1
|
Hailemariam T, Sisay S, Mebratu Y, Belay F, Getinet T, Solomon S, Belina M, Abebe A, Hilawi Tewodros B, Manyazewal T. Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis. Eur J Radiol 2024; 170:111237. [PMID: 38039783 DOI: 10.1016/j.ejrad.2023.111237] [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: 08/12/2023] [Revised: 11/05/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial. OBJECTIVES We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children. METHODS We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic. RESULTS A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists. CONCLUSIONS In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.
Collapse
Affiliation(s)
- Tesfahunegn Hailemariam
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia; Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia.
| | - Samuel Sisay
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia.
| | - Yonas Mebratu
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Fekadu Belay
- Wachemo University, College of Medicine and Health Sciences, Department of Pediatrics and Child Health, Hossana, Ethiopia
| | - Tewodros Getinet
- St. Paul's Hospital Millennium Medical College, School of Public Health, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- St. Paul's Hospital Millennium Medical College, School of Public Health, Addis Ababa, Ethiopia.
| | - Merga Belina
- Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | - Abel Abebe
- Detroit Medical Center/Wayne State University, Sinai Grace Hospital, Detroit, MI, USA
| | | | - Tsegahun Manyazewal
- Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| |
Collapse
|
2
|
Pušnik L, Slak P, Nikšić S, Winant AJ, Lee EY, Plut D. Ultrasound-guided hydrostatic reduction of intussusception: comparison of success rates between subspecialized pediatric radiologists and non-pediatric radiologists or radiology residents. Eur J Pediatr 2023:10.1007/s00431-023-04987-1. [PMID: 37148276 DOI: 10.1007/s00431-023-04987-1] [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: 02/24/2023] [Revised: 04/12/2023] [Accepted: 04/16/2023] [Indexed: 05/08/2023]
Abstract
Ileocolic intussusception is the most common cause of intestinal obstruction in children under two years of age. Treatment in most cases is radiologically guided reduction. In Slovenia, ultrasound (US)-guided hydrostatic reduction is currently the standard of care. The purpose of this study was to compare the success rate of US-guided hydrostatic reduction when performed by subspecialty-trained pediatric radiologists, non-pediatric radiologists, or radiology residents. We retrospectively analyzed medical records of patients with ileocolic intussusception who underwent US-guided hydrostatic intussusception reduction at University Medical Centre Ljubljana between January 2012 and December 2022 (n = 101). During regular daily working hours, the reduction was performed by pediatric radiologists. After hours (evenings and overnight), pediatric radiologists, non-pediatric radiologists, or radiology residents performed the reduction procedure. Patients were divided into three groups based on the operator performing the procedure. Data was analyzed using the chi-square test. Pediatric radiologists had thirty-seven (75.5%) successful first attempts, non-pediatric radiologists had nineteen (76.0%), and radiology residents had twenty (74.1%). There was no statistically significant difference in the success rate of ileocolic intussusception reduction depending on the operator who performed the procedure (p = 0.98). No perforation was observed in either group during the reduction attempts. Conclusion: Our results demonstrate that US-guided hydrostatic reduction is a reliable and safe procedure that achieves good results even in the hands of less experienced, however appropriately trained, radiologists. The results should encourage more medical centers to consider the implementation of US-guided hydrostatic reduction of ileocolic intussusception. What is Known: • US-guided hydrostatic reduction is a well-established method of treatment for ileocolic intussusception in children. • The results regarding the influence of operator's experience with the procedure on its success rate are scarce and contradictory. What is New: • US-guided hydrostatic intussusception reduction is a reliable and safe technique that achieves similar success rates when performed by experienced subspecialized pediatric radiologists or less experienced but trained operators such as non-pediatric radiologists and radiology residents. • The implementation of US-guided hydrostatic reduction in general hospitals without subspecialized pediatric radiologists could improve patient care by increasing access to radiologically guided reduction and simultaneously decreasing the time to reduction attempts.
