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Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine

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Section Editor Jason Reynolds, MD


By Amy Baxter, MD
Children’s Healthcare of Atlanta Scottish Rite

BuzzyPain management in pediatrics is a balancing act between the time and efficacy of available treatments and the temperament (and parents) of patients.  In December, pediatric emergency medicine physician Amy Baxter, MD, of Children’s Healthcare of Atlanta Scottish Rite published results of a novel pain relief device that addresses the need for speed and child-friendly interventions.  Her invention “Buzzy”®, a combination high frequency massager with attachable frozen wings, physiologically blocks pain signals on contact.  In the study in Pediatric Emergency Care, Buzzy not only decreased the pain of cannulation in a pediatric emergency department by half, but also increased intravenous access success on the first stick by three times.

“We compared Buzzy to cold spray,” said Baxter, “Because this was our standard of care for needle pain relief, and is similarly fast acting.  Even though the vapocoolant studies don’t necessarily support vasoconstriction,  I do think that Buzzy’s increased success could have been related to that.  Buzzy’s first stick success was 85%, though, so for an ED study that’s a fairly good outcome.”  Baxter notes that due to conflict of interest, she did not personally conduct data collection or analysis.

Buzzy uses gate control and descending noxious inhibitory control (DNIC) to block pain.  The 1965 Melzac and Wall paper first detailing gate theory hypothesized that by stimulating aBeta vibration stimulations and/or cold C fiber transmissions, sharp Adelta pain is diminished.  Common examples include rubbing a bumped elbow or placing a burned finger under running water.  DNIC involves placing a noxious stimulus, such as ice, anywhere on the body to ‘take up bandwidth’ in the anterior cingulate gyrus and stimulate modulating descending interneuron blockade of further pain signals.

Buzzy is a plastic bee the size of a computer mouse.  Two AAA batteries power a vibrating motor with a toggle switch, and an elastic strap on back can hold the optional ice wings.  To use Buzzy, place it 5-10 cm proximal of the painful stimulus.  The ice wings add about 60% of the numbing, but if a child has cold sensitivity or is too young to tell you that the cold is intolerable, use the Buzzy alone.  Activate vibration with a toggle switch prior to the poke, and if using ice try to leave in place at least 15 seconds before starting the procedure.  “Vibration works immediately, as Abeta fibers are myelinated.  Since the C fibers are non-myelinated, the cold is a growing sensation and we find that the pain relief increases over 15 seconds to a minute.”  With Buzzy still in place, perform the procedure.

“I invented Buzzy for my son’s shots, as he became a terrible needlephobe after his 4 year vaccinations.  It’s made a huge difference.  He doesn’t mind going to the pediatrican now so long as I’ve brought Buzzy.  Clinically, though, in the ED I tend to use Buzzy for injecting lidocaine, doing a digital block, or removing a foreign body,” stated Baxter.

Buzzy appears in this month’s Diabetes Forecast for insulin injection pain and distraction, although Baxter notes it can be used for blood glucose checks as well.  “Families who buy Buzzy off the website are usually getting it for insulin or Humira, or any painful burning medication they have to administer at home,” she noted. Buzzy was written up in December’s Contemporary Pediatrics, where Dr. Andrew Schuman declared his own shot with Buzzy “virtually painless” and said he now routinely uses Buzzy for wart removal.

Baxter also invented Bee-Stractors DistrACTION cards, “Because distraction can decrease pain by 50% all by itself.  I keep the cards on my badge for when Child Life isn’t around, or when I walk by a room and see an IV isn’t going well.  The cards have age-stratified finding and counting tasks, like ‘how many monkeys are actually touching the bed?’  I think we fall into a trap of thinking that procedural sedation or pain relief are like a switch.   With kids, you can’t just turn pain or consciousness on or off no matter how effective your cream or drug is.  Making a child comfortable is multi-modal and has to involve mind and body, so that has been my approach.  Buzzy in isolation isn’t as good as playing a game, and distraction alone doesn’t disguise the pinch.”

Hospitals can purchase Buzzy with faxed purchase orders at 877-805-2899.  More information and individual ordering can be done on the website at

Let Us Know What You Think

Over the last decade the field of pediatric sedation has evolved into a specialty within a specialty.  At some institutions this specialty is within anesthesiology and at others it is within a pediatric specialty (critical care, emergency medicine, or hospital medicine).  While the provider type may vary between institutions (and even within institutions), the majority of sedation programs use anesthesia codes to bill for their professional fees. 

This raises the question…  “Are providers being compensated based on the service that they provide (and bill) or based on the market rate for their respective board certification?”  Earlier this year a survey went out across the SPS listserv looking at physician compensation for sedation services.  Please visit the Pediatric Sedation Blog to view the results of this survey and comment on the topic of sedation reimbursement/compensation.

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