Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric proceduralsedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands / 世界急诊医学杂志（英文）

BACKGROUND@# Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians.@*METHODS@# We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire.@*RESULTS@# The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients.@*CONCLUSION@# The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Comparison between chloral hydrate and propofol-ketamine as sedation regimens for pediatric auditory brainstem response testing / Comparação entre o uso de hidrato de cloral e propofol-quetamina como formas de sedação para exames de potenciais evocados auditivos de tronco encefálico

Abstract Introduction: The use of diagnostic auditory brainstem response testing under sedation is currently the "gold standard" in infants and young children who are not developmentally capable of completing the test. Objective: The aim of the study is to compare a propofol-ketamine regimen to an oral chloral hydrate regimen for sedating children undergoing auditory brainstem response testing. Methods: Patients between 4 months and 6 years who required sedation for auditory brainstem response testing were included in this retrospective study. Drugs doses, adverse effects, sedation times, and the effectiveness of the sedative regimens were reviewed. Results: 73 patients underwent oral chloral hydrate sedation, while 117 received propofol-ketamine sedation. 12% of the patients in the chloral hydrate group failed to achieve desired sedation level. The average procedure, recovery and total nursing times were significantly lower in the propofol-ketamine group. Propofol-ketamine group experienced higher incidence of transient hypoxemia. Conclusion: Both sedation regimens can be successfully used for sedating children undergoing auditory brainstem response testing. While deep sedation using propofol-ketamine regimen offers more efficiency than moderate sedation using chloral hydrate, it does carry a higher incidence of transient hypoxemia, which warrants the use of a highly skilled team trained in pediatric cardio-respiratory monitoring and airway management.

Resumo Introdução: O uso de testes diagnósticos de potencial evocado auditivo de tronco encefálico sob sedação é atualmente o padrão-ouro em lactentes e crianças pequenas que não têm desenvolvimento suficiente para realizar o exame. Objetivo: O objetivo do estudo foi comparar a sedação de crianças submetidas a testes de potencial evocado auditivo de tronco encefálico com propofol-quetamina e com hidrato de cloral por via oral. Método: Pacientes entre 4 meses e 6 anos de idade que necessitaram de sedação para a realização do potencial evocado auditivo de tronco encefálico foram incluídos nesse estudo retrospectivo. Foram revisadas as doses dos medicamentos, os efeitos adversos, os tempos de sedação e a eficácia das formas de sedação. Resultados: 73 pacientes foram submetidos à sedação oral com hidrato de cloral, enquanto 117 receberam sedação com propofol-quetamina; 12% dos pacientes do grupo hidrato de cloral não alcançaram o nível desejado de sedação. Os tempos médios de procedimento, recuperação e o tempo total de cuidados de enfermagem foram significativamente menores no grupo propofol-quetamina, entretanto este grupo experimentou maior incidência de hipoxemia transitória. Conclusão: Ambos os regimes de sedação podem ser utilizados com sucesso para sedar crianças para realização do exame de potencial evocado de tronco encefálico. Embora a sedação profunda com propofol e quetamina ofereça mais eficiência do que a sedação moderada com hidrato de cloral, ela apresenta maior incidência de hipoxemia transitória, o que requer uma equipe altamente qualificada, treinada em monitoramento cardiorrespiratório pediátrico e manejo de vias aéreas.

Emergency department procedural sedation for primary electrical cardioversion — a comparison with procedural sedations for other reasons / 世界急诊医学杂志（英文）

@#BACKGROUND:Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures:they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital. METHODS:This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression. RESULTS:A total of 4867 patients were included, 714 for PEC for AF and 4153 for other indications. PEC patients were more likely male (58.5％vs. 47.1％), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6％ vs. 69.0％). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5％ vs. 78.2％). PEC patients were more likely to experience hypotension (27.6％vs. 16.5％) but respiratory AEs (apnea, hypoxia and airway intervention) were not different. CONCLUSION:EDPS for PEC differs from that conducted for other purposes:patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.

