Sedation with propofol for flexible bronchoscopy in children

Nonbacterial Respiratory Pathogens Following the Easing of COVID-19 Restrictive Measures

Nonbacterial respiratory pathogens are major acute respiratory infection (ARI) agents in children. We aimed to characterize the epidemiological changes in 11 common nonbacterial pathogens after easing COVID-19 restrictions in Zhejiang, China, to guide prevention and treatment. A retrospective study was conducted on children with ARIs at Children's Hospital, Zhejiang University School of Medicine in 2023, and epidemiological characteristics were analyzed for gender, age, month, sampling method, and immune status. In total, 59.48% of the children identified pathogens, and Mycoplasma pneumoniae ranked first. Various pathogens showed new features regarding detection rates, seasonal patterns, and susceptible populations. The host age, onset time, sampling method, and immunity status affected the mixed infection rate and unusual coinfection pairs emerged. The epidemiology of respiratory pathogens among children in Zhejiang has changed with local characteristics, and possible preventive actions are needed.

Creation and Implementation of a Hospitalist-Run Propofol Sedation Program

BACKGROUND

Pediatric hospitalists increasingly provide sedation outside the operating room. Given the large body of safety data available, propofol was identified as a beneficial addition to our hospitalist-run sedation service's medication repertoire. Currently, the training required for hospitalists to provide sedation is defined and determined locally by individual institutions.

METHODS

We convened a task force to develop and implement training for hospitalists in the use of propofol for deep sedation. After implementing training, we analyzed the outcome of patients receiving propofol for deep sedation for MRI, including the adverse event rate and successful completion rate. An adverse event was defined as a significant desaturation, persistent upper airway obstruction, laryngospasm, administration of neuromuscular blockade, conversion to anesthesia, call for additional backup, or if the procedure was not able to be completed. Successful completion was defined as any patient being able to complete the imaging study or procedure with sedation performed by a hospitalist physician.

RESULTS

Between September 2015 and September 2018, sedation services sedated 12 979 patients, 3929 of whom were deeply sedated with propofol. During this period, the trained hospitalists had an adverse event rate of 3.6% and a 98.9% rate of successful completion of all studies or procedures when using propofol for deep sedation.

CONCLUSION

With a comprehensive training program for hospitalists in the administration of propofol, we provided effective sedation for a selective population of patients. We now have a standard approach that uses credentialed hospitalists to train new faculty for propofol administration.

Pediatric Airway Endoscopy: Recommendations of the Society for Pediatric Pneumology

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy

AIM

To evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy.

METHODS

A retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants (less than 12 mo), toddlers (1-3 years) and children (4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed.

RESULTS

Of the total 458 bronchoscopies performed, propofol only regimen was used in 337 (74%) while propofol and ketamine was used in 121 (26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be younger and have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia.

CONCLUSION

Children can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers.

A presedation fluid bolus does not decrease the incidence of propofol-induced hypotension in pediatric patients

BACKGROUND AND OBJECTIVE

Propofol is commonly used in pediatric sedation, which may cause hypotension during induction. Our goal was to determine the effect of a preinduction 20-mL/kg isotonic fluid bolus on propofol-induced hypotension, assess clinical signs of hypoperfusion during hypotension, and evaluate for age-related propofol dosing differences.

METHODS

This prospective, randomized, controlled, nonblinded study was conducted at Children's Hospital of Illinois. Patients were children 6 to 60 months of age who needed sedation for MRI or auditory brainstem-evoked response testing. The treatment group received a preinduction 20-mL/kg isotonic saline bolus before procedure initiation. Patients were continuously monitored via cardiorespiratory monitor with pulse oximetry and end-tidal carbon dioxide measurements. Cardiovascular indices and clinical signs of hypoperfusion were compared between groups, and propofol dosing differences were compared between age groups.

RESULTS

One hundred twenty-six patients were randomly assigned to treatment (n=52) or control (n=74) conditions. Twelve patients in the treatment group and 14 patients in the control group experienced postinduction hypotension, as defined by the Pediatric Advanced Life Support guidelines. One patient in each group was given volume resuscitation when blood pressure did not improve after a reduction in the propofol infusion rate. No hypotensive patients had physical signs of hypoperfusion, and patients≤1 year of age needed significantly more propofol.

CONCLUSIONS

A 20-mL/kg preinduction isotonic saline bolus does not prevent propofol-induced hypotension. No clinical signs of hypoperfusion were noted with induced hypotension, and infants≤12 months old need significantly more propofol per kilogram for procedures.

