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      Pediatric procedural sedation and analgesia

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          Abstract

          Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.

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          Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases.

          Steven M Green, Steven Rothrock, Elizabeth Lynch … (1998)
          To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol. We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients. Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. Physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n = 7), laryngospasm (n = 4), apnea (n = 2), and respiratory depression (n = 1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. Ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine. Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. Ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes.
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            Sedation and analgesia for procedures in children.

            Baruch Krauss, Robert S. Green (2000)
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              Reducing pain during propofol injection: the role of the solvent.

              W Kellermann, J. RAU, J Babl … (1996)
              We hypothesized that the concentration of propofol in the aqueous phase may be the most important variable responsible for the pain experienced during injection of the drug. The concentration of propofol in the aqueous phase (18.57 micrograms/mL) can be decreased by increasing the fat content of the solvent. To test this hypothesis, 36 patients were randomly allocated to one of three groups, each receiving a different formulation of propofol. Group A received 20 mL of propofol alone in a commercial preparation (Diprivan(R) with 10 mL of saline); Group B, 20 mL of propofol to which 5 mL of long-chain triglyceride (LCT) fat emulsion and 5 mL of saline and been added; and Group C, 20 mL of propofol and 10 mL of LCT fat emulsion. The propofol emulsion was injected over 30-60 s into a dorsal vein of the hand. Patients reported pain during injection as none, mild, moderate, or severe (almost intolerable). In Group A, 8 of 12 patients reported moderate or severe pain upon injection whereas in Group C only mild pain was reported by 6 of 12 patients. Our results suggest that a smaller concentration of propofol in the aqueous phase of the emulsion reduces pain on injection. With the addition of more lipid (10 mL), a higher percentage of propofol is absorbed by fat particles. If solvents that permit a smaller concentration of the drug in the aqueous phase of oil-in-water emulsions were used for propofol and other drugs that cause pain on injection, pain would be reduced and patient satisfaction may be increased.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Emerg Trauma Shock
                Journal ID (publisher-id): JETS
                Title: Journal of Emergencies, Trauma and Shock
                Publisher: Medknow Publications (India )
                ISSN (Print): 0974-2700
                ISSN (Electronic): 0974-519X
                Publication date (Print): Jul-Dec 2008
                Volume: 1
                Issue: 2
                Pages: 88-96
                Affiliations
                [1 ]Department of Otolaryngology, University of South Florida, Tampa, Florida, USA
                [2 ]Department of Medicine, Division of Emergency Medicine, University of South Florida, Tampa, Florida, USA
                [3 ]Department of Global Health, University of South Florida, Tampa, Florida, USA
                Author notes
                Correspondence: James R Meredith, E-mail: jmeredit@ 123456hsc.usf.edu
                Article
                Publisher ID: JETS-01-88
                DOI: 10.4103/0974-2700.43189
                PMC ID: 2700614
                PubMed ID: 19561987
                SO-VID: a3000c2c-41f5-480e-ae64-d1bc067099db
                Copyright © © Journal of Emergencies, Trauma and Shock
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 01 May 2008
                Date accepted : 21 August 2008
                Categories
                Subject: Symposium

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: analgesia,sedation,pediatric
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: analgesia, sedation, pediatric

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