Risk Factors for Adverse Events in Emergency Procedural Pediatric Sedation

MedicalResearch.com Interview with:

Maala Bhatt MD, MSc., FRCPC Director, Pediatric Emergency Research Staff Physician, Emergency Medicine  Children's Hospital of Eastern Ontario

Dr. Bhatt

Maala Bhatt MD, MSc., FRCPC
Director, Pediatric Emergency Research
Staff Physician, Emergency Medicine
Children’s Hospital of Eastern Ontario 

MedicalResearch.com: What is the background for this study?

Response: Procedural sedation, defined as the administration of medications to minimize pain and awareness, has become standard practice in pediatric emergency departments worldwide to facilitate short, painful procedures such as orthopedic reduction and complex laceration repairs. Although emergency department sedation is regarded as safe, serious adverse events have been reported. The incidence of these events has been difficult to determine due to the infrequency of their occurrence and lack of large, multi-center surveillance studies focused on systematic detection of adverse events. Previous studies of emergency department sedation have been limited by single-center design and small sample sizes. These studies have not been able to reliably predict sedation-related adverse events, their severity or impact on patients.

To improve understanding of the safety and comparative effectiveness of ED procedural sedation, we conducted a large multi-center cohort study using standardized outcome measures that are valid and relevant to clinical practice. Our primary objective was to determine which practices lead to the best outcomes in children undergoing emergency department procedural sedation.

MedicalResearch.com: What are the main findings?

Response: We enrolled 6,295 patients undergoing parenteral procedural sedation for a painful procedure in one of six Canadian pediatric emergency departments from July 2010 to February 2015.

The overall incidence of adverse events in our population was 11.7%. Oxygen desaturation (5.6%) and vomiting (5.2%) were the most common events. Serious adverse events and significant interventions in response to an adverse event were rare occurring in only 1.1% and 1.4% of patients respectively.

We found that choice of sedation medication had the biggest impact on the incidence of adverse events and need for significant interventions in response to those events. The incidence of serious adverse events and significant interventions was lowest among patients sedated with ketamine-alone and highest among patients sedated with combination drugs ketamine+propofol and ketamine+fentanyl. We also found that pre-procedural opioid administration was strongly associated with increased odds of oxygen desaturation, vomiting and need for significant interventions, regardless of sedation medication.

Higher doses of ketamine were associated with increased odds of oxygen desaturation and vomiting. These findings are in opposition to the common belief that ketamine does not exhibit a dose-response relationship.

We also found that pre-procedural anti-emetics were associated with a 50% reduction in the odds of vomiting. However, based on published evidence, use in children under five years may not be as advantageous as their baseline risk is much lower.

MedicalResearch.com: What should clinicians and patients take away from your report?

Response: Procedural sedation for children provided by Emergency Physicians in these tertiary care pediatric emergency departments is safe and effective with low rates of serious adverse events (1.1%) and significant interventions (1.4%). Ketamine, Ketamine and Propofol and Propofol alone are all effective and safe in the hands of competent/experienced providers, however using ketamine alone is associated with fewer serious adverse events and significant interventions.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Our finding that administering opioids prior to sedation increases the odds of oxygen desaturation, vomiting and the need for significant interventions is interesting. Future work could focus on the timing of opioid administration and the incidence of adverse events. We are also interesting in understanding the longer term effects of sedation medications, controlling for age.

Disclosures: This study was supported by a Canadian Institutes of Health Research Team Grant in Pediatric Emergency Medicine.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Sourial N, Roback MG, for the Sedation Safety Study Group of Pediatric Emergency Research Canada (PERC). Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. Published online August 21, 2017. doi:10.1001/jamapediatrics.2017.2135

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

 

 

 

 

 

 

Combination Opioids and Benzodiazepines Raises Risk of Overdose

MedicalResearch.com Interview with:

Eric C Sun MD PhD, assistant professor Department of Anesthesiology Perioperative and Pain Medicine Stanford University School of Medicine Stanford, CA

Dr. Eric Sun

Eric C Sun MD PhD, assistant professor
Department of Anesthesiology
Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, CA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There have been large increases in opioid-related adverse events over the past decade. The goal of our study was to examine the extent to which these increases may have been driven by combined use of opioids and benzodiazepines, a combination that is known to be potentially risky. Overall, we found that the combined use of opioids and benzodiazepines nearly doubled (80% increase) between 2001 and 2013, and that opioid users who also used benzodiazepines were at a higher risk of an opioid-related adverse event. Indeed, our results suggest eliminating the combined use of opioids and benzodiazepines could have reduced the population risk of an opioid-related adverse event by 15%.

