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Jen CK, Lu KC, Chen KW, Lu YR, Huang IT, Huang YC, Huang CJ. Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. J Clin Med 2024; 13:1174. [PMID: 38398486 PMCID: PMC10889161 DOI: 10.3390/jcm13041174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam.
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Affiliation(s)
- Chun-Kai Jen
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - Kuo-Ching Lu
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Department of Anesthesiology, Binkun Women’s and Children’s Hospital, Taoyuan 324, Taiwan
| | - Kuan-Wen Chen
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - Yun-Ru Lu
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
| | - I-Tao Huang
- Emergency Department, Redcliffe Hospital, Redcliffe, QLD 4020, Australia;
- School of Public Health, Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
| | - Yu-Chen Huang
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan;
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
| | - Chun-Jen Huang
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei 116, Taiwan; (C.-K.J.); (K.-C.L.); (K.-W.C.); (Y.-R.L.)
- Integrative Research Center for Critical Care, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
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Alzoubi H, Kabbani S, Taleb A, Bshara N, Altinawi MK, Almonakel MB, Al Kurdi S. Rectal Sedation With Ketamine and Midazolam in the Management of Uncooperative Children During Dental Treatment: A Case Series and Method Description. Cureus 2024; 16:e54825. [PMID: 38529445 PMCID: PMC10962867 DOI: 10.7759/cureus.54825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 03/27/2024] Open
Abstract
Background In pediatric dentistry, sedation aims to eliminate anxiety to facilitate the completion of dental procedures. Sedation in children is a multidimensional field that includes the child, parents/guardians, and the health care team. The rectal route is generally painless, making it suitable for children who are afraid of needles. This route has several advantages over the oral route, including reduced patient cooperation requirements, a faster and more predictable onset, and less physical trauma than the intravenous and intramuscular routes. This case series aimed to evaluate the effectiveness and success rate of rectal sedation with ketamine and midazolam in the management of uncooperative children during dental treatment. Case presentation Ten healthy children with definitely negative behavior were enrolled in this study. Each child was given 7 mg/kg of ketamine in combination with midazolam 0.1 mg/kg by the rectal route. The mean onset sedation time was 9.5 minutes, and pulpotomy procedures were done. Behavioral response was monitored throughout treatment using the Ohio State University Behavioral Rating Scale (OSUBRS), and the depth of sedation was measured using the University of Michigan Sedation Scale (UMSS). The Houpt General Behavior Scale was used to estimate the treatment success rate based on the overall behavior rating. All 10 cases showed good anxiolysis and cooperation following rectal administration, with no side effects observed. Conclusions Rectal administration of ketamine in combination with midazolam may be considered a reliable method in the management of uncooperative children during dental treatment. No adverse effects were observed during or after the sedation procedure.
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Affiliation(s)
- Hasan Alzoubi
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | - Samar Kabbani
- Department of Anesthesia and Reanimation, Damascus University, Damascus, SYR
| | - Ahmad Taleb
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | - Nada Bshara
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
| | | | | | - Saleh Al Kurdi
- Department of Pediatric Dentistry, Damascus University, Damascus, SYR
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Lee D, Yeo H, Lee Y, Park H, Park H. A Survey on Procedural Sedation and Analgesia for Pediatric Facial Laceration Repair in Korea. Arch Plast Surg 2023; 50:30-36. [PMID: 36755661 PMCID: PMC9902079 DOI: 10.1055/s-0042-1759792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/19/2022] [Indexed: 02/08/2023] Open
Abstract
Background Most children with facial lacerations require sedation for primary sutures. However, sedation guidelines for invasive treatment are lacking. This study evaluated the current status of the sedation methods used for pediatric facial laceration repair in Korea. Methods We surveyed one resident in each included plastic surgery training hospital using face-to-face interviews or e-mail correspondence. The health care center types (secondary or tertiary hospitals), sedation drug types, usage, and dosage, procedure sequence, monitoring methods, drug effects, adverse events, and operator and guardian satisfaction were investigated. Results We included 45/67 hospitals (67%) that used a single drug, ketamine in 31 hospitals and chloral hydrate in 14 hospitals. All health care center used similar sedatives. The most used drug administered was 5 mg/kg intramuscular ketamine (10 hospitals; 32%). The most common chloral hydrate administration approach was oral 50 mg/kg (seven hospitals; 50%). Twenty-two hospitals (71%) using ketamine followed this sequence: administration of sedatives, local anesthesia, primary repair, and imaging work-up. The most common sequence used for chloral hydrate (eight hospitals; 57%) was local anesthesia, administration of sedatives, imaging work-up, and primary repair. All hospitals that used ketamine and seven (50%) of those using chloral hydrate monitored oxygen saturation. Median operator satisfaction differed significantly between ketamine and chloral hydrate (4.0 [interquartile range, 4.0-4.0] vs. 3.0 [interquartile range, 3.0-4.0]; p <0.001). Conclusion The hospitals used various procedural sedation methods for children with facial lacerations. Guidelines that consider the patient's condition and drug characteristics are needed for safe and effective sedation.