Collapse
Affiliation(s)
- Luka Pušnik
- Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Slak
- Clinical Radiology Institute, University Medical Center Ljubljana, Ljubljana, Slovenia
- Department of Radiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Stevan Nikšić
- Clinical Radiology Institute, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Domen Plut
- Clinical Radiology Institute, University Medical Center Ljubljana, Ljubljana, Slovenia.
- Department of Radiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| |
Collapse
|
3
|
Giacalone M, Pierantoni L, Selvi V, Morabito A, Baldazzi M, Lima M, Lanari M, Masi S, Incerti F, Fierro F, Basile M, Lo Piccolo R, Catania VD, Bettini I, Parri N. Midazolam premedication in ileocolic intussusception: a retrospective multicenter study. Eur J Pediatr 2022; 181:3531-3536. [PMID: 35732982 DOI: 10.1007/s00431-022-04524-6] [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: 12/01/2021] [Revised: 04/15/2022] [Accepted: 06/04/2022] [Indexed: 11/29/2022]
Abstract
UNLABELLED Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001). CONCLUSION Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients. WHAT IS KNOWN • Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice. WHAT IS NEW • Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.
Collapse
Affiliation(s)
- Martina Giacalone
- Department of Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy.
| | - Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Valeria Selvi
- Department of Experimental and Clinical Biomedical Sciences Radiodiagnostic Unit 2, University of Florence, Careggi University Hospital, Florence, Italy.,Radiology Department, Meyer University Children's Hospital, Florence, Italy
| | - Antonino Morabito
- Department of Emergency, Critical Area and Pediatric Surgery, Meyer University Children's Hospital, University of Florence, Florence, Italy
| | | | - Mario Lima
- Pediatric Surgery, S. Orsola University Hospital, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Stefano Masi
- Department of Emergency Medicine, Meyer University Children's Hospital, Florence, Italy
| | - Filippo Incerti
- Department of Emergency, Critical Area and Pediatric Surgery, Meyer University Children's Hospital, University of Florence, Florence, Italy
| | - Francesca Fierro
- Radiology Department, Meyer University Children's Hospital, Florence, Italy
| | - Massimo Basile
- Radiology Department, Meyer University Children's Hospital, Florence, Italy
| | - Roberto Lo Piccolo
- Department of Emergency, Critical Area and Pediatric Surgery, Meyer University Children's Hospital, University of Florence, Florence, Italy
| | | | - Irene Bettini
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| |
Collapse
|
4
|
Gal M, Gamsu S, Jacob R, Cohen DM, Shavit I. Reduction of ileocolic intussusception under sedation or anaesthesia: a systematic review of complications. Arch Dis Child 2022; 107:335-340. [PMID: 34417187 DOI: 10.1136/archdischild-2021-322706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/08/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite the increased use of sedation in children undergoing stressful procedures, reduction of ileocolic intussusception (RII) is usually performed on awake children without any form of sedation. OBJECTIVE To evaluate the incidence of severe complications of RII under sedation or anaesthesia. DESIGN A systematic review including English language original articles of any date. PATIENTS Children undergoing RII (pneumatic or hydrostatic) under sedation or anaesthesia. DATA SOURCES Ovid Embase, Scopus, PubMed, the Cochrane Database of Systematic Reviews and the internet search engine Google Scholar. DATA EXTRACTION Three authors independently reviewed each article for eligibility. The Newcastle-Ottawa Scale was used to assess the quality of included studies. MAIN OUTCOME MEASURES The primary outcome was the incidence of intestinal perforation during RII. The secondary outcomes were the incidence of sentinel adverse events defined as death, cardiopulmonary resuscitation, permanent neurological deficit and pulmonary aspiration syndrome. RESULTS The search yielded 368 articles. Nine studies with 1391 cases were included in the analysis. Of the nine studies, six had a score of ≤6 stars in the Newcastle-Ottawa Scale assessment, indicating low-to-moderate quality. Propofol-based sedation was used in 849 (59.2%) cases; 5 (0.6%) had intestinal perforation. Intestinal perforation was not reported in patients who were sedated with other sedatives. One patient had pulmonary aspiration syndrome. CONCLUSIONS Although caution remains warranted, current data suggest that the incidence of severe complications due to RII under sedation or anaesthesia is low. Due to the lack of prospective data, it is difficult to ascertain the exact incidence of severe complications.
