EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 7 pptx

Sedation with 50% nitrous oxide effectively decreases patient distress and is associated with a low rate of adverse events in children receiving laceration repair.. Age of the patient gr

complications for pediatric fracture reduction than

ketamine/midazolam

Ketamine and ketamine/midazolam, administered

IV or IM, have been shown to provide safe, effective

procedural sedation and analgesia for pediatric

lacera-tion repair As menlacera-tioned above, ketamine/midazolam

provides better pain control and anxiety relief with less

respiratory complications than midazolam/fentanyl

However, when ketamine is used, vomiting is more

common, and emergence reactions (mostly mild) will

occur, regardless of the addition of midazolam In a

randomized, controlled trial comparing IV to IM

keta-mine for fracture reduction, IM ketaketa-mine provided

more efficacious sedation but resulted in more frequent

vomiting and longer lengths of sedation

The shorter acting agents propofol and etomidate have

been used for ED pediatric procedures such as orthopedic

reductions The properties of sedation, amnesia, and

rapid recovery time make these drugs attractive for ED

use However, the short duration of action limits their use

for pediatric laceration repair

Sedation with 50% nitrous oxide effectively decreases

patient distress and is associated with a low rate of

adverse events in children receiving laceration repair

The use of nitrous oxide is limited by the need for

special delivery and gas scavenger equipment and

patient compliance with holding the face mask in place

to facilitate delivery of the drug

FOLLOW-UP CONSIDERATIONS

Although delayed adverse events associated with pediatric

procedural sedation have been described, significant

adverse events, such as apnea or oxygen desaturations, are

unlikely to occur greater than 30 min after the last sedation

drug administration On discharge from the ED, advise

parents and children about other adverse events that they

may still experience (i.e., vomiting, dizziness, emergence

reactions), instruct them about proper wound care, and

direct them to appropriate follow-up care

SUMMARY

When determining how best to control pain and

patient movement in children with lacerations, consider

patient age and development, the presence of underlying

conditions, and the location and extent of the laceration.Recognize that nonpharmacologic techniques may beused effectively to avoid the use of procedural sedation.Choose sedation drugs to fit the desired depth of seda-tion and estimate length of time needed to perform therepair Recognize that the properties of sedation drugsdiffer, and combinations may be required to providesedation, analgesia, and amnesia of the event Finally, it

is essential to enlist the input of parents or guardians inthe decisions regarding the care of their children

BIBLIOGRAPHY

1 Singer AJ, Thode HC, Hollandaer JE National trends in

ED lacerations between 1992 and 2002 Am J Emerg Med2006;24:183–188

2 Roback MG, Wathen JE, Bajaj L, Bothner JP Adverse eventsassociated with procedural sedation and analgesia in apediatric emergency department: A comparison of commonparenteral drugs Acad Emerg Med 2005;12:508–513

3 Green SM, Rothrock SG, Lynch EL, et al Intramuscularketamine for pediatric sedation in the emergency depart-ment: Safety profile in 1,022 cases Ann Emerg Med1998;31(6):688–697

4 Lawrence LM, Wright SW Sedation of pediatric patientsfor minor laceration repair: Effect on length of emergencydepartment stay and patient charges Pediatr Emerg Care1998;14:393–395

5 Krauss B, Green SM Procedural sedation and analgesia inchildren Lancet 2006;367:766–780

6 Loryman B, Davies F, Chavada G Consigning caine’’ to history: A survey of pharmacological techniques

‘‘bruta-to facilitate painful procedures in children in emergencydepartments in the UK Emerg Med J 2006;23:838–840

7 Sinha M, Christopher NC, Fenn R, et al Evaluation ofnonpharmacologic methods of pain and anxiety manage-ment for laceration repair in the pediatric emergencydepartment Pediatrics 2006;117:1162–1168

8 Hawk W, Crockett RK, Ochsenschlager DW Conscioussedation of the pediatric patient for suturing: A survey.Pediatr Emerg Care 1990;6:84–88

9 Brown ET, Corbett SW, Green SM Iatrogenic monary arrest during pediatric sedation with meperidine,promethazine, and chlorpromazine Pediatr Emerg Care2001;17:351–353

cardiopul-10 Mace SE, Barata IA, Cravero JP, et al Clinical policy:Evidence-based approach to pharmacologic agents used inpediatric sedation and analgesia in the emergency depart-ment Ann Emerg Med 2004;44:342–377

11 Everitt IJ, Barnett P Comparison of two benzodiazepinesused for sedation of children undergoing suturing of alaceration in an emergency department Pediatr EmergCare 2002;18:72–74

12 Theroux MC, West DW, Corddry DH, et al Efficacy ofintranasal midazolam in facilitating suturing of lacerations

in preschool children in the emergency department.

