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Maiandi S, Ghizzardi G, Edefonti V, Giacchero R, Lusignani M, Giannì ML. Is the equimolar mixture of oxygen and nitrous oxide (EMONO) associated with audiovisuals effective in reducing pain and side effects during peripheral venous access placement in children? Protocol for a single-centre randomised controlled trial from Italy. BMJ Open 2023; 13:e067912. [PMID: 37419632 PMCID: PMC10335544 DOI: 10.1136/bmjopen-2022-067912] [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: 09/16/2022] [Accepted: 05/31/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Nurses frequently place a peripheral venous catheter during children's hospitalisation. Many studies suggest treatment of venipuncture-related pain. The administration of an equimolar mixture of oxygen and nitrous oxide (EMONO) is employed for pain control; however, no studies have analysed the association between EMONO and audiovisuals.The purpose of the study is to evaluate the effect of EMONO administration when combined with audiovisuals (EMONO+Audiovisual) versus EMONO alone on perceived pain, side effects and level of cooperation during peripheral venous access placement in children aged 2-5 years. METHODS AND ANALYSIS The first 120 eligible children admitted to the paediatric ward of the Lodi Hospital and presenting the indication for peripheral venous access will be enrolled. Sixty children will be randomly assigned to the experimental group (EMONO+Audiovisual) and 60 to the control group (EMONO alone).The Face, Legs, Activity, Cry, Consolability scale will be used to assess pain in the children aged 2-years old; pain in the children aged 3-5 years will be assessed using the Wong-Baker scale. The cooperation throughout the procedure will be measured using the Groningen Distress Rating Scale. ETHICS AND DISSEMINATION The Milan Area 1 Ethics Committee approved the study protocol (Experiment Registry No. 2020/ST/295). The trial results will be presented at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05435118.
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Affiliation(s)
- Stefano Maiandi
- Healthcare Professions Directorate - ASST di Lodi, Lodi, Italy
| | - Greta Ghizzardi
- Healthcare Professions Directorate - ASST di Lodi, Lodi, Italy
| | - Valeria Edefonti
- Department of Clinical Sciences and Community Health, Branch of Medical Statistics, Biometry and Epidemiology, "G.A. Maccacaro," University of Milan, Milano, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Maura Lusignani
- Department of Biomedical Sciences for Health, University of Milan, Milano, Italy
| | - Maria Lorella Giannì
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy
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Frumer M, Sivan B, May T, Morag R, Khunovich D, Ben-Meir D. The accuracy of cystography under general anesthesia in children with vesicoureteral reflux. Neurourol Urodyn 2023; 42:349-354. [PMID: 36423246 DOI: 10.1002/nau.25105] [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: 08/23/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine the accuracy of cystography under general anesthesia in children with vesicoureteral reflux (VUR). MATERIALS AND METHODS A prospective study of children who had VUR on cystography without general anesthesia (i.e., the gold-standard), and who are candidates for endoscopic VUR repair surgery. All children subsequently underwent a cystography under general anesthesia before injection using standardized method, which was compared to the gold-standard cystography. χ2 and Mann-Whitney U tests were used to compare proportions and medians between groups. RESULTS Between 2017 and 2021, 126 renal units in 13 boys and 50 girls were included. Median age was 3.4 years (interquartile range [IQR] 1.5-6.5). Median time from cystography without to cystography with general anesthesia was 3.8 months (IQR 2.7-6). Of the 126 renal units, 96 had VUR on cystography without general anesthesia. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative and positive predictive values of cystography under general anesthesia were 47% (45/96), 87% (26/30), 34% (26/77) and 92% (45/49), respectively. Accuracy was 56.3%; Cohen's Kappa coefficient was 0.22, indicating poor agreement. In subgroup analysis, the sensitivity of cystography under general anesthesia was significantly lower in primary VUR (20% vs. 55% in secondary VUR, p = 0.01) and active VUR (14% vs. 52% in passive VUR, p = 0.008). CONCLUSION Cystography under general anesthesia was poorly correlated to cystography performed while the child was awake or lightly sedated. Clinical decision relying on this cystography is questionable.
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Affiliation(s)
- Michael Frumer
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bezalel Sivan
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal May
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Morag
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dmitry Khunovich
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Ben-Meir
- Urology Unit, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Reichert M. [Aspects of performing micturition urosonography, particularly sedation with midazolam]. Radiologe 2021; 62:164-166. [PMID: 34928402 DOI: 10.1007/s00117-021-00945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Manfred Reichert
- Praxis für Kinder- und Jugendmedizin, An der Raumfabrik 6, Karlsruhe, Deutschland.
