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Wang JY, Speechley K, Anderson KK, Gainham G, Ali S, Trottier ED, Sabhaney V, Heath A, Sich C, Forbes A, Poonai N. Intranasal midazolam for procedural distress in children in the emergency department: a systematic review and meta-analysis. CAN J EMERG MED 2024; 26:658-670. [PMID: 39198327 DOI: 10.1007/s43678-024-00731-2] [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: 03/25/2024] [Accepted: 05/27/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVES Intranasal (IN) midazolam is the most common anxiolytic for children in the emergency department (ED), but evidence of benefit is conflicting. We synthesized the evidence on IN midazolam for procedural distress in children undergoing ED painful procedures. METHODS We included trials involving painful ED procedures in children 0-18 years involving IN midazolam. Primary outcome was procedural distress. We summarized results using Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," and "unfavorable" (p < 0.05), supporting IN midazolam or comparator, respectively, or "indeterminate" (unable to judge). Where possible, we pooled results using meta-analysis. Methodologic quality of evidence was evaluated using Cochrane Collaboration's risk of bias tool and GRADE system. RESULTS We included 41 trials (n = 2973 participants). Thirty trials involved intravenous insertion. IN midazolam was superior to placebo (RR = 7.2; 95% CI: 3.43, 15.25; 3 trials; I2 = 0%). However, 56-90% of the IN midazolam group resisted the procedure. Focusing on the three trials that used validated measures, IN midazolam was "neutral" versus IN ketamine and either "neutral" or "unfavorable" versus IN dexmedetomidine. There was no difference in the proportion of children with a satisfactory distress score between IN midazolam and oral midazolam (RR = 1.1; 95% CI: 0.74, 1.73; 2 trials; I2 = 53%), IN ketamine (RR = 1.1; 95% CI: 0.91, 1.25; 6 trials; I2 = 0%), or IN dexmedetomidine (RR = 0.4; 95% CI: 0.17, 1.05; 3 trials; I2 = 84%). Ten trials involved laceration repair. IN midazolam was "favorable" versus placebo; however, both groups scored in the anxious range. There was no difference in distress between IN midazolam and oral midazolam (SMD = 0.01; 95% CI:-0.32, 0.34; 2 trials; I2 = 0%) (Fig. 3E) [64,65]. Using validated instruments, IN midazolam was "unfavorable" versus IN dexmedetomidine but "favorable" versus oral diazepam and placebo. CONCLUSIONS There is limited methodologically rigorous evidence that IN midazolam is better than placebo for IV insertion and laceration repair. At the doses studied, preliminary evidence suggests that IN dexmedetomidine may be superior to IN midazolam for both IV insertion and laceration repair.
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Affiliation(s)
- Jie Yi Wang
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Kathy Speechley
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
- Children's Health Research Institute, Lawson Health Research Institute, London, ON, Canada
| | - Kelly K Anderson
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
- Children's Health Research Institute, Lawson Health Research Institute, London, ON, Canada
| | - George Gainham
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Evelyn D Trottier
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Vikram Sabhaney
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Statistical Science, University College London, London, UK
| | - Christy Sich
- Western Libraries, Western University, London, ON, Canada
| | - Arielle Forbes
- Department of Emergency Medicine, London Health Sciences Center, London, ON, Canada
| | - Naveen Poonai
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Western University, London, ON, Canada.
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.
- Children's Health Research Institute, Lawson Health Research Institute, London, ON, Canada.
- Children's Hospital, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, ON, Canada.
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Mondardini MC, Pezzato S, Meneghini L, Agostiniani R, De Cassai A, D'Errico I, Minardi C, Sagredini R, Sbaraglia F, Testoni C, Toni F, Vason M, Amigoni A. Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI). Paediatr Anaesth 2024. [PMID: 38808388 DOI: 10.1111/pan.14936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others. AIMS To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology. METHODS An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method. RESULTS Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability. CONCLUSIONS This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.
