Sedation for peritonsillar abscess drainage in the pediatric emergency department

OBJECTIVE: To evaluate the use of intravenous (IV) sedation in children during peritonsillar abscess (PTA) incision and drainage in the emergency department (ED). DESIGN: Retrospective review of medical records of children with a diagnosis of PTA. SETTING: The ED of a large, urban, academic children's hospital. PATIENTS: Consecutive patients 18 years or younger presenting from April 1995 to November 1998. METHODS: Information was retrieved from a time-based sedation record that included age, sex, ASA classification, time since last liquid or solid, agent and dose, level of sedation (A=alert, V=response to voice, P=purposeful response to pain, U=unresponsive), vital signs, complications, recovery time, and disposition. RESULTS: Forty-two patients had incision and drainage performed with IV sedation in the ED. Mean age was 11.3 +/- 4.3 years (range 4-18 years); 57% were African-American, and 64% were female. Agents used included ketamine plus midazolam (K/M) (n = 36, 86%), morphine plus midazolam (n = 3, 7%), meperidine plus midazolam (n = 2, 5%), and nitrous oxide plus midazolam (n = 1, 2%). No cardiorespiratory complications, including laryngospasm, occurred. Vomiting occurred in 1 patient who received meperidine and midazolam. The deepest level of sedation reached included: 12% A, 64% V, and 24% P. No patient who had an abscess drained in the ED with IV sedation was admitted, and mean recovery time was 81.0 +/- 30.1 minutes. CONCLUSIONS: IV sedation in children for incision and drainage of PTA by skilled personnel in the ED may eliminate the need for admission and surgical drainage in the operating room. K/M was used most frequently, without adverse effect, and all patients were discharged from the ED. Because K/M may result in deep sedation, appropriate personnel and equipment must be present.     

The severity of respiratory syncytial virus bronchiolitis in young infants in the United Arab Emirates

Respiratory syncytial virus (RSV) respiratory infections are very common during infancy and account for the majority of hospitalizations during the fall and winter seasons. Patients vary in the severity of their illnesses, with most hospitalized patients needing oxygen and intravenous fluids. The objective of this study was to assess in hospitalized patients the severity of the disease in relation to age. We compared children who were <90 days old with children who were >90 days old for the duration of oxygen therapy, maximum oxygen concentration used, duration of stay and duration of intravenous fluids. We conducted a retrospective case review of national children <2 years admitted to the pediatric ward at Sheikh Khalifa Medical City with RSV proven bronchiolitis/pneumonia over a 3-month period from 1 September to 30 November 2001. Morbidity for group 1 (birth-90 days) and group 2 (91 days-2 years) was compared by the Mann-Whitney U-test using duration of oxygen therapy, maximum oxygen concentration used, duration of stay and duration of intravenous fluids. Multiple regression for duration of oxygen therapy was tested using the following risk factors as predictors: age group (1 or 2), previous ventilation, bronchopulmonary dysplasia (BPD) and prematurity. A total of 89 patients were admitted during this period. The mean age (SD) of group 1 (n = 28) and group 2 (n = 61) was 46.35 (25.57) days and 275.67 (156.79) days, respectively. The only statistically significant difference using the Mann-Whitney U-test was detected for duration of oxygen between the groups (p = 0.002). Using multiple regression, only age group acted as a predictor for duration of oxygen therapy (p < 0.001). This implies that the youngest children, group 1, are at a risk for prolonged oxygen therapy. Four patients from group 1 were admitted to the intensive care unit, of which two received ventilatory support. RSV respiratory infections affect infants <3 months old in a more severe form than older infants. Even though overall duration of stay was similar for both groups, young infants who in fact did require oxygen had a more protracted and severe illness compared with the older infants. This was evidenced by their longer duration of oxygen and more frequent need to be managed in the intensive care unit.     