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Hanson KA, Rainey SC, Shaikh N, Beekman MK. Characteristics and Outcomes of Patients Receiving Sedation for Voiding Cystourethrography. Cureus 2021; 13:e20207. [PMID: 35004027 PMCID: PMC8730347 DOI: 10.7759/cureus.20207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 12/03/2022] Open
Abstract
Background Voiding cystourethrography (VCUG) is used to diagnose vesicoureteral reflux (VUR); however, it is an invasive procedure and can be psychologically distressing. Procedural sedation is occasionally utilized to alleviate anxiety during VCUG, and some patient populations may get referred more readily for sedation than others. Sedative medications may also impact the results of the test due to their effects on smooth muscle. The goals of this study were to compare patient characteristics between those that were referred for procedural sedation and those that were not and to compare VCUG results between sedated and non-sedated patients. Methodology We performed a retrospective cohort study of patients aged 2-18 years undergoing VCUG during a five-year period. Sedated patients were matched with non-sedated patients controlling for referring provider and procedure year. Exclusion criteria included chronic catheterization, same-day surgery, current intensive care admission, and sedation restrictions. A total of 284 patients were included. Demographic information, medical comorbidities, and VCUG results were analyzed. Results There were no significant differences between sedated and non-sedated patients in any demographic variables. Neurologic, developmental, and gastrointestinal comorbidities were more common in sedated patients. On multivariate analysis, having more than one comorbid condition was the only significant predictor of referral for procedural sedation. There were no significant differences in VCUG results between sedated and non-sedated patients. Conclusions Patients with comorbidities were more likely to receive procedural sedation for VCUG. Procedural sedation did not have a significant impact on test results, suggesting its potential utility in relieving pain and anxiety associated with VCUG.
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Schultz ML, Niescierenko M. Guidance for Implementing Pediatric Procedural Sedation in Resource-Limited Settings. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Johnin K, Kobayashi K, Tsuru T, Yoshida T, Kageyama S, Kawauchi A. Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children. Int J Urol 2018; 26:160-171. [PMID: 30569659 DOI: 10.1111/iju.13881] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 11/14/2018] [Indexed: 12/24/2022]
Abstract
Voiding cystourethrography is the most important fluoroscopic examination in pediatric urology for the investigation of lower urogenital tract diseases, such as vesicoureteral reflux or urethral stricture. However, this invasive procedure imposes a significant burden on children and their parents, and recently there has been a paradigm shift in the diagnosis and treatment of vesicoureteral reflux. In the 2011 revision, the American Academy of Pediatrics guidelines on urinary tract infection recommended abandoning routine voiding cystourethrography after the first febrile urinary tract infection. In 2014, the randomized intervention for children with vesicoureteral reflux study recommended discontinuation of routine continuous antibiotic prophylaxis for vesicoureteral reflux. The time is now ripe to radically reconsider indications for voiding cystourethrography and the procedure itself.
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Affiliation(s)
- Kazuyoshi Johnin
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kenichi Kobayashi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Teruhiko Tsuru
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tetsuya Yoshida
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Susumu Kageyama
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akihiro Kawauchi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Neuman G, Swed Tobia R, Koren L, Leiba R, Shavit I. Single dose oral midazolam for minor emergency department procedures in children: a retrospective cohort study. J Pain Res 2018; 11:319-324. [PMID: 29483782 PMCID: PMC5815472 DOI: 10.2147/jpr.s156080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background In the pediatric emergency department, patients are commonly treated with a single dose of oral midazolam for minor procedures. We sought to evaluate the effect of this treatment on procedure completion rates. Methods We conducted a single-center retrospective cohort study of all patients who were treated with pre-procedure oral midazolam between January 2011 and June 2016. The primary outcome was the procedure completion rate. Results During the study period, 1,504 patients were treated with oral midazolam as per department protocol; 1,467 received midazolam and 37 declined midazolam. Oral midazolam was used in 14 different types of emergency department procedures. The procedure completion rates in the treatment and non-treatment groups were 1,402/1,467 (95.6%) and 24/37 (64.8%), respectively (difference 30.7%; 95% confidence interval [CI] 17.3%–46.8%); p<0.0001. Treatment group patients had procedure completion rates of 25/33 (75.8%), 165/188 (87.8%%), 1,154/1,187 (97.2%), and 58/59 (98.3%), in the less than 0.3 mg/kg group, 0.3 to less than 0.5 mg/kg group, 0.5 to less than 0.7 mg/kg group, and 0.7 to less than 0.9 mg/kg group, respectively. Multivariate regression did not demonstrate an association between sex, ethnicity, dosage of 0.5 mg/kg or greater, type of procedure, and failure to complete procedure. Severe adverse events were not recorded. A dose of less than 0.3 mg/kg was significantly associated with an increased risk of failure to complete a procedure (adjusted odds ratio 8.34, 95% CI 3.32–20.9; p<0.0001). Conclusion The findings suggest that oral midazolam in a single dose of 0.5 mg/kg or greater is associated with successful completion of minor pediatric procedures.
