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Original Investigation
August 21, 2017

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

Author Affiliations
  • 1Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
  • 2Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 4Departments of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  • 6Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  • 7Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 8School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
  • 9Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
  • 10Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  • 11Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
  • 12Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
  • 13Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada
  • 14Department of Family Medicine, McGill University, Montreal, Quebec, Canada
  • 15Department of Pediatrics, University of Minnesota Medical School, Minneapolis
  • 16Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
JAMA Pediatr. Published online August 21, 2017. doi:10.1001/jamapediatrics.2017.2135
Key Points

Question  What practices lead to the best outcomes in children undergoing emergency department procedural sedation?

Findings  In this multicenter cohort study of 6295 children undergoing procedural sedation for painful procedures in emergency departments, administration of ketamine hydrochloride as a single agent for sedation had the best outcomes. The addition of propofol or fentanyl citrate to ketamine increased the rates of serious adverse events and significant interventions.

Meaning  In the hands of emergency department physicians, procedural sedation for children is safe; sedation achieved using ketamine only was associated with the fewest serious adverse events and interventions.

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 Measures  Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting.

Results  Of 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 Relevance  The 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.

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