Ketamine/midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions

Evaluating the safety of procedural sedation in emergency department settings among the pediatric population: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Our meta-analysis aimed to evaluate the safety of procedural sedation and analgesia in pediatric emergency department (ED) settings by investigating the incidence of cardiac, respiratory, gastrointestinal, and neurological adverse events associated with different sedation medications.

METHODS

In accordance with PRISMA guidelines, a comprehensive database search for randomized controlled trials was performed across ten databases from January 2005 to June 2024. Our inclusion criteria included randomized controlled trials involving children under 18 years old undergoing pediatric sedation and analgesia in the ED. Data on medication types, dosages, administration routes, and adverse events were extracted and analyzed. Primary endpoints included cardiac, respiratory, gastrointestinal, and neurological adverse events.

RESULTS

Seventeen studies met the inclusion criteria, a total of 2,302 procedural sedations. The most common adverse events were vomiting, agitation, and hypoxia, which occurred in 104.9 [95% CI = 76.9-132.9], 37.5 [95% CI = 20.6-54.4], 38.3 [95% CI = 23.9-52.6] of each 1000 sedations, respectively. Other adverse events included apnea, hypotension, and the need for bag-valve mask ventilation, which occurred in 8.6 [95% CI: 3.5-13.6], 9.3 [95% CI: -1.4 to 20.1], and 13.5 [95% CI: 3.2-23.8] of each 1,000 sedations, respectively. Severe adverse events were rare, with no reported instances of intubation and only one case of laryngospasm. Subgroup analyses revealed varying incidence rates of adverse events across different sedation protocols, with ketamine and its combinations showing higher rates of specific respiratory complications.

CONCLUSIONS

Procedural sedation in pediatric EDs is generally safe, with a low incidence of adverse events, such as vomiting, agitation, and hypoxia. Life-threatening respiratory adverse events are extremely rare. Our findings thus support the careful selection and monitoring of sedation protocols to minimize risks.

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials

BACKGROUND

We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

METHODS

We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

RESULTS

We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

CONCLUSION

When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Successful Use of Low-Dose Combination Propofol and Fentanyl in Cataract Surgery Phacoemulsification

Background

The combination between sedatives and opioids is one of the recommended anesthetic options in ophthalmic procedures and regimens are more advantageous as smaller amounts of each drug can be administered to reduce side effects and have proper outcomes due to the synergistic effects. This study aims to observe the use of low-dose propofol and fentanyl for patients undergoing phacoemulsification surgery.

Material and Methods

This observational study involves a sample of 125 adult patients who underwent elective cataract procedures using the phacoemulsification technique and had an American Society of Anesthesiologists (ASA) physical status of 1 to 3. Dose amount of fentanyl and propofol, Ramsay score, hemodynamic parameter, side effects, and patient satisfaction were evaluated, recorded, and analyzed using a 5-point Likert scale.

Results

The result showed the mean absolute dose of propofol was 12.46±4.376 mg, with a range between 10 and 30 mg, while the mean per body weight was 0.21±0.075 mg. Similarly, the mean absolute dose for fentanyl was 25.04±3.012 mcg within the range of 10-50 mcg, and the per-body weight dose was 0.43±0.080 mcg. About 90.4% and 9.6% of the patients reached Ramsay 2 and 3, respectively. The analysis of systolic, diastolic blood pressure, mean arterial pressure, and pulse rate showed that the combination of low-dose fentanyl and propofol was significantly lower than before therapy administration in all four values (p < 0.05).

Conclusion

The combination of low-dose propofol and fentanyl in cataract surgery using phacoemulsification successfully reached the targeted sedation level and a significant decrease in blood pressure, MAP, pulse rate, minimal side effects, and high satisfaction rate.

Amnesia after Midazolam and Ketamine Sedation in Children: A Secondary Analysis of a Randomized Controlled Trial

