Symptomatic palliative care for children with neurodisability

Paediatric palliative care and neurodisability are two relatively new, evolving paediatric sub-specialities that have increasing relevance in the current paediatric landscape. For many people palliative care has been synonymous with end of life care, but in paediatrics it encompasses much more and is for all children with life-threatening or life-limiting conditions, from the point of diagnosis. This breadth of focus is demonstrated well through the interface between paediatric palliative care and paediatric neurodisability. In this article we explore this unique interface through the three domains of complex symptom management, advanced care planning and end of life care. We describe the practicalities involved in all three areas and highlight the importance of early referral and the process of “dual” or “parallel” planning. We cover in more depth the specific management of the symptoms: dystonia/abnormalities of muscle tone, seizures, pain, agitation, secretions, respiratory failure, and gut failure.     

脑状态指数预测龋齿手术患儿全麻苏醒期躁动的可行性

目的分析围术期脑状态指数(CSI)与患儿全麻苏醒期躁动(EA)的相关性,并探讨CSI预测EA的可行性。方法选取择期行口腔龋齿治疗手术的患儿100例,男58例,女42例,年龄2～7岁,ASAⅠ或Ⅱ级,根据全麻苏醒期患儿有无躁动分为两组:躁动组(A组)和无躁动组(NA组)。所有患儿静脉麻醉诱导气管插管后使用多功能组合式监护仪(HXD-I)监测CSI,分别记录插管后(T_1)、手术开始20 min(T_2)、停麻醉药时(T_3)、拔管后(T_4)及唤醒时(T_5)的CSI,包括镇静指数(WLi)、镇痛指数(PTi)、皮层下兴奋指数(SCEi)、皮层兴奋指数(CEi)、谵妄指数(DELi)、遗忘指数(AMi)、焦虑指数(ANXi)和舒适指数(CFi)。绘制相关指数的ROC曲线,计算各指数ROC曲线下面积(AUC)。结果患儿发生EA 21例(21%)。T_1—T_5时两组WLi、PTi、DELi和AMi差异均无统计学意义。T_5时A组SCEi、CEi、ANXi和CFi明显大于NA组(P0.05)。SCEi、CEi、ANXi和CFi预测EA的AUC分别为0.765、0.768、0.712和0.717,敏感性分别为81%、100%、85.7%和61.9%,特异性分别为70.9%、44.3%、49.4%和77.2%。结论 SCEi、CEi、ANXi和CFi均可有效预测龋齿手术患儿全麻EA的发生,但SCEi的预测效能最高。     

Zuclopenthixol,melperone and haloperidol/levomepromazine in the elderly. Meta-analysis of two double-blind trials at 15 nursing homes in Norway

Summary

A meta-analysis was carried out of the data from two double-blind. multi-centre studies with identical methodology which compared the effectiveness of treatment of elderly patients with zuclopenthixol and with other antipsychotic drugs. In one study, patients were treated for 4 weeks with either zuclopenthixol or melperone; in the other, with either zuclopenthixol or a combination of haloperidol and levomepromazine. The meta-analysis evaluated the results of 96 patients, 49 in the zuclopenthixol group and 47 in the comparison group. Doses, which were adjusted to individual patient's needs, were low as shown by the percentages of defined daily doses for each of the study drugs. The results indicated that all three treatment alternatives were effective in the treatment of elderly patients with symptoms of agitation and hostility/aggressiveness. There was a trend, however, for zuclopenthixol to have a more rapid onset of effect. Zuclopenthixol also has the advantage for both patients and nursing stuff that dosage is once daily. Only few and mild side-effects were reported with the three drug regimens.     

Datura stramonium intoxication in two children

Datura stramonium is a toxic plant member of the Solanaceae family. Its consumption may result in severe anticholinergic toxicity. We report the intoxication of 5‐ and 4‐year‐old brothers with Datura stramonium, which presented in two different manners. The first child presented agitation, hallucination and mydriasis that improved rapidly with benzodiazepine medication. The second presented comatose, mydriasis and Babinski signs. Gastric lavage and activated charcoal administration were performed. The child was intubated and mechanically ventilated until consciousness improvement. Datura stramonium poisoning may be considered by physicians in case of acute onset of decreased consciousness or behaviour trouble associated with anticholinergic signs and symptoms.     

