Length Of Sedation Research Articles

Safety and Depth of Sedation With Ketamine Alone Versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review.

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. There was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.

Nasal/orotracheal tube switch to reduce length of mechanical ventilation in neurocritical patients: A propensity score matched analysis.

Nasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation. The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients. We conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit. A total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay. In critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

Management of Dog Bite Injuries: Procedural Sedation, Infection, and Operative Indications at a Single-Institution Level I Pediatric Trauma Hospital.

Dog bite injuries are common within the pediatric population. Currently, there are inconclusive data on best sedation practice, antibiotic regimen, and need for plastic surgery referrals for treatment of dog bite injuries in the emergency department (ED) versus operating room (OR). This study set out to determine sedation practice, infection management, and necessity for plastic surgery referral at a level I pediatric trauma center. A retrospective review of all pediatric (0-18 years old) dog bites documented in electronic medical records from January 1, 2010, to December 31, 2019, was performed. Bitten by dog encounters were identified by International Classification of Diseases, Ninth Revision and Tenth Revision codes E906.0 and W54.0, W54.0XXA, and W54, respectively. Data gathered included age, gender, month of injury, circumstance of injury, injury characteristics, location of repair, person performing repair, sedation (if used, then length of sedation), inpatient admission, antibiotics prescribed, dog characteristics (breed, size, sex, age, relationship to patient), and complications. Summary statistics were calculated as mean ± SD. Comparisons for nominal variables were performed using the χ2 test. All analyses were performed using Stata v.16. 1. A total of 1438 pediatric patients were included in this study over a 10-year period. Of injuries requiring repair (n = 846), most repairs were performed in the ED (97.1% [822/846]), whereas 24 (2.8%) required repair in the OR. Of the bites that required repair (n = 846), 81.1% (686/846) were performed by an emergency medicine physician and 147 (17.4%) by plastic surgeons. Procedural sedation in the ED was performed in 146 repairs (17.3%). Documented sedation time ranged from 10 to 96 minutes. Most patients received a prescription for antibiotics (80.5%), usually amoxicillin/clavulanate (90.8%). Infection was the most common sequela (9.5%). There was no significant difference in infection rates between repairs performed in the ED versus those in the OR. Our study indicates that pediatric patient dog bite injuries can be successfully managed in an ED. Procedural sedation has demonstrated no increased safety risks compared with the OR. Rates of infection are also not demonstrated to be significantly higher in repairs done in the ED versus those taken to operating theater.

Safety and efficacy of target controlled infusion administration of propofol and remifentanil for moderate sedation in non-hospital dental practice.

Fearful and anxious patients who find dental treatment intolerable without sedative and analgesic support may benefit from moderate sedation. Target controlled infusion (TCI) pumps are superior to bolus injection in maintaining low plasma and effect-site concentration variability, resulting in stable, steady-state drug concentrations. We evaluated the safety and efficacy of moderate sedation with remifentanil and propofol using TCI pumps in non-hospital dental settings. A prospective chart review was conducted on 101 patients sedated with propofol and remifentanil using TCI pumps. The charts were completed at two oral surgeons and one general dentist's office over 6 months. Hypoxia, hypotension, bradycardia, and over-sedation were considered adverse events and were collected using Tracking and Reporting Outcomes of Procedural Sedation (TROOPS). Furthermore, patient recovery time, sedation length, drug dose, and patient satisfaction questionnaires were used to measure sedation effectiveness. Of the 101 reviewed sedation charts, 54 were of men, and 47 were of women. The mean age of the patients was 40.5 ±18.7 years, and their mean BMI was 25.6 ± 4.4. The patients did not experience hypoxia, bradycardia, and hypotension during the 4694 min of sedation. The average minimum Mean Arterial Pressure (MAP) and heartbeats were 75.1 mmHg and 60.4 bpm, respectively. 98% of patients agreed that the sedation technique met their needs in reducing their anxiety, and 99% agreed that they were satisfied with the sedation 24 hours later. The average sedation time was 46.9 ± 55.6 min, and the average recovery time was 12.4 ± 4.4 min. Remifentanil and propofol had mean initial effect-site concentration doses of 0.96 µ/ml and 1.0 ng/ml respectively. The overall total amount of drug administered was significantly higher in longer sedation procedures compared to shorter ones, while the infusion rate decreased as the procedural stimulus decreased. According to the results of this study, no patients experienced adverse events during sedation, and all patients were kept at a moderate sedation level for a wide range of sedation times and differing procedures. The results showed that TCI pumps are safe and effective for administering propofol and remifentanil for moderate sedation in dentistry.

