Comparison of intravenous midazolam with pentobarbital for sedation for head computed tomography imaging.

OBJECTIVE: To compare the efficacy of intravenous (IV) midazolam with that of IV pentobarbital when used for sedation for head computed tomography (CT) imaging in emergency department (ED) pediatric patients. METHODS: Prospective, randomized clinical trial in an urban children's hospital. During a two-and-a-half-year period, 55 patients were enrolled: 34 males and 21 females. Measurements included induction time, recovery time, efficacy, side effects, complications, and failure with each drug. Success of sedation was graded as good (GS), adequate (AS), poor (PS), or unsuccessful (US). RESULTS: Sedation for CT was used for patients with the following problems: head trauma (21/55), central nervous system pathology (17/55), ventriculoperitoneal shunt evaluation (6/55), periorbital cellulitis (6/55), and retropharyngeal abscess (5/55). Twenty-nine (53%) patients received pentobarbital (mean +/- SD dose 3.75 +/- 1. 10 mg/kg) and 26 (47%) patients received midazolam (mean +/- SD dose 0.2 +/- 0.03 mg/kg). In the pentobarbital group, 28 (97%) patients were scanned and successfully sedated. Pentobarbital's mean induction time was 6 minutes and duration of sedation averaged 86 minutes. In the midazolam group, only five (19%) patients were successfully scanned with midazolam alone. Of the 21 (81%) patients given midazolam who were unsuccessfully sedated, 12 (61%) were subsequently sedated with the addition of pentobarbital for completion of CT imaging. Mild oxygen desaturation, O(2) sat >90% yet <94%, was seen in only four patients. All four patients responded to blow-by oxygen and required no other intervention. CONCLUSION: Intravenous pentobarbital is more effective than IV midazolam for sedation of children requiring CT imaging.

The effect of nitrous oxide diffusion on laryngeal mask airway cuff inflation in children.

We studied the effect of nitrous oxide (N2O) diffusion on size 2 LMA cuff inflation in 52 children, 38 +/- 21 months of age. LMA cuffs were inflated with air (Group A) or 65% N2O, oxygen and halothane (Group B). Cuffs were inflated in a stepwise manner, achieving a cuff leak pressure of 17 +/- 4 cm H2O for all patients. Cuff volume and intracuff pressure increased in Group A (8.5 +/- 1.0 ml to 10.8 +/- 1.4 ml and 101 +/- 36 mmHg to 152 +/- 42 mmHg, respectively) and decreased in Group B (8.9 +/- 1.0 ml to 6.6 +/- 1.5 ml and 90 +/- 30 mmHg to 53 +/- 37 mmHg, respectively). Cuff leak pressure did not change significantly in either group. We conclude that cuff inflation with a mixture of N2O/oxygen prevents N2O diffusion into the cuff, avoiding cuff overinflation without compromising LMA function.

Pediatric sedation. Essentials for the perioperative nurse.

Sedation of children undergoing surgical procedures is one of many issues facing perioperative nurses today. This article reviews relevant professional guidelines for the practice of sedation in children and describes the implications for perioperative nurses. Topics covered include preparation of the patient, monitoring guidelines, and the use of pharmacological agents.

Sedation and analgesia for minor pediatric procedures.

Owing to recent emphasis upon the benefits of effective pain management, parents and health care providers expect infants and children to receive safe, effective sedation and analgesia for diagnostic and therapeutic procedures. The Committee on Drugs of the American Academy of Pediatrics has addressed the issue of safety in its recently revised guidelines for monitoring and management of patients undergoing sedation for procedures. Patients undergoing emergency procedures present additional problems because of the limited opportunity to optimally prepare patients and families. Today, managing children undergoing invasive procedures can include the use of sedatives, analgesics, anesthetics, and nonpharmacologic strategies. New formulations of local and topical anesthetics have enhanced their efficacy and reduced pain associated with administration. Innovations in the administration of sedatives and analgesics, as well as antagonists, have enhanced both efficacy and safety. This article reviews recommended guidelines for monitoring and management of patients undergoing sedation for minor procedures and discusses various sedative, analgesic, and anesthetic alternatives available to clinicians.

Positive pressure ventilation with the laryngeal mask airway in children.

We studied the safety of positive pressure ventilation (PPV) when using the size 2 laryngeal mask airway (LMA) in 46 ASA physical status I or II children (aged 38 +/- 21 mo) undergoing elective surgery. The LMA cuff was inflated in incremental steps to achieve a cuff leak pressure > or = 15 cm H2O. Abdominal circumference was measured before and after PPV in study patients, as well as in a control group managed with tracheal intubation. Cuff leak pressure was 17 +/- 4 cm H2O (range 12-34 cm H2O). Forty-five patients successfully underwent PPV. Gas leak around the LMA cuff prevented PPV in one infant. The only respiratory variable that changed significantly was end-tidal CO2, which decreased from 40 +/- 6 to 34 +/- 5 mm Hg. Abdominal circumference increased in 28 patients but was not associated with any complications. Change in abdominal circumference in the study group was not significantly different from that observed in the control group. However, abdominal circumference increased 8 cm in one study patient, prompting insertion of an orogastric tube. The size 2 LMA provides an effective airway for PPV. Mild gastric distention often occurs. The risk of clinically significant gastric distention appears to be small, but it warrants close monitoring. We conclude that with certain precautions described in the text, the size 2 LMA provides a relatively safe airway for PPV in children.

Pain management in children.

Pain management in children has only recently been described in medical and nursing literature. The lingering myth that children do not experience pain, combined with difficulties in assessing pain, hamper pain management. Various assessment tools for pediatric pain exist. Options for management include blocks, opioids, topical anesthetics, and nonpharmacological techniques.

Pulmonary edema associated with upper airway obstruction in dogs.

