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Mofidi A, Vesal N. Total intravenous anesthesia with Ketofol in rabbits: a comparison of the effects of constant rate infusion of midazolam, fentanyl or dexmedetomidine. BMC Vet Res 2024; 20:253. [PMID: 38851722 PMCID: PMC11161920 DOI: 10.1186/s12917-024-04112-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 06/04/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND When inhalant anesthetic equipment is not available or during upper airway surgery, intravenous infusion of one or more drugs are commonly used to induce and/or maintain general anesthesia. Total intravenous anesthesia (TIVA) does not require endotracheal intubation, which may be more difficult to achieve in rabbits. A range of different injectable drug combinations have been used as continuous infusion rate in animals. Recently, a combination of ketamine and propofol (ketofol) has been used for TIVA in both human patients and animals. The purpose of this prospective, blinded, randomized, crossover study was to evaluate anesthetic and cardiopulmonary effects of ketofol total intravenous anesthesia (TIVA) in combination with constant rate infusion (CRI) of midazolam, fentanyl or dexmedetomidine in eight New Zealand White rabbits. Following IV induction with ketofol and endotracheal intubation, anesthesia was maintained with ketofol infusion in combination with CRIs of midazolam (loading dose [LD]: 0.3 mg/kg; CRI: 0.3 mg/kg/hr; KPM), fentanyl (LD: 6 µg/kg; CRI: 6 µg/kg/hr; KPF) or dexmedetomidine (LD: 3 µg/kg; CRI: 3 µg/kg/hr; KPD). Rabbits in the control treatment (KPS) were administered the same volume of saline for LD and CRI. Ketofol infusion rate (initially 0.6 mg kg- 1 minute- 1 [0.3 mg kg- 1 minute- 1 of each drug]) was adjusted to suppress the pedal withdrawal reflex. Ketofol dose and physiologic variables were recorded every 5 min. RESULTS Ketofol induction doses were 14.9 ± 1.8 (KPM), 15.0 ± 1.9 (KPF), 15.5 ± 2.4 (KPD) and 14.7 ± 3.4 (KPS) mg kg- 1 and did not differ among treatments (p > 0.05). Ketofol infusion rate decreased significantly in rabbits in treatments KPM and KPD as compared with saline. Ketofol maintenance dose in rabbits in treatments KPM (1.0 ± 0.1 mg/kg/min) and KPD (1.0 ± 0.1 mg/kg/min) was significantly lower as compared to KPS (1.3 ± 0.1 mg/kg/min) treatment (p < 0.05). Ketofol maintenance dose did not differ significantly between treatments KPF (1.1 ± 0.3 mg/kg/min) and KPS (1.3 ± 0.1 mg/kg/min). Cardiovascular variables remained at clinically acceptable values but ketofol infusion in combination with fentanyl CRI was associated with severe respiratory depression. CONCLUSIONS At the studied doses, CRIs of midazolam and dexmedetomidine, but not fentanyl, produced ketofol-sparing effect in rabbits. Mechanical ventilation should be considered during ketofol anesthesia, particularly when fentanyl CRI is used.
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Affiliation(s)
- Arghavan Mofidi
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, 71441-69155, Iran
| | - Nasser Vesal
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, 71441-69155, Iran.
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Isık G, Alpay N, Daglioglu G, Ciftci V. Effects of propofol, ketamine-propofol mixture in pediatric dental patients undergoing intravenous sedation: a clinical study. Sci Rep 2024; 14:11806. [PMID: 38782977 PMCID: PMC11116380 DOI: 10.1038/s41598-024-61823-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
This study aimed to evaluate the clinical effects, complications (peri- and postoperative), depth of sedation, recovery times, and changes in anxiety levels in paediatric dental patients receiving intravenous sedation with propofol and ketamine-propofol mixtures. This prospective clinical study included 69 healthy children (ASA 1) aged 3-7 years. The patients were assigned randomly to propofol group (n = 23), which received propofol; 1:3 ketofol group (n = 23), which received 1:3 ketofol; or 1:4 ketofol group (n = 23), which received 1:4 ketofol. The bispectral index (BIS) and Ramsay Sedation Scale (RSS) score were recorded at intervals of 5 min to measure the depth of sedation, and vital signs were evaluated. Peri- and postoperative complications and recovery times were recorded. Anxiety levels were also evaluated using the Facial Image Scale (FIS) and changes in saliva cortisol levels (SCLs) before and after the intravenous sedation procedure. The Kruskal‒Wallis test and Wilcoxon signed-rank test were used to determine pre- and posttreatment parameters. Dunn's test for post hoc analysis was used to determine the differences among groups. Children's pre- and posttreatment anxiety levels did not differ significantly according to FIS scores, and increases in SCLs were detected in 1:3 ketofol and 1:4 ketofol groups after dental treatment was completed. Compared with those in the other groups, the BIS values of the patients in 1:4 ketofol indicated a slightly lower depth of sedation. The recovery time of the patients in 1:3 ketofol was longer than that of patients in propofol and 1:4 ketofol. The incidence of postoperative complications (agitation, hypersalivation, nausea/vomiting, and diplopia) did not differ among the groups. Ketamine-propofol combinations provided effective sedation similar to that of propofol infusion without any serious complications during dental treatment performed under intravenous sedation. The ketofol infusion increased the anxiety level of paediatric dental patients to a greater extent than the propofol infusion.
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Affiliation(s)
- Gizem Isık
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Sarıçam, 01330, Adana, Turkey
| | - Nilgun Alpay
- Department of Anesthesiology and Reanimation, Faculty of Dentistry, Cukurova University, Adana, Turkey
| | - Gülcin Daglioglu
- Department of Biochemistry, Balcalı Hospital Central Laboratory, Cukurova University, Adana, Turkey
| | - Volkan Ciftci
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Sarıçam, 01330, Adana, Turkey.
