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Dasari LNSS, Ninave S. A Narrative Review of the Efficacy and Safety of Oral Ketamine in Pediatric Sedation: A Critical Analysis of Current Evidence. Cureus 2024; 16:e67550. [PMID: 39310522 PMCID: PMC11416828 DOI: 10.7759/cureus.67550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 08/22/2024] [Indexed: 09/25/2024] Open
Abstract
Sedation in pediatric patients presents unique challenges due to their developmental and physiological differences compared to adults. Oral ketamine, a dissociative anesthetic, has emerged as a promising alternative to traditional sedatives, offering a non-invasive method for achieving sedation in children. This comprehensive review evaluates the efficacy and safety of oral ketamine for pediatric sedation, consolidating evidence from recent studies and clinical trials. The review details the pharmacological properties of oral ketamine, including its mechanism of action and its role in achieving effective sedation. It examines dosing guidelines, clinical applications, and the outcomes of sedation procedures utilizing oral ketamine. Additionally, the review addresses the safety profile of oral ketamine, including standard and serious adverse effects, and provides recommendations for monitoring and managing potential risks. Comparative analyses with other sedation methods highlight the advantages and limitations of oral ketamine, including its effectiveness and ease of administration compared to intravenous (IV) and inhaled sedatives. The review also identifies gaps in the current literature and suggests areas for future research, including long-term safety and potential developmental impacts. In conclusion, oral ketamine represents a valuable option for pediatric sedation, offering a balance of efficacy and ease of use. This review aims to guide clinicians in making informed decisions regarding the use of oral ketamine, contributing to safer and more effective sedation practices in pediatric care.
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Affiliation(s)
- Lakshmi Naga Sai Sivani Dasari
- Anesthesia and Critical Care, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjot Ninave
- Anesthesia and Critical Care, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Aniley HT, Mekuria ST, Kebede MA, Gebreanania AH, Muleta MB, Aniley TT. Magnitude of emergence agitation, its interventions and associated factors among paediatric surgical patients. BMC Anesthesiol 2024; 24:236. [PMID: 39003466 PMCID: PMC11245838 DOI: 10.1186/s12871-024-02623-5] [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: 01/18/2024] [Accepted: 07/08/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND Emergence agitation is a transient confusional state of a child associated with consciousness from general anaesthesia, commonly occurs in the postoperative setting which delays their recovery and exposes them to traumas. The main objective of the current study was to investigate the magnitude of emergence agitation, its interventions and associated factors among paediatric surgical patients at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. METHODS Hospital based cross-sectional study with prospective follow-up framework was conducted on a paediatric surgical patients aged 2-14 years who underwent surgery under general anaesthesia between June 1 - October 30 2022. Stratified sampling method followed by simple random sampling technique was employed to reach study participants. Magnitude of emergence agitation and its interventions done at post-anaesthetic care units were recorded. Data analysis was carried out using a descriptive statistics method and the results were summarized using tables and diagrams. Bivariate analysis was done to identify causal relationship and multivariable analysis to assess the confounding effects of factors associated with emergence agitation. A p-value of less than 0.05 was considered statistically significant factor. RESULTS A total of 150 participants were included in the current study, where 107 (71.3%) were male and 97 (64.7%) were preschool aged. About 81 (54%) of care givers were female and majority of them have completed primary school. The mean (standard deviation) age of the participants was 6.4 (3.57) years. Around 42.7% of them developed emergence agitation with an average duration of 8.39 ± 4.45 minutes. Factors such as propofol administration at the end of procedure (OR of 0.104 with 95% CI [0.035, 0305]), Ear, nose, throat surgery and oral maxillofacial surgery (OR of 2.341 with 95% CI [1.051, 5.211]) and arrival of patient to recovery awake (OR of 0.456 95% CI [0.209, 0.994]) showed statistically significant association with emergence agitation. CONCLUSION Almost half of the study participants experienced emergence agitation which is high magnitude. Ear, nose, throat surgery and oral maxillofacial surgeries were predictive factors of emergence agitation while propofol administration at the end of procedure and arrival of patient to recovery awake significantly decreased risk of emergence agitation. Therefore, anaesthesia personnel should have essential skills and knowledge to effectively care for children perioperatively including to minimize and treat emergence agitation.
