Procedural sedation in Emergency Medicine 2018

Author: Gavin Lloyd / Editors: Steve Fordham, Gavin Lloyd / Codes: C3AP6 / Published: 06/06/2018 / Review Date: 06/06/2020

Introduction

Sedation is a routine aspect of emergency care. The aim is clear: make the procedural experience as comfortable as possible for your patient, whilst ensuring that your practice is safe.

Sedation is a continuum which extends from a normal conscious level to being fully unresponsive. Sedation and recovery move patients along this scale, but it is difficult to accurately assess the precise degree of sedation at any one time, and even harder to maintain a patient at a pre-defined target level.

The American Society of Anesthesiologists (ASA) uses the following useful definitions for sedation:

• Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
• Moderate Sedation/Analgesia (‘Conscious Sedation’) is a drug-induced depression of consciousness during which patients respond purposefully to 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. In the Emergency Department this is most often achieved using a combination of opioids and benzodiazepines.
• Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully 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 Anaesthesia is a drug-induced loss of consciousness during which patients are not rousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients 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 also be impaired.

Not included in the classification is ‘dissociative sedation’, uniquely produced by ketamine it is a trance like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations & cardiopulmonary stability.

A core clinical learning outcome of the 2015 RCEM curriculum for CT1 and CT2 is the provision of safe and effective sedation to ASA 1 and 2 ¹adult patients (table 1), aged less than 80 years of age using a maximum of two short acting agents. The knowledge and skill competencies expected are listed in table 2. Safe sedation of children is covered in Paediatric EM Practical procedures for ST4-6. The 2012 report and recommendations by the Royal College of Anaesthetists and RCEM Safe Sedation of Adults in the Emergency Department covers deeper levels of sedation ².

Table 1: American Society of Anesthesiologists Physical Status Classification
Class	Description	Examples
I	Normal, healthy patient	–
II	Mild systemic disease	Asthma, controlled diabetes
III	Moderate systemic disease	Stable angina, diabetes with hyperglycaemia, moderate chronic obstructive pulmonary disease
IV	Severe systemic disease	Unstable angina, diabetic ketoacidosis
V	Moribund	–

Table 2: RCEM curriculum competencies required for procedural sedation

Knowledge

Can explain: What is meant by conscious sedation and why understanding the definition is crucial to patient safety The differences between conscious sedation and deep sedation and general anaesthesia The fundamental difference in techniques/drugs used/patient safety That the significant risks to patient safety associated with sedation technique requires meticulous attention to detail, the continuous presence of a suitably trained individual with responsibility for patient safety, safe monitoring and contemporaneous record keeping The use of single drug, multiple drug and inhalation techniques The minimal monitoring required during pharmacological sedation

Can describe: The pharmacology of drugs commonly used to produce sedation The indications for the use of conscious sedation The particular risks of multiple drug sedation techniques

Can outline the unpredictable nature of sedation techniques in children

Skills

Can demonstrate the ability to: Select patients for whom sedation is appropriate part of clinical management Explain sedation to patients and to obtain consent Administer and monitor inhalational sedation to patients for clinical procedures Administer and monitor intravenous sedation to patients for clinical procedures Recognise and manage the complications of sedation techniques appropriately including recognition and correct management of loss of verbal responsiveness

Indications for procedural sedation

Whilst you might consider sedation useful for the successful completion of a variety of short painful procedures it is worth revisiting a few points beforehand.

• Have you adequately met the patients analgesic needs using titrated opioids (+/- paracetamol and ibuprofen) and/or local or regional anaesthesia? In fact, can the procedure be performed just as well using local anaesthetics +/- nitrous oxide/ oxygen mixtures?
• Have you put yourself in the patients position and provided an empathetic approach, a clear explanation of the procedure, a distracting conversation or provided perhaps an alternative distractive medium, such as music or a tablet?
• Is a general anaesthetic more appropriate is the procedure more complicated than you think?
• Does the current workload in your department allow safe procedural sedation to take place. Consider time of day, senior cover available should there be a problem, space in designated sedation areas such as the resuscitation room. Does performing procedural sedation now compromise the safety or quality of care for other patients?

Figure 1 lists some typical indications for procedural sedation and stratifies them loosely (you should take each case on its individual merits) in terms of urgency³.

