized to evaluate sedation, anxiety, cooperation, and ease and quality of parental separation and anaesthetic induction. Adverse effects were noted. Preoperatively, sedation was observed in both groups, but children receiving OTFC had significantly less distress at time of separation from parents. Clinically significant less distress at and SpO2 were observed more frequently in children in the OTFC group than in the placebo group. The authors conclude that, in paediatric cardiac surgical patients, OTFC induces preoperative sedation and facilitates separation of the patients from their parents, but is associated with decreases in respiratory rate and SpO2 that may be of clinical importance.

Oral transmucosal fentanyl citrate for premedication of children undergoing laceration repair

STUDY OBJECTIVE

To evaluate the safety and efficacy of two doses of oral transmucosal fentanyl citrate (OTFC) for premedication of children undergoing laceration repair.

DESIGN

Prospective, randomized, nonblinded study.

SETTING

Urban pediatric emergency department.

PARTICIPANTS

Thirty children aged 2 to 8 years requiring laceration repair.

INTERVENTIONS

Premedication with either 10 to 15 micrograms/kg or 15 to 20 micrograms/kg of OTFC.

RESULTS

Activity score, vital signs, oxygen saturation, and pain scores were recorded before and after administration of OTFC. Activity scores decreased significantly 15 to 60 minutes after OTFC. The physician suturing the wound rated the child's sedation/pain control as excellent or good in 83% of patients. Vital signs changes were not clinically remarkable. Oxygen saturations remained at 95% or more except in one child who experienced a transient decrease to 91%. Adverse effects were not serious but included vomiting in 20% of the lower-dose group and 47% of the higher-dose group. There were no significant differences between dose groups for activity or pain score changes, physician assessment, discharge times, or adverse events.

CONCLUSION

Both doses of OTFC reduced activity with comparable efficacy, with no serious vital signs changes. However, the higher-dose group had a greater number (P = NS) of adverse effects.

Preparing children for the operating room: psychological issues

Children respond psychologically to the prospect of surgery in a variable and age-dependent manner. This review summarizes the psychoanalytic, cognitive, behavioural and family system models of child development. It then reviews studies of hospitalization and anaesthesia in children. These studies suggest that younger children, children previously anaesthetized, and children who experience turbulent anaesthetic inductions are at particular risk for postoperative behavioural disturbances. Strategies of dealing with children and their parents during the perioperative period are discussed. Such strategies include: allowing a parent to be present during induction of anaesthesia, administering sedative premedication, creating a supportive environment, educating children and parents (verbal descriptions, tours, books, videos), and establishing rapport with children and their parents. Age-specific techniques of establishing rapport with children are discussed. If children are less anxious during the perioperative period, not only will they often exhibit less behavioural disturbances postoperatively, but they may face subsequent medical care more easily.

The effects of different antiemetic agents on morphine-induced emesis in ferrets

There is interest in the development of antiemetics other than dopamine receptor antagonists for the treatment of postoperative nausea and vomiting. A ferret model of morphine-induced emesis may have wider application in evaluating newer agents than the apomorphine dog model. This study describes the conditions for morphine-induced emesis in ferrets and evaluates five antiemetics that are prototypical of three different mechanisms. The average numbers of vomiting and retching episodes induced by morphine (0.1-2.5 mg/kg s.c.) were distributed as a bell-shaped curve. Maximum number of vomits occurred at 0.3 mg/kg (11.8 +/- 2.1 vomits; 45 +/- 12.5 retches). Antiemetics or vehicle were given i.v. 5 min prior to morphine while each ferret was maintained under isoflurane-O2 anesthesia. Ondansetron, a 5-HT3 receptor antagonist, reduced vomiting episodes by 47% and 70% (3 and 10 mg/kg). Granisetron, a 5-HT3 receptor antagonist was inactive at doses of 0.1, 1.0, 3.0 and 10 mg/kg. Metoclopramide reduced vomiting episodes by 48% and 82% (3 and 10 mg/kg). Droperidol reduced vomiting episodes by 84% at 3 mg/kg. Naloxone reduced vomiting episodes by 91% and 43% at doses of 0.1 and 1.0 mg/kg. In most cases, prolonged latency times to the first episodes accompanied the reduction in total numbers of episodes. The significant reduction of morphine-induced emesis in the ferret by ondansetron, metoclopramide and droperidol is consistent with the reduction of postoperative emesis in man by these compounds when morphine was a component of the anesthetic regimen. These results suggested that the morphine ferret model may be useful for evaluating compounds having the potential for preventing and treating postoperative vomiting.

