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Sun ZY, Chen YM, Xie L, Yang X, Ji T. Free flap reconstruction in paediatric patients with head and neck cancer: clinical considerations for comprehensive care. Int J Oral Maxillofac Surg 2020; 49:1416-1420. [PMID: 32273164 DOI: 10.1016/j.ijom.2020.03.005] [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: 03/01/2019] [Revised: 01/13/2020] [Accepted: 03/04/2020] [Indexed: 11/24/2022]
Abstract
Free flap reconstruction after resection in paediatric patients with head and neck cancer (HNC) has various clinical challenges, which have not yet been fully investigated. This retrospective study was implemented to investigate these factors. Paediatric patients (≤14 years old) who underwent free flap reconstructions following surgery for HNC at a tertiary referral centre during the years 2009-2018 were included. Clinical, pathological, and imaging data were collected and analysed. Overall, 47 patients were included, 26 male and 21 female. Thirty-four patients were ASA status I and 13 were ASA status II. The median operative time was 415 minutes, while the median intraoperative blood loss was 500 ml. Seventeen patients had a tracheotomy. Fourteen medical complications (six pulmonary infection, six diarrhoea, two pulmonary aspiration) and six surgical complications (one haematoma beneath flap, two wound dehiscence, one salivary fistula, one effusion, one tracheotomy haemorrhage) were observed. Tracheotomy was associated with medical complications (P = 0.003) and total complications (P = 0.024). It was confirmed that microvascular reconstruction can be adopted in paediatric HNC patients, while tracheotomy and nasal feeding tubes should be used with caution. Comprehensive preoperative assessment, gentle handling of the tissues during operative procedures, and appropriate postoperative management will reduce the risk of complications.
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Affiliation(s)
- Z Y Sun
- Department of Maxillofacial Surgery, Jiamusi Central Hospital, Heilongjiang, China.
| | - Y M Chen
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
| | - L Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Huangpu District, Shanghai, China.
| | - X Yang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
| | - T Ji
- Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology, National Clinical Research Centre of Stomatology, Shanghai, China.
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Ip U, Saincher A. Safety of pediatric procedural sedation in a Canadian emergency department. CAN J EMERG MED 2012; 2:15-20. [PMID: 17637112 DOI: 10.1017/s1481803500004346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the safety of pediatric procedural sedation performed by emergency physicians working within a structured sedation protocol. METHODS A retrospective review of all children undergoing emergency department (ED) procedural sedation during a 2-year period after the institution of a structured sedation protocol. RESULTS 167 children underwent procedural sedation, primarily for orthopedic manipulation, wound management and foreign body removal. Of these, 82% received ketamine, 17% received fentanyl and midazolam and 1% received midazolam alone. Sedation was adequate in all but 6 patients, who required supplemental ketamine for orthopedic manipulation. Vomiting after arousal occurred in 17 children (10%), but no episodes of clinical aspiration occurred. One child became agitated during recovery and another experienced a transient visual hallucination. There were no cases of laryngospasm, apnea or cardiorespiratory compromise, and no mortality or significant morbidity occurred. CONCLUSION Emergency physicians using a structured sedation protocol can safely perform ED pediatric procedural sedation. Where intravenous access is not already present, intramuscular ketamine, administered in the doses described, is a safe and effective agent for pediatric sedation.
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Affiliation(s)
- U Ip
- Department of Emergency Medicine, Surrey Memorial Hospital, Surrey, British Columbia, Canada
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Abstract
OBJECTIVES The aim of the study was to compare the quality of sedation with 3 different sedation regimens in upper gastrointestinal endoscopy (UGIE) in pediatric patients. METHODS One hundred fifty consecutive children who underwent UGIE were randomly assigned to 1 of the 3 medication regimens. Patients in group A (n = 49) received placebo. Forty-five minutes after the placebo was given, repeated intravenous (IV) doses of 0.1 mg/kg midazolam were administered titrated to achieve a level of deep sedation. Patients in group B (n = 51) received oral ketamine instead of placebo, and patients in group C (n = 50) received oral fentanyl instead of placebo with the same methodology and sedation endpoint. RESULTS The mean dose of midazolam administered in group B patients was remarkably lower compared with that of groups A and C. Patients in group B showed less distress in IV line placement and separation from parents, higher comfort level, more endoscopist satisfaction, and higher sedation depth compared with groups A and C. The recovery time was significantly shorter in group B. All of the 3 regimens were safe. All of the complications were managed successfully. CONCLUSIONS Our data suggest that synergistic sedation with oral ketamine and IV midazolam for UGIE in children is a suitable and safe sedation. The higher rate of vomiting in group B in contrast to previous studies must be caused mainly by the oral route of ketamine administration.
