Pediatrics

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

Photo by Darren Baker

A database containing information on more than 11,000 tumors is now available to researchers studying pediatric cancers.

The database was created as part of UC Santa Cruz Genomics Institute’s Treehouse Childhood Cancer Initiative.

The goal of this initiative is to allow researchers to analyze their patients’ data alongside data from thousands of patients with pediatric and adult cancers, including leukemias and lymphomas.

The intention is to help researchers find hidden causes of cancer that may be missed when they analyze a patient’s data in isolation.

The database, which is available at https://treehouse.xenahubs.net, contains RNA-sequencing gene expression data, as well as information on patients’ age, sex, and disease.

Photo by Darren Baker

A database containing information on more than 11,000 tumors is now available to researchers studying pediatric cancers.

The database was created as part of UC Santa Cruz Genomics Institute’s Treehouse Childhood Cancer Initiative.

The goal of this initiative is to allow researchers to analyze their patients’ data alongside data from thousands of patients with pediatric and adult cancers, including leukemias and lymphomas.

The intention is to help researchers find hidden causes of cancer that may be missed when they analyze a patient’s data in isolation.

The database, which is available at https://treehouse.xenahubs.net, contains RNA-sequencing gene expression data, as well as information on patients’ age, sex, and disease.

Photo by Darren Baker

A database containing information on more than 11,000 tumors is now available to researchers studying pediatric cancers.

The database was created as part of UC Santa Cruz Genomics Institute’s Treehouse Childhood Cancer Initiative.

The goal of this initiative is to allow researchers to analyze their patients’ data alongside data from thousands of patients with pediatric and adult cancers, including leukemias and lymphomas.

The intention is to help researchers find hidden causes of cancer that may be missed when they analyze a patient’s data in isolation.

The database, which is available at https://treehouse.xenahubs.net, contains RNA-sequencing gene expression data, as well as information on patients’ age, sex, and disease.

For many years, pediatric patients undergoing procedures in the ED have received inadequate pain management and sedation. Children’s (and parents’) anxieties and distress leading up to and during a potentially painful or anxiety-inducing procedure are now more easily mitigated by the appropriate use of a variety of pediatric-appropriate analgesics, sedatives, and anxiolytics. The ability to provide adequate, minimally invasive sedation and analgesia is critically important to performing successful procedures in children, and is a hallmark of excellent pediatric emergency care.

The following case vignettes, based on actual cases, illustrate the range and routes of medications available to provide appropriate analgesia, sedation, and anxiolysis.

Cases

Case 1

A 4-year-old boy presented to the ED for evaluation of a fractured wrist sustained after he fell off his bed during a temper tantrum. At presentation, the patient’s vital signs were: blood pressure (BP), 110/70 mm Hg; heart rate (HR), 100 beats/min; respiratory rate (RR), 28 breaths/min; and temperature (T), 99.5°F. Oxygen saturation on room air was within normal limits. The patient’s weight was within normal range for his age and height at 15 kg (33 lb).

Upon examination, the child appeared agitated and in significant distress; his anxiety increased after an initial attempt at placing an intravenous (IV) line in his uninjured arm failed.

The emergency physician (EP) considered several options to ameliorate the child’s anxiety and facilitate evaluation and treatment.

Case 2

After accidentally running into a pole, a 6-year-old girl presented to the ED for evaluation and suturing of a large laceration to her forehead. At presentation, the patient’s vital signs were: BP, 115/70 mm Hg; HR, 95 beats/min; RR, 24 breaths/min; and T, 98.6°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 20 kg (44 lb).

On examination, the patient was awake, alert, and in no acute distress. However, she immediately became tearful and visibly upset when she learned that an IV line was about to be placed in her arm.

The physician instead decided to employ an IV/needle-free strategy for this wound repair, as well as anxiolysis.

Case 3

A 5-year-old girl was brought to a community hospital ED by emergency medical services after falling from a balance beam and landing headfirst on the ground during a gymnastics class. Prior to presentation, emergency medical technicians had placed the patient in a cervical collar. At presentation, the patient’s vital signs were: BP, 105/75 mm Hg; HR, 115 beats/min; RR, 28 breaths/min; and T, 99.1°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 18 kg (39.6 lb).

Although the neurological examination was normal, the patient had persistent midline cervical tenderness as well as hemotympanum. The EP ordered a head and neck computed tomography (CT) scan, but shortly after the patient arrived at radiology, the CT technician informed the EP that she was unable to perform the scan because the patient kept moving and would not stay still.

The EP considered several sedatives to facilitate the CT study.

Case 4

A febrile, but nontoxic-appearing 3-week-old girl was referred to the ED by her pediatrician for a lumbar puncture (LP) to diagnose or exclude meningitis. However, the mother’s own recent negative experience with an epidural analgesia during the patient’s delivery, made the neonate’s mother extremely anxious that the procedure might be too painful for her daughter.

The EP considered the best choice of medication to provide analgesia and allay the mother’s concerns prior to performing the LP in this neonatal patient.

Overview and Definitions

Analgesia describes the alleviation of pain without intentional sedation. However, pediatric patients typically receive sedative hypnotics (anxiolytics) both for analgesia and for anxiolysis to modify behavior (eg, enhance immobility) and to allow for the safe completion of a procedure.¹ The ultimate goal of procedural sedation and analgesia is to provide a depressed level of consciousness and pain relief while the patient maintains a patent airway and spontaneous ventilation.²

Sedation Continuum

The American Society of Anesthesiologists (ASA) classifies procedural sedation and analgesia based on a sedation continuum that affects overall responsiveness, airway, ventilation, and cardiovascular (CV) function.³ Procedural sedation is subcategorized into minimal, moderate, and deep sedation.

Minimal Sedation. Formally referred to as anxiolysis, minimal sedation is a state in which the patient is responsive but somewhat cognitively impaired, while maintaining all other functions rated in the sedation continuum.

Moderate Sedation. Previously referred to as “conscious sedation,” moderate sedation is a state of drug-induced depression of consciousness that still enables the patient to maintain purposeful responses to age-appropriate verbal commands and tactile stimulation, spontaneous ventilation, and CV integrity.

Deep Sedation. Deep sedation causes a drug-induced depression of consciousness that may potentially impair spontaneous ventilation and independent airway patency, while maintaining CV function. A deeply sedated patient is usually arousable with repeated painful stimulation.

Dissociative Sedation. This level of sedation induces a unique, trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. The dissociative state can facilitate the performance of moderate-to-severe painful procedures, as well as procedures requiring immobilization in uncooperative patients.⁴

Contraindications to Procedural Sedation

Though there are no absolute contraindications to procedural sedation in children, its use is generally determined based on ASA’s patient physical status classification system. In this grading system, procedural sedation is appropriate for pediatric patients with a physical status of Class I (normally healthy patient) or Class II (a patient with mild systemic disease—eg, mild asthma).⁵ The EP should consult with a pediatric anesthesiologist prior to sedating a patient with an ASA status of Class II or higher, or a patient with a known laryngotracheal pathology.¹

Pre- and Postsedation Considerations

History and Physical Examination

Prior to patient sedation, the EP should perform a focused history, including a determination of the patient’s last meal and/or drink, and a physical examination. The history should also include known allergies and past or current medication use—specifically any history of adverse events associated with prior sedation. Pregnancy status should be determined in every postpubertal female patient.

The physical examination should focus on the cardiac and respiratory systems, with particular attention to any airway abnormalities or possible sources of obstruction.^1,3

Fasting

A need for fasting prior to procedural sedation remains controversial: Current ASA guidelines for fasting call for fasting times of 2 hours for clear liquids, 4 hours after breastfeeding, 6 hours for nonhuman milk or formula feeding, and 8 hours for solids.⁶

Fasting prior to general anesthesia has become a common requirement because of the risk of adverse respiratory events, including apnea, stridor, bronchospasm, emesis, and pulmonary aspiration of gastric contents. However, these events rarely occur during pediatric procedural sedation in the ED, and it is important to note that the American College of Emergency Physicians’ standards do not require delaying procedural sedation based on fasting times. There is no strong evidence that the duration of preprocedural sedation-fasting reduces or prevents emesis or aspiration.⁷

Equipment

In 2016, the American Academy of Pediatrics (AAP) updated its “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures,”¹ including the essential equipment required for the safe administration of sedation, which can be remembered using the following “SOAPME” mnemonic:

Size: appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction);

Oxygen: An adequate oxygen supply and functioning flow meters or other devices to allow its delivery;

Airway: Size-appropriate equipment (eg, bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, laryngeal mask airway, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask;

Pharmacy: All the basic drugs needed to support life during an emergency, including antagonists as indicated;

Monitors: Functioning pulse oximeter with size-appropriate oximeter probes, end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, electrocardiogram, stethoscope); and

Equipment: Special equipment or drugs for a particular case (eg, defibrillator).¹

Personnel

The 2016 AAP guidelines¹ also indicate the number and type of personnel needed for sedation—in addition to the physician performing the procedure—which is primarily determined by the intended level of sedation as follows:

Minimal Sedation. Though there are no set guidelines for minimal sedation, all providers must be capable of caring for a child who progresses to moderate sedation.

Moderate Sedation. Intentional moderate sedation necessitates two practitioners: one practitioner to oversee the sedation and monitor the patient’s vital signs, who is capable of rescuing the patient from deep sedation if it occurs; and a second provider proficient at least in basic life support to monitor vital signs and assist in a resuscitation as needed.

Deep Sedation. For patients requiring deep sedation, the practitioner administering or supervising sedative drug administration should have no other responsibilities other than observing the patient. Moreover, there must be at least one other individual present who is certified in advanced life support and airway management.¹

Discharge Criteria

Prior to discharge, pediatric patients must meet predetermined criteria that include easy arousability, a return to baseline mental status, stable age-appropriate vital signs, and the ability to remain hydrated.^1,3 In addition, while late postsedation complications are rare, caregivers should be provided with specific symptoms that would warrant immediate return to the ED.

Available Options for Analgesia and Sedation

Several different methods of providing analgesia and pediatric procedural sedation are available, ranging from nonpharmacological methods to topical and parenteral medication administration.

Nonpharmacological Options: Child-Life Specialists

Child-life specialists can be particularly helpful with pediatric emergency patients. With a background in normal child development, child-life specialists utilize myriad distraction techniques and coping strategies to help patients within the stressful environment of an ED. Studies have shown that the presence of a child-life specialist may reduce the depth of sedation needed for certain procedures.¹

Sucrose

Several studies have identified the benefits of sucrose as a pain reliever in neonates. Available as a 12% to 25% solution, sucrose decreases noxious stimuli and is a useful analgesic for such common neonatal procedures as venipuncture, circumcision, heel sticks, Foley catheter insertion, and LP. Efficacy of sucrose for these procedures is greatest in newborns, and decreases gradually after 6 months of age. The effectiveness of sucrose is enhanced when it is given in conjunction with nonnutritive sucking or maternal “skin-to-skin” techniques. There are no contraindications to the use of sucrose.⁸

Nonopioid Systemic Analgesia

Nonopioid oral analgesics (NOAs), such as acetaminophen and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen, are appropriate for mild-to-moderate procedural pain. The NOAs can be given alone or in conjunction with an opioid to enhance the analgesic effect for patients with severe pain.

Acetaminophen. Acetaminophen, which also has antipyretic properties, can be administered orally, rectally, or IV. Since acetaminophen is not an NSAID and does not affect platelet function, it is a good choice for treating patients with gastrointestinal (GI) pain.

Adverse effects of acetaminophen, which is metabolized by the liver, include hepatotoxicity in toxic doses. The suggested oral dose for infants and children weighing less than 60 kg (132 lb) is 10 to 15 mg/kg per dose every 4 to 6 hours as needed, with a maximum dose of 75 mg/kg/d for infants and 100 mg/kg/d for children. Rectal dosing for infants and children weighing less than 60 kg (132 lb) is 10 to 20 mg/kg every 6 hours as needed, with a maximum daily dose of 75 mg/kg/d in infants, and 100 mg/kg/d in children.

Ibuprofen. Ibuprofen, an NSAID with both antipyretic and anti-inflammatory properties, acts as a prostaglandin inhibitor and is indicated for use in patients over 6 months of age. Since ibuprofen inhibits platelet function, it can cause GI bleeding with chronic use. The suggested pediatric dose for ibuprofen is 5 to 10 mg/kg per dose every 6 to 8 hours orally, with a maximum dose of 40 mg/kg/d.⁹

Local Anesthesia

Local anesthetics administered via the topical or subcutaneous (SC) route provide anesthesia by temporarily blocking peripheral or central nerve conduction at the sodium channel.

LET Gel. This topical anesthetic combination composed of 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine (LET gel) is commonly used on patients prior to repair of a skin laceration. Its peak onset of action occurs in 30 minutes, with an anesthetic duration of 45 minutes. The epinephrine component of LET reduces blood flow to the anesthetized area, which increases duration of action but also creates a small risk of vasoconstriction in the areas supplied by end arteries, such as in the penis, nose, digits, and pinna.⁹

EMLA and LMX4. Topical lidocaine anesthetics are extremely useful in the ED because their application can help reduce the pain of minor procedures, when they are applied in adequate time prior to initiating the procedure to reach peak effect. Eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) and liposomal 4% lidocaine (LMX4) are the most commonly used topical lidocaine anesthetics. The peak analgesic effect of EMLA occurs within 60 minutes, with a duration of 90 minutes; LMX4 reaches its analgesic peak after 30 minutes with duration of up to 60 minutes.

Because of the slight delay of the time-to-peak effect, these topical anesthetics are not useful for emergent procedures. Further, neither EMLA nor LMX4 is approved for nonintact skin injuries such as lacerations.⁹ Both LMX4 and EMLA are approved for use in intact skin, providing effective analgesia for procedures such as venipuncture, circumcision, LP, and abscess drainage.

Subcutaneous Lidocaine. When SC injection of lidocaine is preferred, a useful technique to reduce the pain of administration is to warm the lidocaine, alkalinize the solution with 1 mL (1 mEq) sodium bicarbonate to 9 mL lidocaine,⁶ prior to injecting it slowly with a small-gauge needle.⁸Vapocoolant Lidocaine. Vapocoolant sprays produce an immediate cold sensation that is effective in reducing localized pain in adults. Studies looking at its efficacy in children are not as convincing, with some studies suggesting the cold sensation is quite distressing for many children.⁸

Opioids

Opioids are commonly chosen for pediatric procedural sedation because of their short onset of action and ability to produce significant analgesia with varying amounts of sedation. Fentanyl and morphine are the most widely used opioid analgesics to manage moderate-to-severe procedural pain in children.