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Ayandeh A, Farrell N, Sheng AY. Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity? J Emerg Med 2023; 65:e272-e279. [PMID: 37679283 DOI: 10.1016/j.jemermed.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/06/2023] [Accepted: 05/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult. DISCUSSION Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure. CONCLUSION There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.
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Affiliation(s)
- Armon Ayandeh
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Natalija Farrell
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alexander Y Sheng
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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De Vries LJ, Veeger NJGM, Van Roon EN, Lameijer H. Low-dose ketamine or opioids combined with propofol for procedural sedation in the emergency department: a systematic review. Eur J Emerg Med 2023; 30:244-251. [PMID: 37276055 DOI: 10.1097/mej.0000000000001046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 μg/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.
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Affiliation(s)
| | - Nic J G M Veeger
- Department of Epidemiology, MCL Academy, Medical Center Leeuwarden, Leeuwarden
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen
| | - Eric N Van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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Hashemi SR, Vesal N. Ketamine-propofol for total intravenous anaesthesia in rabbits: a comparison of premedication with acepromazine-medetomidine, acepromazine-midazolam or acepromazine-morphine. Vet Anaesth Analg 2023; 50:263-272. [PMID: 36894406 DOI: 10.1016/j.vaa.2023.02.002] [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: 11/03/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To describe ketamine-propofol total intravenous anaesthesia (TIVA) following premedication with acepromazine and either medetomidine, midazolam or morphine in rabbits. STUDY DESIGN Randomized, crossover experimental study. ANIMALS A total of six healthy female New Zealand White rabbits (2.2 ± 0.3 kg). METHODS Rabbits were anaesthetized on four occasions, each separated by 7 days: an intramuscular injection of saline alone (treatment Saline) or acepromazine (0.5 mg kg-1) in combination with medetomidine (0.1 mg kg-1), midazolam (1 mg kg-1) or morphine (1 mg kg-1), treatments AME, AMI or AMO, respectively, in random order. Anaesthesia was induced and maintained with a mixture containing ketamine (5 mg mL-1) and propofol (5 mg mL-1) (ketofol). Each trachea was intubated and the rabbit administered oxygen during spontaneous ventilation. Ketofol infusion rate was initially 0.4 mg kg-1 minute-1 (0.2 mg kg-1 minute-1 of each drug) and was adjusted to maintain adequate anaesthetic depth based on clinical assessment. Ketofol dose and physiological variables were recorded every 5 minutes. Quality of sedation, intubation and recovery times were recorded. RESULTS Ketofol induction doses decreased significantly in treatments AME (7.9 ± 2.3) and AMI (8.9 ± 4.0) compared with treatment Saline (16.8 ± 3.2 mg kg-1) (p < 0.05). The total ketofol dose to maintain anaesthesia was significantly lower in treatments AME, AMI and AMO (0.6 ± 0.1, 0.6 ± 0.2 and 0.6 ± 0.1 mg kg-1 minute-1, respectively) than in treatment Saline (1.2 ± 0.2 mg kg-1 minute-1) (p < 0.05). Cardiovascular variables remained at clinically acceptable values, but all treatments caused some degree of hypoventilation. CONCLUSIONS AND CLINICAL RELEVANCE Premedication with AME, AMI and AMO, at the doses studied, significantly decreased the maintenance dose of ketofol infusion in rabbits. Ketofol was determined to be a clinically acceptable combination for TIVA in premedicated rabbits.
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Affiliation(s)
- Seyed Reza Hashemi
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Nasser Vesal
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, Iran.
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Choudhary D, Dhillon R, Chadha K, Cross K, Carnevale FP. National Survey to Describe the Current Patterns of Procedural Sedation Practices Among Pediatric Emergency Medicine Practitioners in the United States. Pediatr Emerg Care 2022; 38:e321-e328. [PMID: 33136832 DOI: 10.1097/pec.0000000000002275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Deepak Choudhary
- From the Department of Pediatric Emergency Medicine, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Reshvinder Dhillon
- Department of Pediatric Emergency Medicine, John R Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Kunal Chadha
- Department of Pediatric Emergency Medicine, John R Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Keith Cross
- Department of Pediatric Emergency Medicine, John R Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Frank P Carnevale
- Department of Pediatric Emergency Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
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Sun TC, Bellei M, Robinson A, Martinez‐Taboada F. Ketofol: A ketamine‐propofol admixture for induction of anaesthesia in two foals. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tsim Christopher Sun
- Department of Anaesthesia Veterinary Teaching Hospital, University of Sydney Camperdown New South Wales Australia
| | - Maria Bellei
- Scone Equine Hospital Scone New South Wales Australia
| | | | - Fernando Martinez‐Taboada
- Department of Anaesthesia Veterinary Teaching Hospital, University of Sydney Camperdown New South Wales Australia
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Biliškov AN, Ivančev B, Pogorelić Z. Effects on Recovery of Pediatric Patients Undergoing Total Intravenous Anesthesia with Propofol versus Ketofol for Short-Lasting Laparoscopic Procedures. CHILDREN-BASEL 2021; 8:children8070610. [PMID: 34356589 PMCID: PMC8303649 DOI: 10.3390/children8070610] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/25/2021] [Accepted: 07/15/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combining ketamine and propofol (ketofol) was suggested as a new concept for sedation and general anesthesia in pediatric populations for various conditions. The aim of the present study was to determine the effect of total intravenous anesthesia (TIVA) with propofol and ketofol on recovery after laparoscopic surgery in pediatric patients. METHODS Two hundred children with median age of 5 years who underwent laparoscopic surgery were randomized into two groups. Propofol 1% was used for induction and maintenance of anesthesia in group I, while ketamine-propofol combination (ketofol) was used in group II. Ketamine-propofol combination (ketofol) was prepared in the same applicator for group II. Ketofol ratios of 1:4 and 1:7 were used for induction and maintenance of anesthesia, respectively. A reduced McFarlan infusion dose was used in group I (1.2, 1.0, and 0.8 mL/kg/h for 15, 15, and 30 min, respectively), while a McFarlan infusion dose was used in group II (1.5, 1.3, and 1.1 mL/kg/h for 15, 15, and 30 min, respectively). Extubating time, duration of anesthesia, and length of stay in post-anesthesia care unit (PACU) were recorded. RESULTS Extubating time was significantly lower in the ketofol group than in the propofol group (240 s vs. 530 s; p < 0.00001). Significantly shorter duration of anesthesia (47 min vs. 60 min; p < 0.00001) as well as length of stay in the PACU (35 min vs. 100 min; p < 0.00001) were recorded in ketofol compared to the propofol group. Total fentanyl (100 µg (interquartile range, IQR 80, 125) vs. 50 µg (IQR 40, 60); p < 0.00001) and propofol (260 mg (IQR 200, 350) vs. 160 mg (IQR 120, 210); p < 0.00001) consumption per body weight were significantly lower in the ketofol group. CONCLUSIONS TIVA with ketamine-propofol combination (ketofol) using a reduced McFarlan dose regimen shortened extubating time, duration of anesthesia, as well as length of stay in the PACU in pediatric anesthesia after laparoscopic surgery.
