Journal of Emergencies, Trauma, and Shock
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Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 186-189
Procedural sedation for pediatric patients in the emergency department at King Khalid University Hospital, Riyadh, K.S.A

Department of Emergency Medicine, Pediatric Emergency Unit, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia

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Date of Submission12-Jul-2013
Date of Acceptance21-Nov-2013
Date of Web Publication16-Jul-2014


Procedural sedation and analgesia (PSA) has become the standard of care for diagnostic and therapeutic procedures undertaken in the Emergency Department (ED). In the Pediatric Emergency Department (PED) of King Khalid University Hospital (KKUH), which is a major teaching hospital in Riyadh Kingdom of Saudi Arabia we developed a standard protocol for PSA since 2005. The aim of this article is to report the experience at KKUH in pediatric PSA. Objectives: To report the experience at KKUH in pediatric PSA. Materials and Methods: Retrospective cross-sectional study of all cases who underwent PSA for painful procedures in Pediatric Emergency at KKUH from December 2005 to July 2008. Results: A total of 183 patients were reviewed. 179 patients were analyzed. Age ranges from 4 months to 13 years (mean 6 years). Nearly 66% were male. Ketamine was the most commonly used drug. Reduction of fracture/dislocation was the most common indication for sedation. Adverse events were identified in only 5.6% of patients. Vomiting was the most common recorded side-effect. The length of stay in the ED was ranging from 28 to 320 min (mean 111 min). Conclusion: Intravenous Ketamine is a consistently effective method of producing a rapid, brief period of adequate sedation and analgesia in children in the ED with no major side-effects noted in our experience.

Keywords: Ketamine, midazolam, pediatric emergency, procedural sedation and analgesia

How to cite this article:
Salleeh H, Ahmadi TA, Mujawar Q. Procedural sedation for pediatric patients in the emergency department at King Khalid University Hospital, Riyadh, K.S.A. J Emerg Trauma Shock 2014;7:186-9

How to cite this URL:
Salleeh H, Ahmadi TA, Mujawar Q. Procedural sedation for pediatric patients in the emergency department at King Khalid University Hospital, Riyadh, K.S.A. J Emerg Trauma Shock [serial online] 2014 [cited 2018 Jul 17];7:186-9. Available from:

   Introduction Top

Children routinely undergo painful and traumatic diagnostic and therapeutic procedures in Emergency Department (ED), which include fracture reduction, incision and drainage of abscesses, suturing of lacerations, or foreign bodies extraction.

The American College of Emergency Physicians defines procedural sedation as a method to "induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function independently and continuously." [1]

Procedural sedation has become the standard practice in the majority of EDs using different drugs with ketamine being the most commonly used drug. The first publications of ketamine use in children by non-anesthetists in EDs in the US was in the early 1990s. [2],[3],[4],[5]

The administration of procedure sedation requires experienced physicians with comprehensive knowledge of the drugs used and skills in pediatric airway management and resuscitation. The adverse event rate for procedural sedation and analgesia (PSA) performed by pediatric emergency physicians reported as 2.3% with no serious complications noted. [3]

Side-effects of Ketamine include nausea, vomiting, hypersalivation and agitation/hallucination (emergence reaction), but its safety profile has been found to be excellent in various settings. [4],[5] Ketamine has been reviewed extensively and shown to be extremely safe for use in Pediatric Emergency Department (PED). [6],[7],[8],[9],[10]

According to the literature review, there are no reports of procedural sedation in pediatric emergency from Saudi Arabia or middle east-north Africa region and we believe that we will present the first report from this area.

   Materials and methods Top

Study design

Retrospective cross-sectional study of all cases underwent PSA for painful procedures in Pediatric Emergency at King Khalid University Hospital (KKUH) from December 2005 to July 2008.

Study setting and population

This study was performed in the PED of a tertiary care teaching hospital with an average of 42,000 patient visits/year of different level of acuity level. Patients receiving PSA in the ED December 2005-July 2008 by the emergency physicians were included.

Study protocol

Procedural sedation recording sheet were reviewed and data were abstracted for all children who underwent any painful procedure from December 2005 to July 2008. It is the standard of care at our center to have the procedural sedation performed in the resuscitation room where full pediatric resuscitation facilities were available. A trained nurse and pediatrician with advanced airway and pediatric resuscitation skills were present to perform and supervise the sedation while another physician performed the procedure. Patients were monitored with continuous pulse-oximeter and cardiorespiratory monitors. Vital signs measurements were recorded every 5 min by a nurse with a complete presedation assessment sheet. The nurse remains with the patient from the time of administration of the sedation drug to the time the patient was ready for discharge. After completion of the procedure, patients were observed and monitored in the resuscitation room for 30 min after drug administration and then moved to the dedicated observation bed. Upon complete recovery with the normal level of consciousness, patients were discharged.

