Establishing trust with children.

Trust forms the bedrock of the doctor-patient relationship. While establishing trust is a foundational skill for healthcare providers who care for children, there is no systematic approach to teaching this skill set, nor is there formal training during medical school or residency. Traditionally, these skills have been taught by example, in an unstructured and ad hoc manner, with trainees picking it up along the way by observing and modeling their instructors.

Low-Order Mechanistic Models for Volumetric and Temporal Capnography: Development, Validation, and Application.

Objective: Develop low-order mechanistic models accounting quantitatively for, and identifiable from, the capnogram - the CO concentration in exhaled breath, recorded over time (Tcap) or exhaled volume (Vcap).

Methods: The airflow model's single "alveolar" compartment has compliance and inertance, and feeds a resistive unperfused airway comprising a laminar-flow region followed by a turbulent-mixing region. The gas-mixing model tracks mixing-region CO concentration, fitted breath-by-breath to the measured capnogram, yielding estimates of model parameters that characterize the capnogram.

Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation.

Study Objective: Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm.

Methods: Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium.

Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time?

Objective: Traditionally, patient-reported fasting time has been the primary objective presedation measure of aspiration risk. Recently, gastric ultrasound has been used to assess gastric volume for the determination of aspiration risk in patients undergoing anesthesia in the operative setting. We sought to determine the correlation of gastric volume estimated by point-of-care ultrasound (POCUS) to reported fasting time.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update.

We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.

An Enhanced Mechanistic Model For Capnography, With Application To CHF-COPD Discrimination.

Capnography records CO partial pressure in exhaled breath as a function of time or exhaled volume. Time-based capnography, which is our focus, is a point-of-care, noninvasive, effort-independent and widely available clinical monitoring modality. The generated waveform, or capnogram, reflects the ventilation-perfusion dynamics of the lung, and thus has value in the diagnosis of respiratory conditions such as chronic obstructive pulmonary disease (COPD).

Prolonged central apnoea after intravenous morphine administration in a 12-year-old male with a UGT1A1 loss-of-function polymorphism.

Adverse Event: Repeated and prolonged episodes of central apnoea and hypoxia after receiving intravenous morphine for analgesia and ketamine for sedation.

Drug Implicated: Intravenous morphine sulfate.

The Patient: Previously healthy 12-year-old male with no history of sleep apnoea who presented with distal tibia and fibula fracture.

Statistical analysis of the age dependence of the normal capnogram.

The age dependence of the time-based capnogram from normal, healthy subjects has not been quantitatively characterized. The existence of age dependence would impact the development and operation of automated quantitative capnographic tools. Here, we quantitatively assess the relationship between normal capnogram shape and age.

Fever in Children: Pearls and Pitfalls.

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children.

Model-Based Estimation of Respiratory Parameters from Capnography, With Application to Diagnosing Obstructive Lung Disease.

Objective: We use a single-alveolar-compartment model to describe the partial pressure of carbon dioxide in exhaled breath, as recorded in time-based capnography. Respiratory parameters are estimated using this model, and then related to the clinical status of patients with obstructive lung disease.

Methods: Given appropriate assumptions, we derive an analytical solution of the model, describing the exhalation segment of the capnogram.

Characteristics of and Predictors for Apnea and Clinical Interventions During Procedural Sedation.

Study Objective: We describe the characteristics of and predictors for apnea and clinical interventions during emergency department (ED) procedural sedation.

Methods: High-resolution data were collected prospectively, using a convenience sample of ED patients undergoing propofol or ketofol sedation. End tidal CO (etco), respiratory rate, pulse rate, and SpO were electronically recorded in 1-second intervals.

Clustering of capnogram features to track state transitions during procedural sedation.

Procedural sedation has allowed many painful interventions to be conducted outside the operating room. During such procedures, it is important to maintain an appropriate level of sedation to minimize the risk of respiratory depression if patients are over-sedated and added pain or anxiety if under-sedated. However, there is currently no objective way to measure the patient's evolving level of sedation during a procedure.

Model-based estimation of pulmonary compliance and resistance parameters from time-based capnography.

We propose a highly-simplified single-alveolus mechanistic model of lung mechanics and gas mixing that leads to an analytical solution for carbon dioxide partial pressure in exhaled breath, as measured by time-based capnography. Using this solution, we estimate physiological parameters of the lungs on a continuous, breath-by-breath basis. We validate our model with capnograms from 15 subjects responding positively (>20% FEV1 drop from baseline) to methacholine challenge, and subsequently recovering with bronchodilator treatment.