Figure 1: Indications for procedural sedation, stratified by urgency

Emergent (e.g. cardioversion for life-threatening dysrhythmia, reduction of markedly angulated fracture/dislocation with soft tissue or vascular compromise, intractable pain or suffering).

Urgent (e.g. care of dirty wounds and lacerations, animal and human bites, fracture reduction, shoulder reduction, hip reduction, arthrocentesis, neuroimaging for trauma).

Semi-urgent (e.g. care of clean wounds and lacerations, foreign body removal, sexual assault examination).

Learning Bite

Don’t default to providing procedural sedation without considering alternative options or adjuncts

Identifying at risk patients

In this section you will cover four questions. Which of my patients:

• might predictably be difficult to ventilate?
• might predictably desaturate?
• are more likely to regurgitate and potentially aspirate?
• might predictably drop their blood pressure?

Pre-procedural airway evaluation is vital in order to address the first question. Table 3 lists several factors that may be associated with difficulty in airway management. A single factor in isolation may not be significant, but two or more should prompt you to reconsider your strategy.

You may find the simple pneumonic BOOTS helpful:

• Beard
• Obese
• Older patient
• Toothless
• Snores?

Table 3: Airway assessment procedures for sedation and analgesia

History: Previous problems with anaesthesia or sedation (look in the hospital and ED records if possible) Stridor, snoring or sleep apnoea Advanced rheumatoid arthritis Chromosomal abnormality (e.g. trisomy 21) Physical Examination: Habitus Significant obesity (especially involving the neck and facial structure) Head and neck Short neck, limited neck extension, decreased hyoid-mental distance ( < 3cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, dysmorphic facial features (e.g. Pierre-Robin syndrome), excessive facial hair Mouth Small opening ( < 3cm in an adult, edentulous, protruding incisors, high arched palate, macroglossia, tonsillar hypertrophy and nonvisibule uvula) Jaw Micrognathia, retrognathia, trismus and significant malocclusion

Learning Bite

In your preparation for conscious sedation always ask yourself whether you are confident you can ventilate the patient using a bag and mask

Fasting is not needed for minimal sedation, sedation with nitrous oxide/ oxygen mixtures alone, or moderate sedation where verbal contact is maintained.

For an emergency procedure in someone who is not fasted, base the decision to proceed with sedation on the urgency of the procedure and the target depth of sedation. The joint RCoA/RCEM report² recommends that careful judgement is required when assessing the risk of aspiration in relation to the urgency of a proposed procedure. The key factors to consider are:

• The urgency of the proposed procedure. In many life or limb threatening situations (e.g. cardioversion of a cardiac arrhythmia causing significant cardiovascular compromise, or an orthopaedic procedure to correct distal limb ischaemia) the patient is unable to wait and the main question becomes the choice of sedation/anaesthetic technique rather than the possibility of deferment.
• The proposed depth and duration of sedation. Longer periods of sedation, greater sedation depth and airway interventions may stimulate airway reflexes (coughing, hiccoughs or laryngospasm) and gastro-intestinal motor responses (gagging or recurrent swallowing) leading to gastric distension, regurgitation or vomiting.
• Patient factors – conditions such as raised intracranial pressure, hiatus hernia and gastrointestinal obstruction are known to delay gastric emptying, and these patients may be at greater risk. Gastric emptying may also be delayed in patients who have previously undergone upper gastrointestinal surgery, in those recently injured or receiving opioids, and in pregnancy. Morbidly obese patients may be at risk, because the intra-abdominal pressure is higher and the incidence of hiatus hernia is greater than in non-obese patients. The timing of food intake in relation to the injuries also important.

For those un-starved patients needing deeper levels of sedation (for prosthetic hip relocation for example), ensure pre-oxygenation is maximised and consider employing apnoeic oxygenation* so as to minimise the need for bag-valve-mask ventilation (which when delivered may insufflate the stomach and increase the likelihood of regurgitation).

More recently, American College of Emergency Physicians policy 2014 on procedural sedation⁵ makes the following level B** recommendation: do not delay procedural sedation in adults or paediatrics in the ED based on fasting time. Pre-procedural fasting for any duration has not demonstrated the reduction in the risk of aspiration when administering procedural sedation and analgesia.

*Apnoeic oxygenation high flow oxygen delivered via nasal prongs once sedated This is covered in a proposed RCEM learning module Advanced Procedural Sedation.

**Level B recommendation based on evidence from one of more class of evidence II studies or strong consensus of class of evidence III studies.

