Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: a clinical survey

Axilla nerve block in the emergency department

The axilla nerve block is versatile and covers injuries from the elbow to the hand, such as wrist fracture reductions, and may be an option to improve patient care, reduce both length of stay and resource allocation.

National Survey to Describe the Current Patterns of Procedural Sedation Practices Among Pediatric Emergency Medicine Practitioners in the United States

OBJECTIVE

Pediatric procedural sedation (PPS) is used to maintain children's safety, comfort, and cooperation during emergency department procedures. Our objective was to gather data describing PPS practice across the United States to highlight the variations in practice and adherence to National Guidelines.

METHODS

We performed a nationwide survey of PPS practitioners using a secure web-based software program. A link to the survey was sent to all subscribers of a pediatric emergency medicine listserv. We collected participant demographics, their PPS approach for personnel, monitoring, equipment, postsedation observation, and side effects, as well as providers' medication preferences for 3 common PPS scenarios.

RESULTS

We received 211 completed surveys from 34 States. There were 20.6% respondents that were based in New York, 83.4% were pediatric emergency medicine attendings, and 91.7% were based in the United States teaching hospitals. Our participants learned PPS by various methods, most commonly: observation of at least 10 PPS (29.9%); self-study (24.8%); and classroom lectures (24.5%). Seventy-seven percent of our participants reported no body mass index cutoff to do PPS. There were 31.5% of our participants that observe children after PPS up to 1 hour, 30.1% up to 2 hours. There were 67.7% of the PPS providers that were a separate person from the practitioner doing the procedure, and 98.2% required a separate trained nurse to be present for monitoring. There were 92.6% of PPS providers that measure end-tidal carbon dioxide (ETCO2) during the sedation. Most PPS providers reported having no reversal agents (71.4%) and no defibrillator (65.9%) at bedside. For the abscess drainage scenario, 22% of participants preferred local anesthetic alone, and 22.5% preferred utilizing local anesthetic in combination with intravenous ketamine. For a forearm fracture reduction scenario, 62.8% of participants would choose intravenous ketamine alone. For the laceration repair scenario, the most favored drug combination was local anesthesia + intranasal midazolam by 39.8% of participants.

CONCLUSIONS

Our study demonstrates a wide variability in several aspects of PPS and low adherence to national PPS guidelines.

Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department

OBJECTIVES

To compare the efficacy and adverse events of 2 pharmacological strategies: intranasal fentanyl and nitrous oxide (FN) inhaled against intravenous ketamine and midazolam (KM) as procedural sedation and analgesia (PSA) in painful orthopedic procedures in the pediatric emergency department (ED).

METHODS

This is an observational retrospective cohort study. Patients were included that submitted to PSA for carrying out a painful orthopedic procedure in the ED of a tertiary hospital over a period of 2 years. The main outcome variable was efficacy and adverse events of the PSA procedure.

RESULTS

Eighty-three patients were included. Fifty-two patients received FN and 31 KM. The PSA strategy was considered efficacious in 82.7% of the patients in the KM group and 80.6% in the FN cohort. No differences between both strategies were found (P = 0.815). Seventeen children showed early adverse events, 2 in the FN cohort and 15 in the KM group (relative risk of the KM strategy, 23.48; 95% confidence interval (CI), 3.24-169.99). The average of satisfaction obtained by the families was of 10 (CI, 10-10) in the KM cohort and of 9 (CI, 8-9.5) in the FN group (P = 0.152). The length of stay in the ED was longer in the KM cohort (P < 0.001). Hospital admission rate differences were not statistically different (9.6% vs 22.6%, P = 0.144) in the KM versus FN cohort.

CONCLUSIONS

Both PSA strategies presented similar efficacy. The FN strategy was associated with a lower risk of adverse events and shorter ED length of stay than KM in this ED setting.

The intranasal dexmedetomidine plus ketamine for procedural sedation in children, adaptive randomized controlled non-inferiority multicenter trial (Ketodex): a statistical analysis plan

Background

Procedural sedation and analgesia (PSA) is frequently required to perform closed reductions for fractures and dislocations in children. Intravenous (IV) ketamine is the most commonly used sedative agent for closed reductions. However, as children find IV insertion a distressing and painful procedure, there is need to identify a feasible alternative route of administration. There is evidence that a combination of dexmedetomidine and ketamine (ketodex), administered intranasally (IN), could provide adequate sedation for closed reductions while avoiding the need for IV insertion. However, there is uncertainty about the optimal combination dose for the two agents and whether it can provide adequate sedation for closed reductions. The Intranasal Dexmedetomidine Plus Ketamine for Procedural Sedation (Ketodex) study is a Bayesian phase II/III, non-inferiority trial in children undergoing PSA for closed reductions that aims to address both these research questions. This article presents in detail the statistical analysis plan for the Ketodex trial and was submitted before the outcomes of the trial were available for analysis.