Pediatrics 1993;91:624–627

13 McGlone R, Fleet T, Durham S, et al A comparison of

intramuscular ketamine with high dose intramuscular

midazolam with and without intranasal flumazenil in

children before suturing Emerg Med J 2001;18:34–38

14 Younge PA, Kendall JM Sedation for children requiring

wound repair: A randomised controlled double blind

comparison of oral midazolam and oral ketamine Emerg

Med J 2001;18:30–33

15 Kanegaye JT, Favela JL, Acosta M, et al High-dose rectal

midazolam for pediatric procedures: A randomized trial of

sedative efficacy and agitation Pediatr Emerg Care

2003;19:329–336

16 Kennedy RM, Porter FL, Miller JP, et al Comparison

of fentanyl/midazolam with ketamine/midazolam for

pediatric orthopedic emergencies Pediatrics 1998;102:956–963

17 Wathen JE, Roback MG, MacKenzie T, Bothner JP Doesmidazolam alter the clinical effects of intravenous keta-mine sedation in children? A double-blind, randomized,controlled emergency department trail Ann Emerg Med2000;36:579–588

18 Roback MG, Wathen JE, MacKenzie T, et al A ized, controlled trial of IV versus IM ketamine for sedation

random-of pediatric patients receiving emergency departmentorthopedic procedures Ann Emerg Med 2006;48:605–612

19 Luhmann JD, Kennedy RM, Porter FL, et al A randomizedclinical trial of continuous flow nitrous oxide andmidazolam for sedation of young children during lacera-tion repair Ann Emerg Med 2001;137:20–27

FOLLOW-UP CONSIDERATIONS

SUMMARY

BIBLIOGRAPHY

SCOPE OF THE PROBLEM

In virtually all areas of medicine, including pediatrics, the

use of advanced diagnostic imaging has increased

sub-stantially Although utilization of all imaging modalities

has increased, the use of computed tomography (CT) has

grown at a particularly brisk rate, specifically in the

evalu-ation and management of the trauma patient

These increases have implications for physicians in the

emergency department (ED) as procedural sedation is

frequently required to calm and immobilize a child for

these studies It may be possible to perform many

pro-cedures utilizing behavioral or distraction techniques,

obviating the need for procedural sedation However, the

stressful, frightening nature of an injury or ED

environ-ment often requires moderate to deep sedation to

over-come these factors and achieve diagnostic imaging goals

CLINICAL ASSESSMENT

Prior to the administration of any sedative agent, a

careful preprocedure assessment should be undertaken

Special attention should be given to historical featuresthat may complicate procedural sedation including apast history of adverse events with sedation or anes-thesia, medication history, and medication allergies Thehistory should also evaluate the patient for seizurepotential and/or the likelihood of a neurological injury/condition that may result in elevated intracranial pres-sures, as these considerations will be of importance inthe consideration for the appropriateness of ketamine.The guidelines of the American Society of Anesthe-siology recommend delaying sedation for at least 2–3 hrafter the last clear liquids and 4–8 hr after solids or milk.These recommendations are often not feasible whenapplied to the ED and there is a growing body of liter-ature that shorter fasting times are not associated withadverse events during procedural sedation

A thorough examination of the airway should beperformed in every patient prior to sedation with par-ticular attention given to predictors of difficult airwaymanagement including congenital airway anomalies (i.e.,the Pierre-Robin sequence or Beckwith-Wiedemannsyndromes) or acquired conditions (i.e., obesity, trauma,

173

or retropharyngeal abscess) that may make endotracheal

intubation or ventilation problematic The presence of a

difficult airway should alert the clinician that the

proce-dure may be better suited to the more controlled

envi-ronment of the operating room, rather than the ED

Auscultation of the lungs should be performed as the

presence of active upper respiratory infection or asthma

increases the risk of laryngospasm by as much as fivefold

A thorough cardiovascular examination should occur

in every patient, particularly in patients with known

underlying heart disease Volume status assessment is

imperative in all children, especially those with cardiac

disease as most of the agents used for sedation, with the

exception of ketamine, result in vasodilatation and carry

the risk of hypotension in the hypovolemic child

Minimal monitoring requirements include pulse

oximetry, cardiac monitor, and blood pressure

assess-ment Airway resuscitation equipment such as bag-valve

mask, suction, and tools for endotracheal intubation

should be readily available Reversal agents, such as

naloxone and flumazenil, should be on hand if opiates

or benzodiazepines are being employed End-tidal

car-bon dioxide measurements using capnography may alert

the clinician to apnea and hypoventilation prior to a

drop in oxygen saturation and this monitoring

tech-nique is being adopted in many institutions

PAIN/SEDATION CONSIDERATIONS

There are several very important considerations that

impact the planning of procedural sedation for pediatric

diagnostic imaging procedures (Table 27-1) These

include age of the patient, the specific imaging

proce-dure that is planned, whether intravenous contrast is

going to be used, and whether there is going to be any

pain associated with the procedure (i.e., hip aspiration

during ultrasonography or contrast injection during

VCUG) (Figure27-1)

