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Hudson JL, Wong J, Durkin M, Gangathimmaiah V, Furyk J. Review article: Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis. Emerg Med Australas 2024; 36:178-186. [PMID: 38220580 DOI: 10.1111/1742-6723.14372] [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: 06/21/2023] [Revised: 12/13/2023] [Accepted: 12/24/2023] [Indexed: 01/16/2024]
Abstract
Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but ketamine-associated vomiting (KAV) is common. Routine ondansetron prophylaxis could reduce KAV incidence. This literature review evaluated the efficacy of prophylactic ondansetron in reducing KAV incidence. A systematic literature review was performed on databases and trial registries on 14 January 2023 to identify randomised controlled trials. The primary outcome was reduction in KAV incidence, for any route of prophylactic ondansetron, in ED and up to 24 h post-discharge. ED length of stay, parental satisfaction and time to resumption of normal diet were secondary outcomes. Data analysis was performed using Revman 5.3. Meta-analysis was performed using random effects modelling. Risk of bias was assessed using the Cochrane Risk-of-Bias 2 tool. Evidence quality was assessed using Grading of Recommendation, Assessment Development and Evaluation methodology. Five trials with 920 participants met the eligibility criteria. Prophylactic ondansetron resulted in a reduction in KAV incidence overall odds ratio of 0.51 (95% confidence interval: 0.36-0.73). Intravenous and intramuscular prophylactic ondansetron showed benefit whereas the effect of oral administration was unclear. There was no difference between groups for secondary outcomes overall. The quality of evidence was deemed to be low overall because of high risk of bias and imprecision in outcome measures. This review found low to moderate certainty evidence that prophylactic ondansetron reduces KAV incidence. Methodologically rigorous research, with appropriately timed prophylactic ondansetron based on the route of administration, would further elucidate prophylactic oral ondansetron's efficacy.
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Affiliation(s)
- Jack L Hudson
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Julian Wong
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
| | - Michael Durkin
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, University Geelong Hospital, Geelong, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
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Schep LJ, Slaughter RJ, Watts M, Mackenzie E, Gee P. The clinical toxicology of ketamine. Clin Toxicol (Phila) 2023:1-14. [PMID: 37267048 DOI: 10.1080/15563650.2023.2212125] [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: 10/20/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Ketamine is a pharmaceutical drug possessing both analgesic and anaesthetic properties. As an anaesthetic, it induces anaesthesia by producing analgesia with a state of altered consciousness while maintaining airway tone, respiratory drive, and hemodynamic stability. At lower doses, it has psychoactive properties and has gained popularity as a recreational drug. OBJECTIVES To review the epidemiology, mechanisms of toxicity, pharmacokinetics, clinical features, diagnosis and management of ketamine toxicity. METHODS Both OVID MEDLINE (January 1950-April 2023) and Web of Science (1900-April 2023) databases were searched using the term "ketamine" in combination with the keywords "pharmacokinetics", "kinetics", "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". Furthermore, bibliographies of identified articles were screened for additional relevant studies. These searches produced 5,268 non-duplicate citations; 185 articles (case reports, case series, pharmacokinetic studies, animal studies pertinent to pharmacology, and reviews) were considered relevant. Those excluded were other animal investigations, therapeutic human clinical investigations, commentaries, editorials, cases with no clinical relevance and post-mortem investigations. EPIDEMIOLOGY Following its introduction into medical practice in the early 1970s, ketamine has become a popular recreational drug. Its use has become associated with the dance culture, electronic and dubstep dance events. MECHANISM OF ACTION Ketamine acts primarily as a non-competitive antagonist on the glutamate N-methyl-D-aspartate receptor, causing the loss of responsiveness that is associated with clinical ketamine dissociative anaesthesia. PHARMACOKINETICS Absorption of ketamine is rapid though the rate of uptake and bioavailability is determined by the route of exposure. Ketamine is metabolized extensively in the liver. Initially, both isomers are