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Affiliation(s)
- Dongkyu Lee
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hyeonjung Yeo
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea,Address for correspondence Hyeonjung Yeo, MD Department of Plastic and Reconstructive SurgeryDaegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199Korea
| | - Yunjae Lee
- Cheongdam Okay Plastic Surgery Clinic, Seoul, Korea
| | - Hyochun Park
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hannara Park
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
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Hoeffe J, Vogel RG, Ammann RA. Pediatric Sedation and Analgesia Outside the Operating Room: Combining Intranasal Fentanyl and Inhaled Nitrous Oxide. J Pediatr Pharmacol Ther 2022; 27:436-442. [DOI: 10.5863/1551-6776-27.5.436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Combining intranasal fentanyl (IN FENT) with inhaled nitrous oxide (N2O) seems to have good properties for pediatric procedural sedation and analgesia (PSA). This study aims to assess the side effect rate of the combined use of IN FENT and N2O.
METHODS
We performed a retrospective, single-center study. Patients treated in either the pediatric emergency department (PED) or the pediatric surgery outpatient clinic (PSOC) were included, if they received PSA with IN FENT and nitrous oxide with 50% oxygen (N2O 50%).
RESULTS
Three hundred seventy-five patients were included over a period of 4 years. Median age was 9.4 years (range, 3.1 to 15.9) and 39% of patients were female. Overall side effect rate was 30% (114 patients). Most frequent was dizziness (n = 63, 17%; 95% CI, 13–21), followed by nausea (n = 23, 6%; 95% CI, 4–9) and emesis (n = 14, 4%; 95% CI, 2–6), with 35 patients having either nausea and/or emesis (9%; 95% CI, 7–13). No serious side effects were recorded (0%; 95% CI, 0–0.1). Of 298 patients with information regarding satisfaction, 280 patients would like the same sedation for a similar procedure in the future (94%; 95% CI, 90–96). We found no relation between previously described risk factors and emesis and/or nausea.
CONCLUSIONS
N2O 50% combined with IN FENT can be recommended as an effective and safe treatment in the PED and the PSOC. While the side effect rate, primarily dizziness, nausea and emesis was substantial, antiemetic prophylaxis is not indicated owing to the overall low incidence of nausea and emesis.
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Affiliation(s)
- Julia Hoeffe
- Department of Pediatric Emergency Medicine, Department of Pediatrics (JH), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Roland A. Ammann
- Division of Pediatric Hematology and Oncology, Department of Pediatrics (RAA), Inselspital, Bern University Hospital, University of Bern, Switzerland
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Gómez-Manzano FJ, Laredo-Aguilera JA, Cobo-Cuenca AI, Rabanales-Sotos J, Rodríguez-Cañamero S, Martín-Espinosa N, Carmona-Torres JM. Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review. CHILDREN 2022; 9:children9050644. [PMID: 35626821 PMCID: PMC9139737 DOI: 10.3390/children9050644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.