Age of the patient greatly impacts the procedural

sedation strategy as older children may require only

anxiolysis whereas younger children are more likely to

require deeper levels of sedation The time of day also

plays a role as a child that is tired around naptime or at

night may only require a feeding and be allowed to sleep

naturally rather than undergo sedation for a study such

as CT of the head

The type of imaging study is also a factor in the choice

of any sedation strategy Obtaining plain radiographs

or performing an ultrasound rarely requires sedation

In contrast, magnetic resonance imaging because ofthe length of the procedure, the noise involved, andthe inability to visualize and assess the patient on anongoing basis, may require general anesthesia or evenendotracheal intubation

Children younger than 3 months of age typically can

be bundled and imaged without sedation whereas it maynot be possible to achieve the required degree of immo-bility for imaging in older infants and toddlers withoutmoderate to deep sedation Sedation is often required inyounger, uncooperative children, particularly if intra-venous contrast is being used Contrast studies takelonger to perform and the timing of the bolus is critical

to the acquisition of interpretable images Thus, instudies involving coordination or precision of timing,sedation may be needed as the study cannot be ‘‘redone’’

if there is significant patient movement

Some pediatric radiographic studies are coupled withdiagnostic procedures such as ultrasonography and hipaspiration for the evaluation of possible septic arthritis

or fluoroscopic-guided lumbar puncture For these types

of procedures, it is imperative to choose a sedative agentwith analgesic properties (Table27-2)

PAIN/SEDATION MANAGEMENTThere are a variety of agents available and suitablefor procedural sedation for pediatric imaging studies

Table 27-1 Factors to consider for proceduralsedation during pediatric radiographic procedures

 Age of patient

 Time of day (near sleep or naptime)

 Duration of procedure

 Degree of cooperation or immobility required

 Presence of head injury or risk of elevating intracranial pressures

 Hemodynamic stability

 Need for analgesia

 Provider training and experience

Sedative-Hypnotic Agents

Chloral hydrate

Chloral hydrate is a pure sedative agent without analgesic

properties that has been extensively used for procedural

sedation, particularly for outpatient diagnostic imaging in

children under the age of 3 years

Chloral hydrate has an excellent safety profile and can

be given either orally or rectally at a dose of 25–100 mg/kg

The choice of a proper dose for choral hydrate

administration should be adapted to the clinical scenario as

higher doses (75–100 mg/kg) will result in higher rates

of effective sedation when simultaneously prolonging the

sedation period

Advantages to chloral hydrate include predictable

clinical effects and the fact that intravenous access is not

required for administration Disadvantages include a

dose-dependent, prolonged duration of action (60–180

min) There have been selected reports of prolonged

after effects associated with chloral hydrate, including

behavioral changes that may last 24 hr

Benzodiazepines

Midazolam is the benzodiazepine of choice for short

procedures as it provides sedation, anxiolysis, and

amnesia at appropriate doses Midazolam can be give

through a variety of routes including orally (0.2–0.5 mg/

kg) and intravenously (0.1 mg/kg) Midazolam is often

used in combination with a short-acting opioid such as

fentanyl Combination use is associated with higher rates

of respiratory depression and adverse hemodynamic

events, though reversal of sedation with flumazenil is

possible

Some children experience a paradoxical excitatory

response to midazolam This response can be difficult to

treat as the child will be noted to increase in agitation

and anxiousness with midazolam dosing Parents should

be warned beforehand of the potential of this effect as it

can be a frustrating experience that may have to be

countered with higher dosing and/or change to another

sedation agent depending upon the clinical

circum-stances

Barbiturates

Barbiturates, particularly pentobarbital, have been safely

used for sedation during diagnostic procedures for many

years The advantages of barbiturates include a rapidonset and brief duration of clinical effects as well asdose- and route-dependent potent sedative effects Ide-ally, these agents are titrated to effect intravenouslythough a variety of administration routes exist includingthe rectal route

Rectal administration of methohexital and thiopentalhas been described in a number of investigations in themedical literature These reports have characterized thisroute as efficacious and safe, with a reduced rate ofrespiratory depression when compared to intravenousadministration Administration through the rectal route

is complicated by defecation in as many as one-quarter

of the patients, as a consequence of the irritant effect tothe mucosa This effect can be reduced by drug dilutionwith saline, and a consequent large increase in volumeinstilled

Pentobarbital is a vessel irritant and will often burnduring intravenous administration This effect can beattenuated by dilution with normal saline Dose-dependent respiratory depression and hypotension can

be observed Careful titration, particularly in depleted children, is an important consideration

volume-PropofolPropofol is increasingly utilized outside the operatingroom environment for sedation for all manner ofprocedures, including diagnostic imaging Propofol is apowerful sedative hypnotic with characteristics similar

to barbiturates Propofol is administered intravenously

at an initial dose of 1 mg/kg followed by 0.5 mg/kg

to maintain the sedated state The extremely shortduration of action and rapid onset make propofol anideal agent for brief procedures Its rapid metabolismand distribution may require higher dosing in youngerpatients, approximating 2.0–2.5 mg/kg, to achievethe depth of sedation often required for imagingstudies