metabolized to their major active metabolite, norketamine, by CYP2B6, CYP3A4 and CYP2C9 isoforms. The hydroxylation of the cyclohexan-1-one ring of norketamine to the three positional isomers of hydroxynorketamine occurs by CYP2B6 and CYP2A6. The dehydronorketamine metabolite occurs either by direct dehydrogenation from norketamine via CYP2B6 metabolism or non-enzymatic dehydration of hydroxynorketamine. Norketamine, the dehydronorketamine isomers, and hydroxynorketamine have pharmacological activity. The elimination of ketamine is primarily by the kidneys, though unchanged ketamine accounts for only a small percentage in the urine. The half-life of ketamine in humans is between 1.5 and 5 h. CLINICAL FEATURES Acute adverse effects following recreational use are diverse and can include impaired consciousness, dizziness, irrational behaviour, hallucinations, abdominal pain and vomiting. Chronic use can result in impaired verbal information processing, cystitis and cholangiopathy. DIAGNOSIS The diagnosis of acute ketamine intoxication is typically made on the basis of the patient's history, clinical features, such as vomiting, sialorrhea, or laryngospasm, along with neuropsychiatric features. Chronic effects of ketamine toxicity can result in cholangiopathy and cystitis, which can be confirmed by endoscopic retrograde cholangiopancreatography and cystoscopy, respectively. MANAGEMENT Treatment of acute clinical toxicity is predominantly supportive with empiric management of specific adverse effects. Benzodiazepines are recommended as initial treatment to reduce agitation, excess neuromuscular activity and blood pressure. Management of cystitis is multidisciplinary and multi-tiered, following a stepwise approach of pharmacotherapy and surgery. Management of cholangiopathy may require pain management and, where necessary, biliary stenting to alleviate obstructions. Chronic effects of ketamine toxicity are typically reversible, with management focusing on abstinence. CONCLUSIONS Ketamine is a dissociative drug employed predominantly in emergency medicine; it has also become popular as a recreational drug. Its recreational use can result in acute neuropsychiatric effects, whereas chronic use can result in cystitis and cholangiopathy.
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Affiliation(s)
- Leo J Schep
- Professional Practice Fellow, Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | | | - Martin Watts
- Emergency Department, Southland Hospital, Invercargill, New Zealand
| | - Elliot Mackenzie
- Obstetrics and Gynaecology, Women and Childrens Health. Dunedin Public Hospital, Dunedin, New Zealand
| | - Paul Gee
- National Poisons Centre, University of Otago, Dunedin, New Zealand
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Yu Y, Quan J, Zou M, Zhao W, Su Y, Xu Y. Effects of ketamine-induced H3K9 hypoacetylation during pregnancy on cardiogenesis of mouse offspring. Birth Defects Res 2023; 115:770-781. [PMID: 36899481 DOI: 10.1002/bdr2.2168] [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: 11/08/2022] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Prenatal exposure to adverse factors can cause congenital heart defects. Ketamine, a widely used anesthetic drug, produces several adverse reactions such as tachycardia, hypertension, and laryngospasm, especially in pediatric patients. This study aimed to detect the effects of ketamine exposure during pregnancy on the cardiogenesis of mouse offspring and the potential mechanisms. METHODS In this study, ketamine at an addictive dose (5 mg/kg) was administered to mice during early gestation to explore the epigenetic mechanism of its causing cardiac dysplasia. The cardiac morphology of the mouse offspring was observed through hematoxylin-eosin staining and transmission electron microscopy. The heart function of one-month-old neonates was detected by echocardiography. The expression of cardiomyogenesis-related genes was detected by western blot and RT-qPCR. The acetylation level of histone H3K9 at the Mlc2 promoter and its deacetylase level and activity were detected by CHIP-qPCR, RT-qPCR, and ELISA, respectively. RESULTS Our data revealed that ketamine exposure during pregnancy could cause cardiac enlargement, myocardial sarcomere disorganization, and decreased cardiac contractile function in mouse offspring. Moreover, ketamine reduced the expression of Myh6, Myh7, Mlc2, Mef2c, and cTnI. The histone H3K9 acetylation level at the Mlc2 promoter was down-regulated by increasing the histone deacetylase activity and HDAC3 level upon ketamine administration. CONCLUSIONS Our work indicates that H3K9 acetylation is a vital player in cardiac dysplasia in offspring caused by prenatal ketamine exposure and HDAC3 is a key regulatory factor.