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Affiliation(s)
| | - Stefano Pezzato
- Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luisa Meneghini
- Department of Pediatric Surgery, University Hospital of Padova, Padova, Italy
| | | | - Alessandro De Cassai
- Department of Medicine, Anaesthesia and Intensive Care Unit, University Hospital of Padova, Padova, Italy
| | - Ignazio D'Errico
- Department of Neuroradiology, University Hospital of Padova, Padova, Italy
| | - Carmelo Minardi
- Department of Anesthesiology, AOU Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Raffaella Sagredini
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Gemelli IRCCS, Sacro Cuore Catholic University, Rome, Italy
| | - Caterina Testoni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesco Toni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Milo Vason
- Department of Emergency, Anaesthesiology and Intensive Care Unit, Arcispedale Sant'Anna, University of Ferrara, Cona, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, University Hospital of Padova, Padova, Italy
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Siu A, Tran NA, Ali S, Coyle D, Mahood Q, Marks Y, Pechlivanoglou P, Poonai N, Heath A. Pharmacologic Procedural Distress Management During Laceration Repair in Children: A Systematic Review. Pediatr Emerg Care 2024; 40:88-97. [PMID: 37487548 DOI: 10.1097/pec.0000000000003020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
OBJECTIVES To systematically appraise the literature on the relative effectiveness of pharmacologic procedural distress management agents for children undergoing laceration repair. METHODS Six databases were searched in August 2021, and the search was updated in January 2023. We included completed randomized or quasi-randomized trials involving ( a ) children younger than 15 years undergoing laceration repair in the emergency department; ( b ) randomization to at least one anxiolytic, sedative, and/or analgesic agent versus any comparator agent or placebo; ( c ) efficacy of procedural distress management measured on any scale. Secondary outcomes were pain during the procedure, administration acceptance, sedation duration, additional sedation, length of stay, and stakeholder satisfaction. Cochrane Collaboration's risk-of-bias tool assessed individual studies. Ranges and proportions summarized results where applicable. RESULTS Among 21 trials (n = 1621 participants), the most commonly studied anxiolytic agents were midazolam, ketamine, and N 2 O. Oral midazolam, oral ketamine, and N 2 O were found to reduce procedural distress more effectively than their comparators in 4, 3, and 2 studies, respectively. Eight studies comparing routes, doses, or volumes of administration of the same agent led to indeterminate results. Meta-analysis was not performed because of heterogeneity in comparators, routes, and outcome measures across studies. CONCLUSIONS Based on procedural distress reduction, this study favors oral midazolam and oral ketamine. However, this finding should be interpreted with caution because of heterogeneous comparators across studies and minor conflicting results. An optimal agent for procedural distress management cannot be recommended based on the limited evidence. Future research should seek to identify the minimal, essential measures of patient distress during pharmacologic anxiolysis and/or sedation in laceration repair to guide future trials and reviews.
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Affiliation(s)
| | - Nam-Anh Tran
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa
| | | | - Yanara Marks
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario
| | | | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London
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Trotter Z, Mecham C, Bhattarai B. Physician Self-Reported Practice Patterns: Midazolam for Minor Procedures in Pediatric Patients. Clin Pediatr (Phila) 2023; 62:605-614. [PMID: 36468676 DOI: 10.1177/00099228221132020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Midazolam is frequently used as a single agent to provide minimal sedation (also called anxiolysis) when performing procedures in minor children. Published guidelines on the optimal use of intranasal (INM) and oral midazolam (POM) are lacking. The purpose of this study is to explore the self-reported physician practice related to midazolam use in facilitating minor procedures in children. We developed a survey that was approved by the Academy of Pediatrics Section on Emergency Medicine (APP-SOEM) and was then electronically distributed via its listserve. Questions were posed about the therapeutic and maximum dosing of INM and POM, consideration of Nothing-By-Mouth (NPO) status, use of cardiopulmonary monitors, as well as discharge criteria. There was a 47% (218/465) response rate. For therapeutic INM doses, 65% of responders used a dose range of 0.3 to 0.6 mg/kg, and 75% selected a maximum dose of 10 mg irrespective of the child's weight. About 20% of the responders selected a dosage range of 0.7 to 1 mg/kg for therapeutic POM dose, with 43% opting for a maximum dose of 20 mg irrespective of the child's weight. We observed a dichotomous variation in reported physician use of cardiopulmonary monitors; 42% never employ monitors, and the remainder used monitors some of the time. There was consensus on the NPO status and discharge criteria; 80% of physicians did not consider NPO status prior to midazolam use. The level of alertness was the most commonly selected discharge criterion. This nationwide survey of physicians indicates practice variation with midazolam dosing and cardiopulmonary monitor usage when performing minor procedures in children. Implementing practice guidelines, specifically for minimal sedation with mainstay agents such as midazolam, may standardize physician practice and improve overall patient care.
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Affiliation(s)
- Zola Trotter
- Valleywise Health Medical Center, Phoenix, AZ, USA
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Morgan LA, Hrachovec JB, Goodkin HP. Pediatric Status Epilepticus: Treat Early and Avoid Delays. Paediatr Drugs 2023:10.1007/s40272-023-00570-1. [PMID: 37178271 DOI: 10.1007/s40272-023-00570-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Abstract
Pediatric convulsive status epilepticus (cSE) is a neurologic emergency with potential for morbidity and mortality. Rapid treatment and escalation of therapies to achieve early seizure control is paramount in preventing complications and providing the best patient outcomes. Although guidelines recommend early treatment, cessation of out-of-hospital SE is undermined by treatment delay and inadequate dosing. Logistical challenges include prompt seizure recognition, first-line benzodiazepine (BZD) availability, comfort and expertise in administration of BZD, and timely arrival of emergency personnel. In-hospital, SE onset is additionally impacted by delays to first- and second-line treatment and availability of resources. This review presents an evidence-based, clinically oriented review of pediatric cSE, including its definitions and treatments. It provides evidence and rationale for timely treatment of first-line BZD treatment followed by prompt escalation to second-line antiseizure medication therapies for established SE. Treatment delays and barriers to care are discussed, with practical considerations for opportunities for areas of improvement in the initial treatment of cSE.