Disadvantages to propofol use include pain at theinjection site and respiratory depression Childrenshould be monitored closely for adequate ventilationthroughout propofol sedation Monitoring during pro-pofol sedation should be done by a caregiver skilled inemergent rescue interventions The formulation ofpropofol also contains egg proteins and a history of eggallergy is considered a contraindication to its use

Etomidate is an imidazole, amnestic agent with rapid

onset and brief duration of action It has been widely

used as an induction agent for rapid sequence

intuba-tion and only recently has begun to be used for

proce-dural sedation Advantages to etomidate include its

stable hemodynamic profile and cerebroprotective

properties Adverse events associated with etomidate use

include respiratory depression, myoclonus, and

vomit-ing Dosages for procedural sedation range from 0.1 to

0.2 mg/kg IV with a duration of action of 8–10 min

Myoclonus is perhaps the most significant, and unusual,

disadvantage to the use of etomidate occurring in

approxi-mately 20% of patients Series of children sedated with

etomidate for radiographic imaging have been few to date

Ketamine

Ketamine is a unique agent that induces a dissociative

state characterized by maintenance of protective airway

reflexes It is associated with complete amnesia and

analgesia Ketamine can be give intravenously (1 mg/kg

followed by 0.5 mg/kg for maintenance) and

intramus-cularly (4–5 mg/kg IM) and has the advantage of a stable

hemodynamic profile, even in hypovolemic patients

Disadvantages to the use of ketamine include an

in-creased risk of laryngospasm in children with active

upper respiratory infections or asthma and a small risk

of emergence reaction Emergence reactions in children

sedated with ketamine tend to be relatively mild and

short acting Ketamine also causes an increase in

intra-cranial pressure, making it ill-suited for many patients

undergoing diagnostic imaging for head injury or with a

significant seizure history

FOLLOW-UP CONSIDERATIONS

All children undergoing procedural sedation for

diag-nostic imaging should be monitored for respiratory

depression At discharge, the child should be awake,

alert, and at an age-appropriate baseline level of

neu-rologic function and should be accompanied by a parent

or guardian

Sedation-specific discharge instructions including

possible complications and signs of respiratory

depres-sion should be given to each patient, as some sedation

agents may have a prolonged duration of action

SUMMARYSedation of children for radiographic imaging studies

is a common practice in many clinical environments.Pediatric imaging evaluations may require sedation,particularly longer or more complicated radiographicassessments or in younger children and those with highpain levels and/or anxiety

A number of sedative agents and approaches havebeen described as effective for pediatric radiographicimaging The specific approach should be determined by

a number of factors including the clinical setting, patientage, provider experience, specific injury or illnessespresent at the time of the procedure, and the plannedimaging intervention

BIBLIOGRAPHY

1 Krauss B, Zurakowski D Sedation patterns in pediatricand general community hospital emergency departments.Pediatr Emerg Care 1998;14:99–103

2 Clinical policy for procedural sedation and analgesia in theemergency department American College of EmergencyPhysicians Ann Emerg Med 1998;31:663–677

3 Practice guidelines for sedation and analgesia by anesthesiologists Anesthesiology 2002;96:1004–1017

non-4 American Academy of Pediatrics Committee on Drugs:Guidelines for monitoring and management of pediatricpatients during and after sedation for diagnostic andtherapeutic procedures Pediatrics 1992;89:1110–1115

5 Krauss B, Green SM Sedation and analgesia for dures in children N Engl J Med 2000;342:938–945

proce-6 Green SM, Krauss B Pulmonary aspiration risk duringemergency department procedural sedation – an examina-tion of the role of fasting and sedation depth Acad EmergMed 2002;9:35–42

7 Roback MG, Bajaj L, Wathen JE, Bothner J Preproceduralfasting and adverse events in procedural sedation andanalgesia in a pediatric emergency department: Are theyrelated? Ann Emerg Med 2004;44:454–459

8 McQuillen KK, Steele DW Capnography during sedation/analgesia in the pediatric emergency department PediatrEmerg Care 2000;16:401–404

9 Newman DH, Azer MM, Pitetti RD, Singh S When is apatient safe for discharge after procedural sedation? Thetiming of adverse effect events in 1367 pediatric procedur-

al sedations Ann Emerg Med 2003;42:627–635

10 Malviya S, Voepel-Lewis T, Prochaska G, Tait AR.Prolonged recovery and delayed side effects of sedationfor diagnostic imaging studies in children Pediatrics2000;105:1110–1115

