Pediatric Procedural Sedation, Analgesia, and Anxiolysis

In hospitals that restrict the use of propofol in young children outside of the operating room—and when there are no findings suggestive of impending cerebral herniation—a safe and effective alternative is IV ketamine at a dose of 1.5 mg/kg.

Cases Continued

Case 1

[The 4-year-old boy with the fractured wrist.]

Recognizing that repeated attempts at IV placement in a child with a contralateral extremity fracture often leads to escalating distress and anxiety, the EP decided against further attempts to place an IV line. Instead, he gave the child fentanyl via the IN route, which immediately relieved the patient’s pain and facilitated radiographic evaluation. After administrating the fentanyl IN, the EP instructed a member of the ED staff to apply LMX4 cream to several potential IV sites and then cover each site with occlusive dressings. Afterward, the patient was taken to radiology, and X-ray images of the fracture were easily obtained. When the patient returned from imaging, the ED nurse was able to place an IV line at one of the sites that had been previously anesthetized with LMX4 cream.

The EP consulted with the orthopedist, who determined that the child’s distal radius fracture necessitated closed reduction. To facilitate the procedure, the patient was given 1.5 mg/kg of ketamine. After a successful closed reduction, the orthopedic chief resident recommended the EP discharge the 15-kg (33-lb) patient home in the care of his parents, with a prescription for 5 mL oral acetaminophen and codeine suspension four times a day as needed for pain (5 mL = acetaminophen 120 mg/codeine 12 mg, and codeine dosed at 0.5-1 mg/kg per dose). Prior to discharge, the EP counseled the patient’s parents on the risks of codeine hypermetabolism in children. However, based on the parents’ expressed concerns, the EP instead discharged the patient home with a prescription for 4 cc oral acetaminophen-hydrocodone elixir every 4 to 6 hours as needed for pain instead (dosing is 0.27 mL/kg; elixir is hydrocodone bitartrate 7.5 mg/acetaminophen 325 mg/15 mL).

Case 2

[The 6-year-old girl with a large laceration to her forehead.]

The type of laceration sustained by this patient was appropriate for treatment with a local anesthetic combined with an agent for non-IV anxiolysis. Thirty minutes prior to suturing, LET gel was applied over the open wound site, and 5 minutes prior to initiating closure of the wound, the patient received IN midazolam. Since the LET cream was placed on the wound 30 minutes prior to the procedure, the site was well anesthetized for both irrigation and closure. The anxiolytic effects of the IN midazolam resulted in a calm patient, who was happy and playful throughout the procedure.

After successfully closing the wound, the physician discharged the patient home in the care of her parents, with instructions to apply bacitracin ointment to the wound site three times a day for the next 3 days, and give the patient over-the-counter acetaminophen elixir for any mild discomfort.

Case 3

[The 5-year-old boy who suffered cervical spine injuries after falling head-first off of a balance beam during gymnastics.]

Since no mucosal atomizer was available for IN drug delivery, and hospital policy restricted the use of propofol in young children outside of the operating room, the patient was given 1.5 mg/kg of IV ketamine. Within 45 seconds of ketamine administration, the child had adequate dissociative sedation, which allowed for high-quality CT scans of both the head and neck without incident. 

Case 4

[The febrile 3-week-old female neonate referred by her pediatrician for evaluation and LP.]

Since this neonate did not appear toxic, the EP delayed the LP by 30 minutes to allow time for application of a topical anesthetic to minimize associated procedural pain. Thirty minutes prior to the LP, LMX4 cream was applied to the patient’s L4 spinal interspace, and just prior to the procedure, the patient was given a pacifier that had been dipped in a solution of 4% sucrose. The neonate was then positioned appropriately for the LP and barely squirmed when the spinal needle was introduced, allowing the EP to obtain a nontraumatic cerebrospinal fluid sample on the first attempt.

Conclusion

Addressing pediatric pain and anxiety, especially preceding and during procedures and radiographic imaging, is a serious challenge in the ED. Several means are now available to provide safe and effective sedation, analgesia, and anxiolysis in the ED, with or without IV access. Many of the medications utilized, however, can cause significant respiratory and CV depression, making proper patient selection and monitoring, and training of involved personnel imperative to ensure safe use in the ED. Appropriate use of the agents and strategies discussed above will allow EPs to reduce both procedural pain and anxiety for our youngest patients—and their parents.