Robert M. Kennedy

Study Objective To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department. Methods The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED₅₀) and 95% (ED₉₅) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10. Results We enrolled 20 children in each age group. The estimated ED₅₀ was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED₉₅ was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events. Conclusions We estimated ED₅₀ and ED₉₅ for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED₉₅. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

Increasing evidence has demonstrated that pain from venipuncture and intravenous cannulation is an important source of pediatric pain and has a lasting impact. Ascending sensory neural pain pathways are functioning in preterm and term infants, yet descending inhibitory pathways seem to mature postnatally. Consequently, infants may experience pain from the same stimulus more intensely than older children. In addition, painful perinatal procedures such as heel lancing or circumcision have been found to correlate with stronger negative responses to venipuncture and intramuscular vaccinations weeks to months later. Similarly, older children have reported greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures. Fortunately, both pharmacologic and nonpharmacologic techniques have been found to reduce children's acute pain and distress and subsequent negative behaviors during venipuncture and intravenous catheter insertion. This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain.

Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.

Painful procedures are frequently required during treatment of children in the emergency department and are very stressful for the children, their parents and healthcare providers. Pharmacological...