title: The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department.
abstract: 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.
authors.affiliation: University of Maryland Medical System, Baltimore 21201, USA.
authors.forename: L S
authors.initials: LS
authors.lastname: Hart
authors.forename: S D
authors.initials: SD
authors.lastname: Berns
authors.forename: C S
authors.initials: CS
authors.lastname: Houck
authors.forename: D A
authors.initials: DA
authors.lastname: Boenning
mesh_terms: 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*
chemical_list: D004338:Drug Combinations; D006993:Hypnotics and Sedatives; D009294:Narcotics; D002245:Carbon Dioxide; D008614:Meperidine; D011398:Promethazine; D008874:Midazolam; D002746:Chlorpromazine; D005283:Fentanyl