Inpatient Treatment after Multi-Dose RacemicEpinephrine for Croup in the Emergency Department. Emergency department (ED) discharge is safe when croup-related stridor has resolved after corticosteroids and a single dose of racemicepinephrine (RE). Little evidence supports the traditional practice of hospital admission after ≥ 2 doses of RE. Our aim was to describe the frequency and timing
Racemicadrenaline and inhalation strategies in acute bronchiolitis. Acute bronchiolitis in infants frequently results in hospitalization, but there is no established consensus on inhalation therapy--either the type of medication or the frequency of administration--that may be of value. We aimed to assess the effectiveness of inhaled racemicadrenaline as compared with inhaled saline and the strategy for frequency of inhalation (on demand vs. fixed schedule) in infants hospitalized with acute bronchiolitis. In this eight-center, randomized, double-blind trial with a 2-by-2 factorial design, we compared inhaled racemicadrenaline with inhaled saline and on-demand inhalation with fixed-schedule inhalation (up to every 2 hours) in infants (<12 months of age) with moderate-to-severe acute
Cardiovascular Effects of RacemicEpinephrine Pellets The primary aim of this study was to determine if topical racemicepinephrine pellets affect heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) or mean arterial pressure (MAP) in children receiving dental care under general anesthesia (GA). Thirteen patients requiring prefabricated zirconia crowns on both primary maxillary first molars were recruited into a split-mouth randomized controlled pilot study. Patients received a continuous infusion of propofol and remifentanil with inhaled nitrous oxide/oxygen. After patient randomization and tooth preparation, either saline pellets (control) or racemicepinephrine pellets (treatment) were applied directly to gingival tissue. Vital sign measurements were recorded for 5
recommendation; Moderate quality of evidence]. For patients with orolingual angio-edema: 1. IV thrombolysis should be discontinued if still infusing at the first signs of angioedema [Strong recommendation; Moderate quality of evidence]. 2. The following medications are recommended: antihistamines (H1 blocker [e.g., diphenhydramine], H2 blocker [e.g., famotidine]). Consider glucocorticoids inhaled racemicepinephrine as part of standard airway management [Strong recommendation; Low quality of evidence]. For patients with symptomatic ICH following IV thrombolysis refer to section 5.6. Systemic hemorrhage: For patients with spontaneous systemic hemorrhage at a non-compressible site (e.g., gastrointestinal hemorrhage, oral hemorrhage), IV thrombolysis should be discontinued, consideration should be given
Guidance Summary: Sedation-ventilation management April 30, 2020 4 Medical center guidance on extubation Source Policy Yale April 20 Extubations: Extubate to nasal cannula (less than 5L or use 100% NRB with blender) – similar precautions as for intubation (cannot give racemicepinephrine so if concern about airway (no cuff leak or difficult intubation) give steroids and repeat the next day. Recommend
secretions! Usually have a preceding viral prodrome and croup-like illness…then present as a toxic child with high fevers and rapidly worsening stridor that fails to improve with racemicepinephrine. Symptoms may overlap with those of croup and epiglottitis. Features that suggest bacterial tracheitis include a viral prodrome followed by acute decompensation, symptoms atypical for croup (eg, high fever
estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemicepinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88
as asthma by her primary care physician. She subsequently presented to the ED with acutely worsening noisy breathing and dyspnea. Patient and parent denied any recent foreign body ingestions or choking episodes. We gave multiple doses of racemicepinephrine in the ED without symptom improvement. A lateral neck x-ray showed an occlusive subglottic airway mass. Otolaryngology (ENT) evaluation demonstrated
to swallow their own saliva, drooling, or spitting up into a cup Management: * Ensure the patient’s airway remains patent and protected * Consider preventative intubation in anyone who has rapidly progressive symptoms over 6 hrs or less * Have a lower threshold for the diabetic or immunocompromised * IV Abx: * Ceftriaxone * Cefotaxime * Septra * Maybe? * Steroids * Racemicepinephrine (in preparation for intubation) * Analgesia * Humidified oxygen * Observation in a high-acuity area[4] What are the deep spaces of the neck? List 4 deep space infections of the neck 1. Submandibular space: sublingual and submaxillary spaces. Think Ludwig’s Angina here 2. The parapharyngeal space contains the carotid artery, the jugular vein, the cervical sympathetic chain, and cranial
