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When children require painful or anxiety-provoking intervention in the emergency department (ED), procedural sedation is often considered. Procedures that may require sedation include orthopedic reductions, intravenous (IV) access, diagnostic imaging, suturing, and lumbar puncture (LP).
The American Academy of Pediatrics (AAP) outlines five indications for procedural sedation, as follows[1,2]:
Pediatric procedural sedation is safe to perform in the ED, but clinicians must be cognizant of, and prepared for, potential risks and adverse events, as well as be vigilant with appropriate monitoring and drug dosages.
Image of a child who suffered a dog attack courtesy of Cottom H, Tuopar D, Ameerally P. Case Rep Dent. 2011;2011:659756. [Open access.] PMID: 22567444, PMCID: PMC3335724.
Distractions
Distractions have been shown to improve a child's experience during a procedure as well as decrease pain and anxiety.[3-9] Tablets, smartphones, television, and music may be calming to a child. If he/she is developmentally appropriate, discuss the procedure with the child. Bubbles, books, play therapy, and guided meditation have also been proposed to reduce the amount of sedation required for a procedure and improve the patient's comfort. When using intranasal nitrous oxide, a variety of flavors are available and should be offered to the patient.[10]
If child life specialists are available, they should be included in patients' procedure and sedation planning.[11] If family members/guardians elect to stay with the child during a procedure, they should be instructed on appropriate discussion during the procedure: They should not attempt to bribe the patient, nor should they offer false reassurances such as "This won't hurt."[12]
Image of a boy with a smartphone who underwent stapling of a head wound without distress courtesy of Flickr/Juhan Sonin.
Parental presence
Several studies have demonstrated that parents prefer to remain at the bedside with their children during sedations and procedures.[13-16] They can serve as distractors for their children, as well as provide music or videos on their smartphones or tablets.[17] Moreover, parents may even be able to serve as an extra set of hands during the procedure.
However, some parents may increase anxiety in the child during a procedure and/or may become anxious and disruptive themselves. This situation can often be prevented by talking the parent through the procedure prior to starting it—although clinicians should feel comfortable asking parents to step out of the room if they are disrupting the sedation or the procedure.
Image of a mother with her 4-week-old infant and pediatrician Dr Elizabeth Hasert courtesy of the United States Department of Defense (USDOD), Defense Video Imagery Distribution System (DVIDS)/Sgt Christopher Gaylord, 5th Mobile Public Affairs Detachment.
Relevant patient and family history
When considering procedural sedation on a pediatric patient, clinicians must first obtain a thorough clinical history. The history of present illness (HPI) should include details such as the time of last oral (PO) intake and any medications received thus far for pain control or anxiety. The past medical history (PMH) must include any previous sedations and their outcomes, especially the occurrence of any previous complications.[1]
Factors that increase the risk for adverse events during pediatric procedural sedation include age younger than 6 months (greater risk for apnea), obesity, and higher American Society of Anesthesiologists (ASA) physical status classification. Clinicians should also inquire about asthma/reactive airway disease, recent history of an upper respiratory infection (URI), obstructive sleep apnea, previous airway surgery, congenital heart disease, altered mental status, and allergies.
In addition, obtain a family clinical history, with a focus on any relative's previous adverse reactions to anesthesia or sedation.
The images show preparation for ligation of a patent ductus arteriosus in a low birth weight premature infant.
Images courtesy of Metin K, Maltepe F, Kır M, Bilen C, Sokmen A, Oto O, Ugurlu B. J Cardiothorac Surg. 2012;7:129. [Open access.] PMID: 23234577, PMCID: PMC3541976.
Physical evaluation
A meticulous physical examination may provide other insights into the likelihood of success of a procedural sedation. Pay close attention to the stability of the patient's vital signs, features of their cardiopulmonary evaluation, and assessment of their airway.
The Mallampati score is used to assess a pediatric patient's airway and the potential for a difficult intubation in patients older than 4 years; however, its use is limited by patient cooperation,[18] and it cannot be applied reliably in children younger than 4 years.
Pertinent findings in the patient's medical history and physical examination should signal to the clinician that the child may be at increased risk for adverse events. Patients with an assumed higher risk for complications for procedural sedation should be considered for transfer to the operating room (OR) for sedation under the supervision of an anesthesiologist.
Image of a physician and child courtesy of Pixabay/Skeeze.