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Abstract
OBJECTIVE The aim of the study was to assess, by a review of published evidence, the safest and most effective way to provide procedural sedation (PS) in children undergoing gastrointestinal endoscopy (GIE). METHODS The databases MEDLINE, Cochrane Library, and Embase were used. Search terms "endoscopy, gastrointestinal" or "endoscopy, digestive system" were combined with "sedation," "conscious sedation," "moderate sedation," "deep sedation," and "hypnotics and sedatives." The final review was restricted to studies reporting specifically on safety (incidences of adverse events) and/or effectiveness (time characteristics, need for supplemental sedation, need for restraint, procedural success, provider satisfaction, and patient comfort) of PS for GIE in children younger than 18 years. RESULTS The search yielded 182 references and the final selection included 11 randomized controlled trials (RCTs) and 15 non-RCTs. Six sedation categories were identified: propofol, opioid/benzodiazepine, premedication, ketamine-, sevoflurane-, and midazolam-based. Only a few RCTs have compared different categories. Opioid/benzodiazepine- and propofol-based PS have a similar safety profile and a low incidence of major adverse events. Propofol-based sedation turned out to be the most effective regimen, with effectiveness comparable to general anesthesia. The addition of midazolam, fentanyl, remifentanil, and/or ketamine to propofol may increase the effectiveness without creating more adverse events. Data on midazolam-, ketamine- and sevoflurane-based sedation were generally too limited to draw conclusions. CONCLUSIONS Despite a lack of RCTs containing all aspects of effectiveness and safety, the present evidence indicates propofol-based PS to be the best practice for PS in children undergoing GIE. Propofol can be safely administered by specifically trained nonanesthesiologists.
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Abstract
The sedative-hypnotic propofol (2,6-diisopropylphenol) is being increasingly used for sedation during painful diagnostic and therapeutic procedures in adults and children. The purpose of this article is to present a general overview of the use of propofol for endoscopic sedation. Advantages and disadvantages of using propofol for sedation, as well as its pharmacokinetics, preparation for use, dosing for endoscopic sedation, auxiliary sedative and analgesic medication options, methods of administering, adverse effects with interventions, recovery, and patient-physician satisfaction are discussed. Finally, next steps necessary to optimize future use of propofol are suggested.
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Rafeey M, Ghojazadeh M, Feizo Allah Zadeh H, Majidi H. Use of oral midazolam in pediatric upper gastrointestinal endoscopy. Pediatr Int 2010; 52:191-5. [PMID: 19664010 DOI: 10.1111/j.1442-200x.2009.02936.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this prospective, randomized study was to compare the safety and efficacy of oral versus i.v. midazolam in providing sedation for pediatric upper gastrointestinal (GI) endoscopy. METHODS Sixty-one children (age <16 years) scheduled for upper GI endoscopy were studied. Patients were randomly assigned to receive oral or i.v. midazolam. Measurements were made and compared for vital signs, level of sedation, pre- and post-procedure comfort, anxiety during endoscopy, ease of separation from parents, ease and duration of procedure, and recovery time. RESULTS Patients were aged 1-16 years (mean 7.5 + or - 3.42 years); 30 patients received oral medication, and 31 received i.v. medication. There were no statistically significant differences in age or gender between groups. There were no significant differences in level of sedation, ease of separation from parents, ease of ability to monitor the patient during the procedure, heart rate, systolic arterial pressure, or respiratory rate. Oxygen saturation was significantly lower in the i.v. group than the oral group 10 and 30 min after removal of the endoscope, and recovery time was longer in the oral than the i.v. group. CONCLUSIONS Oral administration of midazolam is a safe and effective method of sedation that significantly reduces anxiety and improves overall tolerance for children undergoing esophagogastroduodenoscopy.
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Affiliation(s)
- Mandana Rafeey
- Department of Pediatrics, Liver and Gastrointestinal Diseases Research Center, Iran.
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Amornyotin S, Aanpreung P. Clinical effectiveness of an anesthesiologist-administered intravenous sedation outside of the main operating room for pediatric upper gastrointestinal endoscopy in Thailand. Int J Pediatr 2010; 2010:748564. [PMID: 20811603 PMCID: PMC2929513 DOI: 10.1155/2010/748564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 06/23/2010] [Accepted: 06/23/2010] [Indexed: 02/07/2023] Open
Abstract
Objectives. To review our sedation practice and to evaluate the clinical effectiveness of an anesthesiologist-administered intravenous sedation outside of the main operating room for pediatric upper gastrointestinal endoscopy (UGIE) in Thailand. Subjects and Methods. We undertook a retrospective review of the sedation service records of pediatric patients who underwent UGIE. All endoscopies were performed by a pediatric gastroenterologist. All sedation was administered by staff anesthesiologist or anesthetic personnel. Results. A total of 168 patients (94 boys and 74 girls), with age from 4 months to 12 years, underwent 176 UGIE procedures. Of these, 142 UGIE procedures were performed with intravenous sedation (IVS). The mean sedation time was 23.2 +/- 10.0 minutes. Propofol was the most common sedative drugs used. Mean dose of propofol, midazolam and fentanyl was 10.0 +/- 7.5 mg/kg/hr, 0.2 +/- 0.2 mg/kg/hr, and 2.5 +/- 1.2 mcg/kg/hr, respectively. Complications relatively occurred frequently. All sedations were successful. However, two patients became more deeply than intended and required unplanned endotracheal intubation. Conclusion. The study shows the clinical effectiveness of an anesthesiologist-administered IVS outside of the main operating room for pediatric UGIE in Thailand. All complications are relatively high. We recommend the use of more sensitive equipments such as end tidal CO(2) and carefully select more appropriate patients.
