An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children.

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and Research Tools from the International Committee for the Advancement of Procedural Sedation.

Many hospitals, and medical and dental clinics and offices, routinely monitor their procedural-sedation practices-tracking adverse events, outcomes, and efficacy in order to optimize the sedation delivery and practice. Currently, there exist substantial differences between settings in the content, collection, definition, and interpretation of such sedation outcomes, with resulting widespread reporting variation. With the objective of reducing such disparities, the International Committee for the Advancement of Procedural Sedation has herein developed a multidisciplinary, consensus-based, standardized tool intended to be applicable for all types of sedation providers in all locations worldwide. This tool is amenable for inclusion in either a paper or an electronic medical record. An additional, parallel research tool is presented to promote consistency and standardized data collection for procedural-sedation investigations.

America's tragedy: pediatric trauma.

Resuscitation of the pediatric trauma patient involves immediate assessment of ABCs. Interventions are made immediately upon recognition of abnormalities during the primary survey. After initial assessment and management of life-threatening processes, consider the optimal destination for further care and resuscitation. Keep in mind pediatric considerations like anatomical differences and the need for pediatric-sized equipment. Avoid the common errors that occur when resuscitating a pediatric trauma patient.

Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial.

STUDY OBJECTIVE: This study was conducted to investigate the frequency and severity of adverse effects, specifically emergence phenomena, experienced by patients receiving intravenous ketamine with or without midazolam for sedation in a pediatric emergency department. METHODS: Patients aged 4.5 months to 16 years receiving ketamine sedation were prospectively enrolled in a double-blind, randomized, controlled study at a university-affiliated children's hospital-pediatric ED. All patients received ketamine (1 mg/kg) and glycopyrrolate (5 microgram/kg) intravenously. Patients were randomly assigned to receive midazolam (0.1 mg/kg) intravenously or no midazolam. Total time of sedation, sedation efficacy, and adverse effects were recorded. Adverse effects were compared between patients receiving ketamine versus those who received ketamine and midazolam. Additional comparisons were made based on age and number of ketamine doses administered. RESULTS: Two hundred sixty-six patients were studied; 129 received ketamine and 137 patients received ketamine and midazolam. Time of sedation and efficacy of sedation were equivalent between groups. Overall, adverse effects with ketamine sedation included respiratory events (12 [4.5%]), vomiting (50 [18.7%]), emergence phenomena in the pediatric ED (71 [26.7%]), and emergence phenomena at home (60 [22.4%]). Significant emergence phenomena in the pediatric ED (ie, nightmares, hallucinations, and severe agitation) occurred in 7.1% of the ketamine group and in 6.2% of the ketamine-midazolam group, a rate difference of 0.8 (95% confidence interval [CI] -5.3 to 7.0). The addition of midazolam led to an increased incidence of oxygen desaturation events (ketamine 1.6% versus ketamine-midazolam 7.3%; rate difference -5.7, 95% CI -10.6 to -0.9) but a decreased incidence of vomiting (ketamine 19.4%, ketamine-midazolam 9.6%, rate difference 9.8, 95% CI 1.4 to 18.2). The incidence of emergence phenomena and significant emergence phenomena was not affected by the addition of midazolam. However, the addition of midazolam was associated with more agitation in the pediatric ED in children 10 years or older (ketamine 5.7% versus ketamine-midazolam 35.7%; rate difference -30.0, 95% CI -10.7 to -49.3). Age breakdown further showed 6.3% (95% CI 0.9 to 11.6) more episodes of oxygen desaturation in the ketamine-midazolam group in children younger than 10 years, and 12.1% (95% CI 1.5 to 22.6) more vomiting episodes in the ketamine group in children younger than 10 years. CONCLUSION: Ketamine and combined ketamine and midazolam provided equally effective sedation. The addition of midazolam did not alter the incidence of emergence phenomena. Vomiting occurred more frequently in the ketamine only group, whereas oxygen desaturation occurred more frequently in the ketamine-midazolam group. These findings were more pronounced in patients younger than 10 years. Parental and physician satisfaction remained high for all patients receiving intravenous ketamine sedation.

Are signs and symptoms associated with persistent corneal abrasions in children?

