Half-strength TAC topical anesthetic. For selected dermal lacerations

A prospective evaluation of 75 consecutive children with lacerations of the face, lip, and scalp who received TAC (tetracaine, epinephrine [adrenalin], cocaine) topical anesthetic for the repair of their wound was performed. The TAC preparation contained one-half the conventional concentration of cocaine (5.9%) and tetracaine (0.25%) previously used in other studies that have evaluated its anesthetic efficacy. A maximal dosage of 3 ml of TAC (containing 175 mg cocaine and 7.5 mg tetracaine) was applied to each laceration. The diluted TAC preparation provided complete anesthesia for approximately 95% of the more than 400 sutures placed. No adverse reactions were noted in any patient who received TAC, and in no instance did a complication of wound healing occur. The original formulation of TAC was arbitrarily composed, and the maximum concentration per dosage of the potentially toxic component medications of TAC that can be "safely" applied to dermal lacerations in children remains to be defined. Utilization of this diluted preparation will diminish the risk of potential systemic toxicity from the absorbed component medications of TAC without compromising anesthetic efficacy.     

Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children

To determine whether the tetracaine component traditionally used in tetracaine-adrenaline-cocaine (TAC) is necessary to obtain effective topical anesthesia, a prospective study was performed to compare TAC and adrenaline-cocaine preparations for the repair of facial lacerations in children. Physicians were "blind" to which preparation was being used. Of 55 patients studied, 24 received TAC (103 sutures placed) and 31 received adrenaline-cocaine (151 sutures placed). The anesthetic efficacy of each preparation was approximately 95%; there were no adverse reactions related to administration of either medication or complications of wound healing noted in either group. The tetracaine component of TAC is superfluous for obtaining topical anesthesia of minor dermal lacerations of the face in children. The TAC formulation can be simplified by omitting tetracaine without compromising anesthetic efficacy.     

Efficacy of TAC topical anesthetic for repair of pediatric lacerations

A prospective evaluation of 103 consecutive children who received TAC (tetracaine, epinephrine [adrenaline], cocaine) liquid topical anesthetic for the repair of their minor dermal lacerations was performed. A unique method of TAC application was used that consisted of applying the medication to the inner margins of the wound cavity and allowing it to stand for several minutes prior to the application of a TAC-saturated gauze pad to the wound surface. Of 670 sutures placed, 637 (95%) were done without eliciting pain. The TAC topical anesthetic was more than 95% effective in providing complete anesthesia for wounds located on the face and lip; it was equally efficacious in anesthetizing larger wounds (greater than or equal to 5 cm in length and/or greater than or equal to 5 mm in depth). No adverse reactions resulted from the application of TAC. A single wound healing complication occurred in 103 patients. TAC is a safe, effective method for anesthetizing minor lacerations of the skin in children. Its painless method of application relieves patient discomfort and maximizes patient compliance during the repair procedure, both of which enhance the accurate approximation of lacerated tissue.     

A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children

A randomized, prospective, double-blind study comparing three formulations of the topical anesthetic solution TAC for laceration repair was undertaken in 250 children. The children's wounds were anesthetized with either TAC I (original formulation--0.5% tetracaine, 1:2000 Adrenalin, 11.8% cocaine), TAC II (1.0% tetracaine, 1:4000 Adrenalin, 7.0% cocaine), or TAC III (1.0% tetracaine, 1:4000 Adrenalin, 4.0% cocaine) prior to repair. The solutions were compared with respect to efficacy, acceptability, wound complications, and side effects. We found comparable efficacy of the three formulations, with similar efficacy to 1% lidocaine infiltration for facial and scalp wounds. Anesthesia for extremity wounds was adequate in only 39.9% of cases, regardless of TAC strength. Wound complications and side effects were within expected and acceptable limits. Our findings support use of TAC for face and scalp lacerations and a change to a less concentrated TAC preparation, such as our "TAC III," which is presumably safer for widespread use.     

