Peritonsillar abscess (PTA) is the most common deep neck space infection in children (1). Procedures used to drain PTAs include needle aspiration (2), incision and drainage (3), and abscess tonsillectomy (4). Although none of these interventions has been identified as the optimal drainage procedure (5), bedside needle aspiration followed by incision and drainage is preferred at our institution. This procedure is not effective or safe in an uncooperative patient, in which case operative management and admission are required. The few reports of outpatient PTA management in children do not address the use of sedation during incision and drainage (1,6–10). Safe and effective pharmacologic sedation can avert detrimental patient, parent, and practitioner sequelae and facilitate accomplishment of the procedure. The purpose of this report is to evaluate the use of intravenous (IV) sedation in children during PTA aspiration and drainage in the emergency department (ED).
A retrospective review of ED medical records for all children with a discharge diagnosis of PTA from April 1995 to November 1998 at St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri was conducted. Information was retrieved from physician, nursing, and time-based sedation records that included age, race, sex, weight, time since last oral intake, American Society of Anesthesiologists (ASA) physical status classification (11), medication, dose, respiratory rate, heart rate, oxygen saturation, blood pressure, level of sedation (ie, alert, responsive to voice, responsive to pain, unresponsive) throughout and after the procedure, complications, recovery time, and disposition. Recovery time was defined as completion of procedure to discharge. Data analysis was performed with JMP software (Version 3.1, SAS Institute, Carey, NC, 1995) using descriptive statistics, including frequencies of categoric data and means ± standard deviations for continuous data.
Sixty-two patients with a diagnosis of PTA were identified; 42 of these patients had incision and drainage performed with IV sedation in the ED, and were included in the study group. Of the other 20 patients, 18 had incision and drainage performed in the ED without IV sedation, and 2 patients were admitted to the operating room for incision and drainage. Mean age of the study group was 11.3 ± 4.3 years (range 4–18 years, Fig. 1); 64% were female; 58% were African-American, and 42% were white; 95% were ASA class I, and 5% were ASA class II. All sedation medications were administered by attending or fellow level pediatric emergency physicians with staffing and monitoring in accordance with the American Academy of Pediatric guidelines (12). No patient received supplemental oxygen. All incisions and drainages were performed by otolaryngology residents using topical and injected local anesthesia on patients who were in an upright position. Time-based sedation records were completed at the time of sedation and in all cases by the patient’s emergency nurse. Mean time since last oral intake was 5.2 ± 3.6 hours. Agents used included ketamine plus midazolam (n = 36, 86%), morphine plus midazolam (n = 3, 7%), meperidine plus midazolam (n = 2, 5%), and 50% nitrous oxide by nasal mask plus midazolam (n = 1, 2%). The mean total doses of ketamine were 0.75 ± 0.4 mg/kg, midazolam 0.09 ± 0.06 mg/kg, morphine 0.07 ± 0.003 mg/kg, and meperidine 0.81 ± 0.2 mg/kg.
No cardiorespiratory complications, including laryngospasm or airway obstruction, hypoxia (oxygen saturation < 95%), respiratory distress, clinical pulmonary aspiration, need for positive pressure ventilation, or supplemental oxygen, were documented in any patient. Vomiting occurred after the procedure in 1 patient who received meperidine and midazolam. Emergence dysphoria did not occur in any patient. The deepest levels of sedation achieved during the procedure were: 12% alert, 64% responsive to voice, and 24% purposefully responsive to pain. Successful incision and drainage was accomplished in all children in the ED. Mean recovery time was 81.0 ± 30.1 minutes, and all patients who were sedated for abscess drainage were discharged from the ED.
Of the 20 patients who did not receive sedation for abscess drainage in the ED, 2 patients did not tolerate the procedure and were admitted to the operating room for drainage under general anesthesia. The mean length of hospital admission for these 2 patients was 30.5 hours. There was no difference in age, gender, or race between the study group and those who did not receive sedation. However, it was noted that patients who did not receive sedation for abscess drainage presented for treatment early in the study period.
