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The Mental Health Clinician Jun 2024Catatonia is a syndrome characterized by psychomotor and behavioral disturbances and is associated with a substantially increased mortality risk in adolescent patients....
INTRODUCTION
Catatonia is a syndrome characterized by psychomotor and behavioral disturbances and is associated with a substantially increased mortality risk in adolescent patients. There is a dearth of published literature describing treatment strategies for pediatric patients with catatonia. This dual-case series will describe the treatment course of 2 adolescent patients with catatonia at our pediatric inpatient psychiatric facility.
CASE SERIES
This case series presents 2 adolescent patients (a 17-year-old male and a 16-year-old female) who initially presented with worsening agitation and paranoia, later developing catatonia. Both patients required long durations of hospitalization and were treated with high-dose lorazepam before requiring the addition of electroconvulsive therapy (ECT).
DISCUSSION
Treatment of pediatric patients with catatonia creates a significant burden on patients, families, and the healthcare system. Treatment with high-dose benzodiazepines is high risk, while ECT is both difficult to access and comes with its own risks. Both patients discussed are transitional age, meaning they will soon be young adults who will continue to require high-level psychiatric care. Psychiatric pharmacists have a large role to play in ensuring safe medication management for these complex patients.
CONCLUSIONS
This case series of 2 adolescent patients with catatonia demonstrates marginal reduction in symptoms with high-dose lorazepam in conjunction with ECT, with minimal side effects. This case series adds to the limited available literature regarding treatment of catatonia in pediatric patients and highlights the need for further study into effective treatment alternatives.
PubMed: 38835818
DOI: 10.9740/mhc.2024.06.215 -
BMC Pediatrics May 2024Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the effects of different doses of Dexmedetomidine (DEX) on agitation/delirium and other complications in anesthetized children, providing clinical evidence for dose recommendations of DEX.
METHODS
This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and EMBASE. Two independent researchers performed literature screening, data extraction, and assessed the methodological quality. Data analysis was conducted using R and STATA 16.0.
RESULTS
In the final analysis, 20 randomized controlled trials (RCTs) involving 2521 children were included. The results showed that in comparison to normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX significantly reduced the incidence of post-anesthetic emergence agitation in children with the most effective dose being 2 µg/kg (SUCRA = 0.91). Compared with normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX reduced patient's need for postoperative analgesia, with the most effective dose being 1.5 µg/kg (SUCRA = 0.78). However, 1 µg/kg DEX performed the best in reducing Pediatric Anaesthesia Emergence Delirium (PAED) Scale score (SUCRA = 0.88).
CONCLUSION
Compared with normal saline, intranasal administration of 2 µg/kg DEX and 1.5 µg/kg DEX are the optimal doses to reduce the incidence of agitation and the need for postoperative pain relief in children under general anesthesia. Given effectiveness and safety, intranasal use of 1 µg/kg DEX appears to be the most effective dosage for anesthetized children.
Topics: Dexmedetomidine; Humans; Administration, Intranasal; Child; Hypnotics and Sedatives; Dose-Response Relationship, Drug; Parents; Emergence Delirium; Psychomotor Agitation; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 38822315
DOI: 10.1186/s12887-024-04832-w -
Annals of Transplantation May 2024BACKGROUND We aimed to assess the effect of dexmedetomidine (Dex) combined with remifentanil on emergence agitation (EA) during awakening from sevoflurane anesthesia for... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND We aimed to assess the effect of dexmedetomidine (Dex) combined with remifentanil on emergence agitation (EA) during awakening from sevoflurane anesthesia for pediatric liver surgery. MATERIAL AND METHODS Sixty children who underwent liver surgery in our hospital were prospectively selected and randomly allocated into group A (placebo+remifentanil+sevoflurane) or group B (Dex+remifentanil+sevoflurane). Mean arterial pressure (MAP) and heart rate (HR) at different time points, agitation score during awakening, behavioral status, pain level, and the incidence of postoperative adverse effects were compared in both groups. RESULTS Children in group B had lower HR and MAP levels immediately after tracheal extubation and 5 min after tracheal extubation than those in group A. The Aono's scores, PAED agitation scores, and CHIPP scores at 15 min and 30 min of admission to the PACU were lower in group B than in group A. The incidence of agitation during postoperative anesthesia awakening was lower in group B in contrast to group A. There was no significant difference in postoperative adverse reactions between group A and group B. CONCLUSIONS In pediatric liver surgery, the use of Dex+remifentanil+sevoflurane anesthesia can reduce the incidence of EA during the awakening period, stabilize hemodynamic levels, and relieve postoperative pain, and has fewer postoperative adverse effects, which warrants clinical application.