In order to evaluate the effect of acute upper airway obstruction upon pulmonary edema (PE) formation, we studied seven dogs that were subjected to inspiratory obstruction for three hours. Hypoxia was avoided by the administration of supplemental oxygen during the study period. Six dogs developed pulmonary vascular congestion, and four developed histologic findings of PE. Inspiratory intrapleural pressure decreased to -28 +/- 4 mmHg in dogs that developed PE and to -23 +/- 2 mmHg in dogs that did not. Transmural pulmonary artery pressure and pulmonary artery wedge pressure did not increase significantly. Central venous pressure during inspiration (CVPi) increased in all dogs, and CVP at end expiration (CVPe) was significantly higher in dogs with PE. Dogs that developed PE experienced a decrease in cardiac output and an increase in systemic vascular resistance. Furthermore, alveolar ventilation declined in dogs with PE, ultimately resulting in ventilatory failure. Pulmonary edema formation was not preceded by an increase in pulmonary vascular pressures but was associated with higher CVP, pulmonary vascular congestion, and hypercarbia.

Predictors of outcome in acute meningococcal infection in children.

OBJECTIVES: To develop a rapid and sensitive method for identification of patients at risk for organ system failure and death due to acute meningococcal infection, and to evaluate the reliability of the Pediatric Risk of Mortality score in predicting mortality rates from acute meningococcal infection. DESIGN: A prospective study which followed a retrospective analysis. SETTING: The Emergency Department and pediatric intensive care unit (ICU) of a university-affiliated children's hospital. PATIENTS: The hospital records of 86 pediatric patients with acute meningococcal infection during a 5-yr period (group 1) were reviewed. Twenty-two ICU patients (group 2) were then prospectively evaluated, and the occurrence rate of organ system failure was compared with that rate predicted by the model developed from the analysis of group 1. INTERVENTIONS: The occurrence of prognostic factors was compared with the development of organ system failure and death by Fisher's exact test and logistic regression analysis for patients in group 1. The mortality rates for groups 1 and 2 were compared with those rates that were predicted by the use of the Pediatric Risk of Mortality score. MAIN RESULTS: Eighteen of 86 patients in group 1 developed organ system failure, and seven (8.1%) patients died. Logistic regression analysis found that the combination of circulatory insufficiency, peripheral WBC counts of < 10,000 cells/mm3, and coagulopathy best predicted organ system failure. Ten of 22 patients in group 2 developed organ system failure, and two died. All patients with organ system failure exhibited > or = 1 of three identified prognostic factors. The probability of organ system failure occurring was > .5 for nine of ten patients with organ system failure. A total of nine patients in groups 1 and 2 developed multiple organ system failure, and all nine patients died. Based on Pediatric Risk of Mortality scoring, the mortality risk for nonsurvivors ranged from 27% to 94%, compared with 1% to 48% for survivors. The overall mortality rate was consistent with that rate predicted by the Pediatric Risk of Mortality scoring system. CONCLUSIONS: Patients with acute meningococcal infection who exhibit signs of circulatory insufficiency, a peripheral WBC count of < 10,000 cells/mm3, or a coagulopathy have a high probability of developing organ system failure. Death is highly probable when multiple organ system failure develops, and the overall mortality rate is accurately predicted by the Pediatric Risk of Mortality score.

Intravascular hemolysis associated with hydrocarbon poisoning.

Hydrocarbon ingestion may result in serious complications such as adult respiratory distress syndrome, encephalopathy, and seizures. Hematologic disorders have appeared to be rare complications of hydrocarbon toxicity. After encountering a case complicated by severe intravascular hemolysis, we reviewed the hospital records of all patients admitted to our pediatric intensive care unit (PICU) because of complicated hydrocarbon poisoning. Three of the 12 PICU patients identified developed intravascular hemolysis, and one developed disseminated intravascular coagulation. One patient required transfusion, but all recovered without sequelae. Intravascular hemolysis may be a more frequent complication of hydrocarbon poisoning than previously recognized.

Familial desquamative interstitial pneumonitis occurring in infants.

Desquamative interstitial pneumonitis (DIP) is rare in children. Its cause is unknown. In general, it is of sporadic occurrence. We report 4 infants: 2 sibs in each of 2 separate families, who had DIP. All 4 infants died despite intensive care and immunosuppressive therapy. Our cases, plus one other similar kindred in the literature, confirm the occurrence of familial DIP in infancy. Further, our experience suggests that DIP in these familial cases carries a worse prognosis than that reported in sporadic cases.

Hypertension associated with clonidine ingestion.

Clonidine hydrochloride (CH) is an antihypertensive drug with complex pharmacologic activity including central and peripheral alpha-adrenergic stimulation and CNS depression. We reviewed the records of 5 children admitted to our Pediatric Intensive Care Unit following accidental ingestion of CH. All patients presented with lethargy or stupor, beginning 20-60 minutes after ingestion. Respiratory depression or apnea occurred in 4, requiring endotracheal intubation in 2 and mechanical ventilation in 1. All 5 developed mild to moderate hypertension, and 3 developed asymptomatic bradycardia. The dose of CH ingested was estimated to be 0.2-0.4 mg in 4 out of 5 patients. Treatment consisted of efforts to prevent absorption of CH from the GI tract and supportive care. All signs of CH toxicity resolved within 6-14 hours. Four patients were transferred from ICU within 24 hours and discharged home the following day. One patient developed post-extubation stridor and atelectasis. Significant toxicity occurred even though the amount of CH ingested was relatively small in at least 4 or 5 patients. Transient hypertension occurred early in the hospital course of all patients and resolved without treatment. Hypotension and symptomatic bradycardia were not observed. Apnea was the most serious abnormality observed. All patients recovered without significant morbidity.