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Affiliation(s)
- Gal Neuman
- Clinical Pharmacology and Toxicology Unit
| | - Rana Swed Tobia
- Department of Pediatrics, Ruth Children's Hospital, Rambam Health Care Campus
| | - Liron Koren
- Rappaport Faculty of Medicine, Technion - Institute of Technology
| | | | - Itai Shavit
- Emergency Department, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
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Schettini DA, Freitas FG, Tomotani DY, Alves JC, Bafi AT, Machado FR. Incidence and risk factors for urinary retention in critically ill patients. Nurs Crit Care 2018; 24:355-361. [PMID: 29430778 DOI: 10.1111/nicc.12341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 11/24/2017] [Accepted: 01/15/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Daniel A Schettini
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Flávio Gr Freitas
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Daniere Yv Tomotani
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Jane Cd Alves
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Antonio T Bafi
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
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Kuang H, Johnson JA, Mulqueen JM, Bloch MH. The efficacy of benzodiazepines as acute anxiolytics in children: A meta-analysis. Depress Anxiety 2017; 34:888-896. [PMID: 28504861 PMCID: PMC5629100 DOI: 10.1002/da.22643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/22/2017] [Accepted: 03/25/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Current practice guidelines do not recommend benzodiazepines for acute management of anxiety disorders in pediatric patients. However, in procedural settings, benzodiazepines are commonly used to relieve acute preprocedural stress. This meta-analysis examines the efficacy and tolerability of benzodiazepines as short-term anxiolytics in children. METHOD PubMed was searched for randomized controlled trials assessing the efficacy of benzodiazepines as short-term anxiolytics in pediatric patients. Twenty-one trials involving 1,416 participants were included. A fixed effects model was used to examine the standardized mean difference of improvement in anxiety levels compared to control conditions. In stratified subgroup and meta-regression, the effect of the specific agent, dose, timing, and setting of benzodiazepine treatment was examined. RESULTS A significant benefit was seen for benzodiazepines compared to control (standardized mean difference = 0.71 [95% confidence interval, 0.60-0.82], k = 24, z = 12.7, P < .001). There was also funnel plot asymmetry in this meta-analysis, suggesting some evidence of publication bias. Moderator analyses found that when benzodiazepines were used in dental or nonoperating room procedures, they were more effective than when they were used in operating room procedures (test for subgroup differences Q2 = 6.34, P = .04). Tolerability analysis revealed there was no significant difference in the risk of developing irritability or behavioral changes between benzodiazepine and control groups. CONCLUSIONS Benzodiazepines are effective and well-tolerated when used as short-term anxiolytics in procedural settings for pediatric patients. Further research is needed to determine whether benzodiazepines are effective in pediatric anxiety disorders.
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Affiliation(s)
- Heide Kuang
- School of Medicine, Yale University, New Haven, CT, USA
| | | | | | - Michael H Bloch
- Department of Psychiatry, Yale University, New Haven, CT, USA
- The Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA
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Alizadeh A, Naseri M, Ravanshad Y, Sorouri S, Banihassan M, Azarfar A. Use of sedative drugs at reducing the side effects of voiding cystourethrography in children. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:42. [PMID: 28465701 PMCID: PMC5393102 DOI: 10.4103/1735-1995.202139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/11/2016] [Accepted: 12/02/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Imaging of the kidneys and urinary tract has a significant and critical role for diagnosis of genitourinary system diseases. Although technological progress goes toward less invasive approaches, some of the current methods are still invasive and annoying. Voiding cystourethrography (VCUG) is the best and most accurate method for diagnosis and grading of vesicoureteral reflux. VCUG is a distressful procedure that gives serious anxiety and pain in a large proportion of children and fear for parents; therefore, using effective sedative drugs with the least side effects is necessary and should be considered. MATERIALS AND METHODS In this review article, importance and efficacy of different drugs before catheterization VCUG be compared in the base of literature survey on EMBASE, PubMed, and Cochrane source. RESULTS We found that the treatment should be based on nonpharmacological and pharmacological methods; nonpharmacological treatment includes the psychological preparation before procedures as a safety precaution with little or no risk modality, as well as reassuring support. The presence of parents during painful procedures cannot alleviate children distress. Pharmacological methods include oral midazolam (0.5 mg/kg) and intranasal use (0.2 mg/kg) that had been used 10 min before the procedure can effect on anterograde amnesia and sedation without considerable effect on accuracy and grade of reflux. Nitric oxide has a shorter recovery time versus midazolam but has a potential risk for deep sedation and may interfere with the child's voiding phase. CONCLUSION In summary, oral midazolam of 0.5-0.6 mg/kg or 0.2 mg/kg intranasal is acceptable drug that can be used before VCUG.
