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Sedation for peritonsillar abscess drainage in the pediatric emergency department
Jan D Luhmann1, Robert M Kennedy, John D McAllister
1Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri 63110, USA.
Insights
Intravenous (IV) sedation for pediatric peritonsillar abscess (PTA) drainage in the emergency department (ED) is safe and effective. This approach can avoid hospital admission and operating room procedures, with ketamine plus midazolam being a common and safe agent.
Area of Science:
- Pediatric Emergency Medicine
- Anesthesiology
- Otolaryngology
Background:
- Peritonsillar abscess (PTA) is a common pediatric condition requiring drainage.
- Traditionally, PTA drainage is performed in the operating room, often necessitating hospital admission.
- Intravenous (IV) sedation in the emergency department (ED) offers a potential alternative for managing pediatric PTA.
Purpose of the Study:
- To evaluate the efficacy and safety of IV sedation for pediatric PTA incision and drainage within the ED setting.
- To determine if ED-based procedures can obviate the need for operating room intervention and hospital admission.
Main Methods:
- Retrospective review of medical records for children (≤18 years) diagnosed with PTA.
- Data collected included patient demographics, sedation agents and doses, sedation levels, vital signs, complications, recovery time, and disposition.
- Sedation agents commonly included ketamine plus midazolam (K/M).
Main Results:
- Forty-two pediatric patients underwent PTA incision and drainage with IV sedation in the ED.
- Ketamine plus midazolam (K/M) was the most frequently used agent (86%), with no cardiorespiratory complications reported.
- All patients were discharged from the ED, with a mean recovery time of 81 minutes; no admissions were required.
Conclusions:
- IV sedation for pediatric PTA drainage in the ED by skilled personnel is a safe and effective strategy.
- This approach can successfully avoid hospital admission and surgical drainage in the operating room.
- Ketamine plus midazolam is a frequently used and well-tolerated agent, but requires appropriate personnel and monitoring due to potential for deep sedation.
Objective:
To evaluate the use of intravenous (IV) sedation in children during peritonsillar abscess (PTA) incision and drainage in the emergency department (ED).
Design:
Retrospective review of medical records of children with a diagnosis of PTA.
Setting:
The ED of a large, urban, academic children's hospital.
Patients:
Consecutive patients 18 years or younger presenting from April 1995 to November 1998.
Methods:
Information was retrieved from a time-based sedation record that included age, sex, ASA classification, time since last liquid or solid, agent and dose, level of sedation (A=alert, V=response to voice, P=purposeful response to pain, U=unresponsive), vital signs, complications, recovery time, and disposition.
Results:
Forty-two patients had incision and drainage performed with IV sedation in the ED. Mean age was 11.3 +/- 4.3 years (range 4-18 years); 57% were African-American, and 64% were female. Agents used included ketamine plus midazolam (K/M) (n = 36, 86%), morphine plus midazolam (n = 3, 7%), meperidine plus midazolam (n = 2, 5%), and nitrous oxide plus midazolam (n = 1, 2%). No cardiorespiratory complications, including laryngospasm, occurred. Vomiting occurred in 1 patient who received meperidine and midazolam. The deepest level of sedation reached included: 12% A, 64% V, and 24% P. No patient who had an abscess drained in the ED with IV sedation was admitted, and mean recovery time was 81.0 +/- 30.1 minutes.
Conclusions:
IV sedation in children for incision and drainage of PTA by skilled personnel in the ED may eliminate the need for admission and surgical drainage in the operating room. K/M was used most frequently, without adverse effect, and all patients were discharged from the ED. Because K/M may result in deep sedation, appropriate personnel and equipment must be present.