Morphine. Morphine remains the gold standard for pediatric opioid analgesia, partly because it can be administered SC, IV, intramuscularly (IM), and orally. Its properties are more quickly achieved via the IV route, as the onset of action is 4 to 6 minutes. The standard IV dose of morphine is 0.1 mg/kg per dose, and can provide analgesia for up to 4 hours.

Adverse effects of morphine include dependence (though not an issue with a single emergency dose), respiratory depression, nausea, vomiting, constipation, urinary retention, hypotension, and bradycardia. Naloxone can rapidly reverse these adverse effects.

Fentanyl. Fentanyl, which is 100 times more potent than morphine, can be administered IV, transdermally, or transmucosally. When given IV, the onset of action of fentanyl is 2 to 3 minutes, and duration of action of 30 to 60 minutes. For sedation and analgesia, the suggested IV dose of fentanyl in neonates and young infants is 1 to 4 mcg/kg every 2 to 4 hours as needed, and for older infants and children, 1 to 2 mcg/kg every 30 to 60 minutes as needed.

Adverse effects of fentanyl are respiratory depression and chest wall rigidity,⁹ which can be rapidly reversed with naloxone (the dose of naloxone by patient weight is the same as that given to reverse adverse effects of morphine and fentanyl).

Codeine. A weaker opioid analgesic, codeine is not recommended for routine pediatric use because of its significant potential to hypermetabolize to morphine in some children, leading to overdose.⁶

Benzodiazepines: Midazolam

Benzodiazepines, which act on the type A gamma-aminobutyric acid receptor, causing muscle relaxation, anxiolysis, and anterograde amnesia, are useful for pediatric procedural sedation. Due to its short half-life, midazolam is the most common benzodiazepine used in pediatric patients. Midazolam can be delivered via different routes of administration, including orally, IM, IV, and transmucosally.

Intramuscular Route. Intramuscular midazolam has been shown to cause deep sedation at doses of 0.3 mg/kg, with maximum sedation occurring at 45 minutes, recovery beginning by 60 minutes, and the most common side effect being euphoria.¹⁰

Intravenous Route. Intravenous midazolam is used extensively in pediatric procedural sedation and is usually given at a dose of 0.05 to 0.1 mg/kg, with a maximum dose of 2 mg.

Even among small children, midazolam is usually quite safe when given alone, but because it does not provide effective analgesia, it often requires combination with an opioid for effective procedural sedation. Flumazenil may be given for rapid reversal of known benzodiazepine-induced respiratory depression, but it should be avoided in children with seizure disorders.

Propofol

Propofol is now frequently employed for pediatric sedation outside of the operating room. Propofol has excellent sedation properties but, like midazolam, does not provide analgesia and necessitates a second agent such as ketamine or an opioid for successful completion of more painful procedures. However, for children in whom sedation is required to facilitate simple neuroimaging of the head or spine, propofol is a very useful agent given the child’s quick return to his/her baseline mental status following the procedure.

Regarding contraindications, since propofol contains egg lecithin and soybean oil, it was once considered inappropriate for use in patients with an egg or soy allergy. Recent data, however, have refuted this belief, and while the package insert for propofol still lists patient allergy to egg, egg products, soy, or soybeans as a contraindication to use,¹¹ the American Academy of Allergy, Asthma and Immunology recently concluded that patients with soy allergy or egg allergy can receive propofol without any special precautions.¹²

Since propofol is a powerful sedative and can cause a greater depth of sedation than that intended, providers must be comfortable with both monitoring and managing the pediatric airway. The induction dose of propofol is 1 mg/kg with repeated doses of 0.5 mg/kg to achieve the desired level of sedation. One emergency medicine-specific study by Jasiak et al¹³ found a mean cumulative propofol dose of 2.1 mg/kg for pediatric procedures given in a median of three boluses, with younger children requiring an overall higher mg/kg induction dose. Another study by Young et al¹⁴ showed an induction dose of 2 mg/kg to be well tolerated and without increased adverse events for pediatric procedural sedation.

When used properly, propofol has been shown to be safe and effective in pediatric patients. A recent review by Mallory et al¹⁵ looking at 25,433 cases of EP administration of propofol to pediatric patients noted serious complications in only 2% of patients, including one unplanned intubation, one cardiac arrest, and two aspirations.

Ketamine

Dissociative procedural sedation is frequently utilized in pediatric patients, for which ketamine is usually the agent of choice given its fast onset of action, multiple modes of administration, and robust pediatric safety data. Ketamine is a unique agent because of its sedative, analgesic, and paralytic-like properties. A phencyclidine derivative, ketamine exerts its effect by binding to the N-methyl-D-aspartate receptor, and may be given IM or IV, with usual dosing of 1 to 1.5 mg/kg IV, or 2 to 4 mg/kg IM. Unlike other sedatives, there is a “dissociation threshold” for ketamine, and further dosing does not increase its effects.¹⁶

Because of multiple observations and reported cases of airway complications in infants younger than 3 months of age, it is not recommended for routine use in this age group. While ketamine-associated infant airway events are thought by some experts to not be specific to ketamine (and more representative of infant differences in airway anatomy and laryngeal excitability), risks seem to outweigh benefits for routine use in this cohort.¹⁶

Ketamine is known to exaggerate protective airway reflexes and can cause laryngospasm, so it is best avoided during procedures that cause a large amount of pharyngeal stimulation. The overall rate of ketamine-induced pediatric laryngospasm is low in the general population (0.3%), and when it does occur, can usually be treated easily with assisted ventilation and oxygenation.¹⁷

Prior concerns of ketamine increasing intracranial pressure (ICP) have been shown not to be the case by recent data, which in fact demonstrate that ketamine may instead actually lower ICP.¹⁸

For many pediatric centers, including the authors’, ketamine is a first-line agent to facilitate head and/or neck CT in otherwise uncooperative children. Emesis is the most common side effect of ketamine, but the incidence can be significantly reduced by pretreating the patient with ondansetron.¹⁹ Though ketamine may also be combined with propofol, there is no robust pediatric-specific evidence showing any benefits of this practice.

Nitrous Oxide

Nitrous oxide (N₂O), the most commonly used inhaled anesthetic agent used in the pediatric ED, provides analgesia, sedation, anterograde amnesia, and anxiolysis. It can be given in mixtures of 30% to 70% N₂O with oxygen, has a rapid onset of action (<1 minute), and there is rapid recovery after cessation. In patients older than 5 years of age, N₂O is usually given via a demand valve system, which will fall off the patient’s face if he or she becomes overly sedated.

Nitrous oxide is usually very well tolerated with few serious events, the most common being emesis.²⁰ Absolute contraindications to its use are few and include pneumothorax, pulmonary blebs, bowel obstruction, air embolus, and a recent history of intracranial or middle ear surgery.

Intranasal Analgesia

Intranasal (IN) analgesics are becoming increasingly popular for pediatric procedures because of their rapid onset of action compared with oral medications, without the need for IV or “needle” access prior to administration.

Intranasal Fentanyl. The EP should use a mucosal atomizer when administering midazolam or fentanyl via the IN route. The atomizer transforms these liquid drugs into a fine spray, which increases surface area, improving mucosal absorption and central nervous system concentrations when compared with IN administration via dropper.²¹

In a study by Klein et al,²² IN midazolam effectively provided sedation, with more effective diminution of activity and better overall patient satisfaction than with either oral or buccal midazolam. Intranasal midazolam causes a slight burning sensation, and some patients report initial discomfort after administration. The half-lives of IN and IV midazolam are very similar (2.2 vs 2.4 hours).²³Intranasal Fentanyl. IN fentanyl is an excellent alternative to IV pain medications for patients in whom there is no IV access. When given at a dose of 1.7 mcg/kg, IN fentanyl produces analgesic effects similar to that of morphine 0.1 mg/kg.

The only reported adverse effect associated with IN fentanyl has been a bad taste in the mouth.²⁴ Another study of children aged 1 to 3 years showed a significant decrease in pain in 93% of children at 10 minutes, and 98% of children at 30 minutes, with no significant side effects.²⁵

Intranasal fentanyl is a great choice for initial and immediate pain control in children with suspected long bone fractures, and is especially useful in facilitating their comfort during radiographic imaging.

Managing a Child for Radiographic Imaging

To facilitate a relatively rapid procedure such as obtaining plain films or a CT scan, anxiolysis, rather than analgesia, is required. Given its quick and predictable onset of action, IN midazolam is an excellent choice for pediatric patients requiring imaging studies. If, however, a mucosal atomizer is not available for IN drug delivery and the patient is already in radiology and requires emergent imaging studies, oral midazolam should not be given as an alternative because of its delayed onset of action. In such cases, placing an IV line and administering IV propofol offers the best chance of achieving quick and effective anxiolysis to obtain the images required to exclude clinically important injuries.

In hospitals that restrict the use of propofol in young children outside of the operating room—and when there are no findings suggestive of impending cerebral herniation—a safe and effective alternative is IV ketamine at a dose of 1.5 mg/kg.

Cases Continued

Case 1

[The 4-year-old boy with the fractured wrist.]

Recognizing that repeated attempts at IV placement in a child with a contralateral extremity fracture often leads to escalating distress and anxiety, the EP decided against further attempts to place an IV line. Instead, he gave the child fentanyl via the IN route, which immediately relieved the patient’s pain and facilitated radiographic evaluation. After administrating the fentanyl IN, the EP instructed a member of the ED staff to apply LMX4 cream to several potential IV sites and then cover each site with occlusive dressings. Afterward, the patient was taken to radiology, and X-ray images of the fracture were easily obtained. When the patient returned from imaging, the ED nurse was able to place an IV line at one of the sites that had been previously anesthetized with LMX4 cream.

The EP consulted with the orthopedist, who determined that the child’s distal radius fracture necessitated closed reduction. To facilitate the procedure, the patient was given 1.5 mg/kg of ketamine. After a successful closed reduction, the orthopedic chief resident recommended the EP discharge the 15-kg (33-lb) patient home in the care of his parents, with a prescription for 5 mL oral acetaminophen and codeine suspension four times a day as needed for pain (5 mL = acetaminophen 120 mg/codeine 12 mg, and codeine dosed at 0.5-1 mg/kg per dose). Prior to discharge, the EP counseled the patient’s parents on the risks of codeine hypermetabolism in children. However, based on the parents’ expressed concerns, the EP instead discharged the patient home with a prescription for 4 cc oral acetaminophen-hydrocodone elixir every 4 to 6 hours as needed for pain instead (dosing is 0.27 mL/kg; elixir is hydrocodone bitartrate 7.5 mg/acetaminophen 325 mg/15 mL).

Case 2

[The 6-year-old girl with a large laceration to her forehead.]

The type of laceration sustained by this patient was appropriate for treatment with a local anesthetic combined with an agent for non-IV anxiolysis. Thirty minutes prior to suturing, LET gel was applied over the open wound site, and 5 minutes prior to initiating closure of the wound, the patient received IN midazolam. Since the LET cream was placed on the wound 30 minutes prior to the procedure, the site was well anesthetized for both irrigation and closure. The anxiolytic effects of the IN midazolam resulted in a calm patient, who was happy and playful throughout the procedure.

After successfully closing the wound, the physician discharged the patient home in the care of her parents, with instructions to apply bacitracin ointment to the wound site three times a day for the next 3 days, and give the patient over-the-counter acetaminophen elixir for any mild discomfort.

Case 3

[The 5-year-old boy who suffered cervical spine injuries after falling head-first off of a balance beam during gymnastics.]

Since no mucosal atomizer was available for IN drug delivery, and hospital policy restricted the use of propofol in young children outside of the operating room, the patient was given 1.5 mg/kg of IV ketamine. Within 45 seconds of ketamine administration, the child had adequate dissociative sedation, which allowed for high-quality CT scans of both the head and neck without incident. 

Case 4

[The febrile 3-week-old female neonate referred by her pediatrician for evaluation and LP.]

Since this neonate did not appear toxic, the EP delayed the LP by 30 minutes to allow time for application of a topical anesthetic to minimize associated procedural pain. Thirty minutes prior to the LP, LMX4 cream was applied to the patient’s L4 spinal interspace, and just prior to the procedure, the patient was given a pacifier that had been dipped in a solution of 4% sucrose. The neonate was then positioned appropriately for the LP and barely squirmed when the spinal needle was introduced, allowing the EP to obtain a nontraumatic cerebrospinal fluid sample on the first attempt.

Conclusion

Addressing pediatric pain and anxiety, especially preceding and during procedures and radiographic imaging, is a serious challenge in the ED. Several means are now available to provide safe and effective sedation, analgesia, and anxiolysis in the ED, with or without IV access. Many of the medications utilized, however, can cause significant respiratory and CV depression, making proper patient selection and monitoring, and training of involved personnel imperative to ensure safe use in the ED. Appropriate use of the agents and strategies discussed above will allow EPs to reduce both procedural pain and anxiety for our youngest patients—and their parents.

For many years, pediatric patients undergoing procedures in the ED have received inadequate pain management and sedation. Children’s (and parents’) anxieties and distress leading up to and during a potentially painful or anxiety-inducing procedure are now more easily mitigated by the appropriate use of a variety of pediatric-appropriate analgesics, sedatives, and anxiolytics. The ability to provide adequate, minimally invasive sedation and analgesia is critically important to performing successful procedures in children, and is a hallmark of excellent pediatric emergency care.

The following case vignettes, based on actual cases, illustrate the range and routes of medications available to provide appropriate analgesia, sedation, and anxiolysis.

Cases

Case 1

A 4-year-old boy presented to the ED for evaluation of a fractured wrist sustained after he fell off his bed during a temper tantrum. At presentation, the patient’s vital signs were: blood pressure (BP), 110/70 mm Hg; heart rate (HR), 100 beats/min; respiratory rate (RR), 28 breaths/min; and temperature (T), 99.5°F. Oxygen saturation on room air was within normal limits. The patient’s weight was within normal range for his age and height at 15 kg (33 lb).

