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Lonsdale H, Rodriguez K, Shargo R, Ekblad M, Brown JM, Dolan I, Fierstein JL, Miller A, Dey A, Peck J, Rehman MA, Wilsey MJ. Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients. Paediatr Anaesth 2024; 34:628-637. [PMID: 38591665 PMCID: PMC11156544 DOI: 10.1111/pan.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB. METHODS In this single-center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intra- and postanesthesia complications and the frequency of mid-procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI). RESULTS From the initial search, 326 patients were identified. Among them, 23% (n = 75) were planned for intubation and 77% (n = 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9-5.7, p < .001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p < .001). CONCLUSIONS This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multi-site studies are needed to confirm these findings.
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Affiliation(s)
- Hannah Lonsdale
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kurt Rodriguez
- Department of Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Ryan Shargo
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Morgan Ekblad
- Department of Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Jerry M. Brown
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Isabella Dolan
- Department of Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Jamie L. Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Miller
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Aditi Dey
- Maternal Fetal Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jacquelin Peck
- Department of Pediatric Anesthesia, Joe DiMaggio Children’s Hospital, Hollywood, FL, USA
| | - Mohamed A. Rehman
- Department of Pediatric Anesthesiology and Pain Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Michael J. Wilsey
- Department of Gastroenterology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
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Schneck E, Knittel F, Markmann M, Balzer F, Rubarth K, Zajonz T, Schreiner AL, Hecker A, Naehrlich L, Koch C, de Laffolie J, Sander M. Assessment of risk factors for adverse events in analgosedation for pediatric endoscopy: A 10-year retrospective analysis. J Pediatr Gastroenterol Nutr 2024. [PMID: 38873914 DOI: 10.1002/jpn3.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES Data regarding the occurrence of complications specifically during pediatric anesthesia for endoscopic procedures is limited. By evaluating such data, factors could be identified to assure proper staffing and preparation to minimize adverse events and improve patient safety during flexible endoscopy. METHODS This retrospective cohort study included children undergoing anesthesia for gastroscopy, colonoscopy, bronchoscopy, or combined endoscopic procedures over 10-year period. The primary study aim was to evaluate the incidence of complications and identify risk factors for adverse events. RESULTS Overall, 2064 endoscopic procedures including 1356 gastroscopies (65.7%), 93 colonoscopies (4.5%), 235 bronchoscopies (11.4%), and 380 combined procedures (18.4%) were performed. Of the 1613 patients, 151 (7.3%) patients exhibited an adverse event, with respiratory complications being the most common (65 [3.1%]). Combination of gastrointestinal endoscopies did not lead to an increased adverse event rate (gastroscopy: 5.5%, colonoscopy: 3.2%). Diagnostic endoscopy as compared to interventional had a lower rate. If bronchoscopy was performed, the rate was similar to that of bronchoscopy alone (19.5% vs. 20.4%). Age < 5.8 years or body weight less than 20 kg, bronchoscopy, American Society of Anesthesiologists status ≥ 2 or pre-existing anesthesia-relevant diseases, and urgency of the procedure were independent risk factors for adverse events. For each risk factor, the risk for events increased 2.1-fold [1.8-2.4]. CONCLUSIONS This study identifies multiple factors that increase the rate of adverse events associated anesthesia-based endoscopy. Combined gastrointestinal procedures did not increase the risk for adverse events while combination of bronchoscopy to gastrointestinal endoscopy showed a similar risk as bronchoscopy alone.
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Affiliation(s)
- Emmanuel Schneck
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Fabienne Knittel
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Melanie Markmann
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
| | - Thomas Zajonz
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Anna-Lena Schreiner
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Lutz Naehrlich
- Department of General Pediatrics and Neonatology, University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Jan de Laffolie
- Department of General Pediatrics and Neonatology, University of Giessen, Giessen, Germany
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
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Couloures KG, Anderson MP, Hill CL, Chen A, Buckmaster MA. Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk. J Pediatr Intensive Care 2024; 13:201-208. [PMID: 38919693 PMCID: PMC11196135 DOI: 10.1055/s-0042-1745831] [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: 11/27/2021] [Accepted: 02/21/2022] [Indexed: 10/18/2022] Open
Abstract
This study aimed to create a pediatric sedation scoring system independent of the American Society of Anesthesiology Physical Status (ASA-PS) classification that is predictive of adverse events, facilitates objective stratification, and resource allocation. Multivariable regression and machine learning algorithm analysis of 134,973 sedation encounters logged in to the Pediatric Sedation Research Consortium (PSRC) database between July 2007 and June 2011. Patient and procedure variables were correlated with adverse events with resultant β -regression coefficients used to assign point values to each variable. Point values were then summed to create a risk assessment score. Validation of the model was performed with the 2011 to 2013 PSRC database followed by calculation of ROC curves and positive predictive values. Factors identified and resultant point values are as follows: 1 point: age ≤ 6 months, cardiac diagnosis, asthma, weight less than 5th percentile or greater than 95 th , and computed tomography (CT) scan; 2 points: magnetic resonance cholangiopancreatography (MRCP) and weight greater than 99th percentile; 4 points: magnetic resonance imaging (MRI); 5 points: trisomy 21 and esophagogastroduodenoscopy (EGD); 7 points: cough at the time of examination; and 18 points: bronchoscopy. Sum of patient and procedural values produced total risk assessment scores. Total risk assessment score of 5 had a sensitivity of 82.69% and a specificity of 26.22%, while risk assessment score of 11 had a sensitivity of 12.70% but a specificity of 95.29%. Inclusion of ASA-PS value did not improve model sensitivity or specificity and was thus excluded. Higher risk assessment scores predicted increased likelihood of adverse events during sedation. The score can be used to triage patients independent of ASA-PS with site-specific cut-off values used to determine appropriate sedation resource allocation.
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Affiliation(s)
- Kevin G. Couloures
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, United States
| | - Michael P. Anderson
- Department of Biostatistics, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - C. L. Hill
- Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Allshine Chen
- Department of Biostatistics, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - Mark A. Buckmaster
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Dagher K, Benvenuti C, Virag K, Habre W. The Incidence of Postoperative Complications Following Lumbar and Bone Marrow Punctures in Pediatric Anesthesia: Insights From APRICOT. J Pediatr Hematol Oncol 2024; 46:165-171. [PMID: 38447107 PMCID: PMC10956654 DOI: 10.1097/mph.0000000000002849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Bone marrow aspiration and lumbar puncture are procedures frequently performed in pediatric oncology. We aimed at assessing the incidence and risk factors of perioperative complications in children undergoing these procedures under sedation or general anesthesia. METHODS Based on the APRICOT study, we performed a secondary analysis, including 893 children undergoing bone marrow aspiration and lumbar puncture. The primary outcome was the incidence of perioperative complications. Secondary outcomes were their risk factors. RESULTS We analyzed data of 893 children who underwent 915 procedures. The incidence of severe adverse events was 1.7% and of respiratory complications was 1.1%. Prematurity (RR 4.976; 95% CI 1.097-22.568; P = 0.038), intubation (RR: 6.80, 95% CI 1.66-27.7; P =0.008), and emergency situations (RR 3.99; 95% CI 1.14-13.96; P = 0.030) increased the risk for respiratory complications. The incidence of cardiovascular instability was 0.4%, with premedication as risk factor (RR 6.678; 95% CI 1.325-33.644; P =0.021). CONCLUSION A low incidence of perioperative adverse events was observed in children undergoing bone marrow aspiration or lumbar puncture under sedation and/or general anesthesia, with respiratory complications being the most frequent. Careful preoperative assessment should be undertaken to identify risk factors associated with an increased risk, allowing for appropriate adjustment of anesthesia management.
