Carmen D. Sulton, MD
Procedural sedation is often required in the pediatric emergency department for a variety of chief complaints, including abscess incision and drainage, fracture reduction, laceration repair and burn management. While there have been numerous advances in the field of procedural sedation as well as updates to practice guidelines, there are often no guidelines for indications for sedation or medications for particular patient types.
Miller et al describes patient care variability in the setting of procedural sedation in the pediatric emergency department. The objective of this study was to describe sedation trends over time as well as to quantify the variation in procedural sedation in terms of rate of use, patient characteristics, indications and choice of agents. A retrospective, cross-sectional study was performed. Data were obtained using the Pediatric Health Information System (PHIS) database. This database contains emergency department, inpatient, ambulatory surgery and observation encounter-level data from 45 tertiary care hospitals in the Unites States. Inclusion criteria consisted of children who presented to a participating emergency department between January 1, 2009 and December 31, 2014 and were younger than 19 years of age. The authors identified patients who would potentially receive procedural sedation based on the following diagnostic categories: fractures, lacerations, abscesses, dislocations, and other (burns, amputations, etc.). Patients with chronic comorbid conditions, patients who received paralytics (these were likely used for intubation) and patients receiving sedation medications in the operating room were excluded. Administration of the following medications were considered to constitute procedural sedation: propofol, ketamine, ketamine and propofol, midazolam and fentanyl, dexmedetomidine, etomidate, chloral hydrate, pentobarbital, methohexital, meperidine, promethazine, and chlorpromazine. Single agent use of an opiate or benzodiazepine was not considered procedural sedation.
Results showed that 1,265,386 patients met inclusion criteria. Of this number, 99,951 (7.9%) received procedural sedation medications. The rate of procedural sedation was 7.4% in ages 0-4, 9.3% in ages 5-11 years, and 6.3% in ages 12-18 years. Fractures made up 54.5% of all procedural sedations, followed by laceration repairs, abscess drainage, and dislocations. In the most recent year of the study, ketamine was used most commonly (73.7%), followed by midazolam and fentanyl (15.9%), ketamine with propofol (7.3%) and propofol (2.7%). The combination of midazolam and fentanyl increased over time (OR 1.39), while other sedation medications decreased in use over time including ketamine (OR 0.81), pentobarbital (OR 0.73), etomidate (OR 0.78), chloral hydrate (OR 0.37) and methohexital (0.58). The median sedation rate in 2009 was 6.9% (range 0.03%-15.1%), while in 2014 the median sedation rate was 8% (range 0.21%-32%). After removing outlier hospitals, which constituted the uppermost 25th percentile and lowermost 25th percentiles, there remains ~3-fold difference in overall sedation rate across children’s hospital emergency departments.
There are several limitations to this study. First, data was gathered from a database of tertiary care hospitals and may not be generalizable to all emergency departments. Second, diagnostic codes were used to identify the study population, which is reliant on provider billing for the appropriateness of the condition/diagnosis. Lastly, the authors acknowledge the possibility of some spectrum bias. For example, patients without public insurance may have been more likely to present with conditions that did not require sedation.
It is interesting that such practice variation exists among children’s hospitals in the United States. To date, there is no single study assessing the practice patterns of non-pediatric hospitals regarding procedural sedation in children.