Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department☆☆☆★★★♢

Comparative evaluation of intranasal midazolam-ketamine, dexmedetomidine-ketamine, midazolam-fentanyl, and dexmedetomidine-fentanyl combinations for procedural sedation and analgesia in pediatric dental patients: a randomized controlled trial

Background

In order to assess the effectiveness of various analgesio-sedative combinations for pain relief and sedation in pediatric dental patients, a thorough evaluation of clinical studies and patient outcomes is necessary.

Methods

A total of 128 healthy, uncooperative pediatric dental patients were randomly allocated to receive one of the four combinations of drugs via the intranasal (IN) route: Group I received midazolam-ketamine (MK), Group II received dexmedetomidine-ketamine (DK), Group III received midazolam-fentanyl (MF), and Group IV received dexmedetomidine-fentanyl (DF) in a parallel-arm study design. The efficacy and safety of the combinations were evaluated using different parameters.

Results

The onset of sedation was significantly faster in the DF group than in the DK, MF, and MK groups (P < 0.001). The depth of sedation was significantly higher in the DK and DF groups than in the MK and MF groups (P < 0.01). DK and DF produced significant intra- and postoperative analgesia when compared with combinations of MK and MF. No significant adverse events were observed for any of the combinations.

Conclusions

The DK and DF groups showed potential as analgesio-sedatives in view of their anxiolytic and analgesic effects.

Sedation and Anesthesia for the Adolescent Dental Patient

This article focuses on sedation/anesthesia of adolescent patients in the dental setting. Preoperative evaluation, treatment planning, monitoring, and management are critical components to successful sedation. The authors discuss commonly administered agents and techniques to adolescents, including nitrous oxide/oxygen analgesia. The levels and spectrum of sedation and anesthesia are reviewed. Common comorbidities are also presented as they relate to sedation of the adolescent dental patient.

Procedural moderate sedation with ketamine in pediatric critical care unit

Objective:

To evaluate the safety and efficacy of moderate sedation in the Pediatric Intensive Care Unit (PICU) settings according to moderate sedation protocol using ketamine and midazolam and to determine areas for the improvement in our clinical practice.

Settings and Design:

A retrospective study was conducted in the PICU.

Materials and Methods:

Retrospective chart review was performed for patients who had received moderate sedation between January and the end of December 2011 and who are eligible to inclusion criteria.

Results:

In this study, 246 moderate sedation sessions were included. 5.3% were in infant age, while 94.7% were children (1–14 years). Their gender distributed as 59.8% males and 40.2% females. The majority of them had hematology-oncology disease nature, i.e., 80.89% (n = 199). Lumbar puncture accounted for 65.3% (n = 160) of the producers; the rests were bone marrow aspiration 32.7%, endoscopy 8.2%, and colonoscopy 2.9%. Two doses of ketamine (1–1.5 mg/kg) to achieve moderate sedation during the procedure were given to 44.1% (n = 108) of the patients. One dose of midazolam was given to 77.2% (n = 190), while 1.22% (n = 3) of sessions of moderate sedation was done without any dose of midazolam. Adverse events including apnea, laryngeal spasm, hypotension, and recovery agitation were observed during moderate sedation sessions, and it has been noticed in four sessions, i.e., 1.6%, which were mild to moderate and managed conservatively.

Conclusion:

Moderate sedation in the PICU using ketamine and midazolam is generally safe with minimal side effects as moderate sedation sessions were conducted by pediatric intensivist in highly monitored and equipped environment.

Efficacy and Safety of Midazolam Oral Solution for Sedative Hypnosis and Anti-anxiety in Children: A Systematic Review and Meta-Analysis