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Affiliation(s)
- Habtamu Tilahun Aniley
- Department of Anesthesia, MeQrez General Hospital, Addis Ababa, Ethiopia.
- Department of Anesthesia, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Samrawit Tassew Mekuria
- Department of Anesthesia, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mebratu Abraha Kebede
- Research Directorate office and Nursing Education Department, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Mahteme Bekele Muleta
- Department of Anesthesia, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Tafere Tilahun Aniley
- Department of Statistics, University of South Africa, c/o Christiaan de Wet Road & Pioneer Avenue, Johannesburg, South Africa
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Bhettay A, Gray R, Desalu I, Parker R, Maswime S. Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists. Paediatr Anaesth 2024; 34:602-609. [PMID: 38078553 DOI: 10.1111/pan.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 06/07/2024]
Abstract
BACKGROUND Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries. METHODS A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices. RESULTS One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting. CONCLUSION This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.
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Affiliation(s)
- Anisa Bhettay
- Red Cross War Memorial Children's Hospital, Division of Paediatric Anaesthesia, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Rebecca Gray
- Red Cross War Memorial Children's Hospital, Division of Paediatric Anaesthesia, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Ibironke Desalu
- Department of Anaesthesia, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Salome Maswime
- Head of Division of Global Surgery, University of Cape Town, Cape Town, South Africa
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Wang Y, Chang S, Chen D. Research trends and hotspots of ketamine from 2014 to 2023: a bibliometric analysis. Front Neurosci 2024; 18:1407301. [PMID: 38948929 PMCID: PMC11211255 DOI: 10.3389/fnins.2024.1407301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 07/02/2024] Open
Abstract
Background Despite this growing interest, there remains a lack of comprehensive and systematic bibliometric analyses of ketamine research. This study aimed to summarize the progress in ketamine research through bibliometric analysis, providing insights into the development and direction of the field. Methods Publications related to ketamine were retrieved from the Web of Science Core Collection (WoSCC) database on February 15, 2024. In conducting a comprehensive bibliometric analysis, a variety of bibliographic elements were meticulously collected to map the landscape of research within a specific field. Results Between January 1, 2014, and December 31, 2023, a total of 10,328 articles on ketamine research were published across 1,752 academic journals by 45,891 authors from 8,914 institutions in 128 countries. The publication volume has shown a steady increase over this period. The United States of America (USA) and the People's Republic of China lead in both publication and citation counts. The National Institute of Mental Health (NIMH) and Yale University emerge as the most active institutions in this research domain. Carlos Zarate of the NIH National Institute of Mental Health was noted for the highest number of significant publications and received the most co-citations. The analysis revealed key research themes including mechanism of action, adverse events, psychiatric applications, and perioperative implications. Conclusion This study provided comprehensive bibliometric and knowledge mapping analysis of the global ketamine research landscape, offering valuable insights into the trends, key contributors, and thematic focus areas within the field. By delineating the evolution of ketamine research, this study aims to guide future scholarly endeavors and enhance our understanding of ketamine's therapeutic potential.
