Emergency Physician–Administered Sedation for Thoracostomy in Children With Pleuropneumonia

Abstract

Background: Thoracostomy drainage is sometimes required in children with pleuropneumonia who have large parapneumonic effusion. This procedure is usually performed under sedation. The aim was to report sedation adverse events (SAEs) in pneumonia patients sedated for thoracostomy by pediatric emergency physicians.Methods: A retrospective cohort study was conducted. The medical records of all emergency department patients who underwent thoracostomy between January 1, 2012, and December 31, 2018, were extracted. Study outcomes were SAEs that required intervention.Results: Pigtail catheters were placed by chest surgeons in 28 children with a median age of 2 years (interquartile range [IQR], 1-5 years). All the thoracostomies were successfully performed under sedation performed by 11 pediatric emergency physicians. The median amount of fluid drained after catheter insertion was 200 mL (IQR, 100-500 mL). The median pleural fluid PH was 7.0 (IQR, 6.9-7.3), and the median white blood cell count was 34,600 per mm 3 (IQR, 11,800-109,000 per mm 3 ). Thirteen patients (46.4%) were sedated with a total median dose of 3 mg/kg of ketamine (IQR, 2-4 mg/kg) and 0.2 mg/kg of midazolam (IQR, 0.2-0.3 mg/kg); 11 patients (39.3%) were treated with 1 mg/kg of ketamine (IQR, 0.5-2 mg/kg) and 3 mg/kg of propofol (IQR, 2-4 mg/kg). Four patients (14.3%) were treated exclusively with 4 mg/kg of ketamine (IQR, 3-5 mg/kg). Nine oxygen desaturations required intervention; 1 was associated with laryngospasm and 1 with apnea. All the SAEs were successfully managed. No cases of hypotension, bradycardia, airway obstruction, or pulmonary aspiration were recorded. Conclusions:The first series of pneumonia patients sedated for thoracostomy by pediatric emergency physicians is reported. Sedation was safely performed in this cohort.

Efficacy, Safety, and Complications of Pigtail Thoracostomy for the Treatment of Pediatric Pleuropneumonia

“…2,4 In this tertiary children's hospital, PTs are inserted by acute care pediatric specialists, emergency physicians, or intensivists in a monitored setting under procedural sedation with ketamine (1-3 mg/kg) using the Seldinger technique. 10 A pigtail intercostal catheter (8.5F, Cook Medical, Ind) is the device used. Fibrinolysis is performed by instillation of urokinase (Syner-KINASE, Surrey, UK, 10 mL, 1000 IU/mL solution in children aged <1 year and 40 mL in older children).…”

“…Secondary efficacy outcomes were LOS, duration of in situ PT, and readmission for care postdischarge. 8,[15][16][17] The primary safety outcome was the occurrence of any adverse events during, or immediately after, the insertion procedure [10][11][12] and PT-associated complications. 5,15…”

Adverse events during sedation for oro‐dental trauma in an Israeli paediatric emergency department

“…In the paediatric ED of the hospital, attending paediatric emergency physicians sedate high-risk patients on a regular basis. [8][9][10] The ED protocol allows two protocols: intramuscular ketamine as a single agent with a dose of 3 or 4 mg/kg, or intravenous ketamine with a loading dose of 1 mg/ kg in combination with propofol with a loading dose of 1 mg/kg, followed by propofol boluses of 0.5-1 mg/kg every 0.5-2 min. 9,10 Older and cooperative children are sedated with a nitrous oxide (N 2 O)/oxygen mixture; the N 2 O concentration is gradually increased by 10% every 2-3 min (up to 70%), until the desired sedative effect is achieved.…”

“…[8][9][10] The ED protocol allows two protocols: intramuscular ketamine as a single agent with a dose of 3 or 4 mg/kg, or intravenous ketamine with a loading dose of 1 mg/ kg in combination with propofol with a loading dose of 1 mg/kg, followed by propofol boluses of 0.5-1 mg/kg every 0.5-2 min. 9,10 Older and cooperative children are sedated with a nitrous oxide (N 2 O)/oxygen mixture; the N 2 O concentration is gradually increased by 10% every 2-3 min (up to 70%), until the desired sedative effect is achieved. During sedation and until complete recovery, the patient's pulse oximetry, electrocardiogram and heart rate are monitored continuously.…”

“…During sedation and until complete recovery, the patient's pulse oximetry, electrocardiogram and heart rate are monitored continuously. 9,10 Patient data were extracted from the hospital's electronic medical records (Prometheus, RHCC). This computerized system is a mandatory working tool for all ED healthcare personnel.…”