Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018.

BACKGROUND: Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS: A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS: Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS: The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

A comparative study of propofol alone and propofol combined with midazolam for dental treatments in special needs patients.

ABSTRACT: Although dental treatment with sedation is performed increasingly in special needs patients, data on adding midazolam to intravenous propofol sedation are very limited for this group. The purpose of this study was to identify the factors and procedure time associated with the use of intravenous sedation with propofol alone or propofol combined with midazolam in dental patients with special needs.This was a retrospective data analysis. The sedation medications and relevant covariates, including demographic parameters, disability levels, oral health conditions, dental procedures, treatment time, and side effects, of 718 patients with special needs were collected between April 2013 and September 2014. The unfavorable side effects by sedation types were reported. Factors associated with procedure time and the sedation medications were assessed with multiple logistic regression analyses.Of 718 patients, 8 patients experienced unfavorable side effects (vomiting, sleepiness, or emotional disturbance) after the dental procedures; the rate was 0.6% in the 509 patients who received propofol only. In 209 patients who received propofol and midazolam, 2.4% experienced the side effects. Sedation time was associated with body mass index (BMI) < 25 (adjusted odds ratio [aOR] = 1.45, 95% confidence interval [CI]: 1.04-2.04) and the performance of multiple dental procedures (aOR = 1.44, 95% CI: 1.06-1.97) but not associated with the sedation types. A significant odds ratio for the combined use of propofol and midazolam was shown for adolescents (aOR = 2.22, 95% CI: 1.28-3.86), men (aOR = 2.05, 95% CI: 1.41-2.98), patients with cognitive impairment (aOR = 1.99, 95% CI: 1.21-3.29), and patients undergoing scaling procedures (aOR = 1.64, 95% CI: 1.13-2.39).With the acceptable side effects of the use of propofol alone and propofol combined with midazolam, multiple dental procedures increase the sedation time and the factors associated with the combined use of propofol and midazolam are younger age, male sex, recognition problems, and the type dental procedure in the dental treatment of patients with special needs.

Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City.

OBJECTIVE: Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN: Review of prospectively collected data. METHODS: Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS: One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION: Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2849-E2856, 2021.

Impact of young age on outcomes of emergency department procedural sedation.

OBJECTIVES: Relatively little is known about outcomes of procedural sedation in very young children. Our objective was to examine the association between procedural sedation in young children (≤ 2 years) and the incidence of sedation-related adverse events. METHODS: This is a secondary analysis of a prospective cohort study of children 0 to 18 years undergoing parenteral procedural sedation in six Canadian pediatric emergency departments (ED). The primary risk factor was age ≤ 2 years. Secondary risk factors were sex, procedure type, pre-procedure and sedation medications. The outcomes examined were: serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting. RESULTS: Of the 6295 patients included, 946 (15%) were ≤2 years. Children 13-24 months comprised 90% of the young age group. Children ≤ 2 years were sedated most commonly for laceration repair (n = 450; 47.6%), while orthopedic reduction was most common in children > 2 (n = 3983; 74.5%). Ketamine was the most common medication in both groups, but was used more frequently in children ≤ 2 years (80.9% vs 58.9%; p < 0.001). There was no difference in the odds of SAE (OR 0.83, 95% Confidence Interval (CI) 0.4 to 1.9), significant intervention (OR 0.82, 95% CI 0.4 to 1.7) or oxygen desaturation (OR 0.95, 95% CI 0.7 to 1.3) between age groups, however children ≤ 2 years vomited less frequently (OR 0.24, 95% CI 0.1 to 0.6). CONCLUSIONS: Young age, specifically between 13 and 24 months, was not associated with a significant difference in the incidence of adverse events.

Variability of Dosing and Number of Medications Needed to Achieve Adequate Sedation in Mechanically Ventilated Pediatric Intensive Care Patients.