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Affiliation(s)
| | - Claudia Benvenuti
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Kathy Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Röher K, Trieschmann U, Leister N. [Anaesthesia and Sedation for Diagnostic Procedures in Children]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:409-420. [PMID: 37582352 DOI: 10.1055/a-1925-7009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Constant medical progress leads to an increasing range of indications and consequently increasing number of diagnostic procedures in (early) childhood. To prevent lasting traumatization of children (and parents) and to ensure proper examination conditions, adequate (analgo-)sedation or general anesthesia is usually required for the appropriate management of diagnostic procedures in childhood, whether painful or not. The safety of young patients is the first priority. Administrations, hospitals, and each individual anesthesiologist are responsible for establishing structures, experience, and knowledge in this area so that children of all ages receive optimum care. In this article, the authors provide an overview of basic principles (structures, requirements, recommendations), currently used drugs, and procedure-specific examples for providing procedural analgosedation/anesthesia in children.
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Röher K, Becke-Jakob K, Eich C. Safety and quality in paediatric procedural sedation: what really matters? Curr Opin Anaesthesiol 2023; 36:340-346. [PMID: 36794877 DOI: 10.1097/aco.0000000000001255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW This review gives an overview of the safety aspects for paediatric procedural sedation and a discussion of possibilities for optimizing structure, processes and outcomes. RECENT FINDINGS Procedural sedation in paediatric patients is performed by providers of different specialties and compliance with safety standards is a basic requirement regardless of provider specialty. This includes preprocedural evaluation, monitoring, equipment and profound expertise of sedation teams. The choice of sedative medications and the possibility of incorporating nonpharmacological methods play an important role for optimal outcome. In addition, an ideal outcome from the patient's perspective includes optimized processes and clear and empathetic communication. SUMMARY Institutions providing paediatric procedural sedation must ensure the comprehensive training of sedations teams. Furthermore, institutional standards for equipment, processes and optimal choice of medication depending on performed procedure and comorbidities of the patient must be established. At the same time, organizational and communication aspects should be considered.
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Affiliation(s)
- Katharina Röher
- Department of Anesthesiolgy, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Karin Becke-Jakob
- Department of Anesthesia, Hospital Hallerwiese - Cnopf Children's Hospital, St.-Johannis-Mühlgasse 19, Nürnberg
| | - Christoph Eich
- Department of Anaesthesia, Paediatric Intensiv Care and Emergency Medicine, Auf der Bult Children' s Hospital, Hannover, Germany
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Mahoney LB, Lightdale JR. The Evolution of Sedation for Pediatric Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2023; 33:213-234. [PMID: 36948743 DOI: 10.1016/j.giec.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Sedation for pediatric endoscopy has evolved from an endoscopist-administered component of procedures to an almost entirely anesthesiologist-supported endeavor. Nevertheless, there are no ideal endoscopist or anesthesiologist-administered sedation protocols, and wide practice variation exists in both models. Furthermore, sedation for pediatric endoscopy, whether administered by endoscopists or anesthesiologists, remains the highest risk to patient safety. This underscores the importance of both specialties identifying best sedation practices together that can safeguard patients while maximizing procedural efficiency and minimizing costs. In this review, the authors discuss specific levels of sedation for endoscopy and the risks and benefits of various regimens.
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Affiliation(s)
- Lisa B Mahoney
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jenifer R Lightdale
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Mallory MD, Travers C, Cravero JP, Kamat PP, Tsze D, Hertzog JH. Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium. J Magn Reson Imaging 2023; 57:1106-1113. [PMID: 36173243 DOI: 10.1002/jmri.28392] [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: 04/11/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists. PURPOSE Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI. STUDY TYPE Retrospective analysis of prospectively collected data. SUBJECTS The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017. ASSESSMENT Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined. STATISTICAL TESTS Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method. RESULTS A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time. DATA CONCLUSIONS Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Michael D Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joseph P Cravero
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Pradip P Kamat
- Department of Pediatrics, Division of Critical Care Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Daniel Tsze
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University, New York, New York, USA
| | - James H Hertzog
- Department of Pediatrics, Division of Critical Care Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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ÖZEN Ö, ÜZÜMCÜGİL F, ANKAY YILBAŞ A, AKÇA B, KARAGÖZ H. Incidence of complications in anesthesia applications during magnetic resonance imaging in pediatric patients. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1125733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose: The aim of this study was to investigate complications during sedation of pediatric patients undergoing Magnetic Resonance Imaging (MRI) to determine precautions to take to minimize complications while providing a safer environment for patients and healthcare workers.
Materials and Methods: The files of consecutive patients taken for 6 months in the MRI unit of our hospital were reviewed retrospectively, and a total of 122 pediatric patients were included. Primary parameter in the study is set as peroperative and postoperative complication incidence. Interventions to treat, demographic data, ASA scores, accompanying diseases, agents and their doses for sedation, sedation and recovery time are the secondary parameters and their correlation to complication incidence is assessed.
Results: Using the data of 122 patients, complication rate is found as 6.6% (8/122). During sedation, desaturation in 6, bradycardia and desaturation in 1 and airway obstruction in 1 of the patients was observed. Desaturation was seen in 2, bradycardia was seen in 1 of the patients during recovery. Use of ketamine didn’t decrease the dose of midazolam or propofol used for maintenance but decreased the dose of propofol used for induction.
Conclusion: Complications may occur despite the presence of an experienced anesthesia team. It is important to anticipate such complications and intervene in a timely manner.
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Affiliation(s)
- Özge ÖZEN
- HACETTEPE UNIVERSITY, SCHOOL OF MEDICINE, DEPARTMENT OF SURGICAL MEDICAL SCIENCES, DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
| | - Filiz ÜZÜMCÜGİL
- HACETTEPE UNIVERSITY, SCHOOL OF MEDICINE, DEPARTMENT OF SURGICAL MEDICAL SCIENCES, DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
| | - Aysun ANKAY YILBAŞ
- HACETTEPE UNIVERSITY, SCHOOL OF MEDICINE, DEPARTMENT OF SURGICAL MEDICAL SCIENCES, DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
| | - Başak AKÇA
- HACETTEPE UNIVERSITY, SCHOOL OF MEDICINE, DEPARTMENT OF SURGICAL MEDICAL SCIENCES, DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
| | - Heves KARAGÖZ
- HACETTEPE UNIVERSITY, SCHOOL OF MEDICINE, DEPARTMENT OF SURGICAL MEDICAL SCIENCES, DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
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The Impact of a Dedicated Sedation Team on the Incidence of Complications in Pediatric Procedural Analgosedation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070998. [PMID: 35883982 PMCID: PMC9320875 DOI: 10.3390/children9070998] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
Abstract
The number of pediatric procedural sedations for diagnostic and minor therapeutic procedures performed outside the operating room has increased. Therefore, we established a specialized interdisciplinary team of pediatric anesthesiologists and intensivists (Children’s Analgosedation Team, CAST) at our tertiary-care university hospital and retrospectively analyzed the first year after implementation of the CAST. Within one year, 784 procedural sedations were performed by the CAST; 12.2% of the patients were infants <1 year, 41.9% of the patients were classified as American Society of Anesthesiologists (ASA) grade III or IV. Most children received propofol (79%) and, for painful procedures, additional esketamine (48%). Adverse events occurred in 51 patients (6.5%), with a lack of professional experience (OR 0.60; 95% CI 0.42−0.81) and increased propofol dosage (OR 1.33; 95% CI 1.17−1.55) being significant predictors. Overall, the CAST enabled safe and effective procedural sedation in children outside the operating room.