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Affiliation(s)
- Somchai Amornyotin
- 1Department of Anesthesiology and Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- *Somchai Amornyotin:
| | - Prapun Aanpreung
- 2Department of Pediatric and Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Hayee B, Dunn J, Loganayagam A, Wong M, Saxena V, Rowbotham D, McNair A. Midazolam with meperidine or fentanyl for colonoscopy: results of a randomized trial. Gastrointest Endosc 2009; 69:681-7. [PMID: 19251010 DOI: 10.1016/j.gie.2008.09.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 09/17/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND A combination of midazolam and opioid is usually used to achieve sedation and analgesia during colonoscopy. Two commonly used opioids are meperidine and fentanyl, but few studies have compared their efficacy. OBJECTIVE This randomized trial aimed to compare the efficacy and recovery time of 2 sedation regimens consisting of midazolam in combination with either meperidine or fentanyl. DESIGN, SETTING, AND PATIENTS A total of 300 consecutive, unselected adults attending outpatient colonoscopy at a District General Hospital were enrolled with informed consent and randomized to receive midazolam with meperidine or fentanyl. Data for procedure times, perceived discomfort (according to standard 100-mm visual analog scales [VAS]), and recovery time were collected. Patients and all endoscopy staff directly involved with the procedure were blinded to the regimen used. MAIN OUTCOME MEASUREMENTS Primary: patients' experience of pain (postrecovery VAS score); secondary: recovery time. RESULTS A total of 287 patients (150 female, mean [SD] age 54 [17] years) were studied. Recovery time (in minutes) was significantly shorter in patients receiving fentanyl (n = 138) than in those receiving meperidine (n = 149, mean +/- SE: 13.7 +/- 1.8 vs 18.7 +/- 1.7, P = .03), whereas there was no difference in the patients', endoscopists', or nurses' perception of pain during the procedure between the 2 groups. Both groups received a median dose of 3 mg of midazolam (range 2-5 mg). In patients receiving lower doses (2-2.5 and 3-3.5 mg), recovery times were significantly faster with fentanyl (P < .01 and <.05, respectively), whereas at higher doses of midazolam (> or =4 mg) there was no difference between the 2 groups. LIMITATIONS The use of VAS scores and nurse assessment of recovery time were chosen in this study because, despite their subjectivity, these measures were felt to most closely reflect true clinical practice. CONCLUSIONS The use of fentanyl in combination with low-dose midazolam results in significantly faster recovery from sedation compared with meperidine, without any apparent loss of analgesic effect.
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Affiliation(s)
- Bu'Hussain Hayee
- Department of Gastroenterology, Queen Elizabeth National Health Service Trust, Woolwich, London, United Kingdom.
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Hammer GB, Sam WJ, Chen MI, Golianu B, Drover DR. Determination of the pharmacodynamic interaction of propofol and dexmedetomidine during esophagogastroduodenoscopy in children. Paediatr Anaesth 2009; 19:138-44. [PMID: 19207899 DOI: 10.1111/j.1460-9592.2008.02823.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Propofol is a sedative-hypnotic drug commonly used to anesthetize children undergoing esophagogastroduodenoscopy (EGD). Dexmedetomidine is a highly selective alpha-2 adrenergic receptor agonist that has been utilized in combination with propofol to provide anesthesia. There is currently no information regarding the effect of intravenous dexmedetomidine on the propofol plasma concentration-response relationship during EGD in children. This study aimed to investigate the pharmacodynamic interaction of propofol and dexmedetomidine when used in combination for children undergoing EGD. METHODS A total of 24 children undergoing EGD, ages 3-10 years, were enrolled in this study. Twelve children received dexmedetomidine 1 microg x kg(-1) given over 10 min as well as a continuous infusion of propofol delivered by a computer-assisted target-controlled infusion (TCI) system with target plasma concentrations ranging from 2.8 to 4.0 microg x ml(-1) (DEX group). Another group of 12 children undergoing EGD also received propofol administered by TCI targeting comparable plasma concentrations without dexmedetomidine (control group). We used logistic regression to predict plasma propofol concentrations at which 50% of the patients exhibited minimal response to stimuli (EC50 for anesthesia). RESULTS The EC50 +/- SE values in the control and DEX groups were 3.7 +/- 0.4 microg x ml(-1) and 3.5 +/- 0.2 microg x ml(-1), respectively. There was no significant shift in the propofol concentration-response curve in the presence of dexmedetomidine. CONCLUSION The EC50 of propofol required to produce adequate anesthesia for EGD in children was unaffected by a concomitant infusion of dexmedetomidine 1 microg x kg(-1) given over 10 min.