Background: Midazolam is recommended by health guidelines for sedation and hypnosis in children. Oral solution is a suitable dosage form for children. But there is no conclusive evidence for sedative-hypnosis and antianxiety effects by midazolam oral solution in children. Methods: Relevant studies were identified through searching PubMed, Embase, Cochrane Library, CINAHL, International Pharmaceuticals, four Chinese electronic databases, and relevant lists. Two reviewers independently selected trials, assessed trial quality, and extracted the data. Results: Eighty-nine randomized controlled trials (RCTs) comparing midazolam oral solution with placebo or blank (n = 33), dexmedetomidine (n = 15), ketamine (n = 11), different midazolam doses (n = 10), midazolam injection (n = 8), chloral hydrate (n = 7), diazepam (n = 5), N2O (n = 5), triclofos (n = 4), butorphanol (n = 2), fentanyl (n = 2), hydroxyzine (n = 1), and thiopental (n = 1) were identified. Meta-analysis showed no significant difference in the success rate and duration of sedation and hypnosis between midazolam oral and injectable solution (P > 0.05). The success rate of sedation and hypnosis of midazolam was higher than that of ketamine [risk ratio (RR) = 1.32, 95% CI (1.07, 1.62), I 2 = 0%, P < 0.01]. No significant difference was found in the success rate of sedation and hypnosis, mask acceptance, and parental separation between midazolam oral solution and dexmedetomidine (P > 0.05), and the result of one cohort study was consistent. The results of RCTs and a prospective cohort study showed that the incidence of adverse drug reactions (ADR) was 19.57% (189/966). Incidence of adverse reactions between dose groups of (0.25, 0.5] and (0.5, 1.0] mg/kg was similar [Pf (95% CI) = 0.10 (0.04, 0.24) and Pf (95% CI) = 0.09 (0.02, 0.39), respectively], higher than that of the dose group of (0, 0.25] mg/kg [Pf (95% CI) = 0.01 (0.00, 0.19)]. Conclusions: Available evidence suggests that midazolam oral solution is as good as midazolam injection and dexmedetomidine and is better than ketamine. Based on efficacy and safety results, an oral midazolam solution dose of 0.5-1 mg/kg is recommended for children.

Propofol Versus 4-hydroxybutyric Acid in Pediatric Cardiac Catheterizations

Introduction

Pediatric patients require deep sedation at least for cardiac catheterizations (CCs). Usually, we perform these CCs applying propofol, but we have seen several side effects of this sedative. We have had good experience with 4-hydroxybutyric acid for other sedations. To optimize our standardized CC procedure, we initiated a prospective, randomized trial to compare the two substances.

Methods

We analyzed our sedation protocols of all CCs within a period of 12 months. In addition to the primary endpoints, the feasibility of the CCs and the occurrence of severe complications, several other parameters were included in the analysis (vital parameters, blood gas analysis, intervention measures). The protocols were blinded for the first part of the evaluation.

Results

During the 12-month-period, 36 patients were included in each group. The propofol group showed lower blood pressure values towards the end of the sedations, while the blood gas analyses revealed lower pH levels and higher pCO2 values. The complication rate was low in both groups.

Conclusion

Both procedures are suited for the safe performance of deep sedations for CCs. The application of 4-hydroxybutyric acid seems to have a few advantages with regard to spontaneous breathing, gas exchange, stability of cardiocirculatory parameters and sedation quality.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews

BACKGROUND

Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings.

METHODS

We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED.

RESULTS

Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention).

CONCLUSIONS

This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.

Emergency department procedural sedation and analgesia: A Canadian Community Effectiveness and Safety Study (ACCESS)

Objectives:

To determine the effectiveness and safety of procedural sedation and analgesia (PSA) in a Canadian community emergency department (ED) staffed primarily by family physicians and to assess the role of capnometry monitoring in PSA.

Methods:

One hundred and sixty (160) consecutive procedural sedation cases were reviewed from the ED of a rural hospital in Huntsville, Ont. The ED is mainly staffed by family physicians who have received in-house training in PSA. Safety and effectiveness measures were extrapolated from a standardized PSA form by a blinded research assistant.

Results:

The mean age of the patient population was 33.6 years (standard deviation = 23.6). Fifty-four percent of the patients were male, and 33% of the cases were pediatric. PSA medications included propofol (84%), fentanyl (51%) and midazolam (15%), and the procedural success rate was 95.6%. The adverse event (AE) rate was 18% and included apnea (10%), inadequate sedation (3%), bradycardia (2%), desaturation (1%), hypotension (1%) and bag-valve-mask use (1%). In those aged ≥65 years there was a greater incidence of apnea. There were no episodes of emesis and there were no intubations. A modified jaw thrust manoeuvre was used in 23% of the cases. In the 64% of cases where capnometry was used, there was no association between its use and any AE measures.

Conclusion:

Procedural sedation was safe and effective in our environment. Capnometry recording did not appear to alter outcomes, although the data are incomplete.

Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma

OBJECTIVE

Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children.

METHODS

We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14.

RESULTS

Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate.

