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Part I. Pediatric Procedural Sedation: Personnel, Monitoring, and Patient Assessment
Authors: N. Ewen Wang, MD, Assistant Professor of Surgery, Associate Director of Pediatric Emergency Medicine, Stanford University Hospital, Stanford, CA; and Jonathan Vlahos, MD, Stanford-Kaiser Emergency Medicine, Stanford, CA.
Peer Reviewer: Susan B. Promes, MD, FACEP, Associate Professor and Program Director, Duke University Emergency Medicine Residency Program, Durham, NC.
Pediatric procedural sedation and analgesia (PSA) is commonly used in emergency departments to decrease the pain and anxiety associated with procedures and to assure an environment conducive to the safe performance of necessary interventions. Over the twenty years since PSA initially was used outside the operating room, the indications, pharmacopeia, and literature regarding its practice have expanded considerably. A growing body of evidence demonstrates that properly trained specialists from a variety of backgrounds can safely and effectively use PSA. Emergency physicians have advanced airway, resuscitation, and critical care skills that make them particularly well suited to administer PSA and manage associated complications.
Providing PSA for children presents many unique challenges as they have important emotional, anatomic, and physiologic differences compared to adults. This article reviews the fundamentals of pediatric PSA, including current terminology and practice guidelines. Recent data concerning the rates, nature, and predictors of adverse outcomes are discussed. Recommendations for preprocedure assessment, necessary equipment and personnel, and post-procedure monitoring are included. In the second part of this issue, factors to consider when selecting an agent(s) for PSA and a review of the current pharmacopeia, including notable recent additions such as propofol and etomidate, will be discussed.
— The Editor
Though initially restricted to hospital based practice by anesthesiologists, pediatric procedural sedation (PSA) is now administered by a diverse group of non-anesthesiologist healthcare practitioners in a wide variety of settings. In 1985, the American Academy of Pediatrics (AAP) was the first major specialty organization to publish guidelines attempting to define terms, standardize practice, and improve safety1 in response to the increasing use of PSA outside of the operating room and a growing number of case reports of serious adverse events, including death. Since that time, numerous specialty and regulatory organizations have published guidelines pertaining to PSA with similar goals of improving standardization, safety, and efficacy. The guidelines most pertinent to practicing emergency physicians are shown in Table 1. With respect to recommended terminology, there is no distinction made between adult and pediatric patients by any of the referenced guidelines.1-8
|Table 1. Guidelines and Standards Pertaining to Pediatric Sedation and Analgesia|
The Joint Commission
American College of Emergency Physicians
American Academy of Pediatrics
American Society of Anesthesiologists
The depth of procedural sedation is inherently on a continuum which does not easily lend itself to classification schemes. The complex interaction between the agent(s) selected, route of administration, the patient, and stimulation provided by the procedure can make sedation depth difficult to predict and assess. The nature and severity of complications are correlated with increasing sedation depth.9 The intended sedation depth is the principal factor underlying the recommended level of monitoring, setting, and skill-set of the practitioner.1-8
Many authors, including those that helped coin the term,10 have recommended abandoning the term "conscious sedation" as it is inherently misleading and has been widely misconstrued.10,11 Conscious sedation was originally defined by the AAP as "a medically controlled state of depressed consciousness that 1) allows protective reflexes to be maintained; 2) retains the patient's ability to maintain a patent airway independently and continuously; and 3) permits appropriate response by the patient to physical stimulation or verbal command, e.g. 'open your eyes.'" In practice, most pediatric patients being sedated in the emergency department do not meet this definition, either because they are developmentally unable or because deeper sedation is required to accomplish the procedure.9 The inclusion of "conscious" in a term intended to mean "depressed consciousness" has been criticized as unclear and confusing.10 Though not originally defined this way, "conscious sedation" is commonly used to refer to all levels of procedural sedation. "Moderate sedation"2 most closely approximates the original definition of "conscious sedation" and is now the recommended terminology.