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Meng L, Fan X, Zhang A, Su H, Zhang H, Tian Y. Systematic review and meta-analysis of the incidence rates of adverse events after digestive endoscopy in children. Transl Pediatr 2022; 11:920-932. [PMID: 35800278 PMCID: PMC9253955 DOI: 10.21037/tp-22-179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND With the widespread use of digestive endoscopy in children, a variety of adverse events (AEs) have occurred after digestive endoscopy. However, there are notable differences in the incidence of adverse reactions in digestive endoscopy in children at present, which makes it difficult to assess the safety of digestive endoscopy in children. METHODS Studies related to digestive endoscopy in children were screened from January 2005 to October 2021 from PubMed, Web of Science, Spring, CNKI, and Science Direct databases. RevMan5.3 and Stata were employed to carry out meta-analysis on the incidence of adverse respiratory events, myoclonus, abdominal pain, fever, bleeding, chest pain, sore throat, vomiting, and delayed capsule discharge after digestive endoscopy in children. The article quality was evaluated by the Agency for Healthcare Research and Quality (AHRQ). The chi-square test and I2 were adopted to test literature heterogeneity, and the article publication bias was assessed by displaying an inverted funnel plot as a funnel plot. RESULTS In all, 15 articles were included, involving a total of 27,770 children. In all, 15 articles were included, involving a total of 27,770 children. The risk ratio (RR) value of adverse respiratory events after digestive endoscopy in children was 1.31 [95% confidence interval (CI): 1.17 to 1.47, P<0.00001]; the odds ratio (OR) value of the incidence of myoclonus was 1.21 (95% CI: 1.01 to 1.46, P=0.04); the incidence of abdominal pain was 1.18 (95% CI: 1.11 to 1.27, P<0.00001); the incidence of fever was 1.09 (95% CI: 1.06 to 1.12, P<0.00001); the incidence of bleeding was 1.24 (95% CI: 0.94 to 1.64, P=0.13); the incidence of chest pain was 1.06 (95% CI: 1.03 to 1.09, P<0.0001); incidence of sore throat was 1.11 (95% CI: 1.05 to 1.18, P=0.0004); incidence of vomiting was 1.13 (95% CI: 1.06 to 1.21, P=0.0001); and the incidence of delayed capsule expulsion was 1.18 (95% CI: 1.00 to 1.40, P=0.05). DISCUSSION The incidence of AEs after digestive endoscopy in children was low, which can be used in the diagnosis and therapy of digestive system diseases in children.
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Affiliation(s)
- Liying Meng
- Department of Gastroenterology, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Xueke Fan
- Department of Gastroenterology, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Aiguo Zhang
- Department of Gastroenterology, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Hongjie Su
- Department of Pediatrics, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Haijun Zhang
- Department of Pediatrics, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Yajuan Tian
- Department of Gastroenterology, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
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Lightdale JR, Walsh CM, Oliva S, Jacobson K, Huynh HQ, Homan M, Hojsak I, Gillett PM, Furlano RI, Fishman DS, Croft NM, Brill H, Bontems P, Amil-Dias J, Utterson EC, Tavares M, Rosh JR, Riley MR, Narula P, Mamula P, Mack DR, Liu QY, Lerner DG, Leibowitz IH, Otley AR, Kramer RE, Ambartsumyan L, Connan V, McCreath GA, Thomson MA. Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline. J Pediatr Gastroenterol Nutr 2022; 74:S30-S43. [PMID: 34402486 DOI: 10.1097/mpg.0000000000003264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine. METHODS With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. RESULTS The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%. DISCUSSION It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.
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Affiliation(s)
- Jenifer R Lightdale
- Department of Pediatrics, Division of Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, University of Massachusetts Medical School, Worcester, MA, United States
| | - Catharine M Walsh
- Department of Paediatrics and the Wilson Centre, Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Umberto I - University Hospital, Sapienza - University of Rome, Rome, Italy
| | - Kevan Jacobson
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia's Children's Hospital and British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hien Q Huynh
- Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Matjaž Homan
- Department of Gastroenterology, Faculty of Medicine, Hepatology and Nutrition, University Children's Hospital, University of Ljubljana, Ljubljana, Slovenia
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, University J.J. Strossmayer Medical School, Osijek, Croatia
| | - Peter M Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Raoul I Furlano
- Pediatric Gastroenterology & Nutrition, Department of Pediatrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Nicholas M Croft
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Herbert Brill
- Department of Pediatrics, Division of Gastroenterology & Nutrition, McMaster Children's Hospital, McMaster University, William Osler Health System, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Bontems
- Division of Pediatrics, Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, ICBAS - Université Libre de Bruxelles, Brussels, Belgium
| | - Jorge Amil-Dias
- Pediatric Gastroenterology, Department of Pediatrics, Centro Hospitalar Universitário S. João, Porto, Portugal
| | - Elizabeth C Utterson
- Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, MO, United States
| | - Marta Tavares
- Division of Pediatrics, Pediatric Gastroenterology Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Joel R Rosh
- Division of Pediatric Gastroenterology, Department of Pediatrics, Goryeb Children's Hospital, Icahn School of Medicine at Mount Sinai, Morristown, NJ, United States
| | - Matthew R Riley
- Department of Pediatric Gastroenterology, Providence St. Vincent's Medical Center, Portland, OR, United States
| | - Priya Narula
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom
| | - Petar Mamula
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David R Mack
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Quin Y Liu
- Division of Gastroenterology and Hepatology, Medicine and Pediatrics, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Diana G Lerner
- Division of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Children's of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ian H Leibowitz
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, George Washington University, Washington, DC, United States
| | - Anthony R Otley
- Gastroenterology & Nutrition, Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert E Kramer
- Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, United States
| | - Lusine Ambartsumyan
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Veronik Connan
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Graham A McCreath
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mike A Thomson
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom
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Mace SE, Ulintz A, Peterson B, Nowacki AS, Worley J, Zamborsky S. Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department. Pediatr Emerg Care 2021; 37:e500-e506. [PMID: 34463665 DOI: 10.1097/pec.0000000000002513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). METHODS Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. RESULTS Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. CONCLUSIONS Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.
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Affiliation(s)
| | - Alexander Ulintz
- From the Department of Emergency Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | | | | | - Jasmine Worley
- Ross University School of Medicine, Bridgetown, Barbados
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Kretz FJ, Badelt G, Röher K. Wertvolle Ideen und Impulse zur Sedierung von Kindern durch interdisziplinären Austausch. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01169-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Lee YM, Kang B, Kim YB, Kim HJ, Lee KJ, Lee Y, Choi SY, Lee EH, Yi DY, Jang HJ, Choi YJ, Hong SJ, Kim JY, Kang Y, Kim SC. Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea. J Korean Med Sci 2021; 36:e136. [PMID: 34032029 PMCID: PMC8144592 DOI: 10.3346/jkms.2021.36.e136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/12/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE). METHODS The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed. RESULTS In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis. CONCLUSION Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.
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Affiliation(s)
- Yoo Min Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yu Bin Kim
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Jin Kim
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Jae Lee
- Department of Pediatrics, Hallym University College of Medicine, Chuncheon, Korea
| | - Yoon Lee
- Department of Pediatrics, Korea University Anam Hospital, Seoul, Korea
| | - So Yoon Choi
- Department of Pediatrics, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
- Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Eun Hye Lee
- Department of Pediatrics, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Dae Yong Yi
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hyo Jeong Jang
- Department of Pediatrics, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - You Jin Choi
- Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Suk Jin Hong
- Department of Pediatrics, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Ju Young Kim
- Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Yunkoo Kang
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soon Chul Kim
- Department of Pediatrics, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea.
