What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews

Abstract

BackgroundSedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings.MethodsWe followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure‐related and performed in the ED.ResultsFourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention).ConclusionsThis comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence‐based recommendations for care.

Evaluation of AMSTAR to assess the methodological quality of systematic reviews in overviews of reviews of healthcare interventions

“…These overviews examined questions related to the efficacy or effectiveness of multiple interventions for preventing or treating clinical conditions related to pediatric health [22–28]. For each overview topic, all published English-language Cochrane and non-Cochrane SRs that met the overview’s inclusion criteria were identified from the reference list of the published overview and included in the study sample.…”

Entonox Efficacy for Procedural-Sedation and Analgesia in Pediatrics Undergoing Bone Marrow Aspiration: A Randomized Clinical Trial

“…Hartling et al, performed a review on the systematic reviews carried out in this field and in total deemed the use of ketamine, propofol, and entonox superior to other agents, but affirmed that standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care (16).…”

Mother-child interactions and young child behavior during procedural conscious sedation

“…Another investigation showed the superiority of midazolam/ketamine for children’s behavior management when compared with midazolam alone, although less cooperative behaviors could also be observed in children that received ketamine [20]. In fact, the body of evidence points out to the efficacy and safety of ketamine in pediatric procedural sedation [21]. Thus, one can hypothesize that children who receive ketamine have less interference of parental styles because of the dissociative effect of the drug, but this has to be confirmed in studies with more homogeneous distribution of sedative regimes among groups.…”