Sustitución del tubo nasal/orotraqueal para reducir la duración de la ventilación mecánica en pacientes neurocríticos: análisis de emparejamiento por puntuación de propensión

Introduction and objectivesNasotracheal intubation was advocated to increase patients comfort and tube tolerance, but no study showed a clear benefit of nasotracheal intubation over orotracheal intubation. Neurocritically ill patients are a fragile group with specific requirements regarding ventilation and sedation.The aim of this study was to evaluate whether nasotracheal intubation might reduce length of mechanical ventilation in neurocritically ill patients. Materials and methodsWe conducted a retrospective cohort study with propensity matched analysis including all patients who underwent prolonged mechanical ventilation in the neurocritical Intensive Care Unit. ResultsA total of 4030 patients were admitted during the period of interest and 312 entered the final analysis. Propensity score analysis identified 74 matched couples. Length of mechanical ventilation in patients who underwent early nasotracheal intubation resulted to be statistically significantly shorter than patients who underwent orotracheal intubation. Accordingly, length of sedation was significantly lower in patients with nasotracheal intubation, while no difference in complications occurred with similar length of stay. ConclusionsIn critical care units using nasotracheal intubation in the standard management of patients, the nasotracheal route was associated with lesser need for sedatives leading to shorter mechanical ventilation in neurocritical patients. However, causality has to be proven by future randomized controlled trials.

360 Safety and Depth of Sedation With Ketamine Alone versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). While orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single Level 1 Trauma center over a two-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. There was a statistically significant increase in the occurrence of hypoxia with co-administration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with co-administration of benzodiazepines by approximately 4.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO2 measurements, administration of positive pressure ventilation (PPV), vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with co-administration of midazolam, and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was co-administered. Information on the orthopedic reduction and provider satisfaction was not collected.

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department.

Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status. The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions. Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n=671 [25%]), had procedural sedation not within the ASA guidelines (n=555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n=1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events. There was a significant difference in the length of stay and time from admission to sedation-both approximately 80min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p<0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n=17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups. Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

Evaluation of Postnatal Sedation in Full-Term Infants.

Prolonged sedation in infants leads to a high incidence of physical dependence. We inquired: (1) “How long does it take to develop physical dependence to sedation in previously naïve full-term infants without known history of neurologic impairment?” and (2) “What is the relationship between length of sedation to length of weaning and hospital stay?”. The retrospective study included full-term patients over a period of one year that were <1 year of age and received opioids and benzodiazepines >72 hours. Quantification of fentanyl, morphine, and midazolam were compared among three time periods: <5 days, 5–30 days, and >30 days using t-test or one-way analysis of variance. Identified full-term infants were categorized into surgical (14/44) or medical (10/44) groups, while those with neurological involvement (20/44) were excluded. Physical dependence in full-term infants occurred following sedation ≥5 days. Infants with surgical disease received escalating doses of morphine and midazolam when administered >30 days. A positive association between length of sedation and weaning period was found for both respiratory (p < 0.01) and surgical disease (p = 0.012) groups, while length of sedation is related to hospital stay for the respiratory (p < 0.01) but not the surgical disease group (p = 0.1). Future pharmacological directions should lead to standardized sedation protocols and evaluate patient neurocognitive outcomes.

Factors associated with anxiety in critically ill patients: A prospective observational cohort study

