Combination fentanyl and diazepam for pediatric conscious sedation.

OBJECTIVES: To evaluate the safety and to describe the use of combination IV diazepam and fentanyl in the pediatric emergency department (PED) as outpatient conscious sedation (CS) for orthopedic procedures. METHODS: A retrospective chart review of a standardized protocol for CS administered to 133 consecutive patients requiring CS for outpatient orthopedic procedures. The patients were continuously monitored for heart rate, respiratory rate, and arterial O2 saturation (Sao2) by pulse oximetry. The study was conducted at a large urban PED and regional referral center. RESULTS: A total of 133 children (mean age 8.5 years) received 138 orthopedic procedures. Mean (+/- SD) total diazepam dose was 0.12 +/- 0.05 mg/kg; mean total fentanyl dose was 3.18 +/- 1.04 micrograms/kg. Mean time intervals were 4.6 minutes from initial drug administration to start of procedure, 15.5 minutes to end of procedure, and 56 minutes to meeting criteria for release home. Complications included Sao2 < 90% for 15 patients (11%, 95% CI 6.4-17.4%), vomiting for one (0.7%, 95% CI 0.1-4.2%), and severe pruritus for one (0.7%, 95% CI 0.1-4.2%). An episode of Sao2 < 90% was associated with a higher initial mean fentanyl dose (2.60 vs 1.95 micrograms/kg; p = 0.0005), but was not associated with a higher initial mean diazepam dose (p = 0.28). Parenteral opioid use for pain management prior to CS was not associated with an increased risk for Sao2 < 90% (p = 0.42). Heart rate, respiratory rate, and blood pressure were stable during the observational period. No patient required naloxone, flumazenil, artificial airway control, or admission to the hospital. CONCLUSIONS: At the doses given in the study, the use of combination diazepam and fentanyl for outpatient CS of PED patients during orthopedic procedures was not associated with serious complications. A higher initial fentanyl dose was associated with episodes of Sao2 < 90%. Therefore, an initial dose of < or = 2.0 micrograms/kg fentanyl titrated to effect is recommended.

Ventricular fibrillation in two infants treated with amiodarone hydrochloride.

Antiarrhythmic agents may induce ventricular arrhythmias. Whereas amiodarone is a reported cause of ventricular fibrillation in children, there are no reported cases in infants. We observed two patients with atrial flutter and congestive heart failure who were treated with amiodarone. Both had anatomic heart defects and had failed conventional therapy. Ventricular fibrillation occurred 3 and 12 days after the initial dose. Q-T interval, electrolytes, digoxin level, and amiodarone level (one patient) were normal. Amiodarone may provoke life-threatening ventricular tachyarrhythmias during the convalescent period. Consideration should be given to monitoring in a hospital setting for at least 2 weeks following initiation of amiodarone therapy.

Systemic lupus erythematosus: pulmonary presentation in childhood.

Pulmonary symptoms as the initial or primary manifestation of SLE are rare. When pulmonary symptoms are present, they occur most commonly when other organ systems are involved. The absence of skin and renal involvement, the presence of normal serum complement, and the poor response to corticosteroids in this patient are of interest. Pulmonary disease produced by childhood SLE may represent, as in adults, a subgroup of SLE disease. Our report emphasizes the importance of recognizing diffuse interstitial infiltrates as an initial symptom of childhood SLE even in the absence of more obvious signs.