BACKGROUND: Corneal abrasions are common eye injuries in children. Most are treated with antibiotic drops or ointment, patching of the affected eye, and follow-up within 24 hours to confirm resolution by fluorescein examination. OBJECTIVE: To determine if signs and symptoms at follow-up were associated with the presence of a persistent corneal abrasion or abnormal visual acuity. DESIGN: Retrospective case series. SETTING: A children's hospital. PATIENTS: Children who were aged 4 years or older with the diagnosis of corneal abrasion between May 1992 and December 1996 and who had a follow-up examination. RESULTS: Seventy-seven patients (57% male) were enrolled (median age, 7 years). The respective sensitivities, specificities, positive predictive values, and negative predictive values of selective signs and symptoms for persistent abrasions were as follows: for pain, 53%, 93%, 80%, and 80%; for photophobia, 57%, 100%, 100%, and 80%; for redness, 100%, 46%, 44%, and 100%; for pain and redness, 40%, 96%, 80%, and 80%; and for at least 1 sign or symptom, 95%, 48%, 47%, and 95%. Twenty-six patients had persistent corneal abrasions at follow-up. Six of these 26 patients were symptom free at follow-up, and 15 patients had only redness as a persistent sign. Five patients had abnormal visual acuity, one of whom was asymptomatic. All 3 patients with complications were symptomatic. CONCLUSIONS: Signs and symptoms are inconsistently associated with persistent corneal abrasions. Asymptomatic patients may have persistent corneal abrasions, suggesting the need for selective follow-ups.

Post-varicella epiglottitis and necrotizing fasciitis.

Varicella is a nearly ubiquitous acquired childhood disease. Infectious complications of varicella can be life- or limb-threatening. These complications appear 3 to 4 days after the appearance of varicella exanthem and are heralded by fever, pain, and erythema of the overlying skin. Airway complications of varicella are rare, rapidly evolving, and, unfortunately, difficult to visualize. We report a child who presented with a unique combination of varicella-induced airway complications-acute epiglottitis and subsequent necrotizing fasciitis of the head and neck. varicella, epiglottitis, necrotizing fasciitis, group A beta-hemolytic streptococcus, nasopharyngoscopy.

Chest radiograph in the evaluation of first time wheezing episodes: review of current clinical practice and efficacy.

OBJECTIVE: To evaluate the current clinical use and utility of chest radiographs (CXR) in the workup of pediatric patients with first time wheezing (FTW) episodes. SETTING: Urban children's hospital. DESIGN: Retrospective review of medical records of patients seen in the emergency department in 1994 with disposition diagnoses of asthma or reactive airways disease, bronchiolitis, pneumonia, congenital heart disease, congestive heart failure, or foreign body aspiration to identify those patients presenting with FTW episodes. METHODS: Clinical findings in FTW were compared in patients receiving a CXR (121, 41%) and those who did not (177, 59%). Comparisons were made between patients with a clinically significant CXR (CXR-pos) (29, 24%) and those without (92, 76%). CXR-pos was defined as a CXR result which would be expected to alter patient management. Comparisons between groups were analyzed using the two-tailed Student's t test for continuous variables and the chi2 statistic for categorical data. The level of significance was determined at P < 0.05. RESULTS: Two hundred ninety-eight episodes of FTW were identified of 1984 patient charts reviewed. Patients receiving CXR differed from those who did not by being of a greater age (39 vs 20 months, P < 0.01), having lower pulse oximetry (89.7 vs. 92.7%, P < 0.01), being less likely to have a family history of asthma (47.5 vs 63.2%, P < 0.01), or history of atopy (40.6 vs 59.4%, P < 0.01). Those with localized wheezes (59.4 vs 40.6% P < 0.01), localized rales (59.3 vs 40.7 % P < 0.01), and localized decreased breath sounds (59.3 vs 40.7%, P = 0.01) were also more likely to receive a CXR. Among patients receiving CXR, clinical characteristics associated with CXR-pos were elevated temperature (37.9 vs 37.5 degrees C, P = 0.04), absence of family history of asthma 72.6 vs 27.4%, P < 0.01), and the presence of localized wheezes (76.0 vs 24.0%, P = 0.02), or localized rales (76.0 vs 24.0%, P < 0.01). CONCLUSIONS: Clinicians in this setting do not routinely obtain a CXR in patients with FTW episodes. Retrospective examination of clinician practice revealed several clinical characteristics that were associated with increased use of CXR in FTW. Increased utility of the CXR was associated with patients having elevated temperature, an absence of a family history of asthma, and localized wheezes or rales by ausculatory examination.

Activated protein C concentrate for the treatment of meningococcal endotoxin shock in rabbits.

