Behavioral Changes in Children After Emergency Department Procedural Sedation

Incidence and predictors of nonresponse to intranasal midazolam in children undergoing laceration repair

BACKGROUND/OBJECTIVE

Pediatric laceration repairs are common in the emergency department (ED) and often associated with significant procedural anxiety. Despite the increased use of intranasal midazolam (INM) prior to pediatric ED procedures, there is limited, real-world data on the effects of INM on anxiety. This study aimed to describe the proportion of children who were nonresponsive to INM (i.e., exhibited extreme anxiety) and identify factors associated with INM nonresponse.

METHODS

This cross-sectional study included a sample of 102 children (ages 2-10 years) who received 0.2 mg/kg INM prior to laceration repair in the ED. Procedural anxiety was assessed using the modified Yale Preoperative Anxiety Scale (mYPAS). Children exhibiting extreme procedural anxiety (mYPAS score ≥72.91) when procedure started were labeled as INM nonresponders. Bivariate and multivariable logistic regression analyses explored associations between child age, temperament, laceration location, time from INM administration, and likelihood of INM nonresponse.

RESULTS

In this sample, 45.1% of the children were classified as INM nonresponders, exhibiting extreme procedural anxiety. Bivariate analyses indicated that nonresponders were younger, had lower sociability temperament, longer delay between INM administration and the procedure, and were more likely to have extremity lacerations. In the logistic regression, younger age (odds ratio [OR] 0.79, p = 0.034), lower sociability temperament (OR 0.28, p = 0.002), and extremity lacerations (OR 8.04, p = 0.009) were significantly associated with likelihood of INM nonresponse.

CONCLUSIONS

Nearly half of the children in our sample exhibited extreme procedural anxiety despite receiving INM. The high incidence of nonresponse to INM has important clinical practice implications and suggests that 0.2 mg/kg INM alone may not be sufficient to manage all pediatric procedural anxiety in the ED. Findings highlight a need for further research examining multimodal strategies to manage procedural anxiety in the pediatric ED, particularly for younger children with low sociability temperament or extremity lacerations.

Current sedation practices for non-invasive procedures in tertiary maternity and children's hospitals in China: a 5-year update

BACKGROUND

Sedation techniques can ease anxiety during medical procedures for children. Our previous report on Chinese sedation practices for non-invasive procedures in 2018 is outdated due to the rapid development of sedation services. This study provides an updated report on sedation practices for non-invasive procedures in China.

METHODS

This is a cross-sectional study. Questionnaires were sent to tertiary maternity and children's hospitals nationwide through the WeChat Mini Program. The survey questioned the location and caseloads of hospitals providing sedation services, support facilities, contraindications, fasting practices, sedation regimens, monitoring practices, staff structure, certification requirements for sedation providers and quality control data.

RESULTS

Procedural sedation for non-invasive procedures were provided in 88 of 114 hospitals. These hospitals are located across the country except Heilongjiang province and the Tibet Autonomous Region. Compared with previous reports, significant increases were found in the number of hospitals providing sedation services, dedicated sedation rooms and recovery rooms and full-time sedation providers. Most hospitals advocated the 2-4-6 rule for pre-sedation fasting. Dexmedetomidine was the most used first-choice sedative. Anaesthesiologists remain the primary sedation providers, but nurses are also important. The most mentioned qualification requirements for sedation providers were a professional title of attending doctor, ≥5 years of working experience in paediatric anaesthesia and paediatric advanced life support certification. Sedation service records were used in 83 hospitals, but only 42 and 39 recorded success rates and adverse events, respectively.

CONCLUSIONS

Sedation services for non-invasive procedures are available in most areas of China. More hospitals now provide sedation services and full-time sedation providers. Supporting facilities and sedation regimens have improved. Non-anaesthesiologist sedation providers are important at current stage, developing training programmes for them may be necessary. Attention should be focused on quality control and improvement of sedation services.

Association between pre-procedural anxiety and vomiting in children who undergo procedural sedation and analgesia in the emergency department

INTRODUCTION

Children presenting to the emergency department (ED) often require procedural sedation and analgesia (PSA) prior to procedures. Although ketamine is used widely for PSA safely, there is a risk of adverse effects. Among them, vomiting is significant as it occurs in about 10% of patients and can potentially endanger the airway. Because there is evidence that post-operative complications might be due to anxiety prior to the operation, this study aims to investigate the association between pre-procedural anxiety and vomiting in the ED.