Learning Bite

Before proceeding with sedation of an unstarved patient a senior emergency physician with level 2 sedation training (see section 6) should be present.

The American Society of Anaesthesiologists classification (table 1) is widely used to describe the physical status of patients. Sensibly employed it should help you identify those patients who might become hypotensive or hypoxic (questions 1 and 2).

Table 1: American Society of Anesthesiologists Physical Status Classification
Class	Description	Examples
I	Normal, healthy patient	–
II	Mild systemic disease	Asthma, controlled diabetes
III	Moderate systemic disease	Stable angina, diabetes with hyperglycaemia, moderate chronic obstructive pulmonary disease
IV	Severe systemic disease	Unstable angina, diabetic ketoacidosis
V	Moribund	–

You may wish to consult with senior anaesthetic colleagues regarding those patients classified as III or higher. Neurological conditions, notably myasthenia gravis and cerebral palsy, are worthy of special mention as patients with these conditions may be more sensitive to sedative agents, as are the elderly in general.

Pharmacological agents

The pharmacological agents typically used for procedural sedation in UK emergency medicine practice are listed, along with their properties, in Table 4.

DRUG	DOSE	ONSET (MIN)	PEAK EFFECT (MIN)	DURATION
Morphine	0.1mg/kg iv titrated to effect	1-2	10-15	2-4hrs
Fentanyl	1 – 2 mcg/kg iv titrated to effect	1-2	2-5	20-30min
Nitrous oxide	10 70%	1-2	2	Rapidly wears off
Ketamine	1mg/kg iv titrated to effect given over 60s 2 – 4mg/kg im	1-2 2-5	2 5	30 min 90 min
Midazolam	0.02 0.1mg/kg iv adult titrated to effect 0.025-0.05mg/kg iv child titrated to effect	1-2	3-4	30 min
Propofol	0.5-1.0mg/kg bolus	1	1-2	5-10 min

In general you should deliver these agents via the intravenous route the onset is quick and reliable, allowing you to titrate the drug appropriately. The intramuscular route should be reserved for children (Section 7) and those adults with learning difficulties or behavioural problems. It is worth emphasizing the need to use smaller initial doses in the elderly⁶ and allowing the drug extra time to take effect, given the slower arm-brain circulation time in such patients. In contrast, those patients with regular alcohol consumption that comfortably exceed current recommendations may require larger sedative doses than usual to achieve the required level of sedation. Titration is not necessarily straightforward, the therapeutic window being narrow in these cases. All the drugs listed have the capacity to produce deeper levels of sedation and even anaesthesia if used in excess. Further, combinations of drugs, especially sedatives and opioids, should be employed with caution. The opioids should be given first to allow time to become maximally effective before any sedative is added.

You should be familiar with two reversal agents, naloxone and flumazenil. Naloxone should be titrated 100-200 g every 1-2mins to reverse respiratory depression following opioid administration. Its effects may wear off before the opioid is cleared so you should consider extended patient monitoring. Naloxone may precipitate withdrawal in opioid dependent patients. In excess it will also antagonise analgesia.

Give flumazenil in small increments of 100-200 g every one minute to reverse respiratory depression following benzodiazepine use. Use it with caution in those on long term benzodiazepines to avoid withdrawal symptoms.

The role of propofol for deep sedation in adult patients is covered in detail in a separate RCEM learning module (link). A single analysis of 1000 patients sedated with propofol, demonstrated a sentinel adverse event rate of 1% with no adverse outcomes⁶.

The dissociative drug ketamine offers a unique sedative state that will be considered in detail in the section on sedation for children.

Learning Bites

• If using benzodiazepine/opioid combinations give the opioid first to allow time for it to become maximally effective before any sedative is added
• Use smaller initial doses of sedative in the elderly, debilitated and acutely ill patients

Safe practice

In this section you will cover:

• Training requirements and personnel
• Environment, equipment, monitoring and documentation
• (Patient assessment section 4)
• (Drug selection section 5)
• Consent
• Recovery and discharge
• Governance
• Pearls

Training requirements and personnel

The requirements for Emergency Department sedation are listed in table 5 and are taken from the RCoA/RCEM 2012 report².

