McQueen Alisa, Wright Robert O, Kido Maya M, Kaye Erica, Krauss Baruch
Section of Pediatric Emergency Medicine, The University of Chicago, Chicago, IL, USA.
Ann Emerg Med. 2009 Aug;54(2):191-97.e1-4. doi: 10.1016/j.annemergmed.2009.04.015. Epub 2009 May 22.
Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events after discharge has not been well studied. We compare the postdischarge incidence of adverse behavioral events and vomiting and hypothesize that ketamine would be associated with increased adverse behaviors.
We conducted a prospective observational study of postdischarge behavioral changes and vomiting after sedation with ketamine, ketamine/midazolam, or fentanyl/midazolam. Families were administered a Post Hospital Behavior Questionnaire (PHBQ), with higher scores indicating more adverse behaviors (anxiety, sleep disturbances). We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk adjusting for age, sex, procedure, length of procedure, and parental presence as potential confounders.
Seven hundred eighty-six children were enrolled and 554 children (61% boys; mean age 7.5+/-4.5 years) were contacted. The prevalence of postdischarge vomiting was 18%, but the prevalence of adverse behavioral changes was low. When adjusted for potential confounders, the odds of a higher PHBQ score increased among patients receiving fentanyl/midazolam (fentanyl/midazolam odds ratio [OR] 2.6, 95% confidence interval [CI] 1.08 to 6.03, P=.03; ketamine OR 1.7, 95% CI 0.84 to 3.57; ketamine/midazolam OR 0.5, 95% CI 0.26 to 1.07).
Procedural sedation and analgesia in the ED is well tolerated. Though postdischarge vomiting occurs with some frequency, there is a low prevalence of adverse behavioral events after discharge. The use of fentanyl/midazolam was associated with higher adverse behavioral scores.
尽管儿科急诊科程序性镇静镇痛的安全性和有效性已得到证实，但出院后不良事件的发生率尚未得到充分研究。我们比较出院后不良行为事件和呕吐的发生率，并假设氯胺酮会增加不良行为的发生。
我们对氯胺酮、氯胺酮/咪达唑仑或芬太尼/咪达唑仑镇静后出院后的行为变化和呕吐进行了前瞻性观察研究。向家属发放了一份出院后行为问卷（PHBQ），得分越高表明不良行为（焦虑、睡眠障碍）越多。我们使用线性回归和逻辑回归对PHBQ得分进行建模，并使用逻辑回归对呕吐风险进行建模，将年龄、性别、操作、操作时长和家长在场作为潜在混杂因素进行调整。
共纳入786名儿童，联系到554名儿童（61%为男孩；平均年龄7.5±4.5岁）。出院后呕吐的发生率为18%，但不良行为变化的发生率较低。在对潜在混杂因素进行调整后，接受芬太尼/咪达唑仑的患者PHBQ得分较高的几率增加（芬太尼/咪达唑仑优势比[OR]2.6，95%置信区间[CI]1.08至6.03，P = 0.03；氯胺酮OR 1.7，95%CI 0.84至3.57；氯胺酮/咪达唑仑OR 0.5，95%CI 0.26至1.07）。
儿科急诊科的程序性镇静镇痛耐受性良好。尽管出院后呕吐时有发生，但出院后不良行为事件的发生率较低。芬太尼/咪达唑仑的使用与较高的不良行为得分相关。