11 Mace SE, Barata IA, Cravero JP, et al Clinical policy:Evidence-based approach to pharmacologic agents used in

pediatric sedation and analgesia in the emergency

depart-ment Ann Emerg Med 2004;44:342–377

12 Pershad J, Palmisano P, Nichols M Chloral hydrate: The

good and the bad Pediatr Emerg Care 1999;15:432–435

13 Moro-Sutherland DM, Algren JT, Louis PT, et al

Comparison of intravenous Midazolam with pentobarbital

for sedation for head computed tomography imaging

Acad Emerg Med 2000;7:1370–1375

14 Rothermel LK Newer pharmacologic agents for procedural

sedation of children in the emergency department –

etomidate and propofol Curr Opin Pediatr 2003;15: 200–203

15 Ruth WJ, Burton JH, Bock AJ Intravenous etomidate forprocedural sedation in emergency department patients.Acad Emerg Med 2001;8:13–18

16 Bassett KE, Anderson JL, Pribble CG, Guenther E.Propofol for procedural sedation in children in theemergency department Ann Emerg Med 2003;42:773–782

17 Green SM, Krauss B Clinical practice guideline foremergency department ketamine dissociative sedation inchildren Ann Emerg Med 2004;44:460–471

28 Procedural Sedation for Brief Pediatric Procedures:

Foreign Body Removal, Lumbar Puncture, Bone Marrow

Aspiration, Central Venous Catheter Placement

Michael Ciccarelli and John H Burton

SCOPE OF THE PROBLEM

SCOPE OF THE PROBLEM

The pediatric population accounts for a large percentage

of emergency department (ED) visits annually Many

of these patients will require brief, painful procedures

either in the ED or in another setting such as the

intensive care unit These procedures also occur

fre-quently in the outpatient clinic or inpatient setting for

children with chronic illnesses To affect an optimal

procedural experience for these patients, a pediatric

procedure unit or clinical response team of well-trained

caregivers has been a recent trend

Typical procedures for these patients include lumbar

puncture, bone marrow aspiration, and central venous

catheter placement These procedures, and other brief

diagnostic and therapeutic procedures in this population,

are similar to the adult population in the intervention

and technique required They are distinct from their adult

counterparts, however, in that the pediatric patient will

often require sedation and anxiolysis owing to the child’s

fear, in addition to a need to create an experience that is

positive and supportive instead of a recurrent, negative

association with medical care Younger patients will also

often require a brief period of sedation to optimize

positioning or minimize movement

It has been previously documented that there isconsiderable underuse of analgesia and sedation inchildren requiring brief, painful medical interventions.The goal of procedural sedation in this setting is toprovide sedative, analgesic, and/or dissociative agents toalter recognition of pain and level of consciousness, atthe same time maintaining airway reflexes in order

to provide symptomatic relief of pain and anxiety.Over the last decade, there has been a relative increase

in the recognition of the needs of this populationand innovative approaches These approaches includepharmacological management, caregiver training, andindividualized approaches toward the needs of eachchild

CLINICAL ASSESSMENTThe assessment of children undergoing proceduralsedation and analgesia (PSA) for brief procedures issimilar to the general sedation assessment The patientassessment should include a focused history and physicalexamination to identify issues that may interfere withsedation or increase the risk of adverse sedation events.Discussion with the patient and family regarding risksand benefits of sedation should also be routine prior to

179

adoption of a treatment plan Any patient whose risk of

a serious adverse event outweighs the proposed benefits of

sedation may be better served by delaying the procedure

until a more comprehensive approach can be undertaken,

such as general anesthesia in the operating suite

A focused assessment should also include any prior

history of seizure, head injury, or active condition that

would place the placement at risk of adverse outcome

with a sedation agent that would mildly elevate

intra-cranial pressure Ketamine is an agent that has a very

attractive sedation profile for many of these patients

when an intramuscular or intravenous agent is

consid-ered However, ketamine is unique from other sedation

agents in that it has the potential to elevate intracranial

pressure, cerebral metabolism, and oxygen

consump-tion Many pediatric patients requiring brief medical

procedures will have concurrent head injury or

condi-tions such as seizures that should motivate a cautious

consideration of the risks associated with ketamine

Similarly, the clinical assessment should include

consideration of any condition that places the patient at

risk of adverse outcome for a sedation agent that may

reduce central venous pressure Many intravenous

agents, such as propofol and methohexital, create the

potential for significant decreases in central venous

return and subsequent hypotension Children who are

considered hemodynamically unstable, or at substantial

risk for hemodynamic instability, should be approached

with caution when these agents are considered

PAIN/SEDATION CONSIDERATIONS

Routine patient monitoring during sedation should

include level of consciousness, respiratory status, vital signs,

and oxygen saturation The most commonly encountered

adverse events during sedation in the pediatric population

are respiratory depression and vomiting Except in

sce-narios that utilize very light sedation regimes, ventilation

equipment, suction, and intravenous fluid resuscitation

materials should be immediately available to the clinical

team throughout the sedation encounter

The benefits derived from a procedural sedation

approach include

1 patient experience benefits including anxiolysis,

relaxation, analgesia, and amnesia;