CONCLUSIONS

Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

Efficacy and safety of procedural sedation and analgesia for burn wound care

The study aim was to quantify efficacy and patient safety of registered nurse-administered procedural sedation and analgesia in a regional burn center. The investigators conducted a review of procedural sedation forms for all pediatric and adult patients admitted to this burn center from January 1, 2005, through December 31, 2005, for demographic and clinical data including patient age, gender, body weight, TBSA, dates of burn injury and wound care procedures, length of procedure, pre- and postprocedural pain assessment, procedural sedation/analgesia medications and doses, adverse drug events, and related interventions. During the 12-month study period, a total of 328 burn patients received 1293 procedural sedation procedures; child subjects (≤ 18 years) received 356 procedures and adult subjects (19-87 years) received 937 procedures. The mean (SD) length of the procedure was 60.1 (22.49) minutes with a range of 10 to 170 minutes. The mean subject age was 34.2 years (range: 6 weeks to 87 years), 67% were male, and the mean TBSA was 17% (0.5-68%). Ninety-four percent received fentanyl for analgesia and 85% received midazolam for anxiolysis and amnesia. The mean preprocedural pain score was 3.2 and the mean postprocedural pain score was 2 (t = 14.795; df = 1243; P < .001). Ten adverse events, all respiratory related, were documented in eight patients, two of whom experienced a second adverse event for an overall adverse event rate of 0.77%. No patient required intubation. Procedural sedation administered by a registered nurse competent in administration and monitoring in a burn center provided safe and effective pain management during wound care.

Propofol and Etomidate are Safe for Deep Sedation in the Emergency Department

This study describes deep sedations performed for painful procedures completed in the emergency department at an academic tertiary care hospital during an 18-month period. One hundred consecutive cases were retrospectively reviewed to describe indications, complications, procedural lengths, medication dosing, and safety of these sedations. Propofol and etomidate were the preferred agents. We found that there were relatively few complications (10%), with only 2 of these (2%) being major complications. All complications were brief and did not adversely affect patient outcomes. This data further demonstrate the safety profile of deep sedation medications in the hands of emergency physicians trained in sedation and advanced airway techniques.

[Low dose ketamine for pediatric procedure-related pain]

For painful procedures in children, national recommendations are now available in France. When sedation-analgesia with nitrous oxide/oxygen mixture fails, in order to perform a painful procedure under good conditions, low dose ketamine (IV bolus titration 0.5 mg/kg but not more than 2 mg/kg) is the only drug potentially used by a trained physician, without the presence of an anaesthesiologist (Grade A). With these dosages without drug combination, the highest level of security depends largely on the quality of the hospital environment (Grade A). Intramuscular (<4 mg/kg) is an alternative route, but the recovery time is delayed (Grade B). The optimal management is performed by an anesthesiologist, it is necessary to facilitate access to the operating room for children undergoing this type of procedure (Professional consensus). Mainly IV ketamine can be used by pediatric intensive care and emergency physicians who currently have medical skills to detect and treat side effects.

Intramuscular midazolam for pediatric sedation in the emergency department: a short communication on clinical safety and effectiveness

Background:

Procedural sedation in children continues to be a problem in the emergency department (ED). Midazolam is the first water-soluble benzodiazepine and it has been widely used for procedural sedation in pediatric patients.

Objectives:

The aim of this study was evaluation of clinical safety and effectiveness of intramuscular Midazolam for pediatric sedation in the ED setting.

Materials and Methods:

We performed a self-controlled clinical trial on 30 children who referred to the Baqiyatallah Hospital ED between 2009 and 2010. They received intramuscular Midazolam 0.3 mg/kg for procedural sedation and then they were followed for sedative effectiveness and safety. Vital signs and O2 saturation were also observed. The findings were compared using SPSS ver. 16 software.

Results:

The mean age was 5.50 ± 2.70 years, the mean weight was 19.50 ± 6.63 kilograms and 16 patients (53.3%) were females. The most common adverse effect was euphoria (66.66%) and vertigo (6.7%); 27.7% did not show any side effects. There was an overall complication rate of 72.3%. The vital signs including heart rate, respiratory rate, systolic and diastolic blood pressure and O2 saturation decreased significantly during sedation (P value < 0.05).

Conclusions:

Midazolam is an effective and relatively safe sedative for pediatric patients in the ED. The patient should be observed closely and monitored for psychological and hemodynamic side effects.