METHODS

In this cohort study, a convenient sample of children aged 2 to 14 years who were a candidate for PSA with ketamine in the ED were enrolled. Anxiety was evaluated using the short version of the modified Yale preoperative anxiety scale (mYAS). Vomiting was recorded during the period of hospitalization in the ED and 24 h after discharge by a phone call. Association between anxiety level and vomiting was analyzed using the independent samples t-test and multivariable logistic regression was used to control for covariates.

RESULTS

102 children were enrolled and 93 were included in final analysis. The mean age of participants was 3.95 ± 1.79 years and 55.9% were male. According to the mYAS, the mean score of anxiety was 48.67 ± 21.78 in the waiting room and 59.10 ± 23.86 in the operating room. The mean score of anxiety was 58.3±25.3 and 51.0±20.7 in the vomiting and non-vomiting groups, respectively. At least one episode of vomiting was reported in 23 children of which, 19 took place in the hospital and 4 after discharge. No significant association was observed between pre-procedural anxiety and the occurrence of vomiting. On univariate regression model, the odds ratio of the association between mean anxiety and vomiting was 1.02 (CI 95%: 0.99-1.04) (P-value: 0.16). On the multivariable logistic regression model, after adjusting for all the covariates, the odds ratio was 1.03 (CI 95%: 1.0-1.05) (P-value: 0.05).

CONCLUSION

The present study showed that anxiety before procedural sedation and analgesia with ketamine in children was not associated with the incidence of vomiting.

Turkish Cross-cultural Adaptation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS)

PURPOSE

The purpose of this study is to cross-culturally adapt the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) to Turkish and test its validity and reliability.

DESIGN

This is a methodological study.

METHODS

This study was conducted with 121 children aged 1 to 12 years who underwent ambulatory surgery. The data of the study were collected using a Descriptive Information Form, PHBQ-AS, and the Parents' Postoperative Pain Measure. Data analysis and evaluation were performed using factor analysis, Cronbach's α analysis, item-total score correlation analysis, content validity, construct validity, and concurrent validity.

FINDINGS

PHBQ-AS showed a high level of internal consistency (Cronbach's α = 0.801). The item-total correlation values of PHBQ-AS were found to be 0.458 to 0.753. PHBQ-AS was determined to be a single-factor scale explaining 66% of the variance in the examined variable. PHBQ-AS and Parents' Postoperative Pain Measure scores were moderately correlated.

CONCLUSIONS

The Turkish version of PHBQ-AS was highly valid and reliable for the Turkish population. A recommendation for health care professionals in Turkey is to use the PHBQ-AS scale to evaluate posthospitalization behavioral changes in children who are admitted for ambulatory surgery.

Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes

BACKGROUND

Paediatric laceration repair procedures are common in the ED; however, post-discharge recovery remains understudied. Perioperative research demonstrates that children exhibit maladaptive behavioural changes following stressful and painful medical procedures. This study examined post-discharge recovery following paediatric laceration repair in the ED.

METHODS

This prospective observational study included a convenience sample of 173 children 2-12 years old undergoing laceration repair in a paediatric ED in Orange, California, USA between April 2022 and August 2023. Demographics, laceration and treatment data (eg, anxiolytic medication), and caregiver-reported child pre-procedural and procedural pain (Numerical Rating Scale (NRS)) were collected. On days 1, 3, 7 and 14 post-discharge, caregivers reported children's pain and new-onset maladaptive behavioural changes (eg, separation anxiety) via the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery. Univariate and logistic regression analyses were conducted to identify variables associated with the incidence of post-discharge maladaptive behavioural change.

RESULTS

Post-discharge maladaptive behavioural changes were reported in 43.9% (n=69) of children. At 1 week post-discharge, approximately 20% (n=27) of children exhibited maladaptive behavioural changes and 10% (n=13) displayed behavioural changes 2 weeks post-discharge. Mild levels of pain (NRS ≥2) were reported in 46.7% (n=70) of children on post-discharge day 1, 10.3% (n=14) on day 7 and 3.1% (n=4) on day 14. An extremity laceration (p=0.029), pre-procedural midazolam (p=0.020), longer length of stay (p=0.043) and post-discharge pain on day 1 (p<0.001) were associated with incidence of maladaptive behavioural changes. Higher pain on post-discharge day 1 was the only variable independently associated with an increased likelihood of maladaptive behavioural change (OR=1.32 (95% CI 1.08 to 1.61), p=0.001).

