Evaluation of an oral analgesia protocol for upper-limb fracture reduction in the paediatric emergency department: Prospective study of 101 patients.

BACKGROUND: Upper limb injuries are common in children. When required, closed fracture reduction can be performed in the emergency department without general anaesthesia but causes pain. The primary objective of this study was to assess an oral analgesia protocol for fracture reduction without general anaesthesia. The secondary objectives were to look for associations linking pain intensity to age, sex, and waiting time and to determine the frequency of secondary displacement requiring closed reduction or internal fixation under general anaesthesia at the 1-week follow-up visit. HYPOTHESIS: An oral analgesia protocol combining a loading dose of morphine with other medications would provide sufficient pain control to obviate the need for general anaesthesia. MATERIAL AND METHODS: A prospective observational single-centre study was conducted over a 15-month period (July 2017-October 2018) in consecutive patients younger than 16 years who required reduction of a displaced upper-limb fracture. All patients received the same oral combination of paracetamol (15mg/kg), ibuprofen (7.5-10mg/kg), and a loading morphine dose (0.5mg/kg, up to 20mg) 1hour before the procedure. Patients given morphine more than 2hours before the procedure and those with persistent pain were given an additional morphine dose (0.2mg/kg, up to 10mg). An equimolar mixture of oxygen and nitrous oxide was administered during reduction. An appropriate scale was used to measure pain intensity before, during, and 15minutes after the procedure. Cases of secondary displacement requiring further reduction or internal fixation under general anaesthesia at the 1-week follow-up visit were recorded. RESULTS: The 101 study patients (73 male and 28 female) had a mean age of 9.4 years (range, 2-15 years). Mean pain scores were 5.0±2.6 at admission and 2.1±2.3, 2.6±3.3, and 1.3±2.2 before, during, and after reduction, respectively. Pain intensity during reduction was significantly associated with age. The analgesia was deemed satisfactory by 94 patients and 90 parents. General anaesthesia for further treatment was required in 10 (9.9%) patients, either on the day after the initial treatment, due to inadequate reduction (n=8), or at the 1-week visit, due to secondary displacement (n=2). DISCUSSION: Oral morphine in a sufficient dosage given in combination with other medications was effective and well tolerated when used to control pain during upper-limb fracture reduction. Pain intensity was not significantly associated with sex. In contrast, pain was significantly more severe in the patients older than 10 years of age. The proportions of patients requiring further reduction or internal fixation were consistent with previously published data. Most patients and parents were satisfied with the analgesia protocol. CONCLUSION: A multimodal oral analgesia protocol provides sufficient pain relief to allow closed reduction of upper-limb fractures in children at the emergency department. This management strategy provided high satisfaction rates in both the patients and their parents. LEVEL OF EVIDENCE: II, prospective observational study.

Weaning children from mechanical ventilation with a computer-driven system (closed-loop protocol): a pilot study.

OBJECTIVE: To evaluate the applicability, tolerance, and efficacy of a closed-loop protocol to wean children from mechanical ventilation. DESIGN: Prospective single-center pilot study. SETTING: Tertiary care university hospital. PATIENTS: Twenty mechanically ventilated children aged between 1 and 17 yrs, with a body weight > or =10 kg, no inotropes, and no heavy sedation. INTERVENTIONS: Patients were weaned in pressure support mode by a closed-loop computerized protocol (closed-loop protocol) that interprets clinical data in real time and controls pressure support levels. MEASUREMENTS AND MAIN RESULTS: The closed-loop protocol applicability and tolerance were evaluated. The efficacy of this protocol was evaluated by comparing the duration of mechanical ventilation with a historical group of 20 patients weaned with a clinician-decision protocol. The closed-loop protocol successfully decreased pressure support ventilation in 16 children, recommended separation from the ventilator in 14 children, and did not cause any serious adverse events. Mechanical ventilation duration was 5.1 +/- 4.2 days in the closed-loop group and 6.7 +/- 11.5 days (mean +/- sd) in the clinician-decision group (p = .33) with no difference in the need for reintubation or noninvasive mechanical ventilation (one of 20 and four of 20, respectively; p = .20). CONCLUSIONS: A closed-loop protocol was successfully used to wean children from mechanical ventilation. Further studies are required to assess the impact of this novel therapeutic strategy on the length of mechanical ventilation.