Emergency nurses are frequently asked to assist in

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1 PEDIATRIC INTRAVENOUS MEDICATION ADMINISTRATION IN THE EMERGENCY DEPARTMENT, PART 3: RIP VAN WINKLE S APPROACH TO PEDIATRIC PROCEDURAL SEDATION Authors: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, and Stacey A. Benotti, PharmD, Boston, MA Section Editor: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN Earn Up to 8.5 CE Hours. See page 552. Emergency nurses are frequently asked to assist in procedural sedation for pediatric patients in the emergency department. A typical ED shift may include a 2-year-old child in need of chin laceration repair. The same nurse may be assigned a crying, frightened, 6-yearold child with an arm injury who is in need of a fracture splint and manipulation, while a scared 15-year-old boy with a spontaneous pneumothorax may require a chest tube insertion. Later in the evening a 13-year-old may require significant burn management in the emergency department. Safe pediatric procedural sedation in the emergency department requires the nurse to be aware of the performance steps in procedural sedation, including their institution's training, regulatory, and governing agencies rules. Compassionate pediatric ED patient care involves safe procedural sedation to treat pain and anxiety during therapeutic or diagnostic procedures. Pediatric procedural sedation may be an infrequent or frequent occurrence, depending on the qualifications of the practitioners in your emergency department. As defined by the American College of Emergency Physicians and other practitioners, procedural sedation includes any interventions that alter a patient s response during tests and procedures. Prior to the initiation Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, ised Staff Nurse, Tufts Medical Center, Boston, MA, and Adjunct Nursing Faculty, Northeastern University, Boston, MA. Stacey A. Benotti is Clinical Pharmacy Specialist, Pediatric and Adult ED, Tufts Medical Center, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, 7 Bowl Rd, Chelmsford, MA 01824; pnormandinrn@aol.com. J Emerg Nurs 2016;42: Available online 3 September Copyright 2016 Emergency Nurses Association. Published by Elsevier Inc. of any procedural sedation procedure, the ED nurse should assess the child s age, weight in kilograms, developmental status, behavioral status, medical history, allergies, hospitalizations, current medications, pertinent family history, previous sedation or general anesthesia experience, and physical considerations. Before sedation is initiated, pediatric patients who have potential sedation risks such as major medical conditions affecting the respiratory, cardiovascular, and neurologic systems, as well as patients who have structural airway anomalies or psychiatric disorders, should be identified. Also important is presedation identification of children with a history of snoring or central or obstructive sleep apnea, a history of prematurity, a family history of adverse reaction to sedation, analgesia, or general anesthesia, and pregnancy status. Presedation evaluation should include a physical examination by the clinician, including auscultation of the heart and lungs and assessment of the neck and airway for conditions that may cause a high risk for endotracheal intubation or resuscitation. Collaboration with the parents regarding the child s prior response to stressful events, cultural considerations, and comfort measures is helpful. Parents should be offered the opportunity to stay with the child during the procedure. When the parent decides to stay with the child, clear, concise anticipatory teachings in terms a lay person can understand should be reviewed. Signed informed consent of the parent or guardian regarding the procedure, specific sedation medication, monitoring, pediatric airway management, potential complications, and discharge criteria should be obtained prior to initiation of procedural sedation. ED nurses need to be aware that parental anxiety is a predictor of the child s anxiety. Recognition and management of parental anxiety is crucial to the reduction of the child s anxiety. 1 On December 6, 2013, ENA endorsed the American College of Emergency Physicians document Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department, which was approved on October 11, November 2016 VOLUME 42 ISSUE

2 Sedation states are a continuum that can progress from mild sedation to general anesthesia, and patients can slip from one level of sedation to another. Levels of procedural sedation collaboratively defined by the American Academy of Pediatrics, the American Society of Anesthesiologists, the American Academy of Pediatric Dentists, and the Joint Commission are analgesia, minimal sedation, moderate sedation/analgesia, deep sedation/analgesia, and general anesthesia. 1 The American College of Emergency Physicians defines sedation induced by ketamine as dissociative sedation, which produces profound analgesia and amnesia while retaining airway protective reflexes, cardiopulmonary stability, and spontaneous respirations. Ketamine is not considered part of the standard sedation definitions and should have separate guidelines. Safe, effective procedural sedation and analgesia in the emergency department is important to alleviate pain, including anxiety from medical procedures. Providing effective sedation is beneficial for the patient and family and also includes the ED personnel involved to facilitate a positive experience during a time of patient crisis. Procedural sedation is a treatment strategy of administering sedatives or analgesic medications to purposefully suppress a patient s level of consciousness. The level of sedation should be tailored to needs related to the patient and the procedure. 