Sedation and analgesia in children with developmental disabilities and neurologic disorders

Oral Health Care for Children and Youth With Developmental Disabilities: Clinical Report

Oral health is an essential component of overall health for all individuals. The oral health of children and youth with developmental disabilities (CYDD) involves unique characteristics and needs of which pediatricians and pediatric clinicians can be aware. Risk for oral disease in CYDD is multifactorial and includes underlying medical conditions, medications, and ability to participate in preventive oral health care and treatment, and lack of access to providers is common for this population despite being eligible for Medicaid. Pediatric clinicians are uniquely positioned to support the oral health needs of CYDD and their families through the medical home. This clinical report aims to inform pediatric clinicians about the unique oral health needs of CYDD. It provides guidance on assessing caries risk and periodontal status using structured screening instruments; understanding dental trauma, the role of diet and caries risk, trauma prevention, and malocclusion; and providing anticipatory guidance on oral hygiene that includes tooth brushing, use of fluoridated toothpaste, assessing community water fluoridation, advocating for a dental home by 1 year of age, and transition to adult dental care as part of adolescent health care. It also highlights special considerations for dental treatment rendered under sedation or general anesthesia that CYDD may need. Pediatric clinicians can help reduce risk of CYDD developing dental disease by understanding the unique needs of their patients and their barriers to accessing oral health care in their community, communicating with the child's dental home, and advocating for safe and accessible dental procedures.

Modern sedative agents and techniques used in dentistry for patients with special needs: A review

According to the World Health Organisation, approximately 1.3 billion people worldwide experience substantial disability due to physical, mental or sensory impairment. People with special needs require special consideration and more time or altered delivery methods when receiving dental treatments. Various factors, such as patients' lack of cooperation, cognitive impairment and complex medical status, may lead dental practitioners to recommend conscious sedation. Several pharmacological agents and administrative routes are available, which achieve varying levels of sedation ranging from minimal to deep. Pre-operative assessment and careful case selection are necessary to determine the appropriate sedative agent, route of administration and level of sedation for each patient. Thus, a thorough understanding of the pharmacokinetics, risks and benefits, and implications of various sedatives available for PSN is essential to achieve the desired clinical outcomes. This review critically presents the considerations associated with the use of various sedative agents for PSN in dentistry. Considerations include patients' pre-anaesthesia medical comorbidities, cardiorespiratory adverse effects and cooperativeness, and the viable alternative treatment modalities.

Perioperative management and drug selection for sedated/anesthetized patients undergoing MRI examination: A review

In recent years, magnetic resonance imaging (MRI) technology has become an indispensable imaging tool owing to significant improvements in MRI that have opened up new diagnostic perspectives. Due to the closed environment, long imaging time, and need to remain still during the examination process, the examiner may cannot cooperate with the completion of the examination of the procedure, which increases the need for deep sedation or anesthesia. Achieving this can sometimes be challenging, especially in the special nontraditional environment of MRI equipment (unfamiliar and narrow spaces, away from patients, strong magnetic fields) and in special populations requiring sedation/anesthesia during examinations, which pose certain challenges for the perioperative anesthesia management of MRI. A simple "checklist" is necessary because it allows the anesthesiologist to become familiar with the particular environment and human and material resources as quickly as possible. For the choice of sedative/anesthetic, the traditional drugs, such as midazolam and ketamine, are still used due to the ease of administration despite their low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, propofol, with high effectiveness and rapid recovery, and sevoflurane, which is mild and nonirritating, are preferred for sedation/anesthesia in children and adults undergoing MRI. Therefore, familiarity with the perioperative management of patient sedation and general anesthesia and drug selection in the MRI environment is critical for successful surgical completion and for the safe and rapid discharge of MRI patients receiving sedation/anesthesia.

Effect of Distraction Interventions on Anxiety in Children Undergoing Surgery: A Meta-Analysis

Due to the unfamiliarity of the surroundings, children having surgery endure worry and tension. Untreated anxiety in children impairs postoperative healing and causes changes in postoperative behavior. The purpose of this review was to determine the efficacy of distraction therapies on anxiety in children undergoing surgery. The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. PubMed via MEDLINE, CINAHL, ProQuest, Web of Science, and the Cochrane Central Register of Controlled Trials were used to find relevant trials. Full-text papers published in English from January 1, 2000 to December 31, 2021 were included. Children undergoing surgery aged 1 to 18 years were included. A data extraction form was created to extract data from the selected studies. According to the Cochrane risk of bias assessment tool, studies were classified as “low risk,” “high risk,” or “unclear risk.” Review Manager software was used to do a quantitative meta-analysis. Thirteen studies looked at the effect of distraction intervention on children. Nine of them were selected for meta-analysis. The distraction interventions included in this review were: handheld video game, play dough and play with blocks and puzzles, tablet-based interactive distraction, animated video, painting and storytelling, age-appropriate video, distraction with video glasses, watching a movie, and bringing favorite toy during hospital stay. Meta-analysis showed that distraction interventions are effective on preoperative anxiety in children (standardized mean difference = –17.07, 95% confidence interval: 27.11–7.02, p = 0.0009).