To evaluate the effects of activated protein C therapy in a rabbit model of meningococcal endotoxin-induced shock, we performed a prospective, blinded, placebo-controlled animal trial. Forty New Zealand White rabbits were challenged with intravenous meningococcal endotoxin (lipooligosaccharide) 100 microg/kg. Ten minutes before endotoxin challenge, animals were administered either activated protein C 1600 microg/mL (n = 20) or an equal volume of saline (n = 20) as an initial bolus. After endotoxin challenge, activated protein C treated animals were administered a continuous infusion of activated protein C 160 microg/kg/h and saline-treated animals were administered an equal volume infusion of saline. Both activated protein C treated and saline control animals demonstrated evidence of shock after endotoxin challenge; mean arterial pressure and serum bicarbonate significantly (p < .01) declined, and heart rate significantly (p < .01) increased from baseline. In activated protein C treated animals, mean plasma activated protein C activity was 5.69 microg/mL (+/- 3.2) 1 h after challenge, whereas plasma protein C activity was not detected in controls. Mean prothrombin and activated partial thromboplastin times were significantly (p < or = .01) prolonged compared with saline-treated controls. Other hematologic and chemical measurements did not differ between groups. Fifteen of 20 (75%) animals treated with activated protein C concentrate survived to 24 h, while 9 of 20 (45%) control animals survived to 24 h (p = .05). Those animals treated with activated protein C had improved survival, which corroborates the findings of early clinical studies in which replacement of protein C improved outcome.

Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission.

OBJECTIVE: To determine if there is a difference between patients with bronchiolitis who are discharged from the emergency department (ED) but return requiring admission and those who do not return. DESIGN: Retrospective, case control study. SETTING: Tertiary care children's hospital emergency department. PARTICIPANTS: Fifty-seven study patients under one year of age with bronchiolitis seen from November 1991 to April 1993 who were discharged but returned requiring admission within 96 hours, and 124 controls, matched by diagnosis, who did not return. RESULTS: No differences were found between cases and controls in duration of illness (3.0 vs 3.7 days, P = 0.08), gestational age (39.3 vs 38.8 weeks, P = 0.32), chronologic age (20.9 vs 22.9 weeks, P = 0.31), respiratory rate (49.9 vs 48.0 respirations/ min, P = 0.18), presence of retractions (54.8 vs 54.4%, P = 0.97), oxygen saturation (SaO2; 97.6 vs 98.0%, P = 0.29), or number of nebulized beta-agonists administered in the ED (1.4 vs 1.2 P = 0.35). Cases had higher mean heart rates (HR) than controls (154.8 vs 148.8, P = 0.006). Patients with HR > 150 were more likely to return requiring admission (odds ratio = 2.45, 95% confidence intervals 1.2-4.9). However, only 36 of 57 patients who returned requiring admission had HR > 150 (sensitivity = 0.63), and 73 of 124 who did not return had HR < or = 150 (specificity = 0.59). None of the returns required admission to the intensive care unit, and their mean duration of admission was 59-hours. At the time of admission the cases had lower SaO2 (95.9 vs 97.7%, P = 0.001) and a higher frequency of retractions (83.3 vs 52.6%, P = 0.02) than when seen initially. CONCLUSIONS: Oxygen saturation and clinical assessment failed to differentiate between patients with bronchiolitis who returned requiring admission and patients who did not return.

Delayed incubation of blood culture bottles: effect on recovery rate of Streptococcus pneumoniae and Haemophilus influenzae type B.

This study investigated the effects of incubation delay on the rate of recovery of common pediatric pathogens from blood culture bottles. Known concentrations of Streptococcus pneumoniae and Haemophilus influenzae type b (three isolates each) were inoculated into BACTEC NR-6A bottles with 1.0 mL of donor blood. Bottles were subjected to a time delay (zero to six hours) before incubation. The BACTEC NR-660 was used for incubation and measurement of positive conversion. Data were analyzed using chi 2 analysis, Fisher's exact test, logistic regression, and multiple logistic regression, with P < 0.05 considered significant. Immediate incubation yielded positive blood cultures in 88 of 100 and 65 of 70 bottles containing S. pneumoniae and H. influenzae type b, respectively, in the concentration range 1.0 to 9.99 colony-forming units per milliliter (CFU/ml). For each organism, this was the minimal range required to produce a positive culture (P < 0.0001). Bottles inoculated with 1 ml of blood containing organisms in the range of 1.0 to 9.99 CFU/ml were then subjected to incubation delay. The recovery rate of S. pneumoniae significantly (P = 0.0003) decreased from a two-hour delay (57 of 60; 95%) to a three-hour delay (42 of 60; 70%). No significant change in recovery rate was seen in bottles inoculated with H. influenzae type b subjected to similar delays. Delayed incubation (two to six hours) of bottles inoculated with 1.0 ml of blood containing organisms in a concentration range of 1.0 to 9.99 CFU/ml of blood significantly decreases the recovery rate of S. pneumoniae but has no effect on H. influenzae type b.