When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations.
OBJECTIVE
The optimal timing of discharge from the emergency department (ED) after pediatric procedural sedation and analgesia has not been well studied. Because concern about delayed adverse effects commonly delays discharge after sedation, we attempted to establish the timing of adverse effects in our cohort of procedural sedations.


METHODS
We analyzed data from a prospectively generated database comprising consecutive sedation events throughout a 2-year period. We determined the timing of serious (eg, hypoxia, stridor, hypotension) and other adverse effects from final medication administration and calculated adverse effect risk ratios in relation to sedation characteristics.


RESULTS
In 1341 sedation events, there were 184 (13.7%) adverse effects, of which 159 (11.9%) were serious. The median age of children with and without adverse effects was similar (64 months in both groups). Most adverse effects occurred during the procedure (92%) rather than after the procedure (8%). Serious adverse effects occurred a median of 2 minutes after final medication dose (range -106 to +40 minutes). One hypoxic episode occurred each at 26, 30, and 40 minutes after final medication administration; all were repeated occurrences in children who had experienced previous hypoxia during the expected peak drug effect.


CONCLUSIONS
Adverse effects were common; however, serious adverse effects rarely occurred after 25 minutes from the final medication administration. Those that did occur this late were all preceded by a separate similar adverse effect during the expected peak drug effect, which suggests that when similar medication regimens are used, discharge from the ED may be safe at approximately 30 minutes after final sedation medication administration if no adverse effects have occurred.
Department of Emergency Medicine, St Luke's/Roosevelt Hospital Center, New York, City, NY 10025, USA. Newman44@pol.net
David H
DH
Newman
Melissa M
MM
Azer
Raymond D
RD
Pitetti
Sonia
S
Singh
D000759:Adjuvants, Anesthesia / Q000009:adverse effects; D000762:Anesthesia Recovery Period; D019162:Anesthetics, Combined / Q000009:adverse effects; D000778:Anesthetics, Dissociative / Q000009:adverse effects; D018686:Anesthetics, Intravenous / Q000009:adverse effects; D001285:Atropine / Q000009:adverse effects; D002648:Child; D016292:Procedural Sedation / Q000009:adverse effects* / Q000379:methods / Q000592:standards; D016903:Drug Monitoring / Q000379:methods / Q000592:standards; D004638:Emergency Treatment / Q000379:methods / Q000592:standards; D005260:Female; D005283:Fentanyl / Q000009:adverse effects; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D000860:Hypoxia / Q000139:chemically induced; D007649:Ketamine / Q000009:adverse effects; D008297:Male; D008874:Midazolam / Q000009:adverse effects; D016017:Odds Ratio; D010351:Patient Discharge / Q000592:standards* / Q000706:statistics & numerical data; D010372:Pediatrics / Q000379:methods / Q000592:standards; D011446:Prospective Studies; D012135:Respiratory Sounds / Q000209:etiology; D012307:Risk Factors; D012449:Safety; D016037:Single-Blind Method
D000759:Adjuvants, Anesthesia; D019162:Anesthetics, Combined; D000778:Anesthetics, Dissociative; D018686:Anesthetics, Intravenous; D007649:Ketamine; D001285:Atropine; D008874:Midazolam; D005283:Fentanyl