Procedural Sedation in Children and Young People in the Emergency Department

Publication: 07/12/2011  --
Last review: 19/06/2017  
Next review: 01/07/2020  
Clinical Guideline
CURRENT 
ID: 2774 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Summary

This guideline describes the standards for the safe provision of sedation for children and younger people by Emergency Medicine Consultants in the Emergency Department (ED)

Back to top

Background

Procedural sedation is a common practice in the ED. The aims are to relieve anxiety, reduce pain, facilitate a procedure and provide amnesia. Sedation can produce a continuum of states, ranging from minimal sedation (anxiolysis) through to general anaesthesia. This guideline specifically applies to dissociative techniques using ketamine, moderate sedation (i.e. “conscious sedation”) and deep sedation. The drugs used can produce cardiovascular and respiratory complications.
The introduction of a ketamine pathway into the ED will have benefits for parents and their children as it will avoid an admission and a wait for an Emergency theatre. There are also wider benefits to the health economy as ED sedation has been demonstrated to save ~£614 per case compared to admission for theatre [1]. This is consistent with the aims of the QIPP agenda. The use of sedation in the ED has been evaluated by NICE and its use recommended both to improve care and greater cost effective utilisation of resources [2]. The American College of Emergency Physicians have also recently published an evidence based clinical practice guideline setting the standards for ketamine administration in the ED [3].
Use of a standard protocol and knowledge of the drugs involved are vital to minimize the potential risks.
It is not acceptable for single operators to be sedating and performing a procedure in the ED. The doctor supervising sedation should be familiar with this document and trained to recognise and have the skills to deal with potential complications.

Back to top

Management

 

  1.  
    1. History, contraindications

A full history, including drugs, previous sedation or anaesthesia, allergies and fasting time should be documented. [grade c]
Procedural sedation in the ED is contraindicated if any one of these applies [grade b]

  • Procedures involving stimulation of the posterior pharynx
  • Procedures that are more appropriately performed under general anaesthesia or in sterile operating theatre conditions
  • Patient is ASA grade 3,4 and 5
  • Child less than 12 months
  • History of airway instability, tracheal surgery, or tracheal stenosis or abnormal facial anatomy
  • Active pulmonary infection or disease (including upper-respiratory infection, exception is for asthma)
  • Head injury associated with loss of consciousness, altered mental status, or vomiting
  • Central nervous system masses, abnormalities, or hydrocephalus
  • Poorly controlled seizure disorder
  • Glaucoma or acute globe injury
  1. Fasting guidelines

General guidelines for fasting for procedural sedation in the ED [Evidence B]

Oral intake in the last 3 hours

EMERGENCY
(Life or limb threatening)

URGENT
(To resolve severe pain)

NON URGENT

Nothing

All levels of sedation

All levels of sedation

All levels of sedation

Clear liquids only

All levels of sedation

Up to and including brief sedation

Minimal sedation only

Light snack

Minimal sedation only*

Minimal sedation only

Minimal sedation only

Heavier snack or meal

Minimal sedation only*

Minimal sedation only

Minimal sedation only

Emergency Situations
NICE recommends that for emergency situations in a patient who has not fasted, base the decision to proceed with sedation on the urgency of the procedure and target depth of sedation2.

Ketamine
The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered an absolute contraindication to the use of ketamine (CEM Ketamine guideline). [Evidence B]

  1. Consent
  • Written consent to be completed by a senior staff member
  • Both the parent/guardian and child should be involved in the discussion of the treatment advised
  1. During Sedation
    1. Patient monitoring [grade c]
  • Close observation of the airway by an experienced health care professional until recovery is well-established
  • Exposure of patient such that airway and chest motion can be visualized at all times
  • Availability of oxygen supplementation with pulse oximetry, capnography, ECG, and BP
  • The routine use of supplemental oxygenation may allow SpO2 to remain satisfactory but hide the fact that there is significant hypoventilation and the patient may be on the cusp of losing their airway. In the absence of end tidal CO2 monitoring, consider supplemental O2 unless signs of hypoventilation or hypoxia (sats <94%). For ketamine IM generally oxygen needs to be available rather than given continuously.
  • End tidal CO2 and BP should be monitored if possible, provided that monitoring does not cause the patient to awaken and prevent completion of the procedure2
  • Level of consciousness - will need regular communication with the patient to assess.
  1. Monitoring level of consciousness [grade c]

Objective measurements quantifying the depth of sedation have not yet been fully established. Currently, several qualitative tools are used to measure sedation depth.
Although these can be used for documentation of sedation depth no scale can objectively predict deep sedation with subsequent respiratory depression, which is clearly an undesirable endpoint.