Cardiovascular Safety and Hemostatic Efficacy of Topical Epinephrine in Children Receiving Zirconia Crowns. The primary aim of this study was to determine the cardiovascular safety of topical racemicepinephrine pellets by measuring heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure in children receiving dental care under general anesthesia. The secondary preparation, either saline pellets (control) or racemicepinephrine pellets (experimental) were applied directly to gingival tissue. Vital signs were recorded for 5 minutes. The procedure was repeated on the contralateral side using the alternative (control or experimental) treatment. Topical racemicepinephrine compared to saline produced a significantly larger decrease in mean diastolic blood pressure
Role of nebulized epinephrine in moderate bronchiolitis: a quasi-randomized trial. Bronchiolitis is the most common lower respiratory illness that characteristically affects the children below 2 years of age accounting about 2-3% of patients admitted to hospital each year [1-4]. We compared the effect of racemicepinephrine (RE) and 3% hypertonic saline (HS) nebulization on the length of stay at the frequency of 1 to 4 h. One infant from RE group and three infants from HS group were excluded due to progression towards severe bronchiolitis. The LOS in RE group ranged between 18 and 160 h (mean 45 h), while in HS group, LOS was 18.50-206 h (mean 74.3 h). The LOS was significantly short in RE group (p value 0.015) which was statistically significant. Racemicepinephrine nebulization as first-line
of the impact of the national guide-lines for the treatment of hospitalized patients withbronchiolitis, McCulloh et al55reported outcomes after thenational guidelines for bronchiolitis were implemented at2 academic medical centers. Fewer children received atrial of racemicepinephrine (17.8% vs 12.2%,P.006)or albuterol sulfate (81.6% vs 72.6%,P.001), andalbuterol sulfate was discontinued more often after
shown to have any measurable benefit8,9 Administer epinephrine for severe respiratory distress (i.e., marked sternal wall indrawing and agitation) for the temporary relief of symptoms of airway obstruction o L-epinephrine 1:1000 is as effective as racemicepinephrine – institutional preference may guide the decision as L-epinephrine is no longer readily available in North America10 o Nebulized ml of 2.25% racemicepinephrine and 5.0 ml of epinephrine 1:1000) is used in all children regardless of weight. Children’s relative size of tidal volume is thought to modulate the dose of drug actually delivered to the upper airway. “Continuous” epinephrine is reported to be used in some pediatric intensive care units. However, one published paper reported that an otherwise “normal” child
cold-steel cases (10.4%) (adjusted OR 3.42; 95% CI 1.43, 8.33). CO laser cases were more likely to require post-operative intubation, non-invasive positive pressure ventilation, and nebulized racemicepinephrine. Concomitant neurological condition was associated with an increased risk of prolonged ICU-stay, while extent of surgery and age were not. CO laser supraglottoplasty is associated
into a barky cough with associated stridor at rest and respiratory distress. All were diagnosed with SARS-CoV-2 by polymerase chain reaction testing from nasopharyngeal samples that were negative for all other pathogens including the most common etiologies for croup. Each received multiple (≥3) doses of nebulized racemicepinephrine with minimal to no improvement shortly after medication. All had a prolonged
of benefit.[15]Nebulised racemicadrenaline (epinephrine) - racemic = 1:1 mixture of the dextrorotatory and levorotatory isomers: one study reported that inhaled racemicadrenaline was no better than inhaled saline.[16]Hypertonic saline: thought to act by unblocking mucous plugs and reducing airways obstruction. A Cochrane Review concluded that there was low- to medium-quality evidence that its use did ; Racemicadrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13368(24):2286-93. doi: 10.1056/NEJMoa1301839.Zhang L, Mendoza-Sassi RA, Wainwright C, et al; Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev. 2017 Dec 2112:CD006458. doi: 10.1002/14651858.CD006458.pub4.Farley R, Spurling GK, Eriksson L, et al; Antibiotics
a passageway for air. An oropharyngeal airway can be used temporarily in the unconscious patient.For extrathoracic airway obstruction, as in croup, the following measures may be helpful: * * Inspired humidity: To liquefy secretions * * Heliox (helium and oxygen gas mixture): To decrease the work of breathing * * Racemicepinephrine 2.25% (an aerosolized vasoconstrictor) * * Systemic