The current recommended terminology12-14 for sedation and analgesia states is drawn from the Joint Commission guidelines,2 though is very similar to terminology suggested by the AAP,1,5,6 the American Society of Anesthesiologists (ASA),3,4 and the American College of Emergency Physicians (ACEP).8 Using the term "dissociative sedation" to describe the unique anesthetic state induced by ketamine is recommended by several prominent investigators.15,16 The ACEP definition of "procedural sedation" (see Table 2) is an umbrella term that encompasses the practice of most emergency physicians, which includes light, moderate, deep, and dissociative sedation.
Pediatric Pain Management
Compared to adults, children are less able to communicate their pain, and may have significant anxiety that contributes to their perception of pain. Over the last five years, professional and regulatory bodies have placed renewed emphasis on adequate pain assessment, documentation, and management.17,18 PSA is being used to manage an increasing variety of painful or anxiety-provoking procedures, with more than 20 different procedure types reported in a recent series.19 (See Table 3.) Orthopedic procedures and laceration repair continue to constitute the majority of sedations.19
|Table 3. Emergency Department Uses of Procedural Sedation|
• Wound care
Despite increasing awareness and management options for pediatric pain, children still suffer from inadequate or absent analgesia when compared to adults suffering from similar, painful conditions.20 Selbst and Clark published on the problem of pediatric "oligoanalgesia" in the early 1990s,21 and surprisingly little progress has been made since that time.
A recent study examined analgesic use in 718 pediatric patients with long bone fractures who were seen between 1998 and 2000 in community and urban emergency departments (EDs), by both general and pediatric subspecialty boarded emergency physicians.20 Children with long bone fractures received no analgesia of any kind in the ED 59% of the time, and were given an analgesic prescription only 7% of the time.20 In children who did receive analgesics, non-narcotic medications were used in a majority of cases.20 By comparison, adults receive analgesia in similar circumstances approximately 70% of the time.20
Other series have shown similar trends in analgesic use for children18,22,23 and clearly demonstrate there is still room for improvement. PSA can play an important role in the management of painful injuries that require manipulation, improve satisfaction of both patients and parents, and decrease the anxiety children associate with healthcare providers in the future.
Alternatives to Procedural Sedation
Even in expert hands and under ideal circumstances, procedural sedation always carries risks to the patient. Alternative methods of pain management and anxiolysis can reduce the level of sedation necessary to accomplish a procedure or eliminate the need for PSA entirely. A few common-sense principles help increase the success rate of these alternative methods: using parents and staff to provide distraction and reassurance; applying topical anesthetics well in advance of the anticipated procedure; using local as well as systemic analgesia; and combining multiple strategies, including PSA, when appropriate.
Age appropriate distraction by parents or child life specialists is effective at providing anxiolysis, which may be the primary issue in certain pediatric procedures.24 Forgoing sedation for some diagnostic imaging may be an option, as modern, multi-detector CT scanners have dramatically reduced imaging times (less than 30 seconds for a CT scan of an infant's head). The use of an appropriately shielded parent to help with anxiolysis and restraint on a papoose board may be a safe, effective, and humane alternative to the risk of sedation in a young child with a potential head injury. Alternatively, deferring or modifying a procedure when an alternate management strategy is appropriate (observation versus head CT, wound glue versus suturing) may obviate the need for PSA.
Topical analgesics are widely available and should be considered as an adjunct even when PSA is anticipated. For non-intact skin, use LET (lidocaine, epinephrine, tetracaine) soaked pledgets applied directly to the wound at least 20 minutes before the procedure. LET has largely replaced TAC (tetracaine, Adrenaline [epinephrine], cocaine) because of its improved safety and efficacy.14 There are several options for intact skin. For brief procedures 1-2 minutes in duration, topical sprays such as ethyl chloride (Cryogesic) and dichlorodifluoromethane and trichloromonofluoromethane (Fluori-methane) are moderately efficacious. For longer procedures or increased analgesia, 2.5 percent lidocaine and 2.5 percent prilocaine in a cream base (EMLA) provides 1-2 hours of analgesia but also requires 30-60 minutes for application to reach peak effect. Newer lidocaine based creams such as topical lidocaine (ELA-Max) and lidocaine 4 percent (L.M.X 4) topical anesthetic cream are designed to have more rapid onset with similar overall efficacy. For venipuncture, a commercially available preparation, lidocaine 70 mg and tetracaine 70 mg (SYNERA) is available in a self-activated, heated pouch that provides both enhanced absorption and venodilation. (See Table 4.)
