LETTER TO THE EDITORS

Sedation Dilemmas for Computed Tomography With Oral Contrast in Children To the Editors: he authors of the article by Kharazmi et al1 conclude that propofol sedation of children for abdominal computed tomography (CT) scan is relatively safe after a nil per oral period less than the American Society of Anesthesiologists recommended 2 hours. We believe that this conclusion may be premature based on the sample size. The sample of 85 patients sets an upper limit for adverse events of 3.4%. A much larger sample size is needed to justify the conclusion. The authors cite Cravero et al2 as evidence that the incidence of vomiting and aspiration is very low with use of propofol. Although that may be true, the Cravero article also shows that the overall incidence of airway events is not a low as that of aspiration. Significant desaturation occurred with a 1.54% incidence and laryngospasm occurred at a 0.96% rate. It is also important to note that 99.37% of the sample in the Cravero report had liquid intake more than 2 hours before anesthesia/ sedation and more than 82% had solid intake more than 8 hours prior. It cannot be assumed that a shorter fast will result in the same rate of adverse events. Furthermore, their analysis of the data concludes that the need for timely rescue is significant, implying that unless properly trained individuals are in constant attendance and appropriate monitoring is used, there is the potential for serious adverse events. Before administering sedation for CT scan, the underlying pathology must be

T

372

www.pec-online.com

considered. The presenting pathology of patients in the Kharazmi study was not reported, whereas the American Society of Anesthesiologists status was comparable between the 2 groups. Many patients who present for abdominal CT and need oral contrast media (OCM) have coexisting diseases that can affect the gastrointestinal motility. These patients may not be appropriate candidates for open airway sedation techniques. The ideal fasting intervals for these children have yet to be determined. A recent study that included 101 consecutive patients ages 3 to 17 years who underwent contrast-enhanced abdominal CT for suspected acute appendicitis (n = 90), abdominal trauma (n = 10), or suspected ileus (n = 1) showed that 75% of the patients had OCM in the stomach 48 T 5.2 minutes after its completion, 50% after 74 T 7.9 minutes, and 25% after 135 T 32.5 minutes; 1 patient still had OCM after 162 minutes. The authors of this study advocated waiting at least 3 hours between completion of OCM ingestion and general anesthesia induction,3 although waiting several hours after administration of contrast often results in inadequate opacification of the small bowel and a poor study. The administration of OCM during CT in children who require sedation can be a challenge.4 The challenge lies in balancing technical factors governing the image quality of the study with safety concerns stemming from risks related to sedating a child with a potentially full stomach. Currently, we are not aware of any evidencebased safe sedation plan and clear consensus among institutions that care for these patients. Some clinicians may choose to perform rapid sequence induction of general anesthesia with endotracheal intubation, whereas others may choose deep sedation without definitive airway protection. Others

may negotiate with radiologists to have the oral contrast given 2 hours before the study.

Mohamed Mahmoud, MD Department of Anesthesiology Cincinnati Children’s Hospital Medical Center Cincinnati, OH [email protected]

John McAuliffe, MD, MBA Department of Anesthesiology Cincinnati Children’s Hospital Medical Center Cincinnati, OH

DISCLOSURE The authors declare no conflict of interest. REFERENCES 1. Kharazmi SA, Kamat PP, Simoneaux SF, et al. Violating traditional NPO guidelines with PO contrast before sedation for computed tomography. Pediatr Emerg Care. 2013;29:979Y981. 2. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108: 795Y804. 3. Berger-Achituv S, Zissin R, Shenkman Z, et al. Gastric emptying time of oral contrast material in children and adolescents undergoing abdominal computed tomography. J Pediatr Gastroenterol Nutr. 2010;51:31Y34. 4. Mahmoud M, McAuliffe J, Donnelly LF. Administration of enteric contrast material before abdominal CT in children: current practices and controversies. Pediatr Radiol. 2011;41:409Y412.

Pediatric Emergency Care

&

Volume 30, Number 5, May 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Intravenous access in children in the emergency department.

Intravenous access in children in the emergency department. - PDF Download Free
55KB Sizes 3 Downloads 4 Views