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Croughan S, Barrett M, O'Sullivan R, Beegan A, Blackburn C. Safety and efficacy of a nitrous oxide procedural sedation programme in a paediatric emergency department: a decade of outcomes. Emerg Med J 2024; 41:76-82. [PMID: 38123983 DOI: 10.1136/emermed-2022-212931] [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: 10/20/2022] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) has multiple benefits in paediatric procedural sedation (PPS), but use is restricted by its limited analgesic properties. Analgesic potency could be increased by combining N2O and intranasal fentanyl (INF). We assessed safety and efficacy data from 10 years (2011-2021) of our N2O PPS programme. METHODS Prospectively collected data from a sedation registry at a paediatric emergency department (PED) were reviewed. Total procedures performed with N2O alone or with INF, success rate, sedation depth and adverse events were determined. Contributing factors for these outcomes were assessed via regression analysis and compared between different N2O concentrations, N2O in combination with INF, and for physician versus nurse administered sedation. A post hoc analysis on factors associated with vomiting was also performed. RESULTS 831 N2O procedural sedations were performed, 358 (43.1%) involved a combination INF and N2O. Nurses managed sedation in 728 (87.6%) cases. Median sedation depth on the University of Michigan Sedation Scale was 1 (IQR 1-2). Sedation was successful in 809 (97.4%) cases. Combination INF/N2O demonstrated higher median sedation scores (2 vs 1, p<0.001) and increased vomiting (RR 1.8, 95% CI 1.3 to 2.5), with no difference in sedation success compared with N2O alone. No serious adverse events (SAEs) were reported (desaturation, apnoea, aspiration, bradycardia or hypotension) regardless of N2O concentration or use of INF. 137 (16.5%) minor adverse events occurred. Vomiting occurred in 113 (13.6%) cases and was associated with higher concentrations of N2O and INF use, but not associated with fasting status. There were no differences in adverse events (RR 0.98, 95% CI 0.97 to 1.04) or success rates (RR 0.93, 95% CI 0.56 to 1.7) between physician provided and nurse provided sedation. CONCLUSION N2O can provide effective PED PPS. No SAEs were recorded. INF may be an effective PPS adjunct but remains limited by increased rates of vomiting.
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Affiliation(s)
- Sean Croughan
- Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
- Department of Intensive Care, Cork University Hospital, Cork, Ireland
| | - Michael Barrett
- Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
- Department of Women's and Children's Health, University College Dublin, Dublin, Ireland
| | - Ronan O'Sullivan
- Emergency Medicine, Bon Secours Health System Ltd, Cork, Ireland
| | - Aidan Beegan
- Clinical Research Centre, Children's Health Ireland, Dublin, Ireland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Carol Blackburn
- Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
- Department of Women's and Children's Health, University College Dublin, Dublin, Ireland
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Scholzen EA, Silva JB, Schroeder KM. Unique considerations in regional anesthesia for emergency department and non-or procedures. Int Anesthesiol Clin 2024; 62:43-53. [PMID: 38063037 DOI: 10.1097/aia.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Elizabeth A Scholzen
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Dimopoulou I, Anagnostou T, Savvas I, Karamichali P, Prassinos N. Comparison between the Effect of Lidocaine or Ropivacaine Hematoma Block and of Different Timings of Administration on Post-Operative Pain in Dogs Undergoing Osteosynthesis of Long-Bone Fractures. Animals (Basel) 2023; 13:2858. [PMID: 37760258 PMCID: PMC10525957 DOI: 10.3390/ani13182858] [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: 06/30/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE We aimed to compare the efficacy of intra-operative lidocaine hematoma block (HB) to ropivacaine HB and to compare the efficacy of different timings of ropivacaine HB in controlling post-operative pain in dogs undergoing the osteosynthesis of long-bone fractures. STUDY DESIGN We conducted a randomized, blinded, prospective clinical study. ANIMALS Forty-eight dogs with long-bone fractures were included and were randomly allocated to four groups: lidocaine (L), ropivacaine (Rmid), ropivacaine pre- (Rpre) and ropivacaine post- (Rpost) groups. METHODS The dogs in group L (n = 14) and in group Rmid (n = 11) received a lidocaine or ropivacaine HB, respectively, after fracture reduction and before osteosynthesis material placement. Rpre dogs (n = 11) received ropivacaine HB before fracture reduction, and Rpost dogs (n = 12) received ropivacaine HB after osteosynthesis material placement. Eight post-operative pain assessments were performed using the University of Melbourne Pain Scale (UMPS) and an algometer. Rescue analgesia was administered based on UMPS scoring. For data analysis, the Shapiro-Wilk test of normality, chi-square, Student t test and Split Plot analysis were used. The level of significance was set at α = 0.05. RESULTS Rescue analgesia was administered to one dog in group L, one in group Rmid and one in group Rpost, with no significant differences detected. Compared to group Rmid, group L dogs exhibited significantly higher mean mechanical pain thresholds (p = 0.049) and lower mean UMPS scores (p = 0.001). Group Rpost dogs had statistically significantly higher mean pain thresholds compared to group Rmid (p = 0.009). CLINICAL IMPLICATIONS When performed after fracture reduction and before osteosynthesis material placement, lidocaine HB seems to be more effective than ropivacaine HB in controlling post-operative pain in dogs undergoing osteosynthesis of long-bone fractures. The administration of ropivacaine HB after osteosynthesis material placement seems to be more effective than administration after fracture reduction and before osteosynthesis material placement or administration before fracture reduction in controlling post-operative pain in dogs undergoing osteosynthesis of long-bone fractures.