Topics: Humans; Dexmedetomidine; Remifentanil; Sevoflurane; Female; Male; Anesthetics, Inhalation; Child, Preschool; Emergence Delirium; Prospective Studies; Hypnotics and Sedatives; Infant; Child; Psychomotor Agitation; Liver; Anesthesia Recovery Period; Piperidines; Double-Blind Method; Drug Therapy, Combination; Methyl Ethers; Analgesics, Opioid
PubMed: 38803088
DOI: 10.12659/AOT.943281 -
CJEM Jun 2024We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a...
Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications.
PURPOSE
We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care.
METHODS
Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital's administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020.
PRIMARY OUTCOME
mean quarterly length of stay.
SECONDARY OUTCOMES
delirium, intensive care unit (ICU) admission, other post-admission complications, mortality.
RESULTS
N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI - 0.03 to 0.6), intercept change, 0.06 (- 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2-7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3-5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020).
CONCLUSIONS
This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.
Topics: Humans; Length of Stay; Retrospective Studies; Male; Female; Substance Withdrawal Syndrome; Middle Aged; Alcohol Withdrawal Delirium; Psychomotor Agitation; Aged; Adult
PubMed: 38796808
DOI: 10.1007/s43678-024-00710-7 -
International Journal of Emergency... May 2024Delayed discharge from hospital to home or other care institutions is a significant problem and has been investigated in the international scientific literature for many...
BACKGROUND
Delayed discharge from hospital to home or other care institutions is a significant problem and has been investigated in the international scientific literature for many years. Behind this condition is a health care system based on a hospital-centered concept characterized by a lack of territorial health and social welfare services. This phenomenon causes two different problems: an excessive length of hospital stay, resulting in slow turnover of bed utilization; and overcrowding in emergency rooms (ERs). The phenomenon of frequent users assumes particular importance in this context. These patients repeatedly visit the emergency department (ED) in the same year because care needs are not met by primary care services. The authors in this study tried to describe the Frequent users (FUs) population and the variables associated with this condition.
MATERIALS AND METHODS
A retrospective "single-arm" descriptive study was conducted by analysing all accesses made to the ED of Policlinico Tor Vergata (PTV) from January 1, 2022, to December 31, 2022. FUs were defined as patients who had 4 or more accesses to PTV ER during the year.
RESULTS
A total of 37,800 accesses occurred during the study period. A total of 31,691 users accessed the PS, with a mean age of 55.8 ± 22.2 years. There were 359 FU patients (approximately 1%) who had a total of 1984 accesses, corresponding to 5.2% of the total accesses. The triage codes for the FU patients were red, 2%; orange, 21%; blue, 45%; green, 26%; white, 5%; and not performed, 1%. Considering the 1984 FU accesses, the most frequently attributed "main problems" in the ED were "other symptoms or disorders" (54%), "psychomotor agitation" (12%), "trauma or burn" (8%), "abdominal pain" (6%), "chest pain" (4%), "dyspnea" (4%) and "urological symptoms or disorders" (4%). Multivariate analysis revealed that the main determinants of FUs were psychomotor agitation (HR = 7,23; CL95%:6,194-8,443), urological disorders (HR = 2,16; CL95%:1,68-2,76) and poor socioeconomic status (HR = 2,40; CL95%:2,213-2,663).
CONCLUSIONS
The FUs phenomenon expresses an area of health and social distress where poverty and lack of territorial services oblige people to refer to the ED. Primary care interventions integrated with social support are crucial for managing access to the ED.
PubMed: 38778250
DOI: 10.1186/s12245-024-00641-1 -
Acta Neurologica Belgica May 2024Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients...
INTRODUCTION
Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients diagnosed with ACM who visited our pediatric emergency department (PED).
METHODS
This study was a retrospective review of children who presented to our PED between January 2012 and December 2022 with a discharge diagnosis of ACM.
RESULTS
During the study period, 23 patients were enrolled: 11 males (47.8%) and 12 females (52.2%); median age was 10.8 years (IQR: 8.3-13.6). Eight patients reported a history of headache. The median length of stay of PED was 4.7 h. Onset was abrupt (less than 12 h) in 100% of cases. Changes in the level and content of consciousness occurred in 47.8% and 91.3% of patients, respectively; confusion (73.9%) was the most common neurological manifestation. Eighteen patients had urgent brain CT scans, none showing pathological findings. Four patients required benzodiazepines to control their psychomotor agitation. Nine patients were hospitalized, including one in the intensive care unit. Two patients underwent MRI and one patient underwent EEG during hospitalization, with normal results.