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Affiliation(s)
- Francisco Javier Gómez-Manzano
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- IES Juanelo Turriano, Consejería de Educación, Cultura y Deportes de Castilla-La Mancha, 45007 Toledo, Spain
| | - José Alberto Laredo-Aguilera
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- Correspondence: ; Tel.: +34-925-268-800 (ext. 5613)
| | - Ana Isabel Cobo-Cuenca
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
| | | | - Sergio Rodríguez-Cañamero
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- Hospital Universitario de Toledo, Servicio de Salud de Castilla-La Mancha, 45007 Toledo, Spain
| | - Noelia Martín-Espinosa
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
| | - Juan Manuel Carmona-Torres
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
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Chang JG, Regen RB, Peravali R, Harlan SS, Smeltzer MP, Kink RJ. Intranasal Fentanyl and Midazolam Use in Children 3 Years of Age and Younger in the Emergency Department. J Emerg Med 2021; 61:731-739. [PMID: 34920841 DOI: 10.1016/j.jemermed.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/22/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the efficacy and safety profiles of both intranasal fentanyl and midazolam are well studied in pediatric patients, few studies examine their use in younger children. OBJECTIVES To examine and report our experiences in a pediatric emergency department (ED) with intranasal fentanyl and midazolam in children aged 3 years and younger. METHODS This retrospective study investigated intranasal fentanyl and midazolam administration, alone and in combination, in children 3 years and younger treated in a pediatric ED. RESULTS Of 6198 patients included, 1762 received intranasal fentanyl alone, 1115 received intranasal midazolam alone, and 3321 received combination therapy. The median (interquartile range [IQR]) patient age was 2.2 (1.5-3) years. Initial median (IQR) fentanyl dose was 2.7 (2-3) µg/kg, with 13.3% receiving a repeat dose. Initial median (IQR) midazolam dose was 0.3 (0.2-0.3) mg/kg, with 3.3% receiving a second dose. Children receiving both fentanyl and midazolam had median (IQR) initial doses of 2.8 (2.1-3) µg/kg and 0.3 (0.2-0.3) mg/kg, respectively. Of these, 3.2% received repeat doses of both medications. Laceration repairs (33.8%) and incision and drainage (22.2%) accounted for the majority of indications. Only 2.9% (n = 178) received additional opioids. No serious adverse events requiring a reversal agent or respiratory support were reported. CONCLUSIONS Intranasal fentanyl and midazolam, alone and in combination, can provide analgesia and anxiolysis to children aged 3 years and younger in the ED setting. Further prospective studies are needed to better evaluate their safety and efficacy in this younger population.
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Affiliation(s)
- Jonathan G Chang
- Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Arkansas Medical Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Rebecca B Regen
- Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Rahul Peravali
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sarah S Harlan
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Pharmacy, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Matthew P Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Rudy J Kink
- Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Lee JY, Choi SJ, Park JS, Lee JS, Ryu JM, Yum MS. Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018. J Korean Med Sci 2021; 36:e213. [PMID: 34427061 PMCID: PMC8382566 DOI: 10.3346/jkms.2021.36.e213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.
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Affiliation(s)
- Jeong Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jun Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Sung Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi Sun Yum
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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SASA paediatric guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in children: 2021–2026. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.4.s2.2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers. Pediatr Emerg Care 2020; 36:e494-e499. [PMID: 30789872 DOI: 10.1097/pec.0000000000001782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers. METHODS This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions. RESULTS Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported. CONCLUSIONS Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.
