Introduction
Pain and anxiety are common problems in the emergency department (ED). By relieving pain, the emergency provider faces a less anxious and more cooperative child. This, in turn, may result in a better outcome. The fear, anxiety, and developmental stage of a child contribute to his or her ability to cooperate with necessary procedures. Failure to cooperate is likely to result in a suboptimal outcome.
This article's objectives are (1) to discuss indications for and goals of sedation in children, (2) to emphasize proper preparation and monitoring during procedures, and (3) to discuss methods of drug administration and specific agents.
Commonly held myths regarding children and pain management are as follows:
- Children's immature CNS cannot experience pain.
- Children have no memory of pain.
- A given injury elicits a "correct" amount of pain.
- Children easily become addicted to opioids.
Truths regarding children and pain management are as follows:
- Even neonates demonstrate behavioral and hormonal changes in response to painful procedures.
- Children do not have to understand the meaning of pain to experience pain.
- Preemptive analgesia/anesthesia may decrease postinjury opioid requirements.
- A child is likely to require deep sedation in many instances in which an adult requires minimal or no sedation.
Various individual internal and external factors determine how a child responds to painful procedures; therefore, individualized dosing and titratable agents are often necessary.
Internal factors include the child's age, developmental level, and previous experience. Some children have had previous unpleasant experiences at the hospital and are difficult to manage long before any noxious stimuli occur. These children require sedation when others the same age may not.
External factors have as much, if not more, influence on a child's behavior. These include parental interactions with the child, preparation, clinician skill, and the physical setting where the procedure is performed. Spending a few minutes preparing the anxious child for a procedure is always in the practitioner's best interest. Attempting to build trust and being honest about what will and will not hurt may go a long way to ensure cooperation.
Historical perspective
Pain in children historically has been underreported, undertreated, and misunderstood. Until recently, children too young to verbalize were believed too young to experience pain or fear, and they often received no analgesia even after major surgery. Fortunately, more recent research has documented that even neonates show a physiologic response to painful stimuli. In addition, research has shown that children fail to receive the same treatment as adults with similar painful conditions. Age is apparently a risk factor for oligoanalgesia.
Unfortunately, the current practice of many EDs is not standardized. Many centers and practitioners do not use premedication for painful procedures. Reasons for inadequate treatment include failure to recognize pain, ignorance about drugs and dosages, fear of adverse cardiovascular effects, and fear of delay in treatment and disposition.
Considerations
Various factors must be considered when deciding to premedicate a child who will undergo a procedure. The child's age, developmental level, temperament, and previous experiences must be assessed. The location, size, and complexity of the wound partially determine the need for sedation.
Analgesia, anesthesia, and sedation are not synonymous. Anesthesia may include the following components: (1) analgesia, (2) sedation, (3) amnesia, and/or (4) muscle relaxation.
Sedation is a continuum. Conscious sedation (ie, the patient remains awake) may lead to deep sedation, which, in turn, may lead to general anesthesia, which may lead to cardiorespiratory compromise and loss of airway protective reflexes.
Terminology
Terms to describe sedation are not uniform. Many health care providers practice pediatric sedation. They come from the fields of emergency medicine, anesthesiology, intensive care medicine, and radiology. The American College of Emergency Physicians (ACEP), American Academy of Pediatrics (AAP), and American Society of Anesthesiology (ASA) have established guidelines. Hence, a potential for different practice models exists.
In April 2009, the Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Care Applied Research Network (PECARN) published recommendations for standardizing terminology and reporting adverse events that involve procedural sedation and analgesia in children.1 These recommendations will help guide monitoring and quality assurance of pediatric procedural sedation in emergency departments.
The new recommendation was based upon a systematic review of the literature. The standardization of terminology and definition of adverse reactions were reached by consensus. An adverse reaction was defined as an event that required intervention from the physician. An adverse reaction had occurred when the physician acted upon specific event(s), such as respiratory compromise, vomiting, cardiovascular compromise, excitatory movements, adverse behavioral reactions, or permanent complication.1
For the purpose of the ED practitioner, the term procedural sedation is the most appropriate. Previously used terms such as conscious sedation and moderate sedation are misnomers.