Equipment, Environment and Staff

  • Procedural sedation should take place in the paediatric resuscitation bay.
  • There should be a tilting trolley, suction, oxygen, and equipment for advanced airway management.
  • Where time permits, topical anaesthesia should be considered to reduce the pain of intravenous cannulation or intramuscular injection.
  • Accredited consultant present
  • Minimum of two experienced health care professionals to be involved with procedure if using IM ketamine (1 doctor and one nurse). Two doctors and one nurse for IV sedative agents.
  • Availability of appropriate nursing staff and recovery area
  • If appropriate facilities are not available patients should either be brought back for the procedure the next morning (booked into the PEM Clinic) or referred for a general anaesthetic whichever is the most appropriate pathway.

Choice of Sedation Agent
The sedative agent of choice for the majority of procedures in the ED is ketamine due to its excellent safety profile. Clinicians with experience of using alternative drugs may choose these agents for appropriate procedures: [grade B]

Administration of Sedation
The agent of choice if sedation is required for minor procedures on young children where IV access is anticipated to be either difficult or distressing is IM ketamine, see appendix 6 for appropriate dosing schedule. The dose recommended by Green suggests 4 mg/kg as an IM dose [3], a lower initial dose has been used to reliable effect in various studies and may lower the complication rate [4, 5] . As a result of supply problem of 100 mg/ml racemic ketamine, the ED has switched to S-ketamine 25 mg/ml solution for IM administration only. S-ketamine is roughly 1.7 times more potent, with possibly less side effects. We are using 1.5 mg/kg for initial dose with 1 mg/kg for supplemental doses.

Intravenous sedative/analgesic drugs should be given in small, incremental doses that are titrated to the desired end-point of analgesia and sedation. Again Ketamine is the agent of choice for sedation in children in this department. Familiarity with drugs effects and potential side effects is important (appendix 7 for medicine information).

Analgesic Drugs Used in Procedural Sedation
Where possible for painful injuries, sedation should be augmented by local anaesthesia or pre-procedure analgesia for example paracetamol, ibruprofen, and intranasal diamorphine or IV morphine. Opiates should be given at least 10 minutes before sedation to reduce risk of respiratory depression.

Possible Complications of Sedative Drugs

Complications Treatment

Laryngospasm/stridor

Adrenaline nebs (5mls of 1:1000); maintain airway with tight fitting mask, consider use of Mapleson C anaesthetic circuit

Hypoxia from respiratory depression (SPo2 < 92%)

Airway adjuncts and support ventilation with BVM.

Hypotension (age specific)

Fluids, Ephedrine, Metaraminol

Bradycardia (age specific)

Atropine

Increased level sedation

Support airway and call for help

Adverse effects specifically associated with ketamine sedation [grade b]

  • Laryngospasm (see below)
  • Hypersalivation (~10-30%)
  • Emesis (~5-15%)
  • Emergence phenomena such as recovery agitation (10-20%, with 1-2% clinically significant), dreams, hallucinations and depersonalisation
  • Transient respiratory depression (usually in the first 2-3 minutes following a large, rapidly administered IV dose)
  • Transient mild increase in heart rate and blood pressure
  • Evanescent patchy erythematous rash about the upper torso (5-20%)
  • Nystagmus and random purposeless movements while sedated

Emergence phenomena
Clinically significant unpleasant emergence phenomena are best treated with small doses of Midazolam.
Laryngospasm
Ketamine is known to preserve and exaggerate protective airway reflexes. Laryngospasm is a much feared complication – however, it is extremely rare.
From a 2009 meta-analysis of 32 studies including 8,282 children, Green and colleagues reported a rate of laryngospasm of 0.3% from ketamine sedation. In nearly all cases the laryngospasm was transient and responded to oxygenation and ventilation. Only two children (0.017%) required intubation for laryngospasm [6].