Collapse
Affiliation(s)
- Moran Gal
- Kaplan Medical Centre, Rehovot, Israel
| | | | | | - Daniel M Cohen
- Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | | |
Collapse
|
5
|
Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care 2021; 37:e1209-e1212. [PMID: 31929389 DOI: 10.1097/pec.0000000000001975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thoracostomy drainage is sometimes required in children with pleuropneumonia who have large parapneumonic effusion. This procedure is usually performed under sedation. The aim was to report sedation adverse events (SAEs) in pneumonia patients sedated for thoracostomy by pediatric emergency physicians. METHODS A retrospective cohort study was conducted. The medical records of all emergency department patients who underwent thoracostomy between January 1, 2012, and December 31, 2018, were extracted. Study outcomes were SAEs that required intervention. RESULTS Pigtail catheters were placed by chest surgeons in 28 children with a median age of 2 years (interquartile range [IQR], 1-5 years). All the thoracostomies were successfully performed under sedation performed by 11 pediatric emergency physicians. The median amount of fluid drained after catheter insertion was 200 mL (IQR, 100-500 mL). The median pleural fluid PH was 7.0 (IQR, 6.9-7.3), and the median white blood cell count was 34,600 per mm3 (IQR, 11,800-109,000 per mm3). Thirteen patients (46.4%) were sedated with a total median dose of 3 mg/kg of ketamine (IQR, 2-4 mg/kg) and 0.2 mg/kg of midazolam (IQR, 0.2-0.3 mg/kg); 11 patients (39.3%) were treated with 1 mg/kg of ketamine (IQR, 0.5-2 mg/kg) and 3 mg/kg of propofol (IQR, 2-4 mg/kg). Four patients (14.3%) were treated exclusively with 4 mg/kg of ketamine (IQR, 3-5 mg/kg). Nine oxygen desaturations required intervention; 1 was associated with laryngospasm and 1 with apnea. All the SAEs were successfully managed. No cases of hypotension, bradycardia, airway obstruction, or pulmonary aspiration were recorded. CONCLUSIONS The first series of pneumonia patients sedated for thoracostomy by pediatric emergency physicians is reported. Sedation was safely performed in this cohort.
Collapse
Affiliation(s)
| | - Danielle Shavit
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
| | - Ron Nates
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
| | | | | |
Collapse
|
6
|
Bilder L, Librov S, Gutmacher Z, Pasternak I, Shavit I. Adverse events during sedation for oro-dental trauma in an Israeli paediatric emergency department. Dent Traumatol 2021; 38:156-159. [PMID: 34698441 DOI: 10.1111/edt.12716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 12/17/2022]
Abstract
There is a paucity of data regarding the safety of the practice of sedation for oro-dental trauma in paediatric emergency departments (ED). A previous study reported the safety of intramuscular ketamine administered as a single agent. In the paediatric ED of a tertiary trauma centre in Israel, one of two ketamine-based regimens is used for sedating children with intraoral injuries according to the physician's discretion: a single dose of intramuscular ketamine or a combination of ketamine and propofol (KP) intravenously. The aim of this study was to assess the safety of KP sedation in children undergoing emergency treatment of oro-dental injuries in this paediatric ED. The primary outcome was sedation adverse events that required intervention (SAERI): prolonged oxygen desaturation and apnoea, laryngospasm, hypotension, bradycardia, partial or complete airway obstruction, and pulmonary aspiration. During the 2 years study period, 17 children were sedated with KP, 20 with intramuscular ketamine and 29 with nitrous oxide. Patients who were treated with ketamine-based sedation or with nitrous oxide sedation had a median (interquartile range, IQR) age of 3 (2-4) years and 7 (5-9) years, respectively. No SAERI occurred in patients who were sedated with intramuscular ketamine. One (3.4%) SAERI was reported in a patient who was sedated with N2 O. Six/17 (35%) SAERI occurred in patients who were sedated with KP. These findings suggest that caution should be used when young children with oro-dental injuries are sedated with KP in the ED.
