A Comparison of Sedation with Ketamine-Midazolam versus Ketamine-Propofol for the Lumbar Puncture in Children

PURPOSE: This study was conducted to compare the safety and effectiveness of intravenous ketamine-midazolam (KM) and ketamine-propofol (KP) combination for the lumbar puncture (LP) procedure in children. METHODS: This was a retrospective analysis of patients aged ≤18 years old who received intravenous injection of KM or KP for undergoing LP in the pediatric emergency department. To investigate the effectiveness of KM and KP, we compared the sedation success rate, induction time, procedure time and total sedation time. In addition, adverse events and complications were recorded to assess the safety of the agents. RESULTS: A total 61 patients were enrolled in study. Twenty-eight patients were given KM and 33 patients received KP. All sedations were successful in both groups. While the mean induction time in KM was shorter than in the KP group (3±4 vs. 6±5 minutes, p=0.02), the total sedation time in the KP group was significantly shorter than that in the KM group (33±26 vs. 61±43 minutes, p < 0.01). There were no adverse effects such as hypotension, bradycardia or hypoxic event. CONCLUSION: This study showed that intravenous KM and KP are hemodynamically stable and have few side effects when applied for pediatric sedation during lumbar puncture. Although KM has a shorter induction time than KP, KP has a shorter duration of sedation. Both of these materials can be considered useful agents for sedation when conducting painful procedures in children.

Changes in intravenous hydration frequency and emergency department length of stay after implementation of oral ondansetron therapy in children with dehydration due to acute gastroenteritis

PURPOSE: Oral ondansetron is a safe and effective antiemetic drug to facilitate oral rehydration therapy in acute gastroenteritis (AGE) with mild dehydration. We investigated the effect of oral ondansetron therapy on intravenous (IV) hydration frequency and emergency department length of stay (EDLOS) in dehydrated children with AGE. METHODS: We reviewed 15,813 children aged 12-60 months with primary diagnosis of AGE who visited a tertiary care university-affiliated hospital emergency department. The enrolled children were divided into the pre- (from January 2009 to June 2011) and post- (from January 2016 to June 2018) ondansetron groups according to the implementation of oral ondansetron therapy in the emergency department. As primary outcomes, IV hydration frequency, EDLOS, and hospitalization rate were compared between the 2 groups. As secondary outcomes, EDLOS and hospitalization rate were compared between the children in the post-ondansetron group who underwent the therapy, and those who did not. RESULTS: Of 7,990 enrolled children, 3,300 (41.3%) were designated as the post-ondansetron group, and among them 1,093 (33.1%) underwent oral ondansetron therapy. This group showed a lower IV hydration frequency, a shorter median EDLOS compared to the other group (55.8% vs. 61.9%, P < 0.001; 175.0 vs. 223.0 minutes, P < 0.001, respectively), and a higher hospitalization rate (9.9% vs. 7.9%, P < 0.001). The children in the post-ondansetron group who underwent the therapy showed a shorter median EDLOS and a lower hospitalization rate compared to those who did not (142.0 vs. 205.0 minutes, P < 0.001; 2.9% vs. 13.4%, P < 0.001, respectively). CONCLUSION: Oral ondansetron therapy may reduce IV hydration frequency and EDLOS in dehydrated children with AGE, and can be considered in those having severe vomiting.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.

Utility of end-tidal carbon dioxide monitoring in intramuscular ketamine sedation in the pediatric emergency department

PURPOSE: Recently, the use of end-tidal carbon dioxide (ETCO₂) monitoring has been suggested for early detection of hypoventilation over oxygen saturation (S(P)O₂) monitoring. We aimed to determine the usefulness of capnography in monitoring patients sedated using intramuscular (IM) ketamine in the pediatric emergency department (ED). METHODS: This study retrospectively reviewed medical records of patients younger than 16 years who were sedated using IM ketamine and whose ETCO₂ values were documented in the ED. Age, sex, American Society of Anesthesiologists physical status classification (ASA classification), and purpose of sedation were investigated. Vital signs were recorded at pre-sedation, 5 and 10 minutes after sedation, and after recovery. Hypoventilation was defined as S(P)O₂< 95%, ETCO₂≥ 50 mmHg or ≤ 30 mmHg, or increase in ETCO₂≥ 10 mmHg from the baseline without tachypnea. RESULTS: A total of 49 patients were investigated; 42 of them belonged to ASA classification I, and 7 to II. There was no patient with S(P)O₂< 95%, or ETCO₂≥ 50 mmHg, or increase in ETCO₂≥ 10 mmHg from the pre-sedation value. However, 5 patients had an ETCO₂≤ 30 mmHg, and 4 of them (8.2%) had normal respiratory rate and were suitable for hypopneic hypoventilation. Ten patients showed abnormal range of ETCO₂ (normal range, 35-45 mmHg), but did not meet the definition of hypoventilation. No one had clinically serious respiratory events. CONCLUSIONS: During sedation using IM ketamine, 8.2% of the patients had hypopneic hypoventilation without hypoxemia, and they were all younger than 36 months. Capnography for patients sedated using IM ketamine in the ED is useful in detecting hypopneic hypoventilation, and has the potential for preventing clinically serious respiratory events in patients, especially toddlers.