CONCLUSION

Over 40% of children exhibited maladaptive behavioural changes after ED discharge. Although the incidence declined over time, 10% of children continued to exhibit behavioural changes 2 weeks post-discharge. Pain on the day following discharge emerged as a key predictor, highlighting the potential critical role of proactive post-procedural pain management in mitigating adverse behavioural changes.

No-anesthesia for Colles fracture

BACKGROUND

This study aims to measure the perceived pain during the reduction of Colles fracture without anesthesia in both children and adults. It describes the process and reveals duration for reduction, total hospital stays and compares them with the same procedure under hematoma block.

METHODS

We employed the Wong-Baker FACES pain scale to assess pain reduction in 135 adults and 98 pediatric patients undergoing Colles fracture reduction with or without hematoma block. We also measured the time required for the reduction and the overall process.

RESULTS

For fracture reduction without anesthesia, Wong-Baker FACES scores were 9.2 for children and 8.7 for adults. With hematoma block, scores dropped to 7.5 for children and 5.2 for adults with only a 10 min addition to the hospital stay. Pain scores among pediatric patients exhibited moderate to strong negative correlations with age. The reduction maneuver itself took an average of 5 s.

CONCLUSIONS

The reduction of a Colles fracture is nearly instantaneous, making the reduction without anesthesia tolerable. Pediatric patients don't benefit from hematoma block as much as adult counterparts. It significantly reduced pain scores by 1.7 points in children and 3.5 points in adults.

LEVEL OF EVIDENCE

Level I, Randomized Controlled Trial.

Observational Behavioral Coding in the Pediatric Emergency Department: Development of the Emergency Department Child Behavior Coding System

BACKGROUND

Despite improvements over the past decade, children continue to experience significant pain and distress surrounding invasive procedures in the emergency department (ED). To assess the impact of newly developed interventions, we must create more reliable and valid behavioral assessment tools that have been validated for the unique settings of pediatric EDs.

OBJECTIVE

This study aimed to create and test the Emergency Department Child Behavior Coding System (ED-CBCS) for the assessment of child distress and nondistress behaviors surrounding pediatric ED procedures.

METHODS

Via an iterative process, a multidisciplinary expert panel developed the ED-CBCS, an advanced time-based behavioral coding measure. Inter-rater reliability and concurrent validity were examined using 38 videos of children aged from 2 to 12 years undergoing laceration procedures. Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were used to examine concurrent validity.

RESULTS

The final ED-CBCS included 27 child distress and nondistress behaviors. Time-unit κ values from 0.64 to 0.98 and event alignment κ values from 0.62 to 1.00 indicated good to excellent inter-rater reliability for all but one of the individual codes. ED-CBCS distress (B = 1.26; p < 0.001) and nondistress behaviors (B = -0.69, p = 0.025) were independently significantly associated with FLACC scores, indicating concurrent validity.

CONCLUSIONS

We developed a psychometrically sound tool tailored for pediatric ED procedures. Future work could use this measure to better identify behavioral targets and test the effects of interventions to relieve pediatric ED pain and distress.

Predictors of parental anxiety in a paediatric emergency department

BACKGROUND

Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety.

METHODS

This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models.

RESULTS

Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004).

CONCLUSION

Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.

Evaluating the Safety and Efficacy of Ketamine as a Bronchodilator in Pediatric Patients With Acute Asthma Exacerbation: A Review

Ketamine has emerged as a potential treatment option for pediatric patients with acute asthma exacerbation who do not respond to standard therapy. This review aims to evaluate the safety and efficacy of ketamine in this population and provide an overview of the current literature. A comprehensive search was conducted in PubMed and Google Scholar, resulting in the identification of four relevant studies. The studies demonstrated that ketamine administration led to improvements in respiratory parameters, including a decrease in clinical asthma scores (CASs) and respiratory rates, and an increase in peak expiratory flow and oxygen saturation. Ketamine infusion also showed promise in obviating the need for intubation in patients with severe wheezing due to bronchiolitis. The most common side effects observed were increased tracheobronchial secretions and hallucinations, which were manageable through discontinuation or additional medication. No significant changes in heart rate and blood pressure were reported, indicating hemodynamic stability. Long-term complications of ketamine use were minimal, with no reports of nightmares or dysphoria. In conclusion, ketamine shows potential as a bronchodilator for pediatric patients with acute asthma exacerbation, although further research is needed to fully evaluate its effectiveness and long-term effects. The use of ketamine should be considered in carefully selected cases and closely monitored for adverse events.