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Affiliation(s)
- Yujuan Yu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Department of Anesthesiology, The Third Hospital of Mianyang, Sichuan Mental Health Center, Sichuan, China
| | - Junjun Quan
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Mou Zou
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wei Zhao
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Laboratory of Developmental Biology, Department of Cell Biology and Genetics, Chongqing Medical University, Chongqing, China
| | - Yujuan Su
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ying Xu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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The Impact of a Dedicated Sedation Team on the Incidence of Complications in Pediatric Procedural Analgosedation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070998. [PMID: 35883982 PMCID: PMC9320875 DOI: 10.3390/children9070998] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
Abstract
The number of pediatric procedural sedations for diagnostic and minor therapeutic procedures performed outside the operating room has increased. Therefore, we established a specialized interdisciplinary team of pediatric anesthesiologists and intensivists (Children’s Analgosedation Team, CAST) at our tertiary-care university hospital and retrospectively analyzed the first year after implementation of the CAST. Within one year, 784 procedural sedations were performed by the CAST; 12.2% of the patients were infants <1 year, 41.9% of the patients were classified as American Society of Anesthesiologists (ASA) grade III or IV. Most children received propofol (79%) and, for painful procedures, additional esketamine (48%). Adverse events occurred in 51 patients (6.5%), with a lack of professional experience (OR 0.60; 95% CI 0.42−0.81) and increased propofol dosage (OR 1.33; 95% CI 1.17−1.55) being significant predictors. Overall, the CAST enabled safe and effective procedural sedation in children outside the operating room.
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Taiwo A, Braimah R, Ibikunle A, Adigun O, Lawal S, Ile-Ogendengbe B, Bala M, Olayinka A, Adeyemi M, Farouk M. Applicability of Ambulatory Cleft Lip Repair in North-western Nigeria: Case Series and Review of the Existing Literature. JOURNAL OF CLEFT LIP PALATE AND CRANIOFACIAL ANOMALIES 2022. [DOI: 10.4103/jclpca.jclpca_4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Kwong A, Aldridge ES, Jayawardana R, Brookwick A, Miller J, Buntine PG. Length of stay outcomes in patients receiving ketamine sedation versus Bier's block anaesthesia for procedural closed fracture reduction: A retrospective audit of paediatric emergency department patients. Emerg Med Australas 2021; 34:73-77. [PMID: 34459117 DOI: 10.1111/1742-6723.13844] [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: 03/23/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare length of stay (LOS) for paediatric patients receiving ketamine sedation or Bier's block anaesthesia for procedural closed fracture reduction. METHODS We conducted a retrospective audit of paediatric ED patients aged 3-18 years presenting at one of three metropolitan hospitals in Victoria, Australia (2012-2017). Outcomes were post-procedural LOS (PPLOS), total LOS, incidence of ketamine and Bier's block procedures, and recorded adverse effects. Groups were compared using t-tests. Association between treatment group and admission to a short stay unit (SSU) was assessed using univariate logistic regression. RESULTS Across all three sites, 449 patients were included, 379 of whom received ketamine sedation and 73 of whom underwent Bier's block anaesthesia. Mean age was 9.1 years (ketamine group: 8.3 years; Bier's block group: 13.1 years). Median PPLOS was 75 min shorter for patients who received a Bier's block than for those sedated with ketamine (P < 0.001). Patients sedated with ketamine were also 9.01 times more likely to be admitted to an SSU than those who received Bier's block anaesthesia (95% confidence interval 3.82-21.31, P < 0.001). Ketamine sedation was more common than Bier's block across the three sites. No major adverse events occurred in either group. CONCLUSION Bier's block anaesthesia is a safe alternative to ketamine sedation for paediatric patients presenting to the ED with closed fractures. It is associated with reduced LOS and need for post-procedural observation. However, ketamine may remain preferable for younger paediatric patients, on whom it places fewer demands for cooperation.
