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Sedation Medication Influences Adverse Effects in Children Treated at EDs

The choice of sedation medication has the greatest influence on whether adverse events are likely to occur in pediatric emergency departments and to require significant interventions, according to a new study.

A report in JAMA Pediatrics reviewed the incidence of, and risk factors associated with, sedation-related adverse events in pediatric EDs. The research was part of a multicenter observational study conducted by the Children’s Hospital of Eastern Ontario (CHEO).

Results indicate that the incidence of serious adverse events was lowest among patients sedated with ketamine alone and highest among patients sedated with ketamine combined with propofol or fentanyl.

Background information in the article notes that procedural sedation is commonly used for painful or uncomfortable procedures such setting fractures, repairing lacerations, and draining abscesses in EDs worldwide.

“Although sedation-related serious adverse events occur infrequently, recognition and early intervention is necessary to ensure patient safety," explained lead author Maala Bhatt, MS, MSc, director of pediatric emergency research at CHEO, and assistant professor at the University of Ottawa. “We've been able to identify sedation medications and practices associated with the best clinical outcomes, which is practice-changing.”

More than 6,000 patients sedated with six different medication combinations at six different EDs across Canada were included in the study.

According to the results, the overall incidence of adverse events in the study population was 11.7%. The most common events were determined to be a decrease in oxygen saturation, seen in 5.6% of patients, and vomiting, seen in 5.2% of patients. Still, adverse events requiring significant interventions remained rare at 1.4%.

Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) followed by the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of significant adverse effects, according to the report. At the same time, the combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions.

Researchers also point out that two common practices – receiving an opioid before sedation and undergoing a laceration repair – were more likely to lead to vomiting, oxygen desaturation, and the necessity for significant interventions.

“The low rate of serious adverse events and significant interventions supports the safety of procedural sedation in the hands of emergency department physicians,” Bhatt said. “While all sedation medications and combination of medications are effective and safe in the hands of experienced providers, ketamine alone is associated with the fewest serious adverse events and significant interventions, making it a logical choice for providing procedural sedation for children in emergency departments.”

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