National survey of institutional pediatric disaster preparedness.

OBJECTIVE: Describe institutional disaster preparations focusing upon the strategies to address pediatric patients in disaster preparedness. DESIGN: Descriptive study using survey methodology. SETTING: Hospitals that provide emergency care to pediatric patients throughout the United States. PARTICIPANTS: Survey responses were solicited from hospital personnel that are familiar with the disaster preparedness plan at their institution. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Describe how pediatric patients are included in institutional disaster preparedness plans. The presence of a pediatric-specific lead, policies and procedures, and geographic/demographic patterns are also a focus. RESULTS: The survey was distributed to 120 hospitals throughout the United States and responses were received from 29 states. Overall response rate was 58 percent, with 53 percent of the surveys fully completed. Sixty-three percent of hospitals had an individual responsible for pediatric-specific disaster planning and 78 percent specifically addressed the care of pediatric patients (<16 yo) in their disaster plan. The hospitals with an individual designated for pediatric disaster planning were more likely to have a disaster plan that specifically addresses the care of pediatric patients (90 percent vs 56 percent; p = 0.015), to represent children with special healthcare needs as simulated patients in disaster exercises (73 percent vs 22 percent; p = 0.003), and to include pediatric decontamination procedures in disaster exercises (78 percent vs 35 percent; p = 0.008) than hospitals without a designated pediatric disaster planner. CONCLUSION: The majority of hospitals surveyed incorporate pediatric patients into their disaster preparedness plan. Those hospitals with an individual designated for pediatric disaster planning were more likely to specifically address the care of pediatric patients in their institutional disaster plan.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Oral analgesia before pediatric ketamine sedation is not associated with an increased risk of emesis and other adverse events.

The objective of this study was to determine the association between recent administration of oral analgesics and frequency of adverse events during ketamine sedation in pediatric patients undergoing fracture reduction in the emergency department (ED). This retrospective study was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients aged

Amiodarone-an "old" drug with new recommendations.

Amiodarone has gained recognition as an antiarrhythmic medication after recent publication of the newly revised American Heart Association guidelines for pediatric resuscitation. Although support for the widespread use of amiodarone in adults has been supported by research, the few pediatric studies demonstrate limited efficacy and highlight the need for additional data. Because of the nature of the need for this type of resuscitation medication, controlled prospective studies will be difficult to obtain if not morally contraindicated. This article reviews the properties of amiodarone and the pertinent pediatric studies to provide healthcare providers supplemental information regarding amiodarone when choosing antiarrhythmics for acute resuscitation. Individual providers need to discern whether the pediatric data available supports widespread acceptance into current treatment regimens.