Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

INTRODUCTION@#Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore.@*METHODS@#A retrospective analysis was conducted of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors.@*RESULTS@#Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged less than three years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and the type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors.@*CONCLUSION@#The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.

The Singapore Paediatric Triage Scale Validation Study

<p><b>INTRODUCTION</b>This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation.</p><p><b>METHODS</b>A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition.</p><p><b>RESULTS</b>Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay.</p><p><b>CONCLUSION</b>The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.</p>

Predictors of emesis in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

<p><b>INTRODUCTION</b>Emesis is one of the most common adverse events associated with ketamine sedation. However, its predictors have not been clearly studied among Asian children. This study aimed to determine the incidence and predictors of emesis in children undergoing intramuscular (IM) ketamine sedation in an emergency department (ED) in Singapore and to identify high-risk groups, so that antiemetics may be administered prophylactically.</p><p><b>METHODS</b>In a prospective observational study, all children requiring procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 January 2015 were included. All cases of emesis following ketamine sedation were prospectively documented. Univariate and multivariate logistic regression analyses were performed to identify the predictors of emesis.</p><p><b>RESULTS</b>2,502 sedations were performed using IM ketamine in the ED during the study period. Overall incidence of emesis associated with IM ketamine sedation was 8.4%. Children aged ≥ 8 years were significantly associated with increased risk of emesis (odds ratio 4.636, 95% confidence interval 3.271-6.570; p < 0.001), with an emesis rate of 19.6%. Other variables such as initial dose (3 mg/kg vs. 4 mg/kg), total dosage (including top-ups), type and site of procedure, gender and ethnicity were not significant predictors. The number needed to treat for antiemetics in children aged ≥ 8 years was five.</p><p><b>CONCLUSION</b>Age is a significant predictor of emesis. We recommend conducting a randomised controlled trial to compare the effects of prophylactic oral ondansetron in patients stratified into the age groups of ≥ 8 years and < 8 years.</p>

Effect of location of out-of-hospital cardiac arrest on survival outcomes

<p><b>INTRODUCTION</b>This study aims to study how the effect of the location of patient collapses from cardiac arrest, in the residential and non-residential areas within Singapore, relates to certain survival outcomes.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study of data were done from the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Out-of- hospital cardiac arrest (OHCA) data from October 2001 to October 2004 (CARE) were used. All patients with OHCA as confirmed by the absence of a pulse, unresponsiveness and apnoea were included. All events had occurred in Singapore. Analysis was performed and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI).</p><p><b>RESULTS</b>A total of 2375 cases were used for this analysis. Outcomes for OHCA in residential areas were poorer than in non-residential areas-1638 (68.9%) patients collapsed in residential areas, and 14 (0.9%) survived to discharge. This was significantly less than the 2.7% of patients who survived after collapsing in a non-residential area (OR 0.31 [0.16 - 0.62]). Multivariate logistic regression analysis showed that location alone had no independent effect on survival (adjusted OR 1.13 [0.32 - 4.05]); instead, underlying factors such as bystander CPR (OR 3.67 [1.13 - 11.97]) and initial shockable rhythms (OR 6.78 [1.95 - 23.53]) gave rise to better outcomes.</p><p><b>CONCLUSION</b>Efforts to improve survival from OHCA in residential areas should include increasing CPR by family members, and reducing ambulance response times.</p>

Recognition and treatment of out-of-hospital cardiac arrests by non-emergency ambulance services in Singapore

<p><b>INTRODUCTION</b>Prompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) and defibrillation is necessary for good outcomes from out-of-hospital cardiac arrest (OHCA). This study aims to describe the recognition and treatment of OHCA in patients conveyed by non-emergency ambulance services (EAS) in Singapore.</p><p><b>MATERIALS AND METHODS</b>This is a multi-centre, retrospective chart review, of cases presenting to public emergency departments (EDs), conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. The study was from October 2002 to August 2009. The following variables were examined: ability to recognise cardiac arrest, whether CPR was carried out by the ambulance crew and whether an automated external defibrillator (AED) was applied.</p><p><b>RESULTS</b>Eighty-six patients were conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. Mean age was 63 years (SD 21.8), 70.9% were males. A total of 53.5% of arrests occurred in the ambulance while 70.9% were found to be asystolic upon ED arrival. Seven patients had a known terminal illness. Survival to discharge was 3.5%. Cardiac arrest went unrecognised by the ambulance crew in 38 patients (44.2%). CPR was performed in 35 patients (40.7%) of the 86 patients and AED was applied in only 10 patients (11.6%).</p><p><b>CONCLUSION</b>We found inadequate recognition and delayed initiation of treatment for OHCA. Possible reasons include a lack of training in patient monitoring and detection of cardiac arrest, lack of CPR training, lack of confidence in performing CPR, lack of AEDs on ambulances and lack of training in their use.</p>