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Affiliation(s)
- Ana Nevešćanin Biliškov
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
- Correspondence: ; Tel.: +385-21-556111
| | - Božena Ivančev
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia; (B.I.); (Z.P.)
| | - Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia; (B.I.); (Z.P.)
- Department of Surgery, School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
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SASA paediatric guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in children: 2021–2026. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.4.s2.2635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sahyoun C, Cantais A, Gervaix A, Bressan S, Löllgen R, Krauss B. Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice. Eur J Pediatr 2021; 180:1799-1813. [PMID: 33511466 PMCID: PMC8105204 DOI: 10.1007/s00431-021-03930-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022]
Abstract
Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.Conclusion: Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known: • Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures. • We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms "pediatrics," "hypnotics and sedatives," "conscious sedation," and "ambulatory surgical procedures" and the non-MeSH term "procedural sedation" and found no reports describing the current practice of pediatric PSA in Europe. What is New: • This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia. • Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.
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Affiliation(s)
- Cyril Sahyoun
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Aymeric Cantais
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Alain Gervaix
- Division of Pediatric Emergency Medicine, Children’s Hospital of Geneva, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil, 4, 1205 Geneva, Switzerland
| | - Silvia Bressan
- Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - Ruth Löllgen
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Baruch Krauss
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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Al Hussein H, Al Hussein H, Sircuta C, Cotoi OS, Movileanu I, Nistor D, Cordos B, Deac R, Suciu H, Brinzaniuc K, Simionescu DT, Harpa MM. Challenges in Perioperative Animal Care for Orthotopic Implantation of Tissue-Engineered Pulmonary Valves in the Ovine Model. Tissue Eng Regen Med 2020; 17:847-862. [PMID: 32860183 DOI: 10.1007/s13770-020-00285-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Development of valvular substitutes meeting the performance criteria for surgical correction of congenital heart malformations is a major research challenge. The sheep is probably the most widely used animal model in heart valves regenerative medicine. Although the standard cardiopulmonary bypass (CPB) technique and various anesthetic and surgical protocols are reported to be feasible and safe, they are associated with significant morbidity and mortality rates. The premise of this paper is that the surgical technique itself, especially the perioperative animal care and management protocol, is essential for successful outcomes and survival. METHODS Ten juvenile and adult female sheep aged 7.8-37.5 months and weighing 32.0-58.0 kg underwent orthotopic implantation of tissue-engineered pulmonary valve conduits on beating heart under normothermic CPB. The animals were followed-up for 6 months before scheduled euthanasia. RESULTS Based on our observations, we established a guide for perioperative care, follow-up, and treatment containing information regarding the appropriate clinical, biological, and ultrasound examinations and recommendations for feasible and safe anesthetic, surgical, and euthanasia protocols. Specific recommendations were also included for perioperative care of juvenile versus adult sheep. CONCLUSION The described surgical technique was feasible, with a low mortality rate and minimal surgical complications. The proposed anesthetic protocol was safe and effective, ensuring both adequate sedation and analgesia as well as rapid recovery from anesthesia without significant complications. The established guide for postoperative care, follow-up and treatment in sheep after open-heart surgery may help other research teams working in the field of heart valves tissue regeneration.