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Min JY, Lee JR, Kang YS, Ho JH, Byon HJ. Pediatric characteristics and the dose of propofol for sedation during radiological examinations: a retrospective analysis. J Int Med Res 2021; 49:300060521990992. [PMID: 33641471 PMCID: PMC7923994 DOI: 10.1177/0300060521990992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE The present study aimed to investigate patients' characteristics that can affect the dose of propofol required to sedate children undergoing imaging. METHODS In this retrospective, observational study, we reviewed medical records of children aged 0 to 18 years who were classified as having American Society of Anesthesiologists status 1 or 2 and they underwent imaging under propofol sedation between January 2011 and August 2016. Collected data included patients' demographics, propofol doses, duration of sedation, and complications. Regression analysis was performed to determine patients' characteristics that may affect the dose of propofol required to induce sedation. RESULTS A total of 925 patients were included. Simple linear regression showed that the dose of propofol was correlated with age, height, weight, and body surface area. Using the results of multiple linear regression, the following formula was used to estimate the dose of propofol (mg) for sedation: 0.75 + 0.14 × age (months) + 45.82 × body surface area (m2). CONCLUSION A child's age, height, and body surface area should be considered when deciding the induction dose of propofol. Additionally, the formula that we have proposed can be used to estimate the dose of propofol required to induce sedation in children undergoing imaging.
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Affiliation(s)
- Ji Young Min
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yhen Seoung Kang
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, National Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Jung Hwan Ho
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, National Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Hyo Jin Byon
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Hartjes KT, Dafonte TM, Lee AF, Lightdale JR. Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy. Front Pediatr 2021; 9:709433. [PMID: 34458212 PMCID: PMC8385768 DOI: 10.3389/fped.2021.709433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.
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Affiliation(s)
- Kayla T Hartjes
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, MassGeneral Hospital for Children, Boston, MA, United States
| | - Tracey M Dafonte
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, MassGeneral Hospital for Children, Boston, MA, United States
| | - Austin F Lee
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
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Li J, Scott JB, Lee JH. Defining the optimal role of high-flow nasal cannula in pediatric procedural sedation. Pediatr Pulmonol 2020; 55:3225-3227. [PMID: 33048458 DOI: 10.1002/ppul.25105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/05/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - J Brady Scott
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jan H Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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19
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Kretz FJ, Badelt G, Röher K. Narkose oder Sedierung zu diagnostischen und therapeutischen Prozeduren bei Kindern? Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01037-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Klotz D, Seifert V, Baumgartner J, Teufel U, Fuchs H. High-flow nasal cannula vs standard respiratory care in pediatric procedural sedation: A randomized controlled pilot trial. Pediatr Pulmonol 2020; 55:2706-2712. [PMID: 32696598 DOI: 10.1002/ppul.24975] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 07/08/2020] [Accepted: 07/17/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Respiratory instability is frequently observed during pediatric procedural sedation. The aim of this trial was to estimate the impact of high-flow nasal cannula (HFNC) therapy on respiratory stability during sedation for upper gastrointestinal tract endoscopy in children. METHODS Prospective randomized controlled non-blinded single-center pilot trial. Children were randomly allocated to receive either HFNC (2 L/kg/min) or low-flow nasal oxygen cannula (LFNC, standard care). FiO2 was titrated to maintain SpO2 94% to 98% in both groups. Primary outcome was the number of events of respiratory instability defined by prespecified criteria (hypoxia, hypercapnia, apnea). Secondary outcomes included type and duration of events, number of interventions to regain respiratory stability and cumulative doses of medication. RESULTS Fifty children (mean age, 12.3 ± 3.1 years) were enrolled and treated with HFNC (n = 25) or LFNC (n = 25). Patient and intervention characteristics were not different in the two study groups, including total oxygen flow rate. Mean (SD) number of respiratory events in the HFNC group was 2.0 ± 1.9 events compared to 2.0 ± 1.4 events in the LFNC group (P = .65; 95% CI of difference, -1.0 to 1.0). There was no difference for any secondary outcome criteria, percentage of patients for any outcome criteria and no difference in the number of respiratory events or airway management maneuvers per patient between treatment groups. CONCLUSIONS HFNC did not increase respiratory stability in sedated children undergoing upper gastrointestinal tract endoscopy compared to LFNC.
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Affiliation(s)
- Daniel Klotz
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktor Seifert
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jana Baumgartner
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Teufel
- Department of Gastroenterology, Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans Fuchs
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Setiawan CT, Landrigan-Ossar M. Pediatric Anesthesia Outside the Operating Room: Case Management. Anesthesiol Clin 2020; 38:587-604. [PMID: 32792186 DOI: 10.1016/j.anclin.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anesthesiology teams care for children in diverse locations, including diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology units, and cardiac catheterization laboratories. To provide safe, high-quality care, anesthesiologists working in these environments must understand the unique environmental and perioperative considerations and risks involved with each remote location and patient population. Once these variables are addressed, anesthesia and procedural teams can coordinate to ensure that patients and families receive the same high-quality care that they have come to expect in the operating room. This article also describes some of the considerations for anesthetic care in outfield locations.
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Affiliation(s)
- Christopher Tan Setiawan
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Anesthesiology, Children's Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Mary Landrigan-Ossar
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
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22
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Lee FC, Queliza K, Chumpitazi BP, Rogers AP, Seipel C, Fishman DS. Outcomes of Non-anesthesiologist-Administered Propofol in Pediatric Gastroenterology Procedures. Front Pediatr 2020; 8:619139. [PMID: 33604318 PMCID: PMC7885908 DOI: 10.3389/fped.2020.619139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Non-anesthesiologist-administered propofol (NAAP) has been found to have an acceptable safety profile in adult endoscopy, but its use remains controversial and pediatric data is limited. Our aim was to examine the safety and efficacy of NAAP provided by pediatric hospitalists in pediatric endoscopy. Methods: We retrospectively reviewed 929 esophagogastroduodenoscopy (EGD), colonoscopy, and combined EGD/colonoscopy cases in children aged 5-20 years between April 2015 and December 2016 at a large children's hospital. We analyzed the data for adverse events in relation to demographics and anthropometrics, American Society of Anesthesiologists physical classification score, presence of a trainee, comorbid conditions, and procedure time. Results: A total of 929 cases were included of which 496 (53%) were completed with NAAP. Seventeen (3.4%) of NAAP cases had an adverse event including the following: 12 cases of hypoxia, 2 cardiac, and 3 gastrointestinal adverse events. General anesthesia cases had 62 (14.3%) adverse events including the following: 54 cases of hypoxia, 1 cardiac, 7 gastrointestinal, and 1 urologic adverse event. No adverse events in either group required major resuscitation. NAAP vs. general anesthesia had a lower overall adverse event rate (3.4 vs. 14.3%, p < 0.0004) and respiratory adverse event rate (2.4% vs. 12.5%, p < 0.0004). Overall, cardiac and gastrointestinal adverse event rates between the two groups were comparable. When accounting for all captured factors via logistic regression, both younger age (P < 0.001) and general anesthesia (P < 0.0001) remained risk factors for an adverse event. Conclusion: The overall adverse event rate of NAAP was low (3.4%) with none requiring major resuscitation or hospitalization. This is comparable to studies of NAAP in adult endoscopy and suggests that NAAP provided by pediatric hospitalists has an acceptable safety profile.
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Affiliation(s)
- Frances C Lee
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, United States
| | - Karen Queliza
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, United States
| | - Bruno P Chumpitazi
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, United States.,Children's Nutrition Research Center, United States Department of Agriculture, Houston, TX, United States
| | - Amber P Rogers
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, United States.,Department of Pediatric Hospital Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Catherine Seipel
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, United States
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, United States
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23
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Incidence and risk factors for adverse events during monitored anaesthesia care for gastrointestinal endoscopy in children: A prospective observational study. Eur J Anaesthesiol 2019; 36:390-399. [PMID: 30950900 DOI: 10.1097/eja.0000000000000995] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN An observational study. SETTING Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS Mean ± SD age of the children was 8.5 ± 4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. CONCLUSION The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. TRIAL REGISTRATION ISRCTN70362666.
