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OBJECTIVES:Paediatric patients receive less procedural sedation and analgesia (PSA) in the emergency department compared with adults, especially in countries where emergency medicine is at an early stage of development. The objectives of this study were to evaluate the adverse events and efficacy of paediatric PSA in a country with a recent establishment of emergency medicine and to describe which factors aided implementation.METHODS:This is a prospective, multicentre, observational study of paediatric patients undergoing PSA by the first trained emergency physicians (EPs) in The Netherlands. A standardized data collection form was used at all participating hospitals to collect data on adverse events, amnesia, pain scores, and procedure completion. A survey was used to interpret which factors had aided PSA implementation.RESULTS:We recorded 351 paediatric PSA. The mean age was 9.5 years (95% confidence interval: 9.1-10.0). Esketamine was most frequently used (42.4%), followed by propofol (34.7%). The adverse event rate was low (3.0%). Amnesia was present in 86.8%. The median pain score was 2 (out of 10) for patients without amnesia. Procedures were successfully completed in 93.9% of the cases.CONCLUSION:Paediatric PSA provided by the first EPs in The Netherlands showed appropriate levels of sedation and analgesia with a high rate of procedure completion and a low rate of adverse events. Our paper suggests that EPs provided with a proper infrastructure of mentorship, training and guidelines can implement effective paediatric PSA.

Objective: To describe our experience performing ED procedural sedation in a country where emergency medicine (EM) is a relatively new specialty. Methods: This is a prospective observational study of adult patients undergoing procedural sedation by emergency physicians (EPs) or EM residents in eight hospitals in the Netherlands. Data were collected on a standardised form, including patient characteristics, sedative and analgesic used, procedural success, adverse events (classified according to World SIVA) and rescue interventions. Results: 1711 adult cases were included from 2006 to 2013. Propofol, midazolam and esketamine (S+ enantiomer of ketamine) were the most used sedatives (63%, 29% and 8%). We had adverse event data on all patients. The overall adverse event rate was 11%, mostly hypoxia or apnoea. There was no difference in adverse event rate between EPs and EM residents. However, there was a significantly higher success rate of the procedure when EPs did the procedural sedation (92% vs 84%). No moderate (unplanned hospital admission or escalation of care) or sentinel SIVA outcomes occurred ( pulmonary aspiration syndrome, death or permanent neurological deficit). Conclusion: Adverse events during procedural sedation occurred in 11% of patients. There were no moderate or sentinel outcomes. All events could be managed by the sedating physician. In a country where EM is a relatively new specialty, procedural sedation appears to be safe when performed by EPs or trained EM residents and has comparable adverse event rates to international studies.

OBJECTIVE: The optimal use of pulsed wave Doppler tissue imaging (DTI) in predicting left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT) was investigated. METHODS: DTI was performed in 69 patients before and 3 months after CRT. Echocardiographic reverse remodeling was observed in 38 patients. LV dyssynchrony was measured with the time to onset or peak systolic velocity in 2- and 6-basal segment models. RESULTS: The time to onset and either the standard deviation of 6 segments of > 20 ms or a delay of > or = 60 ms between any 2 of 6 segments had a similar predictive accuracy (sensitivity, 97% and 95%, respectively; specificity, 74% and 73%, respectively). The time to peak systolic velocity or evaluating 2 segments was less accurate. CONCLUSIONS: Evaluation of 6 segments is necessary to predict LV reverse remodeling after CRT. The time to onset of systolic velocity is superior to the time to peak velocity.