Combination of ketamine and propofol versus either agent alone for procedural sedation in the emergency department

PURPOSE

The safety of using ketamine-propofol combinations as an alternative to using either agent alone for procedural sedation is discussed.

SUMMARY

A total of 10 trials comparing the combination of ketamine and propofol with either agent alone for procedural sedation in the emergency department were examined. The evidence reviewed suggests that combining these agents may help to minimize adverse effects such as hypotension and respiratory depression. Ketamine is not commonly used as a single agent in adults because of the risk for emergence reactions; however, when combined with propofol, no significant increase in this adverse effect was found compared with propofol monotherapy. Administering ketamine and propofol can be accomplished by using a two-syringe technique or combining both medications into a single syringe. When two syringes are used, a ketamine 0.3-0.5-mg/kg i.v. bolus dose is administered, followed by a propofol 0.4-1-mg/kg i.v. bolus dose. Sedation is maintained with intermittent i.v. boluses of propofol 0.1-0.5 mg/kg. A 1:1 ratio of ketamine and propofol can also be combined into a single syringe by using the same concentration (10 mg/mL) and equal volumes of each drug, yielding a final concentration of 5 mg/mL for each component.

CONCLUSION

The combined use of ketamine and propofol is a reasonable alternative to propofol alone for procedural sedation in patients at higher risk for respiratory depression or hypotension. Use of the combination requires the development of standardized protocols for drug preparation and dosage to minimize the potential for errors.

Intranasal fentanyl for pain management in children: a systematic review of the literature

Intranasally administered fentanyl (INF) has been studied as an alternate route of delivery for pain relief in children. The purpose of this systematic review is to evaluate the available research evidence on the use of INF in the pediatric population. A search was conducted of PubMed, ISI, Scopus, Popline, CINAHL, and Embase for research studies evaluating INF in this population (0-18 years of age). The studies were graded on the strength of the evidence and the results reviewed. All of the reviewed studies showed similar or improved pain scores when compared with other opioids and administration methods. No severe adverse outcomes were reported. Current evidence suggests that INF is a safe and effective method of pain management for children in a variety of clinical settings.

Procedural Sedation and Analgesia in the Emergency Department

Patients present to the emergency department (ED) for a variety of reasons and some require diagnostic and therapeutic procedures for their conditions. In order for some of these procedures to be carried out successfully, the patient must be at a suppressed level of consciousness in order to tolerate the associated pain and anxiety. Medications administered to achieve these goals include analgesics and sedatives as they decrease the patient’s discomfort and awareness while allowing the patient to maintain their airway. However, medication selection and dosing is critical and should be tailored to each patient and procedure. Pharmacists have an opportunity to reduce medication errors during procedural sedation and analgesia (PSAA) as the majority of medication errors leading to adverse events occur during the ordering and administration steps of the medication use process. Common errors include drug-dosing, potential drug interactions, and administration of the wrong pharmacologic agent. Pharmacists in the ED can provide drug information and assist with drug selection and dosing; medication preparation; and monitoring of the patient and of the time intervals since medication administration relative to the duration of the procedure. Having a pharmacist present provides an extra layer of protection and reduces the likelihood for potential medication errors.

Sedation provider practice variation: a survey analysis of pediatric emergency subspecialists and fellows

OBJECTIVES

Pediatric emergency physicians use various techniques and medications when performing procedural sedation and analgesia. The goals of our study were to assess US pediatric emergency medicine subspecialists and fellows (PEMSSFs) for individual practice variation and to evaluate (1) the use of supplemental oxygen and capnography monitoring and (2) adverse sedation events (ADSEs).

METHODS

A Web-based tool was used to survey and analyze data collected from a selected group of PEMSSFs, regarding their responses to 5 common sedation case scenarios, use of supplemental oxygen and capnography monitoring, and ADSEs. Logistic regression analysis was used to examine the association between medication strategy and various levels of professional experience.

RESULTS

Two hundred one surveys were received. One hundred ninety-five of these were eligible for the study: 140 from specialists and 55 from fellows. Respondents used multiple combinations of pharmaceutical agents to the scenarios presented. For some scenarios, statistical association was found between medication selection strategy and longer professional experience. Sixty percent of respondents do not routinely provide oxygen supplementation. Despite current guidelines supporting the routine use of capnography monitoring, 45% of respondents never use it. Adverse sedation event was reported in 17 cases; all patients were discharged with no further complications. A statistical association was found between years of practitioner experience and the likelihood of reporting an ADSE (P < 0.018).

