Pediatric Procedural Sedation in the Emergency Setting.

BACKGROUND: Pediatric emergency department (ED) visits are common. Many are due to injury, which require procedural treatments with sedation. There are many well researched independent predictors of adverse events for pediatric procedural sedation. The duration of sedation as a predictor of adverse events has not been well studied. This study aims to determine the complication rate and severity of procedural sedation as well as determine if the duration of sedation is correlated with an increased risk of complications. METHODS: After Institutional Review Board approval, a retrospective study was performed on all patients seen at Helen Devos Children's ED who received sedation from August 1, 2011, to August 15, 2016. Study variables included age, weight, type of procedure, American Society of Anesthesiologist (ASA) physical status class, Mallampati score, comorbidities, sedation medication, sedation time, and complication. A logistic regression was performed assessing risk factors for complications. Statistical significance was assessed at P < 0.05. RESULTS: There were 1,814 patients included in the study. Median sedation time was 20 minutes. There were 70 (3.9%) total complications. Controlling for age, weight, comorbidities, ASA class, Mallampati score, and total sedation medication, sedation time was a significant predictor of a complication (odds ratio: 1.021; 95% CI, 1.004-1.039). CONCLUSIONS: Pediatric patients can safely undergo procedural sedation in the ED. This study demonstrates a high safety profile for long procedural sedations with slight increases in risk as sedation time increases. There is no identifiable time where the duration of sedation significantly increases the risk of complication.

Diazepam Premedication in Primary Augmentation Mammoplasty.

Goals/Purpose: To evaluate the effects of preoperative oral diazepam on the postoperative course of patients undergoing primary augmentation mammoplasty in an outpatient surgical center. Methods/Technique: A retrospective review was conducted of 189 patients undergoing primary breast augmentation at an outpatient surgical center from 2012 to 2015. Patients receiving same-day premedication with oral diazepam were compared with a control group without premedication. Patients with combined surgical procedures were excluded with the exception of minor, superficial procedures. Patient demographics, perioperative medication use, operative details, and postoperative numeric pain scale (0-10) scores were collected. Results/Complications: Ninety-three patients (49%) were included in the premedication group and 96 (51%) in the control group. Difference in age, body mass index, implant size, and intraoperative opioid use were not statistically significantly different between the treatment and control groups (P > .05). No difference was noted in postoperative nausea, emesis, or antiemetic use between the 2 groups. The operative time was slightly longer in the control group (64.5 minutes vs 58.5 minutes, P = .006). Immediate postoperative pain (3.6 vs 4.4) and time to discharge (101 minutes vs 110 minutes) were slightly decreased in the premedication group; however, these values did not reach statistical significance. Intraoperative narcotic use was the same between groups, but postoperative narcotic pain medication use was higher in the premedication group (9.68 mg vs 8.26 mg, P = .036). Predischarge pain scores (2.87 vs 2.29, P = .006) were also noted to be slightly higher in the premedication group. Conclusions: Preoperative diazepam administration does not significantly decrease time to discharge in primary breast augmentation mammoplasty. Furthermore, its use may result in increased postoperative narcotic use and higher pain scores at the time of discharge.

Tourniquet Use in Wide-Awake Carpal Tunnel Release.

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Advances in addressing full-thickness skin defects: a review of dermal and epidermal substitutes.

full-thickness skin defects remain a reconstructive challenge. Novel regenerative modalities can aid in addressing these defects. A literature review of currently available dermal and epidermal regenerates was performed. The mechanism and application for each skin substitute was analyzed to provide a guide for these modalities. Available epidermal substitutes include autografts and allografts and may be cultured or noncultured. Dermal regenerate templates exist in biologic and synthetic varieties that differ in the source animal and processing. Epidermal and dermal skin substitutes are promising adjunctive tools for addressing certain soft tissue defects and have improved outcomes in reconstructive procedures. The following article provides a comprehensive review of the biologic materials available and the types of complex wounds amenable to their use.