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Affiliation(s)
- Hussam Al Hussein
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Hamida Al Hussein
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.
| | - Carmen Sircuta
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Ovidiu S Cotoi
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Ionela Movileanu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Dan Nistor
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Bogdan Cordos
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Radu Deac
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Horatiu Suciu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
| | - Klara Brinzaniuc
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania
| | - Dan T Simionescu
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,Clemson University, 306 Rhodes Annex, Clemson, SC, 29634, USA
| | - Marius M Harpa
- Tissue Engineering and Regenerative Medicine Laboratory "TERMLab", The University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Tirgu Mures, 38 Gh. Marinescu Street, 540139, Tirgu Mures, Romania.,The Emergency Institute for Cardiac Diseases and Transplantation of Tirgu Mures, 50 Gh. Marinescu Street, 540136, Tirgu Mures, Romania
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12
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Assessing procedural satisfaction in the pediatric ED: A systematic review. Am J Emerg Med 2020; 43:283-286. [PMID: 32693939 DOI: 10.1016/j.ajem.2020.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
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13
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Ali SA, Aweke Z, Jemal B. Evidence based guideline on use of ketofol (Ketamine and Propofol admixture) for procedural sedation and analgesia (PSA) in pediatrics surgery: Review article. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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14
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Abstract
Pain management in acute orthopedic injury needs to be tailored to the presentation and patient. Subjective and objective assessment, in conjunction with pathophysiology, should be used to provide symptom control. Ideally, treatment should be administered in an escalating fashion, attempting to manage pain with the lowest dose of the safest medication available. There are also adjunctive therapies, including those that are nonpharmacologic, that can provide additional relief.
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Affiliation(s)
- Nupur Nischal
- Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Evangeline Arulraja
- Division of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Stephen P Shaheen
- Emergency Medicine and Orthopedic Surgery, Division of Emergency Medicine, Department of Orthopedic Surgery, Duke University Medical Center, DUMC Box 3096, Durham, NC 27710, USA.
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15
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Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology 2019; 131:164-185. [DOI: 10.1097/aln.0000000000002657] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Propofol administered in conjunction with an opioid such as remifentanil is used to provide total intravenous anesthesia for children. Drugs can be given as infusion controlled manually by the physician or as automated target-controlled infusion that targets plasma or effect site. Smart pumps programmed with pharmacokinetic parameter estimates administer drugs to a preset plasma concentration. A linking rate constant parameter (keo) allows estimation of effect site concentration. There are two parameter sets, named after the first author describing them, that are commonly used in pediatric target-controlled infusion for propofol (Absalom and Kataria) and one for remifentanil (Minto). Propofol validation studies suggest that these parameter estimates are satisfactory for the majority of children. Recommended target concentrations for both propofol and remifentanil depend on the type of surgery, the degree of surgical stimulation, the use of local anesthetic blocks, and the ventilatory status of the patient. The use of processed electroencephalographic monitoring is helpful in pediatric total intravenous anesthesia and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.
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16
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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17
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Yang BW, Waters PM. Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective. J Child Orthop 2019; 13:330-333. [PMID: 31312274 PMCID: PMC6598038 DOI: 10.1302/1863-2548.13.190013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- B. W. Yang
- Harvard Medical School, Boston, Massachusetts, USA,Boston Children’s Hospital, Boston, Massachusetts, USA
| | - P. M. Waters
- Harvard Medical School, Boston, Massachusetts, USA,Boston Children’s Hospital, Boston, Massachusetts, USA, Correspondence should be sent to P. M. Waters, Boston Children’s Hospital, Department of Orthopedic Surgery, Hunnewell 2, 300 Longwood Ave, Boston, Massachusetts 02115, USA. E-mail:
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18
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Preliminary evaluation of ketofol-based sedation for awake craniotomy procedures. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2010.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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19
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Hamimy W, Zaghloul A, Abdelaal A. The application of a new regimen for short term sedation in the ICU (ketofol) – Case series. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- W. Hamimy
- Anesthesia Department, Faculty of Medicine , Cairo University , Egypt
| | - A. Zaghloul
- Anesthesia Department, Faculty of Medicine , Cairo University , Egypt
| | - A. Abdelaal
- Anesthesia Department, Faculty of Medicine , Beni Suef University , Egypt
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20
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Rizk SN, Samir EM. Use of ketofol to control emergence agitation in children undergoing adenotonsillectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sherry N. Rizk
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
| | - Enas M. Samir
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
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21
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Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med 2019; 73:470-480. [DOI: 10.1016/j.annemergmed.2018.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
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22
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Jalili S, Esmaeeili A, Kamali K, Rashtchi V. Comparison of effects of propofol and ketofol (Ketamine-Propofol mixture) on emergence agitation in children undergoing tonsillectomy. Afr Health Sci 2019; 19:1736-1744. [PMID: 31149004 PMCID: PMC6531964 DOI: 10.4314/ahs.v19i1.50] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the effect of propofol and ketofol (ketamine-propofol mixture) on EA in children undergoing tonsillectomy. METHOD In this randomized clinical trial, 87 ASA class I and II patients, aged 3-12 years, who underwent tonsillectomy, were divided into two groups to receive either propofol 100 µg/kg/min (group p, n=44) or ketofol : ketamine 25 µg/kg/min + propofol 75 µg/kg/min (group k, n= 43). Incidence and severity of EA was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scales on arrival at the recovery room, and 10 and 30 min after that time. RESULTS There was no statistically significant difference in demographic data between the two groups. In the ketofol group, the need for agitation treatment and also mean recovery duration were lower than in the propofol group (30 and 41%, and 29.9 and 32.7 min), without statistically significant difference (P value=0.143 and P value=0.187). Laryngospasm or bronchospasm occurred in 2 patients in each group and bleeding was observed in only one individual in the ketofol group. CONCLUSION Infusion of ketofol in children undergoing tonsillectomy provides shorter recovery time and lower incidence of EA despite the non significant difference with propofol.