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Affiliation(s)
- Anahita Alizadeh
- Department of Clinical Toxicology, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Naseri
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yalda Ravanshad
- Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shahabaddin Sorouri
- Department of Internal Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Malihe Banihassan
- Department of Pediatrics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Anoush Azarfar
- Department of Pediatric Nephrology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Ghai B, Jain K, Saxena AK, Bhatia N, Sodhi KS. Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study. Paediatr Anaesth 2017; 27:37-44. [PMID: 27734549 DOI: 10.1111/pan.13010] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation. AIMS The aim of this trial was to compare the effectiveness of oral midazolam and intranasal dexmedetomidine as sole premedicants in children for carrying out both IV cannulation as well as CT scanning, without the need for additional IV sedatives. METHODS Fifty-nine children, aged 1-6 years, scheduled to undergo CT imaging under sedation were randomized to receive either 0.5 mg·kg-1 oral midazolam (group M) or 2.5 mcg·kg-1 intranasal dexmedetomidine (group D). After 20-30 min, intravenous cannulation was performed and response to its placement was graded using the Groningen Distress Rating Scale (GDRS). After cannulation, children were transferred on the CT table, and assessed using the Ramsay sedation score (RSS). CT imaging was performed without any further sedative if the RSS was ≥4. If there was movement or decrease in sedation depth (RSS ≤ 3), ketamine 1 mg·kg-1 IV was given as an initial dose, followed by subsequent doses of 0.5 mg·kg-1 IV if required. RESULTS A Significantly higher proportion of children in group D (67%) achieved RSS ≥ 4 as compared to group M (24%) (P-0.002). The risk ratio (95% CI) was 2.76 (1.38-5.52). Significantly lower GDRS scores were noted in group D (1(1-2)) as compared to group M (2(1-2)) at the time of venipuncture (P = 0.04). CONCLUSION In the doses and time intervals used in our study, intranasal dexmedetomidine (2.5 μg·kg-1 ) was found to be superior to oral midazolam (0.5 mg·kg-1 ) for producing satisfactory sedation for CT imaging.
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Affiliation(s)
- Babita Ghai
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Kajal Jain
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Nidhi Bhatia
- Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
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Shaikh N, Hoberman A, Keren R, Ivanova A, Ziessman HA, Cui G, Mattoo TK, Bhatnagar S, Nadkarni MD, Moxey-Mims M, Primack WA. Utility of sedation for young children undergoing dimercaptosuccinic acid renal scans. Pediatr Radiol 2016; 46:1573-8. [PMID: 27287454 PMCID: PMC5039057 DOI: 10.1007/s00247-016-3649-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/11/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND No studies have examined whether use of sedation during a Tc-99 m dimercaptosuccinic acid (DMSA) renal scan reduces patient discomfort. OBJECTIVE To compare discomfort level during a DMSA scan to the discomfort level during other frequently performed uroradiologic tests, and to determine whether use of sedation during a DMSA scan modifies the level of discomfort. MATERIALS AND METHODS We examined the discomfort level in 798 children enrolled in the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) and Careful Urinary Tract Infection Evaluation (CUTIE) studies by asking parents to rate their child's discomfort level with each procedure on a scale from 0 to 10. We compared discomfort during the DMSA scan and the DMSA image quality between centers in which sedation was used >90% of the time (sedation centers), centers in which sedation was used <10% of the time (non-sedation centers), and centers in which sedation was used on a case-by-case basis (selective centers). RESULTS Mean discomfort level was highest for voiding cystourethrogram (6.4), followed by DMSA (4.0), followed by ultrasound (2.4; P<0.0001). Mean discomfort level during the DMSA scan was significantly higher at non-sedation centers than at selective centers (P<0.001). No difference was apparent in discomfort level during the DMSA scan between sedation centers and selective centers (P=0.12), or between the sedation centers and non-sedation centers (P=0.80). There were no differences in the proportion with uninterpretable DMSA scans according to sedation use. CONCLUSION Selective use of sedation in children 12-36 months of age can reduce the discomfort level experienced during a DMSA scan.
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Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gang Cui
- Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tej K. Mattoo
- Division of Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University School of medicine, Detroit, MI, USA
| | - Sonika Bhatnagar
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Milan D. Nadkarni
- Pediatric Emergency Department, Brenner Children's Hospital, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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Özmert S, Sever F, Tiryaki HT. Evaluation of the effects of sedation administered via three different routes on the procedure, child and parent satisfaction during cystometry. SPRINGERPLUS 2016; 5:1496. [PMID: 27652069 PMCID: PMC5013006 DOI: 10.1186/s40064-016-3164-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/25/2016] [Indexed: 11/10/2022]
Abstract
Purpose In this study, we retrospectively investigated case reports with and without midazolam administration via oral, intranasal and rectal before cystometry procedure. We aimed to compare the data to evaluate the effects of sedation before cystometry on the pediatric patients and parents’ satisfaction. Methods A total of 124 ASA I-II pediatric cases aged 5–14 years were retrospectively investigated from the hospital records. One of the three administration routes was chosen; oral midazolam at a dose of 0.5 mg/kg and nasal or rectal midazolam at a dose of 0.3 mg/kg (maximum 15 mg). Heart rate, blood pressure, oxygen saturation, the Wisconsin Hospital of Children Sedation Scale (CHWSS) score and the Groningen Distress Rating Scale (GDRS) score were recorded. Cystometry measurement values, diagnoses of the cases and procedure durations were recorded from the urodynamic laboratory records. Results 80 female, 44 male cases were evaluated. The CHWSS score at the 10th and 20th minutes after the drug administeration was higher in the oral group than the others (p = 0.001). The duration between the administration of the drug and the start of the procedure was shorter in the nasal group (p = 0.01). Parents satisfaction for sedation was 77 % when comparison of the cystometry with and without sedation. Comparison of the cystometry results with or without sedation no significant difference was found between all parameters (p > 0.01). Conclusion We believe that sedation with midazolam administered through all three routes is a safe, effective and convenient option during cystometry, especially in the young age group.