2 improved parental satisfaction;

3 less stressful situation for medical personnel;

4 improved safety of the patient and staff whenperforming a medical procedure;

5 ability to satisfactorily complete the needed medicalprocedure

The choice of a sedative and/or analgesic approach shouldtake into consideration all of these potential benefitswithin the context of the specific procedure and patient(Table28-1) The caregiver should take into consideration

an assessment of the child’s distress prior to and anticipatedduring the procedure as well as the degree of pain that will

be anticipated during the intervention (Figure28-1) Theseconsiderations should direct the sedation approach, par-ticularly with regard to an emphasis on anxiolysis, sedation,and analgesia

Many nonpharmacologic approaches may sufficesolely, or in part, to achieve the desired effect for thepatient These elements might include parental presenceduring the procedure as well a medical provider’sdemeanor that is calming to the child with a reassuring,nonthreatening approach

SEDATION MANAGEMENTMultiple agents have been studied for procedural seda-tion in the pediatric population Most studies identify-ing appropriate agents for procedural sedation in the EDand procedure-focused setting have been described inpopulations of pediatric patients undergoing painfulorthopedic procedures, including joint reduction andfracture reduction Few studies have been publishedwith a focus population of children undergoing painfulprocedures other than predominantly orthopedic andlaceration repair interventions

Characteristics to consider for any sedation andanalgesia approach in children with brief medical pro-cedures include painless administration, a rapid onset ofclinical effects, the ability to easily titrate the agent(s) to

a desired level of sedation, a rapid recovery time, andlimited side effects – specifically vomiting, respiratorydepression, hypotension, and emergence reactions.The most commonly utilized agents in these settingsare nitrous oxide, benzodiazepines (e.g., midazolam),etomidate, barbiturates (e.g., methohexital), propofol,

and ketamine Each of these agents has specific

advan-tages and disadvanadvan-tages that may enhance its

appro-priateness for any given patient and procedure

(Table28-2)

Nonpharmacologic approaches can also be useful inwhole or as part of an adjunctive strategy with otheragents Additionally, anesthetic agents applied to theskin, including regional block anesthesia, should be

Table 28-1 Sedation, anxiolysis, and analgesia considerations for brief painful procedures

(e.g., foreign body removal, lumbar puncture, bone marrow aspiration, central venous

catheter placement) in pediatric patients

1 Would the patient benefit from analgesia?

Is the patient currently in pain?

Will the procedure be painful?

Will the patient have pain after the procedure?

2 What form of pain control is appropriate, if necessary? Nonpharmacologic,

topical anesthesia, regional block anesthesia, systemic analgesia

3 Would the patient benefit from anxiolysis?

4 What form of anxiolysis is appropriate? Nonpharmacologic, oral agent

(e.g., a benzodiazepine), inhaled nitrous oxide, systemic anxiolytic agent

5 Would the patient benefit from sedation?

6 What depth of sedation is appropriate? Mild, moderate, deep sedation

Patient needs Depth of sedation Length of analgesia

Sedation only

Sedation, analgesia during procedure

Sedation, analgesia during and after procedure

Long Morphine

Figure 28-1 Algorithm for approach to selected brief painful procedures in the pediatric population.

considered in the approach to brief procedures for all

encounters, including pediatric patients

Specific Agents for Sedation/Analgesia during

Brief Pediatric Procedures

Nitrous oxide has been described in a number of reports

in the medical literature for brief pediatric procedures,

particularly laceration repair The advantage of nitrous

oxide is the rapid onset and brief duration of clinical

effects following cessation of inhalation

The analgesic and sedative properties of nitrous oxide

are variable in the pediatric population with up to 20%

of children described as nonresponders Children

responding well to nitrous administration will generally

have light levels of sedation with few sustaining more

moderate levels of sedation The analgesic properties of

nitrous oxide are characterized as significant, although

relatively minor compared to intravenous analgesics

Another advantage of nitrous oxide use in the atric population is its minimal effects on the cardio-vascular system and respiratory effort Hypoventilation

pedi-is quickly resolved with cessation of nitrous inhalationand patient stimulus Given historic concerns for moresubstantial levels of sedation associated with prolongednitrous inhalation, it is generally recommended thatnitrous be ‘‘self-administered’’ or, at the least, carefullymonitored during assisted administration in youngerpediatric patients

Midazolam can be used alone or in combination withopiates for selected procedures It is typically used alone

if there is increased agitation for a nonpainful dure; otherwise, midazolam can be combined withfentanyl for procedures inducing pain

proce-Intravenous fentanyl or midazolam offer attractivehemodynamic profiles for sedation patients Both drugshave short onset times and short half-lives (although

