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<< Best Practices In The Emergency Department Management Of Children With Special Needs

Treatment

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Treatment

Treatment

Gastrostomy And Gastrojejunal Tubes

Gastrostomy Tube Replacement

Tubes placed more recently than 6 weeks can be considered immature, in that the tract between the abdominal wall stoma and the stomach wall may not fully be formed. There is institutional variance as to when a tract is deemed mature, and this should be discussed with the service that placed the tube if there is doubt as to tract maturity. Dislodged G tubes with immature tracts should, ideally, be replaced by the specialist (surgeon or gastrointestinal physician) who placed the tube, but if he or she is unavailable, the emergency clinician can replace the tube, and confirmatory studies should be carried out to ensure the tube is within the stomach and that a false tract has not been created. Rates of complications of G tube replacement are low, with a pediatric study by Showalter et al showing complication rates of 1.2% (3 patients), none of which involved disruption of the tract as seen on dye study.75

Replacing the G tube should be done expeditiously, as delays will allow for stoma closure. Though not studied, some emergency clinicians apply a topical anesthetic (viscous lidocaine 1%) to the exit site area to, theoretically, decrease the pain of replacement. Replace the tube with one the same size as the one that was dislodged, but have a smaller one available in case the stoma has closed. If you cannot fit the original size tube into a narrowed stoma, start with a smaller-sized Foley or replacement tube and dilate it using progressively larger tubes or a set of Hegar dilators until the original tube size can be used. Replacement tubes can be a simple Foley catheter, traditional G tube, or button G tube, depending on availability. Do not force the replacement tubes in, to avoid creating a false tract. Once replaced, clinical confirmation of correct placement can be checked by suctioning gastric contents and checking the pH with litmus paper. Bedside ultrasound confirmation of tube placement has been described as well.76

There is a dearth of literature and no current standard of care for the exact indications for obtaining confirmatory studies. Confirmatory studies may include pH testing of gastric contents suctioned from the tube, and dye studies where a small amount of radiocontrast material (5-10 mL) is placed into the tube and plain films are taken. Use of dye studies to confirm placement is variable among institutions, but this routine practice may not be necessary if one can clinically prove the tube is properly placed. Evidence is limited, but the retrospective study by Showalter et al of 237 children undergoing replacement of G tubes demonstrated only 3 misplaced tubes. All 3 had no clinical confirmation documented on the chart and had symptoms of intestinal obstruction from an overfilled balloon (1 patient) and migration of the tube past the pylorus (2 patients).75

Gastrojejunal Tube Replacement

In cases of GJ tube dislodgement, contact an interventional radiologist to replace the tube under fluoroscopy or transfer the patient to an appropriate center for tube placement. If you cannot replace a tube definitively, at bare minimum, place a small catheter in the stoma to maintain patency until a more definitive feeding tube can be placed.

Removal Of Gastrojejunal Tube Obstruction

If a tube becomes clogged (which is especially common with the long narrow lumen of the GJ tube), a common practice (but unsubstantiated by compelling research) is to dwell room-temperature carbonated liquid for 15 minutes followed by a saline flush.77 Alternatively, pancreatic enzymes can be used to achieve the same relief of tube obstruction. If this fails, consultation with an interventional radiologist or surgeon may be necessary to replace the GJ tube.

Correcting Leakage At The Stoma Site

In cases where there is leakage at the stoma site, replacing the tube with a larger one may result in a progressively expanding stoma, and it is not recommended. In these patients, correct probe position and balloon inflation should be verified by pulling the tube until the balloon is snug against the internal stomach wall.78 Skin-protecting medications (such as liquid sucralfate) can be placed on the skin surrounding the exit site.79 Topical agents such as magnesium hydroxide or menthol/zinc oxide can be used as adjuncts as well. When the leakage persists for several days, the G tube can be removed (in consultation with the specialist who placed the tube) to allow partial stoma closure, and a new PEG tube can then be positioned through the same site.80 Granulation tissue may be treated using silver nitrate sticks (to stanch minor bleeding) or topical steroids.

Irritation from gastric content leakage can sometimes be mitigated by ensuring that the tube is flush against the anterior stomach wall. This can be done by first ensuring that the balloon is inflated, and then gently pulling the G tube portion outward until resistance is met, followed by pushing the external retention disc down toward the skin. This helps to seal any defects in the space between the stoma and the part of the G tube within the stomach lumen, and it prevents further leakage of stomach contents. Place a gauze pad between the disc and the abdominal wall skin. Additionally, topical sucralfate,79 magnesium hydroxide, or menthol/zinc oxide may be used to relieve the irritation of acidic stomach contents on the skin.