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Affiliation(s)
- Lindsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, 4800 Sand Point Way NE, Neurology, MB.7.420, Seattle, WA, 98105, USA.
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Jennifer B Hrachovec
- Quality and Clinical Effectiveness, Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, WA, USA
| | - Howard P Goodkin
- Departments of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
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Comparison of sedative effects of intramuscular and intranasal midazolam for pediatric laceration repair in dental emergency department: A randomized controlled study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101396. [PMID: 36707049 DOI: 10.1016/j.jormas.2023.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/16/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
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Drug delivery to the brain via the nasal route of administration: exploration of key targets and major consideration factors. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2023; 53:119-152. [PMID: 35910081 PMCID: PMC9308891 DOI: 10.1007/s40005-022-00589-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/30/2022] [Indexed: 01/06/2023]
Abstract
Background Cranial nerve-related diseases such as brain tumors, Alzheimer's disease, and epilepsy are serious diseases that continue to threaten human. Brain-related diseases are increasing worldwide, including in the United States and Korea, and these increases are closely related to the exposure to harmful substances and excessive stress caused by rapid industrialization and environmental pollution. Drug delivery to the brain is very important for the effective prevention and treatment of brain-related diseases. However, due to the presence of the blood-brain barrier and the extensive first-pass metabolism effect, the general routes of administration such as oral and intravenous routes have limitations in drug delivery to the brain. Therefore, as an alternative, the nasal-brain drug delivery route is attracting attention as a route for effective drug delivery to the brain. Areas covered This review includes physiological factors, advantages, limitations, current application status, especially in clinical applications, and the necessary factors for consideration in formulation development related to nasal-brain drug delivery. Expert opinion The nasal-brain drug delivery route has the advantage of enhancing drug delivery to the brain locally, mainly through the olfactory route rather than the systemic circulation. The nasal-brain lymphatic system has recently attracted attention, and it has been implied that the delivery of anticancer drugs to the brain nervous system is possible effectively. However, there are limitations such as low drug permeability, as well as nasal mucosa and the mucociliary system, as obstacles in nasal-brain drug delivery. Therefore, to overcome the limitations of nasal-brain drug delivery, the use of nanocarriers and mucoadhesive agents is being attempted. However, very few drugs have been officially approved for clinical application via the nasal-brain drug delivery route. This is probably because the understanding of and related studies on nasal-brain drug delivery are limited. In this review, we tried to explore the major considerations and target factors in drug delivery through the nasal-brain route based on physiological knowledge and formulation research information. This will help to provide a mechanistic understanding of drug delivery through the nasal-brain route and bring us one step closer to developing effective formulations and drugs in consideration of the key factors for nasal-brain drug delivery.
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Gu H, Miao L, Bai J, Lu G, Lei Q, Yang L, Wang D. Combined use of intranasal Dexmedetomidine and an oral novel formulation of Midazolam for sedation of young children during brain MRI examination: a prospective, single-center, randomized controlled trial. BMC Anesthesiol 2022; 22:357. [PMID: 36418946 PMCID: PMC9685922 DOI: 10.1186/s12871-022-01897-x] [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: 06/01/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To evaluate the safety and effectiveness of different dosages of intranasal Dexmedetomidine (DEX) in combination with oral midazolam for sedation of young children during brain MRI examination. METHODS Included in this prospective single-blind randomized controlled trial were 156 children aged from 3 months to 6 years and weighing from 4 to 20 Kg with ASA I-II who underwent brain MRI examination between March 2021 and February 2022. Using the random number table method, they were divided into group A (using 3 ug/kg intranasal DEX plus 0.2 mg/Kg oral midazolam) and group B (using 2 ug/kg intranasal DEX plus 0.2 mg/Kg oral Midazolam). The one-time success rate of sedation, sedation onset time, recovery time, overall sedation time, and occurrence of adverse reactions during MRI examination were compared between the two groups. The heart rate (HR), mean arterial pressure (MAP), and percutaneous SpO2before and after drug administration were observed in both groups. Differences in sedation scores between the two groups were compared before intranasal drug administration (T0), 10 min after drug administration (T1), at the time of falling asleep (T2), at the end of examination (T3), and at the time of recovery (T4). RESULTS The one-time success rate of sedation in group A and B was 88.31% and 79.75% respectively, showing no significant difference between the two groups (P>0.05). The sedation onset time in group A was 24.97±16.94 min versus 27.92±15.83 min in group B, and the recovery time was 61.88±22.18 min versus 61.16±28.16 min, both showing no significance difference between the two groups (P>0.05). Children in both groups exhibited good drug tolerance without presenting nausea and vomiting, hypoxia, or bradycardia and hypotension that needed clinical interventions. There was no significant difference in the occurrence of abnormal HR, MAP or other adverse reactions between the two groups (P>0.05). CONCLUSION 3 ug/kg or 2 ug/kg intranasal DEX in combination with 0.2 mg/kg oral Midazolam both are safe and effective for sedation of children undergoing MRI examination with the advantages of fast-acting and easy application. TRIAL REGISTRATION It was registered at the Chinese Clinical Trial Registry ( ChiCTR1800015038 ) on 02/03/2018.
