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Curtis S, Kilpatrick R, Billimoria ZC, Zimmerman K, Tolia V, Clark R, Greenberg RG, Puia-Dumitrescu M. Use of Dexmedetomidine and Opioids in Hospitalized Preterm Infants. JAMA Netw Open 2023; 6:e2341033. [PMID: 37921767 PMCID: PMC10625033 DOI: 10.1001/jamanetworkopen.2023.41033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
Importance Dexmedetomidine, an α2-adrenergic agonist, is not approved by the Food and Drug Administration for use in premature infants. However, the off-label use of dexmedetomidine in premature infants has increased 50-fold in the past decade. Currently, there are no large studies characterizing dexmedetomidine use in US neonatal intensive care units (NICUs) or comparing the use of dexmedetomidine vs opioids in infants. Objectives To describe dexmedetomidine use patterns in the NICU and examine the association between dexmedetomidine and opioid use in premature infants. Design, Setting, and Participants A multicenter, observational cohort study was conducted from November 11, 2022, to April 4, 2023. Participants were inborn infants born between 22 weeks, 0 days, and 36 weeks, 6 days, of gestation at 1 of 383 Pediatrix Medical Group NICUs across the US between calendar years 2010 and 2020. Main Outcome and Measure Exposure to medications of interest defined as total days of exposure, timing of use, and changes over time. Results A total of 395 122 infants were included in the analysis. Median gestational age was 34 (IQR, 32-35) weeks, and median birth weight was 2040 (IQR, 1606-2440) g. There were 384 infants (0.1% of total; 58.9% male) who received dexmedetomidine. Infants who received dexmedetomidine were born more immature, had lower birth weight, longer length of hospitalization, more opioid exposure, and more days of mechanical ventilation. Dexmedetomidine use increased from 0.003% in 2010 to 0.185% in 2020 (P < .001 for trend), while overall opioid exposure decreased from 8.5% in 2010 to 7.2% in 2020 (P < .001 for trend). The median postmenstrual age at first dexmedetomidine exposure was 31 (IQR, 27-36) weeks, and the median postnatal age at first dexmedetomidine exposure was 3 (IQR, 1-35) days. The median duration of dexmedetomidine receipt was 6 (IQR, 2-14) days. Conclusion and Relevance The findings of this multicenter cohort study of premature infants suggest that dexmedetomidine use increased significantly between 2010 and 2020, while overall opioid exposure decreased. Future studies are required to further examine the short- and long-term effects of dexmedetomidine in premature and critically ill infants.
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Affiliation(s)
- Samantha Curtis
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Ryan Kilpatrick
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Kanecia Zimmerman
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Veeral Tolia
- Pediatrix Medical Group, Baylor Scott and White Healthcare, Dallas, Texas
| | - Reese Clark
- MEDNAX Center for Research, Education, Quality and Safety, San Antonio, Texas
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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Maroda AJ, Coca KK, McLevy-Bazzanella JD, Wood JW, Grissom EC, Sheyn AM. Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery. Otolaryngol Clin North Am 2020; 53:819-830. [PMID: 32622548 DOI: 10.1016/j.otc.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.