Sedation with intravenous ketamine and midazolam for painful procedures in children

BACKGROUND: Children often require relief of pain and anxiety when undergoing painful procedures. The purpose of this study is to evaluate the effectiveness and safety of painful pediatric procedures performed by pediatric intensivist, using the combination of intravenous ketamine and midazolam for sedation and analgesia. METHODS: The records of the patients who received intravenous ketamine-midazolam combination for painful procedures in the pediatric sedation unit of a university hospital over a 3 year period were retrospectively reviewed to determine indications, dosing, assessment of the level of sedation, adverse events, and recovery time for each procedural sedation and analgesia. RESULTS: A total of 227 children aged 4 months to 18 years were admitted to the pediatric sedation unit for a total of 356 procedures. The indications for procedural sedation and analgesia included bone marrow aspiration or biopsy (50.8%), central venous catheter insertion (27%), and others (22%). A total of 46 adverse events (12.9%) were observed. These adverse events included SpO2 below 85% without apnea (n = 14), apnea (n = 3), transient stridor (n = 2), hypertension and tachycardia (n = 8), hypersalivation (n = 6), vomiting (n = 5), hallucinatory emergence reaction (n = 4), and rash (n = 4). There were no adverse outcomes attributable to ketamine and midazolam combination. CONCLUSION: Skilled pediatric intensivists can safely and effectively administer ketamine and midazolam to facilitate painful procedures outside the operating room setting.     

alpha-Amylase standard values in children

In a group of 216 healthy children (age: 3 days-16 years) normal values of alpha-amylase in serum were found out (substrate: p-nitrophenyl-alpha, D-maltoheptaosid). Infants (age: 3-353 days) mostly showed lower catalytic concentrations than older children: alpha-amylase (25 degrees C) up to 30 U/L; alpha-amylase 37 degrees C): up to 60 U/L. But, the collective was too small (n = 30) to give any statistical statement, on the other hand biological and analytical deviations of catalytic concentrations were big. In children (n = 186; age: 1-16 years) the values were not dependent on sex or age. As normal range we propose for children aged 1-16 years alpha-amylase (25 degrees C): 20-110 U/L; alpha-amylase (37 degrees C): 40-200 U/L.     

Intranasal versus intravenous administration of midazolam to children undergoing small bowel biopsy

Sixty-three children under the age of 9 years were randomized to receive intravenous (group A, n = 33) or intranasal (group B, n = 30) midazolam as sedation for small bowel biopsy. Mean doses of midazolam given to produce adequate sedation were 0.31 mg (kg body weight)⁻¹ in group A and 0.34 mg (kg body weight)⁻¹ in group B (NS). Four children in group A and 10 children in group B required additional doses to maintain adequate sedation throughout the biopsy procedure (p <0.05). There was no significant difference between the groups regarding the median procedure time (7 min in group A, 8.5 min in group B) or median fluoroscopy time (5 s in group A, 4 s in group B). All children in group B showed signs of discomfort from the nose when given midazolam intranasally. In conclusion, this study indicates that intravenous administration of midazolam is preferable to the intranasal route.     

Intravenous midazolam for sedation of children undergoing procedures: an analysis of age- and procedure-related factors.

OBJECTIVE: This study was performed to determine the doses of midazolam used for sedation during procedures in children, and the frequency of adverse events. METHODS: We performed a retrospective analysis of data collected for a prospective study of flumazenil in children who had received midazolam for a procedure (n = 91, 1-17 years). RESULTS: Practitioners used a wide range of total midazolam doses (0.03-0.6 mg/kg); mean doses ranged from 0.09 +/- 0.06 mg/kg in adolescents to 0.26 +/- 0.13 mg/kg in toddlers (P < 0.001). Opioids were also used in 84% of patients. Twenty-six percent of children with normal lungs, most of whom had received relatively high opioid doses, developed decreased oxygen saturation (as low as 65%) after sedation. Other adverse events included airway obstruction (n = 3) and vomiting (n = 1). CONCLUSIONS: The frequent choice of midazolam, usually combined with an opioid, indicates its wide acceptance. Midazolam doses were inversely related to age. The presence of vomiting, airway obstruction, and decreased oxygen saturation underlines the importance of appropriate personnel, equipment, and monitors during sedation.     