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Affiliation(s)
- Saeed Jalili
- Anesthesiologist, Assistant Professor of Anesthesiology, Department of Anesthesiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ali Esmaeeili
- Anesthesiologist, Department of Anesthesiology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Koorosh Kamali
- PhD, Associate Professor of Epidemiology, Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Vahideh Rashtchi
- Anesthesiologist, Assistant Professor of Anesthesiology, Department of Anesthesiology, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
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Ketamine-based anesthesia improves electroconvulsive therapy outcomes: a randomized-controlled study. Can J Anaesth 2018; 65:636-646. [PMID: 29700801 DOI: 10.1007/s12630-018-1088-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 12/04/2017] [Accepted: 12/30/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is a common and debilitating condition that can be challenging to treat. Electroconvulsive therapy (ECT) is currently the therapeutic gold standard for treatment-resistant MDD. We tested our hypothesis that ketamine-based anesthesia for ECT results in superior improvement in treatment-resistant MDD outcomes compared with propofol-based anesthesia. METHODS Patients with treatment-resistant MDD were enrolled in a randomized clinical trial with assignment to ketamine- or propofol-based anesthesia arms. Using a modified intention-to-treat analysis, we compared the median number of ECT treatments required to achieve a 50% reduction (primary outcome) and a score ≤ 10 (secondary outcome) on the Montgomery-Asberg depression rating scale (MADRS) between anesthesia groups. RESULTS The study was terminated as significant results were found after the first planned interim analysis with 12 patients in each of the ketamine (intervention) and propofol (control) groups. All ketamine patients achieved at least a 50% MADRS reduction after a median of two ECT treatments whereas ten propofol patients (83%) achieved the same outcome after a median of four ECT treatments. All ketamine patients and seven propofol patients (58%) achieved MDD remission (MADRS ≤ 10). Log rank tests showed that both time-to-50% reduction and remission differed significantly between groups. Adverse events and recovery time were similar between groups. CONCLUSIONS In this early-terminated small-sized study, ketamine-based anesthesia compared with propofol-based anesthesia provided response and remission after fewer ECT sessions. TRIAL REGISTRATION www.clinicaltrials.gov (NCT01935115). Registered 4 September 2013.
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Anaesthesia and orphan disease: sedation with ketofol in two patients with Joubert syndrome. Eur J Anaesthesiol 2018; 33:868-869. [PMID: 27326823 DOI: 10.1097/eja.0000000000000489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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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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26
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Comparison of TIVA with different combinations of ketamine–propofol mixtures in pediatric patients. J Anesth 2017; 32:104-111. [DOI: 10.1007/s00540-017-2438-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023]
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27
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Greer A, Treston G. Factors associated with patient-reported procedural memory following emergency department procedural sedation with ketamine and propofol: A prospective cohort of 563 patients. Emerg Med Australas 2017; 30:200-208. [DOI: 10.1111/1742-6723.12884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 08/16/2017] [Accepted: 09/09/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Greer
- Paediatric Intensive Care; Starship Children's Health; Auckland New Zealand
| | - Greg Treston
- Emergency Department; Mater Hospital; Brisbane Queensland Australia
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Bone marrow aspirations in oncological patients: experience from an in-house standard in paediatrics. Wien Med Wochenschr 2017; 169:82-86. [PMID: 29196827 DOI: 10.1007/s10354-017-0611-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Nearly all paediatric patients require deep sedation when undergoing bone marrow aspiration (BMA). We analyzed the data from our protocols documented in a standardised procedure for bone marrow puncture over a period of 2 years. METHODS Our standard included the documentation of personal data as well as vital parameters. In addition, we documented all medications administered, potential complications and required intervention measures, as necessary. RESULTS A total of 107 protocols were available for the evaluation. Our standard covered the usage of midazolam and S‑ketamine and resulted in complications in just 9 patients, which could be remedied using simple measures. For both active substances, the dosage necessary to reach sufficient deep analgosedation was significantly higher for patients under 24 months of age. CONCLUSIONS Our standard for BMA provides a practical and feasible procedure. In addition to good examination conditions, our standard also helps ensure the safety of our patients.
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Sedation and analgesia for procedures in the pediatric emergency room. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ramalho CE, Bretas PMC, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J) 2017; 93 Suppl 1:2-18. [PMID: 28945987 DOI: 10.1016/j.jped.2017.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. DATA SOURCES Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. DATA SYNTHESIS Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. CONCLUSIONS The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.
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Affiliation(s)
- Carlos Eduardo Ramalho
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Pedro Messeder Caldeira Bretas
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil.
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Khurmi N, Patel P, Kraus M, Trentman T. Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers. Paediatr Drugs 2017; 19:435-446. [PMID: 28597354 DOI: 10.1007/s40272-017-0241-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.
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Affiliation(s)
- Narjeet Khurmi
- Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Perene Patel
- Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Molly Kraus
- Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
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Stevic M, Ristic N, Budic I, Ladjevic N, Trifunovic B, Rakic I, Majstorovic M, Burazor I, Simic D. Comparison of ketamine and ketofol for deep sedation and analgesia in children undergoing laser procedure. Lasers Med Sci 2017; 32:1525-1533. [DOI: 10.1007/s10103-017-2275-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 06/22/2017] [Indexed: 11/28/2022]
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Weisz K, Bajaj L, Deakyne SJ, Brou L, Brent A, Wathen J, Roosevelt GE. Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department. J Emerg Med 2017; 53:1-9. [DOI: 10.1016/j.jemermed.2017.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/20/2017] [Accepted: 03/11/2017] [Indexed: 11/30/2022]
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Two Different Concentrations of Ketofol for Procedural Sedation and Analgesia in Closed Reduction of Nasal Fracture. J Craniofac Surg 2017; 27:996-1000. [PMID: 27213735 DOI: 10.1097/scs.0000000000002660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Ketofol is a mixture of propofol and ketamine in various concentrations. It is accepted as a suitable combination in procedural sedation and analgesia. The mixture of propofol and ketamine with different respiratory and hemodynamic effects may result in fewer dose-related side effects and a probable synergistic effect. This study was designed to compare the adverse effects and quality of analgesia of 2 different intravenous concentrations of ketofol in patients undergoing closed reduction of the nose. METHODS This randomized double-blinded study was conducted on 100 patients who underwent closed reduction of nose. The patients were divided into 2 groups of 50, and received either a combination of propofol/ketamine (1:1) (Group I) or propofol/ketamine (3:1) (Group II). Hemodynamic changes, including systolic blood pressure, diastolic blood pressure, heart rate and O2sat, and side effects such as hallucination, vomiting, coughing and apnea, were recorded. RESULTS Data analysis showed that the demographic characteristics (age, height, and weight) were similar in 2 groups, and there were no significant differences between the 2 groups. There was no significant hemodynamic change between both groups. However, there was a decrease in hallucination and vomiting in the group that received higher concentration of ketofol (ketamine/propofol of 1:3). CONCLUSION There was no significant hemodynamic change between both groups that received concentrations of 1:1 and 3:1 propofol /ketamine. However, there was a reduction in hallucination, vomiting, and recovery duration in the group that received higher concentration of propofol. In conclusion, increasing the concentration of propofol can be useful with fewer side effects and lower duration of recovery.