Costs of sedation using oral midazolam: money, time, and parental attitudes

OBJECTIVE: Many agents suitable for pediatric outpatient sedation have been identified and compared, but less data have appeared on the effect of sedation use on Emergency Department (ED) length of stay (LOS) or visit costs. We sought to discover the relationship between one commonly used method of sedation, orally administered midazolam, and ED LOS and visit costs. Parents were then surveyed to determine their attitudes toward sedation given knowledge of these costs. METHODS: All ED patients under 10 years of age seen in a pediatric ED during April and May of 1996 for repair of lacerations <2.5 cm in length were identified via retrospective chart review. Children were excluded if they had other significant injuries, received sedatives other than oral midazolam, or were repaired by non-ED physicians. Preliminary cost and LOS data from this review was used to create a parental survey measuring attitudes toward the costs of an unnamed form of sedation (not mentioning oral midazolam). A convenience sample of parents in an ED waiting room were asked if they would want sedation administered to a child needing sutures if this increased the visit cost by $100 and/or increased LOS by 30 minutes. Parents were then asked to re-answer these questions assuming that the sedation medication was effective only 50% of the time. RESULTS: Of 120 patients meeting entry criteria, 57 (48%) received oral midazolam. Children sedated with this agent were significantly younger (3.6 vs. 4.6 years, P = 0.015), had more layered repairs (30% vs. 14%, P = 0.047), and more facial lacerations (84% vs. 63%, P = 0.01) when compared with nonsedated patients. Mean LOS for patients with simple lacerations receiving oral midazolam increased by 17.1 minutes (P = 0.03) compared with nonsedated children; for layered repairs, the mean increase was 30.9 minutes (P<0.05). The use of oral midazolam did not effect physician charges, but did significantly increase mean combined nurse/hospital charges and total charges by 73 to 87 dollars, depending on laceration type (P<0.001 all cases). Of 81 parents surveyed, 81% said that they would be willing to wait 30 extra minutes for sedation to be used; this figure fell to 73% if sedation was effective 50% of the time. Seventy-five percent of parents were willing to pay $100 extra for sedation; 67% if sedation was effective only half the time. Willingness to endure a longer LOS or pay increased charges was not associated with parental sex or insurance status. CONCLUSION: The use of oral midazolam significantly increases ED visit LOS and cost. This information is important to review with parents when discussing sedation options. Up to one third of parents surveyed would not want to wait extra time or pay extra money for sedation to be administered, especially if the efficacy of the chosen method was not assured.     

Experience with an anesthesiologist interventional model for endoscopy in a pediatric hospital

BACKGROUND: Endoscopy is now a routine part of the work-up for many patients with gastrointestinal symptoms. Adults tolerate these procedures well, with either no sedation or a relatively light level. In contrast, children often require deep sedation or a general anesthetic to successfully perform these procedures. Therefore, pediatric endoscopies may require more time, personnel, and monitoring equipment to provide optimal conditions for the patient. The goals of this retrospective case series were to describe the anesthesia times and recovery duration of the different procedures, the types and amounts of medications commonly used, and the types and rates of complications experienced. METHODS: Patients (2,306) who underwent endoscopy in the Arkansas Children's Hospital endoscopy suite during a 4-year period were identified. A random sample of 720 charts was reviewed retrospectively. RESULTS: Patients ranged in age from younger than 1 year to 29 years. Patients most often had abdominal pain or multiple gastrointestinal symptoms. Sixty-eight percent of patients underwent esophagogastroduodenoscopies; 30% colonoscopy or a combination of the two. Ninety-five percent of patients received a propofol-based anesthetic. Midazolam, fentanyl, and alfentanil were frequently used as supplemental agents. Complications occurred infrequently and were airway related. All complications were easily treated, with no adverse sequelae. CONCLUSIONS: This model of anesthesiologist-provided sedation/anesthesia for gastrointestinal endoscopy procedures has been extremely successful in the Arkansas Children's Hospital and has served to heighten awareness of many issues surrounding sedation and anesthesia outside of the operating room, while ensuring a high level of care is provided.     

Metal lawn and garden edging: the hidden knife?

OBJECTIVE: Lacerations account for many visits to the pediatric emergency department. We observed children presenting to local emergency departments in a large metropolitan area with lacerations incurred from metal lawn and garden edging, a landscaping tool. We sought to describe the severity of lacerations caused by metal edging, the characteristics of wound repair, and the need for subspecialty consultation. DESIGN: A retrospective chart review including all pediatric patients (< 18 years) presenting with lacerations caused by metal lawn and garden edging from January 1995 to October 1997 was performed. Patients were seen at one of three emergency departments in Colorado. RESULTS: One hundred twenty-six patients were enrolled (76% male, 24% female), with a median age of 9 years. The most frequent location of laceration was the foot (40%), followed by the knee (26%). The median length of laceration was 3 cm (range 1-22 cm). Sixteen patients (13%) received either intravenous or oral antibiotics, and six patients (5%) received orthopedic evaluation. CONCLUSIONS: Metal lawn and garden edging in landscaped neighborhoods presents a previously undescribed laceration danger to children. Some lacerations sustained from the metal lawn edging are extensive, receiving either multiple layer closure and/or the need for subspecialty consultation.     