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Affiliation(s)
- Yida Wang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Science, Sichuan University, Chengdu, China
| | - Sile Chang
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, College of Life Science, Sichuan University, Chengdu, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
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Liu X, Lang B, Zeng L, Huang L, Chen S, Jia ZJ, Cheng G, Yu Q, Zhang L. Comparison of the effects of ketamine via nebulization versus different pharmacological approaches in pediatric sedation: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2023; 23:375. [PMID: 37974083 PMCID: PMC10652489 DOI: 10.1186/s12871-023-02298-4] [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: 06/01/2023] [Accepted: 09/27/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Nebulized drug delivery is commonly used in pediatric clinical practice. The growing number of literatures have reported the application of nebulized ketamine in pediatric sedation in recent years. This meta-analysis of randomized controlled trials comparing the efficacy and safety of nebulized ketamine versus different pharmacological approaches was conducted to estimate the effects of this technique in pediatric sedation. METHODS We searched PubMed, Embase, and Cochrane Library from inception to Feb 2023. All randomized controlled trials used nebulized ketamine as presurgical and pre-procedural sedatives in children were included. Sedative effects and various adverse events were considered as the outcomes. RESULTS Ten studies with 727 pediatric patients were enrolled. Compared to nebulized dexmedetomidine, using of ketamine via nebulization showed similar sedation satisfaction (54.79% vs. 60.69%, RR = 0.88, with 95%CI [0.61, 1.27]), success rate of parental separation (57.27% vs. 73.64%, RR = 0.81, with 95%CI [0.61, 1.08]), and mask acceptability (37.27% vs. 52.73%, RR = 0.71, with 95%CI [0.45, 1.10]). However, the using of combination of two medications (nebulized ketamine plus nebulized dexmedetomidine) was associated with better sedative satisfaction (33.82% vs. 68.11%, RR = 0.50, with 95%CI [0.27, 0.92]) and more satisfactory mask acceptance (45.59% vs. 71.01%, RR = 0.69, with 95%CI [0.56, 0.86]). Compared with nebulized ketamine, using of nebulized dexmedetomidine was associated with less incidence of emergence agitation (18.18% vs. 3.33%, RR = 4.98, with 95%CI [1.88, 13.16]). CONCLUSIONS Based on current evidences, compared to nebulized dexmedetomidine, nebulized ketamine provides inconspicuous advantages in pediatric sedation, and it has a relatively high incidence of emergence agitation. Combination of nebulized ketamine and dexmedetomidine might be considered as one preferred option in pediatric sedation as it can provide more satisfactory sedative effects. However, there is insufficient evidence regarding nebulized ketamine versus ketamine administered through other routes and nebulized ketamine versus other sedatives. The overall low or moderate quality of evidence evaluated by the GRADE system also calls for more high-quality studies with larger sample sizes in future. RESEARCH REGISTRATION The protocol of present study was registered with PROSPERO (CRD42023403226).
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Affiliation(s)
- Xiao Liu
- Department of Pharmacy, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China.
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Yu W, Wu Z, Li X, Ding M, Xu Y, Zhao P. Ketamine counteracts sevoflurane-induced depressive-like behavior and synaptic plasticity impairments through the adenosine A2A receptor/ERK pathway in rats. Mol Neurobiol 2023; 60:6160-6175. [PMID: 37428405 DOI: 10.1007/s12035-023-03474-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 07/02/2023] [Indexed: 07/11/2023]
Abstract
Ketamine is an ionic glutamic acid N-methyl-d-aspartate receptor (NMDAR) antagonist commonly used in clinical anesthesia, and its rapid and lasting antidepressant effect has stimulated great interest in psychology research. However, the molecular mechanisms underlying its antidepressant action are still undetermined. Sevoflurane exposure early in life might induce developmental neurotoxicity and mood disorders. In this study, we evaluated the effect of ketamine against sevoflurane-induced depressive-like behavior and the underlying molecular mechanisms. Here, we reported that A2AR protein expression was upregulated in rats with depression induced by sevoflurane inhalation, which was reversed by ketamine. Pharmacological experiments showed that A2AR agonists could reverse the antidepressant effect of ketamine, decrease extracellular signal-regulated kinase (ERK) phosphorylation, reduce synaptic plasticity, and induce depressive-like behavior. Our results suggest that ketamine mediates ERK1/2 phosphorylation by downregulating A2AR expression and that p-ERK1/2 increases the production of synaptic-associated proteins, enhancing synaptic plasticity in the hippocampus and thereby ameliorating the depressive-like behavior induced by sevoflurane inhalation in rats. This research provides a framework for reducing anesthesia-induced developmental neurotoxicity and developing new antidepressants.
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Affiliation(s)
- Weiwei Yu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China
| | - Ziyi Wu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China
| | - Xingyue Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China
| | - Mengmeng Ding
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China
| | - Ying Xu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China
| | - Ping Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, China.