Table 5: Requirements for ED sedation
Depth of sedation	Minimum staffing levels	Competencies of sedating practitioner	Locations and facilities	Monitoring
Minimal sedation with Entonox	One Physician or Emergency Nurse Practitioner (ENP)	Current Immediate Life Support (ILS) or Advanced Life Support (ALS) certification or equivalent agreed locally	Anywhere within the Emergency Department (ED)	Pulse oximetry
Moderate sedation/ analgesia (conscious sedation) using intravenous agents, typically benzodiazepines	One physician as sedationist and one Physician or ENP as operator and one Nurse	Current ILS or ALS certification Local sign off for Level 1 sedation training*	Resuscitation room facilities****	ECG, NIBP, pulse oximetry The use of capnography is recommended
Deep sedation/ analgesia	As above	Royal College of Anaesthetists initial assessment of competence Local sign off for Level 2 sedation training**	Resuscitation room facilities****	Standards conforming to AABGI guidelines for general anaesthesia The use of capnography is mandatory
Dissociative sedation using ketamine	As above	As above	As above	As above

Specific requirements for level 1 and 2 sedation training are illustrated in table 6.

Table 6: Training requirements for ED sedation

Level 1 sedation training (moderate sedation) ASA grading Pre-procedural assessment including prediction of difficulty in airway management Pre-procedural fasting and risk benefit assessment Consent and documentation Drug selection and preparation: benzodiazepine/opioid combinations, intervals between increments and reversal drugs Monitoring, complications (e.g. hypoxia and hypotension) and rescue strategies Governance and audit Level 2 sedation training (deep sedation/general anaesthesia) As per level 1 Drug selection with emphasis on potential alternative strategies and/or lighter sedation Safe use of propofol Safe use of ketamine

Environment, equipment, monitoring and documentation

Whilst the use of 50% nitrous oxide/oxygen mixtures +/- opioids is generally safe throughout the ED you should ensure procedural sedation takes place in either the resuscitation room or another area with advance life support equipment. Such facilities are outlined in table 7.

Table 7: Resuscitation room facilities (as per RCoA/RCEM joint document)

Full resuscitation equipment for the administration of basic and advanced life support. Equipment and drugs should be checked daily, and after each use. That such checks have occurred should be routinely recorded Difficult airway equipment Continuous high flow oxygen with appropriate devices for administration High pressure suction with appropriate suction catheters A trolley capable of being tipped head down Monitoring: Pulse oximeter, ECG, NIBP and continuous quantitative capnography Appropriate range of intravenous cannulae An appropriate range of intravenous fluids and infusion devices Manual handling devices

ACEP policy⁵ would suggest that your staff record the patient’s vital signs (pulse rate, blood pressure, respiratory rate and oxygen saturations) before, during and after the procedure. There is no guidance in the literature as to how often; every five minutes is probably practical. Several exemplar charts are available on the RCEM website (link), click here for an example (open a pop up with chart). Capnography monitoring and supplementary oxygen is recommended for patients in which conscious sedation or beyond is targeted. An exemplar chart is available in Appendix 1. Perform a ‘timeout’ before starting the procedure: a checklist of right patient, right side, monitoring, equipment, personnel, plan A, plan B etc. Click here for an example of this list (open a pop up with chart)

Consent

Is your department able to provide a ‘patient sedation leaflet’?

You should provide informed consent where appropriate, including in your discussion potential risks vs benefits, side effects and alternative options. Explaining sedation in terms they can understand is good practice (table 8). However you will need to act in the patient’s best interest where pain and/or anxiety is excessive, or similarly where altered mental status means the patient lacks capacity. Written consent, though conventional, is not statutory and in the latter scenarios is of questionable validity. Clear documentation of the process followed in some form in the patient’s notes is essential however

Table 8: Levels of sedation in patient terms (adapted from the fifth National Audit Project7)
	What will this feel like?	What will I remember?	Whats the risk related to the sedation drugs?
Not sedated; awake	I am awake, possibly anxious. There may be some mild discomfort (depending on the what I am having done)	Everything	Nearly zero
Minimal sedation	I am awake and calm. There may be some mild or brief discomfort	Probably everything	Very low risk
Moderate sedation	I am sleepy and calm but remain in control. I may feel some mild discomfort	I might remember some things	Low risk
Dissociative sedation	I am in a trance. I will not be in control. Any pain or sensations I feel may feel oddly remote, as if I am floating away from my body	I may remember being in a trance or may recall vivid dreams	I will need oxygen and special monitoring. I have a 1 in 10 chance of being sick
Deep sedation	I am asleep. I will not be in control	Probably very little	Higher risk. My breathing may slow when I am asleepand I may need help to breathea tube might be inserted into my nose, mouth or (rarely) windpipe. I will need oxygen and special monitoring
Anaesthesia	I am deeply asleep and unable to respond	Very unlikely to remember anything	Higher risk (but the presence of an anaesthetist increases safety). My breathing may slow or stop and my blood pressure and heart rate may fall. I will need a specialist doctor to look after my breathing and support my blood pressure and heart rate I will need oxygen and special monitoring and equipment