Percutaneous closure of atrial septal defects in spontaneously breathing children under deep sedation: a feasible and safe concept

Interventional cardiac catheterization in children and adolescents is traditionally performed with the patient under general anesthesia and endotracheal intubation. However, percutaneous closure of atrial septum defect (ASD) without general anaesthesia is currently being attempted in a growing number of children. The study objective was to evaluate the success and complication rate of percutaneous ASD closure in spontaneously breathing children under deep sedation. Retrospective single centre cohort study of consecutive children undergoing percutaneous ASD closure at a tertiary care pediatric cardiology centre. Transesophageal echocardiography (TEE) and percutaneous ASD closure were performed with the patient under deep sedation with intravenous bolus of midazolam and ketamine for induction and propofol continuous infusion for maintenance of sedation in spontaneously breathing children. One hundred and ninety-seven patients (median age 6.1 years [minimum 0.5; maximum 18.8]) underwent TEE and ASD balloon sizing. Percutaneous ASD closure was attempted in 174 patients (88 %), and device implantation was performed successfully in 92 %. To achieve sufficient deep sedation, patients received a median ketamine dose of 2.7 mg/kg (0.3; 7) followed by a median propofol continuous infusion rate of 5 mg/kg/h (1.1; 10.7). There were no major cardiorespiratory complications associated with deep sedation, and only two patients (1 %) required endotracheal intubation due to bronchial obstruction immediately after induction of sedation. Seventeen patients (8 %) had minor respiratory complications and required frequent oral suctioning or temporary bag-mask ventilation. TEE and percutaneous ASD closure can be performed safely and successfully under deep sedation in spontaneously breathing children of all ages.

Plastic bronchitis in children

Cast or plastic bronchitis (PB) is an unusual disorder that is rarely encountered in children. Plastic bronchitis is characterized by widespread formation of casts in the tracheobronchial tree with partial or complete airway obstruction. The pathologist may receive bronchial casts that have been removed by bronchoscopy for gross and histopathologic analysis. We describe two children with PB in the setting of an apparent lower respiratory tract infection, where the bronchoscopic removal of major cast segments was associated with a favorable outcome. Patients' clinical and radiographic features and gross anatomic and histopathologic characteristics of casts are presented.

Pediatric sedation--evolution and revolution

Pediatric sedation continues to change in terms of the professionals who provide this care, those who produce original research on this topic, guidelines and literature concerning risk, medications employed, and methods for training for new providers. Some of the changes could be categorized as 'evolutionary' or gradual in nature and predictable - such as the changing role of anesthesiologists in the field of pediatric sedation and the use of the well-established dissociative sedative, ketamine. Other changes in pediatric sedation are more radical or 'revolutionary'. They include reconsideration of what is defined as an 'adverse event' during sedation, the use of propofol or dexmedetomidine, and the application of human patient simulation for training. This review will highlight the ongoing changes in the dynamic field of pediatric sedation by focusing on some of the important progress (both evolutionary and revolutionary) that has occurred across the varied specialties that provide this care.

Use of ketofol for procedural sedation and analgesia in children with hematological diseases

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine-propofol admixture ("ketofol") in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration.

METHODS

This was a prospective, observational pilot study. Patients aged between 4 and 12 years requiring sedation for bone marrow aspiration were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was given intravenously in 0.5 mg/kg aliquots each with a 1-min interval and titrated to reach sedation levels of 3 or 4 (Ramsay score). The primary outcome was patient satisfaction with the degree of sedation. Secondary outcomes included injection pain, total sedation time, recovery time, hemodynamic and respiratory parameters, and adverse events.

RESULTS

A total of 20 patients were enrolled in the study. The median total dose of ketofol administered was 1.25 mg/kg each of propofol and ketamine (95%CI 0.77-2 mg/kg). The median score on the visual analog scale was 0 (extremely comfortable) (0-1.5; 95%CI 0.2-2.2). Median recovery time was 23 min (20.5-28 min; 95%CI 17.1-51.2). The incidence of injection pain was 2/20. Two patients had transient diplopia and one child reported dreams. No patients had hypotension, vomiting or required airway intervention.

CONCLUSION

Ketofol provided effective sedation, which was reflected in the high degree of satisfaction recorded by children requiring procedural sedation and analgesia for bone marrow aspiration. We also observed rapid recovery and no clinically significant complications. A large number of patients is required to evaluate and validate these findings.