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Li L, Vlisides PE. Ketamine: 50 Years of Modulating the Mind. Front Hum Neurosci 2016; 10:612. [PMID: 27965560 PMCID: PMC5126726 DOI: 10.3389/fnhum.2016.00612] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/15/2016] [Indexed: 01/14/2023] Open
Abstract
Ketamine was introduced into clinical practice in the 1960s and continues to be both clinically useful and scientifically fascinating. With considerably diverse molecular targets and neurophysiological properties, ketamine’s effects on the central nervous system remain incompletely understood. Investigators have leveraged the unique characteristics of ketamine to explore the invariant, fundamental mechanisms of anesthetic action. Emerging evidence indicates that ketamine-mediated anesthesia may occur via disruption of corticocortical information transfer in a frontal-to-parietal (“top down”) distribution. This proposed mechanism of general anesthesia has since been demonstrated with anesthetics in other pharmacological classes as well. Ketamine remains invaluable to the fields of anesthesiology and critical care medicine, in large part due to its ability to maintain cardiorespiratory stability while providing effective sedation and analgesia. Furthermore, there may be an emerging role for ketamine in treatment of refractory depression and Post-Traumatic Stress Disorder. In this article, we review the history of ketamine, its pharmacology, putative mechanisms of action and current clinical applications.
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Affiliation(s)
- Linda Li
- Department of Internal Medicine, St. Joseph Mercy Hospital Ann Arbor, MI, USA
| | - Phillip E Vlisides
- Department of Anesthesiology, University of Michigan Medical School Ann Arbor, MI, USA
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Ferguson I, Bell A, Treston G, New L, Ding M, Holdgate A. Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine—The POKER Study: A Randomized Double-Blind Clinical Trial. Ann Emerg Med 2016; 68:574-582.e1. [DOI: 10.1016/j.annemergmed.2016.05.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/19/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
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Lahiri S, Schlick K, Kavi T, Song S, Moheet AM, Yusufali T, Rosengart A, Alexander MJ, Lyden PD. Optimizing Outcomes for Mechanically Ventilated Patients in an Era of Endovascular Acute Ischemic Stroke Therapy. J Intensive Care Med 2016; 32:467-472. [PMID: 27543141 DOI: 10.1177/0885066616663168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Endovascular mechanical thrombectomy is a new standard of care for acute ischemic stroke (AIS). The majority of these patients receive mechanical ventilation (MV), which has been associated with poor outcomes. The implication of this is significant, as most neurointerventionalists prefer general compared to local anesthesia during the procedure. Consequences of hemodynamic and respiratory perturbations during general anesthesia and MV are thought to contribute significantly to the poor outcomes that are encountered. In this review, we first describe the unique risks associated with MV in the specific context of AIS and then discuss evidence of brain goal-directed approaches that may mitigate these risks. These strategies include an individualized approach to hemodynamic parameters (eg, adherence to a minimum blood pressure goal and adequate volume resuscitation), respiratory parameters (eg, arterial carbon dioxide optimization), and the use of ventilator settings that optimize neurological outcomes (eg, arterial oxygen optimization).
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Affiliation(s)
- Shouri Lahiri
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Konrad Schlick
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tapan Kavi
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shlee Song
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Asma M Moheet
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Taizoon Yusufali
- 3 Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Axel Rosengart
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael J Alexander
- 2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Patrick D Lyden
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Xavier Scheuermeyer F, Andolfatto G, Lange L, de Jong D, Qian H, Grafstein E. Do injection drug users have more adverse events during procedural sedation and analgesia for incision and drainage of cutaneous abscesses? CAN J EMERG MED 2016; 15:90-100. [PMID: 23458140 DOI: 10.2310/8000.2012.120710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) in the emergency department (ED). We compared adverse events (AEs) for IDUs to those for non-IDUs receiving PSA for incision and drainage of cutaneous abscesses. METHODS This was a retrospective analysis of a PSA safety audit. IDU status was prospectively documented among consecutive patients undergoing PSA at two urban EDs. Structured data describing comorbidities, vital signs, sedation regimens, and adverse events were collected. Primary outcome was the proportion of patients in each group experiencing an AE, whereas the secondary outcomes included recovery times. RESULTS Of 525 consecutive patients receiving PSA for incision and drainage of an abscess, 244 were deemed IDUs and 281 non-IDUs. IDUs received higher doses of sedatives and analgesics, and 14 experienced AEs (5.7%), whereas 10 non-IDUs had AEs (3.6%), for a risk difference of 2.1% (95% CI -1.8, 6.5). Median recovery times were 18 minutes (interquartile range [IQR] 10-36) for IDUs and 12 minutes (IQR 7-19) for non-IDUs, for a difference of 6 minutes (95% CI 2-9 minutes). Median sedation times were also longer in IDUs, for a difference of 6 minutes (95% CI 5-10 minutes). Of 20 IDU patients and 1 non-IDU patient admitted to hospital, none had experienced an AE related to PSA. CONCLUSIONS For ED patients requiring PSA for incision and drainage, IDUs had an AE rate similar to that of non-IDUs but longer sedation and recovery times. In experienced hands, PSA may be as safe in IDUs as in patients who do not use injection drugs.