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Affiliation(s)
- Gregory B Hammer
- Department of Anesthesia, Stanford University, Stanford, CA 94305-5640, USA
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10
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Fredette ME, Lightdale JR. Endoscopic sedation in pediatric practice. Gastrointest Endosc Clin N Am 2008; 18:739-51, ix. [PMID: 18922412 DOI: 10.1016/j.giec.2008.06.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Best sedation practices for pediatric endoscopy involve the consideration of many patient factors, including age, medical history, clinical status, and anxiety level, as well as physician access to anesthesia support. A recent survey of pediatric gastroenterologists suggests that endoscopist-administered intravenous (iv) sedation and anesthesiologist-administered propofol represent common sedation regimens in children. Technical advances in ventilatory monitoring are contributing to increased patient safety for all children undergoing gastrointestinal procedures, regardless of sedation type.
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Affiliation(s)
- Meghan E Fredette
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, Boston, MA 02115, USA
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Lightdale JR, Valim C, Newburg AR, Mahoney LB, Zgleszewski S, Fox VL. Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study. Gastrointest Endosc 2008; 67:1067-75. [PMID: 18367187 DOI: 10.1016/j.gie.2007.11.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Accepted: 11/12/2007] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency. OBJECTIVE AND SETTING To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital. DESIGN Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl. The effect of the type of sedation on these times was assessed by using multiple linear regression by adjusting for other candidate predictors, including concomitant use of other sedatives, endotracheal intubation by anesthesiologists, and the presence of fellow trainees. MAIN OUTCOME MEASUREMENTS Time to onset of sedation (time sedation started to scope in), procedure time (endoscope in to endoscope out), discharge time (endoscope out to hospital discharge), and total time (sedation started to hospital discharge). RESULTS The times for 134 children (mean age 12 +/- 5 years) to receive propofol sedation were compared with those of 195 children (13 +/- 5 years) who received midazolam and fentanyl. Midazolam and fentanyl cases disproportionately included EGDs (P < .001) and patients who were classified as American Society of Anesthesiologists I (P < .03). Patients who received propofol had shorter times until sedated, similar procedure times, longer discharge times, and comparable total times. Multivariate analyses confirmed that fellow participation prolonged the procedure times (P < .0001), and endotracheal intubation prolonged propofol times (P <. 01), but adjusting for these did not change the comparison results. CONCLUSIONS Anesthesiologist-administered propofol sedation in a pediatric teaching endoscopy unit may not lead to faster hospital times when compared with endoscopist-administered midazolam and fentanyl. These results are not explained by controlling for patient characteristics, the presence of a trainee, the sedative doses, or endotracheal intubation for airway management.
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Affiliation(s)
- Jenifer R Lightdale
- Division of Gastroenterology, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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Lee KK, Anderson MA, Baron TH, Banerjee S, Cash BD, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath SB, Lichtenstein D, Shen B, Fanelli RD, Van Guilder T. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc 2008; 67:1-9. [PMID: 18155419 DOI: 10.1016/j.gie.2007.07.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 07/03/2007] [Indexed: 02/08/2023]
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Affiliation(s)
- Michael R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital for Children, NHS Trust, London, UK.
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Abstract
The performance of endoscopy in children generally requires the concomitant administration of sedation to ensure the patient's safety, comfort, and cooperation throughout the procedures. New pharmacological agents, increased procedural volume, variable access to anesthesia support, and improvement in endoscopic technique have contributed to vast differences in sedation regimens for gastrointestinal procedures in patients of all ages. To better understand variation in practice patterns among pediatric gastroenterologists, the NASPGHAN Endoscopy and Procedures Committee surveyed 103 NASPGHAN members during a recent NASPGHAN national meeting. The results of this survey confirm that sedation practices vary widely and reflect continued uncertainty regarding optimal sedation regimens for pediatric endoscopy.
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Tosun Z, Aksu R, Guler G, Esmaoglu A, Akin A, Aslan D, Boyaci A. Propofol-ketamine vs propofol-fentanyl for sedation during pediatric upper gastrointestinal endoscopy. Paediatr Anaesth 2007; 17:983-8. [PMID: 17767636 DOI: 10.1111/j.1460-9592.2007.02206.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this study was to compare the clinical efficacy and safety of propofol-ketamine with propofol-fentanyl in pediatric patients undergoing diagnostic upper gastrointestinal endoscopy (UGIE). METHODS This was a prospective, randomized, double blinded comparison of propofol-ketamine with propofol-fentanyl for sedation in patients undergoing elective UGIE. Ninety ASA I-II, aged 1 to 16-year-old patients were included in the study. Heart rate (HR), systolic arterial pressure, peripheral oxygen saturation, respiratory rate (RR) and Ramsey sedation scores of all patients were recorded perioperatively. Patients were randomly assigned to receive either propofol-ketamine (PK; n = 46) or propofol-fentanyl (PF; n = 44). PK group received 1 mg x kg(-1) ketamine + 1.2 mg x kg(-1) propofol, and PF group received 1 microg x kg(-1) fentanyl + 1.2 mg x kg(-1) propofol for sedation induction. Additional propofol (0.5-1 mg x kg(-1)) was administered when a patient showed discomfort in either group. RESULTS The number of patients who needed additional propofol in the first minute after sedation induction was eight in Group PK (17%), and 22 in Group PF (50%) (P < 0.01) and those who did not need additional propofol throughout the endoscopy were 14 in Group PK (30%) and three in Group PF (7%) (P < 0.01). HR and RR values after induction in Group PF were significantly lower than Group PK (P < 0.01). CONCLUSIONS Both PK and PF combinations provided effective sedation in pediatric patients undergoing UGIE, but the PK combination resulted in stable hemodynamics and deeper sedation though more side effects.