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Affiliation(s)
- Andrew J Maroda
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kimberly K Coca
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer D McLevy-Bazzanella
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua W Wood
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica C Grissom
- Department of Anesthesiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 400, Memphis, TN 38163-2242, USA; Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Li L, Strum D, Pestieau SR, Zalzal G, Preciado D. Sedation withdrawal following single stage laryngotracheal reconstruction: Does dexmedetomidine help? Int J Pediatr Otorhinolaryngol 2020; 129:109758. [PMID: 31704579 DOI: 10.1016/j.ijporl.2019.109758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/09/2019] [Accepted: 10/26/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Single-stage laryngotracheal reconstruction (SS-LTR) requires a period of post-operative intubation, during which time adequate sedation is needed to ensure graft healing. Commonly used agents include benzodiazepines, opioids, and more recently, dexmedetomidine, a centrally-acting α2 adrenoreceptor. This study aims to compare withdrawal outcomes between various sedation regimens following SS-LTR. METHODS Retrospective chart review of 56 patients who underwent SS-LTR between 2008 and 2018 at a tertiary free-standing children's hospital was performed. Of 47 patients with complete records, 18 patients received dexmedetomidine for >75% of their intubation period with midazolam (DexWM), 9 received dexmedetomidine for >75% without midazolam (DexWOM), and 20 received dexmedetomidine for <75% with midazolam (noDex). RESULTS There was no significant difference in length of PICU or hospital stay between the groups. The noDex group trended toward a higher re-intubation rate of 25%, as compared with 11% of DexWOM and 5.6% of DexWM (p = 0.21). There was no significant difference in days of oral sedation taper required or Withdrawal Assessment Tool (WAT-1) score for post-extubation days 1 and 3. By post-extubation day 5, 100% of the DexWM group had WAT-1 scores <3 as compared with 71.4% of the noDex group (p = 0.037). Notably, lower average daily doses of dexmedetomidine and midazolam were used in the DexWM group, as compared with the DexWOM and noDex groups, respectively. CONCLUSION Dexmedetomidine as a primary sedation agent with midazolam allows for adequate sedation following SS-LTR. The combination of the two drugs in the DexWM group not only reduced the dosage of each drug needed, but also significantly improved WAT-1 scores by post-extubation day 5, as compared with the alternative sedation regimens.
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Affiliation(s)
- Lilun Li
- Department of Otolaryngology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA
| | - David Strum
- Department of Otolaryngology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA
| | - Sophie R Pestieau
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA
| | - Diego Preciado
- Department of Otolaryngology, Children's National Health System, 111 Michigan Avenue, Washington, DC, 20010, USA.
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Dexmedetomidine facilitates extubation in children who require intubation and respiratory support after airway foreign body retrieval: a case-cohort analysis of 57 cases. J Anesth 2018; 32:592-598. [PMID: 29948375 DOI: 10.1007/s00540-018-2519-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/03/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to investigate whether dexmedetomidine had sedative weaning advantage for extubation after airway foreign body (FB) removal in children. METHODS A retrospective case-cohort comparison study with total of 57 critical children who required mechanical ventilation after rigid bronchoscopy was performed. After tracheal intubation, group D (received dexmedetomidine 1 µg/kg over 10 min, followed by an infusion of 0.8 µg/kg/h), and group RP (received remifentanil-propofol 6-10 µg/kg/h and 1-3 mg/kg/h, respectively). The primary outcome was successful extubation rate on first weaning trial. The minor outcomes included weaning time, emergency agitation, coughing score and the incidence of respiratory adverse complications on emergency. MAIN RESULTS All 57 patients were included in the analysis, with 30 patients in group D and 27 controlled cases in group RP. The success rate of first weaning trial in the D group was 96.7 vs 77.8% in the RP group, risk ratio (RR) 1.56, 95% CI [0.78-1.98]. Time for resuming spontaneous breathing after termination infusion was shorter in the D group (median 8 min, IQR 15 min) vs RP group (median 12 min, IQR 19 min, P = 0.02, RR 0.56, 95% CI 0.14-6.57). CONCLUSIONS In mechanical ventilation of pediatric patients following rigid bronchoscopy, in comparison to remifentanil-propofol, dexmedetomidine is proved to have high success rate for weaning strategy. WHAT IS ALREADY KNOWN?: Remifentanil is proved to be effective for weaning in ICU patients. Dexmedetomedine can provide similar rates of smooth extubation for pediatric patients who underwent airway surgery. WHAT THIS ARTICLE ADDS?: Invasive ventilation is used for patients with severe comorbidity after airway surgery, but the correct strategy for pediatric extubation after removal of airway foreign body remains unclear. For these patients with short-term mechanical ventilation, dexmedetomedine may improve the extubation rate, when compared with remifentanil-propofol.