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Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S21-35. [DOI: 10.1097/aco.0000000000000316] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
OBJECTIVES In Israel, the recommendation for the use of propofol is age limited. Furthermore, procedural sedations involving propofol must be performed only by anesthesiologists. Propofol is frequently used in the PICUs in Israel. DESIGN Questionnaire survey. SETTING PICUs in Israel. SUBJECTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physicians from 13 PICUs (86.6%) responded to the questionnaire. Propofol was used for induction, procedural sedation, and ongoing ICU sedation in 100%, 70%, and 12% of cases, respectively. Eighty-eight percent of the participants limited the duration of propofol infusion to 24 hours at a dose of less than or equal to 4 mg/kg/1 hr, but 40% administered propofol as needed without specifying an upper dose limit. Twenty-five percent encountered adverse effects such as apnea, desaturation, and bradycardia, but only two of the participants suspected propofol infusion syndrome, each in one patient. All the participants agreed to expand the indications for propofol use in the pediatric age group. Ketamine was the drug mostly used instead of propofol (50%), followed by fentanyl (30%), midazolam (30%), and remifentanil (5%). Apart from anesthesiologists, PICU physicians support the use of propofol by physicians who have the technical skills for rapid-sequence intubation and advanced airway management. CONCLUSIONS Off-label use of propofol is an accepted practice in Israeli PICUs. Propofol has a unique profile that makes it an attractive sedative agent in many clinical settings. PICU physicians may want to prescribe it, at least for short periods and at low doses.
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Abstract
As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.
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Affiliation(s)
- John W Berkenbosch
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville, Kosair Children's Hospital, 571 S. Floyd, Ste 332, Louisville, KY, 40202, USA.
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Yan JW, McLeod SL, Iansavitchene A. Ketamine-Propofol Versus Propofol Alone for Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2015; 22:1003-13. [PMID: 26292077 DOI: 10.1111/acem.12737] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/11/2015] [Accepted: 04/22/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Propofol is an agent commonly used for procedural sedation and analgesia (PSA) in the emergency department (ED), but it can cause respiratory depression and hypotension. The combination of ketamine-propofol (K-P) is an alternative that theoretically provides a reduction in adverse events compared to propofol. The primary objective of this review was to determine if K-P has a lower frequency of adverse respiratory events in patients undergoing PSA in the ED than propofol alone. Secondary objectives were to compare the proportion of overall adverse events, sedation time, procedure time, and recovery time between K-P and propofol. METHODS Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) published in English comparing the use of K-P to propofol alone for PSA in the ED were included. RESULTS Six RCTs were included with a combined total of 932 patients (K-P = 520, propofol = 412). Five RCTs reported the proportion of adverse respiratory events; the pooled estimate revealed fewer adverse respiratory events with K-P compared to propofol (29.0% vs. 35.4%; risk ratio [RR] = 0.82; 95% confidence interval [CI] = 0.68 to 0.99). There was no significant difference with respect to the proportion of overall adverse events (38.8% vs. 42.5%; RR = 0.88; 95% CI = 0.75 to 1.04). Procedure time was similar when the groups were compared. CONCLUSIONS The premise of combining ketamine with propofol is based on the many synergies that theoretically exist between these two agents. In this study, K-P had a lower frequency of adverse respiratory events in patients undergoing PSA in the ED compared to propofol alone.
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Affiliation(s)
- Justin W. Yan
- Division of Emergency Medicine; Department of Medicine; Schulich School of Medicine and Dentistry; The University of Western Ontario; London Ontario
- London Health Sciences Centre; London Ontario Canada
| | - Shelley L. McLeod
- Division of Emergency Medicine; Department of Medicine; Schulich School of Medicine and Dentistry; The University of Western Ontario; London Ontario
- London Health Sciences Centre; London Ontario Canada
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Kennedy MJ, Smith LJ. A comparison of cardiopulmonary function, recovery quality, and total dosages required for induction and total intravenous anesthesia with propofol versus a propofol-ketamine combination in healthy Beagle dogs. Vet Anaesth Analg 2015; 42:350-9. [DOI: 10.1111/vaa.12218] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 05/23/2014] [Indexed: 01/09/2023]
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Aghdaii N, Ziyaeifard M, Faritus SZ, Azarfarin R. Hemodynamic Responses to Two Different Anesthesia Regimens in Compromised Left Ventricular Function Patients Undergoing Coronary Artery Bypass Graft Surgery: Etomidate-Midazolam Versus Propofol-Ketamine. Anesth Pain Med 2015; 5:e27966. [PMID: 26161330 PMCID: PMC4493732 DOI: 10.5812/aapm.27966v2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/01/2015] [Accepted: 03/08/2015] [Indexed: 11/16/2022] Open
Abstract
Background: Various methods have been suggested to prevent hemodynamic instability caused by propofol and adverse effects caused by etomidate induction. The current study evaluated hemodynamic effects of propofol-ketamine mixture in comparison to etomidate-midazolam mixture during anesthesia induction. Objectives: The aim of this study was to evaluate the hemodynamic effects of etomidate-midazolam by comparing it with propofol-ketamine for the induction of anesthesia in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery. Patients and Methods: One-hundred patients aged between 40 and 65 with coronary artery disease and low ejection fraction scheduled for elective coronary artery bypass surgery participated in this study. The patients were randomly allotted to one of the two groups to receive either propofol-ketamine or etomidate-midazolam combination. Two groups were compared for pain on injection and myoclonus, Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Cardiac Index (CI) and Systemic Vascular Resistance (SVR), before and one minute after induction of anesthesia, and one, three and five minutes after intubation. Results: Incidence of pain on injection (2 - 4%) and myoclonus (10%) was less in both groups. The hemodynamic response was similar in the two groups for all variables over the time interval, except for CI at one and three minutes after intubation (P = 0.024 and P = 0.048, respectively), and SVR in five minutes after intubation (P = 0.009), with differences being statistically significant. Conclusions: Both anesthetic regimens were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction undergoing coronary artery bypass graft surgery.