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Affiliation(s)
- Zeynep Tosun
- Department of Anesthesiology, Erciyes University School of Medicine, Kayseri, Turkey.
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Abstract
Endoscopy in children has developed along with pediatric gastroenterology over the last four decades. Introduction of endoscopic techniques in adults precedes application in children, and pediatric endoscopists do fewer procedures than their adult counterparts whether routine or as an emergency. Training for pediatric endoscopists therefore needs to be thorough. This article in particular highlights developments in pediatric gastroenterology of importance to emergency procedures.
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Affiliation(s)
- Khalid M Khan
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Minnesota, 420 Delaware Street Southeast, Mayo Mail Code 185, Minneapolis, MN 55455, USA.
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Mamula P, Markowitz JE, Neiswender K, Zimmerman A, Wood S, Garofolo M, Nieberle M, Trautwein A, Lombardi S, Sargent-Harkins L, Lachewitz G, Farace L, Morgan V, Puma A, Cook-Sather SD, Liacouras CA. Safety of intravenous midazolam and fentanyl for pediatric GI endoscopy: prospective study of 1578 endoscopies. Gastrointest Endosc 2007; 65:203-10. [PMID: 17258977 DOI: 10.1016/j.gie.2006.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 05/01/2006] [Indexed: 12/10/2022]
Abstract
BACKGROUND Data on safety of intravenous sedation in pediatric GI endoscopy are sparse. OBJECTIVE To evaluate safety of intravenous sedation for GI endoscopy. DESIGN/SETTING Single-center prospective series of outpatient GI endoscopies performed from February 2003 to February 2004 at The Children's Hospital of Philadelphia. The recorded information included demographic, medication, and adverse event data. PATIENTS A total of 1226 patients were studied. MAIN OUTCOME MEASUREMENTS Description of adverse events relating to intravenous sedation. RESULTS A total of 2635 endoscopies were performed, of which 1717 were outpatient procedures with the patient under intravenous sedation. Sedation data were available on 1578 procedures (92%, M/F 674/552): 758 esophagogastroduodenoscopies (EGD) alone, 116 colonoscopies (COL) alone, and 352 combined EGD and COL. The median dose of fentanyl was 2.77 microg/kg (SD 0.97, range 0-6.73), and of midazolam was 0.11 mg/kg (SD 0.06, range 0-0.39). The mean recovery time was 118 minutes (SD 47.3, range 31-375). Ten patients (0.8%) failed intravenous sedation. Serious adverse events (apnea) were noted in 2 patients (0.2%). Mild or moderate adverse events included desaturation below 92% for less than 20 seconds (100 patients, 9%), vomiting (64 patients, 5%), agitation (15 patients, 1%), desaturation below 92% for greater than 20 seconds (12 patients, 0.7%), and rash (8 patients, 0.7%). No cardiopulmonary resuscitation or sedation reversal was necessary. No patients required hospitalization. Patients younger than 6 years were more likely to develop respiratory adverse event (P < .01). CONCLUSIONS Intravenous sedation with midazolam and fentanyl is safe for pediatric GI endoscopy. Serious adverse events are rare and no patient required hospitalization.
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Affiliation(s)
- Petar Mamula
- Division of GI and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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19
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Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2005. [PMID: 15520705 DOI: 10.1016/j.annemergmed.2004.06.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA 92354, USA.
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Ali S, Davidson DL, Gremse DA. Comparison of fentanyl versus meperidine for analgesia in pediatric gastrointestinal endoscopy. Dig Dis Sci 2004; 49:888-91. [PMID: 15259516 DOI: 10.1023/b:ddas.0000030106.01928.b4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study compared the safety and efficacy of fentanyl and meperidine for analgesia in pediatric gastrointestinal endoscopy. In a double-blind, randomized trial, 24 patients (11 males) received either fentanyl (1 microg/kg) or meperidine (1 mg/kg). These analgesics were administered in unmarked syringes by an investigator who did not participate in the procedure or in the evaluation of the patient's sedation. There were 17 Caucasians and 7 African-Americans whose mean age was 10.4 +/- 4.4 years. Thirteen patients received meperidine and 11 received fentanyl. Midazolam was given to all patients as needed to provide sufficient sedation for the procedure. Study subjects underwent EGD (n = 17) or colonoscopy (n = 7). There were no differences as assessed by patient, endoscopist, or assistant for tolerance, discomfort, procedure ease, recovery time, complications, heart rate, blood pressure, or oxygen saturation. We conclude that meperidine and fentanyl are equally effective in providing analgesia for pediatric gastrointestinal endoscopy.
