Annals of Emergency Medicine
Volume 53, Issue 4 , Pages 426-435.e4 , April 2009

Consensus-Based Recommendations for Standardizing Terminology and Reporting Adverse Events for Emergency Department Procedural Sedation and Analgesia in Children

  • Maala Bhatt, MD

      Affiliations

    • Division of Emergency Medicine, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
    • Corresponding Author InformationAddress for correspondence: Maala Bhatt, MD, Division of Emergency Medicine, Montreal Children's Hospital, 2300 Tupper Street, Rm T-122, Montreal, QC, H3H 1P3 Canada; 514-412-4400 ext 22740, fax 514-412-4397
    • ,
  • Robert M. Kennedy, MD

      Affiliations

    • Division of Emergency Medicine, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
    • ,
  • Martin H. Osmond, MDCM

      Affiliations

    • Division of Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
    • ,
  • Baruch Krauss, MD, EdM

      Affiliations

    • Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA
    • ,
  • John D. McAllister, MD

      Affiliations

    • Division of Pediatric Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
    • ,
  • J. Mark Ansermino, MBBCh, MSc

      Affiliations

    • Department of Pediatric Anesthesia, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Lisa M. Evered, MD, MSc

      Affiliations

    • Division of Emergency Medicine, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
    • ,
  • Mark G. Roback, MD

      Affiliations

    • Division of Emergency Medicine, University of Minnesota Children's Hospital Fairview, University of Minnesota Medical School, Minneapolis, MN
    • ,
  • Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Care Applied Research Network (PECARN)

Received 10 June 2008 ,Revised 11 September 2008 ,Accepted 26 September 2008.