Infection

Oral antibiotics covering skin flora are usually adequate to treat simple peristomal cellulitis. If the child is ill-appearing, there is a large area or rapidly progressing cellulitis, or the child is vomiting (and unable to take oral antibiotics), admission for intravenous antibiotics is indicated.

Tracheostomy Tubes

Replace tubes that have broken cuff balloons. Tracheostomy tube ties should be applied to prevent accidental decannulation of the airway once a tracheostomy tube is replaced and location is confirmed by x-ray. Suction the tube if there is evidence of secretions or occlusion from mucus. The use of albuterol may help to break up mucus plugging, as beta-2-adrenoceptor agonists increase beat frequency of cilia and may, therefore, facilitate mucociliary clearance.81 Humidification can help thin secretions that are thick.

Treatment of a tracheoinnominate fistula includes surgical diversion of blood flow and endovascular interventions, such as stent grafts, until more definitive surgical therapy can be instituted.30 Temporizing measures may include inflation of the cuff of the tracheostomy tube to occlude the innominate vessel.

Antibiotics, ideally based on prior respiratory cultures, can be given enterally or intravenously (for more severe cases) to treat tracheitis and bacterial pneumonia. Oral or even topical antibiotics covering skin flora (for mild infections) are usually adequate to treat peristomal cellulitis. Ill-appearing children or children who are unable to maintain hydration or take medications will require admission for intravenous antibiotics.

Ventricular Shunts

Shunt Obstruction

Shunt obstruction is treated with revision of the shunt, either the distal segment for distal or valve obstructions or a total shunt revision for proximal shunt obstruction. In cases of possible shunt obstruction in which imaging is normal or flow studies are normal, but symptoms persist or worsen, it is reasonable to admit the patient for observation and undergo delayed revision.72 Emergent removal of CSF from the shunt reservoir (ie, tapping the shunt) can acutely reduce ICP. Hypertonic saline or mannitol can theoretically be life-saving in cases where herniation is imminent, though there are no studies examining the efficacy of these medications in this particular clinical scenario. While awaiting definitive surgical treatment, keep the head of the patient’s bed elevated to 30° and maintain systemic blood pressure within a normal range to avoid a decrease in cerebral perfusion pressure.

Shunt Infection

Shunt infections are treated by removing the infected shunt, placing an external ventricular drain, and administering intravenous antibiotics. The use of intravenous antibiotics in conjunction with removal of the infected shunt has been shown to be superior to the use of intravenous antibiotics alone without shunt removal.82,83 Some centers also give intraventricular antibiotics to provide antibiotics directly into the CSF, but this is not without controversy. There are reports of antibiotic-related toxicity and elevated endotoxin levels in infants with meningitis and ventriculitis who received intraventricular antibiotics when compared with patients who received intravenous antibiotics alone.84 However, other studies have demonstrated higher long-term cure rates using intraventricular antibiotics without increased morbidity.85,86

Antibiotics should initially include coverage for gram-positive and gram-negative organisms until culture results are known. Review past cultures, if available, and use these to guide therapy. Due to the increasing incidence of methicillin-resistant S aureus, vancomycin should be considered, often as the first-line therapy. If an abdominal pseudocyst is present, consider empiric addition of an antibiotic that covers anaerobes and coliforms.42 Although antibiotic-im-pregnated shunt systems are initially more expensive than standard shunts, they reduce shunt-related infections without breeding antibiotic-resistant organisms, and they may save money spent on revisions and hospitalizations for shunt infections.87,88

Abdominal Pseudocyst

Abdominal pseudocyst treatment involves seeking and treating the underlying infection of the shunt, as well as replacing either the distal part of the shunt (when no infection is present), or completely replacing the shunt (when infection is present and after antibiotic therapy is completed). If infection cannot be eradicated or the peritoneum is no longer suitable for the distal shunt, alternative sites can be used (eg, pleural space, right atrium, gall bladder) for the distal segment of the new shunt.

Children With Developmental And Behavioral Disabilities

Behaviorally complex children can be challenging to manage, due to their lack of ability to communicate and their varying levels of cooperation. Patients may be nonverbal and/or unable to understand the need for diagnostic imaging or a simple procedure. Because of this, patients with ASD or developmental disorders may require sedation for diagnostic procedures and therapeutic interventions that developmentally normal children would tolerate without such measures.

