Procedural sedation for intra-articular corticosteroid injections in juvenile idiopathic arthritis (JIA) should be a standard of care

We appreciated the report by Casado et al. regarding sedation for intra-articular corticosteroid injections (IACI) in juvenile idiopathic arthritis (JIA) [2]. However we cannot share their conclusions since they compared Sevoflurane sedation with no sedation, without considering other possible approaches. In our institute, non-anesthesiologists-administered propofol (NAAP) and nitrous oxide (N₂O) are routinely used for sedation for IACI. The safety and efficacy of NAAP in defined settings after proper training and patient selection is reported in literature [3]. In the period between 2000 and 2013 in our institute, 461 patients underwent IACI with NAAP without any relevant complication. Inhaled N₂O has also been shown to provide effective and safe sedation for JIA children undergoing IACI [1]. Since 2012, N₂O was offered by us to children older than 6 scheduled for joint injection. We performed 43 procedures in 35 patients (median age, 11 years; range, 6–18). Premedication with oral midazolam (0.5 mg/kg) was used in 23/35 patients. All patients completed a visual analogue pain scale (VAS; 0–10 cm) immediately after the procedure and after 30 and 60 min. Ramsay score and recall of the procedure were used to assess the level of sedation. Median Ramsay score was 2 (range, 1–3), corresponding to a quiet and collaborating patient. No pain (VAS 0) was reported in 27/35 patients immediately after the procedure and in 28/35 patients after 60 min. Median reported VAS was 4 (range, 0–10) immediately after the procedure, 3 after 30 min (range, 0–8) and 1.5 after 60 min (IQR, 1–2.5; range, 0–7). Vomiting occurred in one patient. No other adverse event was observed. Six out of 35 patients had memory of the procedure. Avoidance of pain and discomfort during hospitalization is a priority for children with chronic illness: procedural sedation, either deep or moderate, can be safely performed in JIA children by trained pediatricians and should be considered as a standard of care.