山东省多中心儿童重症监护室镇静镇痛治疗及管理状况调查

目的了解山东省三级甲等医院儿童重症监护室(PICU)镇静镇痛治疗及管理状况,为镇静镇痛治疗方案的改进提供依据。方法本研究为一项多中心回顾性研究,山东省6家三级甲等医院的PICU参与了本研究。收集2016年1月至2018年12月入住这6家PICU的1340例患儿,调阅病历资料,统计患儿的年龄、性别、入院24 h小儿死亡风险评分Ⅲ、是否接受机械通气、是否接受镇静和(或)镇痛治疗、是否监测镇静和(或)镇痛情况、住院病死率等。依据是否接受镇静治疗和(或)镇痛治疗,将患儿分为单纯镇静组(798例)、镇静+镇痛组(120例)及非镇静镇痛组(422例),比较各组的病种、机械通气比例、低血压发生率、平均住PICU天数及院内病死率。结果1340例患儿的平均年龄为(13.3±6.4)个月,其中男786例(58.7%)。6家PICU均已开展镇静治疗,其中5家PICU进行常规镇静评估;已开展镇痛治疗的PICU有4家,其中仅有2家进行常规疼痛评估。共有918例(68.5%)患儿接受了镇静治疗和(或)镇痛治疗,咪达唑仑是最常用的镇静药物,其次是右美托咪定。526例(57.3%)患儿进行了镇静评估监测,最常用的评估方法是Richmond躁动镇静量表。120例(9.0%)患儿接受了镇静联合镇痛治疗,芬太尼是最常用的镇痛药物,38例(31.7%)患儿接受了常规疼痛评估。3组患儿年龄和性别差异无统计学意义。镇静+镇痛组外科疾病的比例最高,该组机械通气患儿的比例也最高(100.0%,120/120),非镇静镇痛组机械通气患儿的比例最低(11.4%,48/422),两组比较差异有统计学意义(P<0.01)。镇静+镇痛组的平均机械通气时间略短于单纯镇静组,但组间比较差异无统计学意义(P>0.05)。镇静+镇痛组低血压发生率最高,非镇静镇痛组低血压发生率最低[21.7%(26/120)比2.1%(9/422),P<0.01]。院内病死率和平均住PICU天数3组间比较差异无统计学意义。结论苯二氮类药物仍是目前山东省PICU中主要使用的镇静药物,右美托咪定的应用逐渐增加,但镇痛剂应用的比例很低。目前镇痛镇静治疗主要用于外科术后及接受机械通气治疗的患儿,镇痛镇静治疗虽未增加患儿的院内病死率及平均住PICU天数,但增加了低血压的发生率。山东省PICU的镇静镇痛治疗和监测仍欠规范,主要体现在镇痛治疗以及对镇静和疼痛水平的评估未受到重视。     

Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study

OBJECTIVES: The primary objective of the present study was to compare the required dose of intravenous (IV) propofol between group A (synergistic sedation with an oral dose of midazolam combined with IV propofol) and group B (IV propofol alone), in diagnostic upper gastrointestinal endoscopy (UGIE) in pediatric patients. The secondary objective was to compare the safety, the efficacy, the ease of IV line placement and the ease of separation from parents between the 2 groups. METHODS: Fifty-four consecutive children (aged 3 y or older) who underwent UGIE were randomly assigned to 1 of the 2 medication regimens. Patients in group A (n = 26, mean age: 8.1 y) received midazolam (0.5 mg/kg) orally. Thirty minutes after the midazolam dose was given, repeated IV doses of propofol 0.5 mg/kg were administered titrated to achieve the level of deep sedation. Patients in group B (n = 28, mean age: 9 y) received IV propofol alone with the same methodology and sedation end point. RESULTS: The mean dose (1.8 +/- 0.7 mg/kg) of propofol administered in group A patients was remarkably lower compared with that (2.9 +/- 0.9 mg/kg) of group B. Multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, the synergistic sedation was the only factor associated with the ease of IV line placement (chi(2) = 16.3, P < 0.001) and the ease of separation from parents (chi(2) = 41.6, P < 0.001). Additional multivariate stepwise logistic regression analysis revealed that among sex, age, ASA grade and the type of sedation, synergistic sedation was the only factor associated with a higher level of patient comfort (chi(2) = 35.5, P < 0.001). The recovery time was significantly shorter in group B patients (7.7 +/- 3.6 min) compared with that of group A (25.9 +/- 4.1 minutes) (P < 0.01). The 2 regimens were equally safe. CONCLUSIONS: Our data suggest that synergistic sedation with an oral dose of midazolam combined with propofol may benefit the children who undergo UGIE with regard to lower mean dose of propofol used, easier IV line placement, easier separation from the parents, less pain induced by the IV line placement and greater patient comfort.     