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New Scoring System Guides Surgical Risks During Pregnancy

MedicalResearch.com Interview with:
Adam Sachs MD

Assistant Professor of Anesthesiology
University of Connecticut School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: When women undergo appendectomy or cholecystectomy during pregnancy they are obviously concerned about the well being of their fetus. Unfortunately, the majority of the data available to council pregnant women is outdated and medical practice has significantly changed since their publication.

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Over 1/3 of Anesthesia Now Delivered Outside of Traditional Operating Rooms

MedicalResearch.com Interview with:
Dr. Richard Dutton, MD

Chief quality officer
U.S. Anesthesia Partners
Dallas

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We wanted to document the change in national anesthesia practice over the past 5 years, specifically the increase in non-operating room anesthesia NORA. We found that non-operating room anesthesia now accounts for more than 1/3 of all anesthetics. The proportion continues to rise as minimally invasive procedures are developed in gastroenterology, cardiology, radiology and other non-surgical disciplines. These procedures are often performed in complex patients, and require anesthesia involvement to facilitate.

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Liposomal Bupivacaine Infiltration Reduced Costs and Opioid Use in TKA Surgery

MedicalResearch.com Interview with:
Bryan Sakamoto MD, PhD
Department of Anesthesia
Richard L. Roudebush, Veterans Affairs Medical Center
Department of Anesthesia
Indiana University School of Medicine
Indianapolis, Indiana

MedicalResearch.com: What is the background for this study?

Response: Liposomal bupivacaine is a novel extended-duration anesthetic that has recently become a popular option in total knee arthroplasty (TKA) for post-operative pain management. Although liposomal bupivacaine is widely used, it is unknown if the benefits justify the cost in the veteran population at our institution. The main purpose of this medication use study was to evaluate the cost verses benefit of using this agent in our veteran patient population.

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Repeat Urine Drug Testing Can Improve Compliance of Patients on Opioid Medications

MedicalResearch.com Interview with:

N. Nick Knezevic, MD, PhD Vice Chair for Research and Education Associate Professor of Anesthesiology and Surgery at University of Illinois Advocate Illinois Masonic Medical Center Department of Anesthesiology Chicago, IL 60657

Dr. N. Nick Knezevic

N. Nick Knezevic, MD, PhD
Vice Chair for Research and Education
Associate Professor of Anesthesiology and Surgery at University of Illinois
Advocate Illinois Masonic Medical Center
Department of Anesthesiology
Chicago, IL 60657

MedicalResearch.com: What is the background for this study?

Response: Even though serious efforts have been undertaken by different medical societies to reduce opioid use for treating chronic non-cancer pain, still many Americans seek pain relief through opioid consumption. The purpose of this study was to accurately assess compliance of chronic opioid consuming patients in an outpatient setting and evaluate if utilizing repeated urine drug testing could improve compliance.

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Persistent Postpartum Pain Linked To Higher Risk of Depression

MedicalResearch.com Interview with:
MS WEI DU, First author
Third Year Medical Student
DUKE-NUS Medical School and
DR BAN LEONG SNG, Senior Author
Senior Consultant Department of Women’s Anesthesia KK
Women’s and Children’s Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

MS WEI DU: We performed a cohort study involving 200 healthy women who received epidural pain relief during the deliveries of their firstborns to investigate the relationship between persistent childbirth pain, psychological and pain vulnerability with postnatal depression. Postnatal depression was evaluated using the Edinburgh Postnatal Depression Score (EPDS).

Patients with persistent pain (>4 weeks postpartum) had significantly higher EPDS scores as compared to patients whose pain resolved by 4 weeks by a difference of 2.44 mean score, and compared to patients who never had pain postpartum by a difference of 4.07 mean score. Other significant factors that were associated with higher EDPS score included higher levels of stress, greater pain vulnerability during the intrapartum period and higher anxiety level at 6 to 8 weeks postpartum.

DR BAN LEONG SNG: Patients with persistent pain (>4 weeks postpartum) had significantly higher EPDS scores as compared to patients whose pain resolved by 4 weeks by a difference of 2.44 mean score, and compared to patients who never had pain postpartum by a difference of 4.07 mean score. Other significant factors that were associated with higher EDPS score included higher levels of stress, greater pain vulnerability during the intrapartum period and higher anxiety level at 6 to 8 weeks postpartum.

