An update on pediatric hospital-based sedation

Development and Stability of a New Formulation of Pentobarbital Suppositories for Paediatric Procedural Sedation

Pentobarbital is a drug of choice to limit motion in children during paediatric procedural sedations (PPSs). However, despite the rectal route being preferred for infants and children, no pentobarbital suppositories are marketed, and therefore they must be prepared by compounding pharmacies. In this study, two suppository formulations of 30, 40, 50, and 60 mg of pentobarbital sodium were developed using hard-fat Witepsol^® W25 either alone (formulation F1) or with oleic acid (formulation F2). The two formulations were subjected to the following tests described in the European Pharmacopoeia: uniformity of dosage units, softening time, resistance to rupture, and disintegration time. The stability of both formulations was also investigated for 41 weeks of storage at 5 ± 3 °C using a stability-indicating liquid chromatography method to quantify pentobarbital sodium and research breakdown product (BP). Although both formulae were compliant to uniformity of dosage, the results were in favour of a faster disintegration of F2 compared to F1 (-63%). On the other hand, F1 was found to be stable after 41 weeks of storage unlike F2 for which several new peaks were detected during the chromatographic analysis, suggesting a shorter stability of only 28 weeks. Both formulae still need to be clinically investigated to confirm their safety and efficiency for PPS.

Implementing Safe and Effective Pediatric Procedural Sedation in the Emergency Department

There has been a great increase in the number of diagnostic and therapeutic procedures performed in the emergency department (ED) setting over the past several decades. Most of these procedures are unscheduled, unplanned, and much more likely to be successful and result in a positive outcome when the child's pain, fear, anxiety, and movement are controlled. To promote patient quality and safety, increase the effectiveness and efficiency of care, and improve patient and caregiver satisfaction, there has been a proportionate increase in the number of pediatric procedural sedations performed in the ED. With proper education and skills verification, pediatric procedural sedation can be safely and efficaciously performed in the ED. The purpose of this article is to present an overview of pediatric analgesia, anxiolysis, and sedation to promote compassionate, evidence-based emergency care of children and optimize procedural performance and outcomes.

Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

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.

Stability of Pentobarbital Hydrogel for Rectal Administration in Pediatric Procedural Sedation

Purpose: Pentobarbital is a sedative agent to limit children motion during computed tomography or magnetic resonance imaging (MRI) and ensures the successful completion of the imaging procedure. However, data on rectal drug formulation and its stability in practice are not available. The aim of this study was to formulate and evaluate the stability of a ready-to-use rectal pentobarbital gel. Methods: The formulation consisted of a hydrated gel containing 25 mg/mL of pentobarbital sodium, packaged in 10-mL amber glass bottles and stored at either 22°C to 25°C or 2°C to 8°C. At each predetermined time point, samples were taken for visual inspection, pH measurement, and analysis by a validated stability-indicating high-performance liquid chromatography (HPLC) method. The viscosity parameters of the hydrogel formulation were assessed. Results: The freshly prepared rectal formulations appeared clear, colorless, and particular-free with pH readings of 9.75 to 9.83. Over the 90 days of the study period, there was no significant change in appearance or pH values for all stability samples. The HPLC results confirmed the chemical stability when stored at 2°C to 8°C or at 22°C to 25°C. Conclusion: Pentobarbital hydrogel 25 mg/mL are stable chemically at least 90 days and can be administered to children for an effective and fast sedation.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

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.

Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric Procedural Sedation Using Dexmedetomidine: A Report From the Pediatric Sedation Research Consortium

OBJECTIVES

Dexmedetomidine (DEX) is widely used in pediatric procedural sedation (PPS) by a variety of pediatric subspecialists. The objective of our study was to describe the overall rates of adverse events and serious adverse events (SAEs) when DEX is used by various pediatric subspecialists.

METHODS

Patients from the Pediatric Sedation Research Consortium (PSRC) database were retrospectively reviewed and children that received DEX as their primary sedation agent for elective PPS were identified. Demographic and clinical data, provider subspecialty, and sedation-related complications were abstracted. SAEs were defined as death, cardiac arrest, upper airway obstruction, laryngospasm, emergent airway intervention, unplanned hospital admission/increased level of care, aspiration, or emergency anesthesia consult. Event rates and 95% confidence intervals (CIs) were calculated.

RESULTS

During the study period, 13 072 children were sedated using DEX, accounting for 5.3% of all sedation cases entered into the PSRC. Of the sedated patients, 73% were American Society of Anesthesiologists Physical Status class 1 or 2. The pediatric providers responsible for patients sedated with DEX were anesthesiologists (35%), intensivists (34%), emergency medicine physicians (12.7%), hospitalists (1.1%), and others (17%). The overall AE rate was 466/13 072 (3.6%, 95% CI 3.3% to 3.9%). The overall SAE rate was 45/13 072 (0.34%, 95% CI 0.19% to 0.037%). Airway obstruction was the most common SAE: 35/13 072 (0.27%, 95% CI 0.19% to 0.37%). Sedations were successful in 99.7% of cases.

