| | Procedural sedation and analgesia for children in the emergency department
The management of pain, anxiety and motion in children undergoing procedures, or procedural sedation and analgesia (PSA), has developed substantially during recent years [1], [2]. With the availability of short-acting opioids, sedative–hypnotics, dissociative agents available through multiple routes of administration, specific opioid and benzodiazepine antagonists, and portable noninvasive monitoring modalities, PSA has become an integral component of the practice of emergency medicine. This article provides an overview of PSA for children in the emergency department (ED), including terminology, standards, pharmacopoeia, strategies of administration, and future directions.
Definitions and terminology  Because the applications of PSA have continued to expand, fundamental problems regarding the terminology used to describe drug-induced altered states of consciousness have emerged. The major specialty societies have published definitions regarding the states of sedation most applicable to children (Table 1) [3], [4], [5], [6]. The central theme of PSA is identifying levels of sedation where protective airway reflexes are preserved. Unfortunately, the progression of mild sedation or analgesia to general anesthesia, where these reflexes are depressed or lost entirely, is not linear and therefore not easily divided into discrete stages. Patients may drift up and down the sedation continuum during a single procedure, moving back and forth between moderate and deep sedation. Furthermore, the measurement of these reflexes in children is often difficult, especially if the child is sedated to the point of being asleep. Objective scoring systems measuring the depth of sedation, such as the Ramsay scale [7], have not been extensively studied in children undergoing PSA. Because little consensus can be found in these definitions, this article focuses on an approach to pharmacologic control of pain, anxiety, and motion, whose goal is to avoid depressing the protective airway reflexes. | | |  | Reference | Definition | |
|---|
| American College of Emergency Physicians, 1998 [6] | Procedural sedation and analgesia: “A technique of administering sedatives 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 but one 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.” | |
| American Academy of Pediatrics, 1992 [4], [5] | Conscious sedation: “A medically controlled state of depressed consciousness that (1) allows protective reflexes to be maintained; (2) retains the patient's ability to maintain a patent airway independently and continuously: and (3) permits appropriate response by the patient to physical stimulation or verbal command, e.g., ‘open your eyes’”. | |
| | Deep sedation: “A medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patent airway independently and respond to purposefully to physical stimuli and verbal command.” | |
| | General anesthesia: “A medically controlled state of unconsciousness accompanied by a loss of protective reflexes, including the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.” | |
| American Society of Anesthesiologists, 1999 [3] | Minimal sedation (anxiolysis): “A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular commands are unaffected.” | |
| | Moderate sedation/analgesia (“conscious sedation”): “A drug-induced depression of consciousness during which patients respond purposefullyato verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.” | |
| | Deep sedation/analgesia: “A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefullya following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.” | |
| | General anesthesia: “A drug-induced loss of consciousness during which patients are not arousable, even by painful stimuli. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.” | | | | |
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a
Reflex withdrawal from painful stimulus is not considered a purposeful response. |
Standards and guidelines Most of the published guidelines from various specialty societies and government agencies are based on the degree of sedation rather than on the specific pharmacologic agent administered [3], [4], [5], [6], [8], [9], [10], [11], [12], [13], [14], [15]. Because the definitions of the degree of sedation vary significantly between these societies and agencies, no standardized guidelines exist that apply across specialties. Standard recommendations regarding PSA in the ED, however, can be made for preprocedure evaluation, assessment and preparation, and postprocedure recovery. Preprocedure evaluation, assessment, and preparation Physical assessment Preparation of the patient is an essential component of PSA. A directed history and physical examination should precede all sedations [1], [2], [16]. Underlying medical conditions should be assessed, as should information about medication use, allergies, and previous adverse experiences with sedation or general anesthesia. In addition, any recent exacerbations of chronic illnesses, such as asthma, along with recent infections, should be considered. Table 2 shows the physical status classification of the American Society of Anesthesiologists (ASA), which can be used to determine the degree of risk associated with different classes of patients [16]. | | | | Class | Description | |