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Lopez MM, Zech D, Linton JL, Blackwell SJ. Dexmedetomidine Decreases Postoperative Pain and Narcotic Use in Children Undergoing Alveolar Bone Graft Surgery. Cleft Palate Craniofac J 2018; 55:688-691. [DOI: 10.1177/1055665618754949] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: Dexmedetomidine is a parenteral agent that combines the benefits of cooperative sedation, anxiolysis, and analgesia without the risks of respiratory depression. Off-label use has been reported in children. We have introduced dexmedetomidine for use in patients having undergone alveolar bone graft (ABG). The objective is to demonstrate the value and safety of postoperative dexmedetomidine infusion in a non-ICU setting following ABG. Design: A retrospective review was performed on patients who underwent ABG by the senior author. Patients were divided into 2 groups: those who received postoperative dexmedetomidine and those who received patient-controlled anesthesia. Main Outcome Measure(s): The primary study outcome measures included patient demographics, adverse events, length of stay, pain scores, and doses of narcotics during admission were collected. Results: Inclusion criteria were met by 54 patients; 39 received dexmedetomidine whereas 15 did not. There were no significant differences between groups in age, gender, and length of stay. The patients who received dexmedetomidine used oral narcotics less often ( P = .01). In addition, more patients reported no pain after surgery ( P = .05) and at the time of discharge if they received dexmedetomidine ( P < .01). There were no reported adverse effects. Conclusions: Dexmedetomidine provided superior pain control after surgery and at the time of discharge, as well as a significant decrease in the use of oral narcotics. In our institution, it has since replaced the PCA as a postoperative pain control modality. Absent the risk for respiratory depression, dexmedetomidine has demonstrated a safe option for postoperative pain control in our focused group of pediatric patients.
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Affiliation(s)
- Mariela M. Lopez
- Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Derrick Zech
- Department of Oral and Maxillofacial Surgery, Health Science Center, University of Texas Houston, Houston, TX, USA
| | - Judith L. Linton
- Department of Plastic Surgery, Shriners Hospitals for Children-Houston, Houston, TX, USA
| | - Steven J. Blackwell
- Department of Plastic Surgery, Shriners Hospitals for Children-Houston, Houston, TX, USA
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
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Fauman KR, Durgham R, Duran CI, Vecchiotti MA, Scott AR. Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay. Laryngoscope 2015; 125:2216-9. [PMID: 26152806 DOI: 10.1002/lary.25176] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/19/2014] [Accepted: 01/05/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Karen R Fauman
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Rashed Durgham
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Carlos I Duran
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Mark A Vecchiotti
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
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Chen K, Shen X. Dexmedetomidine and propofol total intravenous anesthesia for airway foreign body removal. Ir J Med Sci 2014; 183:481-4. [PMID: 24619368 DOI: 10.1007/s11845-014-1105-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To detail our experience using dexmedetomidine in combination with propofol for airway foreign body removal in spontaneously breathing patients. CLINICAL FEATURES Dexmedetomidine and propofol intravenous anesthesia as a primary anesthetic was used for three pediatric patients with severe respiratory impairment due to foreign body aspiration and two elderly patients requiring airway foreign body removal by rigid bronchoscopy. All patients were spontaneously ventilating, and had successful airway foreign body removal without severe hypoxemia. The three pediatric patients maintained stable respiratory and hemodynamic profiles. However, dexmedetomidine caused a significant change in the hemodynamics of the elderly patients. CONCLUSION Dexmedetomidine and propofol intravenous anesthesia provided good anesthesia without causing respiratory depression. However, this technique related to more hemodynamic depression in elderly patients than in pediatrics.
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Affiliation(s)
- K Chen
- Department of Anesthesiology, The Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai Medical College of Fudan University, Shanghai, 200031, China
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Lee JS, Park SJ, Min KT. Dexmedetomidine for rigid bronchoscopy in an infant with tracheal web after ventricular septal defect patch repair. Yonsei Med J 2014; 55:539-41. [PMID: 24532530 PMCID: PMC3936630 DOI: 10.3349/ymj.2014.55.2.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We report herein successful rigid bronchoscopy with preserved spontaneous breathing of a 54-day-old infant with tracheal web associated with previous ventricular septal defect (VSD) repair. We considered the use of dexmedetomidine in conjunction with intermittent ketamine from the following three clinical aspects. First, this infant was suffering from respiratory distress with chest retraction, the cause of which was not revealed by a computerized scan of the neck and chest. Second, the patient was scheduled for rigid bronchoscopy, which is accompanied by brief but strong stimulation. Third, this infant underwent congenital VSD heart repair approximately 1 month earlier.