New non-cocaine-containing topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations

OBJECTIVE: To compare the effectiveness of three new topical anesthetics that do not contain cocaine (prilocaine-phenylephrine, tetracaine-phenylephrine [tetraphen], and tetracaine-lidocaine-phenylephrine) to that of tetracaine-adrenaline-cocaine (TAC) during laceration repair in children. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: The emergency department of an urban children's hospital. PARTICIPANTS: Children 1 year of age or older with a laceration /= 5 years of age using a visual analogue scale (VAS). Suture technicians, research assistants, and parents also scored pain using a seven-point Likert scale. In addition, suture technicians completed an anesthetic effectiveness scale. RESULTS: There was consistently no difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. A statistically significant difference was seen among anesthetics when comparing VAS and Likert scale scores of suture technicians and Likert scale scores of research assistants. Based on post hoc analyses, these statistically significant differences were between TAC and prilocaine-phenylephrine (suture technician VAS and Likert scale) and between TAC and tetracaine-lidocaine-phenyl-ephrine (suture technician Likert scale), but not between TAC and tetraphen. When power analyses were performed using alpha = 0.05 and beta = 0.20, it was possible to detect a difference of 1.2 VAS units for each of the observer groups. Based on anesthetic effectiveness scale scores, the three new topical preparations collectively performed significantly better on the face and scalp than on the extremities (relative risk = 1.83; 95% confidence interval 1.20 < relative risk < 2.79). CONCLUSION: This study demonstrated the effectiveness and safety of three new non-cocaine-containing topical anesthetics. Consistently, there was no statistical difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. Tetraphen offers an effective alternative to TAC during laceration repair in children.     

Intranasal Ketamine for Procedural Sedation in Pediatric Laceration Repair: A Preliminary Report

OBJECTIVE: The objective of this study was to compare the efficacy of 3 doses of intranasal ketamine (INK) for sedation of children from 1 to 7 years old requiring laceration repair. METHODS: This was a randomized, prospective, double-blind trial of children requiring sedation for laceration repair. Patients with simple lacerations were randomized by age to receive 3, 6, or 9 mg/kg INK. Adequacy and efficacy of sedation were measured with the Ramsay sedation score and the Observational Scale of Behavioral Distress-Revised. Serum ketamine and norketamine levels were drawn during the procedure. Sedation duration and adverse events were recorded. RESULTS: Of the 12 patients enrolled, 3 patients achieved adequate sedation, all at the 9-mg/kg dose. The study was suspended at that time as per predetermined criteria. CONCLUSIONS: Nine milligrams of INK per kilogram produced a significantly higher proportion of successful sedations than the 3- and 6-mg/kg doses.     

Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department

OBJECTIVES: (1) To determine if oral diazepam (POD) is as effective in sedating children less than 6 years of age for laceration repair as oral midazolam (POM) or intranasal midazolam (INM); and (2) To determine if patients stayed longer in the department after sedation when given POD for sedation. DESIGN/METHODS: Block-randomized, single-blind trial. SETTING: Tertiary pediatric emergency department. PARTICIPANTS: Patients 1 to 5 years old with a laceration requiring sutures were enrolled. INTERVENTIONS: All patients had topical anesthetic applied to the wound and were randomly assigned to POD 0.5 mg/kg, POM 1.0 mg/kg, or INM 0.4 mg/kg for sedation. RESULTS: One hundred twenty-nine patients were enrolled, 42 POD, 45 POM, and 42 INM. Each group was similar at baseline for age, heart rate, respiratory rate, blood pressure, oxygen saturation, previous laceration or sedation, anxiety score, and site of laceration. POM and POD were better tolerated than INM (P = 0.05 and 0.034), respectively. Time to sedation was significantly longer in POD (31.0 +/- 9 min) than INM (26.1 +/- 9 min) (P = 0.011) but there was no significant difference when comparing the other groups. However, this difference was not clinically significant. POD was significantly worse at sedating children compared with POM and INM on all four scores (ie, doctor, nurse, parent, and investigator), but INM and POM were equivalent. Total time in the department was no different between POM and INM or POM and POD, but was significantly different for POD (53.9 +/- 16 min) and INM (48 +/- 12 min); however, this difference was minimal. More patients were said to be drowsy at home in the POM group (51%) than the POD group (32%). CONCLUSIONS: The oral route of delivery of POM and POD was better tolerated than INM. POM and INM were more effective at sedation than POD, but there was no clinical difference between any groups for time to sedation or time to discharge. More patients in the POM group had side effects after leaving the department. POD may be an alternative to POM, but a higher dose may be required, possibly with longer recovery times.     