Ketamine and midazolam for invasive procedures in children with malignancy: a comparison of routes of intravenous, oral, and rectal administration

We investigated the efficacy of a combination of ketamine and midazolam, comparing intravenous, oral, and rectal administrations for invasive procedures in children with malignancy. Seventy-three children under 5 years of age, who were scheduled for invasive procedure, were assigned to one of three groups: IV group (n = 25), ketamine 1 mg/kg and midazolam 0.05-0.1 mg/kg were given intravenously; PO group (n = 24), ketamine 3 mg/kg and midazolam 0.5 mg/kg were given orally; and PR group (n = 24), ketamine 3 mg/kg and midazolam 0.5 mg/kg given rectally. Vital signs including blood pressure, pulse rate, respiratory rate, and oxygen saturation were monitored, and patients were observed for side-effects. Optimal sedation (drowsy and asleep) was provided in 78 per cent of all patients and no statistical difference was observed among the three groups. No severe complications were observed in all groups. Recovery time from sedation was significantly longer in the intravenous group (>120 min in two patients). Hallucination was noted in three (12 per cent) patients given intravenous medication, but not in those given oral or rectal medications. It is concluded that intravenous, oral, and rectal midazolam/ketamine are equally effective for invasive procedures in children with malignancy. The use of intravenous ketamine/midazolam may produce prolonged sedation and psychedelic effects in children. These adverse effects may alter the child's comfort and parental satisfaction.     

Evaluation of intranasal midazolam in refraction and fundus examination of young children with strabismus

PURPOSE: To determine the clinical sedative effect and dosage of intranasal midazolam in refraction and fundus examination of children with strabismus. PATIENTS AND METHODS: Refraction and fundus examination with (n = 28) and without (n = 24) sedation were performed in 52 children with strabismus whose ages ranged from 7 to 26 months. We delivered a 5-mg/mL solution of midazolam via a syringe for 60 seconds to provide a dose of 0.2 mg/kg. We repeated the dose to a maximum of 0.3 mg/kg if there was no clinical sedative response after 10 to 15 minutes. The ease of examination and sedation for each patient was scored by a blinded observer. The groups were evaluated for ease of examination and the time needed to complete it. RESULTS: We obtained clinically adequate sedation at a mean (+/- standard deviation) of 15 minutes (+/- 2.69 minutes). Sedation was achieved with a mean dose of 2.64 mg/kg (+/- 0.66 mg/kg). Children receiving midazolam had significantly calmer examination scores. The time needed to complete the examination was statistically significantly shorter for these children than for children not receiving sedation (P < .05). CONCLUSIONS: Intranasal midazolam is a beneficial drug and method of delivery for the sedation of anxious children with strabismus undergoing refraction and fundus examination. Sedation prior to examination is effective in reducing the anxiety and time associated with ophthalmologic examination of children with strabismus.     

Capnography during sedation/analgesia in the pediatric emergency department

OBJECTIVE: To measure changes in end-tidal carbon dioxide levels (ETCO2) during sedation/analgesia in pediatric patients and to describe ETCO2 changes associated with different sedation strategies. METHODS: This was a prospective, observational patient series in an urban pediatric emergency department (PED). Participants included 106 children with a mean age of 6.8 years. (range 1.2-16.6 years). Sedation/analgesia was given for fracture reduction (55%), laceration repair (37%), abscess incision and drainage (4%), and lumbar puncture (LP) (4%). Medications included fentanyl, morphine, ketamine, and midazolam. Continuous ETCO2 waveforms were recorded via a Capnogard ETCO2 Monitor. Oxygen saturation was recorded using a Nelcor N-200 pulse oximeter. Recording began prior to sedation and continued until the patient was awake or when it was necessary to remove the patient from the monitor for further medical care. Each record was analyzed for peak ETCO2 and averaged over five consecutive breaths, before and after the administration of medications. The main outcome measure was the change in ETCO2 levels. RESULTS: The mean increase in ETCO2 was 6.7 mmHg (P is included in, 0.00001; range: +0.16 to +22.3). ETCO2 increased by 3.2 mmHg (95% CI = 2.2-4.2) for midazolam alone, 5.4 mmHg (95% CI = 4.5-6.4) for midazolam and ketamine, and 8.8 mmHg (95% CI = 7.4-10.2) for midazolam and opiate. Two patients had transient SpO2 desaturations below 93%, which corrected with stimulation. CONCLUSIONS: Commonly used agents for pediatric sedation result in significant increases in ETCO2. ETCO2 is a useful adjunct in assessing ventilation and may serve as an objective research tool for assessing different sedation strategies.     