Table 28-2 Summary of sedation and analgesia considerations for selected pediatric brief

diagnostic and therapeutic procedures

Nitrous oxide Inhaled Rapid onset

Minimal side effects Analgesic properties

No IV required Very short acting

Light sedation Cooperation required

Midazolam Oral

Intranasal Intravenous

No IV required Oral and nasal routes Titratable sedation levels

Longer acting Less reliable sedation levels Deep sedation with IV form Propofol Intravenous Reliable sedation levels

Rapid onset Short acting

IV required Deep sedation Decrease in venous return Respiratory depression Etomidate Intravenous Reliable sedation levels

Rapid onset Short acting

Myoclonus Deep sedation Respiratory depression

IV required Methohexital Intravenous Reliable sedation levels

Rapid onset Short acting

Deep sedation Decrease in venous return Respiratory depression

IV required Ketamine Intramuscular

Intravenous

Reliable sedation levels

IV not required for IM Rapid onset

Analgesic properties

Vomiting Longer acting Elevation of intracranial pressure and intraocular pressure

midazolam has a longer period of clinical effects than ultra

short-acting drugs such as etomidate or propofol), with

the added benefit of available reversal agents Caution

should be exercised with the common practice of

com-bining these drugs, as often performed in stable patients

requiring analgesia and sedation for brief procedures The

combination of these drugs will increase the likelihood

of hemodynamic changes (e.g., hypotension) as well as

clinically significant respiratory depression

Ketamine is frequently used for pediatric procedures

It is known as a dissociative anesthetic agent because it

produces a trance-like effect in the patient Ketamine is

unique in that it has sedative effects with amnestic and

analgesic properties Typically, patients will maintain

muscle tone, ventilation, and airway reflexes during

ketamine sedation It has been used for pediatric

seda-tion via multiple routes including intravenous and

intramuscular administration

Compared with propofol and etomidate, ketamine

effects a longer sedation recovery time for pediatric

patients; however, there is less respiratory and

cardio-vascular adverse risk Important side effects include

vomiting, which occurs more often with ketamine as

compared to other sedation medications Another

common side effect of ketamine is an emergence

delir-ium reaction Emergence reactions are more common in

children under 5 years of age and in adults

Ketamine should be avoided in the head injured

pa-tient secondary to its sympathomimetic effect and

sub-sequent elevation of systemic blood pressure causing

cerebral vasodilatation leading to increased intracranial

pressure Laryngospasm is a rare occurrence (<1%)

associated with ketamine usage

Etomidate has recently been described for a role in

pediatric procedural sedation Etomidate has minimal

respiratory effects and no cardiovascular adverse

out-comes, making it a consideration for a potentially

hemodynamically unstable patient

The most common side effect reported for etomidate

is myoclonus, which occurs in approximately 20% of

patients Reports of etomidate use in pediatric patients

remain few, and the incidence of myoclonus in the

pe-diatric procedural sedation population remains unclear

Propofol has become increasingly common as an agent

for procedural sedation in the pediatric population

for brief procedures Propofol is an ultra short-acting

sedative hypnotic Propofol has a very rapid onset andbrief duration of action, with sedation occurring at lessthan 1 min following administration and recovery timetypically described as occurring within 5–15 min.For brief pediatric procedures, propofol has been typi-cally administered through bolus intravenously, at a dose

of 1 mg/kg, with repeat boluses of 0.5 mg/kg to maintainadequate sedation for the procedure Pediatric patientsgenerally require larger bolus doses and maintenancedosing, 25–50% greater, as compared to adult patients,likely secondary to a larger volume of distribution.The main adverse effect from propofol administration

is cardiopulmonary depression Propofol has a relativelyhigh incidence of respiratory depression that may lead tohypoxia and apnea In most cases of respiratory depres-sion, airway repositioning, suctioning, and supplementaloxygen correct the hypoventilatory event, although theuse of bag-mask ventilation should be anticipated withthis agent, as with any deep sedation agent

The clinical use of intravenous barbiturates for briefpediatric procedures has been characterized as similar topropofol Barbiturates have a rapid onset of action withthe most common adverse events noted as respiratorydepression and decreased venous return Given theadvantages associated with ultra short-acting agentssuch as propofol, the use of intravenous methohexitalwould seem most advantageous compared to otherbarbiturates The characterization in the medical litera-ture of the use of methohexital for brief pediatric pro-cedures has been few to date, compared to intravenouspropofol

FOLLOW-UP/CONSULTATIONCONSIDERATIONS

Discharge instructions for pediatric patients undergoingsedation for procedures should include proceduralsedation instructions as well as instructions to return tothe ED, or patient care setting, if there are any concernsfollowing the sedation