BackgroundAnxiety is an unpleasant emotion that most intensive care patients experience. This emotion is an important issue in intensive care settings because of its prevalence, adverse effects and severity. Little is known about the factors associated with state and trait anxiety during critical illness. ObjectivesTo describe the patterns of state anxiety reported by intensive care patients, and identify factors associated with state and trait anxiety. DesignProspective observational cohort study. SettingsOne mixed intensive care unit in Brisbane, Australia. ParticipantsAdults (n=141, ≥18 years) admitted to the intensive care unit for ≥24h; able to communicate verbally or non-verbally; understand English; and, open their eyes spontaneously or in response to voice. MethodsOutcomes were state anxiety as measured by the Faces Anxiety Scale and trait anxiety as measured by the State-Trait Anxiety Inventory. Pre-intensive care factors tested for possible associations with both state and trait anxiety were: age, gender, marital status, employment status, level of education, smoking status, personality trait of optimism and evidence of mental health care/treatment. Intra-intensive care factors tested were: reason for admission to the intensive care unit, delirium, pain, airway status, hours of mechanical ventilation, severity of illness, days of stay in intensive care, exposure to corticosteroids, opioids, benzodiazepines, anxiolytics, antidepressants, beta-blockers, anaesthetic agents and analgesics; length of sedation and analgesia and total doses of sedatives and analgesics. ResultsOf 141 participants, 98 (70%) were male with an average age of 54 (standard deviation: ±15) years and stayed in intensive care for about 4 (Interquartile Range: 3–7) days. The majority (n=115; 82%) of participants experienced state anxiety at least once during their stay in intensive care, with 57% reporting moderate to severe levels. Factors related to state anxiety in intensive care were pain and trait anxiety. Factors associated with trait anxiety were trait optimism, state anxiety, evidence of mental health care/treatment and age. ConclusionsThis study provides a better understanding of contributing factors for anxiety in the critically ill. Trait anxiety and state anxiety were significantly associated with each other, namely, patients who were anxious by nature experienced higher levels of state anxiety, which persisted throughout their stay in the intensive care unit. Recognising the importance of state and trait anxiety assessments using validated tools and determining ways to manage anxiety in the critically ill are critical aspects of the intensive care nurses role.

EFFECT OF REPEATED INTRAVENOUS ADMINISTRATION OF XYLAZINE ON SEDATION, ANALGESIA AND ECG PARAMETERS IN DONKEYS (EQUUS ASINUS)

Xylazine Hcl was generally used in veterinary medicine for its sedative and moderate analgesic effect. This experimental study was undertaken to determine the effect of repeated intravenous (IV) administration of xylazine on sedation and analgesia as well as cardiac arrhythmia using ECG in donkeys. Three repeated injections of xylazine (0.5 mg/kg) with 10 minute interval were injected IV in six healthy adult donkeys. Sedation score, analgesic score, heart rate (HR), respiratory rate, rectal temperature and ECG parameters were recorded before and after 2, 5 and 10 minutes from injection for each injection and then at 5 minutes intervals until complete recovery from sedation and the normal ECG was recorded. Deep sedation was obtained 5 minutes after the second injection in all donkeys, and the length of sedation lasted 71 ± 6 minutes. The deep analgesia was obtained 5 minutes after the third injection in all donkeys, and the length of analgesia lasted 62 ± 5 minutes. There was a highly significant decrease in HR after the third injection (P < 0.01). Normal HR was obtained in all donkeys after 75 ± 10 minutes of the third injection. Cardiac arrhythmia as atrial fibrillation and AV block were recorded after second and third injection but this arrhythmia was transient. We can conclude that repeated injection of xylazine Hcl give acceptable results either for sedation or ECG parameters in donkeys.

Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center

Freestanding imaging centers are popular options for health care systems to offer services accessible to local communities. The provision of deep sedation at these centers could allow for flexibility in scheduling imaging for pediatric patients. Our Children's Sedation Services group, comprised of pediatric critical care medicine and pediatric emergency medicine physicians, has supplied such a service for 5 years. However, limited description of such off-site services exists. The site has resuscitation equipment and medications, yet limited staffing and no proximity to hospital support. To describe the experience of a cohort of pediatric patients undergoing sedation at a freestanding imaging center. A retrospective chart review of all sedations from January 2012 to December 2012. Study variables include general demographics, length of sedation, type of imaging, medications used, completion of imaging, adverse events based on those defined by the Pediatric Sedation Research Consortium database and need for transfer to a hospital for additional care. Six hundred fifty-four consecutive sedations were analyzed. Most patients were low acuity American Society of Anesthesiologists physical class ≤ 2 (91.8%). Mean sedation time was 55 min (SD ± 24). The overwhelming majority of patients (95.7%) were sedated for MRI, 3.8% for CT and <1% (three patients) for both modalities. Propofol was used in 98% of cases. Overall, 267 events requiring intervention occurred in 164 patient encounters (25.1%). However, after adjustment for changes from expected physiological response to the sedative, the rate of events was 10.2%. Seventy-five (11.5%) patients had desaturation requiring supplemental oxygen, nasopharyngeal tube or oral airway placement, continuous positive airway pressure or brief bag valve mask ventilation. Eleven (1.7%) had apnea requiring continuous positive airway pressure or bag valve mask ventilation briefly. One patient had bradycardia that resolved with nasopharyngeal tube placement and continuous positive airway pressure. Fifteen (2.3%) patients had hypotension requiring adjustment of the sedation drip but no fluid bolus. Overall, there were six failed sedations (0.9%), defined by the inability to complete the imaging study. There were no serious adverse events. There were no episodes of cardiac arrest or need for intubation. No patient required transfer to a hospital. Sedation provided at this freestanding imaging center resulted in no serious adverse events and few failed sedations. While this represents a limited cohort with sedations performed by predominately pediatric critical care medicine and pediatric emergency medicine physicians, these findings have implications for the design and potential scope of practice of outpatient pediatric sedation services to support community-based pediatric imaging.

