Deep Sedation for Pediatric Dental Procedures: Is this a Safe and Effective Option?

OBJECTIVE: Sedation may be needed for safe, effective completion of pediatric dental procedures. Procedural sedation is performed in a children's hospital based dental office. The three sedation approaches: a propofol-only (P-O) approach (2-3 mg/kg titrated to the needed level of sedation), an approach that includes either i.v. ketamine (K+P) (0.25 or 0.5 mg/kg) or i.v. fentanyl (F+P) (0.5-1 mcg/kg) prior to propofol administration. We sought to determine safety and efficacy of various propofol based sedation protocols. STUDY DESIGN: Retrospective review of 222 patients receiving a propofol-only (P-O), ketamine+propofol (K+P) or fentanyl+propofol (F+P) approach. RESULTS: There were 44 patients in P-O group, 154 in K+P group and 24 in F+P group with mean age (4.8±3.4 y) and mean weight (19.7±6.7 kg). All the patients completed procedures successfully. Mild hypoxemia occurred in 24% of cases and resolved with nasal cannula. Mean total dose of propofol was similar in all groups (P-O 8.2 mg/kg, K+P 9.5 mg/kg, F+P 9.6 mg/kg, p=0.15). Although procedure and recovery times were similar in all groups, discharge times in K+P group were significantly shorter than P-O group and F+P group respectively (K+P 9.35±8.93.min, P-O 13.57±10.42 min, F+P 10.42±4.40 p= 0.002). CONCLUSION: Sedation can be accomplished safely and effectively in a children's hospital based dental office using propofol-based sedation.

Successful use of intravenous dexmedetomidine for magnetic resonance imaging sedation in autistic children.

OBJECTIVES: Autism and autism spectrum disorders (A/ASD) represent a family of neurodevelopmental conditions that are associated with overactive, difficult-to-control behaviors. Sedating these patients for magnetic resonance imaging (MRI) poses challenges. Children with A/ASD were examined against clinical controls to determine the effectiveness and safety of intravenous (IV) dexmedetomidine for deep sedation. METHODS: The quality assurance data on all of the children who received IV dexmedetomidine sedation for MRI between July 2007 and December 2012 were reviewed. Patients in both groups were sedated by an intensivist-based team with a standard plan of 2 µg/kg IV dexmedetomidine administered for 10 minutes followed by an infusion of 1 µg · kg(-1)· hour(-1). The amount of IV dexmedetomidine was titrated to the deep level of sedation. A total of 56 patients in the A/ASD group and 107 in the control group were sedated with no reported sedation failures. Sedation parameters were compared between the A/ASD and control groups using analysis of covariance models, controlling for age, sex, and weight. RESULTS: Children in the A/ASD group were predominantly male (73%) and older (6.1 ± 0.3 years) than children in the control group (56%; 5.0 ± 0.2 years; P < 0.05 for both). Procedure time was significantly shorter for patients in the A/ASD group than in control patients (34.6 ± 2.4 vs 44.3 ± 1.6 minutes; P < 0.05). The A/ASD and control groups required a similar IV bolus of dexmedetomidine (2.6 µg/kg ± 0.1 vs 2.4 µg/kg ± 0.10; P = 0.29), with a significantly lower infusion dose in the A/ASD group (0.74 µg/kg ± 0.05 vs 0.89 µg/kg ± 0.03; P < 0.05). Heart rates were similar in the A/ASD group and the control group (67.0 beats per minute ± 1.6 vs 69.3 ± 1.1 beats per minute; P = 0.250). There were no complications. Recovery time was approximately 7 minutes longer in the A/ASD group than in the control group, but this was nonsignificant (101.2 ± 3.5 minutes vs 94.2 ± 2.4 minutes; P = 0.12). Analyses were performed using analysis of covariance methods and generalized linear models to control for age, sex, and weight. CONCLUSIONS: Children with A/ASD can be successfully sedated for MRIs with IV dexmedetomidine without complications.