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Paquin H, Trottier ED, Pastore Y, Robitaille N, Dore Bergeron MJ, Bailey B. Evaluation of a clinical protocol using intranasal fentanyl for treatment of vaso-occlusive crisis in sickle cell patients in the emergency department. Paediatr Child Health 2020; 25:293-299. [PMID: 32765165 PMCID: PMC7395317 DOI: 10.1093/pch/pxz022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visits and admission in children with sickle cell disease (SCD). OBJECTIVES This study aims to evaluate whether the use of a new pain management pathway using intranasal (IN) fentanyl from triage leads to improved care, translated by a decrease in time to first opiate dose. METHODS We performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) with VOC, in the period pre- (52 patients) and post- (44 patients) implementation period of the protocol. Time to first opiate was the primary outcome and was evaluated pre- and postimplementation. Patients received a first opiate dose within 52.3 minutes of registration (interquantile range [IQR] 30.6, 74.6), corresponding to a 41.4-minute reduction in the opiate administration time (95% confidence interval [CI] -56.1, -27.9). There was also a 43% increase in the number of patients treated with a nonintravenous (IV) opiate as first opiate dose (95% CI 26, 57). In patients who were discharged from the ED, there was a 49% decrease in the number of IV line insertions (95% CI -67, -22). There was no difference in the hospitalization rates (difference of 6 [95% CI -13, 25]). CONCLUSIONS This study validates the use of our protocol using IN fentanyl as first treatment of VOC in the ED by significantly reducing the time to first opiate dose and the number of IVs.
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Affiliation(s)
- Hugo Paquin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Evelyne D Trottier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
| | - Yves Pastore
- Department of Pediatrics, Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | - Nancy Robitaille
- Department of Pediatrics, Division of Hematology and Oncology, CHU Ste-Justine, Montréal, Quebec
| | | | - Benoit Bailey
- Department of Pediatrics, Division of Pediatric Emergency Medicine, CHU Ste-Justine, Montréal, Quebec
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Lee JL, Tham LP. Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department. Singapore Med J 2020; 63:28-34. [PMID: 32588587 DOI: 10.11622/smedj.2020095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore. METHODS A retrospective analysis was done of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors. RESULTS Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged < 3 years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors. CONCLUSION The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.
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Affiliation(s)
- Jia Le Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Lai Peng Tham
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Anxiety and Salivary Cortisol Levels in Children Undergoing Esophago-Gastro-Duodenoscopy Under Sedation. J Pediatr Gastroenterol Nutr 2019; 68:3-6. [PMID: 30169453 DOI: 10.1097/mpg.0000000000002142] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Esophagogastroduodenoscopy (EGD) can cause fear and anxiety in children. Cortisol, which is the most important glucocorticoid hormone in humans, can increase under physiological stress. The purpose of this study was to measure the salivary cortisol level (SCL) and anxiety level in patients undergoing EGD and evaluate their effects on the procedure. METHODS Children undergoing EGD under sedoanalgesia with propofol for various reasons were included. Their basal SCLs were compared with those of healthy age- and sex-matched controls. Moreover, SCL of the patient group at 30 minutes before EGD and 2 hours after the procedure were measured. Their anxiety scores were calculated using the modified Yale Preoperative Anxiety Scale before EGD. Duration of endoscopy, sedation, and recovery and total propofol doses were recorded. RESULTS Demographic properties of the patient group (n = 119; 10.9 ± 3.2 years; 43.7% boys) and control group (n = 85; 11.8 ± 2.8 years; 45.1% boys) were not significantly different. Basal SCLs of both groups were similar (16.9 ± 0.7 vs 19.7 ± 1.8 ng/mL, P = 0.16). SCL before EGD in the patient group was significantly higher than basal and post-EGD values (P < 0.001 for each). Pre-EGD SCL was positively correlated with anxiety level, propofol dose, and duration of sedation, procedure, and recovery. Anxiety levels of patients were positively correlated with propofol dose and duration of sedation and recovery, and negatively correlated with age. CONCLUSIONS Childhood EGD is a significant stress factor, which was reflected by the pre-procedural SCL in this study. Increased anxiety resulted in increased propofol doses and sedoanalgesia-related procedural durations, which may cause potential complications.