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Affiliation(s)
- Irene Dimopoulou
- Anaesthesia, Analgesia, Emergency and Critical Care Unit, Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University, 54627 Thessaloniki, Greece; (T.A.); (I.S.); (P.K.)
| | - Tilemachos Anagnostou
- Anaesthesia, Analgesia, Emergency and Critical Care Unit, Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University, 54627 Thessaloniki, Greece; (T.A.); (I.S.); (P.K.)
| | - Ioannis Savvas
- Anaesthesia, Analgesia, Emergency and Critical Care Unit, Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University, 54627 Thessaloniki, Greece; (T.A.); (I.S.); (P.K.)
| | - Panagiota Karamichali
- Anaesthesia, Analgesia, Emergency and Critical Care Unit, Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University, 54627 Thessaloniki, Greece; (T.A.); (I.S.); (P.K.)
| | - Nikitas Prassinos
- Surgery & Obstetrics Unit, Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University, 54627 Thessaloniki, Greece;
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Poonai N, Creene C, Dobrowlanski A, Geda R, Hartling L, Ali S, Bhatt M, Trottier ED, Sabhaney V, O'Hearn K, Jain R, Osmond MH. Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis. CAN J EMERG MED 2023:10.1007/s43678-023-00507-0. [PMID: 37171705 DOI: 10.1007/s43678-023-00507-0] [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: 12/19/2022] [Accepted: 04/02/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES The objective of this study was to synthesize indication-based evidence for N2O for distress and pain in children. STUDY DESIGN We included trials of N2O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N2O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively. RESULTS We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N2O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I2 = 0%) and 50% N2O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I2 = 43%) were superior to EMLA. 50% N2O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I2 = 15%). For distress and pain during laceration repair, N2O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N2O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N2O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N2O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N2O plus EMLA was "favorable" versus N2O and EMLA alone. Common adverse effects of N2O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N2O alone (278/1147 (24.2%)) versus N2O plus midazolam (48/52 (92.3%)) and N2O plus fentanyl (123/201 (61.2%)). CONCLUSIONS There is sufficient evidence to recommend N2O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, ON, Canada.
- Division of Emergency Medicine, Western University, London, ON, Canada.
- Children's Health Research Institute, London Health Sciences Centre, London, ON, Canada.
- Division of Pediatric Emergency Medicine, Children's Hospital, London Health Sciences Centre, London, ON, Canada.
| | | | | | - Rishika Geda
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Maala Bhatt
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Evelyne D Trottier
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Vikram Sabhaney
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Katie O'Hearn
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rini Jain
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Martin H Osmond
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Hozack BA, Kistler JM, Vaccaro AR, Beredjiklian PK. Benzodiazepines and Related Drugs in Orthopaedics. J Bone Joint Surg Am 2022; 104:2204-2210. [PMID: 36223476 DOI: 10.2106/jbjs.22.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants. ➤ The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic. ➤ Benzodiazepines can increase the risk of prolonged opioid use and abuse. ➤ Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications. ➤ Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.
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Affiliation(s)
- Bryan A Hozack
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Koris J, Deo S. Parental acceptability of pediatric forearm manipulations in a UK district hospital emergency department. J Child Orthop 2022; 16:98-103. [PMID: 35620126 PMCID: PMC9127884 DOI: 10.1177/18632521221084176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Pediatric forearm fractures are a common presentation to Accident and Emergency departments. Standard treatment for the majority of these is manipulation under sedation within the department, followed by cast application. Concerns have been raised about the acceptability of such interventions, and reluctance to perform these procedures has led to increased admissions and manipulations performed under general anesthetic. METHODS A prospective case series of all pediatric patients with forearm fractures who underwent a manipulation under sedation in the Accident and Emergency department was collected over 12 months. All parents were invited to complete an acceptability questionnaire, adapted from the Swedish Pyramid Questionnaire for Treatment, based on their experiences. RESULTS A total of 77 patients were included and their parents were asked to complete a Swedish Pyramid Questionnaire of Treatment. Forty-four parents (55%) agreed to fill out the questionnaire. Patient demographics and fracture characteristics were compared between the group that responded and those that did not, with no significant differences. Average level of satisfaction was 9.4/10 (range = 7-10). 98% of respondents were satisfied with the level of analgesia provided, but only 86% with the timeliness of administration. CONCLUSION This parent-focused evaluation of treatment confirms high levels of parental satisfaction with the management of pediatric forearm fractures in Accident and Emergency, with regard to care, analgesia, and information. It provides insights about parental concern relating to the injury and their anxiety as information useful to further improving care, a template for assessing quality improvement and should be considered as part of further studies in this field. LEVEL OF EVIDENCE Level IV case series.
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Affiliation(s)
| | - S Deo
- S Deo, Trauma and Orthopaedic Consultant, Great Western Hospital, Marlborough Road, Swindon SN3 6BB, UK.
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Goh AXC, Yeo JW, Gao JF, Ong MEH, Chong SL, Siddiqui FJ, Ho AFW. Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review. Emerg Med J 2022; 39:888-896. [PMID: 35177437 DOI: 10.1136/emermed-2021-212108] [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: 10/23/2021] [Accepted: 02/04/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. METHODS MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use. RESULTS 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA. CONCLUSION Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.
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Affiliation(s)
- Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Fahad Javaid Siddiqui
- Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Míguez MC, Ferrero C, Rivas A, Lorente J, Muñoz L, Marañón R. Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:e136-e140. [PMID: 30925568 DOI: 10.1097/pec.0000000000001788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ma Concepción Míguez
- From the Emergency Pediatrician, Sección de Urgencias de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study. Pediatr Emerg Care 2020; 36:e671-e676. [PMID: 33181793 DOI: 10.1097/pec.0000000000002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department. METHODS The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10. RESULTS We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events. CONCLUSIONS We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.