Safety and Efficacy
PSA provided in the ED is safe and effective.19,25-31 Failed PSA, typically defined as inability to provide sedation adequate to accomplish the procedure, occurs less than 2% of the time9,32,33 Because of their increased anxiety, and decreased ability to cooperate and communicate pain, sedation is used for a wider variety of procedures in children as compared to adults. Procedures like foreign body removal that are typically performed without sedation in adults are more successful when PSA is used.34 Using PSA to accomplish laceration repairs results in higher parental satisfaction and a decreased need for physical restraint.35 For highly painful maneuvers such as fracture reduction, PSA may be the only method available to humanely accomplish the procedure.
Children are at an increased risk compared to adults of suffering complications due to PSA because they have decreased pulmonary reserve, they require more frequent sedation dosing, their sedation level is more difficult to assess, and appropriate resuscitation equipment is less likely to be available.5 Adverse drug events (ADEs) associated with PSA are categorized as serious (hypoxia, apnea, hypotension, stridor, laryngospasm, aspiration) and minor (nausea, emesis without aspiration, rash, agitation, emergence reactions, dizziness, fussiness). (See Table 5.) Clinically significant aspiration during procedural sedation, one of its most feared potential complications, has rarely been reported in the English language literature in the emergency department setting.33,36
|Table 5. Adverse Drug Events Associated with PSA|
Hospital-wide implementation of Joint Commission mandated record keeping has provided a wealth of data about the frequency and nature of adverse drug events (ADEs) associated with PSA. Investigators in a large, multicenter, prospective registry of such data recently published their first report of 30,037 pediatric sedation events. They report an overall complication rate of 5.3% with no deaths, one sedation requiring CPR, and one aspiration event in a PICU patient.33 Depending on the definitions used and the setting, previous studies report serious adverse events in approximately 2-15% of sedations.9,19,28-33,37 Hypoxia accounts for the large majority (75% or more) of serious ADEs and is generally easily treated with supplemental oxygen. Other respiratory complications (stridor, laryngospasm, apnea) are less common, occurring in less than 1-3% of cases.9,19,29-33,37 Respiratory complications requiring bag-valve-mask ventilation or endotracheal intubation as well as cardiovascular ADEs (hypotension, bradycardia) are all rare, occurring less than 1% of the time.9,19,29-33,37 When they do occur, hypotension and bradycardia most often are self-limited and do not require active management beyond close monitoring.
Of the minor ADEs associated with PSA, emesis is the most common, occurring in 1-8% of cases9,19,29-32,37 No clear link between fasting time and the incidence of emesis has been established.19,31,36-38 Though aspiration is a potential risk of emesis, this complication has not been reported during PSA in the ED as noted above. In a series examining the timing of adverse events, there appeared to be a bimodal distribution of vomiting over time, with 25% of episodes occurring within 8 minutes of medication administration and the remainder occurring greater than 40 minutes later.30 Other minor ADEs occur less than 1% of the time and include agitation, rash, dizziness, fussiness, abdominal pain, headache, and dystonia.9,28-30,32 Up to 10% of children will have a minor ADE following discharge. Of these, vomiting remains the most common, representing 75% of all post-discharge ADEs.9 Parents should be specifically advised of this complication.