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Affiliation(s)
- Hongbin Gu
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Liyan Miao
- grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jie Bai
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Guolin Lu
- grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qian Lei
- grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Lijun Yang
- grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Denggui Wang
- grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China ,grid.256112.30000 0004 1797 9307Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Thoene J, Gavin RF, Towne A, Wattay L, Ferrari MG, Navarrete J, Pal R. In vitro activity of cysteamine against SARS-CoV-2 variants. Mol Genet Metab 2022; 137:192-200. [PMID: 36115282 PMCID: PMC9444157 DOI: 10.1016/j.ymgme.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/09/2023]
Abstract
Global COVID-19 pandemic is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Continuous emergence of new variants and their rapid spread are jeopardizing vaccine countermeasures to a significant extent. While currently available vaccines are effective at preventing illness associated with SARS-CoV-2 infection, these have been shown to be less effective at preventing breakthrough infection and transmission from a vaccinated individual to others. Here we demonstrate broad antiviral activity of cysteamine HCl in vitro against major emergent infectious variants of SARS-CoV-2 in a highly permissible Vero cell line. Cysteamine HCl inhibited infection of wild type, alpha, beta, gamma, delta, lambda, and omicron variants effectively. Cysteamine is a very well-tolerated US FDA-approved drug used chronically as a topical ophthalmic solution to treat ocular cystinosis in patients who receive it hourly or QID lifelong at concentrations 6 times higher than that required to inhibit SARS CoV-2 in tissue culture. Application of cysteamine as a topical nasal treatment can potentially1) mitigate existing infection 2) prevent infection in exposed individuals, and 3) limit the contagion in vulnerable populations.
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Affiliation(s)
- Jess Thoene
- Division of Pediatric Genetics, University of Michigan, United States of America.
| | | | - Aaron Towne
- Mechanical Engineering, College of Engineering, University of Michigan, United States of America
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Lynch TV, Callas PW, Peterson TD, Schlein SM. Intranasal Fentanyl for On-the-Hill Analgesia by Ski Patrol. Wilderness Environ Med 2022; 33:296-303. [PMID: 35851192 DOI: 10.1016/j.wem.2022.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Intranasal fentanyl offers a means for safe and effective pain management in austere environments. Prehospital analgesia traditionally involves intravenous or intramuscular medication. However, for wilderness rescuers, these methods are often impractical. METHODS We conducted a retrospective review of health records to evaluate the safety and efficacy of intranasal fentanyl administered by EMT-Basic certified ski patrollers. Our primary aim was to measure the reduction in initial pain scores to subsequent measurements at 5, 10, and 15 min using the pain numeric rating scale (0-10). Clinically significant reduction in severe pain has been established as ≥1.8 points. We used paired t-tests and multilevel modeling to measure statistical significance and potential interactions and reviewed patient charts for adverse events, including respiratory depression or the use of naloxone. RESULTS We compiled the results from the winter seasons for 2007 through 2012 and 2016 through 2020. A total of 247 patients were included. The initial pain score was 8.6±1.5 (mean±SD). The decrease in pain scores from 0 to 5, 10, and 15 min, respectively, was -1.8, -2.4, and -2.9 (P<0.0001), which demonstrated a clinically and statistically significant decrease in pain scores. There were no adverse events. CONCLUSIONS Traditional standard of care analgesics are invasive, elongate scene times, and increase the risk of environmental exposure and provider needlestick. Intranasal fentanyl offers a safe, noninvasive, and rapid analgesia that is well-suited for austere winter environments, such as those encountered at ski resorts. This study demonstrates the safety and efficacy of the administration of intranasal fentanyl by EMT-Basic certified providers.