Measurements/data collection

For all patients receiving PSA in this ED, procedural sedation sheet, which become part of the medical record, are automatically generated. Nurses and physicians caring for the patients complete these sheets. Data pertaining to procedure type, drugs and doses used, vital signs, adverse events and length of stay in the ED were extracted from the procedural sedation sheet and recorded in a separate data collection sheets made for this study. Further chart review done to confirm the data. Descriptive Statistical analysis was performed using the statistical package for the social sciences software.

   Results Top

During the study period, 183 patients received PSA in the PED. Four patients were excluded from the analysis because certain documentations were missing in their medical records. A total of 179 patients were analyzed. The age ranged from 4 months to 13 years (mean 6 years) with 66% of the patients being male.

Different drug combinations were used as per the patient's condition and the treating physician's preference [Table 1]. Ketamine was used in 90% of cases. Nearly 34.5% were pretreated with Atropine. The doses of ketamine ranged from 0.07 to 3 mg/kg with a mean of 1.2 mg/kg.
Table 1: Drugs used in the procedural sedation

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Fasting guidelines according to application of the American college of emergency physicians recommendation were met in 165 patients (92.2%).

The most frequent indications for sedation were Fracture and Dislocation Reduction (60.9%), Repair of fingertip injuries (11.7%) and abscess drainage (11.7%) [Table 2]. 10 patients (5.6%) developed adverse events [Table 3].
Table 2: The indications of procedure sedation

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Table 3: Description of patients developed adverse effects

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Of those adverse effects vomiting was the most common occurring in six patients (60%) during the recovery period. Three of these patients had met the fasting guidelines and two did not. In one patient, the fasting status was not documented. Respiratory adverse events were observed in one patient who had apnea and oxygen desaturation to 80% in room air at 5 min after the start of sedation, however he was managed by bag mask ventilation with 100% oxygen and recovered within a few seconds while the procedure continued [patient 7 in [Table 3]. Two patients (1.2%) developed emergence reaction during recovery. One was a 9-year-old girl who received ketamine and developed emergence reaction during her recovery. She required treatment by midazolam [patient 8 [Table 3]. The other was an 11-year-old male who received ketamine and atropine who required no treatment for the emergence reaction [patient 9 [Table 3].

One patient developed jerky movement and shivering during the sedation with ketamine. She was managed by 100% oxygen and intravenous (IV) midazolam [patient number 10 [Table 3].

All the procedures were successfully completed without any co morbidity and none of the patients were admitted to the hospital secondary to adverse events associated with PSA.

The length of stay in the ED was calculated from the start of procedural sedation until the time patients left the ED. It was ranging from 28 to 320 min (mean 110 min).

   Discussion Top

In our series, the overall incidence of adverse events (5.6%) is comparable to the reported adverse effects in the literatures (2.3-4.5%). [3],[11] and however less than what reported by Roback et al. (17%). [12]

Vomiting is the most common adverse effect (60%) and despite variations in fasting recommendations, there were no episodes of aspiration. Vomiting incidence ranges from 0% to 43% in reviewed literature with rare incidence of pulmonary aspiration of gastric content. . [13],[ 14]

None of the recent case series as well as our study have reported any episodes of apnea requiring intervention other than supplemental oxygen or brief manual ventilation assistance. As noted in previous studies, laryngospasm is very rare with incidence of 0.017%. [4] Whereas we did not encounter any case of laryngospasm, which may be due to small sample size of our study.

The overall incidence of respiratory adverse events and vomiting in our series (3.9%) is less than that of Pitetti et al. (17.9%) [9] and Roback et al. (15%) [12] but higher than that found by Peña and Krauss (2.3%). [3] This could be due to the relatively smaller number of patients in our study.

The incidence of emergence phenomena is 0-10% and rare in children under 10 years old. [12]

In this study, two patients (1%) developed Emergence phenomena during recovery. Both were above 9 years and received ketamine without midazolam. Previous studies have commented on the inability of midazolam to diminish emergence reactions associated with ketamine sedation. A study by Wathen et al. commented further that in their 266 patients, those who received ketamine/midazolam were more likely to have desaturation but less likely to vomit than those receiving ketamine alone. [11]

In our study, the majority of patients received ketamine without midazolam and only two developed emergence phenomena and none of the twelve patients who received midazolam had any adverse event.

Seizure activity with ketamine has been rarely reported and it is said to have anticonvulsant properties. [12]

One patient in our series was reported to have jerky movement and shivering (but not generalized tonic clonic movement). This was thought to be seizure activity and the child was given IV midazolam, which controlled the abnormal movements. It is quite possible that the "shaking episodes" described to have occurred in this patient may have been exaggerated muscular hyper tonicity rather than true seizure activity.

Muscular hypertonicity has been reported to occur commonly with ketamine sedation and was not observed in this study, this may be due to underreporting this effect by the physician and nurses as this specific effect is not mentioned in the adverse effect box in the sedation sheet.