The complication rates discussed above are averages derived from case series using various agents. Specific factors, however, may be predictive of adverse events. PSA using fentanyl and versed is associated with a higher rate of complications, in large part due to the higher incidence of the most common complication (hypoxia).9,30 In contrast, there is no consistent association between adverse events and route of drug administration, pre-medication with analgesics, length of procedure, type of procedure, sex, or age of the patient.9,28,30,39,40
Though overall when properly administered and monitored PSA is very safe, tragic outcomes, including death, do still rarely occur, and primarily have been published in case reports.41 Adverse events leading to catastrophic outcomes (death, permanent neurologic injury) are associated with dosing errors; use of three or more agents; drugs administered by non-medical professionals; inadequate observation time; the use of agents with long half lives like chloral hydrate and long acting barbiturates; inadequate resuscitation; delayed recognition of complications, particularly hypoxia; failure to use or properly interpret pulse oximetry; and lack of an independent observer dedicated to patient monitoring during the procedure.39,40 (See Table 6.) Appropriate training of personnel and methodical attention to patient assessment and monitoring as detailed below should greatly reduce or eliminate the preventable deaths and disability related to PSA.
|Table 6. Factors Contributing to Devastating Outcomes with PSA|
• Dosing errors
Administration of Pediatric Procedural Sedation
In response to a number of deaths associated with PSA, The Joint Commission has published increasingly specific regulations governing administration of PSA outside of the operating room.42,43 All hospitals are required to develop institution specific policies governing the use of PSA that must apply uniformly regardless of where in the hospital PSA is used. Joint Commission requirements only apply in cases in which the medications administered "may reasonably be expected to result in a loss of protective [airway reflexes]." In other words, a patient administered morphine for analgesia and lorazepam for anxiolysis in doses not expected to produce sedation need not be monitored in the same fashion as a patient undergoing PSA. In addition to these mandatory requirements, numerous subspecialty organizations have made recommendations concerning the practice of PSA. Guidelines published by ACEP, ASA, and AAP are the most relevant to the practicing emergency physician.1,3-8,44 These guidelines and Joint Commission regulations uniformly emphasize preprocedure patient assessment, adequately trained personnel, and appropriate monitoring and rescue equipment as the cornerstones of safe and effective PSA administration. Though there is a lack of strong evidence supporting many of the specific monitoring recommendations, implementation of standardized monitoring practices has been shown to increase the safety of PSA.32
Providers should have training and experience in selecting, dosing, and reversal agents to provide as safe and reliable a level of sedation as possible. Equally important, personnel should be able to rapidly recognize and reverse cardiorespiratory complications associated with PSA, including hypoventilation, laryngospasm, partial and complete airway obstruction, aspiration, bradycardia, and hypotension. According to the Joint Commission, "practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes [one level] deeper than initially intended. Individuals administering moderate sedation/analgesia should be able to manage patients who enter a state of deep sedation/analgesia, while those administering deep sedation should be able to manage patients who enter a state of general anesthesia."42,43 As most PSA used in the emergency department is intended to produce at least moderate sedation, the provider should possess the advanced airway skills (including excellent bag-valve-mask ventilation and definitive airway placement), and pediatric resuscitation experience needed to rescue a patient from inadvertent deep sedation, general anesthesia, and complications of sedation. Because of these requirements, most providers of PSA will be physicians. Though not strictly mandated by The Joint Commission or ACEP, most guidelines recommend an additional person, often a nurse or respiratory therapist, who is dedicated to patient monitoring during the procedure. As noted in the preceding section, providers with inadequate rescue skills and PSA utilizing only one provider have been associated with death and permanent neurologic injury as a consequence of PSA.25,28,39,40
Monitoring during PSA falls into three broad categories: respiratory, cardiovascular, and sedation depth. Commonly monitored parameters include general appearance, respiratory rate, oxygen saturation, heart rate, cardiac rhythm monitoring, and response to stimulation. All of these parameters should be regularly documented in a routine fashion in the written medical record. Other, less commonly utilized but potentially useful monitoring modalities, such as the bispectral index and capnography, may be useful when monitoring patients in deep sedation. A summary of suggested monitoring equipment as well recommended emergency airway supplies and resuscitative medications are shown in Table 7.