DISCUSSION
ACM is a rare condition in pediatric neurology characterized by acute onset of confusion or altered mental status before, during, or after migraine headache. Clinical features overlap with other neurological disorders, making diagnosis challenging. To improve the diagnosis, treatment, and research of AMC, it is essential to include it in the International Classification of Headache Disorders and establish standardized diagnostic criteria.
PubMed: 38755330
DOI: 10.1007/s13760-024-02582-1 -
Fewer emergency department alarms is associated with reduced use of medications for acute agitation.The American Journal of Emergency... Jul 2024Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of...
BACKGROUND AND OBJECTIVES
Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation.
METHODS
Our emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered.
RESULTS
Between the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (-37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (-92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8-2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference - 4, 95% CI -1 to -7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1-1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0-1.1) more administrations of sedating medication.
CONCLUSION
A reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.
Topics: Humans; Emergency Service, Hospital; Clinical Alarms; Male; Psychomotor Agitation; Female; Middle Aged; Antipsychotic Agents; Adult; Aged; Benzodiazepines; Monitoring, Physiologic; Hypnotics and Sedatives
PubMed: 38733663
DOI: 10.1016/j.ajem.2024.04.021 -
Pediatric Emergency Care Jul 2024Datura stramonium , jimsonweed, is a toxic plant with hallucinogenic properties. Although there are many studies on Datura poisoning, none reported cases in Jordan. This...
OBJECTIVES
Datura stramonium , jimsonweed, is a toxic plant with hallucinogenic properties. Although there are many studies on Datura poisoning, none reported cases in Jordan. This study offers a comprehensive review on D. stramonium ingestion, covering its epidemiology, clinical presentation, and treatment. We aimed to provide better understanding of the factors for Datura ingestion, identify prevention and management strategies, and address research challenges.
METHODS
This study adopted a retrospective review design to evaluate the cases of Datura poisoning in Al Karak, province of Jordan during the spring of 2022. Data collected from medical records, toxicology databases, and consultation records were analyzed using descriptive statistics.
RESULTS
The common symptoms of Datura poisoning included agitation, mydriasis, and tachycardia. The management approaches comprised supportive care, administration of Diazepam for agitation, and, in some cases, neostigmine to counteract anticholinergic effects.
CONCLUSIONS
Understanding the risks associated with D. stramonium poisoning and implementing effective prevention and management strategies are crucial. This study highlights the importance of recognizing Datura poisoning as a potential diagnosis in children presenting with unexplained anticholinergic symptoms or agitation to the emergency room.
Topics: Humans; Retrospective Studies; Jordan; Child; Datura stramonium; Male; Female; Child, Preschool; Adolescent; Infant; Plant Poisoning; Mydriasis; Psychomotor Agitation; Tachycardia; Poisoning
PubMed: 38718809
DOI: 10.1097/PEC.0000000000003189 -
Neurocase Aug 2023Pitt-Hopkins syndrome (PTHS) is a rare genetic disorder resulting from TCF4 gene mutations which is characterized by dysmorphic facial features, psychomotor delay,...
Pitt-Hopkins syndrome (PTHS) is a rare genetic disorder resulting from TCF4 gene mutations which is characterized by dysmorphic facial features, psychomotor delay, intellectual disability, breathing anomalies, and seizures. Psychiatric conditions are occasionally seen. We present the case report of a seven-year-old PTHS patient with anxiety, insomnia, and agitation. We discuss the psychopharmacological intervention options for this patient. The present case study reports on a 7-year-old female with PTHS, autism spectrum disorder (ASD), and intellectual disability. She had insomnia, crying spells and agitation complaints. For anxiety symptoms and agitation, risperidone, fluoxetine, and clonazepam treatment were given by the neurologist which caused behavioral disinhibition, paroxysmal agitation and no benefit. After admission to our hospital, aripiprazole and hydroxyzine were prescribed for anxiety and ASD-related irritability. She showed a minimal improvement but hyperventilation attacks were still ongoing. Hydroxyzine was stopped, and quetiapine was given to eliminate sleep disturbance. Her sleep period went up to eleven hours. For the anxiety symptoms, escitalopram was prescribed. She showed improvements in sleep, diminished hyperactivity and decreased frequency of abnormal breathing spells. Also, enhancement of social communication skills like increased eye contact and response to her name was observed. Patients with genetic syndromes may have various psychiatric complaints. Psychopharmacological interventions should be administered carefully for the side effects.
Topics: Humans; Female; Psychomotor Agitation; Child; Intellectual Disability; Sleep Initiation and Maintenance Disorders; Hyperventilation; Autism Spectrum Disorder; Anxiety; Facies; Antipsychotic Agents
PubMed: 38700147
DOI: 10.1080/13554794.2024.2348230