During the past decade, there has occurred an increased recognition of the importance of providing safe and effective outpatient management of pain and anxiety during painful procedures in children (13). Effective analgesia and sedation are essential to facilitate successful surgical management of children with PTA in the ED (14–17). Several reports comment on the failure to perform the procedure in children because of poor patient cooperation (7,10,16,18). In 1 report of 189 children with PTA, successful outpatient drainage was accomplished without general anesthesia in 92.5% of the children by having a parent hold the child tightly in his/her arms in a sitting position (10). In addition, this report suggests that although the procedure was considered difficult, violent, or even cruel for children, the majority of patients tolerated it well, and their parents consented in order to avoid the risk of surgical or anesthetic complications. Another report of 41 children describes selectively attempting the procedure if the children were able to sit quietly without moving (7).
Adequate treatment of procedure-related distress is essential for all children. An equally important goal for sedation during PTA drainage is to ensure technical safety and acceptable surgical conditions. Bedside incision and drainage has been considered too difficult or dangerous in children because of poor patient cooperation (18). The procedure generally involves advancing a needle into the superior, medial, or inferior pole of the tonsillar area. The risk of injury to the internal carotid artery, which can pass as close as 1.5 cm to the posterolateral aspect of the tonsillar fossa, necessitates both a cooperative patient and IV access (19). Because of this, ED incision and drainage in patients with syndromes, such as velocardiofacial syndrome, where the carotids may be especially close to the pharynx, is not recommended.
Several studies have documented safe management of PTA in an outpatient setting (5,14–16). However, the potential risks include aspiration of the abscess content and hemorrhage into the airway. This is a significant concern in the deeply sedated patient who may have diminished protective airway reflexes. Laryngospasm is a reported complication of ketamine (20), and the risk may be increased with purulent or bloody fluid in the oropharynx. Careful titration to the minimally effective depth of sedation is essential for minimizing this risk. We did not observe any adverse cardiorespiratory events in our series, but the sample size and retrospective design preclude definitive conclusions regarding safety. We believe these preliminary data warrant further prospective evaluation to determine safety and efficacy.
Because this study was conducted in a tertiary care pediatric ED staffed by nurses and physicians experienced in the care of critically ill and injured children, caution in generalization of these results to other clinical settings is warranted. The minimum number of health providers present during the sedation and procedure included (1) an attending emergency physician or fellow who was responsible for administration of the medications, monitoring, and management of any complications, (2) an ED registered nurse who was responsible for monitoring patient recovery and documenting data on a standardized sedation record, and (3) the otolaryngology physician who performed the surgical procedures. Pediatric emergency medicine fellows are required to complete sedation training which includes reading an instructional packet of guidelines, protocols, recent literature, and bedside teaching with attending physicians. In addition, all fellows receive airway management instruction as part of a 1-month rotation in pediatric anesthesia. After this, fellows are directly observed by attending physicians for determination of competency to independently perform sedations. Resuscitation equipment was immediately available in the treatment room, and included: catheter and Yankauer suction; oxygen delivery system including mask, bag-valve-mask device, oral airways; “crash cart” complete with intubation equipment; resuscitation medications. Furthermore, the sedation plan was developed by the attending emergency physician after individual patient evaluation for the risk of sedation, coexisting illness, ASA physical status classification, age, and recent oral intake. Only ASA classification I and II patients should be considered candidates for this procedure. The sedation protocols were consistent with current Joint Commission on Accreditation of Healthcare Organizations policies on hospital sedation (21). These assumptions should not be generalized to other institutions without careful review of operating procedures and training protocols.
We conclude that carefully titrated intravenous sedation of children by skilled pediatric emergency physicians facilitates incision and drainage of peritonsillar abscess in the emergency department.
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