The incidence of peri-procedural amnesia following procedural sedation in children is unclear and difficult to determine. This study aimed to apply quantitative and qualitative approaches to better understand amnesia following dental sedation of children. After Institutional Review Board Approval, children scheduled for sedation for dental procedures with oral midazolam (OM), oral midazolam and ketamine (OMK), or intranasal midazolam and ketamine (IMK) were recruited for examination of peri-procedural amnesia. Amnesia during the dental session was assessed using a three-stage method, using identification of pictures and an animal toy. On the day following the sedation, primary caregivers answered two questions about their children's memory. One week later, the children received a semi-structured interview. Behavior and level of sedation during the dental session were recorded. Quantitative data were analyzed using descriptive statistics and comparison tests. Qualitative data were analyzed using content analysis. Triangulation was used. Thirty-five children (age: 36 to 76 months) participated in the quantitative analysis. Most children showed amnesia for the dental procedure (82.9%, n = 29/35) and remembered receiving the sedation (82.1%, n = 23/28 for oral administration; 59.3%, n = 16/27 for intranasal administration). The occurrence of amnesia for the dental procedure was slightly higher in the oral midazolam group compared with the other groups (44.8%, n = 13/29 for OM, 13.8%, n = 4/29 for OMK, and 41.4%, n = 12/29 for IMK). Twenty-eight children participated in the qualitative approach. The major theme identified was that some children could remember their procedures in detail. We conclude that peri-procedural amnesia of the dental procedure was common following sedation.

Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department

OBJECTIVES

To compare the efficacy and adverse events of 2 pharmacological strategies: intranasal fentanyl and nitrous oxide (FN) inhaled against intravenous ketamine and midazolam (KM) as procedural sedation and analgesia (PSA) in painful orthopedic procedures in the pediatric emergency department (ED).

METHODS

This is an observational retrospective cohort study. Patients were included that submitted to PSA for carrying out a painful orthopedic procedure in the ED of a tertiary hospital over a period of 2 years. The main outcome variable was efficacy and adverse events of the PSA procedure.

RESULTS

Eighty-three patients were included. Fifty-two patients received FN and 31 KM. The PSA strategy was considered efficacious in 82.7% of the patients in the KM group and 80.6% in the FN cohort. No differences between both strategies were found (P = 0.815). Seventeen children showed early adverse events, 2 in the FN cohort and 15 in the KM group (relative risk of the KM strategy, 23.48; 95% confidence interval (CI), 3.24-169.99). The average of satisfaction obtained by the families was of 10 (CI, 10-10) in the KM cohort and of 9 (CI, 8-9.5) in the FN group (P = 0.152). The length of stay in the ED was longer in the KM cohort (P < 0.001). Hospital admission rate differences were not statistically different (9.6% vs 22.6%, P = 0.144) in the KM versus FN cohort.

CONCLUSIONS

Both PSA strategies presented similar efficacy. The FN strategy was associated with a lower risk of adverse events and shorter ED length of stay than KM in this ED setting.

Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial

OBJECTIVE

Pain and distress associated with intranasal midazolam administration can be decreased by administering lidocaine before intranasal midazolam (preadministered lidocaine) or combining lidocaine with midazolam in a single solution (coadministered lidocaine). We hypothesized coadministered lidocaine is non-inferior to preadministered lidocaine for decreasing pain and distress associated with intranasal midazolam administration.

METHODS

Randomized, outcome assessor-blinded, noninferiority trial. Children aged 6 months to 7 years undergoing laceration repair received intranasal midazolam with preadministered or coadministered lidocaine. Pain and distress were evaluated with the Observational Scale of Behavioral Distress-Revised (OSBD-R) (primary outcome; non-inferiority margin 1.8 units) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Faces, Legs, Activity, Cry, Consolability (FLACC) scales and cry duration (secondary outcomes). Secondary outcomes also included adverse events, clinician and caregiver satisfaction, and pain and distress associated with intranasal lidocaine administration.

RESULTS

Fifty-one patients were analyzed. Mean OSBD-R scores associated with intranasal midazolam administration were 6.4 (95% confidence interval [CI] 5, 7.8) and 7 (95% CI 5.2, 8.9) units for preadministered and coadministered lidocaine, respectively. The difference of 0.6 (95% CI -1.7, 2.8) units represented an inconclusive non-inferiority determination. CHEOPS and FLACC scores and cry duration were similar between groups. OSBD-R, CHEOPS, and FLACC scores and cry duration associated with intranasal lidocaine administration were 3.8, 9.9, and 6 units, and 56 seconds, respectively. Clinicians considered coadministered lidocaine easier to administer.

CONCLUSION

Pain and distress associated with intranasal midazolam administration were similar when using coadministered or preadministered lidocaine, but our non-inferiority determination was inconclusive. Administration of intranasal lidocaine by itself was associated with a measurable degree of pain and distress.Keywords: intranasal, midazolam, anxiolysis, sedation, emergency department, emergency medicine, pain, distress, pediatric, lidocaine, laceration.