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Affiliation(s)
- Alex Kwong
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Emogene S Aldridge
- Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Rachith Jayawardana
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Peninsula Health, Melbourne, Victoria, Australia
| | - Anna Brookwick
- Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia.,School of Medicine, Cardiff University, Cardiff, UK
| | - Joseph Miller
- Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Paul G Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Emergency Department, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
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Patel D, Talbot C, Luo W, Mulvaney S, Byrne E. The use of esketamine sedation in the emergency department for manipulation of paediatric forearm fractures: A 5 year study. Injury 2021; 52:1321-1330. [PMID: 33454059 DOI: 10.1016/j.injury.2020.12.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/20/2020] [Accepted: 12/27/2020] [Indexed: 02/02/2023]
Abstract
The purpose of this study is to assess the use of esketamine as procedural sedation for the reduction of paediatric forearm fractures in the emergency department (ED). A retrospective analysis was undertaken of forearm fractures between 1st January 2012 to 31st December 2016 which were treated with manipulation in ED using esketamine sedation. Patient demographics and fracture configuration were collected. Patient radiographs were evaluated and cast index calculated. 151 patients (103 male, 48 female) were included (average age of 8.5 [1 to 15]). Four (2.6%) patients were lost to final follow up. 11 (7%) fractures were not accepted after initial manipulation and required formal surgical management under general anaesthetic. At one week follow up, a further 5 (3%) fractures displaced requiring operative management. 100% of patients who slipped at one week had a cast index greater than 0.8 [average 0.86, 95% CI 0.80-0.92]. At final follow up successful reduction was achieved in 89.1% (131/144) of patients. No adverse events occurred following administration of esketamine. This study provides evidence that manipulation of paediatric forearm fractures using esketamine as procedural sedation in the ED is comparable to other methods in achieving acceptable outcomes. This is in addition to the potential for cost savings. However, future studies formally assessing cost effectiveness and patient outcomes are needed.
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Affiliation(s)
- Dhawal Patel
- Department of Orthopaedics, Liverpool University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, United Kingdom.
| | - Christopher Talbot
- Department of Orthopaedics, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
| | - Weisang Luo
- Department of Orthopaedics, Liverpool University Hospital NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, United Kingdom
| | - Shirley Mulvaney
- Department of Emergency Medicine, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
| | - Eileen Byrne
- Department of Emergency Medicine, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L14 5AB
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8
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:dic-2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
Background One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. Methods Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors’ personal collections of literature were reviewed. The terms “palliative care”, “ketamine”, “neuropathic pain”, “procedural pain”, “status epilepticus”, “refractory pain” and “child”, adding “age: birth–18 years” on a further filter were used for the search. Discussion The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. Conclusion Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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10
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Lee JL, Tham LP. Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department. Singapore Med J 2020; 63:28-34. [PMID: 32588587 DOI: 10.11622/smedj.2020095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore. METHODS A retrospective analysis was done of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors. RESULTS Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged < 3 years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors. CONCLUSION The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.