Nonpharmacologic Measures

Patients with ASD may be amenable to nonpharmacologic methods of management. There are few studies on communicating and managing behaviorally complex children with neurodevelopment disorders. Seasoned caregivers can offer valuable insight into what works in a given situation. Recommendations from experts in the management of these children suggest several different techniques. Communicate in a manner consistent with the patient’s primary method of communication. A reward-based system, such as giving toys or treats to the patient af-ter cooperation, may be an effective way to promote desired behaviors. Address the need for routine and sameness for the child. While it is difficult to recreate the child’s normal environment in the ED, there are some steps (as outlined in Table 4 ) that can be taken to increase cooperation in the ED. If available in your ED, a child life specialist can be a valuable resource in communicating with these patients exactly how a procedure will be performed. Setting expectations and laying out the plan of care with the patient and caregiver is a way to familiarize the patient with the procedure and minimize unwelcome surprises. Use of a child life specialist may help decrease stress in children undergoing painful procedures such as venipuncture and laceration repair, but no large controlled trials have been performed for children with developmental disorders or ASD.89,90

Table 4_ Nonpharmacological Measures To Reduce Anxiety In Children With Developmental Delay Or Autism Spectrum Disorder

Sedative/Analgesia Considerations

When nonpharmacologic interventions are not possible, or when they fail, then sedation may become necessary to safely and effectively care for these children. In selecting the level of sedation required, it is important to consider the level of cooperation by the patient to perform a needed procedure. Simple procedures such as intravenous line placement or splinting may only require minimal sedation (anxiolysis) with oral agents. Minimal sedation allows patients to continue to respond to commands and maintain cognitive function, and it requires minimal intermittent observation rather than continuous monitoring. In general, oral agents are effective for minimal sedation. Moderate sedation is necessary when a depressed level of consciousness is needed to obtain patient compliance. Moderate sedation maintains a level of consciousness and patient cooperation to verbal commands and tactile stimulation. Drugs used should be such that there is low risk of the patient slipping further into losing consciousness and into a level of deep sedation.93 Deep sedation is a state of depressed consciousness where the patient is difficult to arouse and responds only to repeated verbal commands or vigorous stimulation. Deep sedation requires a higher level of monitoring with personnel trained in the management and rescue of sedated children.94

Determine the level of sedation needed for a given procedure using the lowest dosage of medication necessary in order to reduce adverse events. In behaviorally complex children with developmental disorders or ASD, sedation with oral agents can be effective, allowing for minimal monitoring of the patient. Titration of oral agents can be challenging, as absorption of these agents can vary among patients. If a higher level of sedation than desired occurs, the emergency clinician should be prepared to switch to an increased level of monitoring as required for moderate sedation levels.93 If a patient requires more than minimal sedation, the physician should be prepared for appropriate cardiac and respiratory monitoring, including continuous electrocardiography, oxygen saturation monitoring, airway interventions, and, if available, capnography. When selecting an agent for sedation, the following should be considered: the level of sedation desired, analgesic effect, amnestic effect, pharmacokinetic profile, and side-effect profile.

There are few studies related to the use of specific medications for procedural sedation in behaviorally complex children with neurodevelopmental disorders. In a study assessing sedation for MRI among developmentally normal children versus children with developmental disorders, of 486 patients aged 1 to 18 years, 53.5% of patients were classified as having developmental disabilities. Patients were sedated with pentobarbital and fentanyl. Results revealed no difference in the doses required for sedation between the 2 groups. Children with developmental disorders had a threefold increase in hypoxic events (defined as oxygen saturation [SaO2] < 93%) compared to normal children.95 However, in a follow-up case-control study by the same authors, 140 children aged 3 to 10 years with developmental disorders had no increase in medication requirement with pentobarbital and fentanyl or pentobarbital and midazolam, when compared with developmentally normal children. This study also showed no increase in hypoxic events (defined in this study as SaO2 of < 90% for > 30 seconds requiring airway intervention), compared to the control group.96 The differences in hypoxic events in these 2 studies are likely related to differences in definitions, with the latter study having a lower threshold for the definition of hypoxia and reporting of hypoxic events within the studies. The latter study suggests that there is no increase in hypoxic events among children with developmental disorders, and that they may be as sedated as developmentally typical children in the ED setting. Furthermore, Ross et al reported that medication requirements for sedation of autistic children were no different than developmentally typical children, showing that there was no increase in medication requirement when sedated with pentobarbital. In fact, the ASD group had a decreased requirement for fentanyl when compared to controls.97