Use of intramuscular ketamine for endoscopy sedation in children

OBJECTIVE: To report the experience of the use of intramuscular (IM) ketamine for endoscopy sedation in children. METHODOLOGY: Children over 6 months of age scheduled for elective endoscopy - esophagogastroduodenoscopy (EGD), bronchoscopy and nasopharyngolaryngoscopy (NPL) were enrolled for (2 mg/kg to 3 mg/kg) intramuscular ketamine sedation. A repeated dose of 2 mg/kg intramuscular ketamine was administered to those who failed the first sedation. Alternative sedation (intravenous midazolam and fentanyl) was given to children who failed ketamine sedation twice. Sedation was regarded as successful if the procedure was completed by endoscopist with a single dose of ketamine. RESULTS: Sixty children were enrolled for the study. Overall success rate in our patients was 78.3%. Failure rate in infants was 50%, i.e. 4 out of 8. For children aged 1-7, the failure rate was 32%. Failure rate dropped markedly to 6.7% for those older than 7 years of age, and it showed significant difference when compared with the other two groups. Two cases of laryngospasm were experienced in the present study. CONCLUSION: Intramuscular ketamine is an effective medication for sedation in endoscopy undertaken in children over age 7 years, but it should be avoided with children under age 7 because of the high failure rate.     

Reversible neurologic abnormalities associated with prolonged intravenous midazolam and fentanyl administration

An encephalopathy developed in three infants in the intensive care unit after heavy sedation with midazolam and fentanyl for 4 to 11 days. The affected infants had poor social interaction, decreased visual attentiveness, dystonic postures, and choreoathetosis. Symptoms cleared completely in 5 days to 4 weeks. Retrospective review of records of all children treated in the intensive care unit with prolonged intravenous administration of midazolam revealed that 45 children could be assessed neurologically on withdrawal of sedation. Three children had definite and two had possible neurologic sequelae (5/45, 11.1%). All had received concomitant intravenous fentanyl therapy. Neurologic sequelae were significantly associated with young age, female gender, low serum albumin concentration, and concomitant administration of aminophylline. This encephalopathy may represent a benzodiazepine withdrawal syndrome, a prolonged agonist action on the benzodiazepine receptor, or the combined effects of multiple toxic, metabolic, and infectious insults to the central nervous system of infants in the intensive care unit. Prolonged use of intravenous midazolam sedation necessitates careful dosing, monitoring, and discontinuation, particularly in infants and young children.     

Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial

OBJECTIVE: The comparative safety and efficacy of chloral hydrate and midazolam for sedation of children has not been adequately studied. METHODS: In a double-blind randomized trial, at a single university hospital, we enrolled 40 children, ages 2 months to 8 years, in an out-patient neuroimaging study. Children judged to require sedation were enrolled during a 14-month period ending August 1995. They received identically appearing liquids of equal volume of either chloral hydrate (75 mg/kg, maximum 2 g) or midazolam (0.5 mg/kg, maximum 10 mg) by mouth. Children were monitored for changes in arterial blood pressure, oxygen saturation, pulse, respiration and anxiety. Efficacy was judged by evaluating the child's ability to complete the intended scan. Supplemental dosing was administered to children who were judged inadequately sedated 30 minutes after the initial medication. RESULTS: Interim analysis demonstrated a significant sedation failure rate. Of 40 enrolled children, 33 completed the protocol. Efficacy was significantly improved for the chloral hydrate group for both ability to perform the scan, chloral hydrate = 11/11 (100%, 95% CI = 72-100) vs. midazolam = 11/22 (50%, 95% CI = 29-71), and the need for supplementary dosing, chloral hydrate = 1/11 (9%, 95% CI = 0-26) vs midazolam = 12/22 (55%, 95% CI = 34-76), P<0.05. Mean duration of sedation was not significantly different. No physiological deterioration occurred and no oxygen administration was required. CONCLUSIONS: We conclude that, in these doses, oral chloral hydrate may provide more effective sedation than midazolam for brief neuroimaging studies in young children.     