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O'Connell NC, Woodward HA, Flores‐Sanchez PL, McLaren SH, Ieni M, McKinley KW, Shen ST, Dayan PS, Tsze DS. Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial. J Am Coll Emerg Physicians Open 2020; 1:1562-1570. [PMID: 33392564 PMCID: PMC7771777 DOI: 10.1002/emp2.12227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Nicole C. O'Connell
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
- Department of Emergency MedicineWestchester Medical CenterValhallaNew YorkUSA
| | - Hilary A. Woodward
- Department of Child LifeNewYork‐Presbyterian Morgan Stanley Children's HospitalNew YorkNew YorkUSA
| | - Pamela L. Flores‐Sanchez
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Son H. McLaren
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Maria Ieni
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Kenneth W. McKinley
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
- Division of Pediatric Emergency MedicineChildren's National HospitalWashingtonDCUSA
| | - Sripriya T. Shen
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Peter S. Dayan
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Daniel S. Tsze
- Department of Emergency MedicineDivision of Pediatric Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
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O'Connell NC, Woodward HA, Flores-Sanchez PL, McLaren SH, Ieni M, McKinley KW, Shen ST, Dayan PS, Tsze DS. WITHDRAWN: Comparison of Preadministered and Coadministered Lidocaine for Treating Pain and Distress Associated With Intranasal Midazolam Administration in Children: A Randomized Clinical Trial. Ann Emerg Med 2020:S0196-0644(20)30292-4. [PMID: 32507490 DOI: 10.1016/j.annemergmed.2020.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Nicole C O'Connell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Department of Emergency Medicine, Westchester Medical Center, Valhalla, NY
| | - Hilary A Woodward
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Pamela L Flores-Sanchez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Son H McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Maria Ieni
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kenneth W McKinley
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Sripriya T Shen
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Sengab A, Krijnen P, Schipper IB. Risk factors for fracture redisplacement after reduction and cast immobilization of displaced distal radius fractures in children: a meta-analysis. Eur J Trauma Emerg Surg 2019; 46:789-800. [PMID: 31502066 PMCID: PMC7429528 DOI: 10.1007/s00068-019-01227-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/31/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Displaced distal radius fractures in children are common and often reduced if necessary and immobilized in cast. Still, fracture redisplacement frequently occurs. This can be prevented by fixation of fracture fragments with K-wires, but until now, there are no clear guidelines for treatment with primary K-wire fixation. This meta-analysis aimed to identify risk factors for redisplacement after reduction and cast immobilization of displaced distal radius fractures in children, and thereby determine which children will benefit most of primary additional K-wire fixation. METHODS Eight databases were searched to identify studies and extract data on the incidence of and risk factors for redisplacement of distal radius fractures after initial reduction and cast immobilization in children. RESULTS Twelve studies, including 1256 patients, showed that initial complete displacement (odds ratio [OR] 4.69, 95% confidence interval [CI] 2.98-7.39) and presence of a both-bone fracture (OR 1.95, 95% CI 1.34-2.85) were independent risk factors for redisplacement. Anatomical reduction reduced the redisplacement risk (OR 0.14, 95% CI 0.05-0.40). No significant influence on redisplacement risk could be established for female sex, experience level of the attending surgeon, Cast Index < 0.8, Three-Point Index < 0.8 and patient's age. CONCLUSIONS For children with a displaced distal radius fracture, the presence of a both-bone fracture, complete displacement of the distal radius and non-anatomical reduction are risk factors for redisplacement after reduction of their initially displaced distal radius fracture. Children with one or more of these risk factors probably benefit most of reduction combined with primary K-wire fixation.
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Affiliation(s)
- Alysia Sengab
- Department of Trauma Surgery, Leiden University Medical Centre, Post Zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Centre, Post Zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Inger Birgitta Schipper
- Department of Trauma Surgery, Leiden University Medical Centre, Post Zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Motov S, Strayer R, Hayes BD, Reiter M, Rosenbaum S, Richman M, Repanshek Z, Taylor S, Friedman B, Vilke G, Lasoff D. The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine. J Emerg Med 2018. [DOI: 10.1016/j.jemermed.2018.01.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tseng PT, Leu TH, Chen YW, Chen YP. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture? J Orthop Surg Res 2018; 13:62. [PMID: 29580286 PMCID: PMC5869786 DOI: 10.1186/s13018-018-0772-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 03/12/2018] [Indexed: 12/30/2022] Open
Abstract
Background Procedure sedation and analgesia (PSA) is often used to alleviate discomfort and to facilitate fracture reduction for patients with distal radius fracture in emergency departments and clinics, but risks of respiratory distress and needs for different levels of monitoring under PSA are still under concern. Hematoma block (HB) is a simple alternative method of providing rapid pain relief during reduction of distal radius fracture. However, there is still in lack of strong evidence to promote HB over PSA in clinical practice. The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure. Methods The PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing HB or PSA in distal radius fracture reduction. The search revealed four randomized controlled trials and one non-randomized trial, which included two studies of pediatric subjects and three studies of adult subjects. Subgroup meta-analysis for adult and pediatric groups were specifically performed according to age difference to avoid potential bias. Results In the adult group, the effect of HB on post-reduction pain severity was better than that of PSA with significant heterogeneity (Hedges’ g − 0.600, 95% confidence interval (CI) − 1.170 to − 0.029, p = 0.039), although there was no difference on the pain severity during reduction between these two groups with significant heterogeneity (Hedges’ g 0.356, 95% CI − 1.101 to 1.812, p = 0.632). In the pediatric group, the treatment effect on pain severity was significantly better by HB than that by PSA but without significant heterogeneity (Hedges’ g − 0.402, 95% CI − 0.718 to − 0.085, p = 0.013, I2 < 0.001%). Most of the reported adverse effects (AEs) include nausea, vomiting, and respiratory distress developed in adult patients treated by PSA. The rates of reported AEs did not significantly differ between HB and PSA in the pediatric group. Additionally, final outcomes of reduction failure did not significantly differ between HB and PSA in both adult and pediatric groups. Conclusion Hematoma block is a safe and effective alternative of anesthesia in reduction of distal radius fracture without inferior pain relief compared with PSA among adult and pediatric patients. Electronic supplementary material The online version of this article (10.1186/s13018-018-0772-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung City, Taiwan
| | - Tsai-Hsueh Leu
- Department of Orthopaedic Surgery, Wan Fang Hospital, School of Medicine, College of Medicine, Taipei Medical University, Number 111, Section 3, Xinglong Road, Wenshan District, Taipei City, 116, Taiwan
| | - Yen-Wen Chen
- Prospect clinic for otorhinolaryngology & neurology, Kaohsiung City, Taiwan
| | - Yu-Pin Chen
- Department of Orthopaedic Surgery, Wan Fang Hospital, School of Medicine, College of Medicine, Taipei Medical University, Number 111, Section 3, Xinglong Road, Wenshan District, Taipei City, 116, Taiwan.