WITHDRAWN: Comparison of Preadministered and Coadministered Lidocaine for Treating Pain and Distress Associated With Intranasal Midazolam Administration in Children: A Randomized Clinical Trial

This article has been withdrawn at the request of the authors and editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Using anxiolytics in a pediatric otolaryngology clinic to avoid the operating room

INTRODUCTION

There is increasing concern regarding the risks associated with the use of general anesthesia in pediatric patients. Many otolaryngologic procedures performed under general anesthesia can also be performed in clinic. We hypothesize that anxiolytics can aid in performing common procedures in clinic thus avoiding the need to undergo general anesthesia in the OR.

METHODS

We performed a retrospective review of patients undergoing inoffice procedures with anxiolytics in our pediatric otolaryngology outpatient clinic between February 2013 and January 2017. Charts were reviewed for age, past medical history, procedure type/duration, and outcome. These results were then compared to a cohort undergoing similar procedures in the OR.

RESULTS

A total of 34 patients underwent an in-office procedure with an anxiolytic. The success rate was 97% (33/34). The average age was 6.2 years. Six children (17%) had a known history of chromosomal abnormalities and 2 children (6%) had autism. The four most common procedures performed were cerumen impaction removal (8), flexible laryngoscopy (6), ear canal foreign body removal (5), and septal cautery (4). Performing similar procedures in the OR resulted in an average additional cost of $822.

CONCLUSIONS

Performing procedures with anxiolytics in a pediatric otolaryngology clinic is safe, expeditious, and cost-effective. Anxiolytics can provide an effective alternative to general anesthesia.

Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial

BACKGROUND

According to the favorable effects of combination therapy to provide better sedation during phacoemulsification and lack of any studies investigating the sedative effect of etomidate, propofol, and midazolam in combination with fentanyl during the procedure.

OBJECTIVES

The current study aimed at comparing the sedative properties of the mentioned three combination therapies in this field.

METHODS

The current double-blind, randomized, controlled clinical trial was conducted on patients referred for elective phacoemulsification surgery under sedation. They were randomly allocated to the three groups to receive fentanyl plus one of the following medications: Propofol, midazolam, and etomidate. Demographic characteristics, medical condition, and hemodynamic parameters before, during, and after surgery, sedation level, anesthetic complications, sedation-related adverse events, and patients' and surgeons' satisfaction were evaluated and recorded by the anesthesiologist and compared in the three studied groups.

RESULTS

In the current study, out of 150 enrolled patients, 98 completed the study. Frequency of different levels of Ramsay scores was not significantly different between the groups (P = 0.41). Frequency of Ramsay scores 3 and 4 was 92%, 79.4%, and 88.2% in etomidate, midazolam and propofol groups, respectively (P = 0.32). The median recovery time was significantly higher in the midazolam group than the propofol group (P = 0.04); intergroup comparisons indicated that the patients' mean score of satisfaction in the propofol group was significantly higher than that of the etomidate group (P = 0.006).

CONCLUSIONS

The current study findings indicated that though the quality of sedation during phacoemulsification cataract surgery was acceptable in the three agents and the results had no significantly differences among the groups, and considering other factors including recovery time, hemodynamic evaluation, sedation-related complications, and patients' satisfication scores, it is suggested that propofol was superior to the other two agents.

Randomized Trial of Intranasal Fentanyl Versus Intravenous Morphine for Abscess Incision and Drainage

OBJECTIVES

Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children.

METHODS

We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department. Patients received IN fentanyl (2 μg/kg; maximum, 100 μg) or IV morphine (0.1 mg/kg; maximum, 8 mg). The primary outcome, determined independently by blinded assessors, was the Observational Scale of Behavioral Distress-Revised (OSBD-R). The prestated margin of noninferiority (Δ) was 1.80. Secondary outcomes included self-reported pain, treatment failure, and patient and parental satisfaction.

RESULTS

We enrolled 20 children (median age, 15.4 years), 10 in each group. The difference between total OSBD-R scores was -13.45 (95% confidence interval, -24.24 to -2.67), favoring IN fentanyl.There was less self-reported pain in patients who received IN fentanyl immediately after the procedure. Four patients (40%) receiving IV morphine had treatment failures and required moderate sedation or had the procedure terminated. More patients who received IN fentanyl were satisfied with the analgesic administered compared with those who received IV morphine.

CONCLUSIONS

In a small sample of children aged 4 to 18 years undergoing abscess I&D, IN fentanyl was noninferior, and potentially superior, to IV morphine for reducing procedural pain and distress.

What is the level of evidence for the amnestic effects of sedatives in pediatric patients? A systematic review and meta-analyses

Background

Studies have suggested that benzodiazepines are amnestic drug par excellence, but when taken together, what level of evidence do they generate? Are other sedatives as amnestic as benzodiazepines? The aim of this study was to assess the level of scientific evidence for the amnestic effect of sedatives in pediatric patients who undergo health procedures.