Procedural sedation is the administration of sedative or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness that allows the patient to maintain airway control independently and continuously. Specifically, the drugs, doses, and techniques used are not likely to produce a loss of protective airway reflexes.
Preparation for Sedation
The length of procedure, duration of effect, and potential for the medication's side effects dictates decisions regarding the type and route of medication. In addition, the setting in which the medications are used play a role in the decision-making process. Customizing the choices is important.
Most analgesics and sedatives in children have a range of acceptable doses, and the emergency practitioner may prefer to start with the lowest recommended dose (or even half that) and titrate as needed. Reversal agents, when available, should be kept at the bedside, and their proper doses should be double checked.
Discussion about the risks, benefits, and alternatives with the parent or guardian is necessary prior to initiation of procedural sedation. Documentation of this discussion is reflected in the table below. Having written consent is not absolutely needed. The Joint Commission on Accreditation of Healthcare Organizations (JACHO) has not set forth a requirement. The need for written consent may be determined by an institutional, local, or state mandate.
Recommendations for nothing by mouth (NPO) prior to elective procedures exist. This is to prevent aspiration secondary to delayed gastric emptying. Both the AAP and the ASA have issued the following recommendations:
Open table in new window
| Age, mo | Solid and Nonclear Liquids*, h | Clear Liquids |
| <6 | 4-6† | 2 |
| 6-36 | 6 | 2 |
| >36 | 6-8‡ | 2 |
*Infant formula, breast milk, nonhuman milk.
†Four hours according to the AAP guidelines.
‡Eight hours according to the AAP guidelines.
Adapted from Ann Emerg Med. 2003;42:636-646.2
The above recommendations are based on expert opinions. The risk for aspiration is low from pooled general anesthesia data. No reported cases exist of aspiration arising from the ED. Thus, the best course of action is based on the risk and benefits of the procedure and sedation for the patient.
The problem of aspiration and adverse outcome secondary to delayed gastric emptying has not been borne out. The AAP and ASA have issued a guideline, based on age and the type of ingested liquids or solids. The final decision to proceed is determined by the necessity of the procedure. Just as important, delaying or aborting a procedural sedation is dictated by risk to the patient. Proceed forward, assuming the patient has a full stomach. Several recent articles have tried to address NPO status for emergency department patients undergoing procedural sedation; no conclusions can be drawn other than adverse events are extremely low regardless of NPO status, and risk is more related to the depth of sedation.
It is prudent to expect the worst and to have suction and airway equipment at the bedside and ready to use in the rare instance that it becomes necessary. Equipment should include the appropriately sized positive pressure oxygen delivery system, suction apparatus, and appropriate suction catheters (eg, tonsil, Yankauer). Age-appropriate equipment for measuring blood pressure and oxygen saturation should be available, and continuous oxygen saturation monitoring is recommended. A crash cart with age-appropriate drugs and equipment should be readily available.
Note that the above recommendations refer only to medications administered with the goal of sedating a child. Medication used for the sole purpose of analgesia (eg, a narcotic alone) should not require the continuous presence of nursing staff or continuous oxygen saturation monitoring.
Indications for Emergency Department Sedation
The function of sedation is management of anxiety, pain, and control of excessive motion.
Diagnostic procedures include the following:
- Lumbar puncture
- Arthrocentesis
- Bone marrow biopsy
- Sexual assault examination
- Radiologic evaluation (CT, MRI)
Therapeutic procedures include the following:
- Suturing
- Wound care
- Abscess incision and drainage
- Fracture reduction
- Dislocation
- Foreign body removal
- Burn debridement
- Tube thoracostomy
- Any other painful procedure
Treatment Considerations
Analgesia and sedation should be appropriate for the degree of insult. Although the medication dose is calculated based on weight, the response can vary significantly from one child to the next. Flexibility and careful titration are crucial.