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Chayapathi V, Kalra M, Bakshi AS, Mahajan A. A comparison of ketamine + midazolam to propofol for procedural sedation for lumbar puncture in pediatric oncology by nonanesthesiologists-a randomized comparative trial. Pediatr Blood Cancer 2018; 65:e27108. [PMID: 29727056 DOI: 10.1002/pbc.27108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 03/06/2018] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Both ketamine-midazolam and propofol are frequently used in pediatric oncology units for procedural sedation. However, there are no prospective, randomized comparative trials (RCT) comparing the two groups when the procedure is performed by nonanesthesiologists. OBJECTIVE To compare ketamine + midazolam (group A) and propofol (group B) as sedative agents for intrathecal chemotherapy with regard to efficacy, side effects, time to induction, time to recovery, and smoothness of recovery. METHODS A partially-blinded RCT was conducted between August 2015 and March 2017 after gaining institutional ethics committee approval. Children aged 1-12 years requiring intravenous sedation for intrathecal chemotherapy were included. Patients were allocated to two treatment arms using computer-generated randomization tables, after obtaining written consent. The initial doses used were: ketamine 2 mg/kg, midazolam 0.2 mg/kg, and propofol 2.5 mg/kg, as per standard recommendations. The patient, parents, and person analyzing the data were blinded. Time to sedation, dose required, depth of sedation, vital parameters, time and smoothness of recovery, and emergence phenomena were documented. RESULTS We enrolled 152 patients (76 each in group A and B). Nine patients had a failure of sedation (all in group B). Mean time to sedation and recovery was shorter in group B (P < 0.001). Transient drop in saturation was more frequent in group B, without statistical significance (P = 0.174). Mean depth of sedation was greater in group A (P < 0.001). Emergence symptoms were more frequently experienced in group A (P < 0.001). CONCLUSIONS Ketamine-midazolam combination is safer and more effective. Propofol is faster in onset and recovery, and has smoother emergence with poor efficacy at recommended initial doses.
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Affiliation(s)
- Varsha Chayapathi
- Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India
| | - Manas Kalra
- Pediatric Hematology-Oncology Unit, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India
| | - Anita S Bakshi
- Pediatric Intensive Care Unit, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India
| | - Amita Mahajan
- Pediatric Hematology-Oncology Unit, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India
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15
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Lam SHF, Li DR, Hong CE, Vilke GM. Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation. J Emerg Med 2018; 55:51-63. [PMID: 29805070 DOI: 10.1016/j.jemermed.2018.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/26/2018] [Accepted: 04/10/2018] [Indexed: 10/16/2022]
Abstract
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.
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Affiliation(s)
- Samuel H F Lam
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - David R Li
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christian E Hong
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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Zou Y, Shao L, Tian M, Zhang Y, Liu F. Determination of the maximum tolerated dose of intranasal sufentanil and midazolam in Chinese: a pilot study. Acta Anaesthesiol Scand 2018; 62:773-779. [PMID: 29377056 DOI: 10.1111/aas.13081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this study was to determine the maximum tolerated dose (MTD, the dose of causing 10% respiratory depression) of intranasal sufentanil (SUF) and midazolam (MID) for sedation during gastroscopy by continual reassessment method (CRM). METHODS Patients (18-65 years old) scheduled for gastroscopy were recruited in this study. Subjects received intranasal SUF and MID for sedation. The dose of MID (5 mg) was fixed, while the dose of SUF was increased progressively (six incremental doses ranging from 0-0.60 μg/kg, n = 3 for each dose). The first cohort received a conservative, predetermined dose of 5 mg MID and 0 μg/kg SUF, subsequent cohorts received doses of SUF that were determined by the responses of all previous patients using Bayesian-based software. The dose allocated to the next cohort is the one with an updated posterior response probability closest to 10%. RESULTS Thirty Chinese patients scheduled for gastroscopy were included. Probability of respiratory depression at each dose was as follows: 5 mg MID + 0 μg/kg SUF, 0.4%; 5 mg MID + 0.1 μg/kg SUF, 0.8%; 5 mg MID + 0.2 μg/kg SUF, 1.8%; 5 mg MID + 0.3 μg/kg SUF, 3.7%; 5 mg MID + 0.4 μg/kg SUF, 9.9%; 5 mg MID + 0.5 μg/kg SUF, 17.8%; 5 mg MID + 0.6 μg/kg SUF, 36.0%. CONCLUSION The MTD of intranasal MID and SUF for sedation during gastroscopy causing 10% respiratory depression is 5 mg MID + 0.4 μg/kg SUF, based on CRM.