Intranasal fentanyl titration for postoperative pain management in an unselected population

A randomized, double-blind study was undertaken to investigate the suitability of intranasally administered fentanyl for postoperative pain management under routine conditions in an unselected population. For postoperative pain relief, patients received either 0.027 mg fentanyl intranasally and sodium chloride 0.9% intravenously (intranasal group, n = 53) or sodium chloride 0.9% intranasally and 0.027 mg fentanyl intravenously (intravenous group, n = 59). These doses were repeated every 5 min until the patients were free of pain or refused further analgesia. Pain severity was evaluated before beginning opioid titration and 5, 10, 15, 20, 30, 40, 50, 60, 70 and 80 min thereafter. Adequate pain relief was achieved in 52 of 53 patients in the intranasal and in all patients in the intravenous group. Pain intensities evaluated on a 101-point numerical rating scale as well as on a verbal rating scale decreased significantly in both study groups within 5 min. At the 15 min measurement point, numerical rating scale pain intensity and at the 10 and 20 min point, verbal rating scale pain intensity was significantly lower in the intravenous group. The incidence of side effects was low in both groups and no patient complained of intranasal pain. Intranasally administered fentanyl would appear to be suitable for the management of postoperative pain.

[New modes of opioid administration.]

In the last few years great interest has developed in new modes of opioid administration; oral transmucosal, transdermal, peripheral, and nasal administration.Oral transmucosal administration of fentanyl citrate (OTFC) has most often been used for premedication in children. Meanwhile, studies on the use of OTFC in cancer patients for postoperative pain management have also been published. While OTFC may have a limited role in postoperative pain management, it may prove very helpful in the management of incident and breakthrough cancer pain. Patient acceptance is high, and the onset of action is relatively rapid.Transdermal administration of fentanyl (TTS fentanyl) has been extensively examined, especially in postoperative patients. Patient acceptance is high, and TTS-fentanyl-related side-effects (e.g. mild erythema at the site of application) are minor. Application is performed at 72-h intervals. Kinetics are stable with repeated dosing, and serum concentrations approach steady state with the first dose. The slow rise/decline in fentanyl plasma concentration with patch application/removal makes it less well suited for postoperative pain management. However, TTS fentanyl seems to be a promising mode of opioid administration for cancer patients.-Recent papers have unequivocally demonstrated a peripheral antinociceptive effect oflocally applied opioids, especially in inflamed tissue. However, the results of clinical investigations are equivocal so far: about half the reports demonstrate an analgesic effect of peripherally administered opioids, and the other half, not.Intranasal administration was introduced for premedication in children, but benzodiazepines seem to be the better and safer choice. Nonetheless, intranasal opioids guarantee a rapid rise in opioid plasma concentrations as well as a rapid onset of pain relief. This mode of administration seems to be especially suitable for the treatment of acute pain syndromes, such as breakthrough cancer pain or incident pain. Patient acceptance is high, and no local problems were reported.

Perioperative gastric aspiration increases postoperative nausea and vomiting in outpatients

The efficacy of aspiration of gastric contents to reduce postoperative nausea and vomiting was investigated in a controlled randomized, double-blind study of 265 outpatients. Patients in the treated group had their stomachs aspirated with an orogastric tube. In the control group no tube was inserted. Data on the incidence of nausea and vomiting were collected in the recovery room, the day surgery unit and the day after surgery. The overall incidence of postoperative nausea and vomiting was comparable in the two groups. It was also comparable in the recovery room and the day surgery unit. However, treated patients had a higher incidence of both nausea (26.5% vs 12.0%, P < 0.005) and vomiting (16.7% vs 6.8%, P < 0.02) after their discharge from the day surgery unit. We conclude that aspiration of gastric contents with an orogastric tube does not decrease postoperative nausea and vomiting in outpatients and may increase it after discharge of the patient.

Novel delivery systems: oral transmucosal and intranasal transmucosal

During the past 2 decades, anesthesiologists have been provided with a number of new, potent opioid analgesics and sedative/hypnotics, as well as an increased understanding of the pharmacokinetic and pharmacodynamic principles that govern their action and disposition. These developments have suggested that the skin and the buccal and nasal mucous membranes may have use as alternate routes of analgesic and anesthetic drug delivery. A novel transmucosal delivery system for fentanyl has recently been developed by incorporating the drug into a dissolvable matrix on a stick called an "oralete." Oral transmucosal fentanyl citrate has been evaluated as a premedication in the pediatric population and as an analgesicfor acute postoperative and emergency room pain, procedural pain, and breakthrough cancer pain by using fentanyl. Increases in plasma fentanyl and onset of clinical effect are rapid (20-40 min) with this formulation. A potential advantage is the apparent ease of titration to a sedative or analgesic end point. This system may improve premedication, acute postoperative analgesia, and chronic pain therapy in various clinical settings. Delivery of opioids through the nasal mucosa also has been recently investigated. In one study, sufentanil was administered (1.5, 3.0, or 4.5 mu/kg) to 80 children ranging in age from 6 mo to 7yr. Easy separation from parents was achieved in 86% of the children 10 min following administration of the premedication. Unfortunately, 61% of the children cried after drug administration, and side effects included reduced ventilatory compliance (chest-wall rigidity) with higher doses (3.0 and 4.5 microg/kg). Nevertheless, nasal transmucosal drug delivery may have value, especially in frightened or uncooperative children.

Oral transmucosal fentanyl citrate for analgesia and sedation in the emergency department

STUDY OBJECTIVE

To evaluate the safety and efficacy of oral transmucosal fentanyl citrate (OTFC) as a noninvasive method of providing analgesia and sedation for patients in the emergency department.

DESIGN

Prospective, nonblinded.