Methods/design

The Ketodex trial is a multicenter, four-armed, randomized, double-dummy controlled, Bayesian response adaptive dose finding, non-inferiority, phase II/III trial designed to determine (i) whether IN ketodex is non-inferior to IV ketamine for adequate sedation in children undergoing a closed reduction of a fracture or dislocation in a pediatric emergency department and (ii) the combination dose for IN ketodex that provides optimal sedation. Adequate sedation will be primarily measured using the Pediatric Sedation State Scale. As secondary outcomes, the Ketodex trial will compare the length of stay in the emergency department, time to wakening, and adverse events between study arms.

Discussion

The Ketodex trial will provide evidence on the optimal dose for, and effectiveness of, IN ketodex as an alternative to IV ketamine providing sedation for patients undergoing a closed reduction. The data from the Ketodex trial will be analyzed from a Bayesian perspective according to this statistical analysis plan. This will reduce the risk of producing data-driven results introducing bias in our reported outcomes.

Trial registration

ClinicalTrials.gov NCT04195256. Registered on December 11, 2019.

Military trauma and orthopaedics experience of the UK COVID-19 pandemic: a lesson in versatility and how it can influence our deployed role

The COVID-19 pandemic necessitated unprecedented change within the NHS. Some medical staff have been deployed into unfamiliar roles, while others have been exposed to innovative ways of working. The embedded military Trauma and Orthopaedic (T&O) cadre have been integral to this change. Many of these new skills and ways of working learnt will be transferable to deployed environments. Feedback from the T&O military cadre highlighted key areas of learning as changes in T&O services, use of technology, personal protective equipment, redeployment and training. This paper aims to discuss how these changes were implement and how they could be used within future military roles. The T&O cadre played important roles within their NHS trusts and the skills they learnt will broaden their skills and knowledge for future deployments.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol

INTRODUCTION

Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

METHODS AND ANALYSIS

This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

TRIAL REGISTRATION NUMBER

NCT0419525.

A Bayesian response-adaptive dose-finding and comparative effectiveness trial

BACKGROUND/AIMS

Combinations of treatments that have already received regulatory approval can offer additional benefit over Each of the treatments individually. However, trials of these combinations are lower priority than those that develop novel therapies, which can restrict funding, timelines and patient availability. This article develops a novel trial design to facilitate the evaluation of New combination therapies. This trial design combines elements of phase II and phase III trials to reduce the burden of evaluating combination therapies, while also maintaining a feasible sample size. This design was developed for a randomised trial that compares the properties of three combination doses of ketamine and dexmedetomidine, given intranasally, to ketamine delivered intravenously for children undergoing a closed reduction for a fracture or dislocation.

METHODS

This trial design uses response-adaptive randomisation to evaluate different dose combinations and increase the information collected for successful novel drug combinations. The design then uses Bayesian dose-response modelling to undertake a comparative effectiveness analysis for the most successful dose combination against a relevant comparator. We used simulation methods determine the thresholds for adapting the trial and making conclusions. We also used simulations to evaluate the probability of selecting the dose combination with the highest true effectiveness the operating characteristics of the design and its Bayesian predictive power.

RESULTS

With 410 participants, five interim updates of the randomisation ratio and a probability of effectiveness of 0.93, 0.88 and 0.83 for the three dose combinations, we have an 83% chance of randomising the largest number of patients to the drug with the highest probability of effectiveness. Based on this adaptive randomisation procedure, the comparative effectiveness analysis has a type I error of less than 5% and a 93% chance of correcting concluding non-inferiority, when the probability of effectiveness for the optimal combination therapy is 0.9. In this case, the trial has a greater than 77% chance of meeting its dual aims of dose-finding and comparative effectiveness. Finally, the Bayesian predictive power of the trial is over 90%.

CONCLUSIONS

By simultaneously determining the optimal dose and collecting data on the relative effectiveness of an intervention, we can minimise administrative burden and recruitment time for a trial. This will minimise the time required to get effective, safe combination therapies to patients quickly. The proposed trial has high potential to meet the dual study objectives within a feasible overall sample size.

Determining a Bayesian predictive power stopping rule for futility in a non-inferiority trial with binary outcomes

Background/Aims

Non-inferiority trials investigate whether a novel intervention, which typically has other benefits (i.e., cheaper or safer), has similar clinical effectiveness to currently available treatments. In situations where interim evidence in a non-inferiority trial suggests that the novel treatment is truly inferior, ethical concerns with continuing randomisation to the “inferior” intervention are raised. Thus, if interim data indicate that concluding non-inferiority at the end of the trial is unlikely, stopping for futility should be considered. To date, limited examples are available to guide the development of stopping rules for non-inferiority trials.