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Affiliation(s)
- Sengül Özmert
- Department of Anesthesia, Ankara Childrens' Health and Diseases Hematology and Oncology Training and Research Hospital, Kurtdereli Sok, 06110 Ankara, Turkey
| | - Feyza Sever
- Department of Anesthesia, Ankara Childrens' Health and Diseases Hematology and Oncology Training and Research Hospital, Kurtdereli Sok, 06110 Ankara, Turkey
| | - Hüseyin Tuğrul Tiryaki
- Department of Pediatric Urology, Ankara Childrens' Health and Diseases Hematology and Oncology Training and Research Hospital, Ankara, Turkey
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Doumit M, Belessis Y, Stelzer-Braid S, Mallitt KA, Rawlinson W, Jaffe A. Diagnostic accuracy and distress associated with oropharyngeal suction in cystic fibrosis. J Cyst Fibros 2016; 15:473-8. [DOI: 10.1016/j.jcf.2015.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 01/13/2023]
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Thacker PG, Collins HR, Hill J. Distress experienced during pediatric VCUGs - a granular, prospective assessment using the brief behavioral distress scale. Pediatr Radiol 2016; 46:660-5. [PMID: 26860095 DOI: 10.1007/s00247-016-3540-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 11/18/2015] [Accepted: 01/06/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In spite of decades of experience with the procedure, controversy persists as to the overall distress experienced by children and the routine need for sedation in children undergoing voiding cystourethrograms (VCUG). Many studies have attempted to address these issues, often divided into one camp that champions routine sedation while another group believes that pretest preparation is often all that is needed. At the root of these issues are some of the limitations of previous studies as most incorporate inherently subjective parental questionnaires to determine distress levels rather than using an objective, unbiased observer. OBJECTIVE The objective of this study is to use a validated and reliable tool (the brief behavioral distress scale) to objectively evaluate the distress experienced during VCUGs. MATERIALS AND METHODS A prospective study of 26 children (ages 3-7 years old) was performed by the pediatric radiology department at a large urban academic medical center. Patients were evaluated for distress during 12 separate VCUG steps beginning with the patient entering the room and ending with the clothing being replaced at study completion. RESULTS Using a general linear model (repeated measures analysis of variance (ANOVA)), significant distress was identified during two phases of the examination, catheter insertion (P-values ranging <0.001-0.19) and the full bladder phase (P-values ranging 0.005-0.043). The mean distress score for catheter insertion (mean: 1.38, standard deviation [SD]: 1.098) was nearly three times higher than the next most distressful step, i.e. full bladder (mean: 0.65, SD: 0.745). Additionally, entering the room was perceived as significantly more distressing than the catheter out (P = 0.016) and clothing replacement phase (P = 0.006). CONCLUSION We find that despite there being significantly increased distress during the catheter insertion and full bladder phases, the distress levels during VCUGs are markedly less than in previous reports. Even the most distressful stage, catheterization, was less stressful than previously reported with levels closer to that of minor distress evinced by comfort-seeking behavior from a parent rather than more significant distress resulting in screaming. Our findings corroborate and expand on the conclusion of the effectiveness of pretest preparation and child life specialist involvement.
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Affiliation(s)
- Paul G Thacker
- Department of Radiology and Radiological Science and Department of Pediatrics, Medical University of South Carolina, MSC 322, 96 Jonathan Lucas St., Charleston, SC, 29425, USA.