Sedation for children with developmental disorders may have some key differences compared to sedation in the general pediatric population. Physically, airway diameters in children with developmental disorders under pentobarbital sedation for MRI have been shown to be smaller than those with normal development, by 40% at the level of the palate. Theoretically, this may be related to abnormal muscle tone.98

There are some anatomic differences in specific syndromes that should be considered prior to moving forward with sedation. Patients with craniofacial abnormalities (eg, Crouzon, Apert, Pierre-Robin sequence, and others) may have difficult airways should the sedation become complicated. Children with Down syndrome tend to have smaller chins and larger tongues, and they can become a difficult airway. Backup airway assistance (laryngeal mask airways, video-assisted laryngoscopy, emergency tracheostomy kit, or an anesthesiologist) should be arranged before sedating these children. Alternatively, one may consider performing the procedure with an anesthesiologist in the operating suite, if the risk of a difficult airway is deemed to be too great for the ED setting. The less likely that the patient will be able to control his behavior, the deeper the level of sedation required. Children aged < 6 years and children with neurodevelopmental disorders are more likely to require a higher level of sedation compared to older children with developmental disorders and developmentally typical children.99 However, despite these differences, as shown earlier, children with developmental disorders can be safely sedated when required, if a standardized, ordered approach to minimize adverse events is taken.

Painful Procedures

Topical Anesthetics

The use of topical anesthetics for painful procedures should be maximized if a painful procedure is planned. Lidocaine, epinephrine, tetracaine (LET) gel is useful for open wounds, allowing for effective analgesia with minimal stress to the patient. Apply it directly to an open wound and allow it to seep in for at least 30 minutes prior to cleansing and repairing the wound.100 Transdermal lidocaine can also be administered through a needle-free system for placement of intravenous lines or for venipuncture,101 although the system makes a popping sound that the child may find disagreeable. Topical lidocaine creams can be used on intact skin for venipuncture or lumbar puncture, if transdermal lidocaine is deemed to be unnecessary.

Opioids And Benzodiazepines

When selecting a sedating agent for a painful procedure, using an agent or a combination of agents that provides analgesia is preferable. Opioids are a good choice when performing painful procedures, as they not only offer pain control, but also act as a hypnotic. While usually well tolerated, opioids have potential side effects. Respiratory depression, bradycardia, and hypotension may occur. They should be used carefully in any hemodynamically unstable patient or in patients at risk for hypoventilation. They may also cause constipation, urinary retention, pruritus, rash, nausea, and vomiting. Opioids do not have amnestic properties, and if amnesia is desired, then coadministration with another agent, usually a benzodiazepine such as midazolam, is a good choice. Opioids and benzodiazepines may be dosed intramuscularly, orally, or intravenously, making them helpful in large autistic or aggressive patients in whom initial intravenous line placement may not be possible.

Ketamine

Another agent useful for sedation for painful procedures is ketamine. Ketamine is an -methyl- D-aspartate (NMDA) antagonist, phencyclidine derivative with both amnestic and analgesic properties. Ketamine is a sympathomimetic agent with effects on systemic blood pressure and potentially cerebral perfusion pressures. Other effects of ketamine include bronchodilation, as well as increased respiratory secretions. Care should be taken in neurologically impaired patients who are unable to control their secretions.

Ketamine can be given intravenously, intramuscularly, orally, or intranasally, making it a very flexible agent. It offers good analgesia, making it an effective choice for fracture or dislocation reductions, as well as for prolonged or complicated laceration repairs. Given orally, it is an effective choice for nonpainful procedures, such as MRI. One case study showed it to be a good option when used in conjunction with midazolam for an aggressive autistic patient.102

Nonpainful Procedures

For nonpainful procedures in the ED setting (such as obtaining a CT scan), there are several options. Inhaled nitrous oxide, barbiturates, benzodiazepines, propofol, dexmedetomidine, and etomidate, either as single agents or in combination, are options for sedation, despite there being few studies that focus on sedation in patients with developmental disorders. Nitrous oxide should be used with caution in patients with seizure disorders.103

Benzodiazepines

Benzodiazepines have several benefits for sedating behaviorally complex children and children with developmental disorders. Benefits include sedation, anterograde amnesia, anxiolysis, and muscle relaxation. This makes them useful in many different situations, including in agitated autistic patients, anxiolysis for MRI, or in conjunction with opioids for painful procedures. Benzodiazepines work on gamma-aminobutyric acid (GABA) receptors in the brain, decreasing the rate of depolarization of neurons. This makes them useful agents in epileptic patients as well. Common adverse effects are hypotension and hypoventilation.