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Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters. J Clin Med 2019; 8:jcm8122087. [PMID: 31805686 PMCID: PMC6947169 DOI: 10.3390/jcm8122087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/28/2022] Open
Abstract
Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for <60 s is the most prevalent adverse event with a rate of 7.8 per 10,000, followed by airway obstruction at a rate of 5.42 per 10,000. Apnea occurred at a rate of 4.75 per 10,000. Significant predictors of adverse events are ≥ ASA score III (p = 0.0003), procedure time (6:00 pm–12:00 am: p < 0.0001, 12:00–6:00 am: p = 0.0003), and non-hospital location (p < 0.0001). The AE sedation reporting tool has demonstrated that the majority of adverse events in children and adults who receive procedural sedation from multi-specialists internationally required minor interventions and had outcomes of minor risk.
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25
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Epidemiology and incidence of severe respiratory critical events in ear, nose and throat surgery in children in Europe: A prospective multicentre observational study. Eur J Anaesthesiol 2019; 36:185-193. [PMID: 30640246 DOI: 10.1097/eja.0000000000000951] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ear, nose and throat (ENT) surgery, the most frequently performed surgical procedure in children, is a strong predictor for peri-operative respiratory complications. However, there is no clear information about peri-operative respiratory severe critical events (SCEs) associated with anaesthesia management of ENT children in Europe. OBJECTIVE To characterise the epidemiology and incidence of respiratory SCEs during and following ENT surgery in Europe and to identify the risk factors for their occurrence. DESIGN A secondary analysis of the Anaesthesia PRactice In Children Observational Trial, a prospective observational multicentre cohort trial. SETTING The study included 261 centres across 33 European countries and took place over a consecutive 2-week recruitment period between April 2014 and January 2015. PATIENTS We extracted data from 5592 ENT surgical procedures that were performed on 5572 children aged 6.0 (3.6) years (mean (SD)) from the surgical database and compared these with data from 15 952 non-ENT surgical children aged 6.7 (4.8) years. MAIN OUTCOME MEASURES The primary outcome was the incidence of respiratory SCEs (laryngospasm, bronchospasm and new onset of postoperative stridor). Secondary outcomes were the differences in epidemiology between ENT children and non-ENT surgical children and the risk factors for the occurrence of respiratory SCEs. RESULTS The incidence (95% confidence interval) of any respiratory SCE (laryngospasm, bronchospasm and postoperative stridor) was 3.93% (3.46 to 4.48) and was significantly higher than that observed in non-ENT surgical children [2.61% (2.37 to 2.87)], with a relative risk of 1.51 (1.28 to 1.77), P less than 0.0001. Younger age (14% decrease in critical events by increasing year, P < 0.0001), history of snoring, recent upper respiratory tract infection and recent wheezing increased the risk of suffering a SCE by over two-fold (P < 0.0001). There was also some evidence for a positive association with age below 4.6 years and lower surgical volume thresholds (<20 cases/2 weeks). CONCLUSION The results of this study provide additional evidence for strong associations between risk factors and respiratory SCEs in children having ENT surgery. These observations may facilitate the implementation of good clinical practice recommendations for ENT patients in Europe. TRIAL REGISTRATION ClinicalTrials.gov, number NCT01878760.
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26
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Mason KP, Seth N. The pearls of pediatric sedation: polish the old and embrace the new. Minerva Anestesiol 2019; 85:1105-1117. [PMID: 31124622 DOI: 10.23736/s0375-9393.19.13547-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the past decade, as the complexity and breadth of pediatric procedures increases, the actual choices of approved sedatives have remained relatively stagnant. Since the introduction of midazolam, there has not been a sedative approved for pediatric labelling until December 2018. This December, the European approval of ADV6209 (Ozalin) for pediatric usage marked the newest addition to the pediatric sedative armamentarium in over a decade. This review is timely and significant because it will provide a balanced evaluation of the most common sedatives in use today, the most recent sedative to be approved and, most importantly, a critical look at the literature supporting the latest approaches to the most commonly performed procedures.
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Affiliation(s)
- Keira P Mason
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA -
| | - Neena Seth
- Evelina London Children's Hospital, London, UK
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Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Pediatr Crit Care Med 2019; 20:259-261. [PMID: 30431555 DOI: 10.1097/pcc.0000000000001809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient. DESIGN A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey. SUBJECTS Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure. CONCLUSIONS Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.
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28
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The Evolving Role of Mucosal Histology in the Evaluation of Pediatric Functional Dyspepsia: A Review. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1010013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although not required to establish the diagnosis, endoscopy with mucosal biopsy is commonly performed in the evaluation of children with dyspepsia. Traditionally, esophagogastroduodenoscopy (EGD) has been performed in children with abdominal pain to identify pathology or conversely, to “rule-out” organic disease in order to establish a diagnosis of FD. In this review, we discuss the current diagnostic yield of endoscopically-obtained biopsies in identifying disease in children and adolescents with dyspepsia including an expanded discussion of common histologic diagnoses where clinical significance has not been definitively established. In turn, we discuss the transition of endoscopy from a search for disease to a search for biologic contributors to symptom generation, while considering the growing evidence linking non-diagnostic mucosal inflammation to FD, specifically mast cells and eosinophils.
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29
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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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30
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Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr 2017; 171:957-964. [PMID: 28828486 PMCID: PMC5710624 DOI: 10.1001/jamapediatrics.2017.2135] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes. OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis. EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTS Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCE The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Departments of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J. Farion
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne Beno
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - C. Michelle McTimoney
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada,Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Nadia Sourial
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark G. Roback
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis,Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
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31
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Chandran V, Jagadisan B, Ganth B. Validation of Adapted Dartmouth Operative Conditions Scale for sedation during pediatric esophagogastroduodenoscopy. Paediatr Anaesth 2017; 27:621-628. [PMID: 28370856 DOI: 10.1111/pan.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 11/26/2022]
Abstract
AIMS Pediatric esophagogastroduodenoscopy requires deep sedation as it involves stimulation of the airway. Frequency of adverse events is higher with esophagogastroduodenoscopy. Hence, monitoring needs sedation scales like the Dartmouth Operative Condition Scale that identifies safe states of sedation. This study aims at validating the Adapted Dartmouth Operative Condition Scale for sedation rating by pediatricians during pediatric esophagogastroduodenoscopy. METHODS Items in the Dartmouth Operating Conditions Scale were adapted for pediatric esophagogastroduodenoscopy. Videos of 35 procedures were recorded. The recording started 10 min before sedation and continued till recovery. The videos were split into preprocedure videos, intraprocedure videos, and recovery videos, and further split into 30-s clips. Twenty representative intraprocedure videos clips were selected. Ten raters scored the videos with the Adapted Dartmouth Operating Conditions Scale and modified-COMFORT score. The Adapted Dartmouth Operating Conditions Scale scoring was repeated after a month. The preprocedure videos, intraprocedure videos, and recovery videos of ten patients (six clips each) were scored by one rater to assess responsiveness. RESULTS The Adapted Dartmouth Operating Conditions Scale detected nonoptimal sedation states including laryngospasm due to undersedated states. It showed fair interrater reliability at timeline-1 (intraclass correlation coefficient = 0.45) and timeline-2 (intraclass correlation coefficient = 0.65) but poor intrarater reliability (intraclass correlation coefficient = 0.32). There was significant positive correlation with modified-COMFORT (Spearman's rank order correlation, r = 0.150). Responsiveness was demonstrated by the difference in the preprocedure videos, intraprocedure videos, and recovery videos scores (F = 126.50). CONCLUSION The Adapted Dartmouth Operating Conditions Scale detects nonoptimal sedation states during pediatric-esophagogastroduodenoscopy. It shows good criterion validity, interrater reliability, and responsiveness. Poor intrarater reliability seen in our study could be due to item ambiguity arising from the mode of training of the raters in the Dartmouth Operating Conditions Scale.