| | - Heather R Collins
- Department of Radiology and Radiological Science, Medical University of South Carolina, MSC 322, 96 Jonathan Lucas St., Charleston, SC, 29425, USA
| | - Jeannie Hill
- Department of Radiology and Radiological Science and Department of Pediatrics, Medical University of South Carolina, MSC 322, 96 Jonathan Lucas St., Charleston, SC, 29425, USA
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Thomas A, Miller JL, Couloures K, Johnson PN. Non-Intravenous Sedatives and Analgesics for Procedural Sedation for Imaging Procedures in Pediatric Patients. J Pediatr Pharmacol Ther 2016; 20:418-30. [PMID: 26766932 DOI: 10.5863/1551-6776-20.6.418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to describe the method of delivery, dosage regimens, and outcomes of sedatives administered by extravascular route for imaging procedures in children. METHODS Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Database of Systematic Reviews were searched using keywords "child", "midazolam", "ketamine", dexmedetomidine", "fentanyl", "nitrous oxide", and "imaging." Articles evaluating the use of extravascular sedation in children for imaging procedures published in English between 1946 and March 2015 were included. Two authors independently screened each article for inclusion. Reports were excluded if they did not contain sufficient details on dosage regimens and outcomes. RESULTS Twenty reports representing 1,412 patients ranging in age from 0.33 to 19 years of age were included for analysis. Due to discrepancies in doses and types of analyses, statistical analyses were not performed. Oral midazolam was the most common agent evaluated; other agents included intranasal (IN) ketamine, IN midazolam, IN fentanyl, IN and transmucosal dexmedetomidine, and N2O. Most agents were considered efficacious compared with placebo. CONCLUSIONS Most agents showed efficacy for sedation during imaging when delivered through an extra-vascular route. Selection of agents should be based on onset time, duration, patient acceptability, recovery time, and adverse events. More robust studies are necessary to determine the optimal agent and route to utilize for imaging procedures when sedation is needed.
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Affiliation(s)
- Amber Thomas
- Department of Pharmacy, Clinical and Administrative Sciences,College of Pharmacy, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jamie L Miller
- Department of Pharmacy, Clinical and Administrative Sciences,College of Pharmacy, University of Oklahoma, Oklahoma City, Oklahoma
| | | | - Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences,College of Pharmacy, University of Oklahoma, Oklahoma City, Oklahoma
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Azarfar A, Esmaeeili M, Farrokh A, Alamdaran A, Keykhosravi A, Neamatshahi M, Hebrani A, Ravanshad Y. Oral midazolam for voiding dysfunction in children undergoing voiding cystourethrography: a controlled randomized clinical trial. Nephrourol Mon 2014; 6:e17168. [PMID: 25032141 PMCID: PMC4090665 DOI: 10.5812/numonthly.17168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 03/04/2014] [Indexed: 11/22/2022] Open
Abstract
Background: Voiding Cystourethrography (VCUG) is the gold standard of detecting and grading the vesicoureteral reflux. Moreover, VCUG is a part of the standard review for infants and children with a urinary tract infection and urinary dysfunction. Objectives: The purpose of our study was to compare using oral midazolam in contrast to prescribing no sedative medication for voiding dysfunction in children undergoing VCUG. Patients and Methods: In a clinical trial, we studied 84 children referred for VCUG. Children were allocated randomly into two equal groups. The intervention group received 0.5 mg/kg midazolam orally half an hour before the VCUG procedure. Then both groups were compared using statistical methods. Results: Then both groups were compared using statistical methods. In more than half of the patients, the main cause of performing VCUG was urinary tract infection. Dysuria was evaluated immediately after VCUG and was more frequent in girls than in boys (P = 0.006). After one week, the urinary irritation and restlessness in the intervention group was significantly lower than the control group. Conclusion: The use of midazolam 0.5 mg/kg reduced children's stress and increased their cooperation during the procedure.
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Affiliation(s)
- Anoush Azarfar
- Department of Pediatric, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mohammad Esmaeeili
- Department of Pediatric, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Azadeh Farrokh
- Department of Pediatric, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Ali Alamdaran
- Department of Radiology, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Aghilallah Keykhosravi
- Department of Pediatric, Vaseei Hospital, Sabzevar University of Medical Sciences, Sabzevar, IR Iran
| | - Mahboobe Neamatshahi
- Department of Social Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Alireza Hebrani
- Department of Radiology, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Yalda Ravanshad
- Education Development Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding author: Yalda Ravanshad, Education Development Center, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel/Fax: +98-5118713640, E-mail:
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Lachenmyer LL, Anderson JJ, Clayton DB, Thomas JC, Pope JC, Adams MC, Brock JW, Tanaka ST. Analysis of an intervention to reduce parental anxiety prior to voiding cystourethrogram. J Pediatr Urol 2013; 9:1223-8. [PMID: 23769752 DOI: 10.1016/j.jpurol.2013.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The voiding cystourethrogram (VCUG) is a common imaging test in pediatric urology that can be associated with anxiety in the child and parent. We hypothesized that education by mailed brochure would decrease pre-procedure parental anxiety. METHODS Families of children scheduled for VCUG were randomized into an experimental group that was mailed an educational brochure about the VCUG and a control group. Immediately prior to the procedure, parental anxiety was assessed with the self-administered State-Trait Anxiety Inventory (STAI). The parent repeated the STAI at home after the VCUG and answered brief questions about educational resources used to prepare for the VUCG. RESULTS We enrolled 105 families (47 experimental, 58 control). Parental state anxiety was higher before the procedure than after the procedure (p < 0.001). Younger parents had greater pre-procedure state anxiety (p = 0.007). Contrary to our expectations, pre-procedure state anxiety did not differ between control and experimental groups. However, parents in the experimental group demonstrated less anxiety with some individual items in the questionnaire. CONCLUSION An educational brochure mailed to families prior to VCUG did not decrease pre-procedure parental state anxiety. However, the educational brochure can ensure accurate dissemination of information to help families prepare for this potentially distressing procedure.