Efficacy and safety of deep sedation by non-anesthesiologists for cardiac MRI in children

Background

Cardiac MRI has become widespread to characterize cardiac lesions in children. No study has examined the role of deep sedation performed by non-anesthesiologists for this investigation.

Objective

We hypothesized that deep sedation provided by non-anesthesiologists can be provided with a similar safety and efficacy profile to general anesthesia provided by anesthesiologists.

Materials and methods

This is a retrospective chart review of children who underwent cardiac MRI over a 5-year period. The following data were collected from the medical records: demographic data, cardiac lesion, American Society of Anesthesiologists (ASA) physical status, sedation type, provider, medications, sedation duration and adverse events or interventions. Image and sedation adequacy were recorded.

Results

Of 1,465 studies identified, 1,197 met inclusion criteria; 43 studies (3.6%) used general anesthesia, 506 (42.3%) had deep sedation and eight (0.7%) required anxiolysis only. The remaining 640 studies (53.5%) were performed without sedation. There were two complications in the general anesthesia group (4.7%) versus 17 in the deep sedation group (3.4%). Sedation was considered inadequate in 22 of the 506 deep sedation patients (4.3%). Adequate images were obtained in 95.3% of general anesthesia patients versus 86.6% of deep sedation patients.

Conclusion

There was no difference in the incidence of adverse events or cardiac MRI image adequacy for children receiving general anesthesia by anesthesiologists versus deep sedation by non-anesthesiologists. In summary, this study demonstrates that an appropriately trained sedation provider can provide deep sedation for cardiac MRI without the need for general anesthesia in selected cases.     

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.     

Pain relief for neonatal circumcision: a follow-up of residency training practices.

OBJECTIVE: To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision. METHODS: All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940). RESULTS: Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%. CONCLUSIONS: The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.     

Lacerations involving glass. The role of routine roentgenograms.

OBJECTIVE--To determine, when evaluating a laceration caused by glass, whether seeing that the bottom of the wound is free of glass eliminates the possibility that glass is present in the wound. RESEARCH DESIGN--Prospective patient series. SETTING--Two pediatric emergency departments. PARTICIPANTS--226 children with lacerations due to glass occurring in a period of 21 months. SELECTION PROCEDURES--Consecutive sample. INTERVENTIONS--Before obtaining a roentgenogram, the triage nurse or the managing physician visually inspected each wound and recorded whether the bottom of the wound was seen, if glass was seen in the wound, and the length and depth of the wound. Further treatment of the wound was at the discretion of the managing physician. MEASUREMENTS/MAIN RESULTS--Glass was seen in the wounds of 10 children on initial inspection. Of the remaining 216 injuries, glass was contained in 12 (21.4%) of the 56 lacerations when the bottom of the wound was not visualized, and in 11 (6.9%) of the 160 lacerations when the bottom of the wound was visualized. There was a significant association between the depth of the wound and an inability to see the bottom of the wound, and deeper wounds were significantly more likely to contain glass. All but one of the lacerations containing glass had a depth of at least 0.5 cm. CONCLUSIONS--In the population studied, seeing that the bottom of the laceration was free of glass reduced, but did not eliminate, the possibility that glass was present in the wound. In addition, superficial lacerations (less than 0.5 cm) rarely contained undetected glass fragments. We recommended that further investigation concerning the mechanism of injury, the depth of the wound, and the type of glass involved is needed before physicians abandon routine roentgenography for lacerations due to glass.     

Insertion of long lines in the pediatric emergency department.