Upon examination, the child appeared agitated and in significant distress; his anxiety increased after an initial attempt at placing an intravenous (IV) line in his uninjured arm failed.

The emergency physician (EP) considered several options to ameliorate the child’s anxiety and facilitate evaluation and treatment.

Case 2

After accidentally running into a pole, a 6-year-old girl presented to the ED for evaluation and suturing of a large laceration to her forehead. At presentation, the patient’s vital signs were: BP, 115/70 mm Hg; HR, 95 beats/min; RR, 24 breaths/min; and T, 98.6°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 20 kg (44 lb).

On examination, the patient was awake, alert, and in no acute distress. However, she immediately became tearful and visibly upset when she learned that an IV line was about to be placed in her arm.

The physician instead decided to employ an IV/needle-free strategy for this wound repair, as well as anxiolysis.

Case 3

A 5-year-old girl was brought to a community hospital ED by emergency medical services after falling from a balance beam and landing headfirst on the ground during a gymnastics class. Prior to presentation, emergency medical technicians had placed the patient in a cervical collar. At presentation, the patient’s vital signs were: BP, 105/75 mm Hg; HR, 115 beats/min; RR, 28 breaths/min; and T, 99.1°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 18 kg (39.6 lb).

Although the neurological examination was normal, the patient had persistent midline cervical tenderness as well as hemotympanum. The EP ordered a head and neck computed tomography (CT) scan, but shortly after the patient arrived at radiology, the CT technician informed the EP that she was unable to perform the scan because the patient kept moving and would not stay still.

The EP considered several sedatives to facilitate the CT study.

Case 4

A febrile, but nontoxic-appearing 3-week-old girl was referred to the ED by her pediatrician for a lumbar puncture (LP) to diagnose or exclude meningitis. However, the mother’s own recent negative experience with an epidural analgesia during the patient’s delivery, made the neonate’s mother extremely anxious that the procedure might be too painful for her daughter.

The EP considered the best choice of medication to provide analgesia and allay the mother’s concerns prior to performing the LP in this neonatal patient.

Overview and Definitions

Analgesia describes the alleviation of pain without intentional sedation. However, pediatric patients typically receive sedative hypnotics (anxiolytics) both for analgesia and for anxiolysis to modify behavior (eg, enhance immobility) and to allow for the safe completion of a procedure.¹ The ultimate goal of procedural sedation and analgesia is to provide a depressed level of consciousness and pain relief while the patient maintains a patent airway and spontaneous ventilation.²

Sedation Continuum

The American Society of Anesthesiologists (ASA) classifies procedural sedation and analgesia based on a sedation continuum that affects overall responsiveness, airway, ventilation, and cardiovascular (CV) function.³ Procedural sedation is subcategorized into minimal, moderate, and deep sedation.

Minimal Sedation. Formally referred to as anxiolysis, minimal sedation is a state in which the patient is responsive but somewhat cognitively impaired, while maintaining all other functions rated in the sedation continuum.

Moderate Sedation. Previously referred to as “conscious sedation,” moderate sedation is a state of drug-induced depression of consciousness that still enables the patient to maintain purposeful responses to age-appropriate verbal commands and tactile stimulation, spontaneous ventilation, and CV integrity.

Deep Sedation. Deep sedation causes a drug-induced depression of consciousness that may potentially impair spontaneous ventilation and independent airway patency, while maintaining CV function. A deeply sedated patient is usually arousable with repeated painful stimulation.

Dissociative Sedation. This level of sedation induces a unique, trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. The dissociative state can facilitate the performance of moderate-to-severe painful procedures, as well as procedures requiring immobilization in uncooperative patients.⁴

Contraindications to Procedural Sedation

Though there are no absolute contraindications to procedural sedation in children, its use is generally determined based on ASA’s patient physical status classification system. In this grading system, procedural sedation is appropriate for pediatric patients with a physical status of Class I (normally healthy patient) or Class II (a patient with mild systemic disease—eg, mild asthma).⁵ The EP should consult with a pediatric anesthesiologist prior to sedating a patient with an ASA status of Class II or higher, or a patient with a known laryngotracheal pathology.¹

Pre- and Postsedation Considerations

History and Physical Examination

Prior to patient sedation, the EP should perform a focused history, including a determination of the patient’s last meal and/or drink, and a physical examination. The history should also include known allergies and past or current medication use—specifically any history of adverse events associated with prior sedation. Pregnancy status should be determined in every postpubertal female patient.

The physical examination should focus on the cardiac and respiratory systems, with particular attention to any airway abnormalities or possible sources of obstruction.^1,3

Fasting

A need for fasting prior to procedural sedation remains controversial: Current ASA guidelines for fasting call for fasting times of 2 hours for clear liquids, 4 hours after breastfeeding, 6 hours for nonhuman milk or formula feeding, and 8 hours for solids.⁶

Fasting prior to general anesthesia has become a common requirement because of the risk of adverse respiratory events, including apnea, stridor, bronchospasm, emesis, and pulmonary aspiration of gastric contents. However, these events rarely occur during pediatric procedural sedation in the ED, and it is important to note that the American College of Emergency Physicians’ standards do not require delaying procedural sedation based on fasting times. There is no strong evidence that the duration of preprocedural sedation-fasting reduces or prevents emesis or aspiration.⁷

Equipment

In 2016, the American Academy of Pediatrics (AAP) updated its “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures,”¹ including the essential equipment required for the safe administration of sedation, which can be remembered using the following “SOAPME” mnemonic:

Size: appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction);

Oxygen: An adequate oxygen supply and functioning flow meters or other devices to allow its delivery;

Airway: Size-appropriate equipment (eg, bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, laryngeal mask airway, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask;

Pharmacy: All the basic drugs needed to support life during an emergency, including antagonists as indicated;

Monitors: Functioning pulse oximeter with size-appropriate oximeter probes, end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, electrocardiogram, stethoscope); and

Equipment: Special equipment or drugs for a particular case (eg, defibrillator).¹

Personnel

The 2016 AAP guidelines¹ also indicate the number and type of personnel needed for sedation—in addition to the physician performing the procedure—which is primarily determined by the intended level of sedation as follows:

Minimal Sedation. Though there are no set guidelines for minimal sedation, all providers must be capable of caring for a child who progresses to moderate sedation.

Moderate Sedation. Intentional moderate sedation necessitates two practitioners: one practitioner to oversee the sedation and monitor the patient’s vital signs, who is capable of rescuing the patient from deep sedation if it occurs; and a second provider proficient at least in basic life support to monitor vital signs and assist in a resuscitation as needed.

Deep Sedation. For patients requiring deep sedation, the practitioner administering or supervising sedative drug administration should have no other responsibilities other than observing the patient. Moreover, there must be at least one other individual present who is certified in advanced life support and airway management.¹

Discharge Criteria

Prior to discharge, pediatric patients must meet predetermined criteria that include easy arousability, a return to baseline mental status, stable age-appropriate vital signs, and the ability to remain hydrated.^1,3 In addition, while late postsedation complications are rare, caregivers should be provided with specific symptoms that would warrant immediate return to the ED.

Available Options for Analgesia and Sedation

Several different methods of providing analgesia and pediatric procedural sedation are available, ranging from nonpharmacological methods to topical and parenteral medication administration.

Nonpharmacological Options: Child-Life Specialists

Child-life specialists can be particularly helpful with pediatric emergency patients. With a background in normal child development, child-life specialists utilize myriad distraction techniques and coping strategies to help patients within the stressful environment of an ED. Studies have shown that the presence of a child-life specialist may reduce the depth of sedation needed for certain procedures.¹

Sucrose

Several studies have identified the benefits of sucrose as a pain reliever in neonates. Available as a 12% to 25% solution, sucrose decreases noxious stimuli and is a useful analgesic for such common neonatal procedures as venipuncture, circumcision, heel sticks, Foley catheter insertion, and LP. Efficacy of sucrose for these procedures is greatest in newborns, and decreases gradually after 6 months of age. The effectiveness of sucrose is enhanced when it is given in conjunction with nonnutritive sucking or maternal “skin-to-skin” techniques. There are no contraindications to the use of sucrose.⁸

Nonopioid Systemic Analgesia

Nonopioid oral analgesics (NOAs), such as acetaminophen and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen, are appropriate for mild-to-moderate procedural pain. The NOAs can be given alone or in conjunction with an opioid to enhance the analgesic effect for patients with severe pain.

Acetaminophen. Acetaminophen, which also has antipyretic properties, can be administered orally, rectally, or IV. Since acetaminophen is not an NSAID and does not affect platelet function, it is a good choice for treating patients with gastrointestinal (GI) pain.

Adverse effects of acetaminophen, which is metabolized by the liver, include hepatotoxicity in toxic doses. The suggested oral dose for infants and children weighing less than 60 kg (132 lb) is 10 to 15 mg/kg per dose every 4 to 6 hours as needed, with a maximum dose of 75 mg/kg/d for infants and 100 mg/kg/d for children. Rectal dosing for infants and children weighing less than 60 kg (132 lb) is 10 to 20 mg/kg every 6 hours as needed, with a maximum daily dose of 75 mg/kg/d in infants, and 100 mg/kg/d in children.

Ibuprofen. Ibuprofen, an NSAID with both antipyretic and anti-inflammatory properties, acts as a prostaglandin inhibitor and is indicated for use in patients over 6 months of age. Since ibuprofen inhibits platelet function, it can cause GI bleeding with chronic use. The suggested pediatric dose for ibuprofen is 5 to 10 mg/kg per dose every 6 to 8 hours orally, with a maximum dose of 40 mg/kg/d.⁹

Local Anesthesia

Local anesthetics administered via the topical or subcutaneous (SC) route provide anesthesia by temporarily blocking peripheral or central nerve conduction at the sodium channel.

LET Gel. This topical anesthetic combination composed of 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine (LET gel) is commonly used on patients prior to repair of a skin laceration. Its peak onset of action occurs in 30 minutes, with an anesthetic duration of 45 minutes. The epinephrine component of LET reduces blood flow to the anesthetized area, which increases duration of action but also creates a small risk of vasoconstriction in the areas supplied by end arteries, such as in the penis, nose, digits, and pinna.⁹

EMLA and LMX4. Topical lidocaine anesthetics are extremely useful in the ED because their application can help reduce the pain of minor procedures, when they are applied in adequate time prior to initiating the procedure to reach peak effect. Eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) and liposomal 4% lidocaine (LMX4) are the most commonly used topical lidocaine anesthetics. The peak analgesic effect of EMLA occurs within 60 minutes, with a duration of 90 minutes; LMX4 reaches its analgesic peak after 30 minutes with duration of up to 60 minutes.

Because of the slight delay of the time-to-peak effect, these topical anesthetics are not useful for emergent procedures. Further, neither EMLA nor LMX4 is approved for nonintact skin injuries such as lacerations.⁹ Both LMX4 and EMLA are approved for use in intact skin, providing effective analgesia for procedures such as venipuncture, circumcision, LP, and abscess drainage.

Subcutaneous Lidocaine. When SC injection of lidocaine is preferred, a useful technique to reduce the pain of administration is to warm the lidocaine, alkalinize the solution with 1 mL (1 mEq) sodium bicarbonate to 9 mL lidocaine,⁶ prior to injecting it slowly with a small-gauge needle.⁸Vapocoolant Lidocaine. Vapocoolant sprays produce an immediate cold sensation that is effective in reducing localized pain in adults. Studies looking at its efficacy in children are not as convincing, with some studies suggesting the cold sensation is quite distressing for many children.⁸

Opioids

Opioids are commonly chosen for pediatric procedural sedation because of their short onset of action and ability to produce significant analgesia with varying amounts of sedation. Fentanyl and morphine are the most widely used opioid analgesics to manage moderate-to-severe procedural pain in children.

Morphine. Morphine remains the gold standard for pediatric opioid analgesia, partly because it can be administered SC, IV, intramuscularly (IM), and orally. Its properties are more quickly achieved via the IV route, as the onset of action is 4 to 6 minutes. The standard IV dose of morphine is 0.1 mg/kg per dose, and can provide analgesia for up to 4 hours.

Adverse effects of morphine include dependence (though not an issue with a single emergency dose), respiratory depression, nausea, vomiting, constipation, urinary retention, hypotension, and bradycardia. Naloxone can rapidly reverse these adverse effects.

Fentanyl. Fentanyl, which is 100 times more potent than morphine, can be administered IV, transdermally, or transmucosally. When given IV, the onset of action of fentanyl is 2 to 3 minutes, and duration of action of 30 to 60 minutes. For sedation and analgesia, the suggested IV dose of fentanyl in neonates and young infants is 1 to 4 mcg/kg every 2 to 4 hours as needed, and for older infants and children, 1 to 2 mcg/kg every 30 to 60 minutes as needed.

Adverse effects of fentanyl are respiratory depression and chest wall rigidity,⁹ which can be rapidly reversed with naloxone (the dose of naloxone by patient weight is the same as that given to reverse adverse effects of morphine and fentanyl).

Codeine. A weaker opioid analgesic, codeine is not recommended for routine pediatric use because of its significant potential to hypermetabolize to morphine in some children, leading to overdose.⁶

Benzodiazepines: Midazolam

Benzodiazepines, which act on the type A gamma-aminobutyric acid receptor, causing muscle relaxation, anxiolysis, and anterograde amnesia, are useful for pediatric procedural sedation. Due to its short half-life, midazolam is the most common benzodiazepine used in pediatric patients. Midazolam can be delivered via different routes of administration, including orally, IM, IV, and transmucosally.

Intramuscular Route. Intramuscular midazolam has been shown to cause deep sedation at doses of 0.3 mg/kg, with maximum sedation occurring at 45 minutes, recovery beginning by 60 minutes, and the most common side effect being euphoria.¹⁰

Intravenous Route. Intravenous midazolam is used extensively in pediatric procedural sedation and is usually given at a dose of 0.05 to 0.1 mg/kg, with a maximum dose of 2 mg.

Even among small children, midazolam is usually quite safe when given alone, but because it does not provide effective analgesia, it often requires combination with an opioid for effective procedural sedation. Flumazenil may be given for rapid reversal of known benzodiazepine-induced respiratory depression, but it should be avoided in children with seizure disorders.

