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PED-EM-L  January 2015

PED-EM-L January 2015

Subject:

Re: Pain control for intussusception, and radiology

From:

"Rocker, Joshua MD" <[log in to unmask]>

Reply-To:

Rocker, Joshua MD

Date:

Mon, 26 Jan 2015 09:32:57 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (125 lines)

The radiologists at our institution also believe in the bearing down theory.  
The article from Israel below, which was published in Ped Radiology in 2012, demonstrates deep sedation with propofol was extremely effective.  92% success rate.  
For anyone who has witnessed the procedure it is a barbaric therapy.  A strapped down child on a device that can rotate them 90 degrees so that lateral and AP views are obtained quickly without moving the beam of the xray.  It is an effective method and should be performed but in my opinion sedation is the humane thing to do.

http://link.springer.com/article/10.1007/s00247-011-2311-0
Pediatric Radiology
May 2012, Volume 42, Issue 5, pp 562-565
Date: 02 Feb 2012

Deep sedation during pneumatic reduction of intussusception

Anat Ilivitzki, Luda Glozman Shtark, Karin Arish, Ahuva Engel


Abstract
Background
Pneumatic reduction of intussusception under fluoroscopic guidance is a routine procedure. The unsedated child may resist the procedure, which may lengthen its duration and increase the radiation dose. We use deep sedation during the procedure to overcome these difficulties.
Objective
The purpose of this study was to summarize our experience with deep sedation during fluoroscopic reduction of intussusception and assess the added value and complication rate of deep sedation.
Materials and methods
All children with intussusception who underwent pneumatic reduction in our hospital between January 2004 and June 2011 were included in this retrospective study. Anesthetists sedated the children using propofol. The fluoroscopic studies, ultrasound (US) studies and the childrens' charts were reviewed.
Results
One hundred thirty-one attempted reductions were performed in 119 children, of which 121 (92%) were successful and 10 (8%) failed. Two perforations (1.5%) occurred during attempted reduction. Average fluoroscopic time was 1.5 minutes. No complication to sedation was recorded.
Conclusions
Deep sedation with propofol did not add any complication to the pneumatic reduction. The fluoroscopic time was short. The success rate of reduction was high, raising the possibility that sedation is beneficial, possibly by smooth muscle relaxation.


Josh Rocker, MD
Associate Chief, Division of Pediatric Emergency Medicine
Cohen Children's Medical Center


________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of Michelle Fleurat [[log in to unmask]]
Sent: Sunday, January 25, 2015 4:16 PM
To: [log in to unmask]
Subject: Re: Pain control for intussusception, and radiology

Sara and I trained at the same hospital and my understanding of the policy
after talking to one of our head radiologists was that they believe that
the kids bearing down during the procedure makes them reduce easier.

Some of the radiologists at another hospital that I work at actually want
the kids sedated during the procedure.

Thoughts?

Thanks,
Michelle Fleurat MD

On Fri, Jan 23, 2015 at 6:35 PM, Marty Herman <[log in to unmask]> wrote:

> Anyone tried glycopyrrolate? I have and think it helps.
>
> Marty, (Dad, Bro etc.)
> Martin Herman , M.D.
> Sent from my iPhone
>
>
> > On Jan 23, 2015, at 7:45 PM, Meckler, Garth <[log in to unmask]>
> wrote:
> >
> > Great question, thanks for posting.  No restrictions at our institution,
> but I'm curious if there are any pain experts who can comment on whether
> narcotics block nociception from hollow viscous stretch receptors?
> Anecdotally over the years I have tried providing a range of analgesics but
> have not found them very effective for this type of pain.  Even a number of
> studies looking at morphine for appendicitis suggest that, while safe, it
> doesn't significantly change reported pain scores.  Anyone have insights
> into pain control from hollow viscous pain?
> >
> > Garth Meckler, MD, MSHS
> > Division Head, PEM
> > BC Children's Hospital
> >
> >
> >> On Jan 23, 2015, at 15:03, Sara Alexandra Leibovich <
> [log in to unmask]> wrote:
> >>
> >> Hello,
> >> It seems that there is a tradition in radiology about avoiding morphine
> (or
> >> other opioid analgesic) for patients with intussusception prior to
> >> reduction, the idea being that patients who are "too relaxed" are more
> >> likely to perforate during the reduction attempt. At your institution,
> does
> >> radiology request that morphine be withheld from children with
> >> intussusception in the ED? If so, what is their stated reason, and how
> do
> >> you reconcile this with the obvious need for pain control? On the other
> >> hand, at your institution, are reductions normally done with a dose of
> >> morphine or similar on board, or under procedural sedation? Is there any
> >> formal policy?
> >>
> >> Thanks,
> >> Sara Leibovich
> >>
> >> Fellow, Department of Emergency Medicine
> >> UCSF Benioff Children's Hospital Oakland
> >>
> >> For more information, send mail to [log in to unmask] with
> the message: info PED-EM-L
> >> The URL for the PED-EM-L Web Page is:
> >>                http://listserv.brown.edu/ped-em-l.html
> >
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>

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