Midazolam is a short-acting agent that is beneficial for sedation in children with developmental disorders. It may be administered intravenously, intramuscularly, intranasally, orally, or buccally, and it has a rapid onset and rapid metabolism by the liver. Midazolam can cause idiosyncratic paradoxical excitatory reactions, such as hallucinations, disorientation, uncontrollable crying or verbalization, agitation, restlessness, involuntary movement, self-injury, and aggressive or violent behavior. These reactions usually occur within 5 minutes of administration and are more likely in younger patients.104 These reactions do not usually resolve with time and will require another agent to treat them. Several agents have been shown to be effective in treating paradoxical reactions, including ketamine, flumazenil, propofol, increased doses of midazolam, and haloperidol. One study showed that ketamine was effective in the treatment of paradoxical midazolam reactions when compared to control groups of placebo or an increased dose of midazolam.105

Barbiturates

Barbiturates (such as pentobarbital, methohexital, and thiopental) may be used in children with developmental disorders for procedural sedation or sedation for nonpainful procedures. They have a neuroprotective effect, making them ideal agents in the setting of seizures or head trauma with elevated ICP.106 Methohexital and thiopental each have an onset of effect within 1 minute, but the duration of effect for methohexital is 5 to 7 minutes, whereas the duration of thiopental is 10 to 30 minutes. Pentobarbital may last 15 to 20 minutes when given intravenously, and it has been shown to effectively sedate children for diagnostic imaging with a success rate of up to 98%.107 Despite its success rate, however, pentobarbital was shown to have a higher incidence of paradoxical reactions (such as agitation) after administration, compared to chloral hydrate.106 In a study comparing sedative medications for functional MRI, pentobarbital was found to have better sedative effect than propofol; however, it had a higher rate of adverse events.108 Adverse events of pentobarbital include myocardial depression, hypotension, and respiratory depression. Thiopental can be used in patients who require rapid procedures, such as CT or rapid sequence intubation. It may be given intravenously or rectally, and the side effect profile remains the same as with pentobarbital.109

Propofol

Propofol is an excellent medication for procedural sedation for children in the ED setting or for diagnostic imaging. It has a rapid onset and offset, and it is well tolerated. It may be easily titrated for moderate or deep sedation. Its rapid metabolism and rapid patient recovery allows the emergency clinician to continue neurologic examinations post sedation. Propofol has been shown to be efficacious for MRI in pediatric patients. It offers a titratable level of sedation with minimal movement by the patient, allowing for shorter MRI times and better image quality compared to dexmedetomidine.110

Propofol has some possible side effects, including hypotension, bradycardia, and respiratory depression. It does not have any analgesic effects, but it is often used in combination with opioids for painful procedures. One uncommon side effect is propofol infusion syndrome, which results in a lactic acidosis, rhabdomyolysis, cardiac dysrhythmias, hyperlipidemia, and multisystem organ failure in patients who are continuously infused with propofol for > 24 hours. While rare, this complication is potentially fatal. Therefore, caution should be used in pediatric patients requiring prolonged sedation.111,112 Though not reported in the literature, it seems prudent to avoid propofol in children with special needs where there is the potential for lactic acidosis (such as certain inborn errors of metabolism or mitochondrial diseases), or in patients with underlying cardiac dysrhythmias.

Dexmedetomidine

Dexmedetomidine may be a good choice for sedation of children with ASD and developmental disorders. It is an alpha-2 agonist that works in the central nervous system. It can be given orally for short procedural sedation or intravenously for prolonged sedation in intubated patients. Its efficacy in patients with ASD was investigated in a 2009 retrospective review during which 315 patients were sedated for various procedures, most commonly for MRI. Doses required for induction were not different between normal children and autistic children. Seven of the 315 patients required intervention for adverse events of bradycardia and hypotension. There was only 1 adverse respiratory event requiring intervention, and there were 2 episodes of agitation during recovery. Dexmedetomidine had a 98.7% success rate for sedation, showing that it is effective for sedation in children with developmental disorders.113 Dex-medetomidine is generally well tolerated, with the most common side effect being bradycardia. It may cause either hypotension or hypertension due to its alpha-2 agonist effects.