Catheter-associated bloodstream infection in the pediatric intensive care unit: a multidisciplinary approach.

BACKGROUND: Catheter-associated bloodstream infections have been reported to occur in 3% to 8% of all central venous catheters inserted and are the predominant cause of hospital-acquired infection in intensive care units. OBJECTIVE: Decreasing the pediatric intensive care unit rate of catheter-associated bloodstream infections became a high priority in 2008 for all members of the intensive care unit team affiliated with central venous catheter insertion and maintenance. INTERVENTIONS: Through a series of multidisciplinary initiatives, the annual average catheter-associated bloodstream infection rate in the pediatric intensive care unit fell from 7.9 infections per 1000 central catheter days in 2007 to 1.3 infections per 1000 central catheter days in 2009, a decrease of 83%. We attribute this success to the implementation of several key interventions, adherence to published insertion and maintenance bundles, and collaboration among pediatric intensive care unit physicians and nurses in all aspects of central catheter care. MEASUREMENTS AND MAIN RESULTS: Statistically significant interventions included improvements to central venous catheter insertion practices, the development of a dedicated central catheter team, and regular collaborative discussion of central venous catheter necessity. In this 24-month period, this equates to 50 catheter-associated infections avoided, six potential deaths prevented, and an estimated cost savings of $1.45 million (based on $29,000 per infection). CONCLUSION: While implementation of these and other interventions has shown a positive impact, this project will continue into the future to assure sustainable successes and continued best practice improvements.

A Comparison of Safety and Efficacy of Dexmedetomidine and Propofol in Children with Autism and Autism Spectrum Disorders Undergoing Magnetic Resonance Imaging.

Children with autism and autism spectrum disorders have a high incidence of neurologic comorbidities. Consequently, evaluation with magnetic resonance imaging (MRI) is deemed necessary. Sedating these patients poses several challenges. This retrospective study compared the efficacy and safety of dexmedetomidine to propofol in sedating autistic patients undergoing MRI. There were 56 patients in the dexmedetomidine group and 49 in the propofol group. All of the patients successfully completed the procedure. Recovery and discharge times were significantly lower in the propofol group, while the dexmedetomidine group maintained more stable hemodynamics. Both propofol and dexmedetomidine proved to be adequate and safe medications in the sedation of autistic children undergoing MRI.

Intermittent Bolus versus Continuous Infusion of Propofol for Deep Sedation during ABR/Nuclear Medicine Studies.

Objective A comparison of intermittent bolus (IB) versus continuous infusion of propofol for deep sedation. Material and Methods A retrospective review of patients sedated for Auditory Brainstem Response (ABR)/nuclear medicine studies between September 2008 and February 2015. A ketamine bolus (0.5 mg/kg < 20 kg, 0.25 mg/kg > 20 kg) followed by propofol bolus of 1 mg/kg over 2 minutes. In the IB group, maintenance of deep sedation was with incremental bolus of 10 to 20 mg of propofol. In continuous infusion group (CG), maintenance was with a continuous infusion of 83 mcg/kg/min of propofol. Results Of the 326 cases completed, 181 were in CG group and 145 were in IB group. There were no statistical differences in patient's age, weight, and American Society of Anesthesiologist (ASA) classification. The cardiovascular and respiratory parameters in the two groups were not different statistically. Mean total propofol dose was higher in CG group versus IB group (CG 7.6 mg ± 3.6 mg, IB 6.5 mg ± 3.6 mg; p = 0.008). Procedure time in CG group was longer by 8 minutes compared with IB group (CG 49.8 min ± 25.4 min versus 42.3 min ± 19.2 min; p = .003). CG group has both shorter recovery time (CG 8.1 min ± 4.7 min versus IB 10.0 min ± 8.5 min; p = 0.01) and discharge time. Conclusion Satisfactory sedation and completion of the procedure was accomplished with both sedation protocols.

Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy.