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Affiliation(s)
- Jia Le Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Lai Peng Tham
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Aslam SL, Haque A, Jamil MT, Ariff M, Nasir S. Safety and Efficacy of Procedural Sedation and Analgesia in Pediatric Oncology Patients. Cureus 2020; 12:e7442. [PMID: 32351822 PMCID: PMC7186096 DOI: 10.7759/cureus.7442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective Procedural sedation and analgesia are the standard of care for painful procedures in children that require immobility. The aim is to assess the safety and efficacy of procedural sedation and analgesia in pediatric oncological patients in a large tertiary care hospital. Method An observational study performed to review medical records of children who received procedural sedation and analgesia (PSA) for pediatric oncological procedures from July 2018 to September 2018. Patients undergoing oncology procedures (lumbar puncture, intrathecal chemotherapy, bone marrow aspiration +/- trephine) were included, and non-anesthesiologist (intensive care physician/emergency physician certified in pediatric advanced life support) provided PSA. Patients were assessed according to PSA protocol guidelines by the American Society of Anesthesiology (ASA). Low-dose ketamine (0.5 mg/kg) and propofol (2 mg/kg) were administered. Results A total of 565 children underwent 1216 procedures in whom the median age was 7.4 years, and the majority (65.1%) were males. The most common procedure was the lumbar puncture (n = 956; 78.6%) followed by bone marrow aspirate only (n = 137, 11.3%) and both (n = 123, 10.1%). Eight (0.7%) patients developed transient oxygen desaturation only as an adverse effect of ketamine-propofol drug combination with 50% procedures utilizing propofol 1 mg/kg for sedation. Conclusion According to the results of our study, the majority of the pediatric patients responded and reported no adverse events during the procedure with ketamine and propofol. Therefore, we conclude that ketamine and propofol are safe and effective as both sedative and an analgesic in procedures on pediatric oncology patients.
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Affiliation(s)
| | - Anwar Haque
- Pediatrics, The Indus Hospital, Karachi, PAK
| | | | - Madiha Ariff
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Saad Nasir
- Internal Medicine, United Medical and Dental College, Creek General Hospital, Karachi, PAK
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Chen FH, Yu CF, Yang CL, Lin YC, Lin G, Wang CC, Yu HP, Fang J, Chang NF, Hong JH. Multimodal imaging reveals transient liver metabolic disturbance and sinusoidal circulation obstruction after a single administration of ketamine/xylazine mixture. Sci Rep 2020; 10:3657. [PMID: 32108154 PMCID: PMC7046666 DOI: 10.1038/s41598-020-60347-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 02/04/2020] [Indexed: 11/17/2022] Open
Abstract
A ketamine/xylazine (K/X) mixture is widely used before and during experiments in rodents. However, the impact of short-term use of K/X mixture and its influences on data interpretation have rarely been discussed. In this study, we administered one shot of a K/X mixture and examined acute hepatic responses using biochemical analysis, histopathological examination, and non-invasive imaging to determine the delay required prior to further assessment of the liver to avoid confounding effects triggered by anaesthesia. After the K/X injection, aspartate aminotransferase (AST) in serum was significantly elevated from 3 to 48 h. Obstructed sinusoidal circulation lasting for 24 or 36 h was revealed by DCE-MRI and drug distribution analysis, respectively. Metabolic alterations were detected at 3 h by NMR analysis and FDG-PET. Moreover, ultrasonography showed that lipid droplet accumulation increased from 1 to 16 h and declined thereafter. Taken together, our findings show that the K/X mixture induces acute hepatotoxicity and metabolic disturbance, and these disturbances cause hemodynamical disorders in the liver. The required time interval for recovery from K/X impact was dependent on the chosen assay. It took at least 16 h for metabolic recovery and 36 h for recovery of sinusoidal circulation. However, the liver was not fully recovered from the injury within 48 h.
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Affiliation(s)
- Fang-Hsin Chen
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan.,Department of Radiation Oncology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Radiation Biology Research Center, Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Ching-Fang Yu
- Department of Radiation Oncology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Chung-Lin Yang
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chun Lin
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan.,Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Gigin Lin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Imaging Core Laboratory, Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Clinical Metabolomics Core Laboratory, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Chun-Chieh Wang
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan.,Department of Radiation Oncology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Radiation Biology Research Center, Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Jui Fang
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Ning-Fang Chang
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Ji-Hong Hong
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan. .,Department of Radiation Oncology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan. .,Radiation Biology Research Center, Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.