Methods

We used a Bayesian predictive power approach to develop a stopping rule for futility for a trial collecting binary outcomes. We evaluated the frequentist operating characteristics of the stopping rule to ensure control of the Type I and Type II error. Our case study is the Intranasal Ketamine for Procedural Sedation trial (INK trial), a non-inferiority trial designed to assess the sedative properties of ketamine administered using two alternative routes.

Results

We considered implementing our stopping rule after the INK trial enrols 140 patients out of 560. The trial would be stopped if 12 more patients experience a failure on the novel treatment compared to standard care. This trial has a type I error rate of 2.2% and a power of 80%.

Conclusions

Stopping for futility in non-inferiority trials reduces exposure to ineffective treatments and preserves resources for alternative research questions. Futility stopping rules based on Bayesian predictive power are easy to implement and align with trial aims.

Trial registration

ClinicalTrials.gov NCT02828566 July 11, 2016.

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It is important to consider stopping for futility in non-inferiority trials.

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We develop a rule to stop a non-inferiority trial using Bayesian predictive power.

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We provide code and an online application to implement this method.

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We reduce the complexity of developing stopping rules in non-inferiority trials.

Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

PURPOSE

Closed reduction under conscious sedation in the emergency department (ED) has been demonstrated to provide cost-effective, timely care. There has been little research into the efficacy of conscious sedation and reduction from an orthopaedic trauma perspective. This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in our level I paediatric ED.

METHODS

All fracture patients presenting overnight to our level I trauma centre ED between 01 June 2016 and 30 June 2017 were identified. Patient records were reviewed to determine diagnoses, treatments and outcomes. The rate of repeat intervention after successful conscious sedation and reduction and rate of changes in management in which the orthopaedic resident's overnight management plan to provide procedural sedation was altered to surgical intervention after morning case review rounds was calculated.

RESULTS

Conscious sedation and reduction was performed on a total of 386 patients covering ten fracture types during the course of our study, with distal radius fractures (n = 167, 43.3%) comprising the majority of cases. A total of 53 cases (13.7%, 53/386) lost alignment and required repeat intervention, consisting of 33 cases (8.5%, 33/386) that required repeat surgery and 5.2% (20/386) that required cast wedging. In all, 12 patients (3.1%, 12/386) initially reduced under conscious sedation required a change in management and surgical intervention. There were five cases of growth arrest and two cases of malunion.

CONCLUSIONS

Conscious sedation and reduction provides an alternative to general anaesthesia for many paediatric trauma injuries without compromising patient outcomes.

LEVEL OF EVIDENCE

IV.

Reduced Length of Stay and Adverse Events Using Bier Block for Forearm Fracture Reduction in the Pediatric Emergency Department

OBJECTIVES

Forearm fractures are among the most common pediatric injuries. Procedural sedation is frequently used for analgesia during fracture reduction but requires a prolonged recovery period and can be associated with adverse events. Bier block is a safe alternative for fracture reduction analgesia. This study sought to compare Bier block and procedural sedation for forearm fracture reduction.

METHODS

We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. Outcomes assessed were emergency department length of stay, reduction success rates, adverse events, and unscheduled return visits.

RESULTS

Overall, 274 patients were included (Bier block, n = 109; procedural sedation, n = 165). Mean length of stay was 82 minutes shorter for Bier block patients (279 vs 361 minutes, P < 0.001). Subanalysis revealed a reduced length of stay among Bier block patients with forearm fractures involving a single bone (286 vs 388 minutes, P < 0.001) and both bones (259 vs 321 minutes, P < 0.05). Reduction success did not differ between Bier block and procedural sedation (98.2% vs 97.6%, P = 0.74). There were no major adverse events in either group, but Bier block patients experienced fewer minor adverse events (2.7% vs 14.5%, P < 0.001). Return visit rates were similar between Bier block and procedural sedation (17.6% vs 16.9%, P = 0.92).

CONCLUSIONS

Compared with procedural sedation, forearm fracture reduction performed with Bier block was associated with a reduced emergency department length of stay and fewer adverse events, with no differences in reduction success or return visits.

Use of ketamine sedation for the management of displaced paediatric forearm fractures

AIM

To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.

METHODS

Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.

RESULTS

During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.