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Affiliation(s)
- Tierra V Lynch
- Larner College of Medicine, University of Vermont, Burlington, VT.
| | - Peter W Callas
- Larner College of Medicine, University of Vermont, Burlington, VT
| | | | - Sarah M Schlein
- University of Vermont Medical Center, Larner College of Medicine, University of Vermont, Burlington, VT
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11
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Henriques P, Fortuna A, Doktorovová S. Spray dried powders for nasal delivery: Process and formulation considerations. Eur J Pharm Biopharm 2022; 176:1-20. [PMID: 35568256 DOI: 10.1016/j.ejpb.2022.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/18/2022]
Abstract
Powders for nasal delivery have been recognized as advantageous dosage forms over liquids due to increased stability and residence time on nasal mucosa, with improved bioavailability. They can be manufactured by spray-drying, allowing the optimization of the particle properties that are critical to guarantee nasal deposition, as size and shape. It is also a scalable and flexible method already explored extensively in the pharmaceutical industry. However, it is important to understand how process parameters, particle physical properties and formulation considerations affect the product performance. Hence, this review aims to provide an overview of nasal powder formulation and processing through spray drying, with an emphasis on the variables that impact on performance. To this purpose, we describe the physical, biological and pharmacological phenomena prior to drug absorption as well as the most relevant powder properties. Formulation considerations including qualitative and quantitative composition are then reviewed, as well as manufacturing considerations including spray drying relevant parameters.
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Affiliation(s)
- Patrícia Henriques
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; R&D, Drug Product Development, Hovione FarmaCiencia SA, Lisbon, Portugal
| | - Ana Fortuna
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; University of Coimbra, Coimbra Institute for Biomedical Imaging and Translational Research, Coimbra, Portugal
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12
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Gómez-Manzano FJ, Laredo-Aguilera JA, Cobo-Cuenca AI, Rabanales-Sotos J, Rodríguez-Cañamero S, Martín-Espinosa N, Carmona-Torres JM. Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review. CHILDREN 2022; 9:children9050644. [PMID: 35626821 PMCID: PMC9139737 DOI: 10.3390/children9050644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.
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Affiliation(s)
- Francisco Javier Gómez-Manzano
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- IES Juanelo Turriano, Consejería de Educación, Cultura y Deportes de Castilla-La Mancha, 45007 Toledo, Spain
| | - José Alberto Laredo-Aguilera
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- Correspondence: ; Tel.: +34-925-268-800 (ext. 5613)
| | - Ana Isabel Cobo-Cuenca
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
| | | | - Sergio Rodríguez-Cañamero
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
- Hospital Universitario de Toledo, Servicio de Salud de Castilla-La Mancha, 45007 Toledo, Spain
| | - Noelia Martín-Espinosa
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
| | - Juan Manuel Carmona-Torres
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla La Mancha, 45071 Toledo, Spain; (F.J.G.-M.); (A.I.C.-C.); (N.M.-E.); (J.M.C.-T.)
- Grupo de Investigación Multidisciplinar en Cuidados, Universidad de Castilla-La Mancha, 45071 Toledo, Spain;
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Tsze DS, Lubell TR, Carter RC, Chernick LS, DePeter KC, McLaren SH, Kwok MY, Roskind CG, Gonzalez AE, Fan W, Babineau SE, Friedman BW, Dayan PS. Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial. Acad Emerg Med 2022; 29:465-475. [PMID: 34822214 PMCID: PMC10695685 DOI: 10.1111/acem.14422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Tamar R. Lubell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Robert C. Carter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lauren S. Chernick
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kerrin C. DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Son H. McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maria Y. Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Cindy G. Roskind
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ariana E. Gonzalez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shannon E. Babineau
- Departments of Pediatrics and Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Morristown, New Jersey, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Peter S. Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Anderson T, Harrell C, Snider M, Kink R. The Safety of High-Dose Intranasal Fentanyl in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e447-e450. [PMID: 35100749 DOI: 10.1097/pec.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to determine if the use of intranasal (IN) fentanyl in the pediatric emergency department of 2 to 5 μg/kg at doses greater than 100 μg is associated with adverse events in pediatric patients. METHODS We performed a retrospective chart review of patients receiving IN fentanyl at an urban, tertiary care emergency department in Memphis, TN, from January 1, 2011, to December 31, 2017. All adverse events documented through the hospital's voluntary safety reporting system involving IN fentanyl were reviewed to determine patient outcomes. RESULTS A total of 3205 patients received greater than 100 μg of IN fentanyl during the study period from 2011 to 2017. The average (SD) patient age was 13.7 (2.65) years, ranging from 5 to 18 years. The mean (SD) initial dose was 162 (30) μg ranging from 102 to 265 μg (2 doses were given greater than 200 μg in the study period). Initial average (SD) dose for weight was 2.62 (0.5) μg/kg. A total of 13 adverse events were documented, with only 3 occurring at doses greater than 100 μg. No patients required the reversal agent naloxone or invasive respiratory support. CONCLUSIONS To our knowledge, this is the first study using doses greater than 100 μg of IN fentanyl in a pediatric population. Our results indicate that fentanyl can be safely administered at doses of greater than 100 μg without any clinically significant adverse outcomes observed for 7 years of use. It is our hope that this information will increase utilization of IN fentanyl for treatment of acute pain in emergency departments and in the prehospital setting.
