Objetivos: Verificar eficácia da cetamina intranasal na sedação de crianças para punção venosa. Métodos: Estudo randomizado, duplo-cego, placebo controlado realizado no Hospital de Clínicas de Porto Alegre entre janeiro e agosto de 2016. Estudo aprovado pela comissão de ética em pesquisa da instituição. Incluídas crianças que necessitasse de punção venosa, sendo randomizadas a receber cetamina IN 4mg/Kg ou solução fisiológica no grupo Placebo. Os grupos foram comparados quanto: tempo de punção, facilidade do Enfermeiro para realizar o procedimento, eventos adversos, alterações dos sinais vitais e percepção do acompanhante. Resultados: Foram incluídas 39 crianças (21 Intervenção vs 18 Placebo) sem diferenças quanto à idade, sexo, peso, motivo da internação e experiência profissional. A mediana da idade foi 19,8 vs 15,8 meses (Intervenção vs. Placebo) e a do peso foi 10 vs. 11,3Kg. A Cetamina reduziu o tempo de punção (23,0 vs 67,5 segundos; p=0,01), deu maior facilidade ao Enfermeiro para realizar o procedimento (p=0,00009). A cetamina induziu uma maior sonolência 15 minutos após (p=0,003) e reduziu o número de pessoas para contenção da criança (p=0,025). Sem diferença entre os grupos nas alterações dos sinais vitais e eventos adversos. Evento adverso observou-se em 29% das crianças do grupo cetamina e 17% do grupo placebo, sendo irritabilidade o mais comum em ambos. Em 81% do grupo Intervenção, o acompanhante afirmou que a criança ficou mais calma (p=0,0003). Conclusões: Cetamina intranasal (4mg/Kg) reduz o tempo de punção venosa, facilitando o procedimento para o enfermeiro, diminuindo o número de pessoas envolvidas e permitindo um ambiente tranquilo. / Objectives: To verify the efficacy of intranasal ketamine as sedative agent for venous access in children. Method: Randomized, double blind, placebo controlled study conducted at Hospital de Clínicas de Porto Alegre (Brazil) between January and August 2016. Children needing venous access were randomized to receive intranasal ketamine (4mg/Kg) or normal saline solution (Placebo group). Groups were compared regarding the time for venous access, facility for performing the procedure, adverse events, disturbances in vital signs and perception of the accompanying adult. The study was approved by the Local Ethics Committee. Results: 39 children (21 Ketamine; 18 Placebo) were included without differences regarding to age, sex, weight, reason for hospitalization and professional experience. The median age was similar (19.8 vs 15.8 months), as well as the median weight (10.0 vs 11.3Kg). Ketamine reduced the length for venous access (23.0 vs 67.5 seconds; p=0.01), and facilitated the procedure (p=0.00009). Ketamine induced sleepiness 15 minutes after its administration (p=0.003) and reduced the number of people for the child’s restraint (p=0.025). No difference was verified between groups regarding adverse effects or vital signs disturbance´s. Side effects were observed in 29% of the children in the Ketamine group and 17% in the Placebo group, irritability being the most common for both. The accompanying adult reported that 81% of children in ketamine group were calm and quiet (p=0.0003). Conclusions: Intranasal ketamine (4mg/Kg) reduces the time for venous puncture, facilitates the procedure to the nurse, decreases the number of people involved and provides a tranquil environment.

