Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedural Sedation in the Pediatric Emergency Department

BackgroundFasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status.ObjectivesThe goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions.MethodsRetrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events.DiscussionThere was a significant difference in the length of stay and time from admission to sedation—both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups.ConclusionsLength of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.     

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 ≤ 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.     

A Clinical Trial of Propofol vs Midazolam for Procedural Sedation in a Pediatric Emergency Department

OBJECTIVE: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). METHODS: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded. RESULTS: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). CONCLUSION: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.     

Pediatric Procedural Sedation for Radiologic Procedures: A Pilot Program

Pediatric procedural sedation is a growing discipline that strives to meet the demand for effective and safe management of the pain and anxiety associated with health care. Most formal sedation programs geared for children are at large academic centers. In this article, we describe the development of a pediatric sedation program for imaging studies at a community hospital in Baltimore, Maryland. Recognizing the problem of inadequate pain and anxiety control among pediatric patients presenting for care, we identified ways to maximize the resources available to us and established a multidisciplinary team providing graded care for pediatric patients presenting for routine imaging studies. The program has been met with enthusiasm by both staff and families.     

Adverse Events Associated with Procedural Sedation and Analgesia in a Pediatric Emergency Department: A Comparison of Common Parenteral Drugs

Objectives: To compare the frequency and severity of adverse events associated with parenteral drugs commonly used for procedural sedation and analgesia (PSA) in a pediatric emergency department. Methods: A database of consecutive patients receiving parenteral PSA was prospectively generated with the intent of monitoring safety in the emergency department. Data were logged onto a dedicated sedation sheet. A retrospective analysis was performed; comparisons were made based on sedation drugs used. Results: A total of 2,609 patients from June 1, 1996, to September 16, 2003, received PSA by emergency physicians. Patients who received PSA nonparenterally (n= 109) were excluded. A total of 2,500 patients (2,279, intravenous; 221, intramuscular) remained for analysis. Age range was 19 days to 32 years (median, 6.7 years). A total of 1,511 (60.4%) were male. Four major drug combinations were identified: ketamine alone (n= 1,492; 59.7%), ketamine/midazolam (n= 299; 12.0%), midazolam/fentanyl (n= 336; 13.4%), and midazolam alone (n= 260; 10.4%). A total of 113 patients (4.5%) received various other combinations of drugs. A total of 458 adverse events were observed in 426 patients (17%). Respiratory adverse events occurred as follows: ketamine alone, 91 patients (6.1%); ketamine/midazolam, 30 patients (10%); midazolam/fentanyl, 65 patients (19.3%); midazolam alone, 15 patients (5.8%). Vomiting occurred as follows: ketamine alone, 151 patients (10.1%); ketamine/midazolam, 16 patients (5.4%); midazolam/fentanyl, six patients (1.8%); midazolam alone, two patients (0.8%). Conclusions: Drug types used in pediatric PSA are associated with different adverse event profiles. Patients receiving ketamine with or without midazolam experienced fewer respiratory adverse events but more vomiting than the commonly used combination of midazolam and fentanyl. Adverse events may occur in any patient receiving parenteral PSA.     

Procedural Sedation of Critically Ill Patients in the Emergency Department

Objectives: Procedural sedation is routinely performed in the emergency department (ED). However, some authors believe it is unsafe in nonintubated, critically ill patients. The objective of this study was to determine the safety of ED procedural sedation in the American Society of Anesthesiologists (ASA) physical status classification P3 and P4 patients. Methods: This was a prospective observational study of patients undergoing procedural sedation in the ED between August 2002 and December 2003 who were classified as ASA physical status score P3 or P4. Patients received either propofol or etomidate at the discretion of the treating physician before their painful procedure. Doses, vital signs, end‐tidal CO₂ (ETCO₂) by nasal cannulae, and pulse oximetry were recorded. Respiratory depression (RD) was defined as a change from baseline ETCO₂ >10 mm Hg, an oxygen saturation of < 90%, or an absent ETCO₂ waveform at any time. Results: Sixty‐two critically ill, nonintubated patients were enrolled. Thirty‐one patients received propofol, and 31 patients received etomidate. No cardiac rhythm abnormalities were detected. RD was seen in 37 of 62 patients (59.7%): 19 of the 31 (61.3%) who received propofol and 18 of the 31 (58.1%) who received etomidate. The mean decrease from baseline systolic blood pressure was 11.3% (95% confidence interval [CI] = 7.3% to 15.5%): 5.0% (95% CI = 3.0% to 8.1%) for those receiving etomidate and 17.1% (95% CI = 9.9% to 24.3%) for those receiving propofol. No adverse events were reported. Conclusions: The rate of subclinical RD detected by these criteria was similar to previous reports for noncritically ill patients. Procedural sedation of nonintubated ASA physical status score P3 and P4 patients in the ED with either propofol or etomidate appears to be safe.     

Repeat Intravenous Ketamine Dosing in Children Undergoing Emergency Department Procedural Sedation

Background

Patients undergoing procedural sedation with intravenous ketamine often receive repeat doses to maintain dissociation; however, data between doses are lacking.

Effectiveness of Procedural Sedation and Analgesia in Pediatric Emergencies. A Cross-Sectional Study

IntroductionPain is defined as an unpleasant emotional and sensory experience associated with bodily harm or with situations that cause fear and anxiety. However, it is often undertreated in pediatric emergency departments. This study aims to assess the effectiveness of sedation-analgesia techniques, level of satisfaction among health care professionals and relatives, and agreement between the satisfaction of health care professionals and relatives.MethodsA cross-sectional design was conducted. Sociodemographic and clinical variables were recorded, together with those for effectiveness using the Face, Legs, Activity, Cry, and Consolability scale and the Wong-Baker FACES scale, and the satisfaction using the 10-point Likert scale. Stata 16.1 was used for data analysis.ResultsA total of 94 procedures were registered. The results suggested that these techniques were effective or mildly effective in only half of the cases. Satisfaction was considered good across the board, and the agreement between health care professionals (ie, pediatric nurses and pediatricians) was considered substantial. However, the agreement between health care professionals and relatives was moderate.DiscussionOur results suggested that the adequate management of pain in pediatric emergency departments is still a challenge, despite the availability of international guidelines. Future research lines should be focused on analyzing possible causes of the inefficacy of some sedation-analgesia techniques and the causes of the differences between the perspectives of health care professionals and relatives. These research lines may be useful to improve quality of care and pediatric patient comfort.