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Abstract
INTRODUCTION For a drug that has been omnipresent for nearly 200 years, nitrous oxide's (N2O) future seems less certain than its illustrious past. Environmental concerns are coming to the fore and may yet outweigh important clinical benefits. SOURCES OF DATA After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered. AREAS OF AGREEMENT The analgesic and anaesthetic advantages of N2O remain despite a plethora of newer agents. AREAS OF CONTROVERSY N2O greenhouse gas effect and its inhibition of key enzymes involved in protein and DNA synthesis have provided further fuel for those intent on eliminating its further clinical use. GROWING POINTS The use of N2O for treatment-resistant depression has gained traction. AREAS TIMELY FOR DEVELOPING RESEARCH Comparative studies for N2O role in combatting the prescription opioid analgesic epidemic may well provide further clinical impetus.
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Affiliation(s)
- V Lew
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - E McKay
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
| | - M Maze
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,USA
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Tsze DS, Ieni M, Fenster DB, Babineau J, Kriger J, Levin B, Dayan PS. Optimal Volume of Administration of Intranasal Midazolam in Children: A Randomized Clinical Trial. Ann Emerg Med 2016; 69:600-609. [PMID: 27823876 DOI: 10.1016/j.annemergmed.2016.08.450] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 08/13/2016] [Accepted: 08/22/2016] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVE The optimal intranasal volume of administration for achieving timely and effective sedation in children is unclear. We aimed to compare clinical outcomes relevant to procedural sedation associated with using escalating volumes of administration to administer intranasal midazolam. METHODS We conducted a randomized, single-blinded, 3-arm, superiority clinical trial. Children aged 1 to 7 years and undergoing laceration repair requiring 0.5 mg/kg intranasal midazolam (5 mg/mL) were block-randomized to receive midazolam using 1 of 3 volumes of administration: 0.2, 0.5, or 1 mL. Procedures were videotaped, with outcome assessors blinded to volume of administration. Primary outcome was time to onset of minimal sedation (ie, score of 1 on the University of Michigan Sedation Scale). Secondary outcomes included procedural distress, time to procedure start, deepest level of sedation achieved, adverse events, and clinician and caregiver satisfaction. RESULTS Ninety-nine children were enrolled; 96 were analyzed for the primary outcome and secondary outcomes, except for the outcome of procedural distress, for which only 90 were analyzed. Time to onset of minimal sedation for each escalating volume of administration was 4.7 minutes (95% confidence interval [CI] 3.8 to 5.4 minutes), 4.3 minutes (95% CI 3.9 to 4.9 minutes), and 5.2 minutes (95% CI 4.6 to 7.0 minutes), respectively. There were no differences in secondary outcomes except for clinician satisfaction with ease of administration: fewer clinicians were satisfied when using a volume of administration of 0.2 mL. CONCLUSION There was a slightly shorter time to onset of minimal sedation when a volume of administration of 0.5 mL was used compared with 1 mL, but all 3 volumes of administration produced comparable clinical outcomes. Fewer clinicians were satisfied with ease of administration with a volume of administration of 0.2 mL.
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Affiliation(s)
- Daniel S Tsze
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
| | - Maria Ieni
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel B Fenster
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - John Babineau
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Joshua Kriger
- Department of Biostatistics, Columbia University Medical Center, New York, NY
| | - Bruce Levin
- Department of Biostatistics, Columbia University Medical Center, New York, NY
| | - Peter S Dayan
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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18
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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19
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Verma RN, Hasnain S, Sreevastava DK, Murthy TVSP. Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia. Med J Armed Forces India 2016; 72:247-52. [PMID: 27546964 DOI: 10.1016/j.mjafi.2016.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 05/09/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Intravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. METHODS An observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1 ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3 mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. RESULTS 100 cases were studied. Average time of onset of block after HB was 2 min 18 s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. CONCLUSION The use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.
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Affiliation(s)
- R N Verma
- Associate Professor, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
| | - Shahbaz Hasnain
- Professor and Head, Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
| | - D K Sreevastava
- Professor and Head, Department of Anaesthesiology & Critical Care, Command Hospital (Southern Command), Pune 411040, India
| | - T V S P Murthy
- Ex-Consultant, Professor and Head, Department of Anaesthesiology & Critical Care, Command Hospital (Southern Command), Pune 411040, India
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20
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Abstract
Pain is the most common complaint for which patients come to the emergency department (ED). Emergency physicians are responsible for pain relief in a timely, efficient, and safe manner in the ED. The improvement in our understanding of the neurobiology of pain has balanced the utilization of nonopioid and opioid analgesia, and simultaneously has led to more rational and safer opioid prescribing practices. This article reviews advances in pain management in the ED for patients with acute and chronic pain as well as describes several newer strategies and controversies.