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Affiliation(s)
- Sabina Ali
- Department of Pediatrics and Division of Pediatric Gastroenterology, University of South Alabama, Mobile, Alabama, USA
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21
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Abstract
The administration of sedation and analgesia for pediatric gastrointestinal procedures has become routine but is not standardized. For the most part, pediatric endoscopists are encouraged to use their clinical judgment to select between using intravenous (IV) sedation or general anesthesia on an individual patient basis. Commonly administered IV sedation regimens in children combine benzodiazepines with narcotics, but anesthesiologist administered propofol sedation is gaining acceptance among pediatric gastroenterologists. Guidelines for patient monitoring and new technologic advances may help to ensure patient safety for children undergoing endoscopic procedures, no matter what sedation regimen is used.
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Affiliation(s)
- Jenifer R Lightdale
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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Ulmer BJ, Hansen JJ, Overley CA, Symms MR, Chadalawada V, Liangpunsakul S, Strahl E, Mendel AM, Rex DK. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clin Gastroenterol Hepatol 2003; 1:425-32. [PMID: 15017641 DOI: 10.1016/s1542-3565(03)00226-x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy. METHODS One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications. RESULTS The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5). CONCLUSIONS Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.
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Affiliation(s)
- Brian J Ulmer
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Hospital, Indianapolis 46202, USA
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Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG. Ketamine sedation for pediatric gastroenterology procedures. J Pediatr Gastroenterol Nutr 2001; 32:26-33. [PMID: 11176320 DOI: 10.1097/00005176-200101000-00010] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD). METHODS The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD. RESULTS During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intravenous route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists (ASA] class > or =3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (< or =6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness. CONCLUSION Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.
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Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, California, USA.
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25
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Montes RG, Bohn RA. Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy. J Pediatr Gastroenterol Nutr 2000; 31:41-6. [PMID: 10896069 DOI: 10.1097/00005176-200007000-00010] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Sevoflurane is an inhaled anesthetic agent with ideal properties for achieving deep sedation during pediatric outpatient gastrointestinal endoscopy. This is a comparison of experience with this gas and other sedation methods used in the authors' hospital. METHODS Retrospective chart review and statistical analysis of data from children receiving inhaled sevoflurane administered by an anesthesiologist through laryngeal insufflation, intravenous propofol, or intravenous midazolam-fentanyl-ketamine in any combination to achieve deep sedation for outpatient gastrointestinal endoscopy. Anesthesia was administered in a dedicated procedure room. The intravenous drugs were administered by pediatric intensivists in the intensive care unit. The same endoscopist performed all the procedures. RESULTS A total of 248 procedures were reviewed (midazolam-fentanyl-ketamine 67, propofol 114, and sevoflurane 67). All patients were adequately sedated with sevoflurane, and no intravenous access was required. Time (in minutes) to awakening (midazolam-fentanyl-ketamine 47.15, propofol 36.12, sevoflurane 5.70), discharge (midazolam-fentanyl-ketamine 141.99, propofol 91.20, sevoflurane 53.34), and total time, including induction and procedure (midazolam-fentanyl-ketamine 163.97, propofol 119.40, sevoflurane 73.93), were significantly lower for sevoflurane (P < 0.01). The complication rate for sevoflurane (4.5%) was lower (P < 0.05) than for midazolam-fentanyl-ketamine (13.4%) and for propofol (17.5%). Charges for room use and medications were also lower for sevoflurane (P < 0.01). The total charges for sedation (U.S.$) were comparable for sevoflurane (688.10) and propofol (723.08) but were higher for midazolam-fentanyl-ketamine (855.10, P < 0.01). CONCLUSIONS Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy is as safe as conventional sedation techniques, potentially less expensive, increases endoscopy unit productivity, and eliminates the inconvenience associated with obtaining intravenous access in children.
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Affiliation(s)
- R G Montes
- Division of Pediatric Gastroenterology, Phoenix Children's Hospital, Arizona 85006, USA
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Treepongkaruna S, Lee K, Giltinan D, Catto-Smith AG. School absenteeism after upper gastrointestinal endoscopy in children. J Gastroenterol Hepatol 2000; 15:555-62. [PMID: 10847444 DOI: 10.1046/j.1440-1746.2000.02204.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS To examine the functional impact of upper gastrointestinal endoscopy as a day procedure, particularly in relation to subsequent school attendance. METHODS Symptoms and morbidities were prospectively recorded from school-aged children during observation in hospital and for 3 days at home after endoscopy by using a structured questionnaire. Reasons for school absence were identified. RESULTS Sixty children (31 boys, 29 girls) were enrolled in the study (mean age 10.6 +/- 2.8 years, range 6.1-16.2 years). Following the procedure, symptoms were reported at home in 68.3% (same day), 56.7% (day 1) and 20% (day 2).The commonest symptoms were sore throat, tiredness and dizziness. Twenty-nine children (48.3%) did not attend school on the day following the procedure but most (26 of 29) had returned to school by the second day. The main reason for their absence was residual physical discomfort related to the procedure (55.2%). CONCLUSIONS Persisting physical discomfort and school absenteeism are common following upper gastrointestinal endoscopy in children.
