The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department.
BACKGROUND
Many studies have evaluated conscious sedation regimens commonly used in pediatric patients. Recent advances in capnography equipment now enable physicians to assess respiratory parameters, specifically end-tidal CO2 (et-CO2), more accurately in spontaneously breathing sedated children than was possible in the earlier studies. This study was designed to: 1) compare the safety and efficacy of intravenous fentanyl, intravenous fentanyl combined with midazolam, and intramuscular meperidine-promethazine-chlorpromazine (MPC) compound when used for painful emergency department (ED) procedures: and 2) to determine whether the addition of et-CO2 monitoring enabled earlier identification of respiratory depression in this population.


METHODS
Forty-two children requiring analgesia and sedation for painful ED procedures were randomly assigned to receive either fentanyl, fentanyl-midazolam, or MPC compound. Vital signs, oxygen saturation, and et-CO2 were monitored continuously. Pain, anxiety, and sedation scores were recorded every five minutes.


RESULTS
Respiratory depression (O2 saturation < or = 90% for over the minute or any et-CO2 > or = 50) occurred in 20% of fentanyl, 23% of fentanyl-midazolam, and 11% of MPC patients (P = NS). Of those patients manifesting respiratory depression, 6/8 were detected by increased et-CO2 only. MPC patients required significantly longer periods of time to meet discharge criteria than fentanyl and fentanyl-midazolam patients (P < 0.05). No differences were noted in peak pain, anxiety, or sedation scores.


CONCLUSIONS
Fentanyl, fentanyl-midazolam, and MPC produced a high incidence of subclinical respiratory depression. End-tidal CO2 monitoring provided an earlier indication of respiratory depression than pulse oximetry and respiratory rate alone. MPC administration resulted in a significantly delayed discharge from the ED.
Hart
L S
LS
University of Maryland Medical System, Baltimore 21201, USA.
Berns
S D
SD
Houck
C S
CS
Boenning
D A
DA
D019296:Capnography; D002245:Carbon Dioxide / Q000032:analysis; D002648:Child; D002746:Chlorpromazine / Q000009:adverse effects; D016292:Procedural Sedation / Q000009:adverse effects* / Q000379:methods; D004338:Drug Combinations; D004636:Emergency Service, Hospital; D005260:Female; D005283:Fentanyl / Q000009:adverse effects; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects; D007223:Infant; D008297:Male; D008614:Meperidine / Q000009:adverse effects; D008874:Midazolam / Q000009:adverse effects; D009294:Narcotics / Q000009:adverse effects; D010146:Pain / Q000209:etiology; D011398:Promethazine / Q000009:adverse effects; D012120:Respiration Disorders / Q000139:chemically induced / Q000175:diagnosis*
D004338:Drug Combinations; D006993:Hypnotics and Sedatives; D009294:Narcotics; D002245:Carbon Dioxide; D008614:Meperidine; D011398:Promethazine; D008874:Midazolam; D002746:Chlorpromazine; D005283:Fentanyl