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Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters. J Clin Med 2019; 8:jcm8122087. [PMID: 31805686 PMCID: PMC6947169 DOI: 10.3390/jcm8122087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/28/2022] Open
Abstract
Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for <60 s is the most prevalent adverse event with a rate of 7.8 per 10,000, followed by airway obstruction at a rate of 5.42 per 10,000. Apnea occurred at a rate of 4.75 per 10,000. Significant predictors of adverse events are ≥ ASA score III (p = 0.0003), procedure time (6:00 pm–12:00 am: p < 0.0001, 12:00–6:00 am: p = 0.0003), and non-hospital location (p < 0.0001). The AE sedation reporting tool has demonstrated that the majority of adverse events in children and adults who receive procedural sedation from multi-specialists internationally required minor interventions and had outcomes of minor risk.
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Hu Y, Xu W, Cao F. A meta-analysis of randomized controlled trials: combination of ketamine and propofol versus ketamine alone for procedural sedation and analgesia in children. Intern Emerg Med 2019; 14:1159-1165. [PMID: 31493200 DOI: 10.1007/s11739-019-02173-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/08/2019] [Indexed: 11/26/2022]
Abstract
Although ketamine has been used for procedural sedation and analgesia, some researchers have assessed ketamine-propofol as a better alternative because of its reduced adverse events. The goal of this review was to compare adverse events between ketamine-propofol and ketamine for procedural sedation and analgesia in children. We searched the literature from their inception to May 2018 without the restriction of language. We included all randomized controlled trials comparing ketamine-propofol with ketamine for procedural sedation and analgesia in children. The meta-analysis was conducted using the Stata software. A total of six studies involving 693 individuals were included. Pooling of data showed that subjects with ketamine-propofol had similar incidence of respiratory adverse events compared to those with ketamine (RR 1.16, 95% CI 0.68-1.98). However, ketamine-propofol was effective in reducing cardiovascular adverse events compared to ketamine (RR 0.11, 95% CI 0.04-0.31). Ketamine-propofol was also effective in reducing psychomimetic adverse events compared to ketamine (RR 0.39, 95% CI 0.16-0.93). In regard to nausea and vomiting, ketamine-propofol was significantly effective (RR 0.43, 95% CI 0.25-0.74). In addition, we could not demonstrate differences in efficacious sedation between ketamine-propofol and ketamine. Although our study was not able to demonstrate differences in efficacious sedation between ketamine-propofol and ketamine, we confirmed that ketamine-propofol sedation had a lower frequency of adverse events compared to ketamine sedation in children.
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Affiliation(s)
- Yaofei Hu
- The Third Hospital of Nanchang, Nanchang, China
| | - Wujie Xu
- The Third Hospital of Nanchang, Nanchang, China
| | - Fei Cao
- Fuzhou Medical Department of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China.