Propofol

Propofol is now frequently employed for pediatric sedation outside of the operating room. Propofol has excellent sedation properties but, like midazolam, does not provide analgesia and necessitates a second agent such as ketamine or an opioid for successful completion of more painful procedures. However, for children in whom sedation is required to facilitate simple neuroimaging of the head or spine, propofol is a very useful agent given the child’s quick return to his/her baseline mental status following the procedure.

Regarding contraindications, since propofol contains egg lecithin and soybean oil, it was once considered inappropriate for use in patients with an egg or soy allergy. Recent data, however, have refuted this belief, and while the package insert for propofol still lists patient allergy to egg, egg products, soy, or soybeans as a contraindication to use,¹¹ the American Academy of Allergy, Asthma and Immunology recently concluded that patients with soy allergy or egg allergy can receive propofol without any special precautions.¹²

Since propofol is a powerful sedative and can cause a greater depth of sedation than that intended, providers must be comfortable with both monitoring and managing the pediatric airway. The induction dose of propofol is 1 mg/kg with repeated doses of 0.5 mg/kg to achieve the desired level of sedation. One emergency medicine-specific study by Jasiak et al¹³ found a mean cumulative propofol dose of 2.1 mg/kg for pediatric procedures given in a median of three boluses, with younger children requiring an overall higher mg/kg induction dose. Another study by Young et al¹⁴ showed an induction dose of 2 mg/kg to be well tolerated and without increased adverse events for pediatric procedural sedation.

When used properly, propofol has been shown to be safe and effective in pediatric patients. A recent review by Mallory et al¹⁵ looking at 25,433 cases of EP administration of propofol to pediatric patients noted serious complications in only 2% of patients, including one unplanned intubation, one cardiac arrest, and two aspirations.

Ketamine

Dissociative procedural sedation is frequently utilized in pediatric patients, for which ketamine is usually the agent of choice given its fast onset of action, multiple modes of administration, and robust pediatric safety data. Ketamine is a unique agent because of its sedative, analgesic, and paralytic-like properties. A phencyclidine derivative, ketamine exerts its effect by binding to the N-methyl-D-aspartate receptor, and may be given IM or IV, with usual dosing of 1 to 1.5 mg/kg IV, or 2 to 4 mg/kg IM. Unlike other sedatives, there is a “dissociation threshold” for ketamine, and further dosing does not increase its effects.¹⁶

Because of multiple observations and reported cases of airway complications in infants younger than 3 months of age, it is not recommended for routine use in this age group. While ketamine-associated infant airway events are thought by some experts to not be specific to ketamine (and more representative of infant differences in airway anatomy and laryngeal excitability), risks seem to outweigh benefits for routine use in this cohort.¹⁶

Ketamine is known to exaggerate protective airway reflexes and can cause laryngospasm, so it is best avoided during procedures that cause a large amount of pharyngeal stimulation. The overall rate of ketamine-induced pediatric laryngospasm is low in the general population (0.3%), and when it does occur, can usually be treated easily with assisted ventilation and oxygenation.¹⁷

Prior concerns of ketamine increasing intracranial pressure (ICP) have been shown not to be the case by recent data, which in fact demonstrate that ketamine may instead actually lower ICP.¹⁸

For many pediatric centers, including the authors’, ketamine is a first-line agent to facilitate head and/or neck CT in otherwise uncooperative children. Emesis is the most common side effect of ketamine, but the incidence can be significantly reduced by pretreating the patient with ondansetron.¹⁹ Though ketamine may also be combined with propofol, there is no robust pediatric-specific evidence showing any benefits of this practice.

Nitrous Oxide

Nitrous oxide (N₂O), the most commonly used inhaled anesthetic agent used in the pediatric ED, provides analgesia, sedation, anterograde amnesia, and anxiolysis. It can be given in mixtures of 30% to 70% N₂O with oxygen, has a rapid onset of action (<1 minute), and there is rapid recovery after cessation. In patients older than 5 years of age, N₂O is usually given via a demand valve system, which will fall off the patient’s face if he or she becomes overly sedated.

Nitrous oxide is usually very well tolerated with few serious events, the most common being emesis.²⁰ Absolute contraindications to its use are few and include pneumothorax, pulmonary blebs, bowel obstruction, air embolus, and a recent history of intracranial or middle ear surgery.

Intranasal Analgesia

Intranasal (IN) analgesics are becoming increasingly popular for pediatric procedures because of their rapid onset of action compared with oral medications, without the need for IV or “needle” access prior to administration.

Intranasal Fentanyl. The EP should use a mucosal atomizer when administering midazolam or fentanyl via the IN route. The atomizer transforms these liquid drugs into a fine spray, which increases surface area, improving mucosal absorption and central nervous system concentrations when compared with IN administration via dropper.²¹

In a study by Klein et al,²² IN midazolam effectively provided sedation, with more effective diminution of activity and better overall patient satisfaction than with either oral or buccal midazolam. Intranasal midazolam causes a slight burning sensation, and some patients report initial discomfort after administration. The half-lives of IN and IV midazolam are very similar (2.2 vs 2.4 hours).²³Intranasal Fentanyl. IN fentanyl is an excellent alternative to IV pain medications for patients in whom there is no IV access. When given at a dose of 1.7 mcg/kg, IN fentanyl produces analgesic effects similar to that of morphine 0.1 mg/kg.

The only reported adverse effect associated with IN fentanyl has been a bad taste in the mouth.²⁴ Another study of children aged 1 to 3 years showed a significant decrease in pain in 93% of children at 10 minutes, and 98% of children at 30 minutes, with no significant side effects.²⁵

Intranasal fentanyl is a great choice for initial and immediate pain control in children with suspected long bone fractures, and is especially useful in facilitating their comfort during radiographic imaging.

Managing a Child for Radiographic Imaging

To facilitate a relatively rapid procedure such as obtaining plain films or a CT scan, anxiolysis, rather than analgesia, is required. Given its quick and predictable onset of action, IN midazolam is an excellent choice for pediatric patients requiring imaging studies. If, however, a mucosal atomizer is not available for IN drug delivery and the patient is already in radiology and requires emergent imaging studies, oral midazolam should not be given as an alternative because of its delayed onset of action. In such cases, placing an IV line and administering IV propofol offers the best chance of achieving quick and effective anxiolysis to obtain the images required to exclude clinically important injuries.

In hospitals that restrict the use of propofol in young children outside of the operating room—and when there are no findings suggestive of impending cerebral herniation—a safe and effective alternative is IV ketamine at a dose of 1.5 mg/kg.

Cases Continued

Case 1

[The 4-year-old boy with the fractured wrist.]

Recognizing that repeated attempts at IV placement in a child with a contralateral extremity fracture often leads to escalating distress and anxiety, the EP decided against further attempts to place an IV line. Instead, he gave the child fentanyl via the IN route, which immediately relieved the patient’s pain and facilitated radiographic evaluation. After administrating the fentanyl IN, the EP instructed a member of the ED staff to apply LMX4 cream to several potential IV sites and then cover each site with occlusive dressings. Afterward, the patient was taken to radiology, and X-ray images of the fracture were easily obtained. When the patient returned from imaging, the ED nurse was able to place an IV line at one of the sites that had been previously anesthetized with LMX4 cream.

The EP consulted with the orthopedist, who determined that the child’s distal radius fracture necessitated closed reduction. To facilitate the procedure, the patient was given 1.5 mg/kg of ketamine. After a successful closed reduction, the orthopedic chief resident recommended the EP discharge the 15-kg (33-lb) patient home in the care of his parents, with a prescription for 5 mL oral acetaminophen and codeine suspension four times a day as needed for pain (5 mL = acetaminophen 120 mg/codeine 12 mg, and codeine dosed at 0.5-1 mg/kg per dose). Prior to discharge, the EP counseled the patient’s parents on the risks of codeine hypermetabolism in children. However, based on the parents’ expressed concerns, the EP instead discharged the patient home with a prescription for 4 cc oral acetaminophen-hydrocodone elixir every 4 to 6 hours as needed for pain instead (dosing is 0.27 mL/kg; elixir is hydrocodone bitartrate 7.5 mg/acetaminophen 325 mg/15 mL).

Case 2

[The 6-year-old girl with a large laceration to her forehead.]

The type of laceration sustained by this patient was appropriate for treatment with a local anesthetic combined with an agent for non-IV anxiolysis. Thirty minutes prior to suturing, LET gel was applied over the open wound site, and 5 minutes prior to initiating closure of the wound, the patient received IN midazolam. Since the LET cream was placed on the wound 30 minutes prior to the procedure, the site was well anesthetized for both irrigation and closure. The anxiolytic effects of the IN midazolam resulted in a calm patient, who was happy and playful throughout the procedure.

After successfully closing the wound, the physician discharged the patient home in the care of her parents, with instructions to apply bacitracin ointment to the wound site three times a day for the next 3 days, and give the patient over-the-counter acetaminophen elixir for any mild discomfort.

Case 3

[The 5-year-old boy who suffered cervical spine injuries after falling head-first off of a balance beam during gymnastics.]

Since no mucosal atomizer was available for IN drug delivery, and hospital policy restricted the use of propofol in young children outside of the operating room, the patient was given 1.5 mg/kg of IV ketamine. Within 45 seconds of ketamine administration, the child had adequate dissociative sedation, which allowed for high-quality CT scans of both the head and neck without incident. 

Case 4

[The febrile 3-week-old female neonate referred by her pediatrician for evaluation and LP.]

Since this neonate did not appear toxic, the EP delayed the LP by 30 minutes to allow time for application of a topical anesthetic to minimize associated procedural pain. Thirty minutes prior to the LP, LMX4 cream was applied to the patient’s L4 spinal interspace, and just prior to the procedure, the patient was given a pacifier that had been dipped in a solution of 4% sucrose. The neonate was then positioned appropriately for the LP and barely squirmed when the spinal needle was introduced, allowing the EP to obtain a nontraumatic cerebrospinal fluid sample on the first attempt.

Conclusion

Addressing pediatric pain and anxiety, especially preceding and during procedures and radiographic imaging, is a serious challenge in the ED. Several means are now available to provide safe and effective sedation, analgesia, and anxiolysis in the ED, with or without IV access. Many of the medications utilized, however, can cause significant respiratory and CV depression, making proper patient selection and monitoring, and training of involved personnel imperative to ensure safe use in the ED. Appropriate use of the agents and strategies discussed above will allow EPs to reduce both procedural pain and anxiety for our youngest patients—and their parents.

For many years, pediatric patients undergoing procedures in the ED have received inadequate pain management and sedation. Children’s (and parents’) anxieties and distress leading up to and during a potentially painful or anxiety-inducing procedure are now more easily mitigated by the appropriate use of a variety of pediatric-appropriate analgesics, sedatives, and anxiolytics. The ability to provide adequate, minimally invasive sedation and analgesia is critically important to performing successful procedures in children, and is a hallmark of excellent pediatric emergency care.

The following case vignettes, based on actual cases, illustrate the range and routes of medications available to provide appropriate analgesia, sedation, and anxiolysis.

Cases

Case 1

A 4-year-old boy presented to the ED for evaluation of a fractured wrist sustained after he fell off his bed during a temper tantrum. At presentation, the patient’s vital signs were: blood pressure (BP), 110/70 mm Hg; heart rate (HR), 100 beats/min; respiratory rate (RR), 28 breaths/min; and temperature (T), 99.5°F. Oxygen saturation on room air was within normal limits. The patient’s weight was within normal range for his age and height at 15 kg (33 lb).

Upon examination, the child appeared agitated and in significant distress; his anxiety increased after an initial attempt at placing an intravenous (IV) line in his uninjured arm failed.

The emergency physician (EP) considered several options to ameliorate the child’s anxiety and facilitate evaluation and treatment.

Case 2

After accidentally running into a pole, a 6-year-old girl presented to the ED for evaluation and suturing of a large laceration to her forehead. At presentation, the patient’s vital signs were: BP, 115/70 mm Hg; HR, 95 beats/min; RR, 24 breaths/min; and T, 98.6°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 20 kg (44 lb).

On examination, the patient was awake, alert, and in no acute distress. However, she immediately became tearful and visibly upset when she learned that an IV line was about to be placed in her arm.

The physician instead decided to employ an IV/needle-free strategy for this wound repair, as well as anxiolysis.

Case 3

A 5-year-old girl was brought to a community hospital ED by emergency medical services after falling from a balance beam and landing headfirst on the ground during a gymnastics class. Prior to presentation, emergency medical technicians had placed the patient in a cervical collar. At presentation, the patient’s vital signs were: BP, 105/75 mm Hg; HR, 115 beats/min; RR, 28 breaths/min; and T, 99.1°F. Oxygen saturation on room air was within normal limits. The patient’s body weight was normal for her age and height at 18 kg (39.6 lb).

Although the neurological examination was normal, the patient had persistent midline cervical tenderness as well as hemotympanum. The EP ordered a head and neck computed tomography (CT) scan, but shortly after the patient arrived at radiology, the CT technician informed the EP that she was unable to perform the scan because the patient kept moving and would not stay still.

The EP considered several sedatives to facilitate the CT study.

Case 4

A febrile, but nontoxic-appearing 3-week-old girl was referred to the ED by her pediatrician for a lumbar puncture (LP) to diagnose or exclude meningitis. However, the mother’s own recent negative experience with an epidural analgesia during the patient’s delivery, made the neonate’s mother extremely anxious that the procedure might be too painful for her daughter.

The EP considered the best choice of medication to provide analgesia and allay the mother’s concerns prior to performing the LP in this neonatal patient.

Overview and Definitions

Analgesia describes the alleviation of pain without intentional sedation. However, pediatric patients typically receive sedative hypnotics (anxiolytics) both for analgesia and for anxiolysis to modify behavior (eg, enhance immobility) and to allow for the safe completion of a procedure.¹ The ultimate goal of procedural sedation and analgesia is to provide a depressed level of consciousness and pain relief while the patient maintains a patent airway and spontaneous ventilation.²

Sedation Continuum

The American Society of Anesthesiologists (ASA) classifies procedural sedation and analgesia based on a sedation continuum that affects overall responsiveness, airway, ventilation, and cardiovascular (CV) function.³ Procedural sedation is subcategorized into minimal, moderate, and deep sedation.

Minimal Sedation. Formally referred to as anxiolysis, minimal sedation is a state in which the patient is responsive but somewhat cognitively impaired, while maintaining all other functions rated in the sedation continuum.

