Pre-operative anxiolysis in children through a combined pharmacological therapy with hydroxyzine and a non-pharmacological distraction technique with a clown (SONRISA): study protocol for randomised double-blind clinical trial.

BACKGROUND: Surgery can generate significant stress and anxiety in up to 70% of the paediatric population. There are several pharmacological and non-pharmacological strategies to reduce pre-operative anxiety in children, however, they have several side effects and the available information about them is contradictory. The role of clowns and hydroxyzine in the management of anxiety is controversial, with some studies supporting and others contraindicating both strategies. METHODS: We propose a randomised double-blind, controlled clinical trial that will evaluate the effectiveness of both interventions (hydroxyzine and clowns), alone or in combination, to reduce pre-operative anxiety (using the modified Yale scale of preoperative anxiety) in children aged 2-16 years undergoing outpatient surgery (n = 188). Subjects will be randomised into two groups - (1) standard procedure (parental accompaniment) combined with placebo or (2) standard procedure combined with preoperative hydroxyzine. After randomisation, they will be divided by chance into two further groups, depending on the presence of clowns on the patient's surgery day. Control of pre-operative anxiety will be determined in the four groups by a modified Yale scale of preoperative anxiety and cortisol levels. Compliance of children during induction of anaesthesia, time until anaesthesia recovery, presence of postoperative delirium and use of analgesia until discharge will be also assessed. For additional information, the children, parents and healthcare professionals involved in the study will complete a satisfaction survey. CONCLUSIONS: This study aims to gather evidence on which of these four therapeutic options achieves the highest reduction of pre-operative anxiety with the best safety profile to allow paediatricians and anaesthesiologists to use the most effective and safe option for their patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03324828. Registered 21 September 2017.

Artritis séptica de rodilla por Kingella kingae: Presentación de dos casos clínicos

Kingella kingae es un colonizador habitual de la orofaringe en niños pequeños. Aunque en la mayoría de ocasiones la colonización es asintomática, puede dar lugar a infección invasiva. Este microorganismo ha sido crecientemente identificado como agente causal de infección osteoarticular en niños. Los datos limitados de artritis séptica por K. kingae y la dificultad para su identificación en los medios de cultivo habituales, pueden ocasionar retraso diagnóstico y en el inicio del tratamiento. Presentamos dos casos clínicos de lactantes con artritis séptica por K. kingae diagnosticada mediante PCR en líquido articular. El primero de ellos se trata de una mujer de 20 meses con sospecha inicial de sinovitis transitoria de cadera derecha, que acude a urgencias por cojera de 10 días de evolución. Ingresa tras 48 horas de fiebre y tumefacción de rodilla derecha, instaurándose tratamiento empírico con cloxacilina y cefotaxima tras diagnóstico de artritis séptica. Se obtiene PCR positiva para K. kingae en líquido articular. El segundo es un varón de 20 meses que acude a urgencias por dolor, tumefacción y limitación a la flexión de rodilla izquierda de 2-3 semanas, que en las últimas 24 horas se acompaña de fiebre de hasta 38.5ºC. Cuadro catarral previo. Ingresado una semana antes por el mismo motivo, con analítica sin alteraciones y análisis del líquido articular normal. De nuevo se decide ingreso repitiendo las pruebas complementarias e iniciando tratamiento empírico con cloxacilina y cefotaxima. Identificación de K. kingae mediante PCR en segunda muestra de líquido articular. Ambos casos presentaron buena evolución sin secuelas posteriores.

Kingella kingae is a common colonizer of the oropharynx in young children. Although most colonization is asymptomatic, it can lead to invasive infection. This microorganism is increasingly recognized as a cause of osteoarticular infections in children. The limited data of septic arthritis due to K. kingae and the difficulty to identify this organism in routine cultures, can delay the diagnosis and treatment. Two cases of infants with septic arthritis by K. kingae diagnosed by PCR are described. The first one is about a 20-month-old woman with initial suspicion of transient synovitis of the right hip, who came to the emergency department with limping in the last 10 days. She is admitted to hospital because of fever and inflammation on the right knee for 48 hours. We initiated empirical treatment with cefotaxime and cloxacillin after diagnosis of septic arthritis. Positive PCR for K. kingae was obtained in joint fluid. The second case is about a 20-month-old male who came to the emergency room due to pain, swelling and limitation to left knee flexion, 2-3 weeks of evolution, accompanied by fever for the last 24 hours (38.5ºC). He had the antecedent of catarrhal picture previously. He had been admitted to hospital the previous week because of the same symptoms, with blood and joint fluid exams without alterations. He is admitted again with empirical treatment with cloxacillin and cefotaxime after repeating the laboratory exams. K. kingae was identified by PCR in the second sample of joint fluid. Both cases presented had good evolution without subsequent sequels.