Posttraumatic stress in intensive care unit survivors – a prospective study

Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21%) had symptom levels indicating subclinical PTSD. Female, five illness factors: coma time, mechanical ventilation, sedation, benzodiazepine, pain relieving medication, and four psychological factors: symptoms of acute stress (T1), fear of death and/or feeling completely helpless and powerless in relation to the accident and/or ICU (T1), SOC (T1) and more external locus of control (T1) correlated significantly with PTSD symptoms at T2. In the linear regression analysis, female, length of sedation, dissociation (T1), hypervigilance (T1), and external locus of control predicted 58% of the variation of PTSD. Conclusions: High levels of PTSD symptoms occurred in 19.2% of respondents in six months following traumatic injury requiring ICU admission. Screening for the variables gender, length of sedation, dissociation, hypervigilance, and locus of control after ICU admission following traumatic injuries may help to predict who will develop PTSD.

Optimal sedation in pediatric intensive care patients: a systematic review

Sedatives administered to critically ill children should be titrated to effect, because both under- and oversedation may have negative effects. We conducted a systematic review to examine reported incidences of under-, optimal, and oversedation in critically ill children receiving intensive care. A systematic literature search using predefined criteria was performed in PubMed and Embase to identify all articles evaluating level of sedation in PICU patients receiving continuous sedation. Two authors independently recorded: study objective, study design, sample size, age range, details of study intervention (if applicable), sedatives used, length of sedation, sedation scale used, and incidences of optimal, under-, and oversedation as defined in the studies. Twenty-five studies were included. Two studies evaluated sedation level as primary study outcome; the other 23 as secondary outcomes. Together, these studies investigated 1,163 children; age range, 0-18 years. Across studies, children received many different sedative agents and sedation level was assessed with 12 different sedation scales. Optimal sedation was ascertained in 57.6 % of the observations, under sedation in 10.6 %, and oversedation in 31.8 %. This study suggests that sedation in the PICU is often suboptimal and seldom systematically evaluated. Oversedation is more common than undersedation. As oversedation may lead to longer hospitalization, tolerance, and withdrawal, preventing oversedation in pediatric intensive care deserves greater attention.

Escalas de Ramsay e Richmond são equivalentes para a avaliação do nível de sedação em pacientes gravemente enfermos

The main purpose of this study was to compare performance of the Ramsay and Richmond sedation scores on mechanically ventilated critically ill patients, in a university-affiliated hospital.This was a 4-month prospective study, which included a total of 45 patients mechanically ventilated, with at least 48 hours stay in the intensive care unit. Each patient was assessed daily for sedation mode, sedative and analgesic doses and sedation level using the Ramsay and Richmond scores. Statistical analysis was made using Student's t-test, Pearson's and Spearman's correlation, and constructing ROC-curves.A high general mortality of 60% was observed. The length of sedation and daily dose of medication did not correlate with mortality. Deep sedation (Ramsay > 4 or Richmond < -3) was positively correlated with probability of death with an AUC > 0.78. An adequate level of sedation (Ramsay 2 to 4 or Richmond 0 to -3) was sensitively correlated with probability of survival with an AUC > 0.80. A low level of sedation was observed in 63 days evaluated (8.64%), and no correlation was found between occurrence of agitation and unfavorable outcomes. Correlation between Ramsay and Richmond scores (Pearson's > 0.810 - p<0.0001) was good.In this study, Ramsay and Richmond sedation scores were similar for the assessment of deep, insufficient and adequate sedation. Both have good correlation with mortality in over sedated patients.