|---|
| 1 | A normally healthy patient | |
| 2 | A patient with mild systemic disease (no functional limitation) | |
| 3 | A patient with severe systemic disease (definite functional limitation) | |
| 4 | A patient with severe systemic disease that is a constant threat to life | |
| 5 | A morbid patient who is not expected to survive without the operation | | | | |
The time and nature of the patient's last oral intake should be obtained. According to the ASA guidelines, children should not consume clear liquids for 2 to 3 hours or solids and nonclear liquids for 4 to 8 hours before undergoing sedation for an elective procedure [16]. These consensus guidelines were published in an attempt to reduce pulmonary aspiration risk in children undergoing elective procedures. Although the American College of Emergency Physicians, ASA, and American Academy of Pediatrics (AAP) recommend a risk-benefit analysis prior to sedation for nonelective procedures in nonfasted patients, no specific guidelines are given [3], [4], [5], [6]. A recent review of the literature has shown that no compelling evidence supports specific fasting periods for either solids or liquids for reducing aspiration risks in children [17]. A directed physical examination should be performed prior to any procedure. Consideration should be given to active upper and lower respiratory tract illnesses that could lead to acute bronchospasm. Patients with potentially difficult airways should also be identified. This includes patients with short necks, small mandibles, large tongues, or trismus. The proper agent or agents used should then be matched to the individual patient and procedure. In this way, the risk of complications can be minimized while maximizing the likelihood of a successful sedation. Personnel, equipment, and monitoring Whereas adverse events are often difficult to predict, preparation appears to be the most critical factor in minimizing the adverse outcomes of these events [18], [19]. This preparation includes the training of personnel, proper monitoring equipment, and the selection of the most appropriate medication for a particular patient and procedure. The importance of properly trained staff cannot be overstated. The personnel performing PSA must be able to recognize and treat all potential complications of the sedation, including respiratory depression, apnea, airway obstruction, laryngospasm, emesis, and hypersalivation. The formal training of the personnel is not as important as their ability to recognize the earliest signs of airway difficulties, and then manage those problems in whatever manner is necessary. Thus, expertise in the use of all airway equipment, procedures, and medications, including suction, oxygen, airway positioning maneuvers (eg, chin lift, jaw thrust), bag-valve masks (whether anesthesia or self-inflating bags), endotracheal tubes, reversal agents, and, when necessary, paralytic agents, is an absolute requirement when performing PSA. Furthermore, the equipment and medications must be readily available and accessible wherever the sedation is being performed. At least two trained professionals should be present for each sedation, with one person dedicated to the continuous monitoring of the patient while the other performs the procedure [16], [18], [19]. Ideally, the practitioner dedicated to airway management should be different from the practitioner actually performing the procedure, although this can be difficult where available staff is limited. Whoever is ultimately responsible for airway management must be able to recognize the earliest signs of airway difficulties, such as upper airway obstruction or decreased chest wall movements. Often, these conditions are easily corrected by simple maneuvers when recognized early. It is, therefore, strongly encouraged to have this practitioner positioned near the head of the patient, with full view of the child's face and chest wall, so that these signs can be recognized as early as possible. In areas outside the ED, such as the various radiology suites, cameras and microphones should be used whenever direct visualization of the patient is not possible [20]. In connection with direct visualization, proper monitoring equipment is necessary to help minimize adverse consequences. At a minimum, continuous pulse oximetry, with both visual and audible alarms, should be in place [2], [5], [12]. Pulse oximetry reflects only the heart rate and oxygenation of the patient, not the ventilatory status. In fact, the patient's ventilation may be significantly depressed even with normal oxygenation saturation levels, especially when supplemental oxygen is given [16]. Thus, pulse oximetry is an adjunct to, not a substitute for, direct visualization [21]. Capnography, however, is the only direct, noninvasive way to measure the patient's ventilatory status. In spontaneously breathing patients, expired carbon dioxide can be measured by sidestream