Effectiveness of Chloral Hydrate on Brain MRI in Children with Developmental Delay/Intellectual Disability Comparing with Normal Intelligence: Single Tertiary Center Experience

Neurodiagnostic investigation requirements are expanding for diagnostic and therapeutic purposes in children, especially in those with developmental delay/intellectual disability (DD/ID). Thus, determination of optimal sedatives to achieve successful sedation and immobility without further neurological compromise is important in children with DD/ID. The purpose of this study is to assess the effectiveness and adverse reactions of chloral hydrate (CH) for brain magnetic resonance imaging (B-MRI) in children with DD/ID compared to those with normal intelligence (NI). We performed a retrospective chart review of children aged from 1 day to 12 years who required elective sedation using CH for B-MRI. About 730 cases (415 with DD/ID and 315 with NI) of CH sedation were conducted for B-MRI. Children with DD/ID showed a higher failure rate (22%) than did those with NI (6%); additional CH and prolonged sedation time were required. There was no difference in incidence of adverse reactions between DD/ID and NI groups (p = 0.338). Older or heavier children with DD/ID (p = 0.036 and p = 0.013, respectively), as well as those diagnosed with epilepsy or neuropsychiatric disorders showed higher risk of sedation failure (p < 0.001 for each). In conclusion, CH was a suboptimal sedative drug for children with DD/ID compared with those with NI. Other alternative or supplementary sedatives should be taken into consideration especially for those vulnerable groups.

Ten-year experience with standardized non-operating room anesthesia with Sevoflurane for MRI in children affected by neuropsychiatric disorders

Background

Children require anesthesia for MRI to maintain immobility and reduce discomfort; clear indications about the best anesthesiologic management are lacking and each center developed its own protocol. Moreover, children with neuropsychiatric disorders more likely require sedation and are described in literature as more prone to general and respiratory complications. Aim of this study was to analyze the applicability of a sevoflurane-based approach, to describe general and respiratory complications and to identify risk factors in a pediatric neuropsychiatric population.

Methods

Retrospective cohort study, university Hospital (January 2007–December 2016). All the 1469 anesthesiologic records of children addressed from Neuropsychiatric Unit to undergo MRI under general anesthesia were analyzed; 12 patients equal or older than 18-year-old were excluded. We identified post-hoc nine macro-categories: static encephalopathies, metabolic/evolutive encephalopathies, epileptic encephalopathies, neuromuscular diseases, autistic spectrum disorders, migraine, psychiatric disorders, intellectual disabilities, others. A logistic regression model for events with low frequency (Firth’s penalized likelihood approach) was carried out to identify the mutually adjusted effect among endpoints (complications) and the independent variables chosen on the basis of statistical significance (univariate analysis, p ≤ 0.05) and clinical judgment.

Results

Of 1457 anesthesiologic records (age 4.0 (IQR 2.0 to 7.0) year-old, males 891 (61.2%), weight 17.0 (IQR 12.0 to 24.9) kg), 18 were cancelled for high anesthesiologic risk, 50 were cooperative, 1389 were anesthetized. A sevoflurane-based anesthesia was feasible in 92.3%; these patients required significantly less mechanical ventilation (8.6 vs. 16.2%; p = 0.012). Complications’ rate was low (6.2%; 3.1% respiratory). The risk for general complications increases with ASA score > 1 (OR 2.22, 95 CI% 1.30 to 3.77, p = 0.003), male sex (OR 1.73, 95% CI 1.07 to 2.81, p = 0.025), multi-drug anesthesia (OR 2.98, 95 CI% 1.26 to 7.06, p = 0.013). For respiratory complications, it increases with ASA score > 1 (OR 2.34, 95 CI% 1.19 to 4.73, p = 0.017), autumn-winter (OR 2.01, 95 CI% 1.06 to 3.78, p = 0.030), neuromuscular disorders (OR 3.18, 95 CI% 1.20 to 8.41, p = 0.020). We had no major complications compromising patients’ outcome or requiring admission to ICU.

Conclusions

Sevoflurane anesthesia is feasible and safe for children affected by neuropsychiatric disorders undergoing MRI. Specific risk factors for general and respiratory complications should be considered.

Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

OBJECTIVE

To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy.

STUDY DESIGN

This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable.

RESULTS

This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects.

CONCLUSIONS

Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

Pathophysiology and Treatment of Severe Traumatic Brain Injuries in Children

Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.