1,2 Personnel who administer sedation should be comfortable with procedural sedation and understand the pharmacology of the drugs. Airway management competency is mandatory with deep sedation and strongly advised with lower levels of sedation. Clinicians and emergency nurses involved in procedural sedation should be able to manage possible complications, recognize a compromised patient, and intervene. At a minimum, emergency nurses should be able to maintain the child s airway, understand repositioning, and provide bag-mask ventilation. Fasting prior to the procedure for any duration has not been shown to reduce the risk for emesis or aspiration when providing procedural sedation and analgesia. Prior to the procedure the temperature, heart rate, respirations, pulse oximetry, and blood pressure should be measured and recorded. Regarding intravenous catheter access, it is preferred that lighter sedation be used and that sedatives be given by oral, nasal, rectal, or intramuscular injection. If intravenous access is not available, equipment and personnel who are competent in performing vascular access should be immediately available in case any early warning signs of compromise are identified. Deep sedation requires placement of an intravenous catheter to enable administration of medications for sedation or resuscitation. Two personnel should be in attendance during the procedural sedation, including the provider performing the procedure and a nurse to monitor the patient. Capnography is a recommended adjunct to pulse oximetry, with clinical assessment to detect hypoxia and apnea. 1,2 It is important to perform pain assessments before, during, and after the pediatric procedure to manage, control, and alleviate pain. ED nurses should utilize pain assessment tools approved by their facility that are age and developmentally appropriate. The Facial, Legs, Activity, Cry, Consolability (FLACC)/Revised FLACC scale has been found to be an appropriate pain assessment tool for preverbal children younger than 3 years of age, as well as children who are critically ill or have cognitive impairment. A valid and reliable pain assessment tool for children as young as 3 years old is the Faces Pain Rating Scale for children. Infant and other preverbal children pain rating scales that are based on observations instead of the child s report include the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) for infants. 3 Nonpharmacologic pain management interventions are effective adjuncts that reduce pain, fear, and anxiety and should be introduced early, along with pharmacologic interventions. Nonpharmacologic pain management strategies for ED nurses that are helpful include developing trust, being honest with age-appropriate pain descriptors, avoiding judgment of the child s response to pain, and encouraging family inclusion during the procedure. Some distraction techniques include music therapy, playing videos, watching cartoons, playing with bubbles and glitter wands, and using positive self-talk and imagery. If your agency employs Child Life Services personnel, they can assist with nonpharmacologic distraction methods. Children should be allowed to breast feed as a comfort measure when this is an option. Analgesia with oral sucrose is useful for infant pain management in the emergency department along with other analgesics, and the nonpharmacologic interventions of swaddling and nonnutritive sucking on a pacifier also may be used. Nurses can incorporate basic comfort measures of gentle touch, rhythmic movement, and use of a preferred position with nonpharmacologic interventions to relieve anxiety and fears and decrease pain. 3 The goals of pediatric procedural sedation are to ensure patient safety and welfare; promote the comfort of the patient and family; minimize patient pain and physical discomfort; control anxiety; minimize psychological trauma and improve the amnesia effect; control movement and behavior during the procedure to ensure safe completion of the procedure; and return the patient to a presedation level of consciousness. Common ED procedures requiring procedural sedation and analgesia include a sexual assault examination, removal of a foreign body, wound care, 536 JOURNAL OF EMERGENCY NURSING VOLUME 42 ISSUE 6 November 2016

3 TABLE Common pediatric procedural medications Medication name/class Propofol (general anesthetic) Midazolam d (benzodiazepine) Diazepam d (benzodiazepine) Dexmedetomidine d (sedative) Route a Onset Duration Drug information b /antidote IV b 0.5 (rapid) 3 to 10 (bolus) Effect: Provides sedation and amnesia (no analgesic) Administration: Consult local regulations and institutional policies; can cause hypotension (reduce by giving initial bolus in small increments); causes pain upon administration c Adverse effects: respiratory depression, bradycardia (when used in combo with fentanyl), hypotension (more pronounced in hypovolemic patients) Contraindication: Egg or soy allergy; peanut allergy if using Fresenius Propoven 1% Antidote: None Additional information: reduces intracranial pressure; lipophilic emulsion that contains 0.1 g of fat/ml (1.1 kcal/ml) IV,IM,PO,PR, IN, SL, buccal IV=2to3 