|Table 7. Suggested Equipment for Procedural Sedation|
• Continuous pulse oximetry monitor (audible)
Meticulous attention to airway monitoring is of paramount importance as the great majority of PSA related complications are respiratory in nature; in turn, respiratory insufficiency is the precipitating factor in the majority of pediatric arrests.25,39,40 Prompt recognition of airway complications is especially important because physiologic differences between adults and children lead children to decompensate more rapidly than adults. Compared to adults, children have a low functional residual capacity, and a basal oxygen consumption 2-3 times greater, leading to significantly more rapid development of hypoxia. With 5 minutes of preoxygenation, healthy infants reach a SaO2 < 90% after less than 3 minutes of apnea. This happens much more quickly without preoxygenation. After the onset of hypoxia, an infant continues to desaturate much more rapidly than a healthy adult. It occurs at approximately the same rate as an obese, 125 kg patient.45
The provider responsible for monitoring the patient should frequently assess airway patency and the adequacy of oxygenation and ventilation during PSA, though there is no consensus about what constitutes adequate assessment. For every patient, the chest wall should be observed for evidence of ventilation, with particular attention to the presence of sonorous respiration, stridor, or retractions, all of which indicate at least partial upper airway obstruction. Prompt recognition of these airway problems allows corrective measures, such as stimulating the patient, repositioning the airway, or providing positive airway pressure with a bag-valve-mask, to be taken before complete airway obstruction occurs. The general appearance of the patient, as well as continuous pulse oximetry with an audible indicator, are used to assess oxygenation. Unless it is impossible because of the procedure type, the person monitoring the patient must have an unobstructed view of the patient's chest, neck, and face in order to allow the continuous visual assessment described above. Compared to purely clinical assessment, capnography may be a more sensitive, reliable early indicator of hypoventilation and apnea.46-52 Capnography may be particularly useful when the nature of the procedure precludes adequate clinical assessment (facial laceration repair, MRI), or deep sedation is anticipated.
Continuous suction and appropriately sized bag-valve-mask should be immediately available at the bedside. The use of supplemental oxygen during the procedure via nasal canula or non-rebreather mask is not universally recommended and should be used according to "physician preference" per ACEP guidelines.8 Though doing so clearly reduces the incidence of hypoxia, it also may delay recognition of hypoventilation, airway obstruction, and apnea — a possible disadvantage when the cause is reversible upper airway obstruction. There is no evidence that mild hypoxia that is reversed is harmful to patients undergoing PSA. When opiates or benzodiazepines are used for sedation, reversal agents should be available in the room.
Cardiovascular parameters should be monitored, including the patient's general appearance, heart rate, and blood pressure. At a minimum, assessment of blood pressure is recommended before the procedure, after drug administration, upon completion of the procedure, and during the early recovery phase. Although there is no evidence clearly guiding practice, more frequent blood pressure assessment is probably indicated for patients with higher American Society of Anesthesiology (ASA) classes, during longer procedures, and for patients receiving agents with hemodynamic side affects. The use of cardiac monitors has not been shown to reduce the incidence or severity of complications during PSA, although as it is safe, non-invasive and has theoretical benefit, some guidelines recommend its use.3 For patients sedated without parenteral agents, intravenous access is not necessary and no published study has shown an association between lack of intravenous access and adverse outcome.9,25,29,30,39,40 When an IV is not used, supplies and skilled personnel for establishing IV access should be readily available as management of common complications may require administration of parenteral agents or fluids.
Depth of sedation has not been associated with adverse outcomes9,39,40 but has been occasionally associated with the incidence of adverse events.31 However, the depth of sedation may increase the skill required by the provider to manage complications. The Joint Commission, as well as the ACEP, ASA, and AAP guidelines, all recommend monitoring and recording sedation depth during all PSA. Several clinically based instruments have been validated as measures of sedation depth. However, patient response to verbal and tactile stimuli along with the cardiorespiratory monitoring described above are easily achievable, non-invasive, and are generally regarded as sufficient measures of sedation depth during minimal, moderate, and dissociative sedation according to the above guidelines. In contrast, response to stimulus may be inadequate or impractical to use to distinguish deep sedation from general anesthesia. This is of particular importance as newer sedative agents such as propofol frequently result in deep sedation. The bispectral index, derived from processed EEG signals, is a validated, objective measure of sedation depth in the operating room. Initial studies of its use during PSA support its validity in assessing sedation depth across the sedation continuum.12,53,54 Equipment to measure the bispectral index may become increasingly available if the evidence supporting its use continues to grow.
