An Evidence-Based Approach To Pediatric Procedural Sedation

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Definitions
6. Goals Of Sedation
7. Emergency Department Presedation Evaluation And Preparation
   1. Preoperative Fasting
   2. Personnel
   3. Equipment
   4. Monitoring
   5. Vascular Access
   6. Discharge Criteria
8. Analgesic Medications
   1. Topical Agents
      1. LET:
      2. EMLA:
      3. Lidocaine
   2. Systemic Agents
      1. Nonopioids
         • Acetaminophen (APAP, Paracetamol)
         • Ibuprofen
      2. Ketorolac
      3. Opioids
         • Morphine Sulfate
         • Fentanyl Citrate
   3. Sedative/Hypnotic Agents
      1. Midazolam
      2. Barbiturates
         • Methohexital
         • Thiopental
         • Pentobarbital
      3. Propofol
      4. Ketamine
      5. Inhaled Nitrous Oxide
9. Summary
10. Risk Management Pitfalls In Pediatric Procedural Sedation
11. Case Conclusion
12. Clinical Pathway For Choosing The Proper Sedation Agent
13. Tables and Figures
    1. Table 1. American Society of Anesthesiologists Patient Classifications
    2. Table 2. Dosing, Onset, And Duration Of Procedural Sedation Medications
    3. Appendix A. Sample Procedural Sedation Preparation Checklist
14. References

Abstract

Children present a unique challenge when it comes to procedural sedation in the emergency department. For pediatric patients, sedation may be required to facilitate cooperation during a procedure that would not typically require sedation in an adult patient. The amnestic, anxiolytic, and analgesic properties of procedural sedation agents must be weighed against their potential side-effect profiles. The ideal agent should have a favorable safety profile, be quick and easy to administer, provide adequate length and depth of sedation, and result in a relatively rapid return to baseline. An evidence-based evaluation of various agents of procedural sedation is presented in this review.

Case Presentations

A 3-year-old girl with a history of reactive airway disease is brought into the ED by her father. She has sustained a fall that resulted in a small frontal hematoma and a deep, jagged chin laceration. The father states that there was no loss of consciousness and no vomiting at the time of the event, which was 1 hour prior to her arrival to the ED. The father is concerned about her head injury and also inquires about the repair of the cut. Your examination reveals a very anxious child with a chin laceration that is fairly deep and may require extensive repair. You begin to consider sedation. You inquire about her last meal, and the father states that she had a light dinner about 4 hours prior to their arrival. He asks about the relevance of her last meal. You begin to explain that his child may need sedation and try to answer all of his questions. Which sedative will you use? What are the side effects? How long will it last? Is it absolutely necessary? Does it matter that she sustained a head trauma earlier today? Will she need an IV prior to the procedure? How long will it take for her to return to her normal self?

Introduction

Historically, pain and anxiety in the pediatric population has been undermanaged. Some of the reasons for the undertreatment of pain can be attributed to children’s inability to quantify or qualify their pain. Other factors are attributed to the unfamiliarity of medical personnel with the different available agents for pain management and fear of their adverse side effects.^1-4

Nonpharmacologic interventions should always be considered when approaching a child who requires a diagnostic or therapeutic procedure. The developmental stage of the child should always be considered when choosing a proper pharmacologic or nonpharmacologic intervention. A child’s perception of pain is influenced by age, cognitive level, and past experiences of painful episodes. It is also very important to remember that a child’s reactions are often based on the reaction of his or her parents. Involving the parents can ease their concerns and help calm the patient.⁵

Critical Appraisal Of The Literature

An extensive literature search was performed in the PubMed database using multiple combinations of the search terms procedural sedation, conscious sedation, pediatric analgesia, pediatrics, emergency department, and side effects. All relevant articles were selected, reviewed, and included in the bibliography. Over 125 articles were reviewed, 68 of which are cited in this article. Emphasis was placed on reviewing the most recent reports, studies, and guidelines.

Risk Management Pitfalls In Pediatric Procedural Sedation

1. “There is no reason to call a child life specialist. We are going to have to sedate this child.” A child life specialist can be extremely helpful in calming the child and alleviating the anxiety of the parent. Sedation may still be necessary in certain cases, but a child life specialist should always be involved to help aid in the process.
2. “The ED is too busy to wait for the LET to work.” Waiting for the LET to take effect can diminish the need for local infiltration of lidocaine, especially for smaller lacerations, and can significantly diminish the pain and anxiety associated with laceration repair.
3. “I have done many sedations. I can handle doing the sedation and the procedure itself.” There should be a separate, dedicated provider (medical doctor or certified registered nurse anesthetist) for the procedural sedation, along with a nurse or a respiratory therapist to properly record vitals and administer the medication.
4. “The nurse cannot find an ETCO2, so we’ll just use the pulse oximeter.” ETCO₂ has been shown to be more effective at demonstrating decrease in ventilation and should be used during sedations. The room should also be prepared with other equipment in case resuscitation or an advanced airway is necessary.
5. “NPO status is very important and cannot be ignored, even if the procedure is emergent.” When evaluating a patient for an emergent sedation, NPO status needs to be address in the following manner: First, assess the patient’s baseline risk factors. Second, access the timing and nature of recent oral intake. Third, access the urgency of the procedure. Fourth, determine the prudent limit of targeted depth and length of procedural sedation and analgesia. When it is necessary to perform an emergent procedure, one should proceed regardless of the patient’s NPO status.
6. “This patient previously received analgesics and makes a poor candidate for sedation.” Previously receiving analgesics is not a contraindication to procedural sedation as long as proper monitoring, equipment, and drug doses are used.
7. “I used propofol, but I didn’t know this child had an egg allergy.” Propofol is contraindicated in any patient with known or suspected allergy to propofol, eggs, or soy products. Proper history and physical examination should be obtained in all patients prior to proceeding with the procedural sedation. An allergy history is especially important.
8. “This child needs a CT scan. I’m going to use ketamine since I’m very comfortable with that medication." Ketamine is not an ideal medication for radiographic imaging since the child may still move quite a lot. Pentobarbital may be a more preferable choice, since its onset of action is quick and the duration of sedation is short.
9. “The child’s initial IM ketamine dose wore off prior to the orthopedic surgeon being done with the procedure." Although an IV catheter is not necessary with all procedural sedations, it must be anticipated if more than 1 dose will need to be administered or if the case may present other difficulties. If more sedation is required, an IV can be placed after the initial sedation, although it is preferable before.
10. “It’s the middle of the night. Since this child is now sleeping, I’m fairly certain there is no need to wait for the sedation medication to wear off.” Although it can be difficult to assess, the patient should always be observed to return to baseline status. The parents should be encouraged to wake the child up for an evaluation prior to being discharged from the ED.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative

references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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