Pharmacologic considerations
Drug absorption, distribution, and elimination can vary with age. Water comprises 70% of neonates' body weight, compared to 55% in adults. Lipid versus water solubility alters the distribution of agents used. In addition, renal and hepatic elimination improve with age.
Political considerations
Use of anesthetic agents in the ED continues to be an issue at many institutions. To minimize controversy, it is advantageous to anticipate and manage adverse reactions. Many problems can be avoided if individuals with advanced airway skills are immediately available, skilled personnel are present to monitor the patient, appropriate monitoring devices are used, and written policies and procedures are in place. Many hospitals have a credentialing process that helps to ensure knowledge of the procedure. In many institutions, the ED pharmacopeia is restricted, and specific agents (eg, ketamine, propofol) are unavailable or are approved for use only by anesthesiologists.
Safety considerations
Safety during pediatric sedation has been an increasing topic of interest in the emergency department. Studies have shown that the incidence of adverse events with proper preparation and planning is low. The incidence of adverse events has trended downward with the implementation of JCAHO's guideline in 2001 at one institution. While most studies were performed in academic centers, similar findings were found in the community-based emergency departments in one study.
The most common reasons for adverse events are operator error, lack of familiarity with agents being used, lack of rescue systems, and delay in airway and ventilatory support.
Guidelines established by the ACEP, AAP, and ASA evaluate the risk of procedural sedations by assessing key elements of the history and physical. Adherence to these guidelines has lowered the risk of complications. Another component is division of responsibilities of the personnel. Distinct personnel need to be responsible for sedation, monitoring, and performing the procedure.
Even with the risk of aspiration, the risk is low (with pooled data gathered from pooled anesthesia data). Aspirations occur primarily during intubation and extubation. These two events are unlikely events during emergency department procedural sedation.
Other considerations for adverse events are incorrect dosage calculations and failure to recognize potential drug interactions. One of these reactions is between fentanyl and midazolam. An increase in the respiratory depressant effect occurs. The use of 3 or more medications significantly increases the possibility of an adverse reaction.
Preparing for Sedation
An evaluation of a patient for procedural sedation begins with a thorough history and physical.
Important elements of the history are as follows:
- Past medical history, especially prior sedation/anesthesia history
- Last solid and liquid PO intake
- Recent illness
- Medication or drug use
- Allergies or adverse reaction
- Pertinent family history
- Pregnancy status (for postmenarche females)
- Upper respiratory infection (URI) symptoms, history of reactive airway disease
Elements of the physical examination are as follows:
- Age
- Weight
- Vital signs
- Airway examination (head, ears, eyes, nose, and throat [HEENT] and pulmonary examination)
- Cardiovascular examination
- Neurologic/mental status
- Size and location of injury and neurologic status distal to it
The physical examination is focused on the airway, especially for anatomical variations. Assessment, using the Mallampati classification, identifies potentially difficult airway management.
The use of ASA Physical Status Classification was developed for patients undergoing general endotracheal anesthesia. This classification stratifies the risk of complication from a procedural sedation. Class I and II patients are best candidates for general endotracheal anesthesia. Whether this classification can be accurately extrapolated for procedural sedations in the ED is unknown.
- I. Normal healthy patient
- II. Patient with mild systemic disease
- III. Patient with severe systemic disease
- IV. Patient with severe systemic disease that is constant threat to life
- V. Moribund patient not expected to survive without operation
- E. Emergent procedure
However, the existence of a preexisting physical or psychological condition is not an absolute contraindication for procedural sedation. Rather, it should help guide the clinician for careful selection of type and route of medication(s).
Laboratory workup has no role prior to procedural sedation.
Monitoring
Monitoring during the procedure usually should include the following:
- Maintain continuous oxygen saturation and heart rate monitoring.
- Record vital signs and blood pressure every 15 minutes for conscious sedation and every 5 minutes for deep sedation.
- Record drug dose and time administered.
- Record state of consciousness and response to stimulation.
- Consider end-tidal CO2 monitoring.