Akut smärta är det vanligast förekommande symtom som den prehospitala akutsjukvården ställs inför. Behandlingsriktlinjerna presenterar intranasalt Fentanyl som ett alternativ för akut smärtlindring. Då det finns ett begränsat utbud av studier utförda på vuxna och inom prehospital akutsjukvård var syftet med studien att beskriva effekter av intranasal administrering av Fentanyl i prehospital akutsjukvård. Studien genomfördes med en kvantitativ metod och med en retrospektiv, deskriptiv design. Studien baserades på en granskning av 15 patientjournaler från Ambulanssjukvården i Region Halland och deras journalsystem Paratus. Journaler som inkluderades var de där Fentanyl administrerat. Resultatet visar att en majoritet av patienterna i studien drabbats av muskeloskeletal smärta. Resultatet visade på dokumentationsbrister i granskade patientjournaler. Vidare forskning av Fentanyl i den prehospitala akutsjukvården samt översyn av följsamhet till dokumentationsrutiner är nödvändig. / Acute pain is the most common symptom in the prehospital emergency care. The treatment guideline presents Fentanyl as an alternative for treating acute pain. As there is a limited range of studies conducted in adults and in prehospital emergency care the purpose of the study was to illustrate the effects of intranasal administration of Fentanyl in the prehospital emergency care. The study was conducted by a quantitative method and with a retrospective, descriptive design. The study was based on a review of patient records from the Ambulance Service in the Region of Halland and their record system Paratus. Fifteen patient records were Fentanyl was administrated were included in the study. The result showed that a majority of the patients included in the study suffered from musculoskeletal pain. The result showed a lack of documentation in the reviewed records. Further studies and an overview of the compliance of the routines for documentation as well are necessary.

Objetivos: Verificar eficácia da cetamina intranasal na sedação de crianças para punção venosa. Métodos: Estudo randomizado, duplo-cego, placebo controlado realizado no Hospital de Clínicas de Porto Alegre entre janeiro e agosto de 2016. Estudo aprovado pela comissão de ética em pesquisa da instituição. Incluídas crianças que necessitasse de punção venosa, sendo randomizadas a receber cetamina IN 4mg/Kg ou solução fisiológica no grupo Placebo. Os grupos foram comparados quanto: tempo de punção, facilidade do Enfermeiro para realizar o procedimento, eventos adversos, alterações dos sinais vitais e percepção do acompanhante. Resultados: Foram incluídas 39 crianças (21 Intervenção vs 18 Placebo) sem diferenças quanto à idade, sexo, peso, motivo da internação e experiência profissional. A mediana da idade foi 19,8 vs 15,8 meses (Intervenção vs. Placebo) e a do peso foi 10 vs. 11,3Kg. A Cetamina reduziu o tempo de punção (23,0 vs 67,5 segundos; p=0,01), deu maior facilidade ao Enfermeiro para realizar o procedimento (p=0,00009). A cetamina induziu uma maior sonolência 15 minutos após (p=0,003) e reduziu o número de pessoas para contenção da criança (p=0,025). Sem diferença entre os grupos nas alterações dos sinais vitais e eventos adversos. Evento adverso observou-se em 29% das crianças do grupo cetamina e 17% do grupo placebo, sendo irritabilidade o mais comum em ambos. Em 81% do grupo Intervenção, o acompanhante afirmou que a criança ficou mais calma (p=0,0003). Conclusões: Cetamina intranasal (4mg/Kg) reduz o tempo de punção venosa, facilitando o procedimento para o enfermeiro, diminuindo o número de pessoas envolvidas e permitindo um ambiente tranquilo. / Objectives: To verify the efficacy of intranasal ketamine as sedative agent for venous access in children. Method: Randomized, double blind, placebo controlled study conducted at Hospital de Clínicas de Porto Alegre (Brazil) between January and August 2016. Children needing venous access were randomized to receive intranasal ketamine (4mg/Kg) or normal saline solution (Placebo group). Groups were compared regarding the time for venous access, facility for performing the procedure, adverse events, disturbances in vital signs and perception of the accompanying adult. The study was approved by the Local Ethics Committee. Results: 39 children (21 Ketamine; 18 Placebo) were included without differences regarding to age, sex, weight, reason for hospitalization and professional experience. The median age was similar (19.8 vs 15.8 months), as well as the median weight (10.0 vs 11.3Kg). Ketamine reduced the length for venous access (23.0 vs 67.5 seconds; p=0.01), and facilitated the procedure (p=0.00009). Ketamine induced sleepiness 15 minutes after its administration (p=0.003) and reduced the number of people for the child’s restraint (p=0.025). No difference was verified between groups regarding adverse effects or vital signs disturbance´s. Side effects were observed in 29% of the children in the Ketamine group and 17% in the Placebo group, irritability being the most common for both. The accompanying adult reported that 81% of children in ketamine group were calm and quiet (p=0.0003). Conclusions: Intranasal ketamine (4mg/Kg) reduces the time for venous puncture, facilitates the procedure to the nurse, decreases the number of people involved and provides a tranquil environment.