MedicalResearch.com: What should readers take away from your report?

MS WEI DU: We concluded that greater pain vulnerability and stress during intrapartum period, and presence of persistent pain or higher anxiety during postpartum period are positively associated with higher scores on postnatal depression tests.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

DR BAN LEONG SNG: The research findings support the need to address pain comprehensively to lessen the risk of developing postnatal depression. We are currently conducting a larger study to evaluate the impact of pain and postnatal depression in pregnant women.

MedicalResearch.com: Is there anything else you would like to add?

DR BAN LEONG SNG: Postnatal evaluation and management of childbirth pain and postnatal depression is important in our care of mothers and their newborns.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

World Congress of Anaesthesiologists abstract discussing:

Persistent childbirth pain increases risk of postnatal depression

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Opportunities for Improvement in Pediatric Resuscitation Across US EDs

MedicalResearch.com Interview with:
Marc Auerbach, MD, FAAP, MSc
Associate Professor of Pediatrics (Emergency Medicine) and of Emergency Medicine
Co-chair INSPIRE (International Network for Simulation Based Pediatric Innovation Research and Education)
Director, Pediatric Simulation
Yale Center for Medical Simulation;

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Severely ill infants and children present to any of over 5000 United States Emergency Departments every day. A direct comparison of the quality of resuscitative care across EDs is challenging due to the low frequency of these high stakes events in individual EDs. This study utilized in-situ simulation-based measurement to compare the quality of resuscitative care delivered to two infants and one child by 58 distinct interprofessional teams across 30 EDs. Composite quality scores correlated with annual pediatric patient volume, with higher volume departments demonstrating higher scores.

The pediatric readiness score measures compliance with guidelines created by the American Academy of Pediatrics, the American College of Emergency Physicians and the Emergency Nurses Association. The pediatric readiness score correlated with composite quality scores measured by simulation.

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New Drug Class May Prevent Learning Deficits In Infants Exposed To Repeated Anesthesia

MedicalResearch.com Interview with:

Guang Yang, Ph.D. Assistant Professor NYU Langone School of Medicine Alexandria Center for Life Sciences New York, NY 10016

Dr. Guang Yang

Guang Yang, Ph.D.
Assistant Professor
NYU Langone School of Medicine
Alexandria Center for Life Sciences
New York, NY 10016

MedicalResearch.com: What is the background for this study? How common is the problem of long-lasting behavioral deficits after repeated anesthesia exposure in neonates?

Response: Each year, in the United States alone, more than 1 million children under 4 years of age undergo surgical procedures that require anesthesia. Many lines of evidence from animal studies have shown that prolonged or repeated exposure to general anesthesia during critical stages of brain development leads to long-lasting behavioral deficits later in life. The results from human studies are less clear, although some studies suggest a higher incidence of learning disabilities and attention-deficit and hyperactivity disorders in children repeatedly exposed to procedures requiring general anesthesia. To date, there has been no effective treatment to mitigate the potential neurotoxic effects of general anesthesia.

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Limited Anesthesia in Young Children Not Link To Later Cognitive Impairment

MedicalResearch.com Interview with:

Lena S. Sun, MD E. M. Papper Professor of Pediatric Anesthesiology Professor of Anesthesiology and Pediatrics Executive Vice Chairman, Department of Anesthesiology Chief, Division of Pediatric Anesthesiology Columbia University Medical Center New York, New York 10032

Dr. Lena S. Sun

Lena S. Sun, MD
E. M. Papper Professor of Pediatric Anesthesiology
Professor of Anesthesiology and Pediatrics
Executive Vice Chairman, Department of Anesthesiology
Chief, Division of Pediatric Anesthesiology
Columbia University Medical Center
New York, New York 10032

MedicalResearch.com: What is the background for this study?

Dr. Sun: The background for the study is as follow: There is robust evidence in both rodent and non-human primate studies that exposure of the developing brain leads to impairment in cognitive function and behavior later in life. The evidence from human studies derives mostly from retrospective studies and the results have been mixed. Some have demonstrated anesthesia in early childhood was associated with impaired neurocognitive function, while others have found no such association. Our study is the first to specifically designed to address the question of effects of general anesthesia exposure on cognitive function, comparing exposure with no exposure.

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