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Intranasal Analgesia and Sedation in Pediatric Emergency Care—A Prospective Observational Study on the Implementation of an Institutional Protocol in a Tertiary Children's Hospital

Nemeth, Marcus, MD*†; Jacobsen, Nils, MD; Bantel, Carsten, MD, PhD; Fieler, Melanie, MD§; Sümpelmann, Robert, MD, PhD§; Eich, Christoph, MD, PhD*

doi: 10.1097/PEC.0000000000001017
Original Articles

Objectives Children presenting with acute traumatic pain or in need of therapeutic or diagnostic procedures require rapid and effective analgesia and/or sedation. Intranasal administration (INA) promises to be a reliable, minimally invasive delivery route. However, INA is still underused in Germany. We hence developed a protocol for acute pain therapy (APT) and urgent analgesia and/or sedation (UAS). Our aim was to evaluate the effectiveness and safety of our protocol.

Methods We performed a prospective observational study in a tertiary children's hospital in Germany. Pediatric patients aged 0 to 17 years requiring APT or UAS were included. Fentanyl, s-ketamine, midazolam, or combinations were delivered according to protocol. Primary outcome variables included quality of analgesia and/or sedation as measured on age-appropriate scales and time to onset of drug action. Secondary outcomes were adverse events and serious adverse events.

Results One hundred pediatric patients aged 0.3 to 16 years were enrolled, 34 for APT and 66 for UAS. The median time onset of drug action was 5 minutes (ranging from 2 to 15 minutes). Fentanyl was most frequently used for APT (n = 19). Pain scores decreased by a median of 4 points (range, 0-10; P < 0.0001). For UAS, s-ketamine/midazolam was most frequently used (n = 25). Sedation score indicated minimal sedation in most cases. Overall success rate after the first attempt was 82%. Adverse events consisted of nasal burning (n = 2) and vomiting (n = 2). No serious adverse events were recorded.

Conclusions A fentanyl-, s-ketamine-, and midazolam-based INA protocol was effective and safe for APT and UAS. It should then be considered where intravenous access is impossible or inappropriate.

From the Departments of *Anesthesia, Pediatric Intensive Care and Emergency Medicine, and

Pediatrics, Auf der Bult Children's Hospital, Hannover;

University Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Klinikum Oldenburg, Oldenburg; and

§Clinic for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.

Disclosure: The authors declare no conflict of interest.

Reprints: Marcus Nemeth, MD, Department of Anaesthesia, Pediatric Intensive Care and Emergency Medicine, Auf der Bult Children's Hospital, Janusz-Korczak-Allee 12, D-30173, Hannover, Germany (e-mail:

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