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Affiliation(s)
- Y. Zou
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - L. Shao
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - M. Tian
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - Y. Zhang
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - F. Liu
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
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Azizkhani R, Bahadori A, Shariati M, Golshani K, Ahmadi O, Masoumi B. Ketamine versus Ketamine / magnesium Sulfate for Procedural Sedation and Analgesia in the Emergency Department: A Randomized Clinical Trial. Adv Biomed Res 2018; 7:19. [PMID: 29456990 PMCID: PMC5812085 DOI: 10.4103/abr.abr_143_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The present study was designed to evaluate the effectiveness of magnesium sulfate (MgSO4) in procedural sedation and analgesia (PSA) when combined with ketamine in patients with fractures in emergency departments and required short and painful emergency procedures. MATERIALS AND METHODS In this study, 100 patients with fractures and dislocations who were presented to the emergency departments and required PSA for short and painful emergency procedures were randomly allocated to groups of ketamine plus MgSO4 or ketamine alone. Train of four (TOF) stimulation pattern was assessed using nerve stimulator machine and compared between groups. RESULTS The mean age of studied patients was 46.9 ± 9.3 years old. 48% were male and 52% were female. No significant differences were noted between groups in demographic variables. The status of TOF, 2 min after the injection of ketamine (1.5 mg/kg), in both groups was similar. After the injection of the second dose of ketamine (1 mg/kg) the status of TOF in four patients in ketamine plus MgSO4 (0.45 mg/kg) group changed, it was three quarters but in ketamine group, the status of TOF in all patients was four quarters. The difference between groups was not statistically significant (P = 0.12). CONCLUSION The findings revealed that for muscle relaxation during medical procedures in the emergency department, ketamine in combination with MgSO4 with this dose was not effective for muscle relaxation during procedures.
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Affiliation(s)
- Reza Azizkhani
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Bahadori
- Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Shariati
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keyhan Golshani
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- From the Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Miller AF, Monuteaux MC, Bourgeois FT, Fleegler EW. Variation in Pediatric Procedural Sedations Across Children's Hospital Emergency Departments. Hosp Pediatr 2018; 8:36-43. [PMID: 29233853 DOI: 10.1542/hpeds.2017-0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Describe the trends in pediatric sedation use over time and determine variation in use of procedural sedation across children's hospital emergency departments (EDs). METHODS We analyzed ED data from 35 hospitals within the Pediatric Health Information System for patients <19 years old who received sedation medications and were discharged from 2009 to 2014. Patients with chronic comorbidities or undergoing intubation were excluded. We determined frequency and trends in use of sedation and compared these between EDs. Descriptive statistics with appropriate weighting were used. RESULTS Of the 1 448 011 patients potentially requiring sedation who presented to the ED, 99 951 (7.9%) underwent procedural sedation. Medication usage in 2014 included ketamine (73.7%), fentanyl and midazolam (15.9%), ketofol (7.3%), and propofol (2.7%). Use of fentanyl and midazolam increased, whereas use of ketamine, pentobarbital, etomidate, chloral hydrate, and methohexital decreased over time. Significant variation exists in the use of sedation across hospitals; in 2014, the sedation rate ranged 0.2% to 32.0%, with a median of 8.0%. The diagnosis with the largest variation in procedural sedation use was dislocation, with sedation rates ranging from 2% to 35%. CONCLUSIONS There is significant variability across pediatric EDs in the use of procedural sedation, suggesting sedations may be performed too often or too little in some hospitals.