SETTING

ED of a tertiary care university hospital.

TYPE OF PARTICIPANTS

Ten patients, 6 to 34 years old, with acute painful conditions requiring treatment in the ED.

INTERVENTIONS

Premedication with OTFC and local anesthetic prior to incision or wound closure.

MEASUREMENTS AND MAIN RESULTS

Pain and activity (sedation) scores, vital signs (including systolic and diastolic arterial blood pressures, heart and respiratory rates, and pulse oximetry-determined oxygen saturation) were measured before and at two- to ten-minute intervals during and after OTFC consumption. All patients accepted OTFC. Patients received an average of 13.7 +/- 2.5 micrograms/kg of fentanyl citrate in 11.8 +/- 6.8 minutes. Decreases in pain were reported in two patients in two minutes and by all patients 14 minutes after beginning OTFC consumption. Sixty percent of patients became drowsy or sedated 12 to 30 minutes after beginning OTFC. Vital signs and oxygen saturation changes were small and not clinically significant. The most important side effects were pruritus (30%), nausea (20%), and dizziness and dry mouth (40%). All were considered mild and not disturbing, although one patient required post-procedure antiemetic therapy for recurrent vomiting. The mean time to discharge from the ED was 139 +/- 54 minutes after receiving OTFC.

CONCLUSION

OTFC may be useful in providing rapid, noninvasive analgesia and sedation in the ED and deserves further evaluation.

An open label study of oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough cancer pain

Ten patients with advanced cancer and breakthrough pain between the ages of 39 and 78 received oral transmucosal fentanyl citrate (10-15 micrograms/kg) 4 or 5 times each over 2 days (42 total administrations) in an open study. Baseline vital sign and rating scale results did not vary over administrations, except for heart rate which showed an 8 beats/min decrease over 4 administrations. Heart rate and oxygen saturation did not vary significantly over 120 min of evaluation, and minimal changes in blood pressure and respiration rate were found. Significant reduction in pain scores as measured by a pain descriptive scale, the McGill-Melzack scale, and a numeric (VAS) scale were seen at all evaluations from 5 to 120 min. Average time to onset of pain relief was 9.5 min after administration. Wellbeing was significantly increased at all evaluations. Activity level as recorded by the investigator was significantly reduced from 10 to 30 min after administration, however, activity level as reported by the patient was significantly increased at 5 min and from 60 to 120 min after OTFC administration. There were no significant adverse effects.

Oral transmucosal fentanyl citrate for premedication in paediatric outpatients

Two doses (10-15 micrograms.kg-1, Group I, and 15-20 micrograms.kg-1, Group II) of oral transmucosal fentanyl citrate (OTFC) plus a placebo (Group III) were evaluated for premedication in 105 healthy children, aged 2 to 13 yr, undergoing short (less than 1 hr) operations in the hospital short-stay unit. The study was randomized and double-blinded and 91 of the 105 children also received droperidol, 25 micrograms.kg-1 IV, after induction of anaesthesia with halothane and N2O in oxygen. Both doses of OTFC produced significantly greater sedation (first present at 20 min) and anxiolysis (first present in Group I at 40 min) than the placebo. Recovery times were similar in the three groups and analgesic requirements in the recovery room were significantly lower in Group I than Group III. Both OTFC groups took longer to tolerate oral fluids in the postoperative discharge unit than the placebo group and this caused patients in Group I to have a delayed discharge from the hospital compared to Group III. Preoperative pruritus occurred significantly more frequently in Groups I and II (58 and 76 per cent, respectively) than Group III (23 per cent). Although the incidences of nausea and vomiting tended to be slightly higher in the OTFC groups in the preoperative holding and postoperative discharge units, the differences among the groups were not statistically significant. Likewise droperidol did not reduce the incidence of postoperative nausea or vomiting. The data indicate that OTFC may be a safe and effective premedicant in paediatric patients having short operations but delays discharge from the hospital (by 30-50 min) by delaying the time patients tolerate fluids early after operation.

Ketamine sedation for pediatric procedures: Part 1, A prospective series

Emergency physicians frequently perform painful but necessary procedures on frightened children. We conducted a prospective, uncontrolled clinical trial of ketamine sedation (4 mg/kg IM) to facilitate a variety of procedures in 108 children aged 14 months to 13 years. Acceptable conditions were achieved with a single injection in 97% of the patients, and adjunctive restraint or local anesthesia was not required in 86%. Full sedation was produced within five minutes in 83%. Mean duration from injection to dischargeable recovery was 82 minutes (range, 30 to 175 minutes). One 18-month-old child vomited shortly after injection and experienced transient laryngospasm with cyanosis; intubation was not required, and there were no adverse sequelae. Airway patency and independent respirations were fully maintained in all other patients; no hemodynamic instability occurred at any time. There were no other clinically significant complications. Emesis well into the recovery phase was noted in 6% of the patients. Nightmares were not observed. Response from parents and physicians was strongly positive. Ketamine can be effectively used by emergency physicians to facilitate procedural sedation, yet equipment and expertise for advanced airway management are mandatory due to the rare occurrence of laryngospasm.