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Affiliation(s)
- Vanmathi Chandran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Barani Ganth
- Department of Applied Psychology, Pondicherry University, Pondicherry, India
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Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, Leva B, Morton NS, Vermeulen PM, Zielinska M, Boda K, Veyckemans F, Klimscha W, Konecny R, Luntzer R, Morawk-Wintersperger U, Neiger F, Rustemeyer L, Breschan C, Frey D, Platzer M, Germann R, Oeding J, Stoegermüller B, Ziegler B, Brotatsch P, Gutmann A, Mausser G, Messerer B, Toller W, Vittinghoff M, Zangl G, Seidel-Ahyai N, Hochhold C, Kroess R, Paal P, Cnudde S, Coucke P, Loveniers B, Mitchell J, Kahn D, Pirotte T, Pregardien C, Veyckemans F, Coppens M, De Hert S, Heyse B, Neckebroek M, Parashchanka A, Van Limmen J, Van Den Eynde N, Vanpeteghem C, Wyffels P, Lalot M, Lechat JP, Stevens F, Casaer S, De Groote F, De Pooter F, De Villé A, Gerin M, Magasich N, Sanchez Torres C, Van Deenen D, Berghmans J, Himpe D, Roofthooft E, Joukes E, Smitz C, Van Reeth V, Huygens C, Lauweryns J, De Smet K, Najafi N, Poelaert J, Van de Velde A, Van Mossevelde V, Bekavac I, Butkovic D, Heli Litvic D, Kerovec Soric I, Maretic H, Moscatello D, Popovic L, Micici S, Stuck Tus I, Kalagac Fabris L, Simurina T, Sulen N, Kesic-Valpotic G, Djapic D, Žurek J, Jureckova L, Mackova I, Skacel M, Weinlichova S, Divák J, Frelich M, Urbanec R, Biskupova V, Mifsud M, Strachan D, Leva B, Plichon B, Harlet P, Mixa V, Pavlickova J, Afshari A, Bøttger M, Ellekvist MB, Johansen M, Ingeborg Madsen B, Christian Nilsson J, Schousboe BMB, Clausen NG, Hansen TG, Phaff Steen N, Ilmoja ML, Tonise V, Karjagin J, Kikas R, Isohanni M, Lyly A, Takala A, Happo J, Kiviluoma K, Martikainen K, Aantaa R, Manner T, Vilo S, Amory C, Ludot H, Lambotte P, Busche R, Jacqmarcq O, Lejus C, Corouge J, Erb C, Garrigue D, Gillet P, Laffargue A, Lambelin V, Le Freche H, Peresbota D, Richart P, Berton J, Chapotte C, Colbus L, Lehousse T, Monrigal J, Baujard C, Roulleau P, Staiti G, Batoz H, Bordes M, Didier A, Hamonic Y, Lagarde S, Nouette-Gaulain K, Semjen F, Zaghet B, Dekens J, Delcuze A, Dupont H, Legrand A, Raffoflandreur C, Audren N, Camus B, Cartal M, Chazelet C, Davin I, Guillier M, Desjeux L, Larcher C, Grein E, Leclercq M, Levitchi R, Rosu L, Simon D, Zang A, Migeon A, Gagey AC, Bourdaud N, Carre AC, Duflo F, Riche JC, Robert P, Druot E, Maupain O, Orliaguet G, Sabau L, Taright H, Uhrig L, Verchere-Montmayeur J, Debrabant L, Pilla C, Podvin A, Roth B, Dahmani S, Julien-Marsollier F, Sabourdin N, Alexandri B, Brezac G, de la Brière F, Hayem C, Lhubat E, Paul Mission J, Rémond C, Dadure C, Maniora M, Marie A, Pirat P, Saour AC, Sola C, Ecoffey C, Wodey E, Adam C, Standl T, Schindler E, Yamamoto T, Brackhahn M, Eich CB, Guericke H, Kindermann P, Laschat M, Schink C, Wappler F, Hoehne C, Skordou N, Ulrici J, Jetzek-Zader M, Kienbaum P, Meyer-Treschan T, Picker O, Schaefer MS, Mielke G, Baethge S, Ramminger A, Bauer M, Bollinger M, Hinz J, Quintel M, Russo SG, Bauer M, Geil D, Kortgen A, Preussler NP, Hofmann U, Raber M, Reindl D, Becke K, Oppenrieder K, Schierlinger B, Roth J, Funk W, Fischer T, Gernoth C, Wiefelspütz C, Volger H, Zederer N, Diers A, Huber M, Schorer C, Weyland A, Schwarzkopf K, Grau C, Roth W, Holy R, Mader T, Peter L, Supthut H, Kuehhirt T, Milde A, Fiedler F, Isselhorst C, Grundmann U, Pattar A, Reinert J, Ehm B, Fritzsche K, Gaebler R, Meybohm P, Hein M, Guzman I, Jokinen J, Kranke P, Goebel U, Harris S, Eisner C, Ochsenreiter M, Schoeler M, Thil E, Ellerkmann R, Hoeft A, Neumann C, Weber S, Keilhauer J, Kloessing J, Schramm M, Trieschmann U, Knauss K, Sinner B, Steinmann J, Koessler H, Kalliardou E, Malisiova A, Tsiotou A, Chloropoulou P, Chrysi M, Iordanidou D, Ntavlis M, Boda KB, Guerin C, Irwin J, Magner C, Nakhjavani S, O'Hare B, Galvin D, Jamil Y, Lesmes C, Barak Y, Fisher H, Kachko L, Katz J, Kirilov D, Levinzon M, Manevich Y, Nekrasov K, Peled E, Sanko E, Schmain D, Sheinkin O, Simhi E, Tarabikin A, Trabkin E, Yagudaev I, Zeitlin Y, Zunser I, Cerutti E, Maddalena Schellino M, Valzan S, Lucia Pinciroli R, Bortone L, Cerati G, Salici F, Bussolin L, Rizzo G, Rossetti F, Marchesini L, Tesoro S, De Lorenzo B, Guarracino F, Kuppers B, Astuto M, Pitino S, Scalisi R, Scordo L, D'Alessandro S, Dei Giudici L, Farinelli I, Lofino G, Marchetti G, Giuseppe Picardo S, Reali S, Vittori A, Antonio Idone F, Sammartino M, Sbaraglia F, Barbera C, Bevilacqua M, Cento V, Disma N, Kotzeva S, Mameli L, Montobbio G, Passariello L, Punzo C, Sileo R, Viacava R, Volpe C, Zanaboni C, Calderini E, Genco D, Neri S, Ottolina D, Camporesi A, Izzo F, Salvo I, Wolfler A, Sanna A, Sciascia A, Stoia P, Guddo A, Lapi M, Ivani G, Longobardo A, Mossetti V, Pedrotti D, Grazzini M, Meneghini L, Metrangolo S, Michelon S, Minardi C, Tognon C, Zadra N, Busi I, Khotcholava M, Guido Locatelli B, Sonzogni V, Starita G, Almenrader N, Aurilio C, Sansone P, Albarello R, Bracci P, Cecini M, Cristina Mondardini M, Pasini L, Vason M, Zani G, Zoppellari R, Pistidda L, Cortegiani A, Maurizio Raineri S, Hasani A, Hashimi M, Ancupans A, Barzdina A, Straume Z, Zundane A, Chlopin M, Gestautaite D, Lukosiene L, Paliokaite E, Razlevice I, Armoniene I, Bernotiene A, Daugelavicius V, Dockiene I, Gaidelyte L, Saviciene N, Krikstaponiene J, Sidlovskaite-Baltake D, Stasevski V, Vaitoskaite A, Gatt D, Mifsud S, Zammit S, Allison C, Aslami H, Eberl S, van Stijn MFM, Stevens MF, Punt K, van Osch R, Bauwman A, Scholten H, Svircevic V, Adriaens V, Dirckx M, Dogger J, Dons-Sinke I, Machotta A, Moors X, Rad M, Staals L, van der Knijff - van Dortmont A, van der Marel C, Sieben A, van der Zwan T, Veldhuizen M, Alders D, Buhre W, Vermeulen PM, Engel N, Vossen C, Mahadewsing R, Meijer P, Gerling V, van der Schatte Olivier R, van Doorn T, Vons Mark Hendriks K, Lako S, jan Scheffer G, Tielens L, Voet M, Absalom A, Bergsma M, Spanjer V, Spanjersberg R, van de Riet Y, Volkers M, de Graaff JC, Hopman GA, Kappen TH, Hannie J, Megens A, Numan SC, Schouten AN, Turner NM, Van Der Werff DB, Wensing RT, Ephraim E, Nolte C, Reikvam T, Fredrik Lund O, Skaaden L, Marthe Ballovarre K, Bakken Boerke W, Grindheim G, Lindenskov PHH, Beate Solas A, Sponheim S, Ullensvang K, Viken O, Marie Drage I, Gymoese Berthelsen K, Anders Kroken B, Bergland U, Pryzmont M, Talalaj M, Wasiluk M, Zalewska D, Damps M, Siemek-Mitela J, Wieczorek P, Juzwa M, Rosada-Kurasinska J, Bartkowska-Sniatkowska A, Cettler M, Kopycinska R, Rudewicz I, Sobczyk J, Wojciechowski D, Baranowski A, Basiewicz E, Mierzewska-Schmidt M, Retka W, Sawicki P, Checinska M, Zielinska M, Zurawska M, Leal