Objetivos: Verificar eficácia da cetamina intranasal na sedação de crianças para punção venosa. Métodos: Estudo randomizado, duplo-cego, placebo controlado realizado no Hospital de Clínicas de Porto Alegre entre janeiro e agosto de 2016. Estudo aprovado pela comissão de ética em pesquisa da instituição. Incluídas crianças que necessitasse de punção venosa, sendo randomizadas a receber cetamina IN 4mg/Kg ou solução fisiológica no grupo Placebo. Os grupos foram comparados quanto: tempo de punção, facilidade do Enfermeiro para realizar o procedimento, eventos adversos, alterações dos sinais vitais e percepção do acompanhante. Resultados: Foram incluídas 39 crianças (21 Intervenção vs 18 Placebo) sem diferenças quanto à idade, sexo, peso, motivo da internação e experiência profissional. A mediana da idade foi 19,8 vs 15,8 meses (Intervenção vs. Placebo) e a do peso foi 10 vs. 11,3Kg. A Cetamina reduziu o tempo de punção (23,0 vs 67,5 segundos; p=0,01), deu maior facilidade ao Enfermeiro para realizar o procedimento (p=0,00009). A cetamina induziu uma maior sonolência 15 minutos após (p=0,003) e reduziu o número de pessoas para contenção da criança (p=0,025). Sem diferença entre os grupos nas alterações dos sinais vitais e eventos adversos. Evento adverso observou-se em 29% das crianças do grupo cetamina e 17% do grupo placebo, sendo irritabilidade o mais comum em ambos. Em 81% do grupo Intervenção, o acompanhante afirmou que a criança ficou mais calma (p=0,0003). Conclusões: Cetamina intranasal (4mg/Kg) reduz o tempo de punção venosa, facilitando o procedimento para o enfermeiro, diminuindo o número de pessoas envolvidas e permitindo um ambiente tranquilo. / Objectives: To verify the efficacy of intranasal ketamine as sedative agent for venous access in children. Method: Randomized, double blind, placebo controlled study conducted at Hospital de Clínicas de Porto Alegre (Brazil) between January and August 2016. Children needing venous access were randomized to receive intranasal ketamine (4mg/Kg) or normal saline solution (Placebo group). Groups were compared regarding the time for venous access, facility for performing the procedure, adverse events, disturbances in vital signs and perception of the accompanying adult. The study was approved by the Local Ethics Committee. Results: 39 children (21 Ketamine; 18 Placebo) were included without differences regarding to age, sex, weight, reason for hospitalization and professional experience. The median age was similar (19.8 vs 15.8 months), as well as the median weight (10.0 vs 11.3Kg). Ketamine reduced the length for venous access (23.0 vs 67.5 seconds; p=0.01), and facilitated the procedure (p=0.00009). Ketamine induced sleepiness 15 minutes after its administration (p=0.003) and reduced the number of people for the child’s restraint (p=0.025). No difference was verified between groups regarding adverse effects or vital signs disturbance´s. Side effects were observed in 29% of the children in the Ketamine group and 17% in the Placebo group, irritability being the most common for both. The accompanying adult reported that 81% of children in ketamine group were calm and quiet (p=0.0003). Conclusions: Intranasal ketamine (4mg/Kg) reduces the time for venous puncture, facilitates the procedure to the nurse, decreases the number of people involved and provides a tranquil environment.