Dexmedetomidine and midazolam in procedural sedation: a systematic review of efficacy and safety / 吉林大学学报(医学版)

Objective:To systematically review the efficacy and safety of dexmedetomidine and midazolam in procedural sedation. Methods: PubMed,EMBase,Cochrane Library,CNKI,CBM and WanFang databases were retrieved to collect the randomized controlled trials (RCT) about comparion of efficacy and safety between dexmedetomidine and midazolam in procedural sedation up to March, 2017. Based on the inclusion criteria, the data extraction and quality evaluation were performed, and then the systematic evaluation was carried out.The outcome measures for efficacy were the satisfaction scores and pain scores of the patients and clinicians;the outcome measures for safety comparison were hypotension, hypoxia, and circulatory and respiratory complications.Results:There were 14 RCT satisfied the inclusion criteria including 949 patients.Compared with midazolam group, the incidence of pain, delirium, and analgesia of the patients in dexmedetomidine group had significant differences (P0.05).Conclusion:When the adult patients are sedated, dexmedetomidine can be used as an ideal alternative to midazolam sedation.

Factors impacting patient cooperation during elective gastroscopy

BACKGROUND/AIMS: Some people have difficulty tolerating upper endoscopy. The cause of and risk factors for this are not well known. The aim of this study was to investigate the factors involved in poor cooperation during screening upper endoscopy. METHODS: A total of 4,422 subjects who underwent a health inspection with upper endoscopy carried out by a single experienced endoscopist were included. We retrospectively investigated subjects' self-reporting questionnaires and medical records, including endoscopic and histologic findings. The examinees' cooperation and the completeness of endoscopic examination were evaluated based on the operator's subjective judgment. RESULTS: Examinee cooperation during the endoscopic procedure was poor in 358 out of 4,422 subjects (8.1%). Of the subjects with poor cooperation, the endoscopic examination was incomplete in 36 subjects (10.1%). Multivariate analysis revealed that young age (< 40 years), female sex, high body mass index (≥ 25), hiatal hernia, and procedural sedation using midazolam were independent risk factors for poor cooperation. CONCLUSIONS: Cooperation during screening upper endoscopy was poor in a considerable number of examinees. Endoscopists must keep in mind that examinee cooperation is more likely to be poor in the young, obese people, women, patients with hiatal hernias, and those who receive procedural sedation.

End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study / 世界急诊医学杂志（英文）

@#BACKGROUND:This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS:The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction. RESULTS:Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48％ of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71％), cardioversion (12％) and abscess incision and drainage (12％) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO2<90％) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9％ vs. 9.3％,P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3％) patients in the ETC group and 7 (1.4％) in the control group (P=0.048). CONCLUSIONS:The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Procedural Sedation in Paediatric Practice.

Introduction: Providing sedation techniques during the performance of diagnostic and therapeutic procedures on children decreases anxiety and discomfort. A number of drugs are available for the purpose. A retrospective record study in Paediatrics department of Burdwan Medical College & Hospital showed oral triclofos and per rectal diazepam were the two commonly used drugs for the purpose. However, intranasal midazolam is claimed to be a near ideal agent for procedural sedation. So, the above study was to compare efficacy and safety of intranasal midazolam over oral triclofos and per rectal diazepam. Methods: Participants having ASA score I or II having age group 1 to 6 years requiring non-invasive or minimally invasive procedure were divided into three groups- one group received oral triclofos sodium, second group received per rectal diazepam and third group received intranasal midazolam spray prior to the procedure. Levels of sedation and recovery were scored using Ramsey sedation score and modified Aldrete scoring system respectively. Induction of sedation was defined as attainment of Ramsey sedation score of at least 3. Complete recovery was defined as a minimum score of 10 of modified Aldrete scoring system. Results: Both times of induction and recovery were significantly higher in triclofos group when compared to other two groups. Level of sedation attained was higher in per rectal diazepam group, although there was no case of over sedation. Adverse effects were comparable except for nasal irritation which was exclusively limited to midazolam group. Cost of therapy was higher with intranasal midazolam therapy than with per rectal diazepam therapy. Conclusion: Per rectal diazepam appear to be a more ideal drug for procedural sedation over intranasal midazolam and oral triclofos.

Comparative study between inj. Ketamine hcl-Midazolam hcl & inj. Fentanyl citrate- Midazolam hcl in Paediatric Patient for Procedural Sedation (RT/CT/MRI).