Etomidate

Etomidate, a GABA-receptor type-A agonist, is commonly used in the ED setting for sedation, amnesia, and anxiolysis. It has a rapid onset and short duration of action, making it ideal for procedures such as rapid sequence intubation or CT. It is generally well tolerated, and it has a lower occurrence of hypotension compared to barbiturates. Possible side effects include respiratory depression, hypotension, myoclonus, and adrenal suppression. A 40-patient study that looked at etomidate for use in performing lumbar puncture in autistic children showed that it was effective, and that, when combined with flumazenil, recovery times were shorter than with etomidate alone.114

Chloral Hydrate

Chloral hydrate has been a commonly used agent for sedation for diagnostic imaging. However, due to its side-effect profile, variable bioavailability, and variable sedative effects when compared to other agents, its use has decreased in the ED setting. Despite decreased use, it still remains an option for emergency clinicians who are comfortable with its administration, which can be either oral or rectal. Oral administration has a more consistent absorption profile than rectal. It is believed to work in the CNS by increasing GABA type-A receptor activation. The onset of action is usually within 30 to 60 minutes, and the duration of action is 4 to 8 hours. Repeat dosing at half of the initial dose is often required to achieve sedation.

Common adverse effects include vomiting and diarrhea. It has also been associated with paradoxical reactions of hyperactivity and anxiety. Rarely, it may cause respiratory depression or airway obstruction. Chloral hydrate has a 95% success rate for moderate sedation, with a rate of adverse events of 1.8% in a retrospective review by Delgado et al.115 Overall, it is considered a safe option for sedation for children, but its sporadic absorption and sometimes prolonged duration of action makes this agent a less useful choice in an ED setting.

Nitrous Oxide

Nitrous oxide is an option for procedures where a noninvasive means of sedation is desired. It is an inorganic inhalant that is generally well tolerated. It has a rapid onset, and it can be titrated rapidly. It can achieve amnesia while maintaining hemodynamic stability. As a single agent, nitrous oxide easily achieves minimal sedation and does not require continuous monitoring at minimal sedation levels. In a prospective observational study of 7802 procedures on children aged 33 days to 18 years, children were administered 70% nitrous oxide for various procedures. The overall adverse event rate was 4.3%, with the majority of adverse events being nausea, vomiting, and diaphoresis. The authors of the study also reported 9 potentially serious adverse events; however, these all resolved without complication.116

There is evidence that nitrous oxide can be administered without fasting or postoperative monitoring. A retrospective review looked at its efficacy and safety in 1058 children who received nitrous oxide as a single agent when undergoing elective procedures. Procedures included incision and drainage of an abscess, cyst or mole removal, foreign body removal, and central line removal. The patients received a topical anesthetic at the procedure site and were asked to eat within 2 hours of the procedure. Their findings showed that 98.2% of patients had no adverse events. The most common adverse event was vomiting, occurring in 0.7% of the patients.117

There are case reports in the literature of nitrous oxide being temporally related to seizures. However, these events are rare, and no causality has been established. Nitrous oxide has been routinely used in dental offices for patients with seizure disorders, without reported ill effects,103 but caution is urged in using nitrous oxide in patients with known seizure disorders.

Given the ease of administration and overall safe profile of nitrous oxide, it is another reasonable option for sedation in pediatric patients, including children with developmental disorders, ASD, and behaviorally complex children, or when intravenous access is not established.

Alternate Routes Of Sedation/Analgesia

Although not formally studied in children with developmental disorders or ASD, intranasal fentanyl, ketamine, and midazolam are promising options for effective administration of analgesia and anxiolysis without having to resort to painful injection or intravenous starts.118,119 Doses of 1.7 mcg/kg of fentanyl have been demonstrated to be equivalent to 0.1 mg/kg of morphine.120 One study investigated the efficacy of intranasal midazolam, ketamine, or a combination of both in young, uncooperative dental patients (aged 2-6 years). Doses of intranasal medications used were midazolam 0.3 mg/kg, ketamine 6 mg/kg, and a mixture of both midazolam and ketamine at 0.2 mg/kg and 4 mg/kg, respectively. The overall success rate was 89% with ketamine alone, 84% with the combination of drugs, and 69% with midazolam alone.121 Intranasal midazolam has been successfully used to abort seizures in epileptic children.122

Publication Information
Authors

Solomon Behar, MD; John Cooper, DO

Publication Date

June 2, 2015

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