Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

Abstract

IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs.DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURESFour outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTSOf the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCEThe incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.

Impact of Timing of Preprocedural Opioids on Adverse Events in Procedural Sedation

“…Only two pediatric studies have examined the relationship between adverse events and opioid administration prior to ED sedation and to our knowledge there are no studies that have assessed the impact of timing of opioid administration. In our cohort of 6,295 patients, we demonstrated that opioids administered prior to sedation were significantly associated with oxygen desaturation, need for PPV, and vomiting . In a retrospective, unadjusted analysis of a smaller number of ED ketamine sedations ( n = 858), Waterman and colleagues detected no difference in the incidence of adverse events between those patients who did and did not receive preprocedural opioids.…”

“…Characteristics of children included in the study are presented in Table . Of the 6,295 sedations included in the final analysis of the parent study, 1,806 (29% of the original cohort) received a preprocedural opioid. Of those who received an opioid, 1,255 (69.5%) patients received morphine, 523 (29.0%) received fentanyl, and 8 (0.4%) received hydromorphone.…”

“…In our recent multicenter ED procedural sedation cohort of 6,295 children, we found a strong, positive association between the administration of preprocedural opioids and both the occurrence of oxygen desaturation and the need for positive pressure ventilation (PPV), the only significant intervention performed in our study. We also observed a weak positive association with the occurrence of vomiting . Based on these findings of association between the administration of preprocedural opioids and adverse events, the objective of this study was to examine whether the risk of sedation‐related adverse events changes with the timing of opioid administration.…”

“…We also observed a weak positive association with the occurrence of vomiting. 10 Based on these findings of association between the administration of preprocedural opioids and adverse events, the objective of this study was to examine whether the risk of sedation-related adverse events changes with the timing of opioid administration. To our knowledge, this association has never been studied in procedural sedation.…”

BET 2: Antiemetic use in paediatric sedation with ketamine

“…Langston et al 1 demonstrated that ondansetron significantly reduces emesis in children of all ages undergoing intravenous ketamine procedural sedation, with an NNT of 8 in children older than 5 years, although this subanalysis has a wide CI. Bhatt et al 2 have shown in a multicentre, prospective cohort study that the use of antiemetic is associated with a reduced rate of vomiting in ketamine procedural sedation. This study also showed that the use of preprocedural opioids is associated with a higher rate of emesis during ketamine sedation in children.…”