Procedural Sedation and Analgesia in Children in Emergency Department—Role of Adjunct Therapies

Objective: To compare sedation efficacy and parent/consultant satisfaction between standard sedation, sedation with music listening, and sedation with Certified Child life Specialists (CCLS) in children undergoing procedural sedation in the Pediatric Emergency Department (PED). Methods: Eligible children, aged 3 - 18 years, were randomly allocated to one of 3 groups: 1) standard sedation;2) sedation with music listening;3) sedation with CCLS intervention. All 3 groups received intravenous ketamine. The child life group received age appropriate comforting measures, while the music group listened to music of their choice during the procedure. The primary outcome was sedation efficacy, measured by Ramsay Sedation scale, FACES-P scale and need for re-dosing. The secondary outcome was parent/consultant satisfaction. Results: Fifty nine patients were analyzed (standard sedation: 20;sedation with music listening: 20;and sedation with CCLS: 19). There was no significant difference in mean initial ketamine dosing (1.58 ± 0.44 vs. 1.68 ± 0.36 vs. 1.42 ± 0.47, p = 0.26). There was no significant difference in median Ramsay Sedation scores [6(IQR:4,6) vs. 6 (IQR:4,6) vs. 6 (IQR:5,6)], FACES-R pain score [0 (IQR:0.0) vs. 0 (IQR:0.0) vs. 0 (IQR:0.0)] and need for re-dosing [9/20 (45%) vs. 4/20 (20%) vs. 8/19 (42.1%)] amongst the 3 groups. Parent and consultant satisfaction was high in all 3 groups. Conclusion: Our pilot study did not demonstrate a difference in sedation efficacy or parent/consultant satisfaction when adjunct therapies were used during PSA. Further studies with a large sample size are needed to define the role for such adjunct therapies during procedural sedation in PED.

Anteroposterior Airway Diameter during Sedation for Brain MRI in Children with and without Developmental Disabilities

Objective: Our study objective was to compare the anteroposterior (AP) oropharyngeal airway diameter measured using static MRI images in children with and without developmental disabilities during sedation. Methods: We performed a secondary analysis on a prospective, observational age-matched, 1:2 case-control study of children aged 3 - 10 years who were sedated for brain MRI. AP airway diameters were determined at the level of soft palate (airway_SP) and tongue (airway_T) from midline sagittal images by a single blinded radiologist. Results: Airway diameter was evaluated in 134 controls (C) and 68 cases (D). There was no difference in the overall adverse events (D: 30% C: 32.9%;p = 0.7) as well as hypoxia (D: 10%;C: 9.3%, p = 0.9). There was no significant difference in mean airway_T (D: 10.62 ± 3.48 vs. C: 10.38 ± 3.47;p = 0.64) and airway_SP diameter (D: 4.59 ± 2.36 vs. C: 5.17 ± 3.9;p = 0.14) between the two groups. There was no significant difference in airway_T and airway_SP diameters amongst those who experienced and those who did not experience hypoxia in cases. Amongst controls however, the airway_SP was smaller in those who experienced hypoxia compared to those who did not experience hypoxia. Conclusions: There was no difference in the AP airway_T and airway_SP diameter during sedation using static MRI images in children with and without developmental disabilities. Changes in airway_SP was associated with hypoxia amongst controls in our study cohort.