Is Unenhanced Abdominal CT Scan Necessary for the Diagnosis of Acute Appendicitis in Children?

PURPOSE: This study was designed to evaluate the question of whether a computed tomography (CT) protocol without an unenhanced phase could be used for diagnosis of appendicitis in pediatric patients who visited the emergency department (ED) with acute non-traumatic right lower abdominal pain. METHODS: We retrospectively selected 100 samples from pediatric abdominal CT scans performed in the ED and read by pediatric radiologists. Thirty emergency physicians were separately asked to evaluate the samples twice. The first evaluation was performed without the unenhanced phase (protocol A). The second evaluation was performed with both the unenhanced phase and the contrast-enhanced phase (protocol B). The sensitivity and specificity of each protocol for diagnosis of suspected acute appendicitis were determined. Intraobserver and interobserver agreements were measured using kappa statistics. RESULTS: The mean sensitivity and specificity of the two protocols were similar. The sensitivities of protocol A and protocol B were 97.13% (95% Confidence interval=96.13-98.14) and 97.60% (96.67-98.53), respectively. The specificities of protocol A and protocol B were 95.47% (94.34-96.59) and 94.67% (93.33-96.00), respectively. The mean kappa value for intraobserver agreement between results from the two protocols was 0.91 (0.88-0.93). The kappa value for interobserver agreement was 0.90 (0.89-0.91) for protocol A and 0.87 (0.86-0.88) for protocol B. CONCLUSION: It is feasible to perform a CT scan without an unenhanced phase for evaluation of suspected appendicitis in children with abdominal pain visiting the ED.

Non-Oliguric Hyperkalemia in Extremely Low Birth Weight Infants

PURPOSE: It is to examine clinical manifestations, early biochemical indicators, and risk factors for non-oliguric hyperkalemia (NOHK) in extremely low birth weight infants (ELBWI). MATERIALS AND METHODS: We collected clinical and biochemical data from 75 ELBWI admitted to Ajou University Hospital between Jan. 2008 and Jun. 2011 by reviewing medical records retrospectively. NOHK was defined as serum potassium > or =7 mmol/L during the first 72 hours of life with urine output > or =1 mL/kg/h. RESULTS: NOHK developed in 26.7% (20/75) of ELBWI. Among NOHK developed in ELBWI, 85% (17/20) developed within postnatal (PN) 48 hours, 5% (1/20) experienced cardiac arrhythmia and 20% (4/20) of NOHK infants expired within PN 72 hours. There were statistically significant differences in gestational age, use of antenatal steroid, and serum phosphorous level at PN 24 hours, and serum sodium, calcium, and urea levels at PN 72 hours between NOHK and non-NOHK groups (p-value <0.050). However, there were no statistical differences in the rate of intraventricular hemorrhage, arrhythmia, mortality occurred, methods of fluid therapy, supplementation of amino acid and calcium, frequencies of umbilical artery catheterization and urine output between the two groups. CONCLUSION: NOHK is not a rare complication in ELBWI. It occurs more frequently in ELBWI with younger gestational age and who didn't use antenatal steroid. Furthermore, electrolyte imbalance such as hypernatremia, hypocalcemia and hyperphosphatemia occurred more often in NOHK group within PN 72 hours. Therefore, more use of antenatal steroid and careful control by monitoring electrolyte imbalance should be considered in order to prevent NOHK in ELBWI.

Limitations of 99mTc-DMSA scan in diagnosing acute pyelonephritis in children / 소아과

PURPOSE: We aimed to prove the relative limitation of 99mTc-DMSA scintigraphy (DMSA) compared to computed tomography (CT) in diagnosing acute pyelonephritis (APN) in children. METHODS: Since September 2006, after a 64-channel CT was imported, 10 DMSA false-negative patients have been identified: these patients underwent a CT scan for acute abdomen or acute febrile symptoms and were diagnosed as having APN; however, their DMSA scans were clear. We focused on these 10 DMSA false-negative patients and analyzed their clinical findings and CT results. We used Philips Brilliance Power 64-channel CT scanner for the CT scan and Siemens Orbitor Nuclear Camera 60 Hz for the DMSA scan. RESULTS: The 10 DMSA false-negative patients were mostly males (80%) and infants (80%). They had fever for a mean of 1.1-day duration before admission and showed increase in acute reactants: leukocyte, erythrocyte sedimentation rate, and C-reactive protein. The CT findings of renal lesions were focal in 6 (60%) cases and diffuse in 4 (40%) cases, and most of the lesions were unilateral in 80% of patients. CT proved that 22 renal lesions were neglected by DMSA. Differential renal function test by DMSA was also of no use in the evaluation of renal lesions. CONCLUSION: In this study, DMSA scan showed limitation in finding renal cortical lesions of CT-proven APN patients. DMSA false-negative results seem to occur at early-phase disease of infantile age, but more prospective studies are needed to determine the reasons and their prevalence.