- Noninvasive methods to monitor patients in the operating room have been investigated as alternatives or adjuncts. These two methods are capnography and bispectral index monitor. Capnography measures end-tidal carbon dioxide concentration during ventilation. It identifies hypoventilation and apnea at an earlier stage. Bispectral index monitoring measures the depth of sedation from electroencephalographic signals.
Medication
Opioid analgesic agents
These agents are frequently used to control pain. They may be used as single agents or in combination with sedative/anxiolytic agents. In some scenarios, they can be used as hypnotic agents; however, the risk of respiratory depression is greater with this use. The analgesic effect occurs at the mu opioid receptor. Other opioid receptors (eg, kappa, delta) have been implicated in other effects (ie, some sedation and no amnestic properties). These effects are dose-related. When using opioid analgesics, a reversal agent should be readily available. Naloxone (Narcan) is an opioid reversal agent that can be administered as 0.1 mg/kg IV, IM, SC, ET q2-3min until response for children 5 y or younger or weighing £ 20 kg. Naloxone's dose for children older than 5 y (or weighing >20 kg) is 2 mg IV, IM, SC, ET q2-3min until response. Naloxone's half-life is 1-2 h. Rebound sedation and apnea may occur.
Morphine sulfate
Indicated for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Elicits analgesia, possesses some sedative effect, but has no amnestic properties. Peak effect observed 15-30 min following IV administration and 30-60 min following IM.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Pediatric
Procedural analgesia and sedation: 0.08-0.1 mg/kg/dose IV/IM/SC before procedure and q5-10min prn
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, bronchospasms secondary to histamine release, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Fentanyl (Sublimaze)
A synthetic opioid that is 75-200 times more potent and much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure. Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Onset of action is immediate following IV administration. Easily and quickly reversed by naloxone.
Adult
Induction: 2-3 mcg/kg/dose slow IV push (over 1-2 min)
Pediatric
<6 years: 0.3-1.5 mcg/kg/dose slow IV push (over 1-2 min); may repeat q1-2h
>6 years: 1-5 mcg/kg/dose slow IV push (over 1-2 min); may repeat dose IV q1-2h (dosage range varies 1-10 mcg/kg/dose)
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome (associated with doses above 15 mcg/kg and given as rapid bolus), may require neuromuscular blockade in order to increase ventilation; these adverse reactions are partially reversed by naloxone but may require administration of a muscle paralytic and intubation
Benzodiazepines
This class of medication is used as sedative-hypnotic agents. They have anxiolytic, amnestic, and skeletal muscle relaxant properties. However, they do not have any analgesic properties. Exert effects on GABA receptors and potentiate GABA neuron inhibitory actions as well as chlorine channel opening and postsynaptic neuronal hyperpolarization. Midazolam is commonly used because of its short half-life and prompt onset of action. Diazepam may be given but has a long half-life and active metabolites. Lorazepam is a poor choice for procedural sedation because of its long duration of action. The benzodiazepine reversal agent is flumazenil (pediatric dose is 0.01-0.02 mg/kg IV, may repeat every min to maximum cumulative dose of 1 mg). Flumazenil can precipitate seizures in patients who ingested TCAs or have chronic benzodiazepine use.
Midazolam (Versed)
Favored in procedural sedation as a sedative-hypnotic agent because its water solubility allows versatile routes of administration (eg, PO, IV, IM, intranasal, PR). Elicits rapid onset when administered IV (2-5 min), easily titrated, less pain at the injection site, and has a shorter duration of action than other commonly used benzodiazepines. Dose response curve is highly variable in pediatrics; weight-based dosing produces variable levels of sedation in agitated children of the same weight; this is common with IM and PO dosing.