As in adults, mandatory fasting times have not been supported by large trials conducted about procedural sedation.[1] It is inappropriate to delay a medically emergent procedure on the basis of fasting time.[1,6]
A growing body of evidence suggests that the rate of aspiration during a procedural sedation is unaffected by the time of last PO intake. However, before performing procedural sedation, if feasible, the ASA suggests waiting 2-3 hours after a patient's last meal for clear liquids (children and adults) and 4-6 hours for solids and nonclear liquids in children younger than 6 months (6-8 hours for solids/nonclear liquids for those aged >6 months).[2,19,20] Thus, 2 hours is the minimum recommended fasting period for clear liquids, 4 hours for human milk, and 6 hours for infant formula, nonhuman milk, and light meals (eg, toast and clear liquids).[19,20]
The use of ketamine as the sedative agent has been shown to increase the patient's risk of vomiting; however, pretreatment with an antiemetic medication (eg, ondansetron) mitigates this risk.[21] (Although IV ondansetron appears to be more effective than the PO formulation in this setting.[22]) If a clinician highly suspects that the patient will vomit during the sedation, propofol may be considered as an alternative to ketamine, as it has a much lower chance of causing emesis.[23]
Image courtesy of Wikimedia Commons/Intropin.
Preparation of the procedure room prior to initiating any pediatric procedural sedation is critical. Continuous cardiac monitoring and pulsoximetry of the patient should occur before, during, and after the procedure. Check the blood pressure every 3 minutes during the procedure.
Equipment required to manage the patient's airway, breathing, and circulation must be available and easily accessible. This includes supplemental oxygen, suction tools, bag-valve-mask apparatus, oral and nasal airways, and a pediatric "code cart."[23]
Keep in mind that anatomic differences between children and adults places children at higher risk of airway obstruction and makes their airways more difficult to manage. Physicians and nurses skilled in pediatric airway management should be present during a pediatric sedation, and back-up airway adjuncts, including laryngeal mask airways (LMAs) and a needle cricothyrotomy kit, must be available.[2]
Image courtesy of USDOD, DVIDS/Petty Officer 1st Class James Stenberg, Naval Hospital Pensacola.
Carefully monitor the pediatric patient's respiratory status during all sedations, as respiratory depression and apnea are among the most serious adverse events that may occur with sedative medications.
Previously, monitoring chest rise and oxygen saturation was all that was required for tracking respirations. However, end-tidal carbon dioxide (EtCO2) monitoring/capnography is the current standard of care during pediatric procedural sedations.[24] Capnography allows physicians to identify hypoventilation and apnea before desaturation occurs,[25] as well as monitors respiration in situations in which other means of assessing ventilation, including watching chest rise, are limited, such as when patients are within magnetic resonance imaging (MRI) machines.[2]
Many EDs supply nasal cannulas that allow simultaneous delivery of oxygen and measurement of EtCO2. The numeric value provided by the capnometer is not as important as the provided qualitative data that assess whether or not the child is ventilating.[2]
Example of a capnogram courtesy of Wikimedia Commons/Rschiedon.
Some young patients will present with severe pain to the ED. Although PO medications such as ibuprofen and acetaminophen are useful for alleviating mild to moderate pain, these drugs require the child's cooperation for administration. Furthermore, quick IV access may be difficult to obtain in a suffering child.
Intranasal administration
Intranasal application of analgesic or anxiolytic medications allows for fast and easy administration, and it has been shown to provide reliable effects.[26] Before administration, instruct the child to take a deep breath as if trying to smell a flower.
However, avoid using intranasal agents in patients with congested nasal passages, as their absorption will be reduced. When possible, use concentrated preparations of the medications to decrease the volumes necessary for the doses. Administration in both nostrils increases the available surface area for absorption and decreases run-off.
Image of an intanasal Mucosal Atomization Device (MAD) courtesy of Buonsenso D, Barone G, Valentini P, Pierri F, Riccardi R, Chiaretti A. BMC Pediatr. 2014;14:67. [Open access.] PMID: 24598046, PMCID: PMC3974003.
Nitrous oxide
The availability of nitrous oxide for pediatric sedation is increasing. This intranasal or nebulized medication provides fast, reliable anxiolysis and pain control. Thus, it is an appropriate sedative of choice for laceration repairs, IV access, urine catheterization, foreign body removal, and fracture reduction.[27] Nitrous oxide has also been used to aid the performance of wound examination, abscess drainage, and joint aspiration.[28] Some studies have shown nitrous oxide to be as effective as IV ketamine—but with the added bonus of a faster recovery time.[29,30]
Nitrous oxide is administered via nebulizer and is dosed by percentage concentration with oxygen. The base dose is usually 50% (50:50), but it can be titrated to adjust the depth of sedation (to a maximum dose of 70% [ie, 70:30]).[1,31]
Side effects include vomiting, headache, dysphoria, and restlessness.[1] Nitrous oxide should not be used in patients with pneumothorax, bowel obstruction, or middle ear disease, as it rapidly diffuses and expands into air-filled regions, thereby increasing the pressure in enclosed areas[30]; this gas is also contraindicated in patients with altered mental status (it can itself cause changes in mental status) or suspected head injuries (to avoid increasing intracranial pressure [ICP]).[32]
Image of a jet nebulizer hand unit courtesy of Praveen Buddiga, MD.