Children admitted to the pediatric intensive care unit (PICU) often require multiple medications to achieve comfort and sedation. Although starting doses are available, these medications are typically titrated to the desired effect. Both oversedation and undersedation are associated with adverse events. The aim of this retrospective study was to evaluate cumulative medication burden necessary to achieve comfort in patients in the PICU and determine relevant predictors of medication needs. In order to account for all of the sedative medications, z-scores were used to assess the population average dose of each medication and compare each patient day to this population average. Sedation regimens for 130 patients in the PICU were evaluated. Mean overall infusion rates of fentanyl, morphine, and hydromorphone were 1.67 ± 0.81 µg/kg/hour, 0.12 ± 0.08 mg/kg/hour, and 17.84 ± 13.4 µg/kg/hour, respectively. The mean infusion rate of dexmedetomidine was 0.59 ± 0.28 µg/kg/hour, and midazolam was 0.14 ± 0.1 mg/kg/hour. Summation z-sores were used to rank the amount of sedation medication needed to achieve comfort for each individual patient for his/her PICU stay in relation to the entire sample. Patient age, weight, and length of mechanical ventilation were all significant predictors of sedation requirement. This study will provide data necessary to develop a model of cumulative medication burden needed to achieve appropriate sedation in this population. This descriptive model in appropriately ranking patients based on sedative needs is the first step in exploring potential genetic factors that may provide an insight into homing in on the appropriate sedation regimen.

Determination of the ED95 of a single bolus dose of dexmedetomidine for adequate sedation in obese or nonobese children and adolescents.

BACKGROUND: With the increasing prevalence of children who are overweight and with obesity, anaesthesiologists must determine the optimal dosing of medications given the altered pharmacokinetics and pharmacodynamics in this population. We therefore determined the single dose of dexmedetomidine that provided sufficient sedation in 95% (ED95) of children with and without obesity as measured by a minimum Ramsay sedation score (RSS) of 4. METHODS: Forty children with obesity (BMI >95th percentile for age and gender) and 40 children with normal weight (BMI 25th-84th percentile), aged 3-17 yr, ASA physical status 1-2, undergoing elective surgery, were recruited. The biased coin design was used to determine the target dose. Positive responses were defined as achievement of adequate sedation (RSS ≥4). The initial dose for both groups was dexmedetomidine 0.3 µg kg-1 i.v. infusion for 10 min. An increment or decrement of 0.1 µg kg-1 was used depending on the responses. Isotonic regression and bootstrapping methods were used to determine the ED95 and 95% confidence intervals (CIs), respectively. RESULTS: The ED95 of dexmedetomidine for adequate sedation in children with obesity was 0.75 µg kg-1 with 95% CI of 0.638-0.780 µg kg-1, overlapping the CI of the ED95 estimate of 0.74 µg kg-1 (95% CI: 0.598-0.779 µg kg-1) for their normal-weight peers. CONCLUSIONS: The ED95 values of dexmedetomidine administered over 10 min were 0.75 and 0.74 µg kg-1 in paediatric subjects with and without obesity, respectively, based on total body weight. CLINICAL TRIAL REGISTRATION: ChiCTR1800014266.

[Palliative Sedation at the End of Life: A Comparative Study of Chronic Obstructive Pulmonary Disease and Lung Cancer Patients].

BACKGROUND: Although patients with chronic obstructive pulmonary disease (COPD) receive poor-quality palliative care, information about the use of palliative sedation (PS) in the last days of life is very scarce. OBJECTIVES: To compare the use of PS in hospitalized patients who died from COPD or lung cancer and identify factors correlating with PS application. METHODS: In a retrospective observational cohort study, from 1,675 patients died at a teaching hospital between 2013 and 2015, 109 patients who died from COPD and 85 from lung cancer were compared. Sociodemographic data, clinical characteristics, health care resource utilization, application of PS and prescribed drugs were recorded. RESULTS: In the last 6 months of life, patients who died from COPD had more hospital admissions due to respiratory causes and less frequent support by a palliative home care team (PHCT). Meanwhile, during their last hospitalization, patients who died from COPD had fewer do-not-resuscitate orders and were subjected to more intensive care unit admissions and cardiopulmonary resuscitation maneuvers. PS was applied less frequently in patients who died from COPD than in those who died from lung cancer (31 vs. 53%, p = 0.002). Overall, previous use of opioid drugs, support by a PHCT, and a diagnosis of COPD (adjusted odds ratio 0.48, 95% CI: 0.26-0.89, p = 0.020) were retained as factors independently related to PS. In COPD patients, only previous use of opioid drugs was identified as a PS-related factor. CONCLUSION: During their last days of life, hospitalized COPD patients receive PS less frequently than patients with lung cancer.

Does postoperative non-sedation improve outcomes for patients after head and neck cancer reconstruction?: A STROBE compliant study.