Objetivos: Avaliar a segurança e a eficácia do midazolam intranasal (MIN) para sedação para tomografia em crianças, bem como a qualidade dos estudos radiológicos obtidos com esta técnica. Material e métodos: Entre dezembro de 2011 e julho de 2012, este estudo prospectivo avaliou o MIN como sedativo para crianças submetidas à tomografia sem acesso venoso. Após aprovação do Comitê de Ética em Pesquisa e consentimento dos responsáveis, 0,4 mg/kg de MIN foi administrado, sendo feita dose adicional de 0,1 mg/kg se o nível de sedação avaliado pela Escala de Sedação de Ramsay não fosse atingida após 15 minutos da primeira dose. Os desfechos relacionados à sedação incluíram tempo para sedação e para atingir os critérios de alta; parâmetros fisiológicos como oximetria de pulso e frequência cardíaca foram registrados a cada cinco minutos até a alta. A qualidade dos exames tomográficos foi avaliada quanto à presença de artefatos de imagem e movimento. Resultados: 60 eventos de sedação foram realizados em 58 pacientes. A idade média foi de 15,5 meses, sendo 90,9% dos exames tomográficos de crânio. O tempo médio para sedação foi de 15,2 minutos (5-40) e o tempo médio para atingir os critérios de alta foi de 74,7 minutos. Eventos adversos foram observados em 5 crianças (8,4%), incluindo reação paradoxal (3), tempo de recuperação prolongado (1) e vômitos (1). Apenas 4 pacientes (6,7%) não foram adequadamente sedados com MIN. Imagens consideradas excelentes, sem artefatos, foram obtidas em 56 (93,3%) sedações. Não houve eventos como bradicardia, hipoxemia ou hipotensão. Conclusões: O midazolam intranasal, administrado via atomizador nasal, é um método simples e não-invasivo para sedação segura, eficaz e previsível para crianças na obtenção de estudos tomográficos de qualidade / Objective: To evaluate the safety, efficacy and image quality of sedation with aerosolized intranasal midazolam for pediatric CT studies. Materials and Methods: Between December 2011 to May 2012, this prospective study evaluated aerosolized intranasal (AIN) midazolam as a sedative for CT of children without intravenous access. After IRB approval and parental consent, 0,4 mg/kg of AIN midazolam was administered, and repeated with 0.1 mg/kg if adequate sedation evaluated by Ramsay Sedation Scale not achieved in 15 minutes after the first dose. Sedation outcome variables which included time to achieve sedation, to meet discharge criteria and physiological vital signs of pulse oximetry and heart rate, were recorded every five minutes until discharge. The quality of CT images was reviewed and graded for presence of motion and imaging artifacts, Results: 60 sedation encounters were performed in 58 children. Mean age was 15.5 months, and 90.9% of CT scans were brain scans. Mean time to sedation was 15.2 minutes (range 5-40) and mean time to achieve discharge criteria was 74.7 minutes. Adverse events were recorded in 5 children (8.4%) that underwent sedation - paradoxical reaction (3), prolonged recovery time (1) and vomiting (1). Only 4 patients (6.7%) failed to sedate. Excellent CT imaging, with no artifacts, were obtained in 56 (93.3%) of sedation encounters. No adverse events like bradycardia, hypoxia or hypotension were documented. Conclusions: The aerosolized route of administration of midazolam is a simple and noninvasive approach for predictable, effective and safe sedation of children for quality CT imaging studies

Objetivos: Avaliar a segurança e a eficácia do midazolam intranasal (MIN) para sedação para tomografia em crianças, bem como a qualidade dos estudos radiológicos obtidos com esta técnica. Material e métodos: Entre dezembro de 2011 e julho de 2012, este estudo prospectivo avaliou o MIN como sedativo para crianças submetidas à tomografia sem acesso venoso. Após aprovação do Comitê de Ética em Pesquisa e consentimento dos responsáveis, 0,4 mg/kg de MIN foi administrado, sendo feita dose adicional de 0,1 mg/kg se o nível de sedação avaliado pela Escala de Sedação de Ramsay não fosse atingida após 15 minutos da primeira dose. Os desfechos relacionados à sedação incluíram tempo para sedação e para atingir os critérios de alta; parâmetros fisiológicos como oximetria de pulso e frequência cardíaca foram registrados a cada cinco minutos até a alta. A qualidade dos exames tomográficos foi avaliada quanto à presença de artefatos de imagem e movimento. Resultados: 60 eventos de sedação foram realizados em 58 pacientes. A idade média foi de 15,5 meses, sendo 90,9% dos exames tomográficos de crânio. O tempo médio para sedação foi de 15,2 minutos (5-40) e o tempo médio para atingir os critérios de alta foi de 74,7 minutos. Eventos adversos foram observados em 5 crianças (8,4%), incluindo reação paradoxal (3), tempo de recuperação prolongado (1) e vômitos (1). Apenas 4 pacientes (6,7%) não foram adequadamente sedados com