Clinical Uses of Ketamine in Children: A Narrative Review

Ketamine is a phencyclidine derivative that acts as a noncompetitive N-methyl-D-aspartate as well as a glutamate receptor antagonist. It also has other minor mechanisms that contribute to its extensive drug profile. Ketamine is a bronchodilator and maintains normal airway reflexes and, thus, permits spontaneous respiration. This, coupled with the fact that it produces potent analgesia, makes it highly suitable for children.

Despite its many merits, the drug’s side effects, along with its cultural image of being a drug of abuse, a drug used in veterinary medicine, or a “date-rape drug” have sullied its reputation within the armamentarium of medicine. Even though it is widely used in developing countries, its use in Western nations has diminished. We have strived to explore the various clinical uses of ketamine in children through this article. In addition, the article also highlights how some of the fears associated with using the drug are unfounded and provides ways by which the drug’s side effects can be prevented and managed.

Predictors for COVID-19-related new-onset maladaptive behaviours in children presenting to a paediatric emergency department

BACKGROUND AND OBJECTIVE

The goal of the present study was to determine the incidence of new onset maladaptive behaviours in paediatric emergency department (PED) patients during the COVID-19 pandemic and to examine whether child and parent anxiety and parental health status were predictors for the new-onset of maladaptive behaviours.

METHODS

Participants included child-parent dyads seen in a PED following the state's issuance of mandatory stay-at-home orders on 19 March 2020. A total of 351 children age 0-25 years and 335 parents enrolled in the study. Parents provided baseline demographic data and completed standardised surveys that assessed aspects of parental and child anxiety and parental health, as well as child new-onset maladaptive behaviours. Children ≥8 years of age completed surveys that assessed child anxiety.

FINDINGS

Parents reported the new onset of maladaptive behaviours in children during the pandemic with frequencies up to 43%. Bivariate analysis identified predictors such as child anxiety (t(96) = -2.04, P = 0.044) as well as parental variables such as state anxiety (t(190) = -4.91, P < 0.001) and parental sensitivity to anxiety (t(243) = -3.19, P = 0.002). A logistic regression model identified parent mental health and COVID-19 anxiety as predictors of new onset maladaptive behaviours in children (X² (6) = 42.514, P < 0.001). Specifically, every unit change in parental anxiety of COVID-19 was associated with a unit increase in maladaptive behaviours in children.

CONCLUSIONS

We identified distinct parent and child-related factors that predicted new onset child maladaptive behaviours during the COVID-19 pandemic. The identification of such predictors may help clinicians to prevent maladaptive responses to the pandemic quarantine.

Complications after dental rehabilitation under general anesthesia in Isfahan during February to May 2016

BACKGROUND

Children undergoing dental rehabilitations by general anesthesia (GA) commonly experience postoperative symptoms such as pain, fever, sore throat, and sleepiness. The aim of the present study was to investigate the specific complications of pediatric dental GA procedure.

MATERIALS AND METHODS

In this observational study sample included 72 children attending GA for dental treatment at the School of Dentistry, Isfahan University of Medical Sciences. Children with American Society of Anesthesiologists physical status I and without any communication or mental health problems were included. GA protocol was standardized. A number of complications were recorded by parents via filling a questionnaire for 2 days postoperatively. Data were analyzed using SPSS statistical software by Wilcoxon and Chi-squared test. P < 0.05 considered as significant level.

RESULTS

The most postoperative nonpsychological complications were dental pain (59.7 and 47.2% on days 1 and 2, respectively), followed by inability to eat normal (55.6 and 41.7% on days 1 and 2, respectively). All the patients' nonpsychological complaints had significantly decreased from day one to day two (P < 0.05). The most postoperative psychological complications were Attachments to parents (70.8 and 65.2% on days 1 and 2, respectively) followed by excessive crying (56.9 and 45.8% on days 1 and 2, respectively). All psychological complaints reduced by day two nonsignificantly except excessive crying which decreased significantly after 48 h (P = 0.004).

CONCLUSION

The most postoperative complications after dental rehabilitation under GA were attachments to parents, dental pain, and inability to eat normal and excessive crying, respectively.