CONCLUSIONS

This group of PEMSSFs reported a wide spectrum of medication sedation strategies, dichotomous approaches to the use of oxygen supplementation and capnography monitoring, and a low rate of ADSEs.

Procedural Sedation and Analgesia in Children: Perspectives from Paediatric Emergency Physicians

Procedural sedation and analgesia in children is now widely practised in many emergency departments internationally. In this article, we address the general principles, indications, guidelines, medications, adverse events and future research in paediatric procedural sedation and analgesia in the Emergency Department.

Procedural sedation and analgesia is the use of sedative, analgesia and dissociative drugs to provide anxiolysis, analgesia, sedation and motor control during painful or unpleasant diagnostic and therapeutic procedures. It is a continuous spectrum from mild, moderate, deep sedation and then general anaesthesia. Dissociative sedation from ketamine is also commonly used.

Internationally, major clinical guidelines have been issued and revised since the 1980s. The guidelines should include the following components and documentation: pre-sedation assessment, intra-procedural monitoring and post-procedural monitoring and discharge criteria. The pre-sedation assessment involves assessing suitability of patient as candidate for sedation, any contraindications, fasting time, ensuring that the necessary equipment and drugs are available and the personnel providing the sedation are skilled in sedation and resuscitation.

The common medications for sedation in the emergency departments include ketamine, midazolam, fentanyl, morphine, oral chloral hydrate and nitrous oxide inhalation. Propofol and etomidate are used widely in some of the paediatric emergency departments internationally.

Procedural sedation has been documented to be safe and effective when performed by trained emergency physicians. The overall incidence of complications was 5.3% in a large prospective study, including airway and respiratory events (laryngospasm, apnoea, desaturations) and emesis. Aspirations are rare complications. Though the risks of adverse events are not high, emergency physicians need to have core competencies in sedation and resuscitation skills. The future of procedural sedation and analgesia will focus on enhancing training, safety and effectiveness.

Ketamine/midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions

BACKGROUND

Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidate's safety and efficacy in pediatric procedural sedation.

OBJECTIVE

The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED.

METHODS

Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation.

RESULTS

Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group.

CONCLUSIONS

This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.

Intravenous thiamylal and local anesthetic infiltration for pediatric facial repair procedures performed in emergency departments

Thiamylal is widely used for procedural sedation in emergency departments (ED); however, there are limited safety data for doses of thiamylal > 5 mg/kg in children. We investigated whether intravenous thiamylal in combination with local anesthetics is safe and effective for pediatric procedural sedation in the ED and to identify the association between increasing doses thiamylal and adverse events. Between July 2004 and June 2008, 227 children who underwent procedural sedation met the inclusion criteria, including 105 males (46.3%) and 122 females (53.7%). Facial laceration was the most common indication for procedural sedation. All children received an intravenous injection of thiamylal, with a loading dose of 5 mg/kg. Eighty-one children (35.7%) received a supplemental dose of 2.5 mg/kg thiamylal because of inadequate sedation. Of these, 27 (11.9%) received a second supplemental dose of 2.5 mg/kg because of inadequate sedation. Sixty-six patients (29.1%) experienced 75 mild and self-resolving adverse events, and most of which (15/75; 20%) were drowsiness. Four (1.8%) patients experienced oxygen saturation below 96%, which was related to the supplemental dose of thiamylal (p = 0.002). No children suffered from any lasting or potentially serious complications. Our results indicate that intravenous thiamylal in combination with local anesthetic infiltration is a well tolerated for therapeutic procedures in the ED. Thiamylal offers rapid onset of sedation without compromising the patient's cardiorespiratory function during pediatric procedural sedation.

Total procedural requirements as indication for emergency department sedation

Indications for pediatric procedural sedation and analgesia are generally based on the need to manage pain or elicit cooperation for a single major procedure in the emergency department setting. However, multiple minor procedures such as vascular access, urethral catheterization, lumbar puncture, or superficial abscess drainage may be required in the care of a single child, and combining these activities may produce as much stress as a single major procedure. The use of procedural sedation in children based on total procedural requirements is proposed with 2 illustrative cases as examples of this concept.