Adult
<60 years: 1-2.5 mg IV over at least 2 or more min; cumulative dose >5 mg typically not necessary
>60 years: 1-1.5 mg IV push over 2 or more min; cumulative dose >3.5 mg typically not necessary
Pediatric
<6 months: Not established
IV: Allow 2-3 min after dose before administering additional doses
6 months to 12 years: 0.05-0.1 mg/kg IV; titrate to desired effect; younger children (ie, <5 y) may require higher cumulative doses up to 0.6 mg/kg or 6 mg
>12 years: 0.01-0.05 mg/kg IV (approximately 0.5-4 mg for a typical adult) may be given slowly or infused over several min; may repeat q10-15min; not to exceed cumulative dose of 10 mg
PO: 0.25-1 mg/kg/dose PO; not to exceed 20 mg/dose
IM: 0.1-0.15 mg/kg/dose IM 30-60 min before procedure or surgery; not to exceed 10 mg/dose
Intranasal: 0.2-0.5 mg/kg intranasal
Coadministration with other CNS depressants, especially narcotics, increases sedation and respiratory depression; medications that inhibit the P450 3A4 enzyme (eg, erythromycin, diltiazem, ketoconazole, cimetidine) decrease elimination and increase sedation and risk of respiratory depression
Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Respiratory distress risk increases when coadministered with opioids; may cause paradoxical excitation; caution with congestive heart failure, pulmonary disease, renal impairment, and hepatic failure; may cause hypoventilation, hypoxemia, and hypotension, especially with high doses
Diazepam (Valium)
Modulates postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. Appears to act on part of the limbic system, thalamus, and hypothalamus, to induce a calming effect. Peak effect for rectal administration is 1.5 h. The negative attributes for pediatric sedation are that it has a long half-life, with active metabolites, and erratic absorption. Additionally, causes pain with injection.
Adult
2-10 mg/dose IV, adjust dose to response; repeat q2-4h prn, not to exceed 30 mg in 8 h
Pediatric
IV/IM
<30 days: Not established
>30 days: 0.25 mg/kg/dose IV/IM, administer over 3 min to avoid respiratory depression; may repeat after 15-30min; not to exceed 10 mg/dose
Rectal gel:
<2 years: Not established
2-5 years: 0.5 mg/kg/dose PR
6-11 years: 0.3 mg/kg PR
>12 years: 0.2 mg/kg PR
Phenothiazines, narcotics, barbiturates, MAO inhibitors, and other antidepressants or CNS medications increase CNS toxicity when administered concurrently; valproate potentiates diazepam by displacement from plasma albumin and inhibiting metabolism
Documented hypersensitivity; uncontrolled acute narrow-angle glaucoma and open-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause hypotension or muscular weakness, particularly when used with opioids, barbiturates, or alcohol
Barbiturates
These agents elicit action at GABA receptors and hyperpolarize nerve cell membrane via chlorine channels. They produce sedation and amnesia and reduce anxiety, but they have no analgesic effects. This class of medication produces a reproducible dose-response effect, based on weight. Additionally, these agents provide neuroprotective properties by the ability to lower intracranial pressure and anticonvulsant properties. Disadvantages include hypotension, hypoventilation, and apnea.
Pentobarbital (Nembutal)
Widely used for procedural sedation. Short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. Prompt onset of sedation with IV administration (within 3-5 min) and duration of action lasts 15-45 min. When administered IM, produces sedation in 10-20 min and duration of action is 1-2 h.
Adult
100 mg slow IV push, may repeat q1-3 min; not to exceed a cumulative dose of 200-500 mg; alternatively, 150-200 mg IM
Pediatric
2-5 mg/kg/dose slow IV push; not to exceed 100 mg/dose
2-6 mg/kg/dose IM; not to exceed 100 mg/dose
Concomitant use with alcohol may produce additive CNS effects and death; chloramphenicol may inhibit pentobarbital metabolism; pentobarbital may enhance chloramphenicol metabolism; MAO inhibitors may enhance sedative effects of barbiturates; valproic acid appears to decrease barbiturate metabolism, increasing toxicity
Barbiturates can decrease effects of anticoagulants (patients may require dosage adjustments if barbiturates added to or withdrawn from regimen); decreased contraceptive effect may occur due to induction of microsomal enzymes (alternate form of birth control is suggested); barbiturates may decrease corticosteroid and digitoxin effects through induction of hepatic microsomal enzymes, which increase metabolism; barbiturates decrease theophylline levels and may decrease effects; pentobarbital may decrease verapamil bioavailability
Documented hypersensitivity; liver failure
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Patient may become tolerant to hypnotic effects; caution in hypovolemic shock, respiratory dysfunction, renal dysfunction, congestive heart failure, previous addiction to sedative-hypnotics, and congestive heart failure; persistent drowsiness may occur for up to 24 h, regardless of administration route; respiratory desaturation risk, especially within first 5 min following IV administration; may cause hypotension, respiratory depression, apnea, laryngospasms, and bronchospasms
Methohexital (Brevital)
Ultra–short-acting barbiturate. Onset of action is less than 1 min and duration of action is about 10 min.