How can laryngospasm be prevented? [grade b]

  • Avoid ketamine sedation in children if:
  • <12 months of age — Very young children have a higher risk of airway problems, laryngospasm and apnoea from all forms of sedation and anesthesia
  • Active URTI (RR 5.5)
  • Active asthma (RR 3.7)
  • Ensure adequate depth of sedation before commencing the procedure and avoid stimulation of the posterior pharynx.

Management of laryngospasm includes the following:

  • Stop the procedure. Call for expert help. Ensure equipment for difficult intubation is at hand.
  • Administer 100% oxygen through a mask with a tight seal and a closed expiratory valve to try to force the vocal cords open with positive pressure. Hypoxia can occur rapidly in children when ventilation is inadequate.
  • Clear the airway of blood and secretions, if the child is adequately oxygenated.
  • Attempt manual ventilation while continuing to apply continuous positive airway pressure (CPAP).

Post Sedation Management [grade c]
Recovery area

  • Minimal physical contact or other psychic disturbance. Quiet area with dim lighting if possible
  • Recovery should be complete within 60-120 minutes
  • Advise parents or caretakers not to stimulate patient prematurely
  • Continue oxygen saturation monitoring until alert (or for 30 minutes post IM ketamine injection)
  • After 30 minutes children having had IM ketamine can be moved to a cubicle to recover, the risk of airway complications is extremely rare at this stage and the child can be allowed to recover. If IV agents are used then nursing staff should observe the patient until they are alert.

Discharge Criteria

  • Recovery time depends on drug(s) used
  • Awake, able to move all 4 limbs voluntarily or on command, able to breathe and cough freely, able maintain Oxygen saturation >94% on room air and BP± 20 mm of Hg of pre-sedation level
  • Ability to take oral fluids.
  • Give discharge instructions (see advice sheet):Restricting food for 2 hours (due to risk of nausea and vomiting)

Personnel and Training [grade c]

The use of these techniques to deliver moderate/dissociative or deep sedation to children within the ED is restricted to Emergency Medicine Consultants who have attained the relevant competencies.
All clinicians should be thoroughly conversant with this guideline before delivery of a sedation service.
For ketamine sedation an accredited clinician should be present to assess the competence of clinical staff in training prior to being accredited as competent (see appendix 7 which outlines the training competencies and relevant work based assessment requirements).

Healthcare professionals delivering sedation should have the following

Knowledge and understanding of
and competency in:

Practical experience of:

Documented up-to-date evidence
of competency including:

Sedation drug pharmacology and
applied physiology

Effectively delivering the chosen
sedation technique and
managing complications

Satisfactory completion of a
theoretical training course
covering the principles of
sedation practice

Assessment of children and
young people

Observing clinical signs
(for example, airway patency,
breathing rate and depth, pulse,
pallor and cyanosis, and depth
of sedation)

A comprehensive record of
practical experience of sedation
techniques, including details of:
– sedation in children and
young people performed
under supervision
– successful completion of
work-based assessments

Monitoring

Using monitoring equipment.

 

Recovery care

   

Complications and their
immediate management,
including paediatric life support

   

 

Members of the sedation team should have the following life support skills

 

Minimal sedation,
sedation with
nitrous oxide alone
(in oxygen)

Moderate sedation

Deep sedation/Dissociative drugs

All members

Basic

Basic

Basic

At least one member

 

Intermediate

Advanced

 

Back to top

Appendix 1: Abbreviation list

ASA-American Society of Anaesthesiologists
CEM-College of Emergency Medicine
ED- Emergency Department
NICE-National institute of clinical effectiveness
QIPP-quality, innovation, prevention, productivity

Back to top

Appendix 2 - American Society of Anesthesiologists (ASA) physical status grade

  1. Healthy patient. Localised surgical pathology with no systemic disturbance.
  2. Mild to moderate systemic disturbance (the surgical pathology or other disease process) No activity limitation.
  3. Severe systemic disturbance from any cause. Some activity limitation.
  4. Life-threatening systemic disorder. Severe activity limitation.
  5. Moribund patient with little chance of survival.