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Suttorp M, Sembill S, Kalwak K, Metzler M, Millot F. Priapism at Diagnosis of Pediatric Chronic Myeloid Leukemia: Data Derived from a Large Cohort of Children and Teenagers and a Narrative Review on Priapism Management. J Clin Med 2023; 12:4776. [PMID: 37510891 PMCID: PMC10380995 DOI: 10.3390/jcm12144776] [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: 06/01/2023] [Revised: 07/04/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Pediatric chronic myeloid leukemia (CML) is a very rare malignancy (age-related incidence 0.1/100,000) typically presenting with leucocyte counts >100,000/µL. However, clinical signs of leukostasis are observed at diagnosis in only approximately 10% of all cases and among these, priapism is infrequent. Here, we analyze data from pediatric CML registries on the occurrence of priapism heralding diagnosis of CML in 16/491 (3.2%) boys (median age 13.5 years, range 4-18) with pediatric CML. In the cohort investigated, duration of priapism resulting in a diagnosis of CML was not reported in 5 patients, and in the remaining 11 patients, occurred as stuttering priapism over 3 months (n = 1), over 6 weeks (n = 1), over 1-2 weeks (n = 2), over several days (n = 2), or 24 h (n = 1), while the remaining 4 boys reported continuous erection lasting over 11-12 h. All patients exhibited splenomegaly and massive leukocytosis (median WBC 470,000/µL, range 236,700-899,000). Interventions to treat priapism were unknown in 5 patients, and in the remaining cohort, comprised intravenous fluids ± heparin (n = 2), penile puncture (n = 5) ± injection of sympathomimetics (n = 4) ± intracavernous shunt operation (n = 1) paralleled by leukocyte-reductive measures. Management without penile puncture by leukapheresis or exchange transfusion was performed in 3 boys. In total, 7 out 15 (47%) long-term survivors (median age 20 years, range 19-25) responded to a questionnaire. All had maintained full erectile function; however, 5/7 had presented with stuttering priapism while in the remaining 2 patients priapism had lasted <12 h until intervention. At its extreme, low-flow priapism lasting for longer than 24 h may result in partial or total impotence by erectile dysfunction. This physical disability can exert a large psychological impact on patients' lives. In a narrative review fashion, we analyzed the literature on priapism in boys with CML which is by categorization stuttering or persisting as mostly painful, ischemic (low-flow) priapism. Details on the pathophysiology are discussed on the background of the different blood rheology of hyperleukocytosis in acute and chronic leukemias. In addition to the data collected, instructive case vignettes demonstrate the diagnostic and treatment approaches and the outcome of boys presenting with priapism. An algorithm for management of priapism in a stepwise fashion is presented. All approaches must be performed in parallel with cytoreductive treatment of leukostasis in CML which comprises leukapheresis and exchange transfusions ± cytotoxic chemotherapy.
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Affiliation(s)
- Meinolf Suttorp
- Pediatric Hematology and Oncology, Medical Faculty, TU Dresden, 01307 Dresden, Germany
| | - Stephanie Sembill
- Pediatric Oncology and Hematology, Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany; (S.S.); (M.M.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany
| | - Krzysztof Kalwak
- Supraregional Center of Pediatric Oncology “Cape of Hope”, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Markus Metzler
- Pediatric Oncology and Hematology, Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany; (S.S.); (M.M.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany
| | - Frederic Millot
- Inserm CIC 1402, University Hospital of Poitiers, 86000 Poitiers, France;
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Zheng X, Huang J, Wei S, Tao Y, Shen Y, Wang Y, He P, Zhang M, Sun Y. Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial. Front Pediatr 2023; 11:1126522. [PMID: 37441574 PMCID: PMC10333751 DOI: 10.3389/fped.2023.1126522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
Background and Aims Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children. Methods A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia. Results Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05). Conclusion The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high. Clinical Trial Registration Chinese Clinical Trial Registry: ChiCTR2000040500.