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Affiliation(s)
- Nahid Aghdaii
- Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Ziyaeifard
- Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Mohsen Ziyaeifard, Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-2123922152, Fax: +98-2122663293, E-mail:
| | - Seyedeh Zahra Faritus
- Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran
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Randomized, Double-Blinded, Clinical Trial of Propofol, 1:1 Propofol/Ketamine, and 4:1 Propofol/Ketamine for Deep Procedural Sedation in the Emergency Department. Ann Emerg Med 2015; 65:479-488.e2. [DOI: 10.1016/j.annemergmed.2014.08.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 07/31/2014] [Accepted: 08/04/2014] [Indexed: 11/22/2022]
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Scheier E, Gadot C, Leiba R, Shavit I. Sedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis. Am J Emerg Med 2015; 33:815-7. [PMID: 25819203 DOI: 10.1016/j.ajem.2015.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/15/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Literature to date has suggested advantages of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. However, there is a paucity of data regarding sedation with the combination of ketamine and propofol in pediatric emergency medicine. METHODS A retrospective case series analysis of children who underwent sedation with the combination of ketamine and propofol in a pediatric emergency department was conducted. Study covariates were extracted from the emergency department medical records. RESULTS Four hundred twenty-nine patients, 297 males and 132 females, with a median age of 6.8 years (interquartile range, 3.9-10.9 years), underwent sedation by pediatric emergency physicians. Serious adverse events during sedation (SAEDS) were recorded in 52 procedures (12.1%), which included 39 hypoxic events (9.1%), 12 apneic events (2.8%), and 1 laryngospasm (0.2%). All SAEDS were managed successfully, and no child underwent intubation because of an adverse reaction or required hospitalization. Multivariate logistic regression analysis did not reveal any association between age, weight, fasting time, analgesic medication provided before sedation, length of procedure, capnography use, dosages of medications, and the presence of SAEDS. CONCLUSIONS This is the largest reported series of sedation with the combination of ketamine and propofol in pediatric emergency medicine. Findings suggest that sedation with the combination of ketamine and propofol can be safely performed by a skilled emergency physician.
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Affiliation(s)
- Eric Scheier
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Chen Gadot
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronit Leiba
- Quality of Care Unit, Rambam Health Care Campus, Haifa, Israel
| | - Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel.
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Martinez-Taboada F, Leece EA. Comparison of propofol with ketofol, a propofol-ketamine admixture, for induction of anaesthesia in healthy dogs. Vet Anaesth Analg 2014; 41:575-82. [DOI: 10.1111/vaa.12171] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 11/25/2013] [Indexed: 12/21/2022]
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Abstract
OBJECTIVE Intraoral procedures (IOPs) are performed within the oral cavity of a spontaneously breathing, deeply sedated child. The objective of this study was to retrospectively evaluate the safety of sedation for IOP in a pediatric emergency department. METHODS An unmatched, case-control study was conducted. The records of patients who had an IOP between January 1, 2012, and December 31, 2012, were analyzed. We evaluated the rate of serious adverse events during sedation (SAEDS) in patients who had an IOP (case subjects) and in patients who had a closed reduction of a forearm fracture (controls) and compared the 2 cohorts. RESULTS Forty-one study subjects and 38 controls had complete records. Demographic characteristics were similar for both groups. Cases and controls were treated with the combination of propofol-ketamine for most of the cases (30/41 [73.2%] and 32/38 [84.2%]), and doses were similar between the groups. Study subjects had 5 hypoxic events and 2 apneic events; controls had 4 hypoxic events and 2 apneic events. No aspiration events were recorded. There were no statistically significant differences in the rate of SAEDS between the 2 groups (P = 0.55 and P = 0.54, respectively). All SAEDS were successfully managed in the emergency department, and no patient required hospitalization due to an adverse reaction. CONCLUSIONS Findings of this study suggest that when performed by a skilled provider, sedation for an IOP is as safe as sedation for a fracture reduction.
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Habibi MR, Hasanzadeh Kiabi F, Soleimani A, Emami Zeydi A. Sedation and analgesia during bone marrow aspiration in children: Is ketamine and propofol combination (Ketofol) an appropriate agent? Indian J Med Paediatr Oncol 2014; 34:337-9. [PMID: 24604974 PMCID: PMC3932612 DOI: 10.4103/0971-5851.125268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mohammad Reza Habibi
- Department of Anesthesiology, Faculty of Medicine, Faculty of Paramedicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Farshad Hasanzadeh Kiabi
- Department of Anesthesiology, Faculty of Medicine, Faculty of Paramedicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Aria Soleimani
- Department of Anesthesiology, Faculty of Medicine, Faculty of Paramedicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Amir Emami Zeydi
- PhD Student in Nursing, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran E-mail:
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