Back to top

Appendix 3: Sedation score/Pain score

Sedation score

  1. Co-operative /unreactive
  2. Intermittent crying
  3. Continuous crying
  4. Uncontrolled crying

Pain score

  1. I don’t hurt at all
  2. It hurts just a little bit
  3. Some hurt
  4. It hurts a lot
  5. The hurt is the worst I’ve ever had

Back to top

Appendix 4: Patient pathway for ketamine

Back to top

Appendix 5: Emergency Department Paediatric Sedation Proforma


Back to top

Appendix 6: Ketamine dose/weight chart

PDF Version - S-Ketamine dosage chart

S-KETAMINE 25 mg/ml solution for IM use in children
S-ketamine is supplied in 2 ml ampoules (50 mg/ampoule)

Kg

Dose (mg) 1.5 mg/kg

Volume (ml)*

Additional top up dose
1 mg/kg

Additional top up volume (ml)

10

15

0.6

10 mg

0.40

11

16.5

0.66

11 mg

0.44

12

18

0.72

12 mg

0.48

13

19.5

0.78

13 mg

0.52

14

21

0.84

14 mg

0.56

15

22.5

0.90

15 mg

0.60

16

24

0.96

16 mg

0.64

17

25.5

1.00*

17 mg

0.68

*Dose rounded down to 1 ml as max volume in syringe.

An additional top up dose should be administered as 1 mg/kg.
Example a 10 kg child would receive 15 mg (0.6 ml) for the initial dose and 10 mg (0.4 ml) for the top up dose.

Because injection of more than 1 ml IM is painful, then children larger than 17 Kg should have IV ketamine if sedation is required for painful procedures.

YOU SHOULD NOT NEED TO USE A SYRINGE LARGER THAN 1 ML. FOR USE IN LARGER CHILDREN ADMINISTRATION OF IV KETAMINE AT A CONCENTRATION OF 10 MG/ML IS PREFERRED AND SHOULD ONLY BE USED BY EXPERIENCED CLINICIANS COMPETENT IN THE USE OF IV KETAMINE

Back to top

Appendix 7: Ketamine for intravenous sedation use

Ketamine is administered as a 10 mg/ml solution. Initial bolus of 0.5-1 mg/kg should be administered slowly over a minute. i.e for a 40 kg child 2-4 ml of solution should be administered. Additional boluses of ~0.25 mg/kg should be given i.e. 10 mg or 1 ml.

Back to top

Appendix 8: Competency Framework for Paediatric Sedation using Ketamine in the Emergency Department

PDF Version

Background
Procedural sedation is common practice in UK Emergency Departments and it is expected that practitioners would be able to work within this competency framework before being able to safely deal with children and younger people who need procedural sedation in the ED.
The purpose of this document is not to detailed indications or process of sedation, but rather the competences needed required. It would be anticipated that practitioners are familiar with the following documents, before being signed off as competent:-

  1. The NICE children and young adults sedation guideline.
  2. Procedural sedation analgesia in children and young people

PEM Sedation Training

  • The sedationist must have APLS/EPLS skills and be a trainee at CT3 level or above in Emergency Medicine, an accredited Consultant should always be present for trainees even after attainment of competencies.
  • Two healthcare professionals must be present during the procedure, in addition to the sedationist, both of which are capable of basic life support in children.
  • There must be access to resuscitation equipment.
  • Each procedure must be accompanied by a completed sedation protocol, which will be filled in the patient’s records and scanned to WinDip (plus a copy made for the practitioners training file, if required).
  • Until the practitioner has been signed off, each procedure should be witnessed by a practitioner of Consultant level who is familiar with paediatric sedation.
  • It is anticipated that at least 5 sedations will be completed, before leading to a triggered assessment by the PEM sedation lead (or equivalent) before the practitioners has signed off as competent.
  • Each sedation proforma should be kept on file for review at the final sign off.

Assessment Process

  • The assessment process usually can be triggered after 5 practice sedations. However if the practitioner feels confident that these competencies have been gained prior to completing 5 sedations, then the final assessment can be triggered.
  • The number of training procedures is entirely dependent on the grade and previous experience of the person who is being assessed. Some senior doctors with previous extensive experience in PEM sedation and advanced airway skills may choose to have final triggered assessment.
  • Other trainees may require more practice procedures and may chose to submit evidence of additional WPBAs, such as CbD sot Mini-CEX relating to PEM sedation that they have kept on file.
  • A triggered assessment must be completed by Paediatric Emergency Medicine Lead for sedation or their equivalent.
  • The assessor will observe the clinical practice and previous sedation proforma’s completed before signing off the practitioner as competent.