CONCLUSIONS

We report the largest series of PPS using DEX outside the operating room. Within the PSRC, PPS performed using DEX has a very high success rate and is unlikely to yield a high rate of SAEs.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

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.

What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews

BACKGROUND

Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings.

METHODS

We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED.

RESULTS

Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention).

CONCLUSIONS

This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.

Ketamine-based procedural sedation and analgesia for botulinum toxin A injections in children with cerebral palsy

INTRODUCTION

Adequate procedural sedation and analgesia (PSA) is essential to reduce pain and distress for children undergoing intramuscular botulinum toxin (BoNT-A) injections. This study describes our institution's experience with ketamine-based PSA in terms of safety and efficacy in children with cerebral palsy receiving BoNT-A injections.

MATERIAL AND METHODS

This is an analysis of ketamine-based PSA for children undergoing BoNT-A injections between January 2000 and October 2014. All patients received PSA according to our institution's sedation protocol. From 2000 to 2012, intravenous ketamine and midazolam PSA was administered. From 2013 onwards, intravenous ketamine was used as a sole agent for PSA.

RESULTS

A total of 152 BoNT-A procedures were performed successfully on 87 children. The median age of the children was 5 years 5 months with 9 children younger than 36 months. Ten procedures (6.6%) were associated with acute transient self-limiting side effects: Four developed rashes, three had nausea and vomiting, one child had limb tremors and another child complained of mild headache. One child reported nightmares on the evening of the procedure during the two-week post-procedure review. No child experienced serious adverse events.

CONCLUSION

Administration of ketamine-based PSA for intramuscular BoNT-A procedures in children can be both safe and efficacious.

Current State of Institutional Privileging Profiles for Pediatric Procedural Sedation Providers

BACKGROUND AND OBJECTIVE

Providers from a variety of training backgrounds and specialties provide procedural sedation at institutions in the United States. We sought to better understand the privileging patterns and practices for sedation providers.

METHODS

Surveys were sent to 56 program directors belonging to the Society for Pediatric Sedation using Research Electronic Data Capture to 56 pediatric sedation programs. The survey was designed to gather information regarding characteristics of their sedation service and the privileging of their sedation providers.

RESULTS

The overall response rate was 41 (73%) of 56. Most programs surveyed (81%) said their physicians provided sedation as a part of their primary subspecialty job description, and 17% had physicians whose sole practice was pediatric sedation and no longer practiced in their primary subspecialty. Fifty-one percent of surveyed sedation programs were within freestanding children's hospitals and 61% receive oversight by the anesthesiology department at their institution. Eighty-one percent of the sedation programs require physicians to undergo special credentialing to provide sedation. Of these, 79% grant privileging through their primary specialty, whereas 39% require separate credentialing through sedation as a stand-alone section. For initial credentialing, requirements included completion of a pediatric sedation orientation and training packet (51% of programs), sedation training during fellowship (59%), and documentation of a specific number of pediatric procedural sedation cases (49%).

CONCLUSIONS

In this survey of pediatric sedation programs belonging to the Society for Pediatric Sedation, the process for privileging providers in procedural sedation varies significantly from institution to institution. An opportunity exists to propose privileging standards for providers of pediatric procedural sedation.

Transient Central Diabetes Insipidus Induced by Ketamine Infusion

Objective: Report a case of central diabetes insipidus (DI) associated with ketamine infusion. Case Summary: A 2-year-old girl with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency and stable hypertrophic cardiomyopathy was admitted to the pediatric intensive care with pneumonia. She subsequently developed respiratory failure and required intubation. Continuous ketamine infusion was used for the sedation and facilitation of mechanical ventilation. Shortly after infusion of ketamine, the patient developed DI and responded appropriately to vasopressin. Discussion: The Naranjo adverse drug reaction probability scale indicated a probable relationship between the development of central DI and ketamine. The most likely mechanism involves ketamine’s antagonist action on N-methyl-d-aspartate receptors, resulting in inhibition of glutamate-stimulated arginine vasopressin release from the neurohypophysis. Conclusion: This is the second case report of ketamine-induced central DI and the only report in children. Clinicians who sedate children with continuous ketamine infusions should monitor patients for developing signs and symptoms of DI by measuring serum sodium and urine output prior to, during, and after ketamine infusion in order to make a timely diagnosis of this potentially serious complication.

Pediatric sedation

Pediatric sedation is an evolving field performed by an extensive list of specialties. Well-defined sedation systems within pediatric facilities are paramount to providing consistent, safe sedation. Pediatric sedation providers should be trained in the principles and practice of sedation, which include patient selection, pre-sedation assessment to determine risks during sedation, selection of optimal sedation medication, monitoring requirements, and post-sedation care. Training, credentialing, and continuing sedation education must be incorporated into sedation systems to verify and monitor the practice of safe sedation. Pediatric hospitalists represent a group of providers with extensive pediatric knowledge and skills who can safely provide pediatric sedation.