Paediatric procedural sedation within the emergency department

Introduction

Emergency department (ED) attendances due to acute pain are very common in children. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) reported on 314 025 attendances around Australia and New Zealand, and 28 123 attendances to Royal Darwin Hospital. ^, In both cohorts, forearm fractures and lacerations were among the most common diagnoses. Pain can be the trigger for ED presentation but may also be the consequence of necessary medical management within the ED.

The development of procedural sedation (PS) parallels the development of paediatric emergency medicine as a subspecialty. As clinicians developed confidence in managing the sedated child, procedures previously performed in the operating theatre have migrated to the ED. ED performance of PS allows more rapid discharge, reduces costs, and increases clinician skills and job satisfaction, while making unpleasant procedures more tolerable to children and their families. ^,

The goal of procedural sedation

The ultimate goal of PS is to safely achieve a level of sedation that allows successful completion of the necessary procedure, a return to consciousness and discharge home within a reasonable time frame. However, it is not enough to safely sedate a child. A practitioner competent in the procedure that is deemed necessary must be available. If there is doubt, then ED PS may be inappropriate.

Collaborative planning between the ED staff and other specialists may be required. The procedure may need to be done in an operating theatre or may still be achieved with the ED practitioner taking responsibility for safe sedation and a relevant proceduralist undertaking the procedure. One clinician must remain responsible for, and focus on, safe PS, whether or not the procedure is undertaken by an ED clinician or another specialist.

Although serious adverse events are rare, sedation providers should be prepared to intervene should complications occur. Coté and Hoffman demonstrated that patient selection, adherence to a prescribed process and minimisation of the number of sedating agents were important in reducing PS risks. Sedation registries have provided data accumulated over many thousands of sedation events. The Pediatric Sedation Research Consortium ( www.pedsedation.org ) in the United States receives data from over 30 centres that perform PS. No deaths, one cardiac arrest (requiring CPR) and one aspiration event were reported by Cravero et al. in a cohort who represented 30 000 PS episodes. Unplanned intervention was needed in 336 PS episodes (111.9 per 10 000 PS episodes), with bag-valve-mask ventilation (63.9 per 10 000 PS episodes) and intubation (9.7 per 10 000 PS episodes) the most invasive. Hertzog et al. reported anaphylaxis risk of PS at 1:37 972 with ketamine, midazolam, methohexital and morphine more likely than other medications to cause this rare event.

The phases and the tasks involved in PS can be divided as follows: preprocedure, intraprocedure and postprocedure ( Fig. 3.2.1 ). This division provides a framework to build one’s practice upon.

Preprocedure

Ensuring safe governance, training of staff and preprocedure preparedness reduces adverse events during PS. ^{, ,} Prior to a PS episode there should be careful risk assessment, preparation of staff and environment as well as a decision on use of the most appropriate pharmacological and nonpharmacological methods for the particular patient and procedure. COVID-19 risks to ED staff and patients must be considered. For example, nitrous oxide administration is a low risk aerosol generating procedure (AGP). The location of nitrous oxide must be in either a negative pressure room or in a room where the door is closed and only essential staff wearing high level personal protective equipment (N95 mask, eye protection, hair coverings, gown and gloves) are permitted in the room. It is also important to note, before any avoidance of nitrous oxide is considered, that crying due to procedural distress poses a risk of aerosol generation, perhaps greater than appropriate sedation.