The timing of adverse events is of critical importance to emergency physicians as adequate post-procedure monitoring is critical for patient safety, but also impacts the ED length of stay. As many more recent additions to the pharmacopeia such as ketamine that have shorter half-lives than older agents like chloral hydrate, the appropriate post-procedure monitoring time has decreased. A study from 2003 by Newman and coworkers examined the timing of adverse events in a series of 1367 sedations.30 This study only examined PSA using combinations of the most commonly used agents: ketamine, midazolam, and fentanyl. The median time of ADEs was 2 minutes after the final dose of medication, and 92% of all ADEs occurred during the procedure itself. In patients who did not have an ADE during the procedure, no serious ADEs occurred greater than 25 minutes after the final medication administration. Minor ADEs, especially vomiting, continued to occur later in the ED stay and after discharge. For particularly painful procedures, this risk of adverse events may increase during the minutes following discontinuation of the painful stimulus. Though the appropriate monitoring time for these commonly used short-acting agents may be as little as 30-60 minutes after the final drug administration, current guidelines recommend 1-2 hours of post-procedure observation. This time should be increased to 2-4 hours when longer-acting or reversal agents are used, and for patients with developmental delay, age < 1-2 years, or other factors that may make assessing mental status more difficult. All patients should be assessed in a routine fashion prior to discharge including assessment of vital signs, mental status, and pain. Post-anesthesia scores such as the modified Aldrete score55 (> 18) have been validated for predicting safe discharge from the Post Anesthesia Care Unit (PACU) and may be adapted for use in the ED setting. Recommended discharge criteria are shown in Table 8.
|Table 8. Discharge Criteria*|
Documented preprocedure assessment prior to PSA is now required by The Joint Commission.2 The history should focus on the last PO intake, allergies, personal and family history of previous sedation/anesthesia, history of snoring/obstructive sleep apnea/stridor, and the presence of significant renal or hepatic disease that may impact drug clearance, the presence of significant cardiopulmonary disease (i.e., asthma) or current upper respiratory infection (URI), both of which may increase the likelihood of adverse events.56,57 (See Table 9.) The ASA class (see Table 10) should be determined. Though ED sedation of class 3 and 4 patients may be appropriate,58 strong consideration should be given to alternatives such as performing the procedure in the operating room or accomplishing the procedure without sedation.
|Table 9. Essentials of the Preprocedure Assessment|
The physical examination should give special attention to the airway for factors associated with difficult bag-valve-mask ventilation (edentulous, obesity, abnormal facies, facial hair) or endotracheal intubation (high Mallampati score, short neck, small chin, obesity, limited neck or jaw mobility). A high ASA class or a potentially difficult airway should prompt consideration of alternatives to PSA. The cardiovascular and respiratory examinations are important to detect unknown and/or active disease that may affect the success of PSA.
The risks, benefits, and alternatives to procedural sedation should be discussed with the family; at a minimum, verbal consent should be documented. Written consent is not currently required by The Joint Commission, but institutional guidelines and/or protocols may require it and should be reviewed. Discussing common but minor complications such as emesis in advance decreases parental concern and anxiety if and when such complications occur.
The necessity of preprocedural fasting is an area of ongoing controversy. The ASA currently recommends fasting times of 2 and 4 hours for clear liquids and breast milk respectively and 6 hours for non-human milk, formula, or a light meal. In making these recommendations, the ASA acknowledges that the standards only apply to elective procedures (thus not applicable to most ED procedures) and that "the literature does not provide sufficient evidence to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation."3
Though preprocedural fasting theoretically decreased the risk of aspiration during sedation, there is little evidence to support this contention. ACEP guidelines state: "recent food intake is not a contraindication for administering procedural sedation and analgesia, but should be considered in choosing the timing and the target level of sedation."8
Two large studies have recently examined the relationship between preprocedural fasting and complication rates. In a series of 1014 patients by Agrawal and colleagues,31 56% of patients did not meet ASA fasting guidelines. There were no statistically significant differences in adverse events between patients who meet fasting guidelines and those who did not, and the overall rate of complications was low (6.7%). A large study by Roback and coworkers19 in 2004 had similar findings, although this study had fasting data missing for 25% of the patients studied. A set of evidence-based, emergency medicine specific consensus guidelines was recently published with specific fasting recommendations based on patient risk and procedure duration.38 These guidelines are the most specific to date, although their complexity precludes discussion within the scope of this article. In general, the provider should weigh the risks and benefits of immediate versus delayed PSA in patients who do not meet current fasting guidelines.
