Sedation and Analgesia for Reduction of Pediatric Ileocolic Intussusception
Naveen Poonai, Daniel M. Cohen, Doug MacDowell, Rakesh D. Mistry, Santiago Mintegi, Simon Craig, Damian Roland, Michael Miller, Itai Shavit, Nishit Patel, Camilo Gutiérrez, Emily Roben, Chris Pruitt, Kimberly S. Quayle, Alicia I. Rolin, Dan Kornfeld, Justin Davis, Jackie Grupp-Phelan, Amanda Bogie, Heather Territo, Eli Hershman, Jānis Kolbergs, Virginia Stanton, Sarah Sheedy, Steve Forester, Liz Binham, Laura Dell’Era, Assunta Tornesello, Yvette Wang, Alan L. Nager, Theodore Heyming, Rebekah Burns, Indi Trehan, Matthew J. Lipshaw, Carmen Sulton, Joyce Li, Aderonke Ojo, Susan Kelly, Matthew E. Thornton, Kerry Caperell, Iluonose Amoni, Anna M. H. Abrams, Myto Duong, Muhammad Wassem, Adrienne L. Davis, Jocelyn Gravel, Evelyne D Trottier, Neta Bar, Graham C. Thompson, Vikram Sabhaney, Garth Meckler, Rini Jain, Samina Ali, Silvia Bressan, Tiziana Zangardi, G. Villa, Martina Giacalone, Michelle Seiler, Cyril Sahyoun, Fabrizio Romano, Zsolt Bognár, Szofia Hajósi-Kalcakosz, Lisa H. Amir, Saı̈d Hachimi-Idrissi, Zanda Pučuka, Astra Zviedre, Emīlija Zeltiņa, Natalie Phillips, Meredith L Borland, Sharon O’Brien, Jeanette Marchant, Amit Kochar, Shane George, Victoria Pennington, Mark D Lyttle, Jen Browning, Anna McLoughlin, Stuart Hartshorn, Chaman Urooj, Lucy Johnston, Emily Walton, Deepika Subrahmanyam Puthucode, Philip J. Peacock, James W. Conroy, Rafael Marañón, Silvia García, Nuria Cahís, Amaia Cámara-Otegui, Arantxa Gomez, M Carbonero, Carlos Miguel Angelats Romero, Adriana Yock‐Corrales, Gabriela Hualde, Fabian Spigariol, Alex Donas, Cinthia Gübeli Linné, Alessia Rocchi, A Pedrazzini, Giorgio Cozzi, Dino Barbi
Abstract
Importance: Ileocolic intussusception is an important cause of intestinal obstruction in children. Reduction of ileocolic intussusception using air or fluid enema is the standard of care. This likely distressing procedure is usually performed without sedation or analgesia, but practice variation exists. Objective: To characterize the prevalence of opioid analgesia and sedation and assess their association with intestinal perforation and failed reduction. Design, Setting, and Participants: This cross-sectional study reviewed medical records of children aged 4 to 48 months with attempted reduction of ileocolic intussusception at 86 pediatric tertiary care institutions in 14 countries from January 2017 to December 2019. Of 3555 eligible medical records, 352 were excluded, and 3203 medical records were eligible. Data were analyzed in August 2022. Exposures: Reduction of ileocolic intussusception. Main outcomes and measures: The primary outcomes were opioid analgesia within 120 minutes of reduction based on the therapeutic window of IV morphine and sedation immediately before reduction of intussusception. Results: We included 3203 patients (median [IQR] age, 17 [9-27] months; 2054 of 3203 [64.1%] males). Opioid use was documented in 395 of 3134 patients (12.6%), sedation 334 of 3161 patients (10.6%), and opioids plus sedation in 178 of 3134 patients (5.7%). Perforation was uncommon and occurred in 13 of 3203 patients (0.4%). In the unadjusted analysis, opioids plus sedation (odds ratio [OR], 5.92; 95% CI, 1.28-27.42; P = .02) and a greater number of reduction attempts (OR, 1.48; 95% CI, 1.03-2.11; P = .03) were significantly associated with perforation. In the adjusted analysis, neither of these covariates remained significant. Reductions were successful in 2700 of 3184 attempts (84.8%). In the unadjusted analysis, younger age, no pain assessment at triage, opioids, longer duration of symptoms, hydrostatic enema, and gastrointestinal anomaly were significantly associated with failed reduction. In the adjusted analysis, only younger age (OR, 1.05 per month; 95% CI, 1.03-1.06 per month; P < .001), shorter duration of symptoms (OR, 0.96 per hour; 95% CI, 0.94-0.99 per hour; P = .002), and gastrointestinal anomaly (OR, 6.50; 95% CI, 2.04-20.64; P = .002) remained significant. Conclusions and Relevance: This cross-sectional study of pediatric ileocolic intussusception found that more than two-thirds of patients received neither analgesia nor sedation. Neither was associated with intestinal perforation or failed reduction, challenging the widespread practice of withholding analgesia and sedation for reduction of ileocolic intussusception in children.