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Affiliation(s)
- Xiaosu Zheng
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jinjin Huang
- Department of Anesthesiology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Sisi Wei
- Department of Anesthesiology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingying Tao
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Shen
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanting Wang
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pan He
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mazhong Zhang
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Sun
- Department of Anesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Comparison of the Effect of Adding Low-dose Ketamine to Dexmedetomidine and Propofol on the Quality of Sedation and Hemodynamic Response in Children During Upper Gastrointestinal Endoscopy: A Double-blind Randomized Clinical Trial. Anesth Pain Med 2023. [DOI: 10.5812/aapm-134581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background: As endoscopy is an invasive and painful procedure, it is necessary to use a suitable sedative with a minimum dose, especially in children. Objectives: This study aimed to compare the effect of adding low-dose ketamine to dexmedetomidine and propofol on the quality of sedation and hemodynamic response in children during upper gastrointestinal endoscopy. Methods: This double-blind, randomized clinical trial was conducted on 52 children who were candidates for endoscopy in 2 groups, each consisting of 26 patients. In the first group (Ketadex group), infusion of dexmedetomidine (0.7 - 1 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. In the second group (Ketofol group), infusion of propofol (50 - 100 μg/kg) for 10 minutes and ketamine bolus (0.4 mg/kg) for anesthesia induction was prescribed. Results: The mean blood pressure of children decreased slightly during and after the endoscopic procedure in the Ketadex group than in the Ketofol group (P < 0.05). The recovery time was significantly less in the Ketofol group (41.85 ± 7.03 minutes) than in the Ketadex group (55.12 ± 7.55 minutes; P < 0.001). Conclusions: The addition of the low-dose ketamine to propofol and dexmedetomidine did not result in any significant changes in the level of sedation, the incidence of adverse effects, and the endoscopist’s satisfaction; however, the recovery time was shorter in the propofol-ketamine combination than in the dexmedetomidine-ketamine combination.
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11
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Li X, Tian M, Deng Y, She T, Li K. Advantages of Sedation With Remimazolam Compared to Midazolam for the Removal of Impacted Tooth in Patients With Dental Anxiety. J Oral Maxillofac Surg 2023; 81:536-545. [PMID: 36852757 DOI: 10.1016/j.joms.2023.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE Although midazolam is commonly used to sedate patients with dental anxiety, it has shortcomings that reduce the satisfaction of patients and doctors. The aim of this study was therefore to explore the advantages of remimazolam as a sedative. METHODS The study design was a prospective randomized controlled trial. Patients with dental anxiety and who were to undergo impacted tooth removal were randomized into remimazolam and midazolam groups. They were sedated with remimazolam or midazolam prior to receiving nerve blocker. The predictor variable was the type of sedative, while the primary outcome variables were the onset time, awakening time, recovery time, and postoperative side effects. Secondary outcome variables were the Modified Dental Anxiety Scale score before and after surgery, patient satisfaction and comfort levels scores, and doctor satisfaction level scores. Other variables included the patient demographics and the operation time. Data were analyzed using the Student's t-test, Mann-Whitney test, χ2 test, and two-way repeated measurement ANOVA test (SPSS Version 25.0). RESULTS A total of 83 patients were included in this study, with 42 randomized to the remimazolam group and 41 to the midazolam group. There were no significant differences between the two groups in terms of demographic features and operation time. Patients in the remimazolam group had significantly shorter onset time, awakening time, and recovery time compared to those in the midazolam group (each P < .001). Postoperative side effects were more frequent in the midazolam group (P < .001). Following surgery, the Modified Dental Anxiety Scale scores in both groups were significantly lower than prior to surgery (P < .001). Satisfaction levels scores for the patients and doctor were higher in the remimazolam group than in the midazolam group (P < .001). CONCLUSIONS The use of remimazolam results in faster onset, more rapid recovery, and lower incidence of postoperative side effects compared to midazolam, leading to improved satisfaction for patients and doctors. Remimazolam therefore appears to have several advantages over midazolam for the sedation of patients with dental anxiety associated with the removal of impacted teeth.