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Affiliation(s)
- S Treepongkaruna
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia
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Affiliation(s)
- V Tolia
- Division of Pediatric Gastroenterology and Nutrition, Wayne State University, Children's Hospital of Michigan, Detroit 48201, USA
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Abstract
Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The causes, diagnostic evaluation, and management are discussed, and differences with adult medicine are highlighted.
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Affiliation(s)
- V L Fox
- Harvard Medical School, Boston, Massachusetts, USA
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Abstract
OBJECTIVES We have created a pediatric sedation unit (PSU) in response to the need for uniform, safe, and appropriately monitored sedation and/or analgesia for children undergoing invasive and noninvasive studies or procedures in a large tertiary care medical center. The operational characteristics of the PSU are described in this report, as is our clinical experience in the first 8 months of operation. METHODS A retrospective review of quality assurance data was performed. These data included patient demographics and chronic medical diagnoses, procedure, or study performed; sedative or analgesic medication given; complications (defined prospectively); and sedation and monitoring time. Patient-specific medical records related to the procedure and sedation were reviewed if a complication was noted in the quality assurance data. RESULTS Briefly, the PSU was staffed with an intensivist and pediatric intensive care unit nurses. Patients were admitted to the PSU and assessed medically for risk factors during sedation. Continuous heart rate, respiratory rate, and pulse oximetry monitoring were used, and blood pressure was determined every 5 minutes. After sedation and stabilization, with monitoring continued, the patient was transported to the site to undergo the procedure or study. The pediatric intensive care unit nurse remained with the patient at all times. All necessary emergency equipment was transported with the patient. After the procedure or study was completed, the patient was returned to the PSU for recovery to predetermined parameters. We were able to analyze 458 episodes of sedation for this review. Procedures and studies included radiologic examinations, cardiac catheterization, orthopedic manipulations, solid organ and bone marrow biopsy, gastrointestinal endoscopy, bronchoscopy, evoked potential measurements, and others. Patients were 2 weeks to 32 years of age. The average time from initiation of sedation to last dose of medication administered was 84 minutes. The average time from initiation of sedation to full recovery was 120 minutes. Sedative and analgesia medications use was not standardized; however, the majority of children needing sedation received propofol or midazolam. For patients requiring analgesia, ketamine or fentanyl was added. In 79 of 458 (12%) sedation episodes, complications were documented. Mild hypotension (4.4%), pulse oximetry <93% (2.6%), apnea (1.5%), and transient airway obstruction (1.3%) were the most common complications noted. Cancellation of 11 (2.4%) procedures was attributable to complications. No long-term morbidity or mortality was seen. CONCLUSIONS Many children require sedation or analgesia during procedures or studies. Safe sedation is best ensured by appropriate presedation risk assessment and with monitoring by a care provider trained in resuscitative measures who is not involved in performing the procedure itself. Uniformity of care in a large institution is a standard met by the creation of a centralized service, with active input from the department of anesthesiology. We present the PSU as a model for achieving these goals.
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MESH Headings
- Adolescent
- Adult
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthesiology/organization & administration
- Anesthesiology/standards
- Anesthetics, Dissociative/administration & dosage
- Anesthetics, Dissociative/adverse effects
- Child
- Child, Preschool
- Conscious Sedation/standards
- Drug Monitoring
- Fentanyl/administration & dosage
- Fentanyl/adverse effects
- Humans
- Hypnotics and Sedatives/administration & dosage
- Hypnotics and Sedatives/adverse effects
- Infant
- Infant, Newborn
- Intensive Care Units, Pediatric/organization & administration
- Intensive Care Units, Pediatric/standards
- Ketamine/administration & dosage
- Ketamine/adverse effects
- Midazolam/administration & dosage
- Midazolam/adverse effects
- Monitoring, Physiologic
- Ohio
- Pediatrics/organization & administration
- Pediatrics/standards
- Propofol/administration & dosage
- Propofol/adverse effects
- Quality Assurance, Health Care
- Retrospective Studies
- Risk Assessment
- Workforce
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Affiliation(s)
- L Lowrie
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Liacouras CA, Mascarenhas M, Poon C, Wenner WJ. Placebo-controlled trial assessing the use of oral midazolam as a premedication to conscious sedation for pediatric endoscopy. Gastrointest Endosc 1998; 47:455-60. [PMID: 9647368 DOI: 10.1016/s0016-5107(98)70244-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study was performed to evaluate the effect of midazolam, as premedication before intravenous conscious sedation, on preprocedural, procedural, and post-procedural patient comfort and anxiety in children undergoing endoscopy. METHODS A placebo-controlled, double-blind, randomized study was conducted in 123 children (age 7.75 +/- 4.46 years, 56% male) using oral midazolam (0.5 mg/kg, maximum 20 mg) as a premedication before insertion of an intravenous access device (i.v.) and upper endoscopy. Patients were evaluated with regard to changes in vital signs, level of sedation during i.v. placement, level of pre- and post-procedure conscious sedation, ease of separation from parents, ease and duration of procedure, recovery time, and amnesia to objects shown before i.v. placement and immediately before the start of the procedure. RESULTS A significant difference was noted in the study group for the following parameters: level of sedation for i.v. placement (p < 0.0001), pre-procedural sedation (p < 0.001), ease of i.v. insertion (p < 0.003), ease of separation from parents (p = 0.022), and ease of the nursing personnel's ability to monitor the patient during the procedure (p = 0.0012). The patient's amnesia to an object shown immediately before beginning the endoscopy was increased (p < 0.001). Patients and parents were also more satisfied with the procedure process (p < 0.05). No significant difference was noted with regard to the length or performance of the procedure or recovery time or in the dose of i.v. medication required for successful completion of the endoscopy. CONCLUSION Oral midazolam is an effective and safe premedication for children undergoing upper endoscopy and should be used in all anxious children and in patients previously judged to be difficult to sedate.