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Affiliation(s)
- Andrew F Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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Piteau S. Update in Pediatric Emergency Medicine: Pediatric Resuscitation, Pediatric Sepsis, Interfacility Transport of the Pediatric Patient, Pain and sedation in the Emergency Department, Pediatric Trauma. UPDATE IN PEDIATRICS 2018. [PMCID: PMC7123355 DOI: 10.1007/978-3-319-58027-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shalea Piteau
- Chief/Medical Director of Pediatrics at Quinte Health Care, Assistant Professor at Queen’s University, Belleville, Ontario Canada
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20
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Sedation and analgesia for procedures in the pediatric emergency room. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ramalho CE, Bretas PMC, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J) 2017; 93 Suppl 1:2-18. [PMID: 28945987 DOI: 10.1016/j.jped.2017.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. DATA SOURCES Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. DATA SYNTHESIS Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. CONCLUSIONS The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.
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Affiliation(s)
- Carlos Eduardo Ramalho
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Pedro Messeder Caldeira Bretas
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil.
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Olsen K, Weinberg E. Pain-Less Practice: Techniques to Reduce Procedural Pain and Anxiety in Pediatric Acute Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Kim YS, Lim BG, Kang SW, Lee SH, Lee W, Lee IO. Assessment of chloral hydrate-centered pediatric sedation performed by non-anesthesiologists. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.4.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Young Sung Kim
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sung Wook Kang
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - So Hyun Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Wonjoon Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il Ok Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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25
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Bellolio MF, Puls HA, Anderson JL, Gilani WI, Murad MH, Barrionuevo P, Erwin PJ, Wang Z, Hess EP. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open 2016; 6:e011384. [PMID: 27311910 PMCID: PMC4916627 DOI: 10.1136/bmjopen-2016-011384] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE AND DESIGN We conducted a systematic review and meta-analysis to evaluate the incidence of adverse events in the emergency department (ED) during procedural sedation in the paediatric population. Randomised controlled trials and observational studies from the past 10 years were included. We adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. SETTING ED. PARTICIPANTS Children. INTERVENTIONS Procedural sedation. OUTCOMES Adverse events like vomiting, agitation, hypoxia and apnoea. Meta-analysis was performed with random-effects model and reported as incidence rates with 95% CIs. RESULTS A total of 1177 studies were retrieved for screening and 258 were selected for full-text review. 41 studies reporting on 13 883 procedural sedations in 13 876 children (≤18 years) were included. The most common adverse events (all reported per 1000 sedations) were: vomiting 55.5 (CI 45.2 to 65.8), agitation 17.9 (CI 12.2 to 23.7), hypoxia 14.8 (CI 10.2 to 19.3) and apnoea 7.1 (CI 3.2 to 11.0). The need to intervene with either bag valve mask, oral airway or positive pressure ventilation occurred in 5.0 per 1000 sedations (CI 2.3 to 7.6). The incidences of severe respiratory events were: 34 cases of laryngospasm among 8687 sedations (2.9 per 1000 sedations, CI 1.1 to 4.7; absolute rate 3.9 per 1000 sedations), 4 intubations among 9136 sedations and 0 cases of aspiration among 3326 sedations. 33 of the 34 cases of laryngospasm occurred in patients who received ketamine. CONCLUSIONS Serious adverse respiratory events are very rare in paediatric procedural sedation in the ED. Emesis and agitation are the most frequent adverse events. Hypoxia, a late indicator of respiratory depression, occurs in 1.5% of sedations. Laryngospasm, though rare, happens most frequently with ketamine. The results of this study provide quantitative risk estimates to facilitate shared decision-making, risk communication, informed consent and resource allocation in children undergoing procedural sedation in the ED.
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Affiliation(s)
- M Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Henrique A Puls
- Universidade Federal das Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Jana L Anderson
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Waqas I Gilani
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Preventive, Occupational and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia Barrionuevo
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S21-35. [DOI: 10.1097/aco.0000000000000316] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Barcelos A, Garcia PCR, Portela JL, Piva JP, Garcia JPT, Santana JCB. Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies. Rev Assoc Med Bras (1992) 2015; 61:362-7. [DOI: 10.1590/1806-9282.61.04.362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 11/22/2022] Open
Abstract
SummaryObjective:to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.Methods:randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team.Results:13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222).Conclusion:by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.