Reducing distress for children during invasive procedures: randomized clinical trial of effectiveness of the PediSedate

BACKGROUND

Procedural pain control remains problematic for young children, especially during anxiety-causing procedures for which children should not be deeply sedated. The PediSedate was designed to address this problem by delivering nitrous oxide in oxygen through a simple nosepiece, combined with an interactive video component, so that children can use attention and distraction with drug delivery.

OBJECTIVES

We conducted a randomized clinical trial to evaluate the effectiveness of the PediSedate for reducing children's behavioral distress in comparison with standard care in the emergency department. Secondary objectives were to assess children's acceptance, cooperation, and pain.

METHODS

Thirty-six children, aged 3-9 years old, who required invasive procedures associated with high levels of anxiety and low levels of pain such as sutures, IVs, and lumbar punctures were randomized to receive either the standard care or the PediSedate. The primary outcome was children's distress (observational scale of behavioral distress) that was monitored before and during the procedure.

RESULTS

Children randomized to the PediSedate group had significantly less distress during invasive procedures (mean = 1.8, sd = 3.2) than children receiving standard care (mean = 9.3, SD = 5.6; anova, P < 0.0001). Also, children in the PediSedate group were more cooperative [chi(2)(1) = 22.05, P < 0.0001] and fewer children reported pain [chi(2)(1) = 14.45, P < 0.001].

CONCLUSIONS

Previous studies have demonstrated the effectiveness of nitrous oxide sedation alone for minimizing pain and distress during invasive procedures. We have found that delivering nitrous oxide sedation via a system combined with an interactive video component is also effective. Further studies should determine which factors are dominant and determine the specific failure rate for this delivery system in comparison with other systems.

Sedation for emergent diagnostic imaging studies in pediatric patients

PURPOSE OF REVIEW

To review and summarize current literature regarding sedation for imaging studies in pediatric patients in the Emergency Department and acute care setting.

RECENT FINDINGS

Multiple guidelines about preparation, monitoring, and appropriate training of personnel administering pediatric sedation have been published. Recommendations for fasting prior to sedation remain in flux. Agents such as chloral hydrate, barbiturates, and benzodiazepines that have been used for pediatric sedation for many years continue to be studied. These agents are compared with newer agents such as etomidate, propofol, and dexmedetomidine.

SUMMARY

Although avoiding sedation for diagnostic imaging studies is optimal, there are multiple agents with reasonable safety profiles that can be utilized by personnel trained in pediatric airway management in order to obtain adequate emergent imaging studies.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

STUDY OBJECTIVE

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

METHODS

We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

RESULTS

In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.

CONCLUSION

Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Challenges and advances in intubation: rapid sequence intubation

Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.

Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel

OBJECTIVES

The aim was to compare the rate of procedural sedation-related adverse events of pediatric residents with specific training in "patient safety during sedation" and pediatric emergency physicians (PEPs) who completed the same course or were teaching faculty for it.

METHODS

This prospective single-blinded, nonrandomized study was conducted in two university-affiliated pediatric emergency departments (PEDs) in Israel. Pediatric residents who were authorized to perform unsupervised sedations had previously completed a course in patient safety during sedation. Unsupervised sedations by residents were defined as sedations where the entire procedure was performed independently. Study subjects had autonomy in choosing medications for sedation. Adverse events were defined as transient hypoxia (oxygen saturation < or = 90%) or apnea. Adverse outcomes were situations where intubation or hospitalization directly related to sedation complications would occur. Sedations over 12 consecutive months were recorded, and rates of adverse events in each group were compared.

RESULTS

A total of 984 eligible sedations were recorded, 635 by unsupervised residents and 349 by PEPs. A total of 512 (80.6%) sedations were performed by residents when attending physicians were not in the ED. The total adverse event rate was 24/984 (2.44%). When the two groups used a similar type drugs, residents had 8/635 (1.26%) events, compared to 11/328 (3.35%) by PEPs. There was no statistically significant difference in the rates of hypoxia or apnea between the two groups (p = 0.29 and p = 0.18, respectively). Adverse outcomes did not occur.

CONCLUSIONS

Unsupervised pediatric residents with training in patient safety during sedation performed procedural sedations with a rate of adverse events similar to that of PEPs.

Clinical Practice Advisory: Emergency Department Procedural Sedation With Propofol

We present an evidence-based clinical practice advisory for the administration of propofol for emergency department procedural sedation. We critically discuss indications, contraindications, personnel and monitoring requirements, dosing, coadministered medications, and patient recovery from propofol. Future research questions are considered.

