Study objective Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from ...relatively small studies. Methods We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. Results In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of ≥2.5 mg/kg or a total dose of ≥5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. Conclusion Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.
We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research ...warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.
Children commonly require sedation and analgesia for procedures in the emergency department. Establishing accurate adverse event and complications rates from the available literature has been ...difficult because of the difficulty in aggregating results from previous studies that have used varied terminology to describe the same adverse events and outcomes. Further, serious adverse events occur infrequently, necessitating the study of large numbers of children to assess safety. These limitations prevent the establishment of a sufficiently large database on which evidence-based practice guidelines may be based. We assembled a panel of pediatric sedation researchers and experts to develop consensus-based recommendations for standardizing procedural sedation and analgesia terminology and reporting of adverse events. Our goal was to create a uniform reporting mechanism for future studies to facilitate the aggregation and comparison of results.
A growing number of students are completing undergraduate degrees in statistics and entering the workforce as data analysts. In these positions, they are expected to understand how to use databases ...and other data warehouses, scrape data from Internet sources, program solutions to complex problems in multiple languages, and think algorithmically as well as statistically. These data science topics have not traditionally been a major component of undergraduate programs in statistics. Consequently, a curricular shift is needed to address additional learning outcomes. The goal of this article is to motivate the importance of data science proficiency and to provide examples and resources for instructors to implement data science in their own statistics curricula. We provide case studies from seven institutions. These varied approaches to teaching data science demonstrate curricular innovations to address new needs. Also included here are examples of assignments designed for courses that foster engagement of undergraduates with data and data science.
Received November 2014. Revised July 2015.
Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk ...stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.
Study objective We investigate the effect of ondansetron on the incidence of vomiting in children who receive intravenous (IV) ketamine for procedural sedation and analgesia in the emergency ...department (ED). Methods In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IV ketamine (1 mg/kg) for ED procedures were randomized to receive either IV ondansetron (0.15 mg/kg; maximum 4 mg) or identical placebo. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction. Results One hundred twenty-seven children were randomized to placebo and 128 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was less common with ondansetron: 6 of 128 (4.7%) versus 16 of 127 (12.6%), P =.02, difference 7.9% (95% confidence interval 1.1% to 14.7%), number needed to treat 13. Follow-up was successful in 82.7%, with vomiting in the ED or after discharge less frequent with ondansetron: 10 of 128 (7.8%) versus 24 of 127 (18.9%), P =.01, difference 11.1% (95% confidence interval 2.7% to 19.5%), number needed to treat 9. ED length of stay and parental satisfaction were similar between groups. Conclusion IV ondansetron significantly reduces the incidence of vomiting associated with IV ketamine procedural sedation in children.
Abstract Objective The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the ...emergency department (ED). Methods We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18 years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18 years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2 mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events. Results A total of 171 children were enrolled of whom 125 (1 mg/kg, 50; 1.5 mg/kg, 35; 2 mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1 mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 interquartile range {IQR}, 4-6 vs 6 IQR, 4-6 vs 6 IQR, 5-6), FACES-R score (0 IQR, 0-4 vs 0 IQR, 0-0 vs 0 IQR, 0-0), sedation duration in minutes (23 IQR, 19-38 vs 24.5 IQR, 17.5-34.5 vs 23 IQR, 19-29), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1 mg/kg group (79.6% vs 94.1% vs 97.3%). Conclusions Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0 mg/kg intravenous required less redosing and resulted in greater physician satisfaction.
Influenza causes substantial morbidity and mortality despite available treatments. Anecdotal reports suggest that plasma with high antibody titres to influenza might be of benefit in the treatment of ...severe influenza.
In this randomised, open-label, multicentre, phase 2 trial, 29 academic medical centres in the USA assessed the safety and efficacy of anti-influenza plasma with haemagglutination inhibition antibody titres of 1:80 or more to the infecting strain. Hospitalised children and adults (including pregnant women) with severe influenza A or B (defined as the presence of hypoxia or tachypnoea) were randomly assigned to receive either two units (or paediatric equivalent) of anti-influenza plasma plus standard care, versus standard care alone, and were followed up for 28 days. The primary endpoint was time to normalisation of patients' respiratory status (respiratory rate of ≤20 breaths per min for adults or age-defined thresholds of 20-38 breaths per min for children) and a room air oxygen saturation of 93% or more. This study is registered with ClinicalTrials.gov, number NCT01052480.
Between Jan 13, 2011, and March 2, 2015, 113 participants were screened for eligibility and 98 were randomly assigned from 20 out of 29 participating sites. Of the participants with confirmed influenza (by PCR), 28 (67%) of 42 in the plasma plus standard care group normalised their respiratory status by day 28 compared with 24 (53%) of 45 participants on standard care alone (p=0·069). The hazard ratio (HR) comparing plasma plus standard care with standard care alone was 1·71 (95% CI 0·96-3·06). Six participants died, one (2%) from the plasma plus standard care group and five (10%) from the standard care group (HR 0·19 95% CI 0·02-1·65, p=0·093). Participants in the plasma plus standard care group had non-significant reductions in days in hospital (median 6 days IQR 4-16 vs 11 days 5-25, p=0·13) and days on mechanical ventilation (median 0 days IQR 0-6 vs 3 days 0-14, p=0·14). Fewer plasma plus standard care participants had serious adverse events compared with standard care alone recipients (nine 20% of 46 vs 20 38% of 52, p=0·041), the most frequent of which were acute respiratory distress syndrome (one 2% vs two 4% patients) and stroke (one 2% vs two 4% patients).
Although there was no significant effect of plasma treatment on the primary endpoint, the treatment seemed safe and well tolerated. A phase 3 randomised trial is now underway to further assess this intervention.
National Institute of Allergy and Infectious Diseases, US National Institutes of Health.
The atmospheric neutrino flavour ratio measured using a 1.52 kton-year exposure of Soudan 2 is found to be 0.72 ± 0.19
−0.07
+0.05 relative to the expected value from a Monte Carlo calculation. The ...possible background of interactions of neutrons and photons produced in muon interactions in the rock surrounding the detector has been investigated and is shown not to produce low values of the ratio.
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