注射用甲磺酸齐拉西酮对双相Ⅰ型障碍躁狂发作急性激越症状的疗效和安全性

目的分析注射用甲磺酸齐拉西酮治疗双相Ⅰ型障碍躁狂发作急性激越症状的疗效和安全性。方法选取2019年4月至2020年4月本院收治的60例双相Ⅰ型障碍躁狂发作急性激越症状患者,按治疗方式的不同分为两组,各30例。对照组采用氟哌啶醇注射液治疗,研究组采用甲磺酸齐拉西酮注射液治疗。比较两组不良反应发生率、阳性与阴性症状量表兴奋因子(PANSS-EC)评分、临床疗效总评量表-病情程度(CGI-SI)评分等。结果治疗后,研究组CGI-SI评分略低于对照组,但差异无统计学意义;治疗前及治疗后2、6、24、48、72 h两组PANSSEC评分比较差异无统计学意义;研究组不良反应总发生率为6.67%,低于对照组的43.33%,差异有统计学意义(P<0.05)。结论与氟哌啶醇注射液比较,临床采用注射用甲磺酸齐拉西酮药物治疗双相Ⅰ型障碍躁狂发作急性激越症状,虽疗效基本相当,但给药安全性更高,对疾病治疗有利。     

Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department

ObjectivesA multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting.MethodsThis analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken.ResultsIn the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval ?770.89, 685.90).ConclusionsIM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.     

三种不同时机下术前导尿配合手术室护理对全麻手术患者苏醒期躁动的影响

摘要 目的 观察三种不同时机下术前导尿配合手术室护理对全身麻醉（全麻）手术患者苏醒期躁动的影响。方法 选择2017年1月～2018年12月于我院行择期全麻手术的患者100例，根据术前导尿时机分为3组：A组（手术当日清晨在病房导尿，33例）、B组（麻醉前在手术室导尿，30例）、C组（麻醉平稳后在手术室导尿，37例）。记录并比较3组麻醉时间、术中输液量、术中出血量、苏醒时间及导尿前后收缩压（SBP）、舒张压（DBP）及心率（HR）变化，比较3组一次性导尿成功率、术后导尿管适应度及苏醒期躁动发生情况，采用自拟问卷调查患者护理满意度。结果 3组麻醉时间、术中输液量、术中出血量及苏醒时间比较，差异无统计学意义（P>0.05）；A组导尿后SBP、DBP、HR较导尿前均显著升高（P<0.05），B组和C组SBP、DBP、HR与导尿前比较，差异无统计学意义（P>0.05）；A组一次性导尿成功率显著低于B组和C组，术后导尿管适应度显著差于B组和C组（P<0.05）；A组苏醒期躁动发生率显著高于C组，苏醒期躁动分级显著高于C组P<0.05）；A组护理满意度评分显著低于B组和C组，差异有统计学意义（P<0.05）。结论 在麻醉前后于手术室进行导尿的效果明显优于手术当日清晨在病房导尿，配合手术室护理干预可有效提高患者术后对导尿管的适应度，降低苏醒期躁动发生率，提高患者护理满意度。     

地佐辛降低手术患者全麻苏醒期躁动的临床效果

目的 探讨地佐辛对全麻苏醒期躁动的影响。方法 选取全麻手术患者140例,根据病历单双号随机分为观察组(73例)和对照组(67例)。观察组患者在手术结束前30 min给予5 mg地佐辛静脉注射;对照组给予5 mL 0.9% NaCl溶液静脉滴注。对两组患者拔管前5 min、拔管时及拔管后5 min进行躁动评分和镇静评分;于拔管后10 min对两组患者舒适度进行评价;记录两组患者拔管时间、睁眼时间以及呼吸恢复时间。结果 拔管前5 min、拔管时以及拔管后5 min观察组患者躁动评分分别为(1.11±0.13)分、(1.13±0.11)分和(0.44±0.05)分,均明显低于对照组,差异有统计学意义(P < 0.05);观察组患者镇静评分分别为(1.82±0.14)分、(2.18±0.30)分及(2.63±0.21)分,均明显高于对照组,差异有统计学意义(P < 0.05)。拔管后10 min观察组患者Bcs舒适度得分为(2.73±0.21)分,明显高于对照组,两组比较差异有统计学意义(P < 0.05)。观察组患者拔管时间、睁眼时间以及呼吸恢复时间与对照组比较,差异无统计学意义(P > 0.05)。结论 术前给予地佐辛静脉注射可以有效降低手术患者全麻苏醒期躁动,提高患者舒适度,并且不会抑制患者的呼吸,临床应用安全。