The use of a pediatric emergency medicine-staffed sedation service during imaging: a retrospective analysis

HYPOTHESIS

A sedation service staffed by pediatric emergency medicine (PEM) physicians can sedate children during imaging, with a low adverse event risk and minimal sedation failures.

DESIGN/METHODS

We reviewed 1042 PEM-administered sedations during a 12-month period, collecting data regarding demographics, presedation evaluation, medications used, sedation length, adverse events, corrective measures, and postsedation disposition. Successful image completion without patient awakening defined effective sedation. Minor adverse events included hypoxia (<93%), malaligned airway, self-resolving transient bradycardia, and atypical reactions to sedation agents. Cardiorespiratory incidents requiring resuscitation were considered major events.

RESULTS

Of 923 sedation episodes, 92 (10.0%) experienced adverse events; 7 (0.76%) were major. Sedation failed in 17 (1.8%). No sedation resulted in an increased level of care or permanent injury.

CONCLUSIONS

A PEM-staffed sedation service provided sedation to children undergoing imaging with a low adverse event risk, minimal failures, and no residual morbidity. However, all sedating clinicians should possess critical airway skills.

Anesthetic and procedural sedation techniques for wound management

Emergency physicians come across a wide variety of painful conditions and perform a large number of uncomfortable procedures on a typical shift. This article describes the local anesthetic agents and their potential applications. The peripheral nerve blocks that are regularly done in the emergency department are described. Lastly, procedural sedation and analgesia are covered, to include general principles and specific agents for its use in the emergency department.

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

BACKGROUND

There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens.

METHODS

Patients were prospectively randomized to receive either midazolam/fentanyl (M/F) or midazolam/ketamine (M/K) i.v. The Children's Hospital of Wiscosin Sedation Scale was used to score the sedation level.

RESULTS

Fifty seven patients were studied (28 M/F and 29 M/K). Group M/F received midazolam (0.24 +/- 0.11 mg.kg(-1)) and fentanyl (1.68 +/- 0.83 microg.kg(-1)) and group M/K received midazolam (0.26 +/- 0.09 mg.kg(-1)) and ketamine (1.40 +/- 0.72 mg.kg(-1)). The groups were similar in age, weight, risk classification time and sedation level. Median total sedation times for M/F and M/K were 97 vs 105 min, respectively (P = 0.67). Minor complications occurred in 3.5% (M/F) vs 20.7% (M/K) (P = 0.03). M/F promoted a greater reduction in respiratory rate (P = 0.005).

CONCLUSIONS

In this study of nonventilated children in PICU undergoing central line placement, M/F and M/K provided a clinically comparable total sedation time. However, the M/K sedation regimen was associated with a higher rate of minor complications. A longer period of study is required to assess the efficacy and safety of these sedative agents for PICU procedures in nonintubated children.

Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry

OBJECTIVES

Emergency department procedural sedation practices for children have been reported for pediatric tertiary care centers. This report describes these same practice patterns and outcomes for community hospital-based general emergency physicians (EPs) in their treatment of pediatric patients.

METHODS

The Procedural Sedation in the Community Emergency Department registry is a prospective observational database composed of consecutive EP-directed procedural sedation cases in community hospitals. Information on sedation cases is collected at the time of the patient encounter and entered into an Internet-accessed database.

RESULTS

A total of 1028 procedural sedations were performed on 977 patients at 14 study sites, with 341 procedures performed in 339 patients younger than 21 years. The most common specified pediatric procedures performed included laceration repairs (n = 86, 25%), shoulder relocations (n = 78, 23%), and fracture care of the upper extremity (n = 56, 16%). Medications used included ketamine (n = 141, 41%), midazolam (n = 10, 32%), etomidate (n = 54, 16%), fentanyl (n = 51, 15%), and propofol (n = 47, 14%). Complications were reported in 2 cases (0.6%), 1 episode of apnea requiring a reversal agent and 1 episode of hypoxia responsive to supplemental oxygen. Of procedures attempted, 339 (99.4%) were successfully completed. Emergency physicians both directed the sedation and performed the procedure in 252 cases (74%), whereas in another 69 cases (20%), they directed the sedation for another physician performing the procedure. In 20 cases (5.8%), the EP directed sedation for a painless diagnostic study.

CONCLUSIONS

Community EPs in the Procedural Sedation in the Community Emergency Department registry deliver safe and effective pediatric sedation using a broad selection of agents.