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Affiliation(s)
- Lisa L Lachenmyer
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Gebarski KS, Daley J, Gebarski MW, Keshavarzi N, Hernandez RJ, Ivanzic V, Gebarski SS. Efficacy of a cartoon and photograph montage storybook in preparing children for voiding cystourethrogram. Pediatr Radiol 2013; 43:1485-90. [PMID: 23703228 DOI: 10.1007/s00247-013-2713-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/09/2013] [Accepted: 04/10/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Undergoing voiding cystourethrogram (VCUG) can be distressing for children. OBJECTIVE To assess the efficacy of a cartoon and photograph montage storybook in preparing children for VCUG. MATERIALS AND METHODS Outpatient children (ages 2-14 years) who had VCUGs between December 2011 and June 2012 were randomly assigned to two groups; one group received the storybook a week before the procedure. Parents and guardians were asked to complete an anonymous survey rating their child's tolerance of the exam from 1 to 5, worst to best, immediately after VCUG. The VCUG technologist also rated the child's tolerance. RESULTS Children prepared for VCUG with the storybook had less distress than those without. Results were analyzed by Cochran-Mantel-Haenszel and Cochran-Armitage Trend exact tests, a P value of both tests of 0.0092 indicating a statistically significant difference between the tolerance scores of children prepared with the storybook and those without. Effects of gender and history of VCUG were not statistically significant. Two-thirds of all children had no other source of information. CONCLUSION The cartoon and photograph montage storybook format of preparing children for VCUG was effective in increasing their tolerance for the procedure. The storybook should be mailed out in advance because the majority of families did not pursue information on preparing their children for VCUG.
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Affiliation(s)
- Kathleen S Gebarski
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA,
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Thevaraja AK, Batra YK, Rakesh SV, Panda NB, Rao KLN, Chhabra M, Aggarwal M. Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study. Paediatr Anaesth 2013; 23:415-21. [PMID: 23061785 DOI: 10.1111/pan.12046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2012] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics. MATERIALS AND METHODS ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1)) followed by infusion of 10-20 μg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1)) followed by 1-2 μg·kg(-1) ·min(-1). The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002). RESULTS A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly. CONCLUSIONS Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.
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Affiliation(s)
- Arun K Thevaraja
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Affiliation(s)
- Karen Blumberg
- Department of Radiology, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Ave., Minneapolis, MN 55404, USA.
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Rao J, Kennedy SE, Cohen S, Rosenberg AR. A systematic review of interventions for reducing pain and distress in children undergoing voiding cystourethrography. Acta Paediatr 2012; 101:224-9. [PMID: 21981332 DOI: 10.1111/j.1651-2227.2011.02482.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria. CONCLUSION Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.
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Affiliation(s)
- Jia Rao
- Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
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Ferguson GG, Chen C, Yan Y, Royer ME, Campigotto M, Traxel EJ, Coplen DE, Austin PF. The Efficacy of Oral Midazolam for Decreasing Anxiety in Children Undergoing Voiding Cystourethrogram: A Randomized, Double-Blind, Placebo Controlled Study. J Urol 2011; 185:2542-6. [DOI: 10.1016/j.juro.2011.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Genoa G. Ferguson
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Cathy Chen
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Yan Yan
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Michele E. Royer
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Mary Campigotto
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Erica J. Traxel
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas E. Coplen
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
| | - Paul F. Austin
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
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Sandy NS, Nguyen HT, Ziniel SI, Minnillo BJ, Penna FJ, Franceschi AM, Chow JS. Assessment of Parental Satisfaction in Children Undergoing Voiding Cystourethrography Without Sedation. J Urol 2011; 185:658-62. [DOI: 10.1016/j.juro.2010.09.120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Indexed: 11/30/2022]
Affiliation(s)
- Natascha S. Sandy
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Hiep T. Nguyen
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Sonja I. Ziniel
- Clinical Research Program, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Brian J. Minnillo
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Frank J. Penna
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Angela M. Franceschi
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Jeanne S. Chow
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
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Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study. J Pediatr Urol 2009; 5:336-41. [PMID: 19570724 PMCID: PMC3163089 DOI: 10.1016/j.jpurol.2009.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 05/13/2009] [Indexed: 11/22/2022]
Abstract
UNLABELLED The current management of vesicoureteral reflux (VUR) focuses on the prevention of urinary tract infections (UTI), with curative surgery being limited to those children that fail conservative measures. This is based on the assumption that UTIs are preventable with the use of prophylatic antibiotics, leading to reduction of renal scarring, and the possibility that VUR in children can resolve spontaneously. METHODS Review of the recent literature has demonstrated a growing concern that antibiotic prophylaxis may not lead to prevention of UTIs. Additionally, data indicate that renal scarring may not be preventable with antibiotic prophylaxis or even surgical correction of VUR. An overview of all of the current controversies is presented in this paper. RESULTS Does antibiotic prophylaxis lead to reduction in UTIs in children with VUR? To address this question, the National Institutes of Health have developed a randomized placebo-controlled study of children with VUR (the RIVUR Study), identified following the development of a UTI. CONCLUSIONS There are far reaching consequences of the results of the RIVUR Study. If antibiotic prophylaxis does not prevent UTI in children with VUR, or lead to reduction in renal scarring, does identification of VUR provide any benefits? Perhaps appropriate treatment of UTI may be all that is necessary for preserving renal function. Final answers will have to wait until the completion of this study.