capnography via a nasal cannula [22], [23]. These devices can measure both the end-tidal carbon dioxide (EtCO2) and respiratory rate. In addition, readings from the capnograph in both digital and waveform configurations allow for early detection of hypoventilation, as detected by characteristic changes in the waveform and EtCO2, and apnea, as represented by loss of waveform. These changes in both the measured EtCO2 and waveform configurations have been shown to precede any changes in pulse oximetry [24], [25], [26]. Because capnography provides the earliest warning of respiratory depression and apnea during PSA, and because the Joint Commission on Accreditation of Healthcare Organizations and the AAP view deep sedation and general anesthesia as “virtually inseparable for the purposes of monitoring” [5], [27], [28], capnography is often mandated as an essential monitoring component during deep sedation. Cardiac monitoring equipment can also be used, as it is readily available and inexpensive. There is little evidence that this modality can minimize adverse outcomes in those children without significant cardiac disease, however [2]. Procedures The pharmacopoeia of PSA consists of four general classes of medications: sedative-hypnotic, analgesic, dissociative, and inhalation agents. Clinicians can now choose from a wide range of short-acting medications with multiple routes of administrations, including topical, local, regional, transmucosal, oral, intranasal, rectal, intramuscular (IM), intravenous (IV), and via inhalation [23], [29]. Recommended dosages of medications used for PSA in children are shown in Table 3 [2]. A general review of these medications by type of procedure, reversal agents, and customizing strategies, is discussed in this section. | | | | Drug | Dose | Time to onset, min | Duration of action, min | |
|---|
| Sedative-hypnotic agents | |
|  Chloral hydrate | PO: 25–100 mg/kg of body weight; after 30 min, may repeat 25–50 mg/kg. Maximum total dose: 2 g or 100 mg/kg (whichever is less). Only single use in neonates | 15–30 | 60–120 | |
| Midazolam | IV (age of child, 0.5–5 y): initially 0.05–0.1 mg/kg, then adjusted to a maximum of 0.6 mg/kg | 2–3 | 45–60 | |
| | IV (6–12 y): initially 0.025–0.05 mg/kg, then adjusted to a maximum of 0.4 mg/kg | | | |
| | IM: 0.1–0.15 mg/kg | 10–20 | 60–120 | |
| | PO: 0.5–0.75 mg/kg | 15–30 | 60–90 | |
| | IN: 0.2–0.5 mg/kg | 10–15 | 60 | |
| | PR: 0.25–0.5 mg/kg | 10–30 | 60–90 | |
| Pentobarbital | IV: 1–6 mg/kg, adjusted in increments of 1–2 mg/kg to desired effect IM: 2–6 mg/kg, to a maximum of 100 mg | 3–5 | 15–45 | |
| | PO or PR (<4 y): 3–6 mg/kg, to a maximum of 100 mg | 10–15 | 60–120 | |
| | PO or PR (≥ 4 y): 1.5–3 mg/kg, to a maximum of 100 mg | 15–60 | 60–240 | |
| Methohexital | PR: 25 mg/kg | 10–15 | 60 | |
| Thiopental | PR: 25 mg/kg | 10–15 | 60–120 | |
| Analgesic agents | |
| Fentanyl | IV: 1.0 μg/kg/dose, may repeat every 2–3 min, adjust to desired effect | 2–3 | 30–60 | |
| Dissociative agents | |
| Ketamine | IV: 1–1.5 mg/kg slowly over 1–2 min, may repeat 1/2 dose every 10 min as required | 1 | Dissociation: 15; recovery: 60 | |
| | IM: 4–5 mg/kg, may repeat after 10 min | | Dissociation: 15–30; recovery: 90–150 | |
| Inhalation agents | |
| Nitrous oxide | Preset mixture with minimum of 40% oxygen self-administered by demand-valve mask or continuous systems | <5 | <5 after discontinuation | |
| >Reversal agents (antagonists) | |
| Naloxone | IV, IM, or SQ: 0.1 mg/kg/dose, to a maximum of 2 mg/dose; may be repeated every 2 min as required | IV: 2 IM, SQ 10–15 | IV: 20–40 IM, SQ: 60–90 | |
| Nalmefene | IV, IM, or SQ: 0.25 μg/kg, to a maximum of 1 μg/dose; may be repeated every 2–5 min as required | IV: 5 IM, SQ 15–20 | 210 | |
| Flumazenill | IV: 0.02 mg/kg/dose, may be repeated every 1 min to a maximum 1 mg | 1–2 | 30–60 | | | | |
Noninvasive procedures The most common noninvasive procedures requiring PSA in the ED are diagnostic imaging studies (CT, ultrasonography, and MRI). The goals of PSA for these noninvasive procedures are motion control and anxiolysis [2]. Sedative-hypnotic drugs (eg, chloral hydrate, benzodiazepines, and barbiturates) provide sedation and anxiolysis without pain control. All sedative–hypnotics, in sufficient doses, can produce respiratory depression and relaxation of the upper airway musculature leading to airway compromise. Children receiving these agents must be monitored closely as previously described. Chloral hydrate Chloral hydrate, one of the first PSA agents, has a long track record and safety profile. In the ED, it is now used exclusively for diagnostic imaging studies. It may be given both orally and rectally, although rectal absorption is erratic. After rapid absorption, with onset of sedation in 15 to 60 minutes, it is metabolized in the liver to both active and inactive metabolites, which are then eliminated in the urine. Acute toxicity may cause hepatitis. It should therefore be avoided in patients with significant hepatic and renal disease. Chloral hydrate is also contraindicated in patients requiring the use of vasopressors, such as in those patients with