IV=15to 60 (dose dependent) Effect: Provides sedation, anxiolysis, and retrograde amnesia (no analgesia) Administration: If oral syrup is not available, IV form can be given PO; IV form also can be given SL and buccally; intranasal administration causes an unpleasant taste in the mouth and can cause nasal irritation, increasing agitation; premedicating with lidocaine can alleviate symptoms Adverse effects: respiratory depression, hypotension, paradoxical reactions Antidote: Flumazenil (IV, IN); caution with use in patients with seizure disorders who take benzodiazepines chronically IV, PO, PR IV = 4 to 5 IV = 60 to 120 Effect: provides sedation, anxiolysis, and retrograde amnesia (no analgesia) Administration: IV form can be given PO and PR (if rectal formulation is not available); give slowly; rapid injection may cause hypotension and respiratory depression Adverse effects: respiratory depression, paradoxical reactions Antidote: Flumazenil (IV, IN); caution with use in patients with seizure disorders who take benzodiazepines chronically Additional information: vesicant IV, IN, IM, buccal IV = 5 to 10 IV = 30 to 70 Effect: provides sedation, anxiolysis, and mild analgesic effects Administration: does not cause respiratory depression; IV formulation can be given IN, IM, and buccally Adverse effects: hypotension (loading dose), hypertension/bradycardia (continuous infusion) Caution if using atropine or glycopyrrolate for bradycardia because it may cause severe hypertension Antidote: None continued November 2016 VOLUME 42 ISSUE

4 Table TABLE Continued Medication name/class Etomidate (general anesthetic) Route a Onset Duration Drug information b /antidote Additional information: caution in patients with heart block, severe ventricular dysfunction, hypovolemia, or chronic hypertension IV to 15 Effect: provides sedation (no analgesia) Administration: very irritating; avoid administration into small vessels; may premedicate with lidocaine Adverse effects: may cause adrenal suppression Additional information: minimal effects on hemodynamics Pentobarbital d (barbiturate) IV, PO, PR IV = 1 to 5 IV = 15 to 90 Effect: sedation and hypnosis (no analgesia) Administration: administer slowly e Adverse effects: respiratory depression (especially in combination with other sedatives/opioids) Contraindications: patients with porphyria Additional information: IV formulation may be given PO Chloral hydrate (sedative-hypnotic) PO, PR PO = 10 to 15 PO = 60 to 240 Effect: sedation and hypnosis (no analgesia) Administration: do not crush capsule; contains liquid with unpleasant taste; can give syrup formulation orally and rectally Adverse effects: gastrointestinal irritation and vomiting when given orally; prolonged sedation, coma, paradoxical agitation, respiratory depression Contraindications (relative): patients with cardiac, liver, or renal impairment Fentanyl d (opioid) IV, IN IV = 1 to 3 IV = 30 to 60 Effect: analgesia Administration: IV formulation may be given IN by giving half the dose into each nostril using an atomizer or dripping slowly into the nostril with a syringe if nasal spray is not available Adverse effects: respiratory depression, hypotension, chest wall rigidly Antidote: naloxone Morphine (opioid) Ketamine d (general anesthetic) IV, PO, IM, SC, SL IV = 20 IV = 240 Effect: analgesia Administration: inspect vial closely for particulate matter and discoloration prior to administration; utilize preservative-free formulation when possible Adverse effects: respiratory depression/apnea, hypotension Antidote: naloxone IV, IM, IN, PO IV = 1 to 2 IV = 15 to 30 Effect: sedation, dissociative amnesia, analgesia Administration: IV formulation may be given IM, IN, and PO Adverse effects: vomiting (can premedicate with ondansetron), emergence reaction, laryngospasm, and apnea (most common with IM administration; can usually be managed with positive pressure bag-mask ventilation) continued 538 JOURNAL OF EMERGENCY NURSING VOLUME 42 ISSUE 6 November 2016

5 Table TABLE Continued Medication name/class Nitrous oxide (inhaled anesthetic) Route a Onset Duration Drug information b /antidote Contraindications: Younger than 3 months old and patients with known/suspected psychosis Additional information: use cautiously in patients with airway instability, cardiac disease (angina/heart disease), hypertension, increased intracranial pressure, glaucoma, acute eye injury, porphyria, and thyroid disease INH 2 to 5 Rapid Effect: mild analgesia, sedation, amnesia, and anxiolysis Administration: Follow all manufacturer and facility guidelines Pregnant medical personnel should not administer A gas scavenging system should be used for employees to minimize occupational exposure Ensure proper patient size mask fit to reduce the risk of nitrous oxide leakage and increased worker exposure, which is an Occupational & Safety Health hazard May cause vomiting; must be able to remove mask quickly Adverse effects: nausea, vomiting, dysphoria Contraindications: trapped gas within a body cavity (eg: bowel obstruction, middle ear infection, middle ear or eustachian tube compromise from inflammation, pneumothorax, retinal surgery), pregnancy, altered mental status, adverse reaction to prior nitrous oxide, difficult airway, severe pulmonary disease, heart failure, severe sinus conditions, severe phobia Antidote: remove mask and it rapidly dissipates; some studies advise opioid antagonist, naloxone if prolonged depression Additional information: precautions with