OBJECTIVE: The purpose of this study was: 1) to evaluate the role of the pediatric emergency department (PED) in placing peripherally inserted midline or central catheters (long lines), and 2) to review indications and complications to use this technology to reduce the number and duration of admissions and provide an alternative method for administering intravenous therapy. METHODS: Retrospective chart review of all patients taken from a procedure log who had long lines placed in the emergency department of a children's hospital. RESULTS: Twenty-eight patients had 30 long line insertions over a 36-month period. Fourteen were female; age ranged from 1 to 36 years with a median of 9 and a mean of 11.1 +/- 8.4. The indication for insertion was for parenteral antibiotics in 27 of 28 (96%) patients and for parenteral nutrition in 1 (4%) patient. The catheters varied in length from 8 to 60 cm. Twelve of 30 (40%) catheters terminated centrally in the subclavian or superior vena cava, while 18 (60%) were in the peripheral cephalic, basilic, or axillary veins. Chest radiography confirmed positioning in 12 of 12 inserted centrally and in 15 of 18 (83%) in the peripheral circulation. Half of the patients received no premedication for the procedure; 10 (33%) received topical anesthetic cream; 2 (7%) local infiltration of anesthetic, and 2 (7%) parenteral sedation. Twenty-one of 30 (70%) patients were discharged directly from the emergency department; 3 (10%) were discharged after admission to the hospital to complete treatment at home with their long lines, and 6 (20%) used their long lines for in-hospital therapy only. Eight of 30 (27%) placements were for patients specifically referred to the PED for placement or replacement of a long line. Twelve of 30 (40%) lines were placed in children presenting for intravenous therapy for cellulitis. These patients received a long line with home i.v. therapy instead of the traditional admission. The duration of intravenous treatment documented for all patients ranged from 1 to 62 days with a median of 10.5, and a mean of 16.2 +/- 17.8, compared with the duration of the line ranging from 1 to 28 days with a median of 4, and a mean of 7.3 +/- 8.0. Ten of 30 (33%) had their line for 3 days or less. The short duration was due to problems with line function in 5 of 10, and intentional removal secondary to improved cellulitis in 5. There were no significant complications with the lines reported during placement or while in use; however, 8 of 30 (27%) of the lines placed developed problems with function, requiring repair or replacement. CONCLUSIONS: 1) Long lines can be inserted in the pediatric emergency department by physicians with different levels of training with minor complications and no adverse clinical effects; 2) the placement of long lines can eliminate the need for hospitalization in some cases, reduce the duration of hospitalization in others, and lessen the need for repeated venipunctures for routine peripheral catheter replacement in patients requiring i.v. therapy; 3) the planned duration of therapy as well as other factors not analyzed in this study should be considered when selecting patients for long line placement in the emergency department.     

Inpatient reports of suspected child abuse or neglect (SCAN): a question of missed opportunities in the acute care setting

OBJECTIVE: To determine reasons inpatient reports of suspected child abuse or neglect (SCAN) were not initiated at the time of evaluation in the acute care setting. DESIGN: Retrospective case series. SETTING: Urban children's hospital. PATIENTS: Forty-four children with reports of SCAN filed as hospital inpatients between January 1 and December 31, 1993. INTERVENTIONS: None. RESULTS: Prior to admission, the 44 patients were evaluated in the following settings: pediatric emergency department (PED) (50%), general emergency department (GED) (30%), PED and GED (9%), and outpatient clinic (11%). Inpatient reports were more often for suspicion of neglect than for physical abuse, when compared to reports made in the ambulatory setting (P<0.001). In 23% of cases, the injury or illness necessitating admission was not related to the SCAN. Mean delay in filing a SCAN report following admission was 2.7 days (range 0-20 days). In 45% of cases, it was determined that inadequate information was available at the time of the acute visit to file a SCAN report. Compared with admissions from a PED, a higher percent of admissions from a GED had inpatient reports without additional findings after the acute care evaluation (P<0.05). Seventy-five percent of patients in whom no additional information was obtained during the admission required admission to an intensive care unit (ICU) setting. Forty-eight percent (21 of 44) of inpatient SCAN reports were determined substantiated following Child Protective Services (CPS) investigation. Forty-two percent (10 of 24) of those cases in which no additional information was uncovered following admission were determined substantiated. CONCLUSIONS: Inpatient reports are often the result of additional findings obtained after admission. A higher percentage of admissions from a GED than from a PED had inpatient reports of SCAN without additional findings. Patients who have an inpatient report filed for SCAN are often of high medical acuity, less likely to have physical findings, and may present with injuries or illnesses unrelated to the SCAN.     