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Affiliation(s)
- Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
| | - Lewis S Nelson
- New York University School of Medicine, 455 First Avenue, New York, NY, USA
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21
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Kurien T, Price KR, Pearson RG, Dieppe C, Hunter JB. Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department: a 2.5-year study. Bone Joint J 2016; 98-B:131-6. [PMID: 26733526 DOI: 10.1302/0301-620x.98b1.36118] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation. The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method. TAKE HOME MESSAGE Simple easily reducible fractures of the distal radius and forearm in children can be successfully and safely treated in the ED using this approach, thus avoiding theatre admission and costly hospital stay.
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Affiliation(s)
- T Kurien
- University Hospital, Derby Road, Nottingham NG7 2UH, UK
| | - K R Price
- University Hospital, Derby Road, Nottingham NG7 2UH, UK
| | - R G Pearson
- The University of Nottingham, Nottingham, UK
| | - C Dieppe
- University Hospital, Derby Road, Nottingham NG7 2UH, UK
| | - J B Hunter
- University Hospital, Derby Road, Nottingham NG7 2UH, UK
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22
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Nitrous Oxide, From the Operating Room to the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016; 4:11-18. [PMID: 27073749 PMCID: PMC4819505 DOI: 10.1007/s40138-016-0092-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nitrous oxide is a gas inhalation agent that has a long history of administration in procedures requiring analgesia and sedation. Although use may be limited by patient condition, patient comorbidities, and appropriate scavenging equipment, nitrous is a proven and safe tool for use in many health care settings—from the dental office to the operating room to the emergency department.
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23
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Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S21-35. [DOI: 10.1097/aco.0000000000000316] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Tsze DS, Mallory MD, Cravero JP. Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium. J Pediatr 2016; 169:260-5.e2. [PMID: 26547401 DOI: 10.1016/j.jpeds.2015.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/24/2015] [Accepted: 10/06/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To describe practice patterns and adverse events associated with nitrous oxide (N2O) administration as the primary sedative outside the operating room in varied settings by a diverse range of providers, and to identify patient and sedation characteristics associated with adverse events. STUDY DESIGN Data prospectively collected by the Pediatric Sedation Research Consortium, which is comprised of 40 children's and general/community hospitals, was retrospectively analyzed for children who received N2O as the primary sedative. Descriptive measures of patient and sedation characteristics and adverse events were reported. A multivariable regression model was used to assess potential associations between patient and sedation characteristics and adverse events. RESULTS A total of 1634 N2O administrations were identified. The majority was performed in sedation units, and most by advanced practice nurses or physician assistants. The most common adjunct medication was midazolam. There was a low prevalence of adverse events (6.5%), with vomiting as the most common (2.4%) and only 3 (0.2%) serious adverse events reported. The odds of vomiting increased when concomitant opioids were administered (OR 2.89, 95% CI 1.14, 7.32) and when nil per os (NPO) clear fluids <2 hours (OR 4.16, 95% CI 1.61, 10.76). NPO full meal <6 hours did not change the odds of vomiting (OR 1.42, 95% CI 0.57, 3.57). There were no aspiration events. CONCLUSIONS There was a very low prevalence of serious adverse events during N2O administration in children outside of the operating room and by nonanesthesiologists. The odds of vomiting increased when concomitant opioids were administered and NPO clear fluids <2 hours.
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Affiliation(s)
- Daniel S Tsze
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY.
| | - Michael D Mallory
- Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA
| | - Joseph P Cravero
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, Boston, MA
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Babl FE, Grindlay J, Barrett MJ. Laryngospasm With Apparent Aspiration During Sedation With Nitrous Oxide. Ann Emerg Med 2015; 66:475-8. [PMID: 26003005 DOI: 10.1016/j.annemergmed.2015.04.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/13/2015] [Accepted: 04/20/2015] [Indexed: 12/16/2022]
Abstract
Nitrous oxide and oxygen mixture has become increasingly popular for the procedural sedation and analgesia of children in the emergency department. In general, nitrous oxide is regarded as a very safe agent according to large case series. We report a case of single-agent nitrous oxide sedation of a child, complicated by laryngospasm and radiographically confirmed bilateral upper lobe pulmonary opacities. Although rarely reported with parenteral sedative agents, laryngospasm and apparent aspiration has not been previously reported in isolated nitrous oxide sedation. This case highlights that, similar to other sedative agents, nitrous oxide administration also needs to be conducted by staff and in settings in which airway emergencies can be appropriately managed.
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Affiliation(s)
- Franz E Babl
- Murdoch Children's Research Institute and the Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Pediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
| | - Joanne Grindlay
- Murdoch Children's Research Institute and the Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Pediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Joseph Barrett
- Murdoch Children's Research Institute and the Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia; Paediatric Emergency Research Unit, National Children's Research Centre, Dublin, Ireland
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26
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Abstract
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.
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Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study. Ann Emerg Med 2015; 65:640-648.e2. [PMID: 25595951 DOI: 10.1016/j.annemergmed.2014.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 11/25/2014] [Accepted: 12/03/2014] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE We estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing forearm fracture reduction in the emergency department. METHODS We used the up-down method to estimate the median dose of intravenous ketamine infused during less than or equal to 5 seconds that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years who were undergoing forearm fracture reduction. Most patients were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was assessed by modified Aldrete score. RESULTS We enrolled 20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an empirically derived ED95 was 0.8 mg/kg. All patients who received the empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95 in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered. No participant experienced serious adverse events. CONCLUSION We estimated ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture reduction. Total sedation time was shorter than that in most previous studies.