Adult
Induction: 50-120 mg or 1-1.5 mg/kg/dose IV
Maintenance: 20-40 mg IV every 4-7 min
Pediatric
Induction: 0.75-1 mg/kg/dose IV
Maintenance: 0.5 mg/kg/dose IV q2-3min
Coadministration with CNS depressants, salicylates or sulfisoxazole increases toxicity
Documented hypersensitivity; porphyria
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid in patients with temporal lobe epilepsy; directly depresses myocardium and may lead to hypotension with reflex tachycardia; adverse effects include respiratory depression, apnea, myocardial depression, cardiac arrhythmias, prolonged somnolence and recovery, sneezing, coughing, bronchospasm, laryngospasm, and shivering; caution in hepatic or renal insufficiency, asthma, severe cardiovascular disease, unstable aneurysm, hypotension or shock, laryngospasm, Addison disease, myxedema, increased blood urea level, severe anemia, and myasthenia gravis
Thiopental (Pentothal)
This medication can be used as an induction agent for endotracheal intubation. Decreases ICP. Onset of action is 30-40 sec. Half-life is 3-8 h (may be prolonged with repeat doses due to accumulation in fatty tissues).
Adult
50-100 mg/dose slow IV push; may repeat with additional doses of 25-50 mg slow IV push
Pediatric
2-5 mg/kg/dose IV for induction; no recommended initial dose due to great variability of response; age, gender, and body weight affect dose; larger doses (ie, mg/kg) are often needed compared with adults and/or elderly persons
Coadministration with CNS depressants, salicylates, or sulfisoxazole increases toxicity
Documented hypersensitivity; variegate porphyria (South African) or acute intermittent porphyria
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse reactions include respiratory depression, apnea, myocardial depression, cardiac arrhythmias, prolonged somnolence and recovery, sneezing, coughing, bronchospasm, laryngospasm, and shivering; caution in hepatic or renal insufficiency, asthma, severe cardiovascular disease, unstable aneurysm, hypotension or shock, laryngospasm, Addison disease, myxedema, increased blood urea level, severe anemia, and myasthenia gravis
Sedative-hypnotics, miscellaneous
Induction agents – Hypnotic agents that provide rapid loss of consciousness include nitrous oxide, ketamine, and propofol. Ketamine also provides analgesia and amnestic effects. Etomidate (Amidate), an ultra–short-acting sedative agent, is used frequently in adults for rapid sequence induction. It appears to have neuroprotective properties and minimal cardiovascular effects. Although studies in pediatrics using etomidate are emerging and have shown efficacy, its use in pediatrics has not been fully established.
Nitrous oxide
Elicit anxiolytic, amnestic, and mild-to-moderate analgesia. However, the analgesic property is variable, requiring additional analgesic agents. Has little effect on the cardiovascular or respiratory system. In addition, there is minimal effect on the airway reflex. Peak onset of action occurs within 30-60 seconds and maximum effect within 5 min. Effects are rapidly lost once inhalation ceases, and recovery occurs within 5 min.