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Affiliation(s)
- Xue Li
- Attending Physician, Department of Anesthesiology, Hospital of Stomatology, Zunyi Medical University, Zunyi, Guizhou, People's Republic of China
| | - Meijun Tian
- Postgraduate Student, Zunyi Medical University, Zunyi, Guizhou, People's Republic of China
| | - Yilan Deng
- Postgraduate Student, Zunyi Medical University, Zunyi, Guizhou, People's Republic of China
| | - Tingzhi She
- Professor, Department of Anesthesiology, Hospital of Stomatology, Zunyi Medical University, Zunyi, Guizhou, People's Republic of China
| | - Ke Li
- Chief Physician, Professor, Department of Anesthesiology, Hospital of Stomatology, Zunyi Medical University, Zunyi, Guizhou, People's Republic of China.
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Petrucci E, Cofini V, Pizzi B, Cascella M, Marrocco G, Ceccaroni G, Necozione S, Vittori A, Marinangeli F. Pain in critically ill COVID-19 patients: An Italian retrospective study. Open Med (Wars) 2022; 17:1803-1810. [PMID: 36447524 PMCID: PMC9673487 DOI: 10.1515/med-2022-0600] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 08/26/2023] Open
Abstract
We retrospectively analyzed the data from patients admitted to the intensive care unit (ICU) of the Hospital of L'Aquila during the first and second waves of pandemic to identify pain related to COVID-19. Pain was evaluated by using the Numerical Rating Scale, and the assessment for neuropathic disturbances of pain was performed with von Frey's hair and Lindblom tests. Pain increased significantly during hospitalization (from 48% at hospital admission to 94.3% at ICU discharge). Female patients were affected by somatic pain in 32.8% of the cases and by somatic pain and pain with neuropathic features (NFs) in 23.5% of the cases, during the ICU stay. Somatic pain and pain with NFs affected more frequently patients with cardiological and respiratory comorbidities. Patients treated with continuous positive airway pressure via helmet had a higher frequency of somatic pain and pain with neuropathic disturbances (84 and 74%, respectively). The frequency of somatic pain and pain with neuropathic disturbances was lower in patients sedated with propofol combined with ketamine. Females have been associated with a higher risk of somatic pain and pain with NFs. Patients with cardiological and respiratory comorbidities undergoing noninvasive ventilation had higher levels of pain. As conclusion, ketamine may reduce the promotion or the worsening of pain in COVID-19 patients.
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Affiliation(s)
- Emiliano Petrucci
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L’Aquila, 67100, L’Aquila, Italy
| | - Vincenza Cofini
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100, L’Aquila, Italy
| | - Barbara Pizzi
- Department of Anesthesia and Intensive Care Unit, SS Filippo and Nicola Academic Hospital of Avezzano, 67051, Avezzano, L’Aquila, Italy
| | - Marco Cascella
- Department of Anesthesia and Critical Care, Istituto Nazionale Tumori, IRCCS, Fondazione Pascale, 80131, Naples, Italy
| | - Gioele Marrocco
- Department of Anesthesiology, Intensive Care and Pain Treatment, University of L’Aquila, L’Aquila, Italy
| | - Gianmaria Ceccaroni
- Department of Anesthesiology, Intensive Care and Pain Treatment, University of L’Aquila, L’Aquila, Italy
| | - Stefano Necozione
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100, L’Aquila, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Franco Marinangeli
- Department of Anesthesiology, Intensive Care and Pain Treatment, University of L’Aquila, L’Aquila, Italy
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13
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Ciccozzi A, Pizzi B, Vittori A, Piroli A, Marrocco G, Della Vecchia F, Cascella M, Petrucci E, Marinangeli F. The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101438. [PMID: 36291372 PMCID: PMC9600107 DOI: 10.3390/children9101438] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/11/2022] [Accepted: 09/17/2022] [Indexed: 06/01/2023]
Abstract
The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.
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Affiliation(s)
- Alessandra Ciccozzi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Barbara Pizzi
- Department of Anesthesia and Intensive Care Unit, SS Filippo and Nicola Academic Hospital of Avezzano, 67051 L’Aquila, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, 00165 Rome, Italy
| | - Alba Piroli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Gioele Marrocco
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Federica Della Vecchia
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Marco Cascella
- Department of Anesthesia and Critical Care, Istituto Nazionale Tumori—IRCCS, Fondazione Pascale, 80131 Naples, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L’Aquila, 67100 L’Aquila, Italy
| | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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