The generic areas of competences to be assessed are described as follows

Knowledge

Assessment Method

GMP

Can explain what is meant by conscious sedation and that it and general anaesthesia are fundamentally different techniques, each requiring meticulous patient care and the continuous presence of a suitably trained individual with responsibility for patient safety, monitoring and record keeping

Mi, D, CbD

1,2,3

Describes the pharmacology of drugs commonly used to produce sedation

Mi, D, CbD

1

Can explain the minimal monitoring required during pharmacological sedation

Mi, D, CbD

1

Describes the indications for the use of conscious sedation

Mi, D, CbD

1,2

Describes the risks associated with conscious sedation: Respiratory depression, loss of airway etc

Mi, D, CbD

1,2

Can explain the use of single drug, multiple drug and inhalation techniques

Mi, D, CbD

1,2

Describes the particular risks of multiple drug sedation techniques

Mi, D, CbD

1,2,3

Explains the unpredictable nature of sedation techniques in young children

Mi, D, CbD

1,2,3

Skills

Assessment Method

GMP

Demonstrates the ability to select patients for whom sedation is appropriate part of management

Mi, D, CbD

1,2,3

Demonstrates the ability to explain sedation to patients and to obtain consent

Mi, D, CbD

1,2,3

Demonstrates the ability to administer and monitor inhalational sedation to patients for clinical procedures including dentistry

Mi, D, CbD

1,2,3

Demonstrates the ability to administer and monitor intravenous sedation to patients for clinical procedures

Mi, D, CbD

1,2,3

Demonstrates the ability to recognise and manage the complications of sedation techniques appropriately. In particular that loss of verbal responsiveness indicates that the patient has become unconscious and requires a level of care identical to that needed for general anaesthesia

Mi, D, CbD

1,2,3

Not all of these competences can be sampled at final assessment, but it is expected that the following elements will be specifically reviewed and signed off.

Trigger assessment sign off for procedural sedation

Name of clinician being assessed:

Indication for procedure:

Drug/route of administration:

DOPS - as evident on sedation proforma

Task Completed

1. Demonstrates the ability to select patients for whom sedation is appropriate part of management

 

2. Is able to safely select, dose and prescribe the appropriate drug

 

3. Demonstrates the ability to administer and monitor sedation to children for clinical procedures

 

4. Is able to recognise any complications during sedation and manage these effectively.

 

5. Is able to fully recover the child in the appropriate environment

 

6. Log book id reviewed of previous sedations and other WPBA’s

 

Sign of by

Name

Date

 

Please file this document in your portfolio

Back to top

Provenance

Record: 2774
Objective:

Aims

This guideline is to help Emergency department clinicians safely deal with children and younger people who need procedures requiring sedation in the ED e.g. joint reduction, fracture manipulation, and suturing.
This guideline should not be used outside of the ED resuscitation room.
Sedation covers the continuum from mild to deep sedation and also the state of dissociation produced by ketamine.

Objectives

To ensure that:

  • All children undergo a process of appropriate pre-sedation assessment with the appropriate documentation of this assessment
  • The assessment will judge the suitability for sedation and whether more appropriate methods to perform a procedure should be used e.g. local infiltration, general anaesthetic
  • Appropriate information is supplied to the child and parents to enable them to make an informed choice about the procedure
  • Healthcare professionals are appropriately supervised and trained while attaining paediatric sedation competencies
  • The appropriate monitoring, and staffing is available prior to initiation of sedation
  • The appropriate drug is selected to successfully perform the procedure while having a wide safety margin to minimize complications
Clinical condition:

Sedation

Target patient group: Children and younger people within the ED
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

  1. Boyle, A., et al., Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation. Emergency Medicine Journal, 2011. 28(5): p. 383-386.
  2. National Institute for Health and Clinical Evidence, Sedation in children and young people, 2010, London: National Institute for Health and Clinical Evidence.
  3. Green, S.M., et al., Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of Emergency Medicine, 2011. 57(5): p. 449-461.
  4. McGlone, R., et al., A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing. Emergency Medicine Journal, 2001. 18(1): p. 34-38.
  5. McGlone, R.G., M.C. Howes, and M. Joshi, The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emergency Medicine Journal, 2004. 21(3): p. 290-295.
  6. Green, S.M., et al., Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children. Annals of Emergency Medicine,2009. 54(2): p. 158-168.

Evidence Base:

References and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.