Association of BMI With Propofol Dosing and Adverse Events in Children With Cancer Undergoing Procedural Sedation

Impact of Propofol Exposure on Neurocognitive Outcomes in Children With High-Risk B ALL: A Children's Oncology Group Study

PURPOSE

Many children treated for ALL develop long-term neurocognitive impairments. Increased risk of these impairments is associated with treatment and demographic factors. Exposure to anesthesia is an additional possible risk factor. This study evaluated the impact of cumulative exposure to anesthesia on neurocognitive outcomes among a multicenter cohort of children with ALL.

METHODS

This study was embedded in AALL1131, a Children's Oncology Group phase III trial for patients with high-risk B-ALL. In consenting patients age 6-12 years, prospective uniform assessments of neurocognitive function were performed during and at 1 year after completion of therapy. Exposure to all episodes of anesthetic agents was abstracted. Multivariable linear regression models determined associations of cumulative anesthetic agents with the primary neurocognitive outcome reaction time/processing speed (age-normed) at 1 year off therapy, adjusting for baseline neurocognitive score, age, sex, race/ethnicity, insurance status (as a proxy for socioeconomic status), and leukemia risk group.

RESULTS

One hundred and forty-four children, 76 (52.8%) males, mean age of 9.1 (min-max, 6.0-12.0) years at diagnosis, underwent a median of 27 anesthetic episodes (min-max, 1-37). Almost all patients were exposed to propofol (140/144, 97.2%), with a mean cumulative dose of 112.3 mg/kg. One year after therapy, the proportion of children with impairment (Z-score ≤-1.5) was significantly higher compared with a normative sample. In covariate-adjusted multivariable analysis, cumulative exposure to propofol was associated with a 0.05 Z-score decrease in reaction time/processing speed per each 10 mg/kg propofol exposure (P = .03).

CONCLUSION

In a multicenter and uniformly treated cohort of children with B-ALL, cumulative exposure to propofol was an independent risk factor for impairment in reaction time/processing speed 1 year after therapy. Anesthesia exposure is a modifiable risk, and opportunities to minimize propofol use should be considered.

A Quality Initiative to Improve Appropriate Medication Dosing in Pediatric Patients with Obesity

Introduction

Emerging evidence supports the use of alternative dosing weights for medications in patients with obesity. Pediatric obesity presents a particular challenge because most medications are dosed based on patient weight. Additionally, building system-wide pediatric obesity safeguards is difficult due to pediatric obesity definitions of body mass index-percentile-for-age via the Center for Disease Control growth charts. We describe a quality initiative to increase appropriate medication dosing in inpatients with obesity. The specific aim was to increase appropriate dosing for 7 high-risk medications in inpatients with obesity ≥2 years old from 37% to >74% and to sustain for 1 year.

Methods

The Institute for Healthcare Improvement model for improvement was used to plan interventions and track outcomes progress. Interventions included a literature review to establish internal dosing guidance, electronic health record (EHR) functionality to identify pediatric patients with obesity, a default selection for medication weight with an opt-out, and obtaining patient heights in the emergency department.

Results

Appropriate dosing weight use in medication ordered for patients with obesity increased from 37% to 83.4% and was sustained above the goal of 74% for 12 months.

Conclusions

Implementation of EHR-based clinical decision support has increased appropriate evidence-based dosing of medications in pediatric and adult inpatients with obesity. Future studies should investigate the clinical and safety implications of using alternative dosing weights in pediatric patients.

Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis

BACKGROUND

To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

METHODS

We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

RESULTS

In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol.

CONCLUSIONS

The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.

The Influence of Age on Propofol Dosing Requirements During Procedural Sedation in the Emergency Department

Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing.

Adjuvant lidocaine to a propofol-ketamine-based sedation regimen for bone marrow aspirates and biopsy in the pediatric population

Pediatric patients with hematological malignancies repeatedly undergo painful bone marrow aspirates and biopsies (BMABs) in routine care. No standard sedation regimen has been established. This study evaluated the addition of injected local lidocaine to a propofol-ketamine sedation for BMAB and its effects on propofol dosing, safety, and efficacy. A retrospective analysis of children undergoing BMAB with propofol-ketamine with (PK+L) and without (PK-only) the injection of local lidocaine. Patients were matched through propensity probability scores. To measure efficacy, dosing, procedure length, and recovery time were evaluated. To assess safety, adverse and serious events were recorded. As an indirect measurement of analgesia, changes in heart rate and blood pressure were analyzed. Of the 420 encounters included, 188 matched pairs (376 patients) were analyzed. Patient demographics were comparable. The median dose of propofol was not significantly different between both groups. The incidence of adverse events was similar. There were no significant differences in the changes in heart rate and blood pressure with sedation between groups.Conclusion: This study suggests that the addition of local lidocaine injection to a propofol-ketamine sedation for BMAB pediatric patients does not affect the propofol dose, safety, or efficacy properties of the regimen. What is Known: •Although propofol is commonly used, there is no standard sedation regimen for pediatric patients undergoing bone marrow aspiration and biopsy. •Local lidocaine is used in analgesia in the adults undergoing the same procedure. What is New: •Local lidocaine adjuvant to propofol-ketamine sedation does not affect propofol dosing, the safety of efficacy properties of the regimen in the pediatric population.