schizophrenia or bipolar disorders; elimination occurs by expiration IO, Intraosseous; IV, intravenous; IM, intramuscular; IN, intranasal; INH, inhalation; PO, by mouth; PR, per rectum; SC, subcutaneous; SL, sublingual. a IV formulation can be given intraosseously. b This table is noninclusive and does not include age-specific recommendations. See other drug information resources for complete dosing monographs. c To lessen pain from IV propofol, pretreatment can be provided via systemic lidocaine injected into the vein with a tourniquet applied for 1 minute, or the propofol can be given with an opioid. d Onset and duration of action vary by route. e Rapid IV administration of pentobarbital can cause respiratory depression, apnea, laryngospasm, bronchospasm, and hypotension. abscess drainage, dental trauma, a slit lamp examination, and fracture reduction. Burn care, cardioversion, a lumbar puncture, dislocation reduction, joint aspiration, chest tube placement, and laceration repair may require sedation. Procedural sedation is helpful for diagnostic imaging, including magnetic resonance imaging and computerized axial tomography scans, along with barium enemas. ED nurses should consider the use of procedural preparation, play, distraction, and reduction of stimulation and noise in conjunction with procedural sedation. Additional pain relief strategies include topical numbing agents, acetaminophen, ibuprofen, other oral pain relievers, buffered lidocaine for injections, and vapo-coolant sprays. 1,3 Emergency nurses have many roles and responsibilities before sedation is initiated, during the sedation procedure, and afterward, including monitoring during the recovery period, assisting patients during recovery, ensuring that discharge criteria are met, and providing a follow-up plan. November 2016 VOLUME 42 ISSUE

6 Prior to assisting with procedural sedation, emergency nurses should ensure proper credentialing, including the resuscitation qualifications of the practitioner. Emergency nurses should collaboratively discuss behavioral interventions, monitoring interventions, and pharmacologic interventions with the parent(s) and the practitioner performing the procedure. Behavioral interventions include explaining the procedure in a nonthreatening, age-appropriate level in a quiet and calm manner. Monitoring interventions include ensuring the availability of appropriately sized equipment such as blood pressure cuffs and face masks, along with cardiac monitoring equipment, oxygen, capnography monitoring equipment, a nasal cannula, a bag-valve mask, a suctioning canister, and tonsil tip suction. Nurses also should ensure that alarms are set at the correct parameters and working well. It is recommended that emergency resuscitation equipment be in close proximity. Pharmacologic interventions for the emergency nurse encompass calculating medications prior to the procedure based on kilogram weight, labeling and preparing all medications, verifying orders, establishing intravenous access, preparing saline solution flushes, and calculating reversal agent dosages and having them available at the bedside. 3 The choice of sedative agents depends on multiple factors, such as the degree of expected pain, patient factors, and how much movement is permitted to complete the procedure. Some patient factors that influence the choice of sedative agent include asthma, upper respiratory tract infections, severe sinusitis, altered mental status, severe chronic obstructive pulmonary disease, chest trauma, recent retinal surgery, ear conditions, age, ability to cooperate, anxiety level, medications problems, and airway abnormalities. Common pediatric procedural medications include morphine sulfate, fentanyl citrate, diazepam, midazolam, pentobarbital sodium, chloral hydrate, ketamine, etomidate, propofol, dexmedetomidine, and nitrous oxide (Table). 1,4,5,6 It is recommended that institutions develop protocols, training, appropriate credentialing, and quality improvement measures for all pediatric ED procedural sedations to maintain maximum patient safety. Emergency nursing involves advocacy for the safe, painless, and least distressing patient and family experience during their emergency. ED nurses need to provide anticipatory guidance and follow-up information to parents regarding the fact that this traumatic event may result in a long-term posttraumatic stress response. Supportive, comforting, and caring behaviors will make a lasting positive experience during this time of family distress and, it is hoped, help the child s recovery to his or her preinjury state. REFERENCES 1. Hsu DC, Cravero JP. Procedural sedation in children outside the operating room. Updated August 8, Accessed on August 10, Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2): Emergency Nursing Association. Emergency Nursing Pediatric Course Provider Manual. 4th ed. Des Plaines, IL: Emergency Nursing Association; Roback MG, Douglas CW, Babl FE, Kennedy RM. Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol. 2016;29(suppl 1):S21-S Yuen VM, Hui TW, Irwin MG, et al. Optimal timing for the administration of intranasal dexmedetomidine for premedication in children. Anaesthesia. 2010;65: Lexicomp I. Pediatric & Neonatal Lexi-Drugs Clinical Database. Hudson, OH: Lexicomp, Inc; Submissions to this column are encouraged and may be sent to Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN pnormandinrn@aol.com 540 JOURNAL OF EMERGENCY NURSING VOLUME 42 ISSUE 6 November 2016