CONCLUSION

Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

Intravenous regional anaesthesia (Bier's block) for pediatric forearm fractures in a pediatric emergency department-Experience from 2003 to 2014

STUDY OBJECTIVES

To evaluate the efficacy (length of stay in the emergency department and failure rate of Bier's block) and safety profile (death and major complications) of Bier's block in its use for manipulation and reduction of paediatric forearm fractures.

METHODS

This is a retrospective cohort study of pediatric patients in KKWomen's and Children's Hospital Children's Emergency Department with forearm fractures between Jan 2003 and Dec 2014 who underwent manipulation and reduction using Bier's block. Demographic data, time from registration to discharge, major complications and success rate were collated in a standardized data collection form. A subanalysis of the Bier's block group from 2009 to 2014 was performed and compared to a corresponding data set of paediatric patients who underwent manipulation and reduction of forearm fractures using ketamine for procedural sedation from 2009 to 2014.

RESULTS

1781 cases of paediatric forearm fractures were analysed. The mean age of patients in the Bier's block group was 12.0 years (range 5.5-17.8 years old). Of all patients undergoing Bier's block, 1471 out of 1781 patients were male (82.7%). The mean length of stay (LOS) in the department was 168±72min, measured from time of registration till departure. From our subanalysis of data from 2009 to 2014, the mean LOS for the Bier's block group was shorter - 170min compared to 238min for the ketamine group (P <0.0001). 2 patients had failed Bier's block which required a repeat procedural sedation using ketamine. 96% of patients who underwent Bier's block were discharged with an outpatient orthopaedic appointment. There were no deaths or major complications identified in our study.

CONCLUSION

Bier's block is a safe technique for reduction of fractures when used in the appropriate population and fracture types, with a low failure rate and no major complications including death. Compared to the ketamine group, it has a shorter length of stay in the emergency department. We recommend the adoption of this practice for manipulation and reduction of pediatric forearm fractures in the Emergency Department with a formalised protocol to reduce and prevent any human errors that can potentially result in complications.

Intranasal ketamine for procedural sedation and analgesia in children: A systematic review

BACKGROUND

Ketamine is commonly used for procedural sedation and analgesia (PSA) in children. Evidence suggests it can be administered intranasally (IN). We sought to review the evidence for IN ketamine for PSA in children.

METHODS

We performed a systematic review of randomized trials of IN ketamine in PSA that reported any sedation-related outcome in children 0 to 19 years. Trials were identified through electronic searches of MEDLINE (1946-2016), EMBASE (1947-2016), Google Scholar (2016), CINAHL (1981-2016), The Cochrane Library (2016), Web of Science (2016), Scopus (2016), clinical trial registries, and conference proceedings (2000-2016) without language restrictions. The methodological qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, respectively.

RESULTS

The review included 7 studies (n = 264) of children ranging from 0 to 14 years. Heterogeneity in study design precluded meta-analysis. Most studies were associated with a low or unclear risk of bias and outcome-specific ratings for quality of evidence were low or very low. In four of seven studies, IN ketamine provided superior sedation to comparators and resulted in adequate sedation for 148/175 (85%) of participants. Vomiting was the most common adverse effect; reported by 9/91 (10%) of participants.

CONCLUSIONS

IN ketamine administration is well tolerated and without serious adverse effects. Although most participants were deemed adequately sedated with IN ketamine, effectiveness of sedation with respect to superiority over comparators was inconsistent, precluding a recommendation for PSA in children.

Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study

INTRODUCTION

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N₂O) allow for short recovery time and obviates painful and time-consuming IV access insertions.

METHODS

We performed a bicentric, prospective, observational cohort study. Patients aged 4-18years were included if they received combined PSA with IN fentanyl and N₂O for the reduction of mildly/moderately displaced fracture or of dislocation. Facial Pain Scale Revised (FPS-R) and Face, Leg, Activity, Cry, Consolability (FLACC) scores were used to evaluate pain and anxiety before, during and after procedure. University of Michigan Sedation Score (UMSS), adverse events, detailed side effects and satisfaction of patients, parents and medical staff were recorded at discharge. A follow up telephone call was made after 24-72h.

RESULTS

90 patients were included. There was no difference in FPS-R during the procedure (median score 2 versus 2), but the FLACC score was significantly higher as compared to before (median score 4 versus 0, Δ 2, 95% CI 0, 2). Median UMSS was 1 (95% CI 1, 2). We recorded no serious adverse events. Rate of vomiting was 12% (11/84). Satisfaction was high among participants responding to this question 85/88 (97%) of parents, 74/83 (89%) of patients and 82/85 (96%) of physicians would want the same sedation again.

CONCLUSION

PSA with IN fentanyl and N₂O is effective and safe for the reduction of mildly/moderately displaced fracture or dislocation, and has a high satisfaction rate.