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Yee R, Chay PL, Tham LP. Safety and effectiveness of intramuscular ketamine sedation in the management of children with oro-dental trauma in a paediatric emergency department. Dent Traumatol 2019; 36:19-24. [PMID: 31162805 DOI: 10.1111/edt.12497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Ketamine sedation has not been reported to be widely used as a pharmacological behavioural management strategy to facilitate the treatment of acute paediatric oro-dental trauma. The aim of this study was to investigate the safety and effectiveness of intramuscular ketamine sedation for managing paediatric oro-dental trauma in a paediatric Emergency Department (ED). METHODS The database of all paediatric procedural sedations performed in the hospital ED from 01 January 2014 to 31 December 2016 was reviewed to identify cases where intramuscular ketamine sedation was administered for dentists' treatment of oro-dental trauma. Patient demographics and epidemiological data, the type and number of sedation-related adverse events, and interventions performed were extracted from the database. Clinical notes were reviewed to verify the dental diagnoses and dental treatment performed. Adverse events were further risk stratified using the World SIVA adverse event reporting tool. RESULTS In the study period, 167 intramuscular ketamine sedations were administered by ED doctors for dental treatment of oro-dental trauma. The patients' median age was 3.6 years (range 1.1 to 12 years). All dental procedures were successfully completed. Nineteen adverse events were reported (11.4%, n = 19) with the most common being emesis (9.0%) followed by transient desaturation (1.8%) and hypersalivation (0.6%). The lowest oxygen saturation level was 90%. None of the patients aspirated, and none required assisted ventilation or chest compression. The most common dental diagnosis was primary tooth luxation (49.1%). The most common dental treatment was primary teeth extraction (70.7%). When adverse events were stratified using the World SIVA tool, there were only 17 (10.2%) minor risk outcomes. CONCLUSIONS The data support the safety and effectiveness of intramuscular ketamine sedation administered by trained ED doctors to facilitate the management of paediatric oro-dental trauma emergencies.
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Affiliation(s)
- Ruixiang Yee
- Dental Service, KK Women's and Children's Hospital, Singapore
| | - Pui Ling Chay
- Dental Service, KK Women's and Children's Hospital, Singapore
| | - Lai Peng Tham
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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Homfray G, Palmer A, Grimsmo-Powney H, Appelboam A, Lloyd G. Procedural sedation of elderly patients by emergency physicians: a safety analysis of 740 patients. Br J Anaesth 2018; 121:1236-1241. [PMID: 30442250 DOI: 10.1016/j.bja.2018.07.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/18/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The elderly are perceived as a high-risk group for procedural sedation. Concern exists regarding the safety of sedation of this patient group by emergency physicians, particularly when using propofol. METHODS We analysed prospectively collected data on patients aged 75 yr or older undergoing sedation between October 2006 and March 2017 in the emergency department of a single centre. We used the World Society of Intravenous Anaesthesia International Sedation Task Force adverse event tool, stratifying identified adverse events according to consensus agreement. RESULTS Of 740 consecutive patients (median age 84 yr), 571 patients received propofol, 142 morphine and midazolam, and 27 other agents. We identified 19 sentinel events: 2 cases of hypoxia, 10 of apnoea (without hypoxaemia), 5 of hypotension, and 2 of both hypoxaemia and hypotension. We also identified 30 moderate, 41 minor, and 7 minimal risk adverse events. There were no adverse outcomes. CONCLUSIONS We observed safe sedation practice in this high-risk group of patients in this department. A sentinel adverse event rate of 2.6% including a hypoxaemia rate of 0.5%, with no adverse outcomes sets a benchmark for elderly sedation. We recommend quality pre-oxygenation, an initial propofol bolus of no more than 0.5 mg kg-1, and a robust training and governance framework.
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Affiliation(s)
- G Homfray
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A Palmer
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - H Grimsmo-Powney
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A Appelboam
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Lloyd
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
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Wiik AV, Patel P, Bovis J, Cowper A, Pastides PS, Hulme A, Evans S, Stewart C. Use of ketamine sedation for the management of displaced paediatric forearm fractures. World J Orthop 2018; 9:50-57. [PMID: 29564214 PMCID: PMC5859200 DOI: 10.5312/wjo.v9.i3.50] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/04/2018] [Accepted: 02/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.
METHODS Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.
RESULTS During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.
CONCLUSION Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.
