Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department

Raymond D Pitetti, Sonia Singh, Mary Clyde Pierce
Archives of Pediatrics & Adolescent Medicine 2003, 157 (11): 1090-6

BACKGROUND: Children often require relief of pain and anxiety when undergoing diagnostic or therapeutic procedures in the emergency department (ED). Procedural sedation and analgesia (PSA) has become standard practice in the outpatient setting for such procedures. Few studies have looked at the overall success and incidence of complications of PSA as performed by nonanesthesiologists.

OBJECTIVES: To prospectively describe PSA as performed in a pediatric ED and to report the success of sedation and incidence of complications.

DESIGN: Prospective descriptive study. Setting and Population Subjects aged 0 to 21 years presenting to the ED of an urban, tertiary care, children's hospital between May 1, 1997, and April 30, 1999, requiring PSA for a diagnostic or therapeutic procedure.

METHODS: A PSA form was designed and used by ED personnel to record pertinent clinical and demographic characteristics of patients, information related to the procedure, vital signs, and occurrence of complications. Success of sedation was defined a priori as successful completion of the procedure in a minimally responsive subject. Complications were defined as apnea, hypoxia (sustained pulse oximetry, <93%), seizure, arrhythmia, laryngospasm, stridor, hypotension, rash, vomiting, disinhibition, or aspiration. Follow-up telephone calls were made to families within 24 to 48 hours of discharge from the ED to document further complications.

MAIN OUTCOME MEASURES: Rate of success of sedation and incidence of complications.

RESULTS: Procedural sedation and analgesia was performed 1244 times in 1215 patients during the study. The median age of the patients was 5.9 years (mean age, 6.9 years; range, 2 months to 19.4 years). There were 791 boys (65.1%) and 424 girls (34.9%). A little more than half of the patients (643 or 52.9%) required PSA for fracture reduction and 396 (32.6%) for laceration repair. Intravenous (IV) fentanyl citrate and midazolam hydrochloride was provided in 734 sedation events (59.0%); IV ketamine hydrochloride, midazolam, and atropine sulfate in 293 (23.6%); and intramuscular ketamine, midazolam, and atropine in 82 (6.6%). Procedural sedation and analgesia was successfully provided in 1177 (98.6%) of 1194 sedation events. Complications occurred in 207 (17.8%) of 1161 events. The most common complication was hypoxia (79.1% of patients), followed by vomiting (6.2% of patients). No patient required intubation. One patient had an oral airway placed, 3 patients received flumazenil, 3 patients received naloxone hydrochloride, and 1 patient received naloxone and bag-valve-mask ventilation. Seventy (9.8%) of 717 patients, following discharge from the ED, reported minor complications related to PSA. The most common complication was vomiting (76.7% of patients), followed by persistent dizziness (6.8% of patients). Patients who received IV fentanyl and midazolam were significantly more likely to experience a complication during PSA (P<.001), while patients sedated using IV ketamine, midazolam, and atropine (P =.006) or IV midazolam alone (P =.005) were less likely. No difference in success of sedation or incidence of complications at follow-up was found between the types of PSA provided.

CONCLUSIONS: Complications related to PSA occurred in 17.9% of patients, but most commonly consisted of hypoxia that was easily treated. Sedation was successful in 98.6% of patients. Procedural sedation and analgesia can be safely and effectively provided by nonanesthesiologists in a pediatric ED.

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