MRI-compatible audio/visual system: impact on pediatric sedation

BACKGROUND: While sedation is necessary for much pediatric imaging, there are new alternatives that may help patients hold still without medication. OBJECTIVE: We examined the effect of an audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI). MATERIALS AND METHODS: All MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated. RESULTS: The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies. CONCLUSION: The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost.     

General Anesthesia for Children With Severe Heart Failure

Severe heart failure in children is uncommon. The anesthetic management of children with this condition is challenging. The authors aimed to identify the frequency with which anesthesia for short noncardiac surgical procedures or investigations was complicated by life-threatening hemodynamic instability and to describe the anesthetic techniques used. This study retrospectively reviewed the anesthetic charts and notes of children admitted acutely with a diagnosis of severe heart failure (fractional shortening of 15% or less) who received general anesthesia for noncardiac surgical or diagnostic interventions during the 3-year period from September 2005 to September 2008. In this study, 21 children received a total of 28 general anesthetics. Two patients (10%) experienced a cardiac arrest, and both required unplanned admission to the authors’ pediatric intensive care unit (PICU) postoperatively. A variety of anesthetic techniques was used. In 27 (96%) of the 28 cases, perioperative inotropic support was required. General anesthesia for children with severe heart failure is associated with a significant complication rate and should be administered by anesthetists familiar with managing all aspects of circulatory support for children in an appropriate setting.     

Esophageal stricture dilatation in awake children

Dilatation of esophageal strictures in children has generally been performed in the hospital under general anesthesia, or under deep sedation. We report here a series of 211 dilatations in 13 pediatric patients who had these procedures performed in the outpatient department, 72% of them without any sedation, during a 4-year period. This report characterizes the children, the method of outpatient dilatation, and our results. At the end of the study period, six of the patients no longer required dilatation after five to 14 procedures; four patients still required dilatation at twice-yearly intervals; and three patients remained on an active schedule of dilatations at intervals less than 5 months. Esophageal lumen diameter increased and symptoms improved in all of the children. Catch-up weight gain occurred in one-half of those initially below the 10th percentile. Dilatation without anesthesia or sedation was preferred by all of the parents, and by those children old enough to express a preference. Estimated reduction of medical costs by more than $100,000 was realized, compared with bouginage using general anesthesia. No episode of perforation, significant hemorrhage, documentable aspiration, or neurologic complication occurred. Outpatient dilatation without anesthesia is an effective method of treating esophageal strictures in children.     

Dental concerns unrelated to trauma in the pediatric emergency department: barriers to care

OBJECTIVES: To describe patients with nontraumatic dental problems treated in our pediatric emergency department (PED) and to determine if barriers to access prompted seeking care in the PED rather than from a dentist or dental clinic. DESIGN: Questionnaire administered to a convenience sample of patients with nontraumatic dental complaints. SETTING: An urban PED. MAIN OUTCOME MEASURES: Insurance status, primary medical and dental care, duration of symptoms, diagnosis, and reason for seeking care in the PED. RESULTS: Two hundred patients were enrolled. Median age was 17 years (range, 1-22 years). Forty-five percent were African American. Forty-nine percent had Medicaid. Fifty percent identified a regular dentist, whereas 71% had a primary care physician. Thirty-four percent of patients 4 years and older had not seen a dentist in more than a year. Children younger than 13 years were more likely than teenagers to identify a regular dentist (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.3-6.1). Those with a regular medical provider were more likely to have a regular dentist (OR = 7.7; 95% CI, 3.4-18). The most common reasons for not going to a dentist were as follows: dentist closed, 34%; lack of dental insurance or money, 17%; and lack of a dentist, 16%. Patients with symptoms for more than 72 hours were more likely to cite lack of a dentist as their reason for coming to the PED (OR = 7.4; 95% CI, 1.9-33). CONCLUSIONS: Many pediatric patients do not have regular dental care, and this is associated with a lack of primary medical care. Access barriers to acute dental care include lack of insurance or funds, lack of a dentist, and limited hours of dental care sites. Improved insurance reimbursement, active enrollment of adolescents into preventive dental care, and expansion of provider hours may limit PED dental visits and improve the health of patients.