Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study.

STUDY OBJECTIVE: To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department. METHODS: The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10. RESULTS: We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events. CONCLUSIONS: We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study.

STUDY OBJECTIVE: We estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing forearm fracture reduction in the emergency department. METHODS: We used the up-down method to estimate the median dose of intravenous ketamine infused during less than or equal to 5 seconds that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years who were undergoing forearm fracture reduction. Most patients were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was assessed by modified Aldrete score. RESULTS: We enrolled 20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an empirically derived ED95 was 0.8 mg/kg. All patients who received the empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95 in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered. No participant experienced serious adverse events. CONCLUSION: We estimated ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture reduction. Total sedation time was shorter than that in most previous studies.

Difficult airway consultation service for children: steps to implement and preliminary results.

BACKGROUND: Failed airway management remains one of the most common causes of cardiopulmonary arrest in the pediatric population. Practice guidelines addressing the difficult airway (DAW) in adults provide anesthesiologists a framework for managing the airway during the perioperative period; however, similar consensus guidelines are lacking in the pediatric population. Many of the adverse events associated with difficult pediatric airway management occur outside the perioperative setting and often result in worse outcomes. The lower frequency of DAW management required in children, lesser awareness of pediatric health care professionals about DAW management, and the need for guiding principles led us to develop a DAW consultative service. This report outlines the steps to establish the Difficult Airway Service (DAS) and the initial experiences with this new consultation service. METHODS: The mission of the DAS is to identify children with known or anticipated DAWs, communicate the diagnosis and collaborate with referring medical and surgical services, and to manage children in those settings that airway management might be required in the context of the patient's ongoing medical care. RESULTS: The initial 3-month experience confirmed that a majority of pediatric DAW events are associated with congenital or acquired abnormalities. Through appropriate consultation and leadership, the DAS was able to physically and electronically identify pediatric patients with a DAW and provide management. Hospital-wide participation was instrumental in the success and exponential growth of DAS: planned preoperative tracheostomy in complicated posterior spinal fusion candidates, participation in EXIT procedures, standardization of airway carts, and implementation of education forums. CONCLUSION: In developing the DAS, our goal was to provide a more comprehensive approach to caring for a child with a DAW that included their entire hospital stay and follow-up care. We believe this approach has improved health care professional awareness as well as the safe management of routine and difficult pediatric airway. Additional studies are needed to determine whether measurable changes in morbidity and mortality are observed over time.

The dose of caudal epidural analgesia and duration of postoperative analgesia.

BACKGROUND: Single dose caudal epidural is commonly utilized for postoperative analgesia in children. Previous studies have determined the optimal concentration of local anaesthetic, and the minimal volume to produce a desired dermatomal distribution. However, none has sought the optimal volume to administer. The specific aim of this study was to determine whether the volume of caudal epidural local anaesthetic influenced the duration of postoperative analgesia. METHODS: Fifty-four children aged 1-6 years and ASAPS I-II scheduled for elective inguinal herniorraphy were enrolled in this randomized and blinded clinical trial. They received a standardized general anaesthetic with one of three possible doses of caudal epidural analgesic: 0.7, 1.0, or 1.3 ml.kg-1 of 0.175% bupivacaine with 1 : 200 000 epinephrine. The patients were assessed by blinded observers during in-hospital recovery and by parents at home. RESULTS: The principal outcome measure of time until first postoperative analgesic requirement was similar between the groups (4.2, 3.6, and 4.8 h respectively). Other effects which might be altered by epidural analgesia, including time until first void, ambulation, and discharge readiness did not differ between groups. CONCLUSIONS: Increasing local anaesthetic dose and volume do not increase the duration of postoperative analgesia of caudal epidural in children undergoing inguinal herniorraphy.