Methods

The literature was searched to identify randomized controlled trials that evaluated anterograde and retrograde amnesia in 1-19-year-olds who received sedative drugs during health procedures. Electronic databases, including PubMed, Scopus and Cochrane Library besides clinical trial registries and grey literature were searched. Two independent reviewers performed data extraction and risk of bias assessment using the Cochrane Collaboration's Tool. The meta-analyses were performed by calculating relative risk (RR) to 95% confidence intervals (CI). The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach.

Results

Fifty-four studies were included (4,168 participants). A higher occurrence of anterograde amnesia was observed when benzodiazepines, the most well-studied sedatives (n = 47), were used than when placebo was used (n = 12) (RR = 3.10; 95% CI: 2.30–4.19, P<0.001; I² = 14%), with a moderate level of evidence. Higher doses of alpha2-adrenergic agonists (clonidine/dexmedetomidine) produced more anterograde amnesia than lower doses (n = 2) (RR = 1.83; 95% CI: 1.03–3.25; P = 0.038; I² = 0%), with a low level of evidence; benzodiazepines’ amnestic effects were not dose-dependent (n = 3) (RR = 1.54; 95% CI: 0.96–2.49; P = 0.07; I² = 12%) but the evidence was low. A qualitative analysis showed that retrograde amnesia did not occur in 8 out of 10 studies.

Conclusions

In children, moderate evidence support that benzodiazepines induce anterograde amnesia, whereas the evidence for other sedatives is weak and based on isolated and small studies. Further clinical trials focused on the amnesia associated with non-benzodiazepine sedatives are therefore needed.

Trial registration

PROSPERO CRD42015017559.

Validation of the Pediatric Sedation State Scale

OBJECTIVES

Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care.

METHODS

The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure.

RESULTS

Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores (P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli.

CONCLUSIONS

The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study.

Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

OBJECTIVES

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

METHODS

Forty-four healthy children aged 7 to 18 years were included. The patients were randomly divided into 2 groups. Group 1 (24 patients) received etomidate and fentanyl, and group 2 (20 patients) received ketamine intravenously. The Ramsay Sedation Scale and American Pediatric Association discharge criteria were used to evaluate the patients.

RESULTS

There were 70 fractured bones and 3 joint dislocations. Except in 1 case (2.3%), all of the injuries were reducted successfully. The mean amount of drugs used to provide adequate sedation and analgesia were 0.25 mg/kg of etomidate and 1.30 μg/kg of fentanyl in group 1 and 1.25 mg/kg of ketamine in group 2. Fourteen patients (31.8%) reported adverse effects, and none required hospitalization. There was no difference between the groups in the recovery times, occurrence of adverse effects, and postsedation observation durations (P > 0.05). The mean (SD) induction time for the patients in group 1 was 4.3 (1.0) minutes, whereas it was 2.2 (1.6) minutes in group 2 (P < 0.001).

CONCLUSIONS

Etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures. Ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Options and Considerations for Procedural Sedation in Pediatric Imaging

As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.

Etomidate in pediatric anesthesiology: Where are we now?

Etomidate is an intravenous anesthetic agent released for clinical use in the United States in 1972. Its popularity in clinical practice is the result of its beneficial effects on intracerebral dynamics with limited effects on hemodynamic function. These properties have made it a safe and effective anesthetic induction agent in both adult and pediatric patients with altered myocardial performance, congenial heart disease, or hypovolemia. However, recent concern has been expressed regarding its effects on the endogenous production of corticosteroids and the impact of that effect on patient outcomes. The following manuscript reviews clinical reports regarding etomidate use in the pediatric population and discusses recent concerns regarding its effects on corticosteroid metabolism and the implications of such effects for clinical use.

Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies

SummaryObjective:to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.Methods:randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team.Results:13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222).Conclusion:by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.