AIM: To evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy. METHODS: A retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants (less than 12 mo), toddlers (1-3 years) and children (4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed. RESULTS: Of the total 458 bronchoscopies performed, propofol only regimen was used in 337 (74%) while propofol and ketamine was used in 121 (26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be younger and have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia. CONCLUSION: Children can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers.

Propofol-Based Procedural Sedation with or without Low-Dose Ketamine in Children.

Objective Examine comparative dosing, efficacy, and safety of propofol alone or with an initial, subdissociative dose of ketamine approach for deep sedation. Background Propofol is a sedative-hypnotic agent used increasingly in children for deep sedation. As a nonanalgesic agent, use in procedures (e.g., bone marrow biopsies/aspirations, renal biopsies) is debated. Our intensivist procedural sedation team sedates using one of two protocols: propofol-only (P-O) approach or age-adjusted dose of 0.25 or 0.5 mg/kg intravenous ketamine (K + P) prior to propofol. With either approach, an initial induction dose of 1 mg/kg propofol is recommended and then intermittent dosing throughout the procedure to achieve adequate sedation to safely and effectively perform the procedure. Approach: Retrospective evaluation of 754 patients receiving either the P-O or K + P approach to sedation. Results A total of 372 P-O group patients and 382 K + P group. Mean age (7.3 ± 5.5 years for P-O; 7.3 ± 5.4 years for K + P) and weight (30.09 ± 23.18 kg for P-O; 30.14 ± 24.45 kg for K + P) were similar in both groups (p = NS). All patients successfully completed procedures with a 16% combined incidence of hypoxia (SPO2 < 90%). Procedure time was 3 minutes longer for K + P group than P-O group (18.68 ± 15.13 minutes for K + P; 15.11 ± 12.77 minutes for P-O; p < 0.01), yet recovery times were 5 minutes shorter (17.04 ± 9.36 minutes for K + P; 22.17 ± 12.84 minutes for P-O; p < 0.01). Mean total dose of propofol was significantly greater in P-O than in K + P group (0.28 ± 0.20 mg/kg/min for K + P; 0.40 ± 0.26 mg/kg/min for P-O; p < 0.0001), and might explain the shorter recovery time. Conclusion Both sedation approaches proved to be well tolerated and equally effective. Addition of ketamine was associated with reduction in the recovery time, probably explained by the statistically significant decrease in the propofol dose.

High dose dexmedetomidine: effective as a sole agent sedation for children undergoing MRI.

Objective. To determine the efficacy and safety of high dose dexmedetomidine as a sole sedative agent for MRI. We report our institution's experience. Design. A retrospective institutional review of dexmedetomidine usage for pediatric MRI over 5.5 years. Protocol included a dexmedetomidine bolus of 2 µg/kg intravenously over ten minutes followed by 1 µg/kg/hr infusion. 544 patients received high dose dexmedetomidine for MRI. A second bolus was used in 103 (18.9%) patients. 117 (21.5%) required additional medications. Efficacy, side effects, and use of additional medicines to complete the MRI were reviewed. Data was analyzed using Student's t-test, Fisher's exact test, and Analysis of Variance (ANOVA). Main Results. Dexmedetomidine infusion was associated with bradycardia (3.9%) and hypotension (18.4%). None of the patients required any intervention. Vital signs were not significantly different among the subgroup of patients receiving one or two boluses of dexmedetomidine or additional medications. Procedure time was significantly shorter in the group receiving only one dexmedetomidine bolus and increased with second bolus or additional medications (P < 0.0001). Discharge time was longer for children experiencing bradycardia (P = 0.0012). Conclusion. High dose Dexmedetomidine was effective in 78.5% of cases; 21.5% of patients required additional medications. Side effects occurred in approximately 25% of cases, resolving spontaneously.

Corrigendum to "High Dose Dexmedetomidine: Effective as a Sole Agent Sedation for Children Undergoing MRI".

[This corrects the article DOI: 10.1155/2015/397372.].