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Tsze DS, Ieni M, Flores-Sanchez PL, Shen ST, Bregstein JS, O'Connell NC, Dayan PS. Quantification of Pain and Distress Associated With Intranasal Midazolam Administration in Children and Evaluation of Validity of Four Observational Measures. Pediatr Emerg Care 2021; 37:e17-e20. [PMID: 29794957 DOI: 10.1097/pec.0000000000001526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aims of this study were to quantify the pain and distress associated with the administration of intranasal (IN) midazolam in young children using 4 observational measures and to evaluate the degree of validity of these measures. METHODS We conducted a prospective observational pilot study. Children aged 1 to 7 years requiring IN midazolam were enrolled. Children were videotaped, and scores were assigned to baseline and administration phases using the Observational Scale of Behavioral Distress-Revised (OSBD-R), Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), and the Faces-Legs-Activity-Cry-Consolability (FLACC) scale. The cry duration following administration was assessed. Interrater reliability and convergent validity were determined for all 4 measures. Internal consistency and responsivity for the OSBD-R, CHEOPS, and FLACC scales were determined. RESULTS We enrolled 20 children. The mean OSBD-R, CHEOPS, and FLACC scores associated with administration of IN midazolam were 27.1 (SD, 13.5), 11.5 (SD, 1.2), and 8.9 (SD, 2.7), respectively. The mean cry duration was 105.5 (SD, 68.8) seconds. The intraclass correlation coefficients for all measures ranged from 0.82 to 0.99. The Cronbach α's for the OSBD-R, CHEOPS, and FLACC were between 0.71 and 0.97. Pearson correlation coefficients for comparisons between OSBD-R, CHEOPS, and FLACC were between 0.82 and 0.96 but were between 0.32 and 0.51 for comparisons involving cry duration. CONCLUSIONS We have identified estimates of pain and distress associated with administration of IN midazolam in young children that can be used to determine desired effect sizes for trials that study interventions to treat this pain and distress. The OSBD-R, CHEOPS, and FLACC scales are suitable choices for outcome measures.
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Affiliation(s)
- Daniel S Tsze
- From the Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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O'Connell NC, Woodward HA, Flores‐Sanchez PL, McLaren SH, Ieni M, McKinley KW, Shen ST, Dayan PS, Tsze DS. Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial. J Am Coll Emerg Physicians Open 2020; 1:1562-1570. [PMID: 33392564 PMCID: PMC7771777 DOI: 10.1002/emp2.12227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Pain and distress associated with intranasal midazolam administration can be decreased by administering lidocaine before intranasal midazolam (preadministered lidocaine) or combining lidocaine with midazolam in a single solution (coadministered lidocaine). We hypothesized coadministered lidocaine is non-inferior to preadministered lidocaine for decreasing pain and distress associated with intranasal midazolam administration. METHODS Randomized, outcome assessor-blinded, noninferiority trial. Children aged 6 months to 7 years undergoing laceration repair received intranasal midazolam with preadministered or coadministered lidocaine. Pain and distress were evaluated with the Observational Scale of Behavioral Distress-Revised (OSBD-R) (primary outcome; non-inferiority margin 1.8 units) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Faces, Legs, Activity, Cry, Consolability (FLACC) scales and cry duration (secondary outcomes). Secondary outcomes also included adverse events, clinician and caregiver satisfaction, and pain and distress associated with intranasal lidocaine administration. RESULTS Fifty-one patients were analyzed. Mean OSBD-R scores associated with intranasal midazolam administration were 6.4 (95% confidence interval [CI] 5, 7.8) and 7 (95% CI 5.2, 8.9) units for preadministered and coadministered lidocaine, respectively. The difference of 0.6 (95% CI -1.7, 2.8) units represented an inconclusive non-inferiority determination. CHEOPS and FLACC scores and cry duration were similar between groups. OSBD-R, CHEOPS, and FLACC scores and cry duration associated with intranasal lidocaine administration were 3.8, 9.9, and 6 units, and 56 seconds, respectively. Clinicians considered coadministered lidocaine easier to administer. CONCLUSION Pain and distress associated with intranasal midazolam administration were similar when using coadministered or preadministered lidocaine, but our non-inferiority determination was inconclusive. Administration of intranasal lidocaine by itself was associated with a measurable degree of pain and distress.Keywords: intranasal, midazolam, anxiolysis, sedation, emergency department, emergency medicine, pain, distress, pediatric, lidocaine, laceration.