Procedural sedation in the emergency department

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

Sedation and analgesia with fentanyl and etomidate for intrathecal injection in childhood leukemia patients

In this study, we tried to find a safe as well as fast effective treatment for sedation and analgesia for intrathecal injection in childhood leukemia patients, relieving treatment difficulties and pain, increasing the success rate of single intrathecal injection.The patients were divided into the experimental group (fentanyl combined with etomidate) and the control group (lidocaine only) randomly. The experimental group was given fentanyl 1 to 2 μg/kg intravenously first, then etomidate 0.1 to 0.3 mg/kg intravenously after the pipe washed. The patients younger than 1.5 years or who did not achieve satisfied sedative and analgesic situation received an additional time of etomidate (0.1-0.3 mg/kg). The patients were given oxygen at the rate of 4-5 L/min during the whole operation, and the finger pulse oximeter was used simultaneously to detect the changes in heart rate (HR) and blood oxygen saturation (SpO2). The doctors who performed the procedures assessed the quality of sedation and analgesia.In the experimental group, the patients' HR increased slightly after given fentanyl combined with etomidate. The patients' SpO2 was stable. Most patients achieved a good sedative and analgesic state within 1 to 2 minutes, and no case of respiration depression or cardiac arrhythmias occurred during the whole operation. The wake-up time was 55.42 ± 20.62 min. In the control group, the patients were not very cooperative during the intrathecal injection, which made the procedures very difficult.During intrathecal injection, pain obviously reduced and the success rate of single lumbar puncture increased. It is safe and effective to apply fentanyl combined with etomidate for sedation and analgesia.

A fixed-dose ketamine protocol for adolescent sedations in a pediatric emergency department

OBJECTIVES

To assess provider and patient satisfaction with a fixed-dose ketamine protocol for procedural sedation of adolescent subjects. We further compared data for normal weight (body mass index [BMI] ≤ 25 kg/m(2)) vs overweight/obese subjects (BMI >25 kg/m(2)).

STUDY DESIGN

Prospective, observational cohort study of adolescent patients undergoing procedural sedation in a pediatric emergency department. Adequate sedation was defined as a Ramsay Sedation Score (RSS) ≥ 5. Subjects received an initial 50 mg intravenous ketamine dose followed by 25 mg intravenous doses to maintain an RSS ≥ 5. The sedating physician, procedural physician, and sedating nurse independently rated the sedations on a 100 mm visual analog scale (0 = "very unsatisfied", 100 = "very satisfied"). Subjects and their guardians were contacted 12-24 hours postsedation.

RESULTS

Forty-three subjects (26 normal weight, 17 overweight/obese), aged 12-17 years, were enrolled in the study. An RSS ≥ 5 was observed in 35 (81.4%) of the subjects following the initial 50 mg ketamine dose and in the remaining 8 subjects following the first additional 25 mg dose. The median combined provider satisfaction score for the sedations was 92.7 (IQR 83.7-95.0) and was similar for the normal weight and overweight/obese groups (93.1 [IQR 84.6-95.9] vs 89.7 [IQR 83.7-93.5], respectively, P = .27). Subjects and guardians in both groups reported high rates of satisfaction.

CONCLUSION

The fixed-dose ketamine protocol resulted in an adequate level of sedation and high provider/patient satisfaction for the majority of patients regardless of weight or BMI status.

Etomidate for short pediatric procedures in the emergency department

OBJECTIVE

This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children.

METHODS

This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 μg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion.

RESULTS

Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes.

CONCLUSIONS

For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.

A comparison of fentanyl with tramadol during propofol-based deep sedation for pediatric upper endoscopy

AIM

This study was conducted to compare the efficacy and safety of tramadol with those of fentanyl and to evaluate the impact of age in pediatric patients undergoing upper gastrointestinal endoscopy (UGIE).

METHODS

Eighty patients with ASA I-II, aged 1-16 years, undergoing UGIE were included in this study. Baseline anesthesia was maintained with 1 mg·kg(-1) propofol, and then, the patients were randomly assigned to receive 2 μg·kg(-1) fentanyl (group F, n = 40) or 2 mg·kg(-1) tramadol (group T, n = 40). Additional propofol, 0.5-1 mg·kg(-1), was administered when needed. Heart rate, mean arterial pressure, oxygen saturation (SpO(2)), and sedation scores were recorded at baseline, induction, and every 5 min. Endoscopy duration, recovery time, and adverse effects were recorded. The data were separated for subgroup analyses based on the age of 0-2, 2-12, and over 12 years.

RESULTS

Fentanyl significantly decreased the saturation at induction, 5th min and 10th min in patients of 0-2 years; at 5th and 10th min in 2-12 years; and at 5th min in >12 years. In all age subgroups, sedation scores at 10th, 15th, and 20th min, the overall frequency of adverse effects, and the recovery time were significantly lower in group T compared with group F.

CONCLUSION

Tramadol in pediatric patients undergoing UGIE provided sedation as efficient as fentanyl with a better hemodynamic and respiratory stability and provided a superior safety and tolerance in younger children.