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Affiliation(s)
- Jeong Soo Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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Inoue K, Sakamoto T, Fujita Y, Yoshizawa S, Tomita M, Min JZ, Todoroki K, Sobue K, Toyo'oka T. Development of a stable isotope dilution UPLC-MS/MS method for quantification of dexmedetomidine in a small amount of human plasma. Biomed Chromatogr 2013; 27:853-8. [PMID: 23401046 DOI: 10.1002/bmc.2870] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 12/15/2012] [Accepted: 12/28/2012] [Indexed: 01/01/2023]
Abstract
Dexmedetomidine (Dex) is a selective central α2-agonist with anesthetic properties and has been used in clinical practice for sedation in the intensive care unit (ICU) after operations. In this study, an analytical assay for the determination of Dex in a small amount of plasma was developed for the application to pediatric ICU trials. The quantification of Dex was constructed using the original stable isotope Dex-d3 for electrospray ionization-tandem mass spectrometry (ESI-MS/MS) in the selected reaction monitoring mode. A rapid ultra-performance liquid chromatography technique was adopted using ESI-MS/MS with a runtime of 3 min. Efficacious concentration levels (50 pg/mL to 5 ng/mL) could be evaluated using a very small amount of plasma (10 μL) from patients. The lower limit of the quantification was 5 pg/mL in the plasma (100 µL). For sample preparation, a solid-phase extraction was used along with the OASIS-HLB cartridge type. Recovery values ranged from 98.8 to 100.3% for the intra- [relative standard deviation (RSD), 0.9-1.3%] and inter- (RSD, 0.9-1.5%) day assays. A stable test had recovery values that ranged from 97.8 to 99.7% with an RSD of 1.0-1.9% for the process/wet extract, bench-top, freeze-thaw and long-term tests. This method was used to measure the Dex levels in plasma from pediatric ICU patients. In the clinical ICU trial, the small amount of blood (approximate plasma volume, 200 μL) remaining from blood gas analysis was reused and targeted for the clinical analysis of Dex in plasma.
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Affiliation(s)
- Koichi Inoue
- Laboratory of Analytical and Bio-Analytical Chemistry, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka, 422-8526, Japan
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McCormick ME, Johnson YJ, Pena M, Wratney AT, Pestieau SR, Zalzal GH, Preciado DA. Dexmedetomidine as a Primary Sedative Agent after Single-Stage Airway Reconstruction. Otolaryngol Head Neck Surg 2013; 148:503-8. [DOI: 10.1177/0194599812471784] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To examine the outcomes of children receiving dexmedetomidine after single-stage airway reconstruction. Study Design Historical cohort study. Setting Tertiary care children’s hospital. Subjects and Methods Of 61 eligible patients, 50 children undergoing single-stage airway reconstruction were included in the study. Thirty children received dexmedetomidine (Dex) as a primary sedative agent, and 20 received a more traditional sedation protocol (no Dex). Primary outcomes included complications, intubation lengths, and lengths of pediatric intensive care unit (PICU)/hospital admission. Secondary analysis incorporating polypharmacy and age was performed using multivariate linear regression models. Results Median age was 18.0 months. Age, sex, and weight were similar between the groups. Intubation length was equal in the 2 groups, and there were no statistical differences between lengths of PICU or hospital stay after extubation. Similarly, overall and individual complications were all similar, and there was no difference between the 2 groups in the amount of polypharmacy administered. On multivariate analysis, polypharmacy and younger age were independently correlated with an increase in overall complications, and polypharmacy alone was correlated with an increased length of stay after extubation. Conclusion The use of dexmedetomidine as a primary sedation agent after single-stage airway surgery does not appear to improve outcomes or decrease the need for additional pharmacologic agents. Polypharmacy was associated with an increase in overall complications and an increased length of stay after extubation. Although success can be expected in greater than 90% of these surgical patients, the optimal postoperative sedation management remains challenging.
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Affiliation(s)
- Michael E. McCormick
- Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Yewande J. Johnson
- Division of Anesthesiology and Pain Medicine, Children’s National Medical Center, Washington, DC
| | - Maria Pena
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Angela T. Wratney
- Critical Care Medicine Department, Children’s National Medical Center, Washington, DC
| | - Sophie R. Pestieau
- Division of Anesthesiology and Pain Medicine, Children’s National Medical Center, Washington, DC
| | - George H. Zalzal
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Diego A. Preciado
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
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