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28
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Del Valle Rubido C, Solano Calvo JA, Rodríguez Miguel A, Delgado Espeja JJ, González Hinojosa J, Zapico Goñi Á. Inhalation analgesia with nitrous oxide versus other analgesic techniques in hysteroscopic polypectomy: a pilot study. J Minim Invasive Gynecol 2015; 22:595-600. [PMID: 25596171 DOI: 10.1016/j.jmig.2015.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE To show the decrease in pain and better tolerance to inhalation analgesia with a 50% equimolar mixture of nitrogen protoxide and oxygen in hysteroscopic polypectomy compared with paracervical anesthesia and a control group. DESIGN One hundred six patients scheduled for office hysteroscopy and polypectomy were divided into the following 3 groups: the control group, the nitrous oxide group, and the paracervical infiltration group. Patients were assigned sequentially (Canadian Task Force classification II-1). SETTING The study took place in a hysteroscopy outpatient clinic under the supervision of a gynecologist and 2 nurses trained to cooperate in the trial. PATIENTS One hundred six women from Area III of Madrid Community, Spain, who had been diagnosed with endometrial polyps at a gynecology office and were scheduled for office hysteroscopy and polypectomy agreed to participate in the study. INTERVENTIONS Patients in group 1 (control group) received no treatment. Group 2 received inhaled nitrous oxide and group 3 paracervical infiltration with 1% lidocaine. MEASUREMENTS AND MAIN RESULTS Pain was assessed using the visual analog scale (0-10). Pain perceived by patients was lower in the nitrous Oxide group (mean: 3.55 ± 0.60, median: 3) versus the control group (mean: 5.49 ± 1.88, median: 6, p < .05) and the paracervical infiltration group (mean: 4.22 ± 1.73, median: 5). Tolerance to pain, assessed by the medical staff using qualitative variables, was bad for the control group, very good for the nitrous oxide group, and good for the paracervical infiltration group (p < .05). There were no complications in 82% of the patients in the nitrous oxide group, whereas in the paracervical infiltration group, there were complications in more than 50% of the patients. No severe complications occurred. CONCLUSION Nitrous oxide is a safe and effective analgesic technique for polipectomy office hysteroscopy compared with the paracervical infiltration and control groups.
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Affiliation(s)
- Cristina Del Valle Rubido
- Department of Obstetrics and Gynecology, Hospital Universitario Príncipe de Asturias, Madrid, Spain.
| | | | | | - Juan José Delgado Espeja
- Department of Obstetrics and Gynecology, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | | | - Álvaro Zapico Goñi
- Department of Obstetrics and Gynecology, Hospital Universitario Príncipe de Asturias, Madrid, Spain
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Bear DM, Friel NA, Lupo CL, Pitetti R, Ward WT. Hematoma block versus sedation for the reduction of distal radius fractures in children. J Hand Surg Am 2015; 40:57-61. [PMID: 25306504 DOI: 10.1016/j.jhsa.2014.08.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children. METHODS Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction. RESULTS Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning. CONCLUSIONS Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.
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Affiliation(s)
- David M Bear
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Nicole A Friel
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Charles L Lupo
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Raymond Pitetti
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - W Timothy Ward
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Evaluating the hematoma block as an adjunct to procedural sedation for closed reduction of distal forearm fractures. Pediatr Emerg Care 2014; 30:474-8. [PMID: 24977996 DOI: 10.1097/pec.0000000000000164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure. METHODS A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam. RESULTS Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups. CONCLUSIONS The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.
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Shaik NA, Rao SS, Chiruvella S, Rao MS, Reddy SV. Effectiveness of butorphanol as an adjuvant to lidocaine for haematoma or periosteal block: A prospective, randomised, double blind study. Indian J Anaesth 2013; 57:150-5. [PMID: 23825814 PMCID: PMC3696262 DOI: 10.4103/0019-5049.111841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The peripheral nerve endings carrying pain contains opiod receptors. Blocking these receptors during haematoma block or periosteal block may provide better analgesia. Aim: Evaluation of effectiveness and safety of butorphanol as an adjuvant to lidocaine for haematoma block. Settings and Design: This is a two centre, prospective, individually randomised, two group, parallel, double-blind clinical trial. Methods: In this study, 115 American society of anaesthesiologist grade I and II adult patients scheduled for closed reduction of fractures were randomly allocated into two groups; Group A received 1% lidocaine (2 mg/kg) where as Group B received 1% lidocaine (2 mg/kg) with butorphanol (0.02 mg/kg) during haematoma block. Pain was assessed before, during and after manipulation of fracture by using visual analogue scale (VAS 0-10). Onset time of block, time for first rescue analgesic, 24 hour analgesic requirement and sedation levels were noted. Statistical Analysis: Data analysed with the unpaired t-test with Welch correction assuming unequal variances and Fisher's exact test using Graph pad Prism 5.02 version. Results: Onset time of haematoma block was significantly less in the butorphanol group compared to the lidocaine group (P=0.0003). The mean time for first rescue analgesic was significantly higher and total analgesic requirement was significantly lower in the butorphanol group (P<0.0001). Mean VAS scores were lower and sedation scores were higher in the butorphanol group. Conclusions: Addition of butorphanol to lidocaine quickens onset of haematoma block, provides excellent post manipulation analgesia and decreases 24 hour total analgesic requirement without excessive sedation.
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Affiliation(s)
- Nawaz Ahmed Shaik
- Department of Anaesthesiology and Critical Care, Rajiv Gandhi Institute of Medical Sciences, Putlampalli, Kadapa, India
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Abstract
PURPOSE OF REVIEW The need for sedation for procedures performed outside the operating room has increased dramatically, and pediatric procedural sedation (PPS) is increasingly performed by practitioners who are not anesthesiologists. With 'sedationists' emerging from various specialties, there are differences in practice and guidelines with regards to presedation assessment, targeted depths of sedation, monitoring requirements, and the training required. Our aim is to identify some of the recent advances in PPS and to describe progress towards greater standardization of practice. RECENT FINDINGS Several studies report attempts to optimize the efficacy of specific pharmaceuticals used in PPS. Ketamine, a dissociative agent, functions uniquely and requires its own sedation practice guidelines. Utilizing less invasive administration of sedation via transmucosal and inhaled routes is gaining popularity. Additionally, replacing subjective measurement of depths of the sedation continuum and the nonstandardized definitions of adverse events with alternatives based on physiological parameters and/or required rescue interventions is underway. Finally, the use of presedation family-centered counseling and adjuncts that provide visual and auditory distraction are enhancing pharmaceutical methods. SUMMARY Further multispecialty collaboration and formation of greater consensus with regards to sedation practice are essential to the development of universal guidelines that optimize patient care.