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Affiliation(s)
- Andrea Barcelos
- Pontifícia Universidade Católica do Rio Grande do Sul, Brazil
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Orel R, Brecelj J, Dias JA, Romano C, Barros F, Thomson M, Vandenplas Y. Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists. World J Gastrointest Endosc 2015; 7:895-911. [PMID: 26240691 PMCID: PMC4515424 DOI: 10.4253/wjge.v7.i9.895] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 02/05/2023] Open
Abstract
AIM To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists. METHODS The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented. CONCLUSION General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.
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Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int 2015; 31:173-80. [PMID: 25385665 DOI: 10.1007/s00383-014-3608-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nitrous oxide's safety and efficacy for minor procedures is an alternative to general anesthesia, complex sedation protocols, or local anesthetic alone. METHODS A retrospective review of prospectively-collected data (2000-2012) identified 1,058 children who received single-agent nitrous oxide for minor surgery. RESULTS Children (n = 1,058, male 42 %, female 58 %) aged 1-23 years (mean = 9.8 + 5.1 years) were identified. Only nine children (0.9 %) fasted. ASA status was I-II in 1,053 (99.5 %) of patients; five (0.5 %) had an ASA III. There were no major complications (desaturation, emergency admission, apnea, airway obstruction, bradycardia) or aborted procedures. Minor complications occurred in 1.8 %; there was no association between these complications and ASA, fasting status or maximum nitrous oxide percentage administered (all p > 0.05). Post-operatively, 98 % of patients denied getting an injection. Eighty-two percent reported mild or no procedural pain. CONCLUSION This is the longest reported study using non-anesthesiologist-administered nitrous oxide as a single-agent for minor surgical procedures. The technique provides safe sedation and excellent amnesia, allowing pain and anxiety-reduced surgery with no fasting or postoperative monitoring.
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Chloral hydrate, chloral hydrate--promethazine and chloral hydrate -hydroxyzine efficacy in electroencephalography sedation. Indian J Pediatr 2014; 81:541-6. [PMID: 24445981 DOI: 10.1007/s12098-013-1298-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare efficacy and safety of chloral hydrate (CH), chloral hydrate and promethazine (CH + P) and chloral hydrate and hydroxyzine (CH + H) in electroencephalography (EEG) sedation. METHODS In a parallel single-blinded randomized clinical trial, ninety 1-7 y-old uncooperative kids who were referred to Pediatric Neurology Clinic of Shahid Sadoughi University, Yazd, Iran from April through August 2012, were randomly assigned to receive 40 mg/kg of chloral hydrate or 40 mg/kg of chloral hydrate and 1 mg/kg of promethazine or 40 mg/kg of chloral hydrate and 2 mg/kg of hydroxyzine. The primary endpoint was efficacy in sufficient sedation (obtaining four Ramsay sedation score) and successful completion of EEG. Secondary endpoint was clinical adverse events. RESULTS Thirty nine girls (43.3 %) and 51 boys (56.7 %) with mean age of 3.34 ± 1.47 y were assessed. Sufficient sedation and completion of EEG were achieved in 70 % (N = 21) of chloral hydrate group, in 83.3 % (N = 25) of CH + H group and in 96.7 % (N = 29) of CH + P group (p = 0.02). Mild clinical adverse events including vomiting [16.7 % (N = 5) in CH, 6.7 % (N = 2) in CH + P, 6.7 % (N = 2) in CH + H], agitation in 3.3 % of CH + P (N = 1) group and mild transient hypotension in 3.3 % of CH + H (N = 1) group occurred. Safety of these three sedation regimens was not statistically significant different (p = 0.14). CONCLUSIONS Combination of chloral hydrate-antihistamines can be used as the most effective and safe sedation regimen in drug induced sleep electroencephalography of kids.
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Ramaiah R, Grabinsky A, Bhananker SM. Sedation and analgesia for the pediatric trauma patients. Int J Crit Illn Inj Sci 2012. [PMID: 23181210 PMCID: PMC3500008 DOI: 10.4103/2229-5151.100897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.
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Affiliation(s)
- Ramesh Ramaiah
- Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, Seattle, WA, USA
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