References 

  1. Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized controlled trial. Pediatrics. 2006;117:e1170–e1178
  2. Barbi E, Gerarduzzi T, Marchetti F, et al. Deep sedation with propofol by nonanesthesiologists: a prospective pediatric experience. Arch Pediatr Adolesc Med. 2003;157:1097–1103
  3. Pena BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999;34(4 pt 1):483–491
  4. Roback MG, Bajaj L, Wathen JE, et al. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?. Ann Emerg Med. 2004;44:454–459
  5. Roback MG, Wathen JE, Bajaj L, et al. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med. 2005;12:508–513
  6. Sacchetti A, Stander E, Ferguson N, et al. Pediatric procedural sedation in the community emergency department: results from the ProSCED registry. Pediatr Emerg Care. 2007;23:218–222
  7. Agrawal D, Manzi SF, Gupta R, et al. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 2003;42:636–646
  8. Bell A, Treston G, McNabb C, et al. Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation. Emerg Med Australas. 2007;19:405–410
  9. Guenther E, Pribble CG, Junkins EP, et al. Propofol sedation by emergency physicians for elective pediatric outpatient procedures. Ann Emerg Med. 2003;42:783–791
  10. Wood C, Hurley C, Wettlaufer J, et al. Retrospective comparison of emergency department length of stay for procedural sedation and analgesia by nurse practitioners and physicians. Pediatr Emerg Care. 2007;23:709–712
  11. Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med. 2003;157:1090–1096
  12. Cummings RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style (A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada and the Australian Resuscitation Council). Circulation. 1991;84:960–975
  13. Idris AH, Berg RA, Bierens BJ, et al. Recommended guidelines for uniform reporting of data from drowning: the ”Utstein Style.”. Circulation. 2003;108:2565–2574
  14. Dick WF, Baskett PJ, Grande C, et al. Recommendations for uniform reporting of data following major trauma—the Utstein style (An international Trauma Anaesthesia and Critical Care Society (ITACCS) initiative). Br J Anaesth. 2000;84:818–819
  15. Hollander JE, Blomkalns AL, Brogan GX, et al. Standardized reporting guidelines for studies evaluating risk stratification of ED patients with potential acute coronary syndromes. Acad Emerg Med. 2004;11:1331–1340
  16. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation. Circulation. 2004;110:3385–3397
  17. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367:766–780
  18. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med. 2000;342:938–945
  19. Green SM, Krauss B. Procedural sedation terminology: moving beyond ”conscious sedation.”. Ann Emerg Med. 2002;39:433–435
  20. Green SM, Roback MG, Miner J, et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49:454–461
  21. Kennedy RM, McAllister JD. Midazolam with ketamine: who benefits?. Ann Emerg Med. 2000;35:297–299
  22. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? (a randomized, double-blind, placebo-controlled trial). Ann Emerg Med. 2000;35:229–238
  23. 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
  24. Streiner DL, Norman GR. Continuous Judgements (Health Measurement Scales). In: 3rd ed.. Oxford, UK: Oxford University Press; 2003;p. 33–34
  25. Burton JH, Miner J. Emergency Sedation and Pain Management. New York, NY: Cambridge University Press; 2008;
  26. Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118:2587–2602
  27. Gross JB, Farmington CT, Bailey PL, et al. American Society of Anesthesiology Task Force on Sedation and Analgesia by Non-Anesthesiologists (Practice Guidelines for sedation and analgesia by non-anesthesiologists). Anesthesiology. 2002;96:1004–1017
  28. Committee on Drugs. Section on Anesthesiology. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics. 1985;76:317–321
  29. Goodwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45:177–196
  30. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med. 2004;44:460–471
  31. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med. 1998;31:688–697
  32. Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation—an examination of the role of fasting and sedation depth. Acad Emerg Med. 2002;9:35–42
  33. Hoffman R, Nowakowski R, Troshynski TJ, et al. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics. 2002;109:236–243
  34. Ramsay M, Savege T, Simpson B, et al. Controlled sedation with alphaxalone-alphadolone. BMJ. 1974;2:656–659
  35. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970;49:929–934
  36. Ambuel B, Hamlett KW, Marx CM, et al. Assessing distress in pediatric intensive care environments: the COMFORT Scale. J Pediatr Psychol. 1992;17:95–109
  37. Miner J, Krauss B. Procedural sedation and analgesia research: state of the art. Acad Emerg Med. 2007;14:170–178
  38. Roback MG, Wathen JE, MacKenzie T, et al. A randomized, controlled trial of IV versus IM ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006;48:605–612
  39. Heistein LC, Ramaciotti C, Scott WA, et al. Chloral hydrate sedation for pediatric echocardiography: physiologic responses, adverse events, and risk factors. Pediatrics. 2006;117:e434–e441
  40. Dalal PG, Murray D, Cox T, et al. Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants: provider and pharmacologic considerations. Anesth Analg. 2006;103:863–868
  41. Sanborn PA, Michna E, Zurakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology. 2005;237:288–294
  42. Antmen B, Saşmaz I, Birbiçer H, et al. Safe and effective sedation and analgesia for bone marrow aspiration procedures in children with alfentanil, remifentanil and combinations with midazolam. Paediatr Anaesth. 2005;15:214–219
  43. Berkenbosch JW, Graff GR, Stark JM, et al. Use of a remifentanil-propofol mixture for pediatric flexible fiberoptic bronchoscopy sedation. Paediatr Anaesth. 2004;14:941–946
  44. Kienstra AJ, Ward MA, Sasan F, et al. Etomidate versus pentobarbital for sedation of children for head and neck CT imaging. Pediatr Emerg Care. 2004;20:499–506
  45. Mensour M, Pineau R, Sahai V, et al. Emergency department procedural sedation and analgesia: a Canadian Community Effectiveness and Safety Study (ACCESS). CJEM. 2006;8:94–99
  46. Willman EV, Andolfatto G. A prospective evaluation of ”ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;49:23–30
  47. Anderson JL, Junkins E, Pribble C, et al. Capnography and depth of sedation during propofol sedation in children. Ann Emerg Med. 2007;49:9–13
  48. Dial S, Silver P, Bock K, et al. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care. 2001;17:414–420
  49. Bassett KE, Anderson JL, Pribble CG, et al. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med. 2003;42:773–782
  50. Hoffman GM, Nowakowski R, Troshynski TJ, et al. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics. 2002;109:236–243
  51. Schreiner MS, O'Hara I, Markakis DA, et al. Do children who experience laryngospasm have an increased risk of upper respiratory tract infection?. Anesthesiology. 1996;85:475–480
  52. Fink BR. The etiology and treatment of laryngeal spasm. Anesthesiology. 1956;17:569–577
  53. Hampson-Evans D, Morgan P, Farrar M. Pediatric laryngospasm. Pediatr Anesth. 2008;18:303–307
  54. Green SM, Kuppermann N, Rothrock SG, et al. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med. 2000;35:35–42
  55. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? (a double-blind, randomized, controlled, emergency department trial). Ann Emerg Med. 2000;36:579–588
  56. Warner MA, Warner ME, Warner DO, et al. Perioperative pulmonary aspiration in infants and children. Anesthesiology. 1999;90:66–71
  57. Gundappa N, Chikyarappa A. A review of patients with pulmonary aspiration of gastric contents during anesthesia reported to the departmental quality assurance committee. J Clin Anesth. 2006;18:102–107
  58. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344:665–671
  59. Borland LM, Sereika SM, Woelfel SK, et al. Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth. 1998;10:95–102
  60. Zaritsky AL, Schexnayder SM, Berg RA, et al. Bradyarryhthmias and tachyarrhythmias. In:  Ralston M,  Hazinski MF,  Zaritsky AL, et al. editor. PALS Course Guide. Dallas, TX: American Heart Association; 2006;p. 45
  61. Zaritsky AL, Schexnayder SM, Berg RA, et al. Circulation. In:  Ralston M,  Hazinski MF,  Zaritsky AL, et al. editor. PALS Course Guide. Dallas, TX: American Heart Association; 2006;p. 17
  62. Doenicke AW, Roizen M, Kugler J, et al. Reducing myoclonus after etomidate. Anesthesiology. 1999;90:113–119
  63. Convulsion. In:  Anderson DM,  Patwell JM,  Plaut K, et al. editor. Dorland's Illustrated Medical Dictionary. 31st ed.. Philadelphia, PA: WB Saunders Co; 2007;
  64. Robin C, Trieger N. Paradoxical reactions to benzodiazepines in intravenous sedation: a report of 2 cases and review of the literature. Anesth Prog. 2002;49:128–132
  65. Kennedy RM, Porter FL, Miller JP, et al. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics. 1998;102:956–963
  66. Kaplan HI, Sadock BJ, Grebb JA. Kaplan and Sadock's Synopsis of Psychiatry. Behavioral Sciences Clinical Psychiatry. 7th ed.. Baltimore, MD: Wilkins & Wilkins; 1994;
  67. Death. In:  Anderson DM,  Patwell JM,  Plaut K, et al. editor. Dorland's Illustrated Medical Dictionary. 31st ed.. Philadelphia, PA: WB Saunders Co; 2007;

 Supervising editor: Steven M. Green, MD

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This work was supported by a Canadian Institutes of Health Research Team Grant in Pediatric Emergency Medicine.

 Publication dates: Available online November 20, 2008.

PII: S0196-0644(08)01849-0

doi: 10.1016/j.annemergmed.2008.09.030

Annals of Emergency Medicine
Volume 53, Issue 4 , Pages 426-435.e4 , April 2009

Article Tools

* Image Usage & Resolution