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Affiliation(s)
- Anatole Vilhelm Wiik
- Department of Surgery and Cancer, Charing Cross Hospital, London W6 8RF, United Kingdom
| | - Poonam Patel
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
| | - Joanna Bovis
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Adele Cowper
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
| | - Philip Socrates Pastides
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Alison Hulme
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Stuart Evans
- Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
| | - Charles Stewart
- Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
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Najafi N, Van de Velde A, Poelaert J. Alterations in haemodynamic parameters during procedural sedation and analgesia in children: Is ketamine really to blame? Hum Exp Toxicol 2018; 37:102-103. [DOI: 10.1177/0960327116689718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- N Najafi
- Department of Anaesthesiology and Perioperative Medicine, Vrije Universiteit Brussel–Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - A Van de Velde
- Department of Anaesthesiology and Perioperative Medicine, Vrije Universiteit Brussel–Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - J Poelaert
- Department of Anaesthesiology and Perioperative Medicine, Vrije Universiteit Brussel–Universitair Ziekenhuis Brussel, Brussels, Belgium
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Sneyd J. Thiopental to desflurane - an anaesthetic journey. Where are we going next? Br J Anaesth 2017; 119:i44-i52. [DOI: 10.1093/bja/aex328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 01/06/2023] Open
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Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr 2017; 171:957-964. [PMID: 28828486 PMCID: PMC5710624 DOI: 10.1001/jamapediatrics.2017.2135] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes. OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis. EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTS Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCE The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Departments of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J. Farion
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne Beno
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - C. Michelle McTimoney
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada,Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Nadia Sourial
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark G. Roback
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis,Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
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Dewdney C, MacDougall M, Blackburn R, Lloyd G, Gray A. Capnography for procedural sedation in the ED: a systematic review. Emerg Med J 2016; 34:476-484. [PMID: 27565194 DOI: 10.1136/emermed-2015-204944] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/28/2016] [Accepted: 08/03/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Procedural sedation and analgesia (PSA) is commonplace in the ED. Previous studies have identified capnography as a reliable indicator of PSA-induced respiratory depression. This review investigates the potential effect on patient safety of the use of capnography in addition to standard monitoring for adult patients undergoing PSA in the ED. METHODS MEDLINE, Embase, Scopus, CINAHL and Google Scholar were searched systematically for ED studies using capnography during PSA. Data extraction was performed by two independent authors. Using MedCalc V.13.3.3 and Meta-DiSc V.1.4, data were aggregated under the random-effects model and heterogeneity was assessed using Cochran's Q-test and the I2 statistic. RESULTS Of the 737 studies that were screened, 7 studies met the eligibility criteria, representing a total of 662 patients. The aggregate diagnostic accuracy for capnography identifying an adverse event included a diagnostic OR of approximately 6 (OR: 5.87; 95% CI 2.41 to 14.3; p<0.001), sensitivity 0.82 (95% CI 0.76 to 0.87), specificity 0.6 (95% CI 0.55 to 0.64), negative likelihood ratio 0.3 (95% CI 0.12 to 0.75) and positive likelihood ratio 1.89 (95% CI 1.53 to 2.34). There was a lack of statistical evidence for a difference in the proportion of adverse events detected when capnography was used in addition to standard monitoring (48.8% (95% CI 32.85 to 64.92)) compared with chance alone (50%). CONCLUSIONS There is no firm evidence that capnography provides additional safety compared with standard monitoring alone during PSA in adults in the ED. There is a paucity of published research involving preoxygenated patients who remain on high-flow oxygen throughout PSA. Well-powered randomised controlled trials, employing an accepted adverse event reporting tool in such patients, are required. Until then, we advocate continued compliance with current professional recommendations for the use of capnography during PSA in adults in the ED.
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Affiliation(s)
- Charlotte Dewdney
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Margaret MacDougall
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Rachel Blackburn
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Gavin Lloyd
- Department of Emergency Medicine, Royal Devon & Exeter Hospital, Exeter, UK
| | - Alasdair Gray
- Emergency Medicine Research Group Edinburgh (EMeRGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Green S, Mason K, Krauss B. Ketamine and propofol sedation by emergency medicine specialists: mainstream or menace? Br J Anaesth 2016; 116:449-51. [DOI: 10.1093/bja/aew048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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