MIN. Imagens consideradas excelentes, sem artefatos, foram obtidas em 56 (93,3%) sedações. Não houve eventos como bradicardia, hipoxemia ou hipotensão. Conclusões: O midazolam intranasal, administrado via atomizador nasal, é um método simples e não-invasivo para sedação segura, eficaz e previsível para crianças na obtenção de estudos tomográficos de qualidade / Objective: To evaluate the safety, efficacy and image quality of sedation with aerosolized intranasal midazolam for pediatric CT studies. Materials and Methods: Between December 2011 to May 2012, this prospective study evaluated aerosolized intranasal (AIN) midazolam as a sedative for CT of children without intravenous access. After IRB approval and parental consent, 0,4 mg/kg of AIN midazolam was administered, and repeated with 0.1 mg/kg if adequate sedation evaluated by Ramsay Sedation Scale not achieved in 15 minutes after the first dose. Sedation outcome variables which included time to achieve sedation, to meet discharge criteria and physiological vital signs of pulse oximetry and heart rate, were recorded every five minutes until discharge. The quality of CT images was reviewed and graded for presence of motion and imaging artifacts, Results: 60 sedation encounters were performed in 58 children. Mean age was 15.5 months, and 90.9% of CT scans were brain scans. Mean time to sedation was 15.2 minutes (range 5-40) and mean time to achieve discharge criteria was 74.7 minutes. Adverse events were recorded in 5 children (8.4%) that underwent sedation - paradoxical reaction (3), prolonged recovery time (1) and vomiting (1). Only 4 patients (6.7%) failed to sedate. Excellent CT imaging, with no artifacts, were obtained in 56 (93.3%) of sedation encounters. No adverse events like bradycardia, hypoxia or hypotension were documented. Conclusions: The aerosolized route of administration of midazolam is a simple and noninvasive approach for predictable, effective and safe sedation of children for quality CT imaging studies

Bakgrund: Ett vanligt symtom inom ambulanssjukvården är smärta, vilken ofta kan förvärra den smärta som redan upplevs av patienten, då de nödvändiga förflyttningarna genomförs av besättningen till bår och ambulans. Det är sjuksköterskorna i ambulansbesättningen som gör bedömningen huruvida smärtlindring krävs akut eller inte under transporten till sjukhus. Syfte: Syftet med studien var att studera patienters upplevelser av intranasal (i.n) smärtlindring jämfört med intravenös (i.v) smärtlindring inom ambulanssjukvården i Stockholm. Metod: Studien är en empirisk studie med deskriptiv design. Huvudresultat: Studien visade endast signifikant skillnad i området där upplevelsen av oro och/eller rädsla mättes i samband med i.n kontra i.v smärtlindringsmetod. Det var fler som upplevde en negativ aspekt i form av oro och eller rädsla i den grupp som fått i.n smärtlindring. Inga andra signifikanta skillnader i upplevelsen av varken, nöjdhet av smärtlindringens effekt, själva sättet att erhålla läkemedlet eller upplevelse av biverkningar påvisades. En jämförelse mellan de rapporterade biverkningarna visade att illamående var den vanligaste biverkningen och den var vanligast i den grupp som erhållit i.n smärtlindring. Slutsats: Med bakgrund av detta resultat kan man ifrågasätta om administreringssättet är avgörande kring effekten och upplevelsen av positiva eller negativa aspekter av smärtbehandlingen. / Background: A common symptom of ambulance care is pain, which can often exacerbate the pain already experienced by the patient, as the necessary movements are carried out by the crew to the stern and ambulance. It is the nurses in the ambulance crew who assess whether pain relief is required urgently or not during transport to hospitals.   Objective: The purpose of this study was to study patient´s experiences of intranasal (i.n) pain relief compared to intravenous (i.v) pain relief within the ambulance service in Stockholm area.    Method: The study is an empirical study with a descriptive design.   Main results: The study showed that the only significant difference in the area where the experience of anxiety and/or fear was measured in connection with i. n versus i. v. pain relief method. It was more that experienced a negative aspect in the form of anxiety and or fear in the group that received in n pain relief. No other significant differences in the experience of pain relief, satisfaction of neither the ring's power, the way to obtain the medicine or experience side effects was demonstrated. A comparison of the reported showed that the most common side effect was nausea, and it was most common in the group that received in n pain relief.   Conclusion: Based on this result, one can question whether the mode of administration is crucial for the effect and experience of positive or negative aspects of pain management.