Moderate Sedation. Previously referred to as “conscious sedation,” moderate sedation is a state of drug-induced depression of consciousness that still enables the patient to maintain purposeful responses to age-appropriate verbal commands and tactile stimulation, spontaneous ventilation, and CV integrity.

Deep Sedation. Deep sedation causes a drug-induced depression of consciousness that may potentially impair spontaneous ventilation and independent airway patency, while maintaining CV function. A deeply sedated patient is usually arousable with repeated painful stimulation.

Dissociative Sedation. This level of sedation induces a unique, trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. The dissociative state can facilitate the performance of moderate-to-severe painful procedures, as well as procedures requiring immobilization in uncooperative patients.⁴

Contraindications to Procedural Sedation

Though there are no absolute contraindications to procedural sedation in children, its use is generally determined based on ASA’s patient physical status classification system. In this grading system, procedural sedation is appropriate for pediatric patients with a physical status of Class I (normally healthy patient) or Class II (a patient with mild systemic disease—eg, mild asthma).⁵ The EP should consult with a pediatric anesthesiologist prior to sedating a patient with an ASA status of Class II or higher, or a patient with a known laryngotracheal pathology.¹

Pre- and Postsedation Considerations

History and Physical Examination

Prior to patient sedation, the EP should perform a focused history, including a determination of the patient’s last meal and/or drink, and a physical examination. The history should also include known allergies and past or current medication use—specifically any history of adverse events associated with prior sedation. Pregnancy status should be determined in every postpubertal female patient.

The physical examination should focus on the cardiac and respiratory systems, with particular attention to any airway abnormalities or possible sources of obstruction.^1,3

Fasting

A need for fasting prior to procedural sedation remains controversial: Current ASA guidelines for fasting call for fasting times of 2 hours for clear liquids, 4 hours after breastfeeding, 6 hours for nonhuman milk or formula feeding, and 8 hours for solids.⁶

Fasting prior to general anesthesia has become a common requirement because of the risk of adverse respiratory events, including apnea, stridor, bronchospasm, emesis, and pulmonary aspiration of gastric contents. However, these events rarely occur during pediatric procedural sedation in the ED, and it is important to note that the American College of Emergency Physicians’ standards do not require delaying procedural sedation based on fasting times. There is no strong evidence that the duration of preprocedural sedation-fasting reduces or prevents emesis or aspiration.⁷

Equipment

In 2016, the American Academy of Pediatrics (AAP) updated its “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures,”¹ including the essential equipment required for the safe administration of sedation, which can be remembered using the following “SOAPME” mnemonic:

Size: appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction);

Oxygen: An adequate oxygen supply and functioning flow meters or other devices to allow its delivery;

Airway: Size-appropriate equipment (eg, bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, laryngeal mask airway, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask;

Pharmacy: All the basic drugs needed to support life during an emergency, including antagonists as indicated;

Monitors: Functioning pulse oximeter with size-appropriate oximeter probes, end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, electrocardiogram, stethoscope); and

Equipment: Special equipment or drugs for a particular case (eg, defibrillator).¹

Personnel

The 2016 AAP guidelines¹ also indicate the number and type of personnel needed for sedation—in addition to the physician performing the procedure—which is primarily determined by the intended level of sedation as follows:

Minimal Sedation. Though there are no set guidelines for minimal sedation, all providers must be capable of caring for a child who progresses to moderate sedation.

Moderate Sedation. Intentional moderate sedation necessitates two practitioners: one practitioner to oversee the sedation and monitor the patient’s vital signs, who is capable of rescuing the patient from deep sedation if it occurs; and a second provider proficient at least in basic life support to monitor vital signs and assist in a resuscitation as needed.

Deep Sedation. For patients requiring deep sedation, the practitioner administering or supervising sedative drug administration should have no other responsibilities other than observing the patient. Moreover, there must be at least one other individual present who is certified in advanced life support and airway management.¹

Discharge Criteria

Prior to discharge, pediatric patients must meet predetermined criteria that include easy arousability, a return to baseline mental status, stable age-appropriate vital signs, and the ability to remain hydrated.^1,3 In addition, while late postsedation complications are rare, caregivers should be provided with specific symptoms that would warrant immediate return to the ED.

Available Options for Analgesia and Sedation

Several different methods of providing analgesia and pediatric procedural sedation are available, ranging from nonpharmacological methods to topical and parenteral medication administration.

Nonpharmacological Options: Child-Life Specialists

Child-life specialists can be particularly helpful with pediatric emergency patients. With a background in normal child development, child-life specialists utilize myriad distraction techniques and coping strategies to help patients within the stressful environment of an ED. Studies have shown that the presence of a child-life specialist may reduce the depth of sedation needed for certain procedures.¹

Sucrose

Several studies have identified the benefits of sucrose as a pain reliever in neonates. Available as a 12% to 25% solution, sucrose decreases noxious stimuli and is a useful analgesic for such common neonatal procedures as venipuncture, circumcision, heel sticks, Foley catheter insertion, and LP. Efficacy of sucrose for these procedures is greatest in newborns, and decreases gradually after 6 months of age. The effectiveness of sucrose is enhanced when it is given in conjunction with nonnutritive sucking or maternal “skin-to-skin” techniques. There are no contraindications to the use of sucrose.⁸

Nonopioid Systemic Analgesia

Nonopioid oral analgesics (NOAs), such as acetaminophen and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen, are appropriate for mild-to-moderate procedural pain. The NOAs can be given alone or in conjunction with an opioid to enhance the analgesic effect for patients with severe pain.

Acetaminophen. Acetaminophen, which also has antipyretic properties, can be administered orally, rectally, or IV. Since acetaminophen is not an NSAID and does not affect platelet function, it is a good choice for treating patients with gastrointestinal (GI) pain.

Adverse effects of acetaminophen, which is metabolized by the liver, include hepatotoxicity in toxic doses. The suggested oral dose for infants and children weighing less than 60 kg (132 lb) is 10 to 15 mg/kg per dose every 4 to 6 hours as needed, with a maximum dose of 75 mg/kg/d for infants and 100 mg/kg/d for children. Rectal dosing for infants and children weighing less than 60 kg (132 lb) is 10 to 20 mg/kg every 6 hours as needed, with a maximum daily dose of 75 mg/kg/d in infants, and 100 mg/kg/d in children.

Ibuprofen. Ibuprofen, an NSAID with both antipyretic and anti-inflammatory properties, acts as a prostaglandin inhibitor and is indicated for use in patients over 6 months of age. Since ibuprofen inhibits platelet function, it can cause GI bleeding with chronic use. The suggested pediatric dose for ibuprofen is 5 to 10 mg/kg per dose every 6 to 8 hours orally, with a maximum dose of 40 mg/kg/d.⁹

Local Anesthesia

Local anesthetics administered via the topical or subcutaneous (SC) route provide anesthesia by temporarily blocking peripheral or central nerve conduction at the sodium channel.

LET Gel. This topical anesthetic combination composed of 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine (LET gel) is commonly used on patients prior to repair of a skin laceration. Its peak onset of action occurs in 30 minutes, with an anesthetic duration of 45 minutes. The epinephrine component of LET reduces blood flow to the anesthetized area, which increases duration of action but also creates a small risk of vasoconstriction in the areas supplied by end arteries, such as in the penis, nose, digits, and pinna.⁹

EMLA and LMX4. Topical lidocaine anesthetics are extremely useful in the ED because their application can help reduce the pain of minor procedures, when they are applied in adequate time prior to initiating the procedure to reach peak effect. Eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) and liposomal 4% lidocaine (LMX4) are the most commonly used topical lidocaine anesthetics. The peak analgesic effect of EMLA occurs within 60 minutes, with a duration of 90 minutes; LMX4 reaches its analgesic peak after 30 minutes with duration of up to 60 minutes.

Because of the slight delay of the time-to-peak effect, these topical anesthetics are not useful for emergent procedures. Further, neither EMLA nor LMX4 is approved for nonintact skin injuries such as lacerations.⁹ Both LMX4 and EMLA are approved for use in intact skin, providing effective analgesia for procedures such as venipuncture, circumcision, LP, and abscess drainage.

Subcutaneous Lidocaine. When SC injection of lidocaine is preferred, a useful technique to reduce the pain of administration is to warm the lidocaine, alkalinize the solution with 1 mL (1 mEq) sodium bicarbonate to 9 mL lidocaine,⁶ prior to injecting it slowly with a small-gauge needle.⁸Vapocoolant Lidocaine. Vapocoolant sprays produce an immediate cold sensation that is effective in reducing localized pain in adults. Studies looking at its efficacy in children are not as convincing, with some studies suggesting the cold sensation is quite distressing for many children.⁸

Opioids

Opioids are commonly chosen for pediatric procedural sedation because of their short onset of action and ability to produce significant analgesia with varying amounts of sedation. Fentanyl and morphine are the most widely used opioid analgesics to manage moderate-to-severe procedural pain in children.

Morphine. Morphine remains the gold standard for pediatric opioid analgesia, partly because it can be administered SC, IV, intramuscularly (IM), and orally. Its properties are more quickly achieved via the IV route, as the onset of action is 4 to 6 minutes. The standard IV dose of morphine is 0.1 mg/kg per dose, and can provide analgesia for up to 4 hours.

Adverse effects of morphine include dependence (though not an issue with a single emergency dose), respiratory depression, nausea, vomiting, constipation, urinary retention, hypotension, and bradycardia. Naloxone can rapidly reverse these adverse effects.

Fentanyl. Fentanyl, which is 100 times more potent than morphine, can be administered IV, transdermally, or transmucosally. When given IV, the onset of action of fentanyl is 2 to 3 minutes, and duration of action of 30 to 60 minutes. For sedation and analgesia, the suggested IV dose of fentanyl in neonates and young infants is 1 to 4 mcg/kg every 2 to 4 hours as needed, and for older infants and children, 1 to 2 mcg/kg every 30 to 60 minutes as needed.

Adverse effects of fentanyl are respiratory depression and chest wall rigidity,⁹ which can be rapidly reversed with naloxone (the dose of naloxone by patient weight is the same as that given to reverse adverse effects of morphine and fentanyl).

Codeine. A weaker opioid analgesic, codeine is not recommended for routine pediatric use because of its significant potential to hypermetabolize to morphine in some children, leading to overdose.⁶

Benzodiazepines: Midazolam

Benzodiazepines, which act on the type A gamma-aminobutyric acid receptor, causing muscle relaxation, anxiolysis, and anterograde amnesia, are useful for pediatric procedural sedation. Due to its short half-life, midazolam is the most common benzodiazepine used in pediatric patients. Midazolam can be delivered via different routes of administration, including orally, IM, IV, and transmucosally.

Intramuscular Route. Intramuscular midazolam has been shown to cause deep sedation at doses of 0.3 mg/kg, with maximum sedation occurring at 45 minutes, recovery beginning by 60 minutes, and the most common side effect being euphoria.¹⁰

Intravenous Route. Intravenous midazolam is used extensively in pediatric procedural sedation and is usually given at a dose of 0.05 to 0.1 mg/kg, with a maximum dose of 2 mg.

Even among small children, midazolam is usually quite safe when given alone, but because it does not provide effective analgesia, it often requires combination with an opioid for effective procedural sedation. Flumazenil may be given for rapid reversal of known benzodiazepine-induced respiratory depression, but it should be avoided in children with seizure disorders.

Propofol

Propofol is now frequently employed for pediatric sedation outside of the operating room. Propofol has excellent sedation properties but, like midazolam, does not provide analgesia and necessitates a second agent such as ketamine or an opioid for successful completion of more painful procedures. However, for children in whom sedation is required to facilitate simple neuroimaging of the head or spine, propofol is a very useful agent given the child’s quick return to his/her baseline mental status following the procedure.

Regarding contraindications, since propofol contains egg lecithin and soybean oil, it was once considered inappropriate for use in patients with an egg or soy allergy. Recent data, however, have refuted this belief, and while the package insert for propofol still lists patient allergy to egg, egg products, soy, or soybeans as a contraindication to use,¹¹ the American Academy of Allergy, Asthma and Immunology recently concluded that patients with soy allergy or egg allergy can receive propofol without any special precautions.¹²

Since propofol is a powerful sedative and can cause a greater depth of sedation than that intended, providers must be comfortable with both monitoring and managing the pediatric airway. The induction dose of propofol is 1 mg/kg with repeated doses of 0.5 mg/kg to achieve the desired level of sedation. One emergency medicine-specific study by Jasiak et al¹³ found a mean cumulative propofol dose of 2.1 mg/kg for pediatric procedures given in a median of three boluses, with younger children requiring an overall higher mg/kg induction dose. Another study by Young et al¹⁴ showed an induction dose of 2 mg/kg to be well tolerated and without increased adverse events for pediatric procedural sedation.

When used properly, propofol has been shown to be safe and effective in pediatric patients. A recent review by Mallory et al¹⁵ looking at 25,433 cases of EP administration of propofol to pediatric patients noted serious complications in only 2% of patients, including one unplanned intubation, one cardiac arrest, and two aspirations.

Ketamine

Dissociative procedural sedation is frequently utilized in pediatric patients, for which ketamine is usually the agent of choice given its fast onset of action, multiple modes of administration, and robust pediatric safety data. Ketamine is a unique agent because of its sedative, analgesic, and paralytic-like properties. A phencyclidine derivative, ketamine exerts its effect by binding to the N-methyl-D-aspartate receptor, and may be given IM or IV, with usual dosing of 1 to 1.5 mg/kg IV, or 2 to 4 mg/kg IM. Unlike other sedatives, there is a “dissociation threshold” for ketamine, and further dosing does not increase its effects.¹⁶

Because of multiple observations and reported cases of airway complications in infants younger than 3 months of age, it is not recommended for routine use in this age group. While ketamine-associated infant airway events are thought by some experts to not be specific to ketamine (and more representative of infant differences in airway anatomy and laryngeal excitability), risks seem to outweigh benefits for routine use in this cohort.¹⁶

Ketamine is known to exaggerate protective airway reflexes and can cause laryngospasm, so it is best avoided during procedures that cause a large amount of pharyngeal stimulation. The overall rate of ketamine-induced pediatric laryngospasm is low in the general population (0.3%), and when it does occur, can usually be treated easily with assisted ventilation and oxygenation.¹⁷

Prior concerns of ketamine increasing intracranial pressure (ICP) have been shown not to be the case by recent data, which in fact demonstrate that ketamine may instead actually lower ICP.¹⁸

For many pediatric centers, including the authors’, ketamine is a first-line agent to facilitate head and/or neck CT in otherwise uncooperative children. Emesis is the most common side effect of ketamine, but the incidence can be significantly reduced by pretreating the patient with ondansetron.¹⁹ Though ketamine may also be combined with propofol, there is no robust pediatric-specific evidence showing any benefits of this practice.