severe cardiac dysfunction, because it may further depress myocardial contractility and shorten the cardiac refractory period, resulting in arrhythmias [30]. Chloral hydrate is most effective when given in doses of 50 to 75 mg/kg to children younger than 3 years; there is decreased efficacy in older children. Chloral hydrate may produce paradoxic excitement, or, conversely, oversedation as it cannot be titrated by either route of administration. It has no analgesic properties, and there are no effective reversal agents [31], [32], [33], [34]. Benzodiazepines Benzodiazepines are the drugs most commonly used in PSA for anxiolysis, sedation, and amnesia, and in combination with opioids for painful procedures. Midazolam is the most frequently used of these agents and has replaced diazepam as the benzodiazepine of choice for PSA in children. It is a short-acting agent that can be administered by multiple routes, including oral, rectal, intranasal, and IV. As with chloral hydrate, paradoxic excitement may occur, especially in younger children. For painful procedures, midazolam is commonly combined with the opioid fentanyl. This combination is safe and effective when following standard dosing and titration guidelines, although caution should be exercised, because the risk of respiratory depression is significantly greater than when either agent is used alone [35]. The mechanism of action of the benzodiazepines is through the central nervous system (CNS) γ-aminobutyric acid (GABA-A) receptors, and the effects may be reversed with the antagonist flumazenil [36]. Barbiturates Barbiturates are most commonly used for PSA in children for diagnostic imaging, with the most common indication being the hemodynamically stable child with head trauma for which emergent CT scan is required. The most frequently used agent in this class is pentobarbital. This intermediate-acting agent may be given by multiple routes, although the IV administration is most reliable. Methohexital and thiopental, both ultra-short-acting barbiturates, have been used successfully for PSA through rectal administration. Paradoxic excitement may occur in younger children, such as with chloral hydrate and the benzodiazepines. Rapid IV administration of barbiturates may cause vasodilatation and decreased myocardial contractility and therefore should be avoided in patients with hypovolemia or cardiac dysfunction. Barbiturates are contraindicated in patients with porphyria, because they induce an δ-aminolevulinic synthetase, a catalyst in the synthesis of porphyrins. Barbiturates act at the GABA-A receptor, provide no analgesia, and are not reversible [37]. Procedures involving minimal pain Emergency procedures involving minimal pain include the following: phlebotomy, lumbar puncture, simple laceration repair, foreign body removal, dental procedures, ocular irrigation, slit lamp examination, and flexible fiberoptic laryngoscopy. Although minimally painful, these procedures may produce high levels of anxiety in children. The goals of PSA for these procedures should focus on sedation and anxiolysis, and adequate motion and pain control [2]. In addition to sedative-hypnotic agents, as previously discussed, topical anesthetics, local anesthetics, and inhalants are also used. Topical anesthetics Topical anesthesia has substantially reduced the discomfort associated with laceration repair, IV cannulation, and lumbar puncture in the ED. The first available topical anesthetic for lacerated skin was the combination of tetracaine, epinephrine, and cocaine (TAC). Although effective as a topical anesthetic, TAC is rarely used today because of concerns of cocaine toxicity, especially when applied to mucosal surfaces. An equally effective, less expensive, and safer topical anesthetic is the combination of lidocaine, epinephrine, and tetracaine (LET). Both TAC and LET are available in aqueous, viscous, and gel formulations that can be made by individual hospital pharmacies. When applied to lacerated skin, the onset time for LET is approximately 20 minutes [38], [39]. Many EDs have created protocols for LET administration by nurses in the triage area. Intact skin may be treated with EMLA (AstraZeneca, Westborough, MA), a combination of 2.5% lidocaine and 2.5% prilocaine in a cream base. This eutectic mixture has a relatively long time to peak effect (60 minutes) and provides anesthesia for 1 to 2 hours [40], [41], [42]. EMLA is most commonly used for lumbar puncture and IV cannulation, although the delay to peak onset often limits its applicability. For procedures lasting less than 1 minute, cooling sprays (eg, ethyl chloride and fluoromethane) may also be applied to intact skin surfaces for analgesia. Unlike ethyl chloride, fluoromethane is nonflammable [43]. Nasal and oral mucosal surfaces may be treated with viscous lidocaine, dental creams, or cetacaine (2% butamben and 2% tetracaine). Cetacaine, along with most dental creams, contains significant concentrations of benzocaine, an anesthetic of the ester class. The topical application of benzocaine has been associated with allergic reactions and the formation of methemoglobinemia, and