Recovery / discharge

Your patient’s vital signs should be monitored until they are no longer at risk for hypoxaemia. The largest study to date⁸ in which the timing of adverse outcomes can be examined included 353 children receiving ketamine and 672 receiving midazolam and fentanyl. Only 8% of the adverse events occurred after the procedure. In addition the median time to serious adverse effects was two and a half minutes following the last intravenous medication. No primary adverse event occurred after 25 minutes from the last intravenous medication.

Guidance regarding discharge is given in Table 9

Table 9: Guidelines for discharge

1. Vital signs should be stable and within acceptable limits. 2. Sufficient time (up to 2 hours) should have elapsed after the last administration of reversal agents (naloxone, flumazenil) to ensure that patients do not become re-sedated after reversal effects have worn off. 3. Patients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any post procedural complications. 4. Patients and their escorts should be provided with written instructions regarding post procedural diet, medications, driving, other activities such as operating machinery and signing legal documents, and a phone number to be called in case of emergency. 5.

Governance

RCEM policy recommends:

• All users of sedation are adequately trained and that both knowledge and skills are maintained.
• That audit of the process and outcome of procedures performed under sedation takes place.
• A clinical governance framework exists so as to enable implementation of these recommendations.

RCEM also recommends a standardised audit tool (link)

Pearls

Three clinical tips that might further enhance safety in your procedural sedation practice:

• Use a decent size pillow pre-emptively to better achieve the sniffing the morning air position; your patients will consider you a saint regardless of whether it prevents airway compromise or not!
• Tilt the head end of the trolley upright if your obese patient is hypoventilating, or if you are required to provide bag mask ventilation. Is there any reason not to have them in this position from the outset?
• Consider a 500ml bolus of saline pre-procedure in elderly patients on hypertensive medication, with a further bolus primed in anticipation of a drop in blood pressure.

Learning Bites

• Capnography is currently recommended for both moderate and deep target sedation levels
• Monitoring for 30 minutes from the last dose of sedative agent is appropriate⁸

Modification of your practice for children

In this final section you will revisit each of the previous sections with emphasis on the paediatric aspects. You will also examine the specific role of ketamine as per the RCEM 2016 Ketamine Sedation of Children in Emergency Departments. An additional RCEM e-learning module (Ketamine Sedation in Children) is available.

Indications for procedural sedation

You should again consider alternative strategies to sedation including the role of topical local anaesthetic agents for wound toilet^10-13, and steristrips or glue for wound closure. The role of music¹⁴, hypnosis^15,16, confusing tactile stimuli¹⁷ and blowing away pain¹⁸ are well described distraction techniques in young children. Information regarding the procedure can also be relayed to the child in the form of a story¹⁹.

The modern day all-in-one-fix-it is a tablet loaded with minions or frozen movies (personal opinion). The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal diamorphine on presentation for more painful conditions²⁰, as well as paracetamol and ibuprofen. You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle.

At risk children

The contraindications to ketamine sedation as listed in the RCEM guideline are illustrated below in Table 10.

With specific regard to fasting, and consistent with your approach to adults, a case by case risk benefit assessment is more consistent with the current literature than setting an arbitrary fasting period²¹.

Table 10: Contraindications to ketamine for procedural sedation

Age less than 12 months Active respiratory infection, active asthma Unstable or abnormal airway. Tracheal surgery or stenosis. Active upper or lower respiratory tract infection Proposed procedure within the mouth or pharynx Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems Significant cardiac disease Recent significant head injury or reduced level of consciousness Intracranial hypertension with CSF obstruction Intra-ocular pathology Previous psychotic illness Uncontrolled epilepsy Hyperthyroidism or thyroid medication Porphyria Prior adverse reaction to ketamine

Ketamine

This drug has an excellent track record in procedural sedation for children in emergency medicine from 1998²², and appears safer than benzodiazepine/opioid combinations²³.