Nitrous Oxide

Nitrous oxide (N₂O), the most commonly used inhaled anesthetic agent used in the pediatric ED, provides analgesia, sedation, anterograde amnesia, and anxiolysis. It can be given in mixtures of 30% to 70% N₂O with oxygen, has a rapid onset of action (<1 minute), and there is rapid recovery after cessation. In patients older than 5 years of age, N₂O is usually given via a demand valve system, which will fall off the patient’s face if he or she becomes overly sedated.

Nitrous oxide is usually very well tolerated with few serious events, the most common being emesis.²⁰ Absolute contraindications to its use are few and include pneumothorax, pulmonary blebs, bowel obstruction, air embolus, and a recent history of intracranial or middle ear surgery.

Intranasal Analgesia

Intranasal (IN) analgesics are becoming increasingly popular for pediatric procedures because of their rapid onset of action compared with oral medications, without the need for IV or “needle” access prior to administration.

Intranasal Fentanyl. The EP should use a mucosal atomizer when administering midazolam or fentanyl via the IN route. The atomizer transforms these liquid drugs into a fine spray, which increases surface area, improving mucosal absorption and central nervous system concentrations when compared with IN administration via dropper.²¹

In a study by Klein et al,²² IN midazolam effectively provided sedation, with more effective diminution of activity and better overall patient satisfaction than with either oral or buccal midazolam. Intranasal midazolam causes a slight burning sensation, and some patients report initial discomfort after administration. The half-lives of IN and IV midazolam are very similar (2.2 vs 2.4 hours).²³Intranasal Fentanyl. IN fentanyl is an excellent alternative to IV pain medications for patients in whom there is no IV access. When given at a dose of 1.7 mcg/kg, IN fentanyl produces analgesic effects similar to that of morphine 0.1 mg/kg.

The only reported adverse effect associated with IN fentanyl has been a bad taste in the mouth.²⁴ Another study of children aged 1 to 3 years showed a significant decrease in pain in 93% of children at 10 minutes, and 98% of children at 30 minutes, with no significant side effects.²⁵

Intranasal fentanyl is a great choice for initial and immediate pain control in children with suspected long bone fractures, and is especially useful in facilitating their comfort during radiographic imaging.

Managing a Child for Radiographic Imaging

To facilitate a relatively rapid procedure such as obtaining plain films or a CT scan, anxiolysis, rather than analgesia, is required. Given its quick and predictable onset of action, IN midazolam is an excellent choice for pediatric patients requiring imaging studies. If, however, a mucosal atomizer is not available for IN drug delivery and the patient is already in radiology and requires emergent imaging studies, oral midazolam should not be given as an alternative because of its delayed onset of action. In such cases, placing an IV line and administering IV propofol offers the best chance of achieving quick and effective anxiolysis to obtain the images required to exclude clinically important injuries.

In hospitals that restrict the use of propofol in young children outside of the operating room—and when there are no findings suggestive of impending cerebral herniation—a safe and effective alternative is IV ketamine at a dose of 1.5 mg/kg.

Cases Continued

Case 1

[The 4-year-old boy with the fractured wrist.]

Recognizing that repeated attempts at IV placement in a child with a contralateral extremity fracture often leads to escalating distress and anxiety, the EP decided against further attempts to place an IV line. Instead, he gave the child fentanyl via the IN route, which immediately relieved the patient’s pain and facilitated radiographic evaluation. After administrating the fentanyl IN, the EP instructed a member of the ED staff to apply LMX4 cream to several potential IV sites and then cover each site with occlusive dressings. Afterward, the patient was taken to radiology, and X-ray images of the fracture were easily obtained. When the patient returned from imaging, the ED nurse was able to place an IV line at one of the sites that had been previously anesthetized with LMX4 cream.

The EP consulted with the orthopedist, who determined that the child’s distal radius fracture necessitated closed reduction. To facilitate the procedure, the patient was given 1.5 mg/kg of ketamine. After a successful closed reduction, the orthopedic chief resident recommended the EP discharge the 15-kg (33-lb) patient home in the care of his parents, with a prescription for 5 mL oral acetaminophen and codeine suspension four times a day as needed for pain (5 mL = acetaminophen 120 mg/codeine 12 mg, and codeine dosed at 0.5-1 mg/kg per dose). Prior to discharge, the EP counseled the patient’s parents on the risks of codeine hypermetabolism in children. However, based on the parents’ expressed concerns, the EP instead discharged the patient home with a prescription for 4 cc oral acetaminophen-hydrocodone elixir every 4 to 6 hours as needed for pain instead (dosing is 0.27 mL/kg; elixir is hydrocodone bitartrate 7.5 mg/acetaminophen 325 mg/15 mL).

Case 2

[The 6-year-old girl with a large laceration to her forehead.]

The type of laceration sustained by this patient was appropriate for treatment with a local anesthetic combined with an agent for non-IV anxiolysis. Thirty minutes prior to suturing, LET gel was applied over the open wound site, and 5 minutes prior to initiating closure of the wound, the patient received IN midazolam. Since the LET cream was placed on the wound 30 minutes prior to the procedure, the site was well anesthetized for both irrigation and closure. The anxiolytic effects of the IN midazolam resulted in a calm patient, who was happy and playful throughout the procedure.

After successfully closing the wound, the physician discharged the patient home in the care of her parents, with instructions to apply bacitracin ointment to the wound site three times a day for the next 3 days, and give the patient over-the-counter acetaminophen elixir for any mild discomfort.

Case 3

[The 5-year-old boy who suffered cervical spine injuries after falling head-first off of a balance beam during gymnastics.]

Since no mucosal atomizer was available for IN drug delivery, and hospital policy restricted the use of propofol in young children outside of the operating room, the patient was given 1.5 mg/kg of IV ketamine. Within 45 seconds of ketamine administration, the child had adequate dissociative sedation, which allowed for high-quality CT scans of both the head and neck without incident. 

Case 4

[The febrile 3-week-old female neonate referred by her pediatrician for evaluation and LP.]

Since this neonate did not appear toxic, the EP delayed the LP by 30 minutes to allow time for application of a topical anesthetic to minimize associated procedural pain. Thirty minutes prior to the LP, LMX4 cream was applied to the patient’s L4 spinal interspace, and just prior to the procedure, the patient was given a pacifier that had been dipped in a solution of 4% sucrose. The neonate was then positioned appropriately for the LP and barely squirmed when the spinal needle was introduced, allowing the EP to obtain a nontraumatic cerebrospinal fluid sample on the first attempt.

Conclusion

Addressing pediatric pain and anxiety, especially preceding and during procedures and radiographic imaging, is a serious challenge in the ED. Several means are now available to provide safe and effective sedation, analgesia, and anxiolysis in the ED, with or without IV access. Many of the medications utilized, however, can cause significant respiratory and CV depression, making proper patient selection and monitoring, and training of involved personnel imperative to ensure safe use in the ED. Appropriate use of the agents and strategies discussed above will allow EPs to reduce both procedural pain and anxiety for our youngest patients—and their parents.

Photo by Bill Branson

Neuroscientists say they have uncovered genetic differences between radiation-induced meningiomas (RIMs) and sporadic meningiomas (SMs).

Their work suggests RIMs have a different “mutational landscape” from SMs, a finding that may have “significant therapeutic implications” for childhood cancer survivors who undergo cranial radiation.

Gelareh Zadeh, MD, PhD, of the University of Toronto in Ontario, Canada, and her colleagues reported these findings in Nature Communications.

“Radiation-induced meningiomas appear the same [as SMs] on MRI and pathology, feel the same during surgery, and look the same under the operating microscope,” Dr Zadeh said.

“What’s different is they are more aggressive, tend to recur in multiples, and invade the brain, causing significant morbidity and limitations (or impairments) for individuals who survive following childhood radiation. By understanding the biology, the goal is to identify a therapeutic strategy that could be implemented early on after childhood radiation to prevent the formation of these tumors in the first place.”

To better understand the biology, Dr Zadeh and her colleagues analyzed 31 RIMs. This included 18 tumors from 16 patients with childhood cancers, 9 with leukemia.

The researchers found NF2 gene rearrangements in 12 of the RIMs and noted that such rearrangements have not been observed in SMs.

On the other hand, recurrent mutations characteristic of SMs—AKT1, KLF4, TRAF7, and SMO—were not found in the RIMs.

The researchers also noted that, overall, chromosomal aberrations in RIMs were more complex than those observed in SMs. And combined loss of chromosomes 1p and 22q was common in RIMs (16/18).

“Our research identified a specific rearrangement involving the NF2 gene that causes radiation-induced meningiomas,” said Kenneth Aldape, MD, of University Health Network in Toronto.

“But there are likely other genetic rearrangements that are occurring as a result of that radiation-induced DNA damage. So one of the next steps is to identify what the radiation is doing to the DNA of the meninges.”

“In addition, identifying the subset of childhood cancer patients who are at highest risk to develop meningioma is critical so that they could be followed closely for early detection and management.”

Photo by Bill Branson

Neuroscientists say they have uncovered genetic differences between radiation-induced meningiomas (RIMs) and sporadic meningiomas (SMs).

Their work suggests RIMs have a different “mutational landscape” from SMs, a finding that may have “significant therapeutic implications” for childhood cancer survivors who undergo cranial radiation.

Gelareh Zadeh, MD, PhD, of the University of Toronto in Ontario, Canada, and her colleagues reported these findings in Nature Communications.

“Radiation-induced meningiomas appear the same [as SMs] on MRI and pathology, feel the same during surgery, and look the same under the operating microscope,” Dr Zadeh said.

“What’s different is they are more aggressive, tend to recur in multiples, and invade the brain, causing significant morbidity and limitations (or impairments) for individuals who survive following childhood radiation. By understanding the biology, the goal is to identify a therapeutic strategy that could be implemented early on after childhood radiation to prevent the formation of these tumors in the first place.”

To better understand the biology, Dr Zadeh and her colleagues analyzed 31 RIMs. This included 18 tumors from 16 patients with childhood cancers, 9 with leukemia.

The researchers found NF2 gene rearrangements in 12 of the RIMs and noted that such rearrangements have not been observed in SMs.

On the other hand, recurrent mutations characteristic of SMs—AKT1, KLF4, TRAF7, and SMO—were not found in the RIMs.

The researchers also noted that, overall, chromosomal aberrations in RIMs were more complex than those observed in SMs. And combined loss of chromosomes 1p and 22q was common in RIMs (16/18).

“Our research identified a specific rearrangement involving the NF2 gene that causes radiation-induced meningiomas,” said Kenneth Aldape, MD, of University Health Network in Toronto.

“But there are likely other genetic rearrangements that are occurring as a result of that radiation-induced DNA damage. So one of the next steps is to identify what the radiation is doing to the DNA of the meninges.”

“In addition, identifying the subset of childhood cancer patients who are at highest risk to develop meningioma is critical so that they could be followed closely for early detection and management.”

Photo by Bill Branson

Neuroscientists say they have uncovered genetic differences between radiation-induced meningiomas (RIMs) and sporadic meningiomas (SMs).

Their work suggests RIMs have a different “mutational landscape” from SMs, a finding that may have “significant therapeutic implications” for childhood cancer survivors who undergo cranial radiation.

Gelareh Zadeh, MD, PhD, of the University of Toronto in Ontario, Canada, and her colleagues reported these findings in Nature Communications.

“Radiation-induced meningiomas appear the same [as SMs] on MRI and pathology, feel the same during surgery, and look the same under the operating microscope,” Dr Zadeh said.

“What’s different is they are more aggressive, tend to recur in multiples, and invade the brain, causing significant morbidity and limitations (or impairments) for individuals who survive following childhood radiation. By understanding the biology, the goal is to identify a therapeutic strategy that could be implemented early on after childhood radiation to prevent the formation of these tumors in the first place.”

To better understand the biology, Dr Zadeh and her colleagues analyzed 31 RIMs. This included 18 tumors from 16 patients with childhood cancers, 9 with leukemia.

The researchers found NF2 gene rearrangements in 12 of the RIMs and noted that such rearrangements have not been observed in SMs.

On the other hand, recurrent mutations characteristic of SMs—AKT1, KLF4, TRAF7, and SMO—were not found in the RIMs.

The researchers also noted that, overall, chromosomal aberrations in RIMs were more complex than those observed in SMs. And combined loss of chromosomes 1p and 22q was common in RIMs (16/18).

“Our research identified a specific rearrangement involving the NF2 gene that causes radiation-induced meningiomas,” said Kenneth Aldape, MD, of University Health Network in Toronto.

“But there are likely other genetic rearrangements that are occurring as a result of that radiation-induced DNA damage. So one of the next steps is to identify what the radiation is doing to the DNA of the meninges.”

“In addition, identifying the subset of childhood cancer patients who are at highest risk to develop meningioma is critical so that they could be followed closely for early detection and management.”

CHICAGO – Screening infants with a port-wine stain for Sturge-Weber syndrome (SWS) with a magnetic resonance imaging brain scan had a 23% false-negative rate and actually delayed seizure detection, according to a recent study.

When infants with port-wine stains receive a dermatology consult, they may also be screened for SWS by means of MRI and by electroencephalography, particularly if their lesion phenotype puts them at higher risk for SWS. But the accuracy and benefit of the screenings has not been well established, said Michaela Zallmann, MD, the study’s first author. Hemifacial lesions that involve both the forehead and cheek and median lesions that are centered around the facial midline are both considered high-risk lesions.