We did not encounter any cardiovascular adverse events. These findings are consistent with those of Peña and Krauss (one episode of bradycardia in 1,180 sedations; 0.001%) [3] and Pitetti et al. (two episodes of hypotension in 1,244 sedations; 0.002%). [9]

Tachycardia and hypertension, which was noted in the vital signs are expected effects of ketamine sedation and were not recorded as complications.

We reported a longer length of stay in the ED compared with that reported by several literatures ranging from 25 to 101 min. This time is defined as the time from injection of ketamine to actual departure from the ED. Green's [15] and Dachs [16] recorded time to "ready for discharge," a better measure of sedation recovery time as it would exclude department management issues such as completion of paperwork and organization of transport. Our longer time could be explained by the time needed for parents to arrange for transportation, completion of consultation and paperwork processing for admitted patients. When we consider the length of stay from the injection time to the time patients were ready for discharge we got a shorter length of stay of 98 min (15-255 min). When we excluded patient who was admitted from the analysis the median discharge time was 95 min (28-210 min) and with further exclusion of those who had adverse events as it prolonged the observation time, the mean time to discharge was 82 min which is comparable to what reported by McGlone et al. (85 min) [17] and Acworth et al. (98 min) [18] however less than those reported by Ellis et al. (101 min). [2]

In our series, there was no relation between the dose of ketamine used and the incidence of adverse events. Green found that there was no clinical or statistical difference in the time to discharge, adverse events, emesis, recovery agitation, time to discharge and adequacy of sedation in relation to ketamine dose, though there was a trend toward improved sedation adequacy with increasing dose. [19]


Our study had limitations. The retrospective nature of the study limited the number of variables that we were able to explore. The relatively small number of patients from a single center limited the ability to do subgroups analysis of the different drug combinations used and adverse events.

   Conclusion Top

Our experience in pediatric PSA at KKUH is comparable to reported data from other centers. IV Ketamine is a consistently effective method of producing a rapid, brief period of profound sedation and analgesia in children in the ED with no major side-effects noted in our experience.

   References Top

1.Clinical policy for procedural sedation and analgesia in the emergency department. American College of Emergency Physicians. Ann Emerg Med 1998;31:663-77.  Back to cited text no. 1
2.Ellis DY, Husain HM, Saetta JP, Walker T. Procedural sedation in paediatric minor procedures: A prospective audit on ketamine use in the emergency department. Emerg Med J 2004;21:286-9.  Back to cited text no. 2
3.Peña BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 1999;34:483-91.  Back to cited text no. 3
4.Green SM, Johnson NE. Ketamine sedation for pediatric procedures: Part 2, Review and implications. Ann Emerg Med 1990;19:1033-46.  Back to cited text no. 4
5.Green SM, Nakamura R, Johnson NE. Ketamine sedation for pediatric procedures: Part 1, A prospective series. Ann Emerg Med 1990;19:1024-32.  Back to cited text no. 5
6.Green SM, Clem KJ, Rothrock SG. Ketamine safety profile in the developing world: Survey of practitioners. Acad Emerg Med 1996;3:598-604.  Back to cited text no. 6
7.Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004;44:460-71.  Back to cited text no. 7
8.Green SM, Rothrock SG, Harris T, Hopkins GA, Garrett W, Sherwin T. Intravenous ketamine for pediatric sedation in the emergency department: Safety profile with 156 cases. Acad Emerg Med 1998;5:971-6.  Back to cited text no. 8
9.Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med 2003;157:1090-6.  Back to cited text no. 9
10.Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, et al. Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97.  Back to cited text no. 10
11.Wathen JE, Roback MG, Mackenzie T, Bothner JP. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial. Ann Emerg Med 2000;36:579-88.  Back to cited text no. 11
12.Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: A comparison of common parenteral drugs. Acad Emerg Med 2005;12:508-13.  Back to cited text no. 12
13.Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J 2004;21:275-80.  Back to cited text no. 13
14.Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation - An examination of the role of fasting and sedation depth. Acad Emerg Med 2002;9:35-42.  Back to cited text no. 14
15.Green SM, Kuppermann N, Rothrock SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35:35-42.  Back to cited text no. 15
16.Dachs RJ, Innes GM. Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med 1997;29:146-50.  Back to cited text no. 16
17.McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J 2004;21:290-5.  Back to cited text no. 17
18.Acworth JP, Purdie D, Clark RC. Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation. Emerg Med J 2001;18:39-45.  Back to cited text no. 18
19.Green SM, Hummel CB, Wittlake WA, Rothrock SG, Hopkins GA, Garrett W. What is the optimal dose of intramuscular ketamine for pediatric sedation? Acad Emerg Med 1999;6:21-6.  Back to cited text no. 19

Correspondence Address:
Hashim Salleeh
Department of Emergency Medicine, Pediatric Emergency Unit, College of Medicine, King Saud University, Riyadh 11472
Saudi Arabia
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Source of Support: Research Centre of College of Medicine, King Saud University., Conflict of Interest: None

DOI: 10.4103/0974-2700.136862

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