Adult
Inhale 1:1 mixture of oxygen and nitrous oxide via handheld mask or mouthpiece
Typically, patients are to maintain the seal to ensure adequate inhalation; once sedation is approached, the patient will lose seal and allow the mask/mouthpiece to fall
Pediatric
Administer as in adults
May prolong neuromuscular blockade when administered with neuromuscular blocking agents (eg, cisatracurium, pancuronium, vecuronium); coadministration enhances effect of other anesthetic agents (eg, sevoflurane); coadministration with St John's wort, lidocaine, or verapamil enhance cardiovascular toxicity; increases toxicity of alfentanil, tubocurarine, or vecuronium
Documented hypersensitivity; pneumocephalus; pneumothorax; bowel obstruction; do not administer without oxygen
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Close monitoring required to prevent diffusion hypoxia (nitrous oxide changes from its dissolved state in the blood back to the gas form in the alveoli in the lungs, with net effect of oxygen dilution), greatest risk for this effect is the first 3-5 min after discontinuing nitrous oxide and is prevented via administration of 100% oxygen during this period; scavenger system needed to remove trace gases in a room, administer in well-ventilated room; other adverse effects include drowsiness, nausea, vomiting, and dizziness
Ketamine (Ketalar)
A dissociative agent induces catalepsy. Elicits sedative, analgesic, and amnestic properties. This agent is related to phencyclidine (PCP) and has shown a history of efficacy. It preserves the airway reflexes as well as has minimal effect on the respiratory drive. This agent has bronchodilatory effects and is especially effective with bronchospasms. In addition, there is a history of a good safety profile in pediatrics. Following IV administration, peak onset is 1 min and duration of action is about 10-15 min. When administered IM, peak onset is about 5-10 min and duration of action is 15-30 min. Rarely used in adults because of hypertension, dysphoria, and agitation.
Adult
0.2-0.75 mg/kg IV infused over 2-3 min
Pediatric
1-1.5 mg/kg slow IV push (not to exceed 0.5 mg/kg/min), may administer additional doses of 0.5 mg/kg IV q10-15min (depending on response and duration of procedure)
Alternatively, 4 mg/kg IM, may administer additional doses of 2-4 mg/kg (depending on response and duration of procedure)
Prolonged recovery time may occur if barbiturates and/or narcotics are coadministered; may prolong neuromuscular blockade when administered with neuromuscular blocking agents (eg, cisatracurium, pancuronium, vecuronium); coadministration enhances effect of other anesthetic agents (eg, sevoflurane); coadministration with St John's wort enhances cardiovascular toxicity; increases risk of respiratory depression with tramadol; increases risk of seizure with theophylline and metrizamide
Documented hypersensitivity; increased ICP; uncontrolled hypertension or conditions where hypertension is hazardous; procedures in the posterior pharynx, conditions associated with or intraocular pressure, thyroid disorders, and porphyria
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases oral secretions, administer with an anticholinergic agent (eg, atropine) to control secretions; laryngospasm may occur (usually transient, with improvement via airway repositioning or positive pressure ventilation); during recovery, an emergence phenomenon, depicted by dysphoria and agitation, may occur (more frequent as the patient becomes older or in adults), coadministration with midazolam may blunt this effect; other adverse effects include transient rash, emesis, nystagmus, random extremity or head movements, ataxia, hypertension, and tachycardia
Propofol (Diprivan)
This medication has no relationship to either of the usual agents, benzodiazepines and barbiturates. This agent is a purely sedative agent. It has no analgesic or amnestic properties. Its initial use had been an induction agent in general anesthesia. However, it has been used as sedation for intubated patients in the ICU setting and in patients undergoing radiographic studies, such as CT and MRI. Has a quick onset of action because of the agent's high lipid solubility. Provides rapid onset within 40 seconds. Duration of action is 1-3 min. Preliminary pediatric studies show the efficacy in terms of sedation and ease of use.
