A recent study evaluated the potential methods of intra-articular corticosteroid injection in children with juvenile idiopathic arthritis, the most common chronic rheumatic disease in children.
Use of sedation for all conditions is a complicated and often difficult proposition. For several reasons, these challenges can be heightened when the patients involved are children. Among other reasons, this can be because of the difficulty of getting a child to remain still for an injection, adverse events that are different than in the adult population, and increased sensitivity to the pain of an injection.
A clinical review in Pediatric Rheumatology evaluated the potential methods of intra-articular corticosteroid injection (IASI) in children with juvenile idiopathic arthritis (JIA), the most common chronic rheumatic disease in children. While there are currently several methods of IASI, there is no widely accepted standard of care. Although IASI is effective enough that many patients need no other therapy, it does come with the disadvantage of pain and anxiety associated with the procedure.
The review took an interesting approach—offering pros and cons for several different approaches, and then looking at how this knowledge can be applied in two patient case studies. In the first, a 2-year-old girl diagnosed with oligoarticular JIA was due for IASI to her right knee. In the second case, a 9-year-old girl with a 4-year history of oligoarticular JIA has been taking methotrexate for a year and now has presented with exacerbation of left ankle arthritis. She had an IASI to the same joint a year ago.
The thorough review includes an examination of the following techniques and offers insight into administration, time to onset, side effects and adverse effects, length of action, extent of potential placebo effect, and whether or not the anesthesia method has an analgesic effect (if not, opioids may be part of the treatment as well). The authors examined everything from local anesthesia, to nitrous oxide and benzodiazepines, propofol, fentanyl, general anesthesia, and even distraction and relaxation techniques that can make the procedure easier to perform.
The authors conclude, “Since JIA is a chronic disease and many affected children will experience numerous injections during the course of their illness, much emphasis should be given in making the procedure as painless, stress free and even pleasant as possible…The decision should be taken after consulting pediatric anesthesia colleagues and taking into consideration the trained staff and the patient himself.”
In case 1, the authors recommend general anesthesia or moderate sedation, in part because the patient is very young and unlikely to cooperate with a painful procedure, and in part because the patient is likely to undergo repeated injections in the future. Thus, it would be beneficial to have the encounter be as pain-free as possible. In case 2, the authors suggest nitrous oxide combined with a distraction technique, so that the patient will not have to face the stress of intravenous cannula insertion and will avoid the risks of benzodiazepine sedation.