SUMMARYPediatric procedural sedation has become increasinglycommon within the ED and pediatric procedure settingsfor both therapeutic and diagnostic simple procedures

It is reasonable and safe to use sedation if a procedure is

particularly painful or if the patient is overly anxious A

diverse range of medications and approaches are

avail-able that should be individualized to the patient’s needs

as well as the patient care providers and setting

BIBLIOGRAPHY

1 Green MS, Rothrock SG, Lynch EL, et al Intramuscular

ketamine for pediatric sedation in the emergency

depart-ment: Safety profile of 1,022 patients Ann Emerg Med

1998;31:688–697

2 Green MS, Nakamura R, Johnson NE Ketamine sedation

for pediatric procedures part 1, A prospective series Ann

Emerg Med 1990;19:1024–1032

3 Green MS, Johnson NE Ketamine sedation for pediatric

procedures Part 2, review and implications Ann Emerg

Med 1990;19:1033–1046

4 Wathen JE, Roback MG, Mackenzie T, Bothner JP Does

midazolam alter the clinical effects of intravenous

keta-mine sedation in children? A double-blind, randomized,

controlled, emergency department trial Ann Emerg Med

2000;36(6):579–588

5 Burton JH, Auble TE, Fuchs SM Effectiveness of 50%nitrous oxide during laceration repair in young pediatricpatients Acad Emerg Med 1998;5(2):72–73

6 Dickinson R, Singer AJ, Carrion W Etomidate forpediatric sedation prior to fracture reduction AcadEmerg Med 2001;8(1):74–77

7 Rothermel LK Newer pharmacologic agents for

procedur-al sedation of children in the emergency department –etomidate and propofol Curr Opin Pediatr 2003;15:200–203

8 Havel CJ, Strait RT, Hennes H A clinical trial of propofol

vs midazolam for procedural sedation in a pediatricemergency department Acad Emerg Med 1999;6:989–997

9 Bassett KE, Anderson JL, Pribble CG, Guenther E.Propofol for procedural sedation in children in theemergency department Ann Emerg Med 2003;42:773–782

10 Guenther E, Pribble CG, Junkins E, Kadish H, Bassett K,Nelson D Propofol sedation by emergency physicians forelective pediatric outpatient procedures Ann Emerg Med2003;42:783–791

11 Roback MG, Wathe JE, MacKenzie T, Bajaj LA ized controlled trial of IV versus IM ketamine for sedation

random-of pediatric patients receiving emergency departmentpediatric procedures Ann Emerg Med 2006;48:605–612

29 Procedural Sedation for Adult and Pediatric

Orthopedic Fracture and Joint Reduction

James Miner and John H Burton

SCOPE OF THE PROBLEM

SCOPE OF THE PROBLEM

The closed reduction of fractures and dislocations

presents an excellent situation in which to perform

procedural sedation Fracture and joint reductions

involve a great deal more pain than the patient feels prior

to or after the reduction Procedural sedation should

provide analgesia prior to and during the procedure,

sedation, muscle relaxation, and procedural amnesia for

these painful events Proper sedation for these procedures

has the additional benefit to the medical care provider(s)

by optimizing patient relaxation to facilitate a successful

reduction

Once a reduction has been completed, patients often

have less pain than prior to the procedure owing to

stabilization of the bone or joint The use of long-acting

sedative agents for procedural sedation, in combination

with long-acting analgesics, may lead to patients who

have unnecessarily extended periods of sedation

partic-ularly following the procedure when stimulus and pain

are minimal Such an extended period may lead to

re-spiratory depression at a time when patient monitoring

has been reduced This concern, in addition to caregiver

desires to shorten procedural sedation times in order to

reduce the period of moderate or deep sedation and the

duration of extensive staff patient monitoring, has led to

significant changes in medical practice in favor of

short-acting sedation agents

CLINICAL ASSESSMENT

Both the urgency of the patient’s requirement for ture or joint reduction and the patient’s current andpreexisting medical conditions must be considered prior

frac-to procedural sedation The depth and timing of tion should achieve an optimal balance for the patient’sneeds, risk of the procedure and/or delays to the pro-cedure, and risk of sedation

seda-The urgency of a patient’s need for fracture or jointreduction is determined by the nature of the injury.Emergent indications for fracture reduction includefractures causing vascular compromise to the effectedextremity and/or intractable pain and suffering to thepatient For this reason, the immediate patient clinicalassessment should emphasize the patient’s global he-modynamic stability and neurological status in addition

to the neurological and vascular status of the affectedextremity Injuries with concerning clinical findingsshould be reduced as quickly as possible to preventinjuries associated with fracture or joint reductiondelays This approach should also apply to patientsdeemed to have intractable pain and suffering

Many acute fractures without associated vascularcompromise or extensive patient suffering are injuries inwhich the patient may achieve a reasonable comfortlevel with simple mechanical immobilization and/orsystemic analgesia These injuries are best classified as

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