Whether a strategy of postoperative non-sedation produces better outcomes compared with sedation in patients after head and neck reconstruction remains controversial. Therefore, we retrospectively investigated outcomes in 150 of these patients in our institution.Patients with head and neck cancer that received free anterolateral thigh flap were studied retrospectively, and were categorized in terms of their postoperative care into "sedation" and "non-sedation" groups. The related parameters of each patient were collected for analysis.Overall, 150 patients were included (sedation protocol (N = 56) and non-sedation strategy (N = 94)). No significant differences were observed between groups in patient demographics or postoperative outcomes. Significantly shorter durations of mean and median intensive care unit (ICU) length of stay, mechanical ventilation, hospitalization, and operative time were observed in the non-sedation group than in the sedation group. Among all patients, the sedation and flap reopen were the common variables related to prolonged ICU stay, mechanical ventilator duration, and hospitalization.The current study suggested the strategy of postoperative non-sedation is associated with a significant decrease in the duration of mechanical ventilation, ICU length of stay, hospitalization. Regardless of hospital stay, there were no differences in postoperative outcome between 2 groups.

Professional dental cleaning in dogs: clinical routines among Swedish veterinarians and veterinary nurses.

BACKGROUND: Dental disease is very common in dogs and veterinary professional dental cleaning and examination, together with daily dental home care, is the foundation for good dental health. To our knowledge, no previous study has investigated professional dental cleaning routines in small animal veterinary practice. A validated questionnaire survey was distributed to all veterinarians and veterinary nurses with registered e-mail addresses in the Swedish national registry (veterinarians; n = 3657, veterinary nurses; n = 1650). Response rates were 32% for veterinarians (V) and 38% for veterinary nurses (VN). RESULTS: In total, 73% (V)/96% (VN) of respondents reported that professional dental cleaning was performed at their work place under general anesthesia, and 27% (V)/18% (VN) that dental cleaning was performed under sedation. Of the respondents, 43% (V)/96% (VN) considered regular dental cleaning under general anesthesia fairly or very important, and 49% (V)/47% (VN) stated that it was sometimes important for good dental health in dogs. A majority of respondents, 84% (V)/97% (VN), reported that dental extractions were performed at their clinic, and 72% (V)/90% (VN) had access to dental radiography equipment. CONCLUSION: A majority of Swedish veterinarians and veterinary nurses perform professional dental cleaning under general anesthesia with access to dental radiography equipment, in accordance with national and international recommendations. However, a considerable proportion of professional dental cleanings were performed under sedation only, and extractions performed without access to dental radiography equipment were common, suggesting several areas of improvement in the routines in Swedish veterinary clinics and hospitals. Our results clearly indicate the need for improved educational efforts to increase the awareness among veterinary health professionals regarding guidelines and official recommendations in canine dental care.

Unsedated Colonoscopy: Impact on Quality Indicators.

BACKGROUND: In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce. AIMS: To determine patient characteristics associated with undergoing unsedated colonoscopy and whether adenoma detection rate (ADR) and cecal intubation rate (CIR) differ between sedated and unsedated colonoscopy. METHODS: Using a single-center electronic endoscopy database, we identified patients who underwent outpatient colonoscopy between 2011 and 2018 with or without sedation. We used multivariable logistic regression to determine factors associated with unsedated colonoscopy, CIR, and ADR. RESULTS: We identified 24,795 patients who underwent colonoscopy during the study period. Of these, 179 patients (0.7%) underwent unsedated colonoscopy. ADR was 27.4% in sedated and 21.2% in unsedated colonoscopies (p = 0.06); CIR was 95.8% in sedated and 85.5% in unsedated patients (p < 0.01). On multivariable analysis, male sex (OR 2.06, CI 1.52-2.79) and suboptimal bowel preparation (OR 1.75, CI 1.24-2.45) were associated with undergoing unsedated colonoscopy, while higher BMI was inversely associated with unsedated colonoscopy (BMI 25-29.9: OR 0.44, CI 0.25-0.77). On multivariable analysis, colonoscopy with sedation was associated with CIR (OR 3.79, CI 2.39-6.00) and ADR (OR 1.45, OR 1.00-2.10). CONCLUSION: We found that undergoing outpatient colonoscopy with sedation as opposed to no sedation was significantly associated with a higher CIR and ADR. Our findings suggest sedation is necessary to meet current CIR and ADR guidelines; however, given the potential cost and safety benefits of unsedated colonoscopy, further investigation into methods to improve patient selection and colonoscopy quality indicators is warranted.

General Anesthesia or Conscious Sedation for Transfemoral Aortic Valve Replacement with the SAPIEN 3 Transcatheter Heart Valve.