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Affiliation(s)
- Nicole C. O'Connell
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
- Department of Emergency MedicineWestchester Medical CenterValhallaNew YorkUSA
| | - Hilary A. Woodward
- Department of Child LifeNewYork‐Presbyterian Morgan Stanley Children's HospitalNew YorkNew YorkUSA
| | - Pamela L. Flores‐Sanchez
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Son H. McLaren
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Maria Ieni
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Kenneth W. McKinley
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
- Division of Pediatric Emergency MedicineChildren's National HospitalWashingtonDCUSA
| | - Sripriya T. Shen
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Peter S. Dayan
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Daniel S. Tsze
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
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Mayel M, Nejad MA, Khabaz MS, Bazrafshani MS, Mohajeri E. Intranasal midazolam sedation as an effective sedation route in pediatric patients for radiologic imaging in the emergency ward: A single-blind randomized trial. Turk J Emerg Med 2020; 20:168-174. [PMID: 33089024 PMCID: PMC7549517 DOI: 10.4103/2452-2473.297461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/21/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES: Prevention and reduction of pain, anxiety, and fear during medical procedures is one of the most important factors that should be considered in pediatric emergencies. The aim of this study was to compare the efficacy of oral versus intranasal midazolam in sedation during radiologic imaging in the largest province of Iran, Kerman. MATERIALS AND METHODS: Eighty children were enrolled in this single-blind clinical trial based on convenience sampling and were divided into two groups receiving 0.5 mg/kg midazolam in oral route administration and 0.2 mg/kg midazolam in intranasal route administration. Finally, 75 patients remained for evaluating medication acceptability, sedation level, onset time of sedation, additional sedative dose, adverse effects of sedation, and provider satisfaction. RESULTS: Children in the intranasal group accepted medication more easily (89.8% vs. 36.9%; P ≤ 0.001), while these children received a lower sedation dose, but the sedation level in both methods was similar (P = 0.72). Our findings showed that children in the intranasal sedation group had a faster onset of sedation compared to the oral group (17.94 ± 8.99 vs. 34.50 ± 11.45; P ≤ 0.001). The frequency of midazolam side effects had no difference between the groups (29.7% vs. 15.8%; P = 0.15). CONCLUSION: Intranasal midazolam with a lower sedation dose induces a faster onset and better acceptance. Intranasal midazolam can be used as an effective sedative method for pediatric patients, especially in emergency wards.
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Affiliation(s)
- Masoud Mayel
- Department of Emergency Medicine, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Ahmadi Nejad
- Department of Anesthesiology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Sadeghi Khabaz
- Department of Emergency Medicine, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Ehsan Mohajeri
- Department of Pharmaceutics, Faculty of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
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Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers. Pediatr Emerg Care 2020; 36:e494-e499. [PMID: 30789872 DOI: 10.1097/pec.0000000000001782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers. METHODS This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions. RESULTS Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported. CONCLUSIONS Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.
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Assessing procedural satisfaction in the pediatric ED: A systematic review. Am J Emerg Med 2020; 43:283-286. [PMID: 32693939 DOI: 10.1016/j.ajem.2020.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
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O'Connell NC, Woodward HA, Flores-Sanchez PL, McLaren SH, Ieni M, McKinley KW, Shen ST, Dayan PS, Tsze DS. WITHDRAWN: Comparison of Preadministered and Coadministered Lidocaine for Treating Pain and Distress Associated With Intranasal Midazolam Administration in Children: A Randomized Clinical Trial. Ann Emerg Med 2020:S0196-0644(20)30292-4. [PMID: 32507490 DOI: 10.1016/j.annemergmed.2020.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Abstract
This article has been withdrawn at the request of the authors and editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.
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Affiliation(s)
- Nicole C O'Connell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Department of Emergency Medicine, Westchester Medical Center, Valhalla, NY
| | - Hilary A Woodward
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Pamela L Flores-Sanchez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Son H McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Maria Ieni
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kenneth W McKinley
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Sripriya T Shen
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Bregstein JS, Wagh AM, Tsze DS. Intranasal Lorazepam for Treatment of Severe Agitation in a Pediatric Behavioral Health Patient in the Emergency Department. Ann Emerg Med 2019; 75:86-89. [PMID: 31280921 DOI: 10.1016/j.annemergmed.2019.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Indexed: 11/25/2022]
Abstract
The treatment of severe agitation, aggression, and violent behavior in behavioral health patients who present to the emergency department (ED) often requires the intramuscular administration of a sedative. However, administering an intramuscular sedative to an uncooperative patient is associated with the risk of needlestick injuries to both patients and health care providers, and times to onset of sedation range from 15 to 45 minutes. Intranasal absorption is more rapid than intramuscular, with sedatives such as lorazepam reaching peak serum concentrations up to 6 times faster when administered intranasally. We present the first report of using intranasal lorazepam as a needle-free method of providing rapid and effective sedation to treat severe agitation in a pediatric behavioral health patient presenting to the ED.
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Affiliation(s)
- Joan S Bregstein
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
| | - Anju M Wagh
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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22
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Tucker C, Tucker L, Brown K. The Intranasal Route as an Alternative Method of Medication Administration. Crit Care Nurse 2019; 38:26-31. [PMID: 30275061 DOI: 10.4037/ccn2018836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intranasal drug administration is a less invasive method of drug delivery that is easily accessible for adult and pediatric patients. Medications administered by the intranasal route have efficacy comparable to intravenous administration and typically have superior efficacy to subcutaneous or intramuscular routes. The intranasal route is beneficial in emergent situations when the intravenous route is not available. The intranasal route is safe and effective in various indications, and therapeutic systemic concentrations of medication can be attained via this route. As the evidence for and comfort with intranasal administration continue to grow, guidance on correct technique, medications, and dosing is vital for appropriate use. This article reviews the process and practices of appropriate intranasal medication administration.