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Abstract
OBJECTIVE The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation. DATA SOURCE A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed. RESULTS The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended. CONCLUSIONS In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.
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Abstract
OBJECTIVE Ketamine is used intramuscularly or intravenously as a sedative when repairing the skin lacerations of children in many emergency departments (EDs). Nitrous oxide (N(2)O) has the advantages of being a sedative agent that does not require a painful injection and that offers shallower levels of sedation and a rapid recovery of mental state. We evaluated the clinical usefulness of N(2)O compared with intravenous ketamine when used for the repair of lacerations in children in the ED. METHODS From January to December 2009, we performed a prospective, randomized study at a single academic ED enrolling pediatric patients aged 3 to 10 years who needed primary repair of a laceration wound. The primary outcome was recovery time, which was defined as the time from completion of procedure to recovery of mental state. Other outcomes were sedation depth, pain scale, adverse effects, and satisfaction with sedation. RESULTS There were 32 children who were randomly assigned. Recovery times were shorter in the N(2)O group compared with those in the ketamine group (median [interquartile range (IQR)], 0.0 minutes, [0.0-4.0 minutes] vs 21.5 minutes [12.5-37.5 minutes], P < 0.05). Sedation levels were deeper in the ketamine group than in the N2O group, but pain scales were comparable between groups. No difference was observed in the satisfaction scores by physicians, parents, or nurses. CONCLUSIONS Nitrous oxide inhalation was preferable to injectable ketamine for pediatric patients because it is safe, allows for a faster recovery, maintains sufficient sedation time, and does not induce unnecessarily deep sedation.
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Use of combined transmucosal fentanyl, nitrous oxide, and hematoma block for fracture reduction in a pediatric emergency department. Pediatr Emerg Care 2012; 28:676-9. [PMID: 22743745 DOI: 10.1097/pec.0b013e31825d20f6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the use of combined inhaled nitrous oxide (NO), hematoma block (HB), and transmucosal fentanyl (TMF) as sedoanalgesia in the reduction of radioulnar fractures in children in a pediatric emergency department (PED). METHODS A retrospective, analytical observational study examining the cases of radioulnar fracture reduction in PED from 2007 to 2009 in children from 4 to 15 years old. The cases were divided into 2 groups: those in which only NO + HB was used and those in which TMF was combined with NO + HB. The pain perceived by the child, the doctor, and the nurse was studied during the procedure with 0- to 10-point scales (10 being severe pain). Satisfaction of the medical professionals, duration of the procedure, and the adverse effects that appeared were also studied. RESULTS Eighty-one children were included. Sixty-four children (79%) received NO + TMF + HB, and 17 children (21%) received NO + HB only. The pain perceived by the child during the procedure in the group receiving NO + TMF + HB was 2.5 (95% confidence interval [CI], 1.8-3.1) compared with 3.9 (95% CI, 2.3-5.5) in the NO + HB group (P = 0.035), the pain perceived by the doctor was 2.6 (95% CI, 2-3.2) compared with 4 (95% CI, 1.6-4), and by the nurse was 2.7 (95% CI, 2-3.3) compared with 3.9 (95% CI, 2.3-5.5), respectively. Adverse events appeared in 15.3% of the NO + TMF + HB group and in 40% of the NO + HB group. CONCLUSIONS The association of NO + TMF + HB in the reduction of radioulnar fractures in PED improves pain control compared with the NO + HB combination. New studies are required to confirm the benefit and safety of this drug combination.
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Chéron G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for the child under spontaneous ventilation?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:369-76. [PMID: 22464837 DOI: 10.1016/j.annfar.2012.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Chéron
- Département des urgences pédiatriques, université Paris Descartes Paris-V, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Orliaguet G. Sédation et analgésie en structure d’urgence. Pédiatrie : quelle sédation et analgésie pour l’intubation trachéale chez l’enfant ? ACTA ACUST UNITED AC 2012; 31:377-83. [DOI: 10.1016/j.annfar.2012.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Orliaguet G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:359-368. [PMID: 22445224 DOI: 10.1016/j.annfar.2012.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- G Orliaguet
- Département d'anesthésie-réanimation, hôpital Necker-Enfants-malades, université Paris Descartes, Paris 5, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Freysz M, Orliaguet G. [Sedation and analgesia in emergency structure. Which are the properties and the disadvantages of the products used?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:283-294. [PMID: 22436603 DOI: 10.1016/j.annfar.2012.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- M Freysz
- Departement de medecine d'urgence, universite de Bourgogne, CHU de Dijon, BP 77908, 21079 Dijon cedex, France.