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Affiliation(s)
- C A Liacouras
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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Lipscomb KJ, Linker NJ, Fitzpatrick AP. Subpectoral implantation of a cardioverter defibrillator under local anaesthesia. Heart 1998; 79:253-5. [PMID: 9602658 PMCID: PMC1728644 DOI: 10.1136/hrt.79.3.253] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate patient acceptability of submuscular implantation of a cardioverter defibrillator (ICD) under local anaesthesia with conscious sedation. DESIGN Retrospective review. Patient acceptability in the second half of the study was routinely assessed within 24 hours. SETTING Regional cardiac centre. PATIENTS 45 consecutive patients with either aborted sudden death or haemodynamically unstable ventricular tachycardia were referred for ICD implantation. INTERVENTIONS A subpectoral implantation technique was employed. Twelve procedures were performed under general anaesthesia. Thirty three patients were sedated with midazolam and diamorphine, and local anaesthesia was achieved with bupivicaine. Ventricular fibrillation for defibrillation threshold testing was induced by alternating current, T wave shock, or ultrarapid burst pacing. Patients were contacted after the procedure to assess acceptability. RESULTS 32 patients having implantation under local anaesthesia did not recall the surgical procedure. One patient described an awareness of "pushing" as the generator was positioned in the pocket. Seven patients said that the procedure was painless but recalled a test shock, four describing it as mildly uncomfortable. All 33 patients stated that they would be willing to have a second implant under local anaesthesia. Twelve patients who had the implant performed under general anaesthesia had no recollection of the procedure. Mean (SD) total procedure duration was significantly longer in those who had general anaesthesia (93 (16) v 67 (17) minutes; p = 0.0009). CONCLUSIONS Subpectoral implantation of ICDs may be performed safely with patient acceptability under local anaesthesia with conscious sedation.
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Affiliation(s)
- K J Lipscomb
- University Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, UK
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Balsells F, Wyllie R, Kay M, Steffen R. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review. Gastrointest Endosc 1997; 45:375-80. [PMID: 9165318 DOI: 10.1016/s0016-5107(97)70147-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the past decade, many pediatric endoscopists have replaced general anesthesia with conscious sedation. Sedation is commonly used to minimize discomfort. METHODS To evaluate the safety and efficacy of conscious sedation we reviewed 2711 reports of lower and upper gastrointestinal endoscopic examinations performed in 2026 patients between July 1981 and December 1992. RESULTS Intravenous sedation was accomplished using meperidine and diazepam (914 examinations, 35%) or meperidine and midazolam (1427 examinations, 55%). Single agents were used for 83 examinations (3%), and 96 examinations (3.5%) were performed with the patient under general anesthesia. In the lower endoscopy group sedated intravenously (n = 713), the cecum was reached in 82% of examinations. The procedure could not be completed in 17 cases in which patients were uncooperative despite sedation. In the upper endoscopy group sedated intravenously (N = 1653), all but 91 endoscopies were completed to the descending duodenum. Esophagoscopy had been planned in 76% of these procedures. Minor complications occurred in 7 patients (0.3%). This included two episodes of significant oxygen desaturation that responded to oxygen administration and narcotic reversal. A major complication occurred in 1 patient (0.04%) who had a gastric perforation during esophageal dilation over a defective guide wire. There were no deaths, episodes of cardiorespiratory arrest, or pulmonary aspirations in our series. The combined major and minor complication rate was 0.3%. CONCLUSIONS Intravenous conscious sedation is safe and effective in children undergoing endoscopic examination of the gastrointestinal tract. Selected patients will require general anesthesia.
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Affiliation(s)
- F Balsells
- Pediatric Gastroenterology and Nutrition, Cleveland Clinic Foundation, OH 44195, USA
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