Adult
Monitored anesthesia care (MAC) sedation: 0.5 mg/kg IV infused over 3-5 min initially
Maintenance: 25-75 mcg/kg/min IV or incremental IV bolus doses of 10-20 mg
Pediatric
Monitored anesthesia care (MAC) sedation: 0.5-1 mg/kg IV push infused over 2 min initially
Maintenance: 0.5-1 mg/kg IV q3-5min prn or alternatively, as a continuous IV infusion of 50-150 mcg/kg/min
Reduce propofol dose when administered concomitantly with benzodiazepines, opiates, phenothiazines, ethanol, and narcotics; propofol may potentiate neuromuscular blockade of vecuronium; theophylline may weaken effects of propofol, and dose increase may be needed
Documented hypersensitivity to propofol or allergy to soybean oil, egg yolk, glycerol, or disodium edentate
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause pain at injection site, hypotension, or apnea; with long-term use, severe lactic acidosis and bradyarrhythmias may occur; aseptic handling of the medication is required secondary to the lipid emulsion preparation; risk of deep sedation and/or general anesthesia is easily attained with this agent; in elderly patients, do not use rapid bolus and decrease dose by 20%
Adjuvant Therapies and Postprocedure Care
Adjuvant therapies
Nonpharmacologic approaches to sedating children are gaining increasing popularity. Adjuvant therapy involves distraction of the patient. This may involve coping skills to focus attention away from the procedure. Physical objects that appeal to children can provide visual or auditory distractions. Role playing, such as pretending to perform a procedure, may help alleviate a child's fear. Guided imagery, hypnosis, and distractions can be powerful adjuvants to sedation in children and adults.
Other considerations are allowing family members to remain with the child during the painful procedure. A family member at bedside may decrease the distress for both child and parent.
Some of the techniques require training, but a practitioner can easily integrate these methods into wound care or painful procedures. Tell anxious children to close their eyes and pretend that they are in their favorite place. Involving parents by having them tell a story or distract the child goes a long way toward reducing anxiety.
Postprocedure care
After completion of the procedure, continuing to record vital signs until the patient responds appropriately to voice or gentle stimulation is important. Sedation is stimulus dependent; when the procedure is completed, the child is much more likely to become more sedated than he or she was during the procedure. This can lead to hypoventilation and hypoxia if the child is not closely monitored.
In general, discharge criteria should be vital signs within 15% (plus or minus) of admission readings. In addition, the child should be ambulatory for age without assistance and should be able to take and retain oral fluids.
Some agents have specific aftercare needs. Ketamine, for example, may cause ataxia for 12-24 hours, and the child should be activity restricted to prevent further injury.
Future of Pediatric Moderate Sedation
The practice of moderate sedation is an evolving field. Recognize that new medication and technology have changed how we practice and that new avenues of research are encouraged. Some examples are clinician competency, effective sedative dosing of medication, and objective sedation scales are a few. Moderate sedation is a dynamic and changing area of medicine.
Controversy in Pediatric Moderate Sedation
Propofol has become an important sedation agent used by emergency department (ED) physicians. Propofol is a unique medication with a short half-life, leading to rapid induction, followed by swift emergence and recovery. Anesthesiologists and nurse anesthetists are among the first health professionals to use this medication. Controversy exists among anesthesiologists and ED physicians about the drug's administration and management of patients.
Procedural sedation policy about propofol use is typically under the direction of the anesthesiology department. They have opposed emergency department use because of this drug’s potential risk of deep sedation (leading to general anesthesia) and hypoxic/respiratory depression. However, emergency medicine physicians have the technical skills for rapid sequence intubation and advanced airway management. The ED practice environment is tailormade for propofol use in a brief controlled setting for moderate sedation.3
Increasing numbers of studies describe propofol use in the ED. Patel et al described how propofol provides effective moderate sedation for procedures ≥30 minutes. In addition, the authors described effective dosing in different age groups. The sedation was performed by a pediatric sedation service staffed by nonanesthesiologists.4
Keywords
pediatric sedation, sedation in children, sedation infants, sedation, drug administration in children, sedation in emergency department, procedural sedation, anesthesia in children, pain relief in children
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Further Reading
Keywords
pediatric sedation, sedation in children, sedation infants, sedation, drug administration in children, sedation in emergency department, procedural sedation, anesthesia in children, pain relief in children