<p>Drug delivery to the nasal and ocular mucosa faces several obstacles. One of these is from the effective clearance mechanisms present in the nose and eye. Polymer gels with suitable rheological properties can facilitate the absorption of poorly absorbed drugs by increasing the contact time of the drug with the mucosa. This has been attributed to the rheological and mucoadhesive properties of the gel. The main objective of this thesis was to investigate the importance of these features for the anticipated in vivo contact time, here exemplified by the ocular and nasal routes of administration.</p><p>The in situ gelling polymer gellan gum was found to have a favourable rheological and in vivo performance. When administered in the nasal cavity of rats, a gel was formed that could remain at the site of administration for up to 4 hours. In addition, the epithelial uptake and transfer of a 3 kDa fluorescein dextran was higher than for a mannitol solution. Therefore, it was concluded that a gellan gum formulation should be a promising strategy for nasal drug delivery.</p><p>The potential mucoadhesive properties of a variety of polymer gels were investigated using a rheological method and by measuring the tensile force required to detach the gel from a mucosa. With both methods the rheological properties of the gel were a determining factor for the results obtained. The rheological method was found to have several limitations. One of these was that a positive response, interpreted as mucoadhesion, was only seen with weak gels. The tensile method could, in contrast, detect strengthening of the mucus only for strong gels. However, this method reflects the in vivo performance of the gel better than the rheological method.</p><p>Finally, dielectric spectroscopy was explored as a tool for investigating the likelihood of intimate surface contact between the gel and the mucus layer. This novel approach involved determining the ease with which a charged particle can pass the gel-mucus interface layer, and may enable the study of the events at the interface closer to the molecular level, than is possible with the rheological and tensile strength methods.</p>

Drug delivery to the nasal and ocular mucosa faces several obstacles. One of these is from the effective clearance mechanisms present in the nose and eye. Polymer gels with suitable rheological properties can facilitate the absorption of poorly absorbed drugs by increasing the contact time of the drug with the mucosa. This has been attributed to the rheological and mucoadhesive properties of the gel. The main objective of this thesis was to investigate the importance of these features for the anticipated in vivo contact time, here exemplified by the ocular and nasal routes of administration. The in situ gelling polymer gellan gum was found to have a favourable rheological and in vivo performance. When administered in the nasal cavity of rats, a gel was formed that could remain at the site of administration for up to 4 hours. In addition, the epithelial uptake and transfer of a 3 kDa fluorescein dextran was higher than for a mannitol solution. Therefore, it was concluded that a gellan gum formulation should be a promising strategy for nasal drug delivery. The potential mucoadhesive properties of a variety of polymer gels were investigated using a rheological method and by measuring the tensile force required to detach the gel from a mucosa. With both methods the rheological properties of the gel were a determining factor for the results obtained. The rheological method was found to have several limitations. One of these was that a positive response, interpreted as mucoadhesion, was only seen with weak gels. The tensile method could, in contrast, detect strengthening of the mucus only for strong gels. However, this method reflects the in vivo performance of the gel better than the rheological method. Finally, dielectric spectroscopy was explored as a tool for investigating the likelihood of intimate surface contact between the gel and the mucus layer. This novel approach involved determining the ease with which a charged particle can pass the gel-mucus interface layer, and may enable the study of the events at the interface closer to the molecular level, than is possible with the rheological and tensile strength methods.