Procedural Sedation for Orthopedic Fracture Reductions in the Pediatric Emergency Department

Abstract

Oz 52 DOI: 10.4274/cayd.66588 J Pediatr Emerg Intensive Care Med 2016;3:52-61 Alkan Bal1, Halim Hennes2 1Izmir Tepecik Training and Research Hospital, Clinic of Child Health and Diseases, Division of Pediatric Emergency, Izmir, Turkey 2Texas Southwestern University Faculty of Medicine, Department of Pediatric Emergency Medicine, Texas, USA Address for Correspondence/Yazisma Adresi: Alkan Bal MD, Izmir Tepecik Training and Research Hospital, Clinic of Child Health and Diseases, Division of Pediatric Emergency, Izmir, Turkey E-mail: balalkan@hotmail.com Received/Gelis Tarihi: 22.03.2016 Accepted/Kabul Tarihi: 11.07.2016 Review / Derleme Introduction Procedural sedation and analgesia (PSA) is an essential element of care for children requiring painful procedures in the pediatric emergency department (PED). While several medications are available for PSA, the ideal agent should have; rapid onset of action, short recovery time, provide adequate analgesia and sedation, and have no or minimal adverse effects. To date there is no single agent that has all these properties. Medication selection for PSA is guided by the patient’s underlying medical conditions, age, anticipated degree of pain, and required procedure. To ensure patient safety during PSA, pre-sedation evaluation, American Society of Anesthesiologists (ASA) status, type of procedure, length of procedure, and monitoring equipment are important adjunct to ensure patient safety during the procedure and selecting appropriate sedation agent.1 The safety and efficacy of PSA, in the PED are well described in the literature.2,3 The objective of this review is to discuss patient evaluation, monitoring, indications, and contraindications of common PS pharmacologic agents properties, dose, indications, contraindications, and adverse effects during orthopedic fracture reductions in the PED. Preparing the Patient for Procedural Sedation and Analgesia The first step in preparing for PSA in the PED is to have; dedicated staff appropriately trained in airway management, monitoring equipment’s, medications, and a sedation plan based on the required procedure. Requirements for safe PS are well documented in the guidelines.4-6 In addition to monitoring equipment, oxygen, bag-mask system, suction catheters, resuscitation medications, laryngoscope with appropriate size blades, endotracheal tubes and the other rescue airway devices should be readily available in the PSA room.4,5 The number of personnel required to provide safe PSA is not clear.6 However, the minimal requirement is one physician skilled in airway management to administer medication, one qualified nurse for monitoring are required.4 The physician responsible for sedation should not be responsible for performing the procedure. Pre-sedation Patient Evaluation A review of the patient allergies, medical and surgical history, and family history relevant to anesthesia is an important to identify contraindication to sedation. Physical examination should include a thorough evaluation of the upper airway including degree of mouth opening (Mallampati classification), respiratory, cardiovascular, and neurologic systems. The goal in evaluating the airway is to identify a potentially difficult airway prior to sedation (facial abnormalities, neck masses, neck mobility, obesity etc.). The Mallampati classification is a simple scoring system to assess mouth opening and visualization of the posterior oropharynx.7 Mallampati class 3 and 4 predicts a potentially difficult airway.8 The ASA classifications categorize the health status of candidates into one of 5 classes. Patients with ASA class 1 and 2 are generally considered appropriate candidates for PSA.4 Patient’s last oral intake [nil per os (NPO) status] for PS in the ED remains controversial. The American Academy of Pediatrics and ASA guidelines recommendations for elective procedures are; 2 hours for clear liquids, 4 hours after breastfeeding, and 6 hours after solid and non-clear fluids.4,5 However, the association between NPO status and vomiting during or following sedation is not well established in the pediatric literature. Several observational studies found no clear association between adverse events and NPO status.9-12 Monitoring Before initiating the PSA, baseline vital parameters (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) should be documented. The minimal monitoring recommendation includes close patient observation by a trained provider, pulse oximetry, heart rate and intermittent assessment of level of sedation. Monitoring in moderate and deep sedation includes; continuous monitoring of oxygen saturation, heart rate, and intermittent recording of respiratory rate and blood pressure. In addition, the Ramsay sedation scale can be used to assess sedation level.13 Other non-invasive monitoring options include the use of capnography to detect hypoventilation and Bispectral index (BIS) to measure the depth of sedation (Table 1). Capnography There are 2 types of hypoventilation. First is bradycardic hypoventilation commonly observed with opioid use and characterized by increased end tidal carbon dioxide (ETCO2) and increased partial pressure of carbon dioxide (PaCO2). The second is hypopneic hypoventilation occurs most commonly with sedative hypnotic drugs and is characterized by a normal or decreased ETCO2 and an increased PaCO2. Capnography is believed to detect hypoventilation during sedation before it becomes apparent by clinical examination or pulse oximetry.4,5,14 Several investigators reported early detection of hypoventilation in sedated pediatric patients when capnography is compared to conventional monitoring 53 Bal and Hennes Procedural Sedation for Orthopedic Fracture Reductions in the Pediatric Emergency Department CAYD 2016;3:52-61