The use of a pediatric emergency medicine–staffed sedation service during imaging: a retrospective analysis

Hypothesis A sedation service staffed by pediatric emergency medicine (PEM) physicians can sedate children during imaging, with a low adverse event risk and minimal sedation failures. Design/Methods We reviewed 1042 PEM-administered sedations during a 12-month period, collecting data regarding demographics, presedation evaluation, medications used, sedation length, adverse events, corrective measures, and postsedation disposition. Successful image completion without patient awakening defined effective sedation. Minor adverse events included hypoxia (<93%), malaligned airway, self-resolving transient bradycardia, and atypical reactions to sedation agents. Cardiorespiratory incidents requiring resuscitation were considered major events. Results Of 923 sedation episodes, 92 (10.0%) experienced adverse events; 7 (0.76%) were major. Sedation failed in 17 (1.8%). No sedation resulted in an increased level of care or permanent injury. Conclusions A PEM-staffed sedation service provided sedation to children undergoing imaging with a low adverse event risk, minimal failures, and no residual morbidity. However, all sedating clinicians should possess critical airway skills.

A Randomized, Controlled Trial of IV Versus IM Ketamine for Sedation of Pediatric Patients Receiving Emergency Department Orthopedic Procedures

We compare adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED). Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children's hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg i.v. or 4 mg/kg i.m. Demographics, adverse events, sedation efficacy, and length of sedation were recorded. Two hundred twenty-five patients were randomized (116 i.v., 109 i.m.). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 i.v. and 99 i.m. Respiratory adverse events were similar between groups (i.v. 8.3% versus i.m. 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the i.m. group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9). Using the Faces Pain Scale, patients in the i.m. group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the i.m. group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 i.m. versus 0.74 i.v.; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the i.m. group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine i.m. In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg i.m. was more effective than 1 mg/kg i.v. but demonstrated significantly longer recovery times and more vomiting.

Efficacy and Safety of Palliative Sedation Therapy: A Multicenter, Prospective, Observational Study Conducted on Specialized Palliative Care Units in Japan

Although palliative sedation therapy is often required in terminally ill cancer patients, its efficacy and safety are not sufficiently understood. The primary aims of this multicenter observational study were to 1) explore the efficacy and safety of palliative sedation therapy, and 2) identify the factors contributing to inadequate symptom relief and complications, using a prospective study design, clearly defined measurement methods, and a consecutive sample from 21 specialized palliative care units in Japan. A sample of 102 consecutive adult cancer patients who received continuous deep sedation were enrolled. Physicians prospectively evaluated the intensity of patient symptoms, communication capacity, respiratory rate, and complications related to sedation. Symptoms were measured on the Agitation Distress Scale, the Memorial Delirium Assessment Scale, and the ad hoc symptom severity scale (0 = no symptoms, 1 = mild and tolerable symptoms, 2 = intolerable symptoms for less than 15 minutes in the previous one hour, and 3 = intolerable symptoms continuing for more than 15 minutes in the previous one hour). Inadequate symptom relief was defined as presence of hyperactive delirium (item 9 of the Memorial Delirium Assessment Scale ≥2) or grade 2 or 3 symptom intensity 4 hours after sedation. The degree of communication capacity was measured on the Communication Capacity Scale. Palliative sedation therapy succeeded in symptom alleviation in 83% of the cases. Median time elapsed before patients initially had one continuous hour of deep sedation was 60 minutes, but 49% of the patients awakened once after falling into a deeply sedated state. The percentage of patients who were capable of explicit communication decreased from 40% before sedation to 7.1% 4 hours after sedation, and the mean Communication Capacity Score significantly decreased to the level of 15 points ( P < 0.001). The respiratory rates did not significantly decrease after sedation (18 ± 9.0 to 16 ± 9.4/min, P = 0.62), but respiratory and/or circulatory suppression (respiratory rate ≤ 8/min, systolic blood pressure ≤ 60mHg, or 50% or more reduction) occurred in 20%, with fatal outcomes in 3.9%. There were no statistically significant differences in patient age, sex, performance status, target symptoms, or classes and initial dose of sedative medications between the patients with adequate and inadequate symptom relief. Respiratory and/or circulatory suppression was significantly more likely to occur in patients receiving sedation for delirium and those with higher levels on the Agitation Distress Scale. Higher dose of midazolam was significantly correlated with younger age, absence of icterus, pre-exposure to midazolam, and length of sedation. Palliative sedation therapy is effective and safe in the majority of terminally ill cancer patients with refractory symptoms. However, a small number of patients experience fatal complications related to sedation. Comparison studies of different sedation regimens are needed to determine the most effective and safe sedation protocol.