Replies to comments by DeCaporale-Ryan, Dadiz, and Peyre (see record 2016-27364-002) on the original article by Kim, Hernandez, Lavery, and Denmark (see record 2016-18380-001). The current authors thank DeCaporale-Ryan, Dadiz, and Peyre for presenting a rich theoretical counterpoint to their article and respond to issues they raised regarding their collaborative reflecting team (CRT) model.
Objectives To describe our experience using ketamine sedation to facilitate pediatric critical care procedures, and to document the safety profile of ketamine in this setting. Design Retrospective consecutive case series. Setting Pediatric intensive care unit of a tertiary children’s hospital. Patients Children receiving ketamine for procedural sedation over a 5-year period. Interventions We reviewed patient records to determine indication, dosing, adverse events, inadequate sedation, and recovery time for each sedation. Outcome Measures Descriptive features of sedation including adverse events. Results During the study period, children in our pediatric intensive care unit received ketamine at total of 442 times to facilitate a wide variety of critical care procedures, most commonly central line placement, esophagogastroduodenoscopy, and wound debridement. Most study children had substantial underlying illness (ASA ≥ 3 in 88%; ASA ≥ 4 in 39%). Inadequate sedation was noted in only nine (2%) procedures. Adverse effects included transient laryngospasm (n = 9), transient partial airway obstruction (n = 5), apnea with bradycardia (n = 1), emesis during the procedure (n = 2), emesis during recovery (n = 9), mild recovery agitation (n = 10), moderate-to-severe recovery agitation (n = 1), and excessive salivation (n = 4). There were no adverse outcomes attributable to ketamine. Conclusion Pediatric intensivists skilled in ketamine administration can safely and effectively administer this drug to facilitate critical care procedures. Despite the ill nature of our patient sample, adverse effects were uncommon.
To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California.Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities.Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar.The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.
Abstract Background: The prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine‐associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated. Objectives: To quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications. Methods: In this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100‐mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation. Results: Of 1,090 ketamine sedations during the 3‐year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., “none,” and only 1.3% of ratings were ≥ 50 mm. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation. Conclusions: When adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting.