Dr. Zallmann, a dermatologist at Monash University and the Royal Children’s Hospital, Melbourne, and her coinvestigators examined data on 126 patients with facial port-wine stains who came to a laser clinic over a 12-month period. Of these, 32 (25.4%) had a high-risk port-wine stain, and 9 of those 32 (28.1%) had a capillary-venous malformation characteristic of SWS. Of the high-risk patients, 14 received a screening MRI or EEG before having had a first seizure. Of those 14 scans, 1 resulted in a diagnosis of SWS; of the 13 patients with a negative MRI screen, 3 (23.1%) were later found to have SWS when their parents or caregivers detected seizures. Thus, a total of four of the high-risk infants who were screened eventually were diagnosed with SWS.

Of the 18 high-risk patients who did not receive a screening MRI, 3 (16.7%) developed seizures, while 2 (11.1%) were seizure free but developed glaucoma severe enough to require treatment. One patient who was also seizure free developed an autism spectrum disorder.

Two patients who were in the high-risk group received screening EEGs that detected abnormalities that were not yet clinically evident. These included sub-clinical seizures and posterior-quadrant focal slowing. Both of these patients had initial negative screening MRIs.

Scanning early in life, using inappropriate imaging protocols, and having an inexperienced radiologist were all factors associated with a higher probability of false negative screening MRI, according to the researchers’ analysis, which was presented in a poster session at the World Congress of Pediatric Dermatology.

All of the false negative MRIs in the study cohort were conducted in infants younger than 9 weeks old. But whether it is useful to reserve imaging for later in infancy is debatable. “While later imaging may have improved sensitivity, 75% of infants with SWS will have already had their first seizure by 12 months of age,” wrote Dr. Zallmann and her colleagues.

Of the infants involved in the study, two of the three patients with false negative scans did not receive a referral to a neurologist, nor did their parents receive seizure education. “False reassurance may delay seizure detection,” Dr. Zallmann said.

For infants with positive MRIs who went on to develop seizures, the mean age of when they experienced their first documented seizure was 10 weeks. For those who did not receive an MRI, the mean age was 14 months, compared with 28 months for patients who had received a false negative MRI.

In discussing the findings, Dr. Zallmann and her colleagues made the point that early referral to a pediatric neurologist is important, especially for infants with the higher-risk port-wine stain patterns of hemifacial and median lesions. Seizure education can help parents detect the often subtle signs of seizures in infants with SWS, which can include staring spells, subtle limb twitching, and lip smacking.

The fact that seizures were detected an average of 14 months later in patients with negative screening MRIs may mean that such subtle signs were missed. “False reassurance may delay the recognition and treatment of seizures and impact neurodevelopmental outcomes,” Dr. Zallmann and her colleagues wrote in the abstract that accompanied the poster.

The study, while small, helps fill in some knowledge gaps, the researchers pointed out; they noted that there is no consensus on what level or type of facial involvement warrants screening, which protocols are best for MRI and EEG, or even whether the screening will improve seizure detection or outcomes.

“Currently there is no evidence that screening improves neurodevelopmental outcomes,” they said. “Conversely, there is a role for early neurological referral, symptom education, and potentially of EEGs in the prevention of complications related to SWS.”

Dr. Zallmann reported no conflicts of interest.
 

koakes@frontlinemedcom.com

On Twitter @karioakes

CHICAGO – Screening infants with a port-wine stain for Sturge-Weber syndrome (SWS) with a magnetic resonance imaging brain scan had a 23% false-negative rate and actually delayed seizure detection, according to a recent study.

When infants with port-wine stains receive a dermatology consult, they may also be screened for SWS by means of MRI and by electroencephalography, particularly if their lesion phenotype puts them at higher risk for SWS. But the accuracy and benefit of the screenings has not been well established, said Michaela Zallmann, MD, the study’s first author. Hemifacial lesions that involve both the forehead and cheek and median lesions that are centered around the facial midline are both considered high-risk lesions.

Dr. Zallmann, a dermatologist at Monash University and the Royal Children’s Hospital, Melbourne, and her coinvestigators examined data on 126 patients with facial port-wine stains who came to a laser clinic over a 12-month period. Of these, 32 (25.4%) had a high-risk port-wine stain, and 9 of those 32 (28.1%) had a capillary-venous malformation characteristic of SWS. Of the high-risk patients, 14 received a screening MRI or EEG before having had a first seizure. Of those 14 scans, 1 resulted in a diagnosis of SWS; of the 13 patients with a negative MRI screen, 3 (23.1%) were later found to have SWS when their parents or caregivers detected seizures. Thus, a total of four of the high-risk infants who were screened eventually were diagnosed with SWS.

Of the 18 high-risk patients who did not receive a screening MRI, 3 (16.7%) developed seizures, while 2 (11.1%) were seizure free but developed glaucoma severe enough to require treatment. One patient who was also seizure free developed an autism spectrum disorder.

Two patients who were in the high-risk group received screening EEGs that detected abnormalities that were not yet clinically evident. These included sub-clinical seizures and posterior-quadrant focal slowing. Both of these patients had initial negative screening MRIs.

Scanning early in life, using inappropriate imaging protocols, and having an inexperienced radiologist were all factors associated with a higher probability of false negative screening MRI, according to the researchers’ analysis, which was presented in a poster session at the World Congress of Pediatric Dermatology.

All of the false negative MRIs in the study cohort were conducted in infants younger than 9 weeks old. But whether it is useful to reserve imaging for later in infancy is debatable. “While later imaging may have improved sensitivity, 75% of infants with SWS will have already had their first seizure by 12 months of age,” wrote Dr. Zallmann and her colleagues.

Of the infants involved in the study, two of the three patients with false negative scans did not receive a referral to a neurologist, nor did their parents receive seizure education. “False reassurance may delay seizure detection,” Dr. Zallmann said.

For infants with positive MRIs who went on to develop seizures, the mean age of when they experienced their first documented seizure was 10 weeks. For those who did not receive an MRI, the mean age was 14 months, compared with 28 months for patients who had received a false negative MRI.

In discussing the findings, Dr. Zallmann and her colleagues made the point that early referral to a pediatric neurologist is important, especially for infants with the higher-risk port-wine stain patterns of hemifacial and median lesions. Seizure education can help parents detect the often subtle signs of seizures in infants with SWS, which can include staring spells, subtle limb twitching, and lip smacking.

The fact that seizures were detected an average of 14 months later in patients with negative screening MRIs may mean that such subtle signs were missed. “False reassurance may delay the recognition and treatment of seizures and impact neurodevelopmental outcomes,” Dr. Zallmann and her colleagues wrote in the abstract that accompanied the poster.

The study, while small, helps fill in some knowledge gaps, the researchers pointed out; they noted that there is no consensus on what level or type of facial involvement warrants screening, which protocols are best for MRI and EEG, or even whether the screening will improve seizure detection or outcomes.

“Currently there is no evidence that screening improves neurodevelopmental outcomes,” they said. “Conversely, there is a role for early neurological referral, symptom education, and potentially of EEGs in the prevention of complications related to SWS.”

Dr. Zallmann reported no conflicts of interest.
 

koakes@frontlinemedcom.com

On Twitter @karioakes

CHICAGO – Screening infants with a port-wine stain for Sturge-Weber syndrome (SWS) with a magnetic resonance imaging brain scan had a 23% false-negative rate and actually delayed seizure detection, according to a recent study.

When infants with port-wine stains receive a dermatology consult, they may also be screened for SWS by means of MRI and by electroencephalography, particularly if their lesion phenotype puts them at higher risk for SWS. But the accuracy and benefit of the screenings has not been well established, said Michaela Zallmann, MD, the study’s first author. Hemifacial lesions that involve both the forehead and cheek and median lesions that are centered around the facial midline are both considered high-risk lesions.

Dr. Zallmann, a dermatologist at Monash University and the Royal Children’s Hospital, Melbourne, and her coinvestigators examined data on 126 patients with facial port-wine stains who came to a laser clinic over a 12-month period. Of these, 32 (25.4%) had a high-risk port-wine stain, and 9 of those 32 (28.1%) had a capillary-venous malformation characteristic of SWS. Of the high-risk patients, 14 received a screening MRI or EEG before having had a first seizure. Of those 14 scans, 1 resulted in a diagnosis of SWS; of the 13 patients with a negative MRI screen, 3 (23.1%) were later found to have SWS when their parents or caregivers detected seizures. Thus, a total of four of the high-risk infants who were screened eventually were diagnosed with SWS.

Of the 18 high-risk patients who did not receive a screening MRI, 3 (16.7%) developed seizures, while 2 (11.1%) were seizure free but developed glaucoma severe enough to require treatment. One patient who was also seizure free developed an autism spectrum disorder.

Two patients who were in the high-risk group received screening EEGs that detected abnormalities that were not yet clinically evident. These included sub-clinical seizures and posterior-quadrant focal slowing. Both of these patients had initial negative screening MRIs.

Scanning early in life, using inappropriate imaging protocols, and having an inexperienced radiologist were all factors associated with a higher probability of false negative screening MRI, according to the researchers’ analysis, which was presented in a poster session at the World Congress of Pediatric Dermatology.

All of the false negative MRIs in the study cohort were conducted in infants younger than 9 weeks old. But whether it is useful to reserve imaging for later in infancy is debatable. “While later imaging may have improved sensitivity, 75% of infants with SWS will have already had their first seizure by 12 months of age,” wrote Dr. Zallmann and her colleagues.

Of the infants involved in the study, two of the three patients with false negative scans did not receive a referral to a neurologist, nor did their parents receive seizure education. “False reassurance may delay seizure detection,” Dr. Zallmann said.

For infants with positive MRIs who went on to develop seizures, the mean age of when they experienced their first documented seizure was 10 weeks. For those who did not receive an MRI, the mean age was 14 months, compared with 28 months for patients who had received a false negative MRI.

In discussing the findings, Dr. Zallmann and her colleagues made the point that early referral to a pediatric neurologist is important, especially for infants with the higher-risk port-wine stain patterns of hemifacial and median lesions. Seizure education can help parents detect the often subtle signs of seizures in infants with SWS, which can include staring spells, subtle limb twitching, and lip smacking.

The fact that seizures were detected an average of 14 months later in patients with negative screening MRIs may mean that such subtle signs were missed. “False reassurance may delay the recognition and treatment of seizures and impact neurodevelopmental outcomes,” Dr. Zallmann and her colleagues wrote in the abstract that accompanied the poster.

The study, while small, helps fill in some knowledge gaps, the researchers pointed out; they noted that there is no consensus on what level or type of facial involvement warrants screening, which protocols are best for MRI and EEG, or even whether the screening will improve seizure detection or outcomes.

“Currently there is no evidence that screening improves neurodevelopmental outcomes,” they said. “Conversely, there is a role for early neurological referral, symptom education, and potentially of EEGs in the prevention of complications related to SWS.”

Dr. Zallmann reported no conflicts of interest.
 

koakes@frontlinemedcom.com

On Twitter @karioakes

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

chestphysiciannews@chestnet.org

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

chestphysiciannews@chestnet.org

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

chestphysiciannews@chestnet.org

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

aotto@frontlinemedcom.com
 

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

aotto@frontlinemedcom.com
 

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

aotto@frontlinemedcom.com
 

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

CHICAGO – A streamlined set of diagnostic criteria from the American Academy of Dermatology’s most recent consensus criteria for diagnosing atopic dermatitis (AD) produced a specificity of more than 95%, and was also highly sensitive, a prospective analysis found.

“Atopic dermatitis typically presents in childhood and is associated with a worsened quality of life, with severe itch and lack of sleep, and substantial health care costs due to therapeutic management and increased hospitalizations,” study author Jeremy Udkoff said at the World Congress of Pediatric Dermatology. “We also know that in order to treat the disease and to learn more about it, we have to have a good tool for diagnosing it. When it comes to clinical studies and research, we require a systematic and refined set of criteria.”

dbrunk@frontlinemedcom.com

CHICAGO – A streamlined set of diagnostic criteria from the American Academy of Dermatology’s most recent consensus criteria for diagnosing atopic dermatitis (AD) produced a specificity of more than 95%, and was also highly sensitive, a prospective analysis found.

“Atopic dermatitis typically presents in childhood and is associated with a worsened quality of life, with severe itch and lack of sleep, and substantial health care costs due to therapeutic management and increased hospitalizations,” study author Jeremy Udkoff said at the World Congress of Pediatric Dermatology. “We also know that in order to treat the disease and to learn more about it, we have to have a good tool for diagnosing it. When it comes to clinical studies and research, we require a systematic and refined set of criteria.”

dbrunk@frontlinemedcom.com

CHICAGO – A streamlined set of diagnostic criteria from the American Academy of Dermatology’s most recent consensus criteria for diagnosing atopic dermatitis (AD) produced a specificity of more than 95%, and was also highly sensitive, a prospective analysis found.

“Atopic dermatitis typically presents in childhood and is associated with a worsened quality of life, with severe itch and lack of sleep, and substantial health care costs due to therapeutic management and increased hospitalizations,” study author Jeremy Udkoff said at the World Congress of Pediatric Dermatology. “We also know that in order to treat the disease and to learn more about it, we have to have a good tool for diagnosing it. When it comes to clinical studies and research, we require a systematic and refined set of criteria.”

dbrunk@frontlinemedcom.com

Photo by Bill Branson

Consolidation therapy that includes arsenic trioxide (ATO) can decrease anthracycline dosing by about 40% in children and young adults with acute promyelocytic leukemia (APL), according to new research.

And it can accomplish this without compromising survival in standard-risk patients.

Outcomes for high-risk patients compared favorably to other pediatric APL trials, the research indicated.

Investigators compared ATO consolidation in the AAML0631 trial to the historic control trial AIDA0493 and reported the results in the Journal of Clinical Oncology.

The AAML0631 phase 3 trial, conducted by the Children’s Oncology Group, compared newly diagnosed pediatric APL patients receiving ATO consolidation to the benchmark of event-free survival (EFS) in standard-risk (SR) patients established by the AIDA0493 trial.

AIDA0493 enrolled patients between January 1993 and June 2000. The protocol involved treatment with all-trans retinoic acid (ATRA), anthracyclines, and high-dose cytarabine. The trial resulted in overall survival (OS) of approximately 90%.

AAML0631

AAML063 investigators defined SR as a white blood cell count (WBC) at presentation less than 10,000 cells/μL. They defined high risk (HR) as a WBC count of 10,000 cells/μL or more.

AAML0631 patients had to be at least 2 years old and younger than 22, and their de novo APL had to be confirmed by PML-RARα polymerase chain reaction.