Probing for nasolacrimal duct obstruction using intranasal midazolam sedation as an alternative to general anesthesia

OBJECTIVE: To investigate the effectiveness of topical anesthesia with sedation using intranasal midazolam in patients with symptomatic congenital nasolacrimal duct obstruction undergoing probing. PATIENTS AND METHODS: In this prospective study, probing was performed with general anesthesia (30 cases) and with topical anesthesia using intranasal midazolam (0.3 mg/kg; 44 cases) in 74 patients who were divided into two groups, those 6 to 36 months old and those older than 36 months. The groups were compared after 12 to 48 months (mean, 18.2 months). RESULTS: For the patients 6 to 36 months old, the success rate was 80% in the group who received general anesthesia and 88.9% in the group who received topical anesthesia with intranasal midazolam; the difference between the two groups was not statistically significant (P > .05). For the patients older than 36 months, the success rate was 20% in the group who received general anesthesia and 25% in the group who received topical anesthesia with intranasal midazolam; there was no statistically significant difference between the two groups (P > .05). CONCLUSIONS: Probing with topical anesthesia in the office setting is usually recommended for patients younger than 8 months. Our results show that this is suitable for children until 4 years of age with the support of intranasal midazolam sedation. Probing under topical anesthesia with intranasal midazolam is cost-effective, safe, and comparable in efficacy to probing under general anesthesia but with less risk.     

Propofol versus midazolam plus meperidine for sedation during ambulatory esophagogastroduodenoscopy

OBJECTIVE: To evaluate the efficacy and safety of propofol and meperidine plus midazolam for sedation during esophagogastroduodenoscopy (EGD) in children. METHODS: Data were collected prospectively and retrospectively from neurologically intact children (0.2-17.7 years of age) who underwent ambulatory diagnostic EGD during a 4-year period. Data were included from 155 consecutive patients receiving propofol with or without premedication with midazolam (PM group). One hundred five consecutive patients who received sedation with a midazolam plus meperidine combination served as a comparison (MM group). Outcome variables were: time required for induction of sedation, length of procedure, time for recovery, need for additional supportive measures, and need for physical restraint. RESULTS: The onset of sedation was faster and the length of procedure and recovery were significantly shorter in the PM group as compared with the MM group (P < 0.01). Patients in the MM group required restraint more often than in the PM group. A higher dose of meperidine and midazolam was used in the prospective study. This led to deeper sedation but increased need for additional support. CONCLUSIONS: Propofol is safe and effective for facilitating EGD in children.     

Home mechanical ventilation in children: Retrospective survey of a pediatric population

BACKGROUND: Home care support is beneficial for children needing mechanical ventilation, when clinically stable. METHODS: A retrospective analysis was carried out of the long-term home ventilation management of a pediatric population with chronic respiratory failure composed of 20 ventilator-dependent children categorized according to age, diagnosis and ventilation support. Age groups consisted of 10% under 1 year, 30% between 2 and 5 years, 30% between 6 and 12 years, and 30% older than 12 years. Diagnostic categories included myopathic disorder, n = 5; congenital central hypoventilation syndrome, n = 6; chest wall disorder, n = 5; cystic fibrosis, n = 1; pulmonary hypertension, n = 1; and diaphragmatic paralysis, n = 2. RESULTS: Sixty-five percent were ventilated using non-invasive mode (NIMV): eight with nasal mask, five with full-face mask, and two children in NIMV also used negative pressure mode; 35% were ventilated using tracheostomy, one of them also used a diaphragmatic pacer. Seventy percent needed nocturnal ventilatory support, (20% 12-18 h, 10% full-day). A total of 18 children were included in the home care and follow-up program. Two children died: one because of worsening of his chronic disease and one because of septic shock. CONCLUSION: Although home care ventilation is not yet widely diffused, it represents a valid alternative to long hospitalization for children with stable chronic respiratory failure.     