This issue deals with the commonly encountered clinical scenario of managing pediatric pain in the emergency department. The indications for PSA may include a laceration repair, fracture reduction, or other painful procedure. Children, because of their unique clinical and physiologic characteristics, may be more challenging to assess and require frequent and careful assessments during PSA. The definitions, required equipment, patient assessment, and critical monitoring are all discussed with an emphasis on the special requirements for children. The next issue will address specific agents used for PSA, specific indications and contraindications for selecting PSA agents, and the use of reversal agents.
1. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Committee on Drugs. Section on anesthesiology. Pediatrics 1985;76(2):317-21.
2. Joint Commission on Accreditation of Healthcare Organizations. 2001 Sedation and Anesthesia Care Standards. Joint Commission on Accreditation of Healthcare Organizations Department of Publications, 2001, Oakbrook Terrace, IL
3. American Society of Anesthesiologists Task Force on Sedation and Analgesia by non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96(4):1004-17.
4. Practice guidelines for sedation and analgesia by non-anesthesiologists. A report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 1996;84(2):459-71.
5. Committee on Drugs. American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics 2002;110(4):836-8.
6. American Academy of Pediatrics Committee on Drugs: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89(6 Pt 1):1110-5.
7. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: A report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 1999;90(3):896-905.
8. Godwin SA, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005;45(2):177-96.
9. 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(11):1090-6.
10. Cote CJ. "Conscious sedation": time for this oxymoron to go away! J Pediatr 2001;139(1):15-7; discussion 18-9.
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12. Agrawal D, et al. Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children. Ann Emerg Med 2004;43(2): 247-55.
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14. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med 2000;342(13):938-45.
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16. Green SM, Krauss B. The semantics of ketamine. Ann Emerg Med 2000;36(5):480-2.
17. Joint Commission on Accreditation of Healthcare Organizations. Pain standards for 2001. 2001.
18. Probst BD, et al. Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care 2005;21(5): 298-305.
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20. Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004;20(4):228-32.
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22. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med 1996;14(2):157-60.
23. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997;13(2):103-6.
24. Sinha M, et al. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics 2006;117(4):1162-8.
25. Yagiela JA, et al. Adverse sedation events in pediatrics. Pediatrics 2001;107(6):1494.
26. Damian FJ, Smith MF, Krauss BS. Conscious sedation roundtable: a collaborative practice model for problem solving in the emergency department. J Emerg Nurs 1997;23(2):153-5.
27. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by nonanesthesiologists. Anesth Analg 1997;85(6):1207-13.
28. Pena BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 1999;34(4 Pt 1):483-91.
29. Roback MG, 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(6):508-13.
30. Newman DH, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med 2003;42(5):627-35.
31. Agrawal D, 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(5):636-46.
32. Pitetti R, et al. Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines. Arch Pediatr Adolesc Med 2006;160(2):211-6.
33. Cravero JP, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006;118(3):1087-96.
34. Brown L, et al. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med 2004;22(4):310-4.
35. Theroux MC, et al. Efficacy of intranasal midazolam in facilitating suturing of lacerations in preschool children in the emergency department. Pediatrics 1993;91(3):624-7.
36. 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(1):35-42.
37. Green SM. Fasting is a consideration—not a necessity—for emergency department procedural sedation and analgesia. Ann Emerg Med 2003;42(5):647-50.
38. Green SM, et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med, 2007;49(4)454-61.
39. Cote CJ, et al. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000;105(4 Pt 1):805-14.
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