September 2022

Clinical Question

How often does laryngospasm happen during paediatric procedural sedation?

Title of Paper

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

Journal and Year

Annals of Emergency Medicine

Lead Author

Peter Cosgrove

Background

• The last time we did a paper on this my background notes were: “Kids get hurt, kids need sedation, ketamine rules, what are the risks?”. That hasn’t changed.
• The last paper we looked at was assessing all the complications associated with paeds procedural sedation.
• This one looks more specifically at the risk that we’re all actually worried about and specifically consenting parents for, laryngospasm.

Study Design

• Secondary analysis of the Pediatric Sedation Research Consortium (PSRC)’s multicentre database
  • 64 institutions including children-only departments, mixed departments (academic), mixed departments (community), imaging centres, dental offices
  • Participating site have to submit over 90% of their paediatric procedural sedation cases to minimise selection bias

Patients Studied

• Patients ≤ 22 years old – because in America you’re a kid until you can drink alcohol?!
• Excluded IM ketamine

Measurements

• Age, sex
• ASA classification
• Presence of URTI
• Location of sedation
• Provider level and specialty
• Primary procedure
• Sedatives used

Outcomes

• Primary: Laryngospasm – “complete of nearly complete lack of air movement with respiratory effort and with or without stridor, not relieved by chin repositioning or oral/nasal airway”

Summary of Results

There are lots of results in this paper, but I’m just picking out the ones that generally matter to us.

Most Common

Location	Radiology
Procedure	Radiological Ix
Provider	Intensivist
Drug	Propofol alone

Worst Predictors

Predictor	Unadj Prev per 1000
URTI	12.4
Airway procedure/Bronchoscopy	27.6
Endoscopy Suite	13.4
Dental	7.9

• NNH for UTRI 103 [60-193]

Factors Relevant to Us

Factor	Unadj Prev per 1000
ED location	1.8
PEM physician	1.8
Emergency Physician	0
Fracture reduction	1.4

When adjusting to exclude ASA III and IV, painful procedures became a positive predictor

Drugs

Drug	Unadj Prev(per 1000)	aOR (compared to propofol)	Predicted Probability(per 1000)
Propofol	2.8	n/a	3 [2.2-3.9]
Ketamine	1.4	0.57 [0.29-1.10]	1.7 [0.6-2.8]
Ketofol	6.6	2.52 [1.41-4.5]	7.6 [3.1-12]
Nitrous	0.2	0.10	0.3 [-0.2-0.8]

Interventions

Intervention	Frequency
Airway manoeuvre	73.9%
BVM	54.3%
CPAP	33.5%
ETT	5.4%
Muscle relaxant	1.5%

Outcomes

Outcome	Frequency
Sats <70% x >30s	19.7%
Arrest
(Both had underlying cardiac)	0.2%

Authors Conclusion

We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decision making.

Clinical Bottom Line

This agrees with previous papers we’ve covered showing that paeds procedural sedation, particularly with the ED patient cohort is really pretty safe. Even our commonly taught caution over upper respiratory tract infections is probably just that, a caution, rather than a contraindication.

As with the paper we covered in Feb 2018, this sort of study can inform our discussions with parents and formal consent process. For example, the gross numbers I’ll take away from this are:

Laryngospasm with ketamine in the ED	1.8/1000
Needing manual ventilation	54.3% (0.98/1000)
Needing an ETT	5.4% (0.09/1000)

Other #FOAMed Resources / References:

The previous paper we covered on New in EM February 2018

The Alfred Health Emergency Education blog has this post on laryngospasm

Clinical Question

Do we need to use sterile gloves for wound suturing?

Title of Paper

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre ransomised controlled trial

Journal and Year

EMJ. 2022.

Lead Author

Juliette Zwaans

Background

– Wounds we see in the ED are contaminated by their nature. They are not surgical wounds.
– Sterile gloves and drapes etc are more expensive and increase packaging waste than non-sterile options.
– There are some small studies showing no increased infection risk for non-sterile glove use in ED patients.

Study Design

– Multicentre, single-blinded, randomised controlled, non-inferiority trial
– Non-inferiority calculation:
– They expected 3.5% infection rate in the sterile group, based on previous literature reporting 2.5-7%.
– Non inferiority margin set at 2% (if they found the non-sterile group to be >2% more infection rate than sterile, it would be considered inferior)

Patients Studied

– Adult ED patients with traumatic wound requiring sutures, excluded:
– Compex wounds (deep structures or clockwork involved)
– Human or animal bites
– Already infected
– >24 hours old

– After randomisation all wounds were prepped by a nurse to remove large contamination and rinse with tap-water
– Physician then closed the wound per the designated protocol
– Both groups had 1% chlorhexidine for disinfection, local anaesthetic, sterile sutures and sterile suture packs

Intervention

– Non-sterile gloves, dressings and gauze
– No sterile fenestrated drape

Comparison

– Sterile gloves, dressings and gauze
– Sterile fenestrated drape

Outcomes

– Wound infection, defined as:
– Abscess from wound
– Cellulitis >10mm
– Purulent fluid
– Dehiscence
– Further wound management (abx, washing etc) on review

Summary of Results

– Sample size target 2140 patients
– Randomised 1480 – there was a drop off in their study recruitment caused by an integration of GP practices in the EDs.

Wound infection rate: Sterile group: 6.8% [4.0-7.5%] vs Non-sterile group: 5.7% [5.1-8.8%]

– Mean difference -1.1% [-3.7-1.5%]

Subgroups:

– More wound infections in lower limb wounds (20.2% vs 12.2%) and with immunosuppressants (6% vs 1.5%)

Authors Conclusion

“This trial suggests that there is unlikely to be a large difference between the non-sterile glvoes and dressings for suturing of traumatic wounds and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED.”

Clinical Bottom Line

While they stopped the trial early and didn’t reach their sample size, they do give reasonable reasons for this and state in their discussion that the investigators were blinded to the treatment allocation and outcome data, and that no interim analysis was performed before they made the decision to stop.

We often discuss non-inferiority trials and how it is important to look at the authors’ defined non-inferiority margin, as they can essentially pluck this from the air so you need to ensure it meets your expectations for reasonable non-inferiority. In this case I think a 2% difference – I think that’s probably acceptable had that been what they found. Reassuringly it looks like the margin is even less – with the numbers actually *favouring* non-sterile in this case – though I think if anything this just tells me that any difference between the groups would be acceptably small.

Will I immediately change my practice? Possibly. I do think the emphasis needs to be more on giving the wound a really good clean, debriding dodgey looking tissue, closing the wound well, with the right choice of sutures, technique, minimal tension etc then giving the patient good care instructions. That’s all going to be more important than whether your gloves are clean or sterile.

Other #FOAMed Resources / References:

The 2004, single ED study. Perelman VS, Francis GJ, Rutledge T, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med 2004;43:362–70. DOI: [10.1016/j.annemergmed.2003.09.008]

doi.org

Incivility in the Emergency Department – Nicki Credland, Dan Derbyshire

Uncommon Nerve Entrapment Syndromes – Jules Blackham

Sexual Assault Aftercare in the Emergency Department – Ellisiv Clarke, Michelle Tun