T, Mascarenhas C, Pedro Pina A, Joao Susano M, Moniz A, Teresa Rocha M, Calvao Santos C, Domingas Patuleia M, Pereira R, Roxo H, Amaral R, Guedes I, Gomes C, Gonçalves M, Salgado H, Santos M, Rodrigues S, Sa A, Machado E, Pé d'Arca S, Seabra M, Mihaela Gheorghe L, Ivascu C, Moraru-Draghici L, Suvejan M, Babici R, Eniko K, Hogea C, Mihaela D, Nicoleta D, Barbunc D, Maria Nistor A, Stefan V, Catalina Ionescu G, Davidescu I, Teodora Nastase A, Dumitru Rusu F, Badarau V, Cindea I, Moscaliuc M, Olteanu D, Petrescu L, Ceuca D, Galinescu I, Badeti R, Capusan A, Cucui-Cozma C, Popescu B, Cimpeanu L, Birliba MP, Miulescu M, Balamat S, Gurita A, Ilie L, Mocioiu G, Pick D, Sirghie R, Tabacaru R, Trante I, Gurita A, Horhota L, Bandrabur D, Ciobanu T, Cuciuc V, Munteanu V, Olaru V, Paiu C, Savu A, Trifan O, Elena Malos A, Glazunov A, Ivanov A, Poduskov E, Popov A, Guskov I, Lugovoy A, Nechaev V, Ovezov A, Basov M, Kochkin V, Lazarev V, Chizhov D, Ostreikov I, Tolasov K, Budic I, Marjanovic V, Draskovic B, Pandurov M, Simin J, Dolinaj V, Janjevic D, Mandras A, Mircetic M, Petrovic S, Rebac V, Slavkovic B, Stevanovic V, Velcev A, Knezevic M, Milojevic I, Puric S, Simic I, Stevic M, Stranjanac V, Simic D, Cabanova B, Hanula M, Grynyuk A, Berger J, Cerne U, Nastran A, Pirc D, Popic R, Stupnik S, Rubio P, del Río C, Benito P, Pino G, Gutierrez I, Gutierrez Valcarcel A, León Carsi I, Perez Garcia A, López Galera S, Marco Valls J, Ricol Lainez L, Vallejo Tarrat A, Artes D, Banus E, Chirichiello L, De Abreu L, De Josemaria B, Helena Gaitan M, Garces A, Lazaro JJ, Manen Berga F, Molies D, Monclus E, Navaro M, Pamies C, Perelló M, Prat M, Ribo L, Angeles Sanz M, Serrano S, Sola Ruiz E, Anuncia Escontrela Rodríguez B, Maria Gago Martinez A, Martínez Ruiz A, De La Cruz Benito F, Gabilondo Garcia G, Martinez Maldonado E, Noriega B, Oller Duque L, Olmos Mendez A, Perez- Ferrer A, Reinoso Barbero F, Acevedo Bambaren I, Domínguez F, Franco T, Jiménez A, Melero A, Feliu M, García I, Montferrer N, Munar F, Muro C, Nuño R, Perera R, Schmucker E, Börjesson G, Gillberg L, Castellheim A, Sandström K, Bauer A, Roos T, Hedlund L, Boegli Y, Dolci M, Marcucci C, Spahr-Schopfer I, Habre W, Pellegrini M, Book M, Errass L, Riggenbach C, Casutt M, Hölzle M, Hurni T, Jöhr M, Mauch J, Anselmi L, Anselmi I, Jacomet A, Oberhauser M, Wossner S, Zettl A, Erb T, Mackiewicz T, Simitzes H, Ozer Y, Takil A, Alanoglu Z, Bermede O, Cakar Turhan K, Alkis N, Yildirim Guclu C, Ceyda Meco B, Hatipoglu Z, Ozcengiz D, Begec Z, Ilksen Toprak H, Kendigelen P, Cigdem Tütüncü A, Karadeniz MS, Seyhan Ozkan T, Sivrikoz N, Kemal Arslantas M, Hizal A, Tore Altun G, Umuroglu T, Baris S, Kazak Bengisun Z, Goncharenko G, Khrapak M, Klymenko T, Pavlenko V, Prysiazhniuk D, Rudio O, Varyvoda M, Vodianytskyi S, Boryshkevych I, Kyselova I, Trikash N, Albokrinov A, Perova-Sharonova V, Sklyar V, Surkov D, Abdelaal A, Barber N, Checuti S, Godsiff L, Johanne L, Simpson J, Underhill H, Diwan R, Kelgeri N, Masip N, Ravi R, Roberts S, Cillis A, Marcus R, Merella F, Love D, Baraggia P, Bird V, Hussey J, Alderson P, Bartholomew K, Moncreiff M, Davidson S, Hare A, Kotecha A, Lee C, Liyanage G, Patel S, Samani A, Abou-Samra M, Boyd M, Hullatt L, Levy D, Pauling M, Sharman SJ, Smith N, Rutherford J, Cavalier A, Locke C, Sage F, Bapat S, Hammerschlag J, Ioannou I, King S, Pegg R, Salota V, Sketcher J, Thadsad M, Zeitlin D, Jack E, Lang C, Ahmed S, Ayyash R, Bari F, Bell SJ, Elizabeth Biercamp C, Briggs S, Gabriella Elena Clement M, Dalton M, Ali Eissa Eid M, Gandhi M, Harmen Herrema I, Khaffaf R, Jeng Min Law S, McClintock J, Ireland N, Majid Saleem M, Smith F, Cohen M, Lee CA, O'Donahue L, Powell A, Rawlinson E, Snoek A, Weiss K, Wellesley H, Crawford M, Abdel-Hafiz M, Day A, Rajamani B, Saha R, Wright D, Chee LC, Bew S, Homer R, Malarkkan N, Wolfe Barry J, Angadi P, Cagney B, De Melo E, Dekker E, Helm E, Jones G, Peiris K, Russell W, Slater P, Sodhi P, Browning M, Phillips T, Van Hecke R, Muir V, Singh P, Soskova T, Cumming C, Farquharson P, Pearson K, Shaw N, Whiteside J, Whyte E, Byers G, Davies K, Engelhardt T, Faliszewski I, Johnston G, Kaufmann N, Kusnirikova Z, Wilson G, Carachi P, Makin A, Foster B, Lipczynski D, Mawer R, Rutherford W, Rogerson D, Rushman S, Taylor C, Tomlinson W, Dix P, Woodward T, Bell G, Boyle D, Cloherty M, Cullen J, Cullen P, Fairgrieve R, Ghent R, Glasgow R, Gordeeva E, Harden A, Hivey S, Jerome K, McKee L, Morton N, Pribul V, Sinclair J, Steiner M, Steward H, Sweeney L, Thomson W, Whiteside J, Dalton A, Ross M, Smith C, Allen C, Anders N, Barlow V, Bassett M, Darwin L, Davison R, Diacono J, Hobbs A, Hutchinson A, Lomas B, Lonsdale H, Nasser L, Oshan V, Patel P, Raistrick C, Scott-Warren V, Talbot L, Wai C, Childs S, Dickinson M, Bloomfield T, Garrioch S, Watson K, Gaynor J, Harrison R, Lee J, Blythe E, Dorman T, Eissa A, Ellwood J, Gooch I, Hearn R, Hodgetts V, John R, Kirton C, Ladak N, Morgan J, Plant N, Shepherd E, Short J, Stack C, Steel S, Taylor M, Thomas D, Wilson C, Wilson-Smith E, Bradbury CL, Hussain N, Mayell A, Mesbah A, Qureshi A, Vaidyanath C, Geary T, Hawksworth C, Parasuraman T, Perry N, Banerjee I, Barr K, Butler P, Davies J, Flewin L, Gande R, Montague J, Plumb J, Pratt T, Sutherland P, Taylor M, Vail H, Wilkins A, Hunter C, Russell S, Thomas A. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. THE LANCET RESPIRATORY MEDICINE 2017; 5:412-425. [DOI: 10.1016/s2213-2600(17)30116-9] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 11/24/2022]
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Wittgrove C, Birisci E, Kantor J, Dalabih A. Gastric Volume and Its Relationship to Underlying Pathology or Acid-suppressing Medication. Anesth Essays Res 2017; 11:881-885. [PMID: 29284843 PMCID: PMC5735482 DOI: 10.4103/aer.aer_149_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Pulmonary aspiration during sedation is a major concern for sedation providers, making identifying high-risk patients a priority. Gastric fluid volume (GFV), an accepted risk factor for aspiration, has not been well characterized in fasting children. We hypothesized that GFV would increase with gastrointestinal (GI) pathology and decrease with regular acid-suppressor use. Aims The primary objective was to determine baseline GFV in fasting children. The secondary objectives were to evaluate the effect of GI pathology and regular use of acid-suppressing medications on GFV. Settings and Study Design This was prospective, observational study. Materials and Methods We endoscopically aspirated and measured GFV of 212 children fasting for >6 h who were sedated for esophagogastroduodenoscopy (EGD). Inclusion criteria were children up to 21 