title: Adverse events of procedural sedation and analgesia in a pediatric emergency department.
abstract: OBJECTIVE
  To determine the adverse event and complication rate for the use of procedural sedation and analgesia for painful procedures and diagnostic imaging studies performed in a pediatric emergency department.
  
  
  METHODS
  This prospective case series was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients younger than 21 years seen between August 1997 and July 1998, who required intravenous, intramuscular, oral, rectal, intranasal, or inhalational agents for painful procedures or diagnostic imaging. All patients who underwent procedural sedation and analgesia were continually monitored. Adverse events and complications were recorded. The ED controlled substance log was checked weekly and all sedations were reviewed. Adverse events were defined as follows: oxygen desaturation less than 90%, apnea, stridor, laryngospasm, bronchospasm, cardiovascular instability, paradoxical reactions, emergence reactions, emesis, and aspiration. Complications were defined as adverse events that negatively affected outcome or delayed recovery.
  
  
  RESULTS
  Of 1,180 patients who underwent procedural sedation and analgesia in the ED, 27 (2.3%) experienced adverse events, which included oxygen desaturation less than 90% requiring intervention (10 patients) [supplemental oxygen (9), bag-mask ventilation (1)], paradoxical reactions (7), emesis (3), paradoxical reaction and oxygen desaturation requiring supplemental oxygen (2), apnea requiring bag-mask ventilation (1), laryngospasm requiring bag-mask ventilation (1), bradycardia (1), stridor and emesis (1) and oxygen desaturation requiring bag-mask ventilation with subsequent emesis (1). There was no statistically significant difference in mean doses for all procedural sedation and analgesia medication regimens between those children who experienced adverse events and those who did not. No single drug or drug regimen was associated with a higher adverse event rate. In addition, there was no significant difference in the adverse event rate between males and females, among the different ages, or among the different indications for procedural sedation and analgesia. No patient required reversal of sedation with naloxone or flumazenil, endotracheal intubation, or hospital admission because of complications from procedural sedation and analgesia.
  
  
  CONCLUSIONS
  The adverse event rate for procedural sedation and analgesia performed by pediatric emergency physicians was 2.3% with no serious complications noted.
authors.affiliation: Division of Emergency Medicine, Department of Pediatrics, Children's Hospital, Harvard Medical School, Boston, MA, USA. pena_b@al.tch.harvard.edu
authors.forename: B M
authors.initials: BM
authors.lastname: Peña
authors.forename: B
authors.initials: B
authors.lastname: Krauss
mesh_terms: D000293:Adolescent; D000328:Adult; D000698:Analgesia / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D016292:Procedural Sedation / Q000009:adverse effects*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005283:Fentanyl; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology*; D007223:Infant; D007231:Infant, Newborn; D007649:Ketamine; D008874:Midazolam; D010372:Pediatrics; D017409:Sufentanil; D014481:United States
chemical_list: D007649:Ketamine; D017409:Sufentanil; D008874:Midazolam; D005283:Fentanyl