Study Objective We aimed to evaluate the efficacy and safety of ketamine in ensuring comfort and sparing conventional drugs when used as an adjuvant for analgesia and sedation in the Pediatric Intensive Care Unit (PICU) as a continuous infusion (≥12 h). Design Observational prospective study. Setting Tertiary‐care‐center PICU. Patients All consecutive patients <18 years who received ketamine for ≥12 h between January 2019 and July 2021. Interventions ketamine infusion for ≥12 h. Measurements and Main Results Seventy‐seven patients (median age 16 months, Interquartile Range (IQR) 7–43) were enrolled. Twenty‐six percent of patients (n = 20) were paralyzed, while 74% (n = 57) were not. The median infusion duration was 90 h (IQR 39–193), with doses between 15 (IQR 15–20) and 30 μg/kg/min (IQR 20–50). At 24 h of ketamine infusion, values of COMFORT‐B‐Scale (CBS) were significantly lower compared with values pre‐ketamine (p < 0.001). Simultaneously, doses/kg/h of opioids and benzodiazepines significantly decreased at 24 h (p < 0.001 and p = 0.002, respectively), while doses/kg/h of propofol (p = 0.500) and dexmedetomidine (p = 0.072) did not significantly change. Seventy‐four percent of non‐paralyzed patients (42/57) had a decrease in CBS ≥2 points with no increase of concomitant analgosedation drugs. Among paralyzed patients (n = 20), 13 (65%) had no increase of concomitant analgosedation within 24 h after ketamine initiation. Overall, 55/77 (71%) of patients responded to ketamine. The mean and maximum ketamine infusion dosages were significantly higher in the non‐responders (p = 0.021 and 0.028, respectively). Eleven patients had adverse events potentially related to ketamine (hypersalivation, systemic hypertension, dystonia/dyskinesia, tachycardia, and agitation) and six patients required intervention (dose reduction, suspension, or pharmacologic therapy). None of the patients developed delirium during ketamine infusion. Conclusions Ketamine used as a continuous infusion in the PICU might represent a valid strategy to ensure comfort and spare opioids and benzodiazepines in difficult‐to‐sedate PICU patients. Adverse events are minor and easily reversible. Future study will be needed to investigate long‐term outcomes.

Transcranial Doppler (TCD) ultrasound is a non-invasive neuromonitoring technique that falls under the umbrella of point-of-care ultrasound. In this article, we provide a primer to encourage clinicians to perform TCD examinations and to aid them with accurately interpreting the scans. We focus on the middle cerebral artery waveforms and use traumatic brain injury as a model for brain insult.

Study Objective: The aim of the project was to compare the efficacy and safety of intranasal and intravenous dexmedetomidine (DEX) in procedural sedation for electroencephalogram (EEG) in patients with behavioural disorders. Design: observational monocentric comparative study Setting: Tertiary care centre Emergency Department Patients: all consecutive patients < 18 years old affected by behavioural disorders, who needed sedation for EEG recording. From 2018 to 2020 a group of children received intravenous administration of DEX, the following year a second group of children received intranasal administration of the same drug. Target of sedation was level 2, according to the Paediatric Sedation State Scale (PSSS) in both groups. Heart rate (HR), pulse oxygen saturation and blood pressure (BP) were registered. EEG recording quality and caregivers’ satisfaction were collected. Results: Twenty-four patients were sedated with intravenous and other twenty-four with intranasal DEX. Sedation success rate was 97.9%. Intranasal administration showed longer onset (p <0.0001), but shorter offset (p 0.0145); 45.8% patients reported adverse effects. Bradycardia occurred in 35.4% of the overall population, cases of hypotension were still reported in the intravenous group. All adverse effects were self-resolved without any intervention. EEG recording quality and level of satisfaction among caregivers and EEG technicians were high. Conclusions: Considering our data dexmedetomidine is an effective and safe drug in patients with behavioural disorders. Intranasal administration could be useful as it is less invasive and with shorter offset. Clinical Trial registration: ID NCT 03799783; date registered: 10/01/2019