Respiratory syncytial virus infections in children admitted to the intensive care unit

During the winter of 1986-1987, 64 children with respiratory syncytial virus (RSV) infection were admitted to our hospital. The diagnosis was made by direct immunofluorescent antibody technique. Twenty-three children (36%) needed intensive care treatment. Nearly 11 (52%) had a preexisting disease state, identified as a risk factor i.e., prematurity (n = 8), bronchopulmonary dysplasia (n = 2), congenital heart disease (n = 1). Twelve patients (50%) were intubated and ventilated. Conditions for intubation and ventilation were repetitive apnea with or without bradycardia (n = 4), clinical deterioration (n = 3) or hypercarbia (n = 5). Seventy-five percent of the patients who needed intensive care management were under three months of age compared to 34% of the children who were admitted to the clinical ward. The mean age for ventilated patients was 7.9 weeks. The mean duration of ventilation was 5.5 days. Volume controlled ventilation was initially applied to all patients. Pulmonary complications (atelectasis, pneumonia, pneumothorax or adult respiratory distress syndrome) were present in 15 (65%) IC patients. Nine (39%) of them also had symptoms of inappropriate antidiuretic hormone secretion (IADHS). Only two patients had symptoms of IADHS and two others had convulsions. Three children (5%) died as a result of respiratory insufficiency. Two of these infants belonged to the risk group.     

Sedation with midazolam for voiding cystourethrography in children: a randomised double-blind study

BACKGROUND: Sedation with midazolam facilitates the performance of diagnostic procedures in children, including voiding cystourethrography (VCUG). However, the influence of sedation on voiding and imaging results have not been adequately evaluated. OBJECTIVE: Midazolam and placebo were compared to assess discomfort during VCUG and to evaluate if sedation influenced the outcome of the examination. MATERIALS AND METHODS: The study was prospective, randomised and double-blind, and included 95 children, 48 in the midazolam group (median age 2.2 years) and 47 in the placebo group (median age 3.2 years). The evaluation included the child's/parent's experience of the VCUG, as well as the examination results. RESULTS: The children/parents in the midazolam group experienced the VCUG as less distressing compared to those in the placebo group ( P<0.001). Forty-six of 48 children sedated with midazolam could void during the imaging procedure compared to 38 of 47 children given placebo ( NS). There was no difference in frequency or grade of vesicoureteric reflux or bladder emptying between the groups. CONCLUSIONS: When sedation is required to perform VCUG in children, midazolam can be used without negative effect on the outcome of the examination.     

Neuroleptic malignant syndrome in a 4-year-old girl associated with alimemazine

Neuroleptic malignant syndrome (NMS) is a rare but serious disorder caused by antipsychotic medication including phenothiazines. For sedative purposes, increasing doses of alimemazine were administered to a 4-year-old multiple handicapped girl, with cerebral damage of the basal ganglia. She developed extra-pyramidal motor disturbances, an autonomic disorder, lowered consciousness and hyperthermia, characterising NMS. Alimemazine was stopped and dantrolene and supportive measures, including ventilation under sedation and paralysis with midazolam and vecuronium, were started. As clinical symptoms remained unabated, increasing doses of bromocriptine were administered. Two days after maximal bromocriptine dosage, her clinical condition improved and paralysis and ventilation were stopped. Midazolam and bromocriptine could be gradually decreased and suspended during the following months. A few days after bromocriptine cessation NMS recurred and was complicated by a fatal cardiorespiratory arrest. CONCLUSION: caution must be exercised when prescribing alimemazine, especially to children with basal ganglia damage and in the case of inexplicable fever and restlessness, neuroleptic malignant syndrome should be considered. Long-term therapy with bromocriptine combined with dantrolene and midazolam may be a successful medical treatment.