Collapse
Affiliation(s)
- Leon Bilder
- Department of Periodontology, School of Graduate Dentistry, Rambam Health Care Campus, Haifa, Israel
| | - Simona Librov
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zvi Gutmacher
- Department of Maxillofacial Rehabilitation and Temporomandibular Disorders Unit, School of Graduate Dentistry, Rambam Health Care Campus, Haifa, Israel
| | - Idit Pasternak
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| |
Collapse
|
7
|
Caro-Domínguez P, Hernández-Herrera C, Le Cacheux-Morales C, Sánchez-Tatay V, Merchante-García E, Vizcaíno R, Fernández-Pineda I. Ileocolic intussusception: Ultrasound-guided hydrostatic reduction with sedation and analgesia. RADIOLOGIA 2021; 63:406-414. [PMID: 34625196 DOI: 10.1016/j.rxeng.2020.04.005] [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: 02/15/2020] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The first-choice treatment for ileocolic intussusception is imaging-guided reduction with water, air, or barium. The objectives of the current study were to evaluate the efficacy and safety of ultrasound-guided reduction of intussusception using water in patients under sedation and analgesia. We compare this approach with our previous experience in reduction using barium under fluoroscopic guidance without sedation and analgesia and investigate what factors predispose to surgical correction. MATERIAL AND METHODS We retrospectively reviewed cases of children with ileocolic intussusception treated in a third-level pediatric hospital during a 52-month period: during the first 24 months, reduction was done using barium and fluoroscopy without sedoanalgesia, and during the following 28 months, reduction was done using water and ultrasound with sedoanalgesia. A pediatric radiologist and a pediatrician reviewed the clinical history, surgical records, and imaging studies. RESULTS In the 52-month period, 59 children (41 boys and 18 girls; mean age, 16.0 months) were diagnosed with ileocolic intussusception at our hospital. A total of 33 reductions (28 patients and 5 recurrences) were done using barium under fluoroscopic guidance, achieving a 61% success rate. A total of 38 reductions (31 patients and 7 recurrences) were done using water under ultrasound guidance with patients sedated, achieving a success rate of 76%. No significant adverse effects were observed in patients undergoing ultrasound-guided hydrostatic reduction under sedation, and the success rate in this group was higher (p = 0.20). The factors that predisposed to surgical reduction were greater length of the intussusception (p = 0.03), location in areas other than the right colon (p = 0.002), and a greater length of time between symptom onset and imaging tests (p = 0.08). CONCLUSION Ultrasound-guided hydrostatic reduction of ileocolic intussusception under sedoanalgesia is efficacious and safe.
Collapse
Affiliation(s)
- P Caro-Domínguez
- Unidad de Radiología Pediátrica, Departamento de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - C Hernández-Herrera
- Unidad de Radiología Pediátrica, Departamento de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - C Le Cacheux-Morales
- Unidad de Radiología Pediátrica, Departamento de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - V Sánchez-Tatay
- Servicio de Urgencias Pediátricas, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - E Merchante-García
- Unidad de Radiología Pediátrica, Departamento de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - R Vizcaíno
- Departamento de Cirugía Pediátrica, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - I Fernández-Pineda
- Departamento de Cirugía Pediátrica, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| |
Collapse
|
8
|
Caro-Domínguez P, Hernández-Hernández C, Le Cacheux C, Sánchez-Tatay V, Merchante E, Vizcaíno R, Fernández I. Invaginación ileocólica: reducción hidrostática ecoguiada con sedoanalgesia. RADIOLOGIA 2021. [DOI: 10.1016/j.rx.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|