must be used with caution in susceptible individuals. As mentioned previously, 4% cocaine is rarely used today because of cost and safety considerations [43]. Local anesthetics The most commonly used local anesthetics are lidocaine and bupivacaine, both of the amide class and thus with a lower potential for allergic reactions. These agents may be used alone or in combination. Lidocaine has a rapid onset of action but a short duration of only 60 to 120 minutes. Bupivacaine has a much slower onset of action but may provide 240 to 480 minutes of anesthesia. Maneuvers that have been shown to minimize pain during the administration of these agents include the following: applying a topical agent prior to administration, buffering the anesthetic with sodium bicarbonate in a ratio of 10 to 1 before injection, warming the anesthetic agent, and infiltrating with a small needle (preferably a number 27 or 30 gauge) at a slow steady rate. To avoid toxicity, the maximum recommended doses for local infiltration of lidocaine and bupivacaine are 5 to 7 mg/kg and 2 to 2.5 mg/kg, respectively [44]. Inhalants Nitrous oxide is an inhalant with a high safety profile. When used for PSA, it is dispensed in a preset mixture of a minimum of 40% oxygen, or it can be blended with oxygen in a flow meter. The mixture is delivered by a demand-valve mask that requires negative inspiratory pressure to initiate gas flow, and thus it can only be used for cooperative children older than 4 years. Continuous flow systems have been used for toddlers but emesis rates have been high (10%), and two physicians are needed to perform the procedure and deliver the gas [45], [46]. The major contraindications to the use of nitrous oxide are pregnancy (of the patient or personnel), preexisting nausea or vomiting, and trapped gas pockets (eg, in middle ear infection, pneumothorax, or bowel obstruction). Although noninvasive, inexpensive, and with a rapid onset and offset in less than 5 minutes, nitrous oxide is generally a weak analgesic, sedative, and anxiolytic in the concentrations used for procedural sedation [47], [48], [49], [50]. Painful procedures The most common emergency procedures associated with a high levels of pain and anxiety in children are as follows: abscess incision and drainage, arthrocentesis, bone marrow aspiration, burn debridement, cardioversion, central venous catheter placement, fracture or dislocation reduction, hernia reduction, interventional radiology procedures, complex laceration repair, paracentesis, paraphimosis reduction, sexual assault examination, thorocentesis, and thorocostomy tube placement. The goals of PSA for these procedures include sedation, anxiolysis, analgesia, amnesia, and motion control [2]. In addition to the agents previously discussed, systemic analgesics and dissociative agents are most commonly used for this purpose. Systemic analgesics Opioids are the most commonly used systemic agents used for analgesia in the ED. For procedures lasting less than 1 hour, the short-acting agents fentanyl and sufentanil are now preferred over the longer-acting agents, such as morphine, meperidine, and hydromorphone. Fentanyl is 100 times more potent than morphine whereas sufentanil is 7 times more potent than fentanyl. Neither fentanyl nor sufentanil administration results in significant histamine release, nausea/vomiting, or cardiovascular instability. Fentanyl is easy to titrate, given its short onset time (2–3 minutes) and duration of action (30–60 minutes). Fentanyl at low doses (1–2 μg/kg) has no sedative effects in contrast to meperidine and morphine, and is most commonly combined with the short-acting benzodiazepine midazolam for painful procedures [51]. The primary disadvantage of these short-acting agents is their higher cost. The rare but serious complication of chest wall rigidity has only been associated with high-dose boluses (10–15 μg/kg) of fentanyl. Thus, initial boluses of more than 5 μg/kg should be avoided. The recommended initial bolus dose of fentanyl is 1 to 2 μg/kg, and there are no reported cases of chest wall rigidity at these lower doses [51], [52]. Fentanyl is also available in a transmucosal vehicle for children. Unacceptably high rates of emesis (31%–45%) have limited its use, however [53], [54]. The only opioid available by the intranasal route is sufentanil, which can be given in doses of 0.7 to 1.0 μg/kg intranasally for analgesia [55], [56]. To date, however, there are insufficient data on the safety and efficacy of nasal sufentanil use in children. Long-acting opioids have the significant disadvantage of releasing histamine, which can result in pruritis, hypotension and nausea/vomiting. Furthermore, meperidine, in the IV form, can precipitate seizure activity by accumulation of its metabolite, normeperidine [57]. Meperidine and morphine are more difficult to titrate than the short-acting opioids for short procedures because of their relatively slow onset (4–6 minutes in IV form) and long duration of action (2–3 hours). All of the opioids available for PSA in children are reversible with the antagonists naloxone and nalmefene [58]. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, have also been shown to be effective agents in enhancing analgesia in children. Ketorolac, in the parenteral dose of 0.5 mg/kg in IM and IV forms, has been shown to be effective in patients with migraine headaches, musculoskeletal injuries, renal colic, and sickle cell crisis [59], [60], [61]. This agent is contraindicated in children younger than 1 year because of insufficient experience. All NSAIDs should be avoided in patients going to the operating room, because of the potential risk of increased bleeding [62]. Dissociative agents Ketamine may be classified as a dissociative agent in that it can rapidly induce a trancelike cataleptic condition characterized by profound analgesia, sedation, amnesia, and immobilization. This unique state of cortical dissociation allows painful procedures to be performed with preservation of upper airway muscular tone and protective airway reflexes. Because it preserves reflexes, ketamine may be a preferred agent for PSA when fasting cannot be assured. It is reliably effective by both IM and IV routes in children, which is unique among PSA medications. The safety and efficacy of ketamine in outpatients for brief, painful procedures have been extensively documented since its introduction in 1970. The most frequently encountered adverse reactions with ketamine are as follows: hypersalivation (which may be offset by the concurrent use of anticholinergic agents, such as atropine or glycopyrrolate); mild cardiovascular stimulation (because of its sympthamimetic qualities); musculoskeletal effects (including muscle hypertonicity, rigidity, and myoclonus); increased intracranial and intraocular pressure (contraindicated in patients with increased intracranial pressure); recovery agitation (in children >8 years, which may be blunted by the concurrent use of benzodiazepines); recovery ataxia (which may last for several hours); vomiting (with an incidence of 6.7%, mostly in the recovery phase); respiratory depression with rapid IV administration (thus, it is recommended to be “pushed slowly” over 1–2 minutes); and laryngospasm (which has an incidence of 0.4% in children without contraindications and is most often treated with airway positioning and/or bag-mask ventilation) [63], [64], [65]. To minimize the frequency and outcomes of these adverse events, clinicians administering ketamine must be aware of the contraindications to its use. The generally accepted contraindications are as follows: patient younger than 3 months; history of airway instability, tracheal surgery, or tracheal stenosis; procedures involving stimulation of the posterior pharynx; active pulmonary infection or disease (including active upper airway infection); ischemic cardiac disease; congestive heart failure; hypertension; substantial head injury, CNS masses or hydrocephalus; glaucoma or acute globe injury; history of seizure disorder; psychosis; porphyria; and thyroid disorder or use of thyroid medication [63], [64], [65], [66], [67], [68], [69]. Reversal agents Opioid and benzodiazepine antagonists have greatly increased the safety profile of procedural sedation. These agents allow medications to be safely titrated so the complication of respiratory depression from oversedation can be rapidly reversed, if necessary. The opioid antagonist naloxone is a short-acting agent with a long safety record in children and neonates. Nalmefene is a newer opioid antagonist with a longer duration of action (3.5 hours versus 60 minutes for naloxone). Because most procedures requiring sedation in the ED last less than 1 hour, however, naloxone remains the opioid antagonist of choice for PSA. Furthermore, the safety and efficacy of nalmefene in children has not been fully established. Flumazenil, first introduced in 1987, is the only available benzodiazepine antagonist. This short-acting agent has a duration of action of only 20 to 60 minutes, and thus multiple doses may be required for reversal of longer-acting benzodiazepines. It is important that the use of flumazenil be avoided when there is a history of long-term benzodiazepine use, or the concomitant ingestion of drugs known to lower the seizure threshold (eg, cyclosporin, isoniazide, lithium, propoxyphene, theophylline, tricyclic antidepressants). In the absence of these contraindications, flumazenil has been show to be safe and effective in children and neonates [70]. Customizing: indications, strategies, and sedation options With the availability of both long- and short-acting sedative and analgesic agents in multiple routes of administration, emergency physicians (EPs) can now customize the sedation strategy to match a particular patient and procedure. Consideration should be given to the anticipated level of pain and/or anxiety, the length of the procedure, and the likelihood of adverse events for the individual patient. As discussed previously, certain drugs are better suited for particular procedures. Suggested strategies for PSA in children are shown in Fig. 1. Because this represents a general overview, it is recommended that clinicians familiarize themselves with a few agents that are flexible