years of age, with the American Society of Anesthesiologists physical Status I and II presenting for elective EGD. After determining baseline GFV, the effect of GI pathology and effect of regular acid-suppressing medication use on GFV was analyzed. Statistical Analysis Analysis of variance was used to compare the GFV among ages and pathology and medication groups. Student's t-test was used to compare GFV between genders and also to compare GFV in confounder analyses. Results For the studied 212 children, average GFV was 0.469 ± 0.448 mL/kg (0-2.663 mL/kg). We found no association between GI pathology and GFV (P = 0.147), or acid-suppressor use and GFV (P = 0.360). Conclusions Average GFV in this study falls within the range of prior EGD-measured GFV in fasting children. Contrary to our hypothesis, we found no association between pathologies or regular acid-suppressor use on GFV. On the basis of GFV, children with GI disorders or those using acid-suppressors do not appear to pose an increased risk of aspiration. Future studies should discern differences in effects on GFV of immediate preprocedural versus the regular use of acid-suppressing medications.
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Affiliation(s)
- Carli Wittgrove
- Department of Child Health, University of Missouri, Columbia, MO, USA
| | - Esma Birisci
- Department of Economics, Uludag University, Bursa, Turkey
| | - Jeff Kantor
- Department of Child Health, University of Missouri, Columbia, MO, USA
| | - Abdallah Dalabih
- Department of Pediatrics, Division of Critical Care, University of Arkansas for Medical Sciences, AR, USA
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Rosero EB, Joshi GP. Ambulatory Anesthesia in Remote Locations. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0181-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chung HK, Lightdale JR. Sedation and Monitoring in the Pediatric Patient during Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2016; 26:507-25. [PMID: 27372774 DOI: 10.1016/j.giec.2016.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sedation is a fundamental component of pediatric gastrointestinal procedures. The 2 main types of sedation for pediatric endoscopy remain general anesthesia and procedural sedation. Although anesthesiologist-administered sedation protocols are more common, there is no ideal regimen for endoscopy in children. This article discusses specific levels of sedation for endoscopy as well as various regimens that can be used to achieve each. Risks and considerations that may be specific to performing gastrointestinal procedures in children are reviewed. Finally, potential future directions for sedation and monitoring that may change the practice of pediatric gastroenterology and ultimately patient outcomes are examined.
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Affiliation(s)
- Hyun Kee Chung
- Pediatric Anesthesia, Department of Anesthesia, UMass Memorial Medical Center, 55 Lake Street North, Worcester, MA 01655, USA
| | - Jenifer R Lightdale
- Pediatric Gastroenterology and Nutrition, UMass Memorial Children's Medical Center, University Campus, 55 Lake Street North, Worcester, MA 01655, USA.
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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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Grunwell JR, Marupudi NK, Gupta RV, Travers CD, McCracken CE, Williamson JL, Stockwell JA, Fortenberry JD, Couloures K, Cravero J, Kamat PP. Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies. Paediatr Anaesth 2016; 26:628-36. [PMID: 27061749 PMCID: PMC5024537 DOI: 10.1111/pan.12903] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. METHODS We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. RESULTS A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). CONCLUSIONS More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.
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Affiliation(s)
- Jocelyn R. Grunwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Neelima K. Marupudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Rohan V. Gupta
- Department of Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Curtis D. Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Julie L. Williamson
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA,Department of Anesthesia, Emory University School of Medicine, Atlanta, GA, USA
| | - Jana A. Stockwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - James D. Fortenberry
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kevin Couloures
- Pediatric Sedation Services, Yale School of Medicine and Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Joseph Cravero
- Department of Anesthesia, Harvard School of Medicine and Boston Children's Hospital, Boston, MA, USA
| | - Pradip P. Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
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Chang B, Urman RD. Non-operating Room Anesthesia: The Principles of Patient Assessment and Preparation. Anesthesiol Clin 2016; 34:223-240. [PMID: 26927750 DOI: 10.1016/j.anclin.2015.10.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A significant number of anesthetics are performed outside of the operating room (OR). Despite the increased requirement for anesthesia services, the framework to perform the necessary preprocedural anesthesia assessments to optimize patients has not been uniformly developed. Performing anesthesia in non-OR locations poses significant and distinct challenges compared with the procedures in the OR. Anesthesiologists are faced with patients with increasingly complicated comorbidities undergoing novel, complex interventional procedures. With unique training in preoperative triaging, and an expertise in intraoperative and postoperative management of complex patients, anesthesiologists can contribute to greater efficiency and patient safety in the non-OR setting.
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Affiliation(s)
- Beverly Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, 300 Pasteur Drive H3580, Stanford, CA 94305, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Threats to safety during sedation outside of the operating room and the death of Michael Jackson. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S36-47. [DOI: 10.1097/aco.0000000000000318] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Is It Safe? Are There Limits With Procedural Sedation for Endoscopy in Children? Pediatr Crit Care Med 2015; 16:783-4. [PMID: 26427813 DOI: 10.1097/pcc.0000000000000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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