Differences in the benefits of conscious sedation (CS) and general anesthesia (GA) during transfemoral aortic valve implantation (TAVI) are unclear.We aimed to assess differences in procedural and clinical outcomes based on the type of anesthesia received during TAVI.We analyzed SOURCE 3 Registry data for patients who received the SAPIEN 3 valve by type of anesthesia used during TAVI.Of the 1694 TAVI patients, 1027 received CS and 667 received GA. Patients were similar at baseline (81.5 years; Society of Thoracic Surgeons risk score 7.0). Compared with the GA group, the CS group had fewer intra-procedural transesophageal echocardiography (TEE) and post implantation dilatations performed, and less contrast medium was used. The CS group had significantly less kidney injury at 7 days post-procedure than the GA group (0.4% versus 1.5%, P = 0.014). Moderate paravalvular leaks (PVL) occurred more frequently in the CS group versus the GA group (2.2% versus 0.8%; P = 0.041). No severe PVL were reported. Median total hospital length of stay (LOS) after TAVI was 10 days in the CS group and 11 days in the GS group. At 30 days, all-cause death was 2.1% in CS and 1.7% in GS (P = 0.47), and myocardial infarction was 0.2% in CS and 0.1% in GS (P = 0.83).Our analyses found no significant major outcome differences between CS and GA during TAVI.

Pain perception during colonoscopy in relation to gender and equipment: a clinical study.

Objectives A trend for gender-related differences in pain perception during colonoscopies has previously been observed. No consecutive clinical studies have been conducted to confirm such a relation. We aimed to investigate gender-related differences during the colonoscopy procedure, and the impact of endoscopic equipment and psychological factors on pain management. Methods In a consecutive clinical study, 391 patients referred for colonoscopy reported pain perception on a 0-10 visual analogue scale (VAS) after the procedure. A sub-group of patients (n=38) were given alternate instructions expertly tailored by a psychologist and their VAS scores were compared with those from the main study population. Data from a previous study from the same specialist practice and same source patient population using previous-generation equipment was included for comparison. Results No overall gender-related difference in VAS reports was found. There was no reduction in VAS when alternate instructions were given. Female patients were, however, more likely to benefit from light sedation (p=0.012). When compared with previous-generation endoscopes, the current generation equipment resulted in a VAS drop of 1.9 points for women and 1.6 for men (p<0.009) and washed out a previously observed gender-related difference. Conclusion No overall gender-related differences were found for pain experience during the colonoscopy procedure. Access to up-to-date endoscopic equipment can reduce procedure-related patient discomfort considerably, even at the expert level of a consultant physician. Implications Gastroenterologists should consider utilizing high-end endoscopic equipment to improve pain management and reduce VAS to very acceptable levels.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures.

PURPOSE: Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial. METHODS: Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated. RESULTS: A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation. CONCLUSIONS: The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia.

BACKGROUND: Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES: To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS: A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS: All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION: Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.

Is Additional Nebulized Lidocaine Helpful in Flexible Bronchoscopy?: A Meta-Analysis.

BACKGROUND: Conflicting evidence of nebulized lidocaine use in bronchoscopy still exist. This study will identify whether there is any difference in various patient-related, physician-related, or procedure-related outcomes with and without lidocaine nebulization before the procedure. METHOD: The authors performed a search in 4 electronic databases, including Pubmed, Scopus, Virtual Health Library, and Google Scholar from inception to August 2019. Data on patient-reported and physician-reported outcomes, doses of sedation, and lidocaine were extracted and pooled into standardized mean difference (SMD) and mean difference (MD) using the random-effect model. RESULTS: Seven randomized controlled trials with 1366 patients were included. Cough was not different between the nebulized lidocaine group and no nebulized lidocaine group (SMD, -0.12; 95% confidence interval, -0.82 to 0.59; I, 95%; P=0.75), so as operator's satisfaction score, ease of the procedure, patient's discomfort, and unwillingness to repeat the procedure. Additional nebulized lidocaine group required higher lidocaine dose (MD, 81.93; 95% confidence interval, 17.14-146.71). Studies using only local anesthesia favored the "no additional lidocaine" group in improving cough, operator's satisfaction score, and ease of the procedure. Subgroup analysis of studies using moderate sedation showed a decrease in midazolam dose and duration of the procedure in the "additional nebulized lidocaine group." CONCLUSION: Additional administration of nebulized lidocaine increased the total dose of lidocaine used and did not improve cough symptoms, operator-satisfaction score, ease of the procedure, and willingness to repeat the procedure. Subgroup analysis of studies using moderate sedation showed a decrease in midazolam use and in procedure duration but the clinical significance of these findings is uncertain.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.