The patients could have had no prior leukemia treatment, except for steroids, hydroxyurea, or leukapheresis.

AAML0631 did not exclude patients based on organ function or performance status. AIDA0493, however, excluded patients with performance status of 4 or liver function tests greater than 3 times the upper limit of normal.

Patients were excluded from AAML0631 if they had preexisting prolonged QT syndrome because of the risk of QT interval prolongation with ATO.

AAML0631 treatment protocol

All patients received ATRA during induction, each consolidation course, and maintenance.

Induction therapy consisted of ATRA and idarubicin.

All patients received 2 cycles of ATO during the first consolidation. SR patients received an additional 2 consolidation courses, and HR patients received 3 consolidation courses that included high-dose cytarabine and anthracycline.

Maintenance therapy consisted of ATRA, oral methotrexate, and 6-mercaptopurine for 2 years.

Patients also received prophylactic treatment with intrathecal cytarabine.

Patient demographics

Investigators enrolled 108 patients between March 2009 and November 2012, of which 101 (66 SR and 35 HR) were evaluable.

Patients were a median age of 15.04 years (range, 2.01 – 21.34), 56% were female, 80% were white, 10% black, 2% Native American, 3% Asian, and 5% unknown.

Three quarters of the patients had an ECOG score of 0 or 1, median WBC counts of 3.8 x 1000 cells/uL (range, 0.4 – 173.8), and median platelet counts of 21.5 x 1000/uL (range, 3 – 198).

Almost two-thirds of patients (63%) had the classic translocation (15;17), and 37% had an additional 1 or more cytogenetic abnormalities.

The SR patients in AAML0631 had similar characteristics to the patients in AIDA0493 except for the distribution of performance status scores and differences in racial/ethnic diversity.

Efficacy

After a median follow-up of 3.73 years (range, 0.003 – 5.97), the 3-year overall survival (OS) was 94% ± 5% and the 3-year EFS was 91% ± 6%.

For SR patients, the OS was 98% ± 3% and the EFS 95% ± 5%.

For HR patients, the OS was 86% ± 12% and the EFS was 83% ± 13%.

SR patients had a 2-year EFS of 97%. This compared with 91% for patients in the AIDA0493 trial, which means that therapy with ATO was not inferior to therapy in the historic comparator trial (P=0.93).

And these results were achieved with a cumulative anthracycline dosing of idarubicin at 51 mg/m² (SR) and 61 mg/m² (HR) and mitoxantrone at 20 mg/m².

This compared with the AIDA0493 cumulative anthracycline dosing of 80 mg/m² of idarubicin and 50 mg/m² of mitoxantrone.

The cumulative daunorubicin equivalent in the AAML0631 trial was 335 mg/m² (SR) and 385 mg/m² (HR) compared with 600 mg/m² in the AIDA 0493 trial.

Toxicity

The percentage of patients with adverse events varied according to treatment cycle and was highest during induction and high-dose cytarabine-containing courses.

The most common adverse events were fever/neutropenia and infection.

Differentiation syndrome occurred in 20% of patients during induction, 31% in HR patients and 13% in SR patients. ATRA was held for 15 of these patients during induction. It was subsequently re-started at a lower dose and increased to the full dose.

QTc interval prolongation of grade 1 or 2 occurred in 16% (n=15) and 12% (n=11) during the ATO cycles.

One patient experienced grade 3 QTc interval prolongation during ATO consolidation. There were no grade 4 or 5 events for this toxicity.

One event of grade 1 ventricular arrhythmia and 1 event of grade 1 left ventricular systolic dysfunction occurred during ATO consolidation.

Two off-therapy cardiac events have been reported: a grade 1 QTc interval prolongation and a grade 2 ventricular arrhythmia.

No cardiac deaths have occurred, and liver toxicity was minimal during ATO cycles.

The investigators believe the favorable results of this study provide a new benchmark for outcomes in pediatric APL.

The Children’s Oncology Group is currently accruing pediatric APL patients to further investigate similar treatment approaches. 

Photo by Bill Branson

Consolidation therapy that includes arsenic trioxide (ATO) can decrease anthracycline dosing by about 40% in children and young adults with acute promyelocytic leukemia (APL), according to new research.

And it can accomplish this without compromising survival in standard-risk patients.

Outcomes for high-risk patients compared favorably to other pediatric APL trials, the research indicated.

Investigators compared ATO consolidation in the AAML0631 trial to the historic control trial AIDA0493 and reported the results in the Journal of Clinical Oncology.

The AAML0631 phase 3 trial, conducted by the Children’s Oncology Group, compared newly diagnosed pediatric APL patients receiving ATO consolidation to the benchmark of event-free survival (EFS) in standard-risk (SR) patients established by the AIDA0493 trial.

AIDA0493 enrolled patients between January 1993 and June 2000. The protocol involved treatment with all-trans retinoic acid (ATRA), anthracyclines, and high-dose cytarabine. The trial resulted in overall survival (OS) of approximately 90%.

AAML0631

AAML063 investigators defined SR as a white blood cell count (WBC) at presentation less than 10,000 cells/μL. They defined high risk (HR) as a WBC count of 10,000 cells/μL or more.

AAML0631 patients had to be at least 2 years old and younger than 22, and their de novo APL had to be confirmed by PML-RARα polymerase chain reaction.

The patients could have had no prior leukemia treatment, except for steroids, hydroxyurea, or leukapheresis.

AAML0631 did not exclude patients based on organ function or performance status. AIDA0493, however, excluded patients with performance status of 4 or liver function tests greater than 3 times the upper limit of normal.

Patients were excluded from AAML0631 if they had preexisting prolonged QT syndrome because of the risk of QT interval prolongation with ATO.

AAML0631 treatment protocol

All patients received ATRA during induction, each consolidation course, and maintenance.

Induction therapy consisted of ATRA and idarubicin.

All patients received 2 cycles of ATO during the first consolidation. SR patients received an additional 2 consolidation courses, and HR patients received 3 consolidation courses that included high-dose cytarabine and anthracycline.

Maintenance therapy consisted of ATRA, oral methotrexate, and 6-mercaptopurine for 2 years.

Patients also received prophylactic treatment with intrathecal cytarabine.

Patient demographics

Investigators enrolled 108 patients between March 2009 and November 2012, of which 101 (66 SR and 35 HR) were evaluable.

Patients were a median age of 15.04 years (range, 2.01 – 21.34), 56% were female, 80% were white, 10% black, 2% Native American, 3% Asian, and 5% unknown.

Three quarters of the patients had an ECOG score of 0 or 1, median WBC counts of 3.8 x 1000 cells/uL (range, 0.4 – 173.8), and median platelet counts of 21.5 x 1000/uL (range, 3 – 198).

Almost two-thirds of patients (63%) had the classic translocation (15;17), and 37% had an additional 1 or more cytogenetic abnormalities.

The SR patients in AAML0631 had similar characteristics to the patients in AIDA0493 except for the distribution of performance status scores and differences in racial/ethnic diversity.

Efficacy

After a median follow-up of 3.73 years (range, 0.003 – 5.97), the 3-year overall survival (OS) was 94% ± 5% and the 3-year EFS was 91% ± 6%.

For SR patients, the OS was 98% ± 3% and the EFS 95% ± 5%.

For HR patients, the OS was 86% ± 12% and the EFS was 83% ± 13%.

SR patients had a 2-year EFS of 97%. This compared with 91% for patients in the AIDA0493 trial, which means that therapy with ATO was not inferior to therapy in the historic comparator trial (P=0.93).

And these results were achieved with a cumulative anthracycline dosing of idarubicin at 51 mg/m² (SR) and 61 mg/m² (HR) and mitoxantrone at 20 mg/m².

This compared with the AIDA0493 cumulative anthracycline dosing of 80 mg/m² of idarubicin and 50 mg/m² of mitoxantrone.

The cumulative daunorubicin equivalent in the AAML0631 trial was 335 mg/m² (SR) and 385 mg/m² (HR) compared with 600 mg/m² in the AIDA 0493 trial.

Toxicity

The percentage of patients with adverse events varied according to treatment cycle and was highest during induction and high-dose cytarabine-containing courses.

The most common adverse events were fever/neutropenia and infection.

Differentiation syndrome occurred in 20% of patients during induction, 31% in HR patients and 13% in SR patients. ATRA was held for 15 of these patients during induction. It was subsequently re-started at a lower dose and increased to the full dose.

QTc interval prolongation of grade 1 or 2 occurred in 16% (n=15) and 12% (n=11) during the ATO cycles.

One patient experienced grade 3 QTc interval prolongation during ATO consolidation. There were no grade 4 or 5 events for this toxicity.

One event of grade 1 ventricular arrhythmia and 1 event of grade 1 left ventricular systolic dysfunction occurred during ATO consolidation.

Two off-therapy cardiac events have been reported: a grade 1 QTc interval prolongation and a grade 2 ventricular arrhythmia.

No cardiac deaths have occurred, and liver toxicity was minimal during ATO cycles.

The investigators believe the favorable results of this study provide a new benchmark for outcomes in pediatric APL.

The Children’s Oncology Group is currently accruing pediatric APL patients to further investigate similar treatment approaches. 

Photo by Bill Branson

Consolidation therapy that includes arsenic trioxide (ATO) can decrease anthracycline dosing by about 40% in children and young adults with acute promyelocytic leukemia (APL), according to new research.

And it can accomplish this without compromising survival in standard-risk patients.

Outcomes for high-risk patients compared favorably to other pediatric APL trials, the research indicated.

Investigators compared ATO consolidation in the AAML0631 trial to the historic control trial AIDA0493 and reported the results in the Journal of Clinical Oncology.

The AAML0631 phase 3 trial, conducted by the Children’s Oncology Group, compared newly diagnosed pediatric APL patients receiving ATO consolidation to the benchmark of event-free survival (EFS) in standard-risk (SR) patients established by the AIDA0493 trial.

AIDA0493 enrolled patients between January 1993 and June 2000. The protocol involved treatment with all-trans retinoic acid (ATRA), anthracyclines, and high-dose cytarabine. The trial resulted in overall survival (OS) of approximately 90%.

AAML0631

AAML063 investigators defined SR as a white blood cell count (WBC) at presentation less than 10,000 cells/μL. They defined high risk (HR) as a WBC count of 10,000 cells/μL or more.

AAML0631 patients had to be at least 2 years old and younger than 22, and their de novo APL had to be confirmed by PML-RARα polymerase chain reaction.

The patients could have had no prior leukemia treatment, except for steroids, hydroxyurea, or leukapheresis.

AAML0631 did not exclude patients based on organ function or performance status. AIDA0493, however, excluded patients with performance status of 4 or liver function tests greater than 3 times the upper limit of normal.

Patients were excluded from AAML0631 if they had preexisting prolonged QT syndrome because of the risk of QT interval prolongation with ATO.

AAML0631 treatment protocol

All patients received ATRA during induction, each consolidation course, and maintenance.

Induction therapy consisted of ATRA and idarubicin.

All patients received 2 cycles of ATO during the first consolidation. SR patients received an additional 2 consolidation courses, and HR patients received 3 consolidation courses that included high-dose cytarabine and anthracycline.

Maintenance therapy consisted of ATRA, oral methotrexate, and 6-mercaptopurine for 2 years.

Patients also received prophylactic treatment with intrathecal cytarabine.

Patient demographics

Investigators enrolled 108 patients between March 2009 and November 2012, of which 101 (66 SR and 35 HR) were evaluable.

Patients were a median age of 15.04 years (range, 2.01 – 21.34), 56% were female, 80% were white, 10% black, 2% Native American, 3% Asian, and 5% unknown.

Three quarters of the patients had an ECOG score of 0 or 1, median WBC counts of 3.8 x 1000 cells/uL (range, 0.4 – 173.8), and median platelet counts of 21.5 x 1000/uL (range, 3 – 198).

Almost two-thirds of patients (63%) had the classic translocation (15;17), and 37% had an additional 1 or more cytogenetic abnormalities.

The SR patients in AAML0631 had similar characteristics to the patients in AIDA0493 except for the distribution of performance status scores and differences in racial/ethnic diversity.

Efficacy

After a median follow-up of 3.73 years (range, 0.003 – 5.97), the 3-year overall survival (OS) was 94% ± 5% and the 3-year EFS was 91% ± 6%.

For SR patients, the OS was 98% ± 3% and the EFS 95% ± 5%.

For HR patients, the OS was 86% ± 12% and the EFS was 83% ± 13%.

SR patients had a 2-year EFS of 97%. This compared with 91% for patients in the AIDA0493 trial, which means that therapy with ATO was not inferior to therapy in the historic comparator trial (P=0.93).

And these results were achieved with a cumulative anthracycline dosing of idarubicin at 51 mg/m² (SR) and 61 mg/m² (HR) and mitoxantrone at 20 mg/m².

This compared with the AIDA0493 cumulative anthracycline dosing of 80 mg/m² of idarubicin and 50 mg/m² of mitoxantrone.

The cumulative daunorubicin equivalent in the AAML0631 trial was 335 mg/m² (SR) and 385 mg/m² (HR) compared with 600 mg/m² in the AIDA 0493 trial.

Toxicity

The percentage of patients with adverse events varied according to treatment cycle and was highest during induction and high-dose cytarabine-containing courses.

The most common adverse events were fever/neutropenia and infection.

Differentiation syndrome occurred in 20% of patients during induction, 31% in HR patients and 13% in SR patients. ATRA was held for 15 of these patients during induction. It was subsequently re-started at a lower dose and increased to the full dose.

QTc interval prolongation of grade 1 or 2 occurred in 16% (n=15) and 12% (n=11) during the ATO cycles.

One patient experienced grade 3 QTc interval prolongation during ATO consolidation. There were no grade 4 or 5 events for this toxicity.

One event of grade 1 ventricular arrhythmia and 1 event of grade 1 left ventricular systolic dysfunction occurred during ATO consolidation.

Two off-therapy cardiac events have been reported: a grade 1 QTc interval prolongation and a grade 2 ventricular arrhythmia.

No cardiac deaths have occurred, and liver toxicity was minimal during ATO cycles.

The investigators believe the favorable results of this study provide a new benchmark for outcomes in pediatric APL.

The Children’s Oncology Group is currently accruing pediatric APL patients to further investigate similar treatment approaches.