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Affiliation(s)
- Calvin Tucker
- Calvin Tucker is the Emergency Medicine/Critical Care Pharmacist at Baptist Health, Jacksonville, Florida. .,Lyn Tucker is a clinical pharmacist, Pediatric Emergency Department, Wolfson Children's Hospital, Jacksonville, Florida. .,Kyle Brown is a critical care specialist at Memorial West, Pembroke Pines, Florida.
| | - Lyn Tucker
- Calvin Tucker is the Emergency Medicine/Critical Care Pharmacist at Baptist Health, Jacksonville, Florida.,Lyn Tucker is a clinical pharmacist, Pediatric Emergency Department, Wolfson Children's Hospital, Jacksonville, Florida.,Kyle Brown is a critical care specialist at Memorial West, Pembroke Pines, Florida
| | - Kyle Brown
- Calvin Tucker is the Emergency Medicine/Critical Care Pharmacist at Baptist Health, Jacksonville, Florida.,Lyn Tucker is a clinical pharmacist, Pediatric Emergency Department, Wolfson Children's Hospital, Jacksonville, Florida.,Kyle Brown is a critical care specialist at Memorial West, Pembroke Pines, Florida
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23
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Cisewski DH, Motov SM. Essential pharmacologic options for acute pain management in the emergency setting. Turk J Emerg Med 2019; 19:1-11. [PMID: 30793058 PMCID: PMC6370909 DOI: 10.1016/j.tjem.2018.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/19/2022] Open
Abstract
Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.
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Affiliation(s)
- David H. Cisewski
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Sergey M. Motov
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, NY, USA
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24
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Drendel AL, Ali S. Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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25
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Mellion SA, Bourne D, Brou L, Brent A, Adelgais K, Galinkin J, Wathen J. Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair. J Emerg Med 2017; 53:397-404. [PMID: 28992870 DOI: 10.1016/j.jemermed.2017.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing. OBJECTIVES We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair. METHODS Children 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events. RESULTS Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients. CONCLUSIONS Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.
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Affiliation(s)
- Sarah A Mellion
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - David Bourne
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Colorado
| | - Lina Brou
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Alison Brent
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Kathleen Adelgais
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
| | - Jeffrey Galinkin
- Department of Anesthesiology, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Joseph Wathen
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Colorado
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26
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Bailey AM, Baum RA, Horn K, Lewis T, Morizio K, Schultz A, Weant K, Justice SN. Review of Intranasally Administered Medications for Use in the Emergency Department. J Emerg Med 2017; 53:38-48. [PMID: 28259526 DOI: 10.1016/j.jemermed.2017.01.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 12/13/2016] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intranasal (IN) medication delivery is a viable alternative to other routes of administration, including intravenous (IV) and intramuscular (IM) administration. The IN route bypasses the risk of needle-stick injuries and alleviates the emotional trauma that may arise from the insertion of an IV catheter. OBJECTIVE This review aims to evaluate published literature on medications administered via the IN route that are applicable to practice in emergency medicine. DISCUSSION The nasal mucosa is highly vascularized, and the olfactory tissues provide a direct conduit to the central nervous system, bypass first-pass metabolism, and lead to an onset of action similar to IV drug administration. This route of administration has also been shown to decrease delays in drug administration, which can have a profound impact in a variety of emergent scenarios, such as seizures, acutely agitated or combative patients, and trauma management. IN administration of midazolam, lorazepam, flumazenil, dexmedetomidine, ketamine, fentanyl, hydromorphone, butorphanol, naloxone, insulin, and haloperidol has been shown to be a safe, effective alternative to IM or IV administration. As the use of IN medications becomes a more common route of administration in the emergency department setting, and in prehospital and outpatient settings, it is increasingly important for providers to become more familiar with the nuances of this novel route of medication delivery. CONCLUSIONS IN administration of the reviewed medications has been shown to be a safe and effective alternative to IM or IV administration. Use of IN is becoming more commonplace in the emergency department setting and in prehospital settings.
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Affiliation(s)
- Abby M Bailey
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Regan A Baum
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Karolyn Horn
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Tameka Lewis
- Department of Pharmacy, Charleston Area Medical Center, Charleston, West Virginia
| | - Kate Morizio
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Amy Schultz
- Department of Pharmacy, Charleston Area Medical Center, Charleston, West Virginia
| | - Kyle Weant
- Department of Pharmacy, Medical University of South Carolina, Charleston, South Carolina
| | - Stephanie N Justice
- Department of Pharmacy, St. Claire Regional Medical Center, Morehead, Kentucky
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