Introduction: Interaction with medical providers is stressful experience for children. Because of this stress and the anxiety, minor procedures often require mild to moderate sedation. Sedation of the paediatric patient is a process carefully planned by the anaesthesia provider while maintaining the heart rate, respiration & oxygen saturation levels at the patient's baseline values. Methodology: We studied 80 patients of either sex aged 2-10 years of ASA grade-1 and 2, undergoing Radiation therapy, CT Scan and MRI. They were randomly allocated in two groups 40 each to compare the efficacy, safety, and tolerability of inj. Ketamine - Midazolam combination to inj. Fentanyl - Midazolam combination for sedation of children during Radiation Therapy (RT)/Computerised Tomography Scan (CT Scan)/Magnetic Resonance Imagine(MRI). Both the groups were given IV inj. Midazolam 0.05 mg/kg before giving IV inj. Ketamine 1 mg/kg in group 1 while IV inj. Fentanyl 2 pg/kg in group 2. Result: In both groups after giving sedation, there were no significant changes in heart rate. Degree of sedation was better in group I than in group II. Recovery from sedation was more prolonged in group 1 than in group 2. Conclusion: It was found that inj. Ketamine-Midazolam combination offers good sedation without compromising respiration but more prolonged recovery and higher incidence of post procedural vomiting, while inj. Fentanyl-Midazolam combination has lower sedation score and higher incidence of respiratory depression.

Impact of the United States propofol ban on emergency providers' procedural sedation agent choice and patient length of stay / 世界急诊医学杂志（英文）

@#BACKGROUND: In the recent past, propofol was temporarily removed from the emergency department (ED) for use in procedural sedation. We sought to determine which agents replaced it in clinical practice and the impact this change had on turnaround times (TAT) for sedated patients. METHODS: This study is a retrospective chart review at a level one trauma center. Patients receiving sedative agents (propofol, ketamine, midazolam, and etomidate) were identified by pharmacy codes, and their charts were then reviewed for demographics and TAT. Propofol was unavailable in the emergency department (ED) between May 2010 and February 2011. The study period extended from May 2009 until May 2011. Patients receiving sedation by non-emergency medicine physicians and those receiving sedation related to intubation were excluded. RESULTS: In total 2466 charts were reviewed and 209 met inclusion criteria. When propofol was available, the most commonly used sedative agent was etomidate (40％), followed by propofol (28％), ketamine (20％), and midazolam (6％). When propofol was unavailable, etomidate remained the most commonly used agent (43％), followed by ketamine (41％), and midazolam (11％). When propofol was available, the median TAT for sedated patients was 163 minutes compared to 178 minutes when propofol was unavailable (P=0.83). When propofol was the primary sedative agent used, the median TAT was 166 minutes as compared with a median TAT of 172 minutes for all other sedative agents combined (P=0.87). CONCLUSION: When propofol was unavailable, ketamine became a preferred ED sedation agent. Removal of propofol from the sedation armamentarium did not affect ED TAT.

Sedative Effect of Etomidate and Fentanyl by the Combinational Administration During Closed Thoracostomy

PURPOSE: As a sedative hypnotic agent, etomidate has a little side effect like respiratory depression and has an excellent pharmacokinetics and hemodynamics. The objective of this study is comparison of etomidate effect in the two groups, only lidocaine injection group and combinational administration group, during closed thoracostomy in the emergency department. METHODS: The patients with respiratory problems, which needed a closed thoracostomy, from March 1, 2003 to February 29, 2004 were enrolled in this prospective study. Thus, we were enrolled 68 patients. etomidate were used for 34 patients and only lidocaine local injection was used for 34 patients. Patients of combinational administration were randomized to receive intravenous boluses of etomidate (0.2 mg/kg) prior to fentanyl (1.0 ug/kg) during PSA (procedural sedation anesthesia). We recorded pre-administration and interval of 5 minute, 10 minute, 15 minute and transcutaneous oxygen saturation, heart rate, respiratory rate, blood pressure, degree of sedation, satisfaction of sedation, and side effects after administration. RESULTS: Of all combinational administration group, significant hemodynamic, as hypotension or bradycardia etc. and respiratory depression, as apnea or tachypnea etc. were absent. With comparison of two groups, significant clinical problems and statistics were not different and degree of sedation was fast and impaired conscious was effective in the combinational administration group. CONCLUSION: We conclude combinational administration with etomidate and fentanyl during procedural sedation is safty and excellent effectiveness. Therefore we recommened the use of etomidate for emergency procedural sedation in emergency department.