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Palmer LS. The role of intraoperative cystography following the injection of dextranomer/hyaluronic acid copolymer. J Urol 2008; 179:1118-20; discussion 1121. [PMID: 18206944 DOI: 10.1016/j.juro.2007.10.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Dextranomer/hyaluronic acid copolymer has become a popular bulking agent for subureteral injection in the treatment of vesicoureteral reflux. The success rates are lower compared to ureteral reimplantation, and, therefore, postoperative voiding cystourethrography is required. We sought to determine if post-injection intraoperative cystography can be useful in improving the success rate of injection and replacing the need for the 3 to 4-month postoperative voiding cystourethrogram. MATERIALS AND METHODS Dextranomer/hyaluronic acid copolymer was injected subureterally by a single surgeon until the orifice was crescentic at the dome of the bolus. Contrast material was instilled by gravity into the bladder until capacity was reached and was monitored fluoroscopically. No voiding phase was obtained. The procedure was deemed successful only in the absence of reflux. Postoperative voiding cystourethrography performed at 3 to 4 months postoperatively was used to determine whether antibiotic administration should be discontinued. The results of the 2 cystograms were compared. RESULTS A total of 41 patients (64 ureters) underwent subureteral injection. Intraoperative post-injection cystogram documented reflux eradication after a single injection in 96.9% of ureters and 95.1% of patients. Two boys had persistent reflux and 1 girl had new contralateral reflux after a single injection. In these cases additional bulking agent was injected and the reflux was confirmed by a second cystogram. There were 32 patients (52 ureters) who underwent intraoperative post-injection cystography plus postoperative voiding cystourethrography at 3 to 4 months. Postoperative voiding cystourethrography documented a 77% ureteral and 69% patient success rate. None of the patients with post-injection reflux had postoperative reflux at 3 to 4 months. CONCLUSIONS Intraoperative cystography following dextranomer/hyaluronic acid copolymer injection may help to determine immediate success and identify cases of new contralateral reflux. However, there is insufficient correlation with the standard 3 to 4-month postoperative cystogram to advocate replacing the current standard postoperative voiding cystourethrography with an intraoperative cystogram.
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Affiliation(s)
- Lane S Palmer
- Division of Pediatric Urology, Schneider Children's Hospital and Smith Institute for Urology of North Shore-Long Island Jewish Health System, Long Island, New York, USA
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Herd DW. Anxiety in children undergoing VCUG: sedation or no sedation? Adv Urol 2008; 2008:498614. [PMID: 18615194 PMCID: PMC2443423 DOI: 10.1155/2008/498614] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 05/14/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Voiding cystourethrograms are distressing for children and parents. Nonpharmacological methods reduce distress. Pharmacological interventions for VCUG focus on sedation as well as analgesia, anxiolysis, and amnesia. Sedation has cost, time, and safety issues. Which agents and route should we use? Are we sure that sedation does not influence the ability to diagnose vesicoureteric reflux? METHODS Literature search of Medline, EMBASE, and the Cochrane Database. Review of comparative studies found. RESULTS Seven comparative studies including two randomised controlled trials were reviewed. Midazolam given orally (0.5-0.6 mg/kg) or intranasally (0.2 mg/kg) is effective with no apparent effect on voiding dynamics. Insufficient evidence to recommend other sedating agents was found. Deeper sedating agents may interfere with voiding dynamics. CONCLUSION Midazolam reduces the VCUG distress, causes amnesia, and does not appear to interfere with voiding dynamics. Midazolam combined with simple analgesia is an effective method to reduce distress to children undergoing VCUG.
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Affiliation(s)
- David W Herd
- Department of Paediatrics, Starship Children's Hospital, University of Auckland, Private Bag 92024, Auckland, New Zealand.
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