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.
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?
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
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.
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.
Inna Elikashvili; Adam E. Vella
August 1, 2012