Safety of ketamine for reducing fractures in a pediatric emergency department. / Seguridad del uso de ketamina para reducir fracturas en un servicio de urgencias pediátrico.

OBJECTIVES: Ketamine is one of the most widely used drugs for analgesia and sedation when reducing fractures in pediatric emergency departments (EDs). We aimed to analyze the safety of intravenous (IV) ketamine when administered by physicians who are not anesthesiologists. MATERIAL AND METHODS: Prospective observational study of adverse events (AEs) related to pediatric ED specialists' use of analgesia and sedation when reducing fractures in children under the age of 14 years between 2011 and 2019. Multivariate analysis was used to identify independent risk factors for AEs. RESULTS: We analyzed 1509 cases of IV ketamine administration for analgesia and sedation. The median age of patients was 8 years (interquartile range, 5-11 years). All had American Society of Anesthesiologists risk classifications of 1 or 2 and Mallampati scores of I or II. Prior to the procedure, 937 children (62.1%) had been administered an opioid analgesic. AEs were observed in 201 children (13.3%; 95% CI, 11.7%-15.1%); 71 experienced respiratory complications (4.7%; 95% CI, 3.2%-5.3%). No child required intubation, other advanced resuscitation maneuvers, or hospital admission because of a ketamine-related AE. Age was the only independent risk factor for developing an AE. The odds ratio (OR) for any type of AE in children aged 8 years or older was 1.9 (95% CI, 1.4-2.6). The OR for respiratory AEs in children aged 6 years or older was 2.6 (95% CI, 1.3-5.6). Opioid administration did not increase risk for AEs. CONCLUSION: Pediatric emergency physicians who are not anesthesiologists can safely administer IV ketamine for reducing fractures. Prior use of opioids is not associated with greater risk for respiratory AEs after ketamine use.

OBJETIVO: La ketamina es uno de los fármacos más utilizados para reducir fracturas en los servicios de urgencias de pediatría (SUP). Se analiza la seguridad de ketamina por médicos no anestesistas en reducciones de fracturas en un SUP. METODO: Estudio prospectivo observacional sobre los efectos adversos (EA) relacionados con procedimientos de analgesia y sedación (PAS) realizados por pediatras de urgencias para reducir fracturas en menores de 14 años en un SUP entre 2011 y 2019. Se realizó un análisis multivariante para identificar factores de riesgo independientes de EA. RESULTADOS: Se analizaron 1.509 PAS con ketamina intravenosa (iv). La mediana de edad fue de 8 años (RIC 5-11), todos con una clasificación American Academy of Anesthesiologists (ASA) I o II y Mallampati I o II. Previo al procedimiento, 937 (62,1%), recibieron opioides. Se registraron EA en 201 (13,3%; IC 95%: 11,7-15,1), 71 respiratorios (4,7%; IC 95%: 3,2-5,3). Ningún niño requirió intubación, otras maniobras de reanimación avanzada o ingreso por un problema secundario al PAS. La edad fue el único factor de riesgo independiente para presentar tanto EA de manera global ( 8 años OR 1,9; IC 95%: 1,4-2,6) como respiratorios ( 6 años OR 2,6; IC 95%: 1,3-5,6). La administración de opioide no se relacionó con mayor riesgo de presentar tanto EA de manera global como respiratorios. CONCLUSIONES: Los PAS con ketamina iv realizados por médicos no anestesistas para reduccir fracturas en urgencias en niños son seguros. La administración previa de opioides no se asocia a mayor riesgo de EA respiratorios.

Secondary Immunosuppression in Pediatric Kidney Transplant Recipients.

OBJECTIVES: Currentimmunosuppressive treatments for kidney transplant recipients have improved graft viability at the expense of impaired immune surveillance. The tools for monitoring immune status in pediatric kidney transplant recipients have not been widely investigated. Better knowledge could help recognize over immunosuppression and allow implementation of individualized preventive strategies. MATERIALS AND METHODS: This retrospective and observational study included 28 pediatric kidney transplant recipients treated at a tertiary hospital. We measured peripheral blood lymphocyte subpopulations, immunoglobulins, immunosuppressivedrug levels, and viral loads. Reference analytical values for different age ranges were used to determine immune status. We recorded overall hospitalizations due to opportunistic infections and positive viral loads posttransplant. RESULTS: We found hypogammaglobulinemia and lymphopenia in 19% and 41% of the patients, respectively. Peripheral blood lymphocyte subpopulations were below normal limits in one-third of the sample. These parameters were not related to the current number or plasma levels of immunosuppressive drugs. During follow-up, cytomegalovirus, Epstein-Barr virus, and BK virus viremias were detected in 60.7% of the patients. Admissions due to opportunistic infections happened in 57.1%, mainly related to severe viral disease (30%) or gastrointestinal infections (26.7%). Most occurred in younger transplant recipients and during the first 2 years posttransplant (73.3%). We found no significant relation between peripheral blood lymphocyte subpopulations and hospital admissions for opportunistic infections or positive viral loads during follow-up. CONCLUSIONS: Recurrent hospitalizations for opportunistic infections and analytical disorders in the immune system suggested that secondary immunosuppression in pediatric kidney transplant recipients was frequent. Immunosuppression was not directly related to plasma drug levels or the number of immunosuppressive drugs. Thus, immune monitoring might be helpful in combination with immunosuppressant levels to assess immunosuppression status and to establish individualized preventive measures.