enough to be used in most procedures [1], [2]. Postprocedure recovery As mentioned previously, monitoring during the sedation should be continuous. Vital signs should be taken at baseline, after drug administration, during recovery, and on completion of recovery. Children are at greatest risk for adverse events (the most common being airway/respiratory related) within the first 10 minutes after the administration of a medication and in the immediate postrecovery phase when the procedural stimuli have been discontinued. Thus, monitoring should continue until there is no longer a risk of respiratory depression. Most hospitals have developed guidelines regarding discharge criteria after the sedation has completed. At a minimum, the child should be awake and alert and returned to an age-appropriate baseline mental status. Written discharge instructions should be given to a responsible adult, with specific references to diet, medications, level of activity, and indications for returning to the ED [1], [16], [71]. Research directions in procedural sedation and analgesia Although published data on PSA have increased greatly during the past 15 years, there is still much to be done to reduce the labor-intensive nature of PSA in children. As in the past, the future of PSA largely depends on research involving the safety and efficacy of medications and delivery systems. For instance, the use of transdermal lidocaine with iontophoresis, which is the delivery of charged molecules into biologic tissue via electric current, has been shown to provide rapid and effective anesthesia in older children and adults undergoing IV placement. Its advantages over EMLA include a shorter onset time (7–15 minutes versus 60 minutes) and a deeper level of penetration (8 mm versus 5 mm). Tingling, warmth, itching, and erythema at the skin site may limit its application to older patients with intact skin surfaces, however [72], [73], [74]. Expanding the use of ultra-short-acting agents will also contribute to the advancement of PSA. These agents have the advantage of rapid onset, allowing for ease and safety of titration, and very rapid recovery times. Much has been published recently on the efficacy of one such agent, propofol, in the outpatient setting. As a pure sedative hypnotic, however, it does not provide substantial analgesia and must be combined with another agent for pain control. Furthermore, pain at the injection site, transient hypotension, the need for strict adherence to aseptic technique, and the individual variability with respect to the induction of apnea have thus far limited its use in the pediatric ED [75], [76], [77]. Further studies are needed to evaluate the safety and efficacy of propofol for PSA in children. Etomidate has also been investigated recently as an agent for PSA. As another ultra-short-acting sedative hypnotic, it has been most frequently used as an induction agent in rapid-sequence intubations (RSI). Reported adverse effects with RSI doses include myoclonus, vomiting, and pain with injection. Transient adrenocortical suppression has been associated with etomidate, although this does not appear to be clinically significant [78], [79], [80]. As with propofol, etomidate must be combined with an analgesic agent during painful procedures. Several studies, such as a prospective study with 51 adult patients [78], a retrospective chart review of 53 children [81], and an abstract with 73 adult patients [82], on the use of etomidate in combination with opioids for PSA have recently appeared in the emergency medicine literature. In these studies, the reported frequency of adverse events was low, and there were no serious complications. The onset of deep sedation, with the potential loss of protective reflexes, was not infrequent, however. As with propofol, larger-scale prospective studies on the use of etomidate for PSA in children are needed before reliable conclusions can be drawn [80]. Expanding the application of nonpharmacologic clinical techniques can also be further explored. Many EPs use forceful immobilization (papoose) for anxious children requiring a procedure, whereas others apply a variety of nonpharmacologic techniques to help minimize anxiety. These techniques are important adjuncts to PSA. The emergency medicine literature contains few studies on this subject. More clinical research regarding these techniques, with age-specific applications, is needed to help guide the EP [83]. Similarly, expanding the use of regional anesthesia as an effective adjunct should also be encouraged. With its selective use, regional anesthesia can reduce the amount of analgesic medication required for painful procedures. Other than the use of the Bier Block for forearm fracture reduction [84], [85], [86], little has been published on its use in children for PSA. Another important area to be further developed is objective scoring/measuring systems for the depth and adequacy of sedation. As mentioned previously, objective measuring devices, including pulse oximetry and capnography, have helped to minimize the adverse consequences of PSA. 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