Ketamine
Ketamine has become increasingly popular for use in pediatric procedural sedation in the ED; it is effective for short, painful procedures. Ketamine provides sedation, amnesia, and analgesia in a single agent, whereas other medications such as propofol provide only amnesia and sedation.[33,34] This drug is also valued for its preservation of patients' airway reflexes, maintenance of spontaneous respirations, and cardiovascular stability.[34,35] Ketamine should be dosed at 0.5 mg/kg intramuscularly (IM) or 1.0 mg/kg IV to reach a dissociative state.[36]
Contraindications to pediatric sedation with ketamine include age younger than 3 months, current respiratory infection, history of airway instability, and known or suspected schizophrenia.[30] Previously, ketamine was discouraged in patients with suspected elevated ICP; however, more recent studies suggest ketamine may not actually affect ICP.[30,33]
Image courtesy of Wikimedia Commons/Psychonaught.
Midazolam and/or fentanyl
Midazolam has been a popular choice for pediatric sedation, but other agents (eg, ketamine) are likely to be more safe and effective. This drug has been thoroughly investigated; most studies have concluded that midazolam alone is unlikely to provide satisfactory sedation.[37] It also does not have any analgesic effects[35] and thus is frequently administered with fentanyl, ketamine, propofol, or nitrous oxide, but these combinations increase the risk of respiratory depression, apnea, laryngospasm, bradycardia, and hypotension.[37]
Fentanyl is an opiate medication that can be administered IV or intranasally for the fast onset of pain relief. Previously, fentanyl was frequently combined with midazolam to provide anxiolysis and analgesia; however, this procedural cocktail is no longer recommended owing to the increased risks of hypoventilation and apnea.[26,30]
Image courtesy of Wikimedia Commons/James Heilman, MD.
Propofol
Propofol is another popular medication for pediatric sedation because it is short acting and provides deep sedation.[37] This agent should be dosed at 0.5-1 mg/kg IV, administered as a slow push to decrease the risks of hypotension and pain with injection.[38]
Keep in mind that propofol, like midazolam, lacks analgesic properties and should be combined with a pain-relieving agent such as fentanyl.[35] Adverse events are generally uncommon with this drug and include hypotension, hypoxia, apnea, and unplanned intubation.[35,37] The risk of subclinical respiratory depression appears to be higher in patients sedated with ketamine as compared to those administered propofol.[39]
Previously, clinicians were cautioned not to administer propofol to children with egg or soy allergies owing to the potential for anaphylaxis with this medication (propofol contains soybean oil and egg lecithin[40]). However, more recent studies and the American Academy of Allergy, Asthma & Immunology have indicated that propofol may be considered as generally safe in these children.[40-43]
Image courtesy of Wikimedia Commons/John Oyston.
Lumbar puncture is a procedure that frequently requires pain control and sedation in the ED. For infants younger than 6 months, sucrose been an effective sedative and pain control agent.[44] Sucrose is much safer than sedative medications and should therefore be used as a first-line agent in this population.
For children older than 6 months, use distraction plus intranasal midazolam. Note that the patient's neurologic examination will likely be altered after administration of this sedative agent; therefore, perform a thorough neurologic assessment prior to sedation. Moreover, as noted earlier, although intranasal midazolam provides the amnesia and anxiolysis required for the lumbar puncture, it does not provide analgesia.[35] Thus, for pain control during lumbar puncture, consider the use of topical lidocaine.
Topical lidocaine 4% has a peak effect within 30 minutes of application.[45] Topical EMLA cream (2.5% lidocaine:2.5% prilocaine) has also been associated with increased procedure success rates.[46] The combination of topical lidocaine and distraction may potentially eliminate the need for systemic sedation.[46]
Images of lumbar punctures in progress in an infant and child, respectively, courtesy of Wikimedia Commons/Bob J Galindo (left) and Marec-Berard P, Bissery A, Kebaili K, et al. BMC Cancer. 2009;9:21. [Open access.] PMID: 19146666, PMCID: PMC2651181 (right).
Postprocedural sedation management is as important as preparation before, and monitoring during, the procedure. Clinicians must know the expected duration of action for each drug used, as well as ensure that the child has returned to his/her baseline condition before discharging the patient home. Thus, the child should remain on cardiac monitoring and pulsoximetry until he/she is awake and alert. Clinicians should document when the patient returns to normal consciousness and normal oxygen saturation without supplemental oxygen.
Prior to discharge, the child should be able to walk independently (if developmentally appropriate and barring any existing ambulatory dysfunction), drink fluids without vomiting, and be in the charge of a responsible caregiver who can closely monitor the patient at home.[2] Several validated assessment tools are available to evaluate whether a postprocedural sedation patient is ready for discharge. In addition, parents/guardians should be provided with comprehensive postsedation discharge instructions prior to leaving the ED.
Image of a clinician recording the postprocedure temperature of a 4-year-old child courtesy of United States Navy/Mass Communication Specialist 3rd Class Laurie Dexter.
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