Safety and Efficacy Associated With a Family-Centered Procedural Sedation Protocol for Children With Autism Spectrum Disorder or Developmental Delay

Routine health care, whether physical examinations, blood sampling, vaccination, or dental care, is challenging and often traumatic for children with autism spectrum disorder (ASD) and children with developmental delay (DD), often requiring physical restraint or being indefinitely postponed. Behavioral interventions are critical for effective treatment of these children; however, in many children who have had traumatic medical experiences, these interventions may not be successful.1 Pharmacologic treatment with oral sedatives may be insufficient to perform common minor procedures, while the intramuscular route, requiring physical restraint for administration, can deepen the fear and lack of trust these children have toward the health care system.2 We describe a consecutive case series using a family-centered integrated behavioral and sedation protocol for common medical procedures in these children

Appendicitis in children less than five years old: A challenge for the general practitioner

Acute appendicitis is one of the most common indications for abdominal surgery in pediatrics with peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon event. The clinical presentation is often varied and the diagnosis may be overshadowed by other medical conditions. Gastroenteritis is the most common misdiagnosis, with a history of diarrhea present in 33% to 41% of patients. Pain is the most common presenting symptom in children less than 5 years old, followed by vomiting, fever, anorexia and diarrhea. The most common physical sign is focal tenderness (61% of the patients) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%). Neonatal appendicitis is a very rare disease with high mortality; presenting symptoms are nonspecific with abdominal distension representing the main clinical presentation. The younger the patient, the earlier perforation occurs: 70% of patients less than 3 years develop a perforation within 48 h of onset of symptoms. A timely diagnosis reduces the risk of complications. We highlight the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in young children and suggest an algorithm for early diagnosis

Physiological Monitoring for Procedural Sedation

Physiological monitoring of vital signs is essential for the safe practice of procedural sedation and analgesia. Oxygenation, ventilation, hemodynamics, and aspects of cortical activity can all be monitored noninvasively in spontaneously breathing patients. This chapter discusses the current guidelines and standards for patient monitoring, the essential monitoring modalities for procedural sedation and analgesia in children, and future directions in the field of monitoring

Current concepts in management of pain in children in the emergency department

4siPain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.partially_openopenKrauss, Baruch S; Calligaris, Lorenzo; Green, Steven M; Barbi, EgidioKrauss, Baruch S; Calligaris, Lorenzo; Green, Steven M; Barbi, Egidi

Pediatric procedural sedation and analgesia in the emergency department: surveying the current European practice

Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare

Model-Based Estimation of Respiratory Parameters from Capnography, with Application to Diagnosing Obstructive Lung Disease

© 1964-2012 IEEE. Objective: We use a single-alveolar-compartment model to describe the partial pressure of carbon dioxide in exhaled breath, as recorded in time-based capnography. Respiratory parameters are estimated using this model, and then related to the clinical status of patients with obstructive lung disease. Methods: Given appropriate assumptions, we derive an analytical solution of the model, describing the exhalation segment of the capnogram. This solution is parametrized by alveolar CO2 concentration, dead-space fraction, and the time constant associated with exhalation. These quantities are estimated from individual capnogram data on a breath-by-breath basis. The model is applied to analyzing datasets from normal (n = 24) and chronic obstructive pulmonary disease (COPD) (n = 22) subjects, as well as from patients undergoing methacholine challenge testing for asthma (n = 22). Results: A classifier based on linear discriminant analysis in logarithmic coordinates, using estimated dead-space fraction and exhalation time constant as features, and trained on data from five normal and five COPD subjects, yielded an area under the receiver operating characteristic curve (AUC) of 0.99 in classifying the remaining 36 subjects as normal or COPD. Bootstrapping with 50 replicas yielded a 95% confidence interval of AUCs from 0.96 to 1.00. For patients undergoing methacholine challenge testing, qualitatively meaningful trends were observed in the parameter variations over the course of the test. Significance: A simple mechanistic model allows estimation of underlying respiratory parameters from the capnogram, and may be applied to diagnosis and monitoring of chronic and reversible obstructive lung disease

Teaching pain recognition through art: the Ramsay-Caravaggio sedation scale

Abstract Background Clinical observation is a key component of medical ability, enabling immediate evaluation of the patient’s emotional state and contributing to a clinical clue that leads to final decision making. In medical schools, the art of learning to look can be taught using medical humanities and especially visual arts. By presenting a Ramsay sedation score (RSS) integrated with Caravaggio’s paintings during a procedural sedation conference for pediatric residents, we want to test the effectiveness of this approach to improve the quality of learning. Methods In this preliminary study, we presented videos showing sedated pediatric patients in the setting of a procedural sedation lesson to two randomized groups of residents, one attending a lesson on RSS explained through the masterpieces of Caravaggio, the other without artistic support. A week later we tested their learning with ten multi-choice questions focused on theoretical questions about sedation monitoring and ten more questions focused on recognizing the appropriate RSS viewing the videos. The primary outcome was the comparison of the total number of RSS layers properly recognized in both groups. We also evaluated the appreciation of the residents of the use of works of art integrated with the lesson. Results Eleven students were randomized to each group. Two residents in the standard lesson did not attend the test. The percentage of correct answers on the theoretical part was similar, 82% in the art group and 89% in the other (p > 0.05). No difference was found in the video recognition part of the RSS recognition test. Residents exposed to paintings shown great appreciation for the integration of the lesson with the Caravaggio’s masterpieces. Conclusions Adding artwork to a standard medical conference does not improve the performance of student tests, although this approach has been greatly appreciated by residents

Statistical analysis of the age dependence of the normal capnogram

The age dependence of the time-based capnogram from normal, healthy subjects has not been quantitatively characterized. The existence of age dependence would impact the development and operation of automated quantitative capnographic tools. Here, we quantitatively assess the relationship between normal capnogram shape and age. Capnograms were collected from healthy subjects, and physiologically-based features (exhalation duration, end-tidal CO2 and time spent at this value, normalized time spent at end-tidal CO2, end-exhalation slope, and instantaneous respiratory rate) were computationally extracted. The mean values of the individual features over 30 exhalations were linearly regressed against subject age, accounting for inter-feature correlation. After data collection, 154 of 178 subjects were eligible for analysis, with an age range of 3-78 years (mean age 39, std. dev. 20 years). The Bonferroni-corrected joint 95% confidence intervals (CIs) of the regression line slopes contained the origin for five of six features (the remaining CI was only slightly offset from the origin). The associated individual r2 values for the regressions were all below 0.07. We conclude that age is not a significant explanatory factor in describing variations in the shape of the normal capnogram. This finding could be exploited in the design of automated methods for quantitative capnogram analysis across a range of ages