Ketamine’s recognised side effects and their reported incidence are reported in Table 11, taken from the RCEM guideline. The emergence phenomena described with ketamine are uncommon. They are not reliably prevented with proactive benzodiazepine^24,25, but benzodiazepines are recommended in the rare event of significant recovery agitation.

Table 11: Potential complications of ketamine sedation
Airway: Noisy breathing is usually due to airway mal-position and occurs at an incidence of  < 1%. This can normally be corrected by paying careful attention to optimal airway positioning. In rare cases mild laryngospasm may occur (0.3%). The reported incidence of intubation for laryngospasm is 0.02%. A meta-analysis26 showed that low IM doses of ketamine ( < 3mg/kg) exhibited significantly less overall airway and respiratory adverse events. There were no occurrences of either laryngospasm or apnoea in the 682 children receiving lower IM doses
Vomiting: Lacrimation and salivation: Transient rash: Transient clonic movements: Significant agitation	5-10% incidence. This usually occurs during the recovery phase 10% 10% < 5 % 1.5%

Training requirements and personnel

The College guideline is clear ‘ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills. Children aged between 12 and 24 months should only receive ketamine sedation from expert staff (usually a consultant)’.

Discuss with senior colleagues how you might secure competency; consider specific manikin-based workshops on laryngospasm management. An excellent discussion on the latter is available²⁷.

At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.

Environment, equipment, monitoring, documentation, recovery and discharge

For mixed adult and paediatric emergency departments with busy resuscitation rooms, securing a quiet child-friendly area with appropriate paediatric life support equipment may prove challenging. Likewise a quiet recovery area can be hard to come by in modern emergency medicine. The former is certainly considered essential for procedural sedation in children using either benzodiazepine/opioid combinations or ketamine; the latter may be over emphasized. Note the monitoring requirement in the College guideline ECG, BP, respiration and pulse oximetry. Supplemental oxygen should be given and suction must be available.

Recovery should be complete between 60 and 120 minutes, depending on the dose and route used. The child can be safely discharged once they are able to ambulate and vocalise/converse at pre-sedation levels. An advice sheet should be given to the parent or guardian advising rest, quiet and supervised activity for the remainder of that day. The child should not eat or drink for two hours after discharge because of the risk of nausea and vomiting.

Downloadable appendices for information sheets of the parents and discharge advice from parents exist within the RCEM guideline.

Governance

You should subject your departmental practice to the same governance standards for paediatric procedural sedation as outlined for adults (section 6). A specific exemplar departmental guide/ monitoring chart for paediatric ketamine sedation is available on the RCEM website (link).

Learning Bites

• RCEM supports the use of 1 mg/kg IV ketamine for procedural sedation in children
• Laryngospasm is a rare but real side effect of ketamine use, and its management should be incorporated within a regular training programme

Key Learning Points:

• Dont default to procedural sedation without considering alternative options or adjuncts to your strategy. The latter may enable you to use lighter levels of sedation
• In your preparation for procedural sedation always ask yourself whether you are confident you can ventilate the patient if necessary
• Before proceeding with sedation of an unstarved patient, a senior emergency physician with level 2 sedation training should be present.
• If using benzodiazepine/opioid combinations give the opioid first to allow time for it to become maximally effective before any sedative is added
• Use smaller initial doses of sedative in the elderly, debilitated and acutely ill patients.
• A sedationist, operator and trained nurse are required for moderate and deep sedation target levels.
• Capnography is currently recommended for both moderate and deep target sedation levels
• Monitoring for 30 minutes from the last dose of sedative agent is appropriate
• The RCEM supports the use of 1 mg/kg IV ketamine for procedural sedation in children
• Laryngospasm is a rare but real side effect of ketamine use, and its management should be incorporated within a regular training programme

References

1. Curriculum
2. 2012 CEM report
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5. ACEP 2014 policy
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18. Kendall JM, Reeves BC, Latter VS. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures. BMJ 2001; 322: 261 265
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25. Reid, C. Larygospasm after Ketamine. Resus Me. 2012
26. Heinz P, Greelhoed GC, Wee C, et al. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emergency Medicine Journal 2006;23:206-209
27. Brown L, Green SM, Sherwin TS, et al. Ketamine with and without atropine; whats the risk of excessive salivation? Acad Emerg Med 2000:10:482-483