Kathlene E Bassett

Propofol sedation by emergency physicians for elective pediatric outpatient procedures

STUDY OBJECTIVE We describe the efficacy of propofol sedation administered by pediatric emergency physicians to facilitate painful outpatient procedures. METHODS By using a protocol for patients receiving propofol sedation in an emergency department-affiliated short-stay unit, a prospective, consecutive case series was performed from January to September 2000. Patients were prescheduled, underwent a medical evaluation, and met fasting requirements. A sedation team was present throughout the procedure. All patients received supplemental oxygen. Sedation depth and vital signs were monitored while propofol was manually titrated to the desired level of sedation. RESULTS There were 291 separate sedation events in 87 patients. No patient had more than 1 sedation event per day. Median patient age was 6 years; 57% were male patients and 72% were oncology patients. Many children required more than 1 procedure per encounter. Most commonly performed procedures included lumbar puncture (43%), intrathecal chemotherapy administration (31%), bone marrow aspiration (19%), and bone biopsy (3%). Median total propofol dose was 3.5 mg/kg. Median systolic and diastolic blood pressures were lowered 22 mm Hg (range 0 to 65 mm Hg) and 21 mm Hg (range 0 to 62 mm Hg), respectively. Partial airway obstruction requiring brief jaw-thrust maneuver was noted for 4% of patient sedations, whereas transient apnea requiring bag-valve-mask ventilation occurred in 1% of patient sedations. All procedures were successfully completed. Median procedure duration was 13 minutes, median sedation duration was 22 minutes, and median total time in the short stay unit was 40 minutes. CONCLUSION Propofol sedation administered by emergency physicians safely facilitated short painful procedures in children under conditions studied, with rapid recovery.

Diagnosis and outcomes of enterovirus infections in young infants

Background: Enterovirus (EV) infections commonly cause fever in infants younger than 90 days of age. The polymerase chain reaction (PCR) has improved our ability to diagnose EV infections. Objective: To evaluate the utility of blood and cerebrospinal fluid (CSF) specimens for the diagnosis of EV infections by PCR and to describe a large cohort of EV-infected infants. Design/Methods: Febrile infants younger than 90 days of age evaluated for sepsis at Primary Childrens Medical Center in Salt Lake City, UT, were enrolled in a prospective study designed to identify viral infections from December 1996 to June 2002. All patients had bacterial cultures of blood, urine and CSF. Testing for EV was performed by PCR and/or viral cultures. Patients who were positive for EV were identified for this study. Results: Of 1779 febrile infants enrolled, 1061 had EV testing and 214 (20%) were EV-positive. EV infections were diagnosed by PCR of blood, CSF or both in 93% of infants. PCR testing was positive in blood in 57%, and blood was the only positive specimen for 22% of EV infected infants. PCR of CSF was positive in 74%. The mean age of infants with EV infection was 33 days, with 18% younger than 14 days and 5% younger than 7 days. Fifty percent of EV-positive infants had CSF pleocytosis. Of EV PCR-positive infants, 91% were admitted, and 2% required intensive care. Possible serious EV disease was diagnosed in <1%, and there were no deaths. Twelve infants (5.6%) had concomitant urinary tract infection, and 3 (1%) had bacteremia. Conclusions: EV infections are common in febrile infants younger than 90 days. Blood and CSF are equally likely to yield positive results by PCR, but the combination of both specimens improved the diagnostic yield.

Use of Propofol Sedation in a Pediatric Emergency Department: A Prospective Study

The purpose of this study was to determine the efficacy and safety of propofol sedation for pediatric procedures in the emergency department. For patients needing painful procedures, propofol was administered intravenously. Vital signs, complications, and time to recovery were recorded. Patient amnesia and parent, patient, and operator satisfaction with sedation were assessed. The mean age was 7.4 years; 65% were male. Most underwent fracture reduction. Mean total dose was 3.3 mg/kg. Thirty percent experienced desaturation. One required assisted ventilation. Most had decreases in blood pressure. Mean recovery time was 18 minutes. Satisfaction with sedation was rated “excellent.” Propofol was an effective sedation with minimal complications in the emergency department setting.

Localizing ingested coins with a metal detector

This study was conducted to determine the utility of metal detection in coin localization by inexperienced operators, and determine the rate of spontaneous passage of asymptomatic esophageal coins. All children who presented to the emergency department of an urban childrens hospital with a suspected coin ingestion were eligible. Coin location was predicted from metal detector results, while radiographs confirmed location. Asymptomatic patients with esophageal coins were observed for spontaneous passage. Ninety-one children (ages 9 months to 17 years) were prospectively enrolled. The metal detector had a sensitivity of 98% (53/54) in coin detection and 98% (81/83) in determining coin location as esophageal. Symptoms were poor predictors of coin location. Six of eight asymptomatic patients with esophageal coins spontaneously passed their coins. These results show that metal detection is a good screening test for coin presence and to determine coin location as esophageal. Spontaneous passage of asymptomatic esophageal coins warrants further study.

Cyclizine abuse by teenagers in Utah

Substance abuse by teenagers is common, often involving use of alcohol and illicit drugs. Ingestion of cyclizine hydrochloride, a nonprescription medication, was noted to occur frequently in Utah for abuse reasons. A retrospective review was conducted of patients younger than 18 years of age over a 3-year period who intentionally ingested cyclizine identified from Utah Poison Control Center records. Eighty patients were included; 42 patients underwent hospital record review. Abuse accounted for 89% of cyclizine ingestions; hallucinations (70%) and confusion/disorientation (40%) were the most notable symptoms. Tachycardia (52%) and systolic hypertension (69%) were frequently present in patients who presented to a hospital. No serious complications occurred. This study illustrates teenage abuse of one nonprescription antihistamine presumably to induce hallucinations. Abuse of over-the-counter medications by adolescents may be more appealing than illicit drug use for numerous reasons, and may be more common than appreciated.

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.