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Seith RW, Theophilos T, Babl FE. Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation. Acad Emerg Med 2012; 19:31-6. [PMID: 22251190 DOI: 10.1111/j.1553-2712.2011.01241.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nitrous oxide (N(2)O) is an attractive agent for pediatric procedural sedation and analgesia (PSA) with rapid onset and offset of sedation. However, it has limited analgesic efficacy. Intranasal fentanyl (INF) provides nonparenteral analgesia. There are currently no data on the combined use of N(2)O and INF for PSA in children. The authors set out to prospectively assess the depth of sedation and incidence of adverse events when N(2)O and INF are used in combination in pediatric patients. METHODS This was a prospective observational pilot study of combined N(2)O and INF for PSA at a tertiary children's hospital emergency department (ED). INF was administered at a precalculated dose of 1.5 μg/kg for preascertained weight ranges. N(2)O concentration, dose, timing of INF, adverse events, and sedation depth were recorded. Sedation depth was recorded using the University of Michigan Sedation Scale (UMSS). RESULTS A total of 41 patients, aged 1 to 14 years, received INF within 2 hours prior to N(2)O. N(2)O was administered at a maximal concentration of 70% in 40 patients, and at 50% in one patient. Most patients (80%) were minimally to moderately sedated (sedation score 1 or 2). Deep sedation (sedation score 3) was recorded in 14.6% of patients (95% confidence interval [CI] = 3.4% to 24.6%). No patients had serious adverse events; vomiting was recorded in 19.5% (95% CI = 7.4% to 31.6%). There were two patients (4.9%) who were deeply sedated and vomited during the procedure. CONCLUSIONS There were no serious adverse events identified in this pilot study of combined N(2)O and INF. However, there was an increased incidence of vomiting and deeper levels of sedation when compared to published data of single-agent use of N(2)O, which could lead to more serious adverse events. Further investigation is needed to establish the analgesic efficacy of combining N(2)O and INF and to clarify the safety profile before this combination can be recommended for PSA in children.
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Affiliation(s)
- Robert W Seith
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
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Abstract
OBJECTIVES Our objective was to determine the odds of having an increased weight status among children with upper extremity fracture (UEF) compared with 3 control groups without fractures. METHODS This is a secondary analysis of data from the Pediatric Risk of Admission (PRISA and PRISA II) data sets. Patients without chronic illness between the ages of 5 to 14 years were included in the following groups: (1) UEF study group, (2) upper extremity nonfracture injured control group, (3) minor-head-injured control group, and (4) noninjured probability control group. Weight for age/sex percentiles was used to evaluate weight status. The proportions of patients with weight for age/sex greater than the 50th, 85th, and 95th percentiles were determined. Logistic regression was used to generate odds ratios comparing the UEF group with each control group stratified by age. RESULTS This analysis included 308 patients in the 5- to 9-year age group and 207 patients in the 10- to 14-year age group. The odds of having a weight greater than the 50th percentile for age/sex were significantly increased among children with UEF aged 5 to 9 years compared with all control groups. There were no significant differences in the corresponding odds ratios for children with UEF aged 10 to 14 years compared with controls. CONCLUSIONS These findings may be related to differential injury mechanisms, mobility patterns, or underlying patient vulnerability to fracture based on weight status and bone qualities in prepubescent versus pubescent populations. Further investigation should explore fracture epidemiology and fracture risk in children stratified by age.
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Bennett J, DePiero A, Kost S. Tailoring Pediatric Procedural Sedation and Analgesia in the Emergency Department: Choosing a Regimen to Fit the Situation. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kost S, Roy A. Procedural Sedation and Analgesia in the Pediatric Emergency Department: A Review of Sedative Pharmacology. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2010.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Khan S, Sawyer J, Pershad J. Closed Reduction of Distal Forearm Fractures by Pediatric Emergency Physicians. Acad Emerg Med 2010; 17:1169-74. [DOI: 10.1111/j.1553-2712.2010.00917.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature. Int J Pediatr 2010; 2010:934298. [PMID: 20652062 PMCID: PMC2905952 DOI: 10.1155/2010/934298] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 05/07/2010] [Indexed: 11/18/2022] Open
Abstract
Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children.
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Green SM, Roback MG, Krauss B. Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate. Acad Emerg Med 2010; 17:157-62. [PMID: 20370745 DOI: 10.1111/j.1553-2712.2009.00634.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. METHODS This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors. RESULTS Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea. CONCLUSIONS This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center & Children's Hospital, Loma Linda, CA, USA.
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Green SM, Coté CJ. Ketamine and Neurotoxicity: Clinical Perspectives and Implications for Emergency Medicine. Ann Emerg Med 2009; 54:181-90. [DOI: 10.1016/j.annemergmed.2008.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 09/23/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:158-68.e1-4. [PMID: 19201064 DOI: 10.1016/j.annemergmed.2008.12.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
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Leahy S, Kennedy RM, Hesselgrave J, Gurwitch K, Barkey M, Millar TF. On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics 2008; 122 Suppl 3:S161-70. [PMID: 18978010 DOI: 10.1542/peds.2008-1055i] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Venipuncture and intravenous cannulation are among the most common and widespread medical procedures performed on children today. Therefore, effective treatment of venous access pain can benefit from an integrated systems approach that enlists multiple players in the health care system. By using case studies that analyze this issue from the perspective of the nurse, the physician, the pharmacist, and the child life specialist, this article illustrates how multidisciplinary programs designed to manage needle pain have been developed successfully in several institutions. Common themes that arise from these case studies include the importance of a multidisciplinary evidence-based approach to advocate change; a system-wide protocol for the administration of local anesthetics; convenient access to topical local anesthetics; department and hospital-wide support for educational efforts, including training in nonpharmacologic techniques used by child life specialists; and ongoing quantification of the overall success of any program. Implementation of these strategies can result in significant improvements in the pediatric venous access experience.
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Affiliation(s)
- Sarah Leahy
- Center for Pain Relief, Children's Healthcare of Atlanta, 1124 Mayfield Dr, Decatur, GA 30033, USA.
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Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, Kennedy RM, Mooney DP, Sacchetti AD, Wears RL, Clark RM. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. J Emerg Nurs 2008; 34:e33-107. [PMID: 18558240 DOI: 10.1016/j.jen.2008.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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