Category Archives: Cutting Edge PEM

Learn what is hot in the realm of pediatric emergency medicine. What is the latest research say and how might that help you optimize your patient management? What are the latest patient care products? This column will help you and your patients.

Is it time to rethink fasting times in the emergency department?

Chumpitazi, CE, Camp, EA, Bhamidipati, DR, et al. “Shortened Preprocedural Fasting in the Pediatric Emergency Department.” The American Journal of Emergency Medicine, vol. 36, no. 9, 2018, pp. 1577–1580.

Carmen D. Sulton, MD

The relationship between pre-procedural fasting times and aspiration and/or pulmonary complications are often a topic in anesthesia and sedation literature. In particular, fasting or nil per os (NPO) guidelines for urgent procedures outside of the operating room continue to be vague.  Prolonged fasting times can often be difficult for both emergency providers and families to manage. The American Society of Anesthesiologists (ASA) guidelines focus on 2 hours of fasting for clear liquids and up to 8 hours for full fatty meals. The American College of Emergency Physicians (ACEP) states that procedures in the emergency department (ED) setting should not be delayed based on fasting times alone. Many studies looking specifically at fasting times and adverse events often are under-powered, or may not focus specifically on patients in the ED setting.  read more

Time to rethink fluids in DKA?

A comment on “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” by Kuppermann et al. (2018)

Jessica Wall, MD, MPH

In medical school and residency we are taught to be vigilant for mental status changes and cerebral edema in our pediatric patients with diabetic ketoacidosis (DKA).  It is medical dogma that we must rehydrate them gently and slowly to prevent such a devastating complication, but the little evidence that we have for this teaching is observational and/or decades old.  Recently, “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” was published in The New England Journal of Medicine, with which Nate Kuppermann and the PECARN DKA FLUID Study Group have taken a major first step in changing how we think about fluid administration in DKA.

The structure of their study is elegant in that they completed a large, randomized study in which there was a 2-by-2 factorial design, allowing for the assessment of both fluid type (0.9% sodium chloride or 0.45% sodium chloride) and rate of administration (10% of body weight replaced in a 36 hour regimen or 5% body weight replaced in a 48 hour regimen).  This design allowed for an assessment of both sodium chloride concentration and fast replacement with a higher volume versus slow replacement with a lower volume.

And drum roll please…  there was no significant difference in proportion of patients with a drop in Glasgow Coma Score or neurocognitive assessment after recovery between all four treatment groups.  Interestingly, there was a trend to a higher incidence of clinically apparent brain injury in the slow hydration groups, but this was not statistically significant.   Now there were a few differences between non-neurologic adverse events, mainly higher rates of hyperchloremic acidosis in the 0.9% sodium chloride group and/or rapid administration group, and higher rates of hypocalcemia and hypophosphatemia in the 0.9% sodium chloride groups.  However, the take home point from this study is that isotonic versus hypotonic intravenous hydration and slow versus fast hydration does not affect the incidence of neurologic compromise in diabetic ketoacidosis.  We can hydrate these patients when they are in extremis without having that nagging thought in the back of our minds that we are increasing the risk of cerebral edema.

It is time to rethink our protocols and open discussion with our endocrinology and critical care colleagues about fluids in DKA.



Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378(24):2275-2287. doi:10.1056/NEJMoa1716816.

Variation in Pediatric Procedural Sedations Across Children’s Hospital Emergency Departments: Research Write-Up

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.

Management of Aggression in Emergency Departments is more than just PRNs

Anik Jhonsa, MD

In recent years pediatric emergency departments have seen a dramatic rise in the number of children and families presenting seeking mental health treatment.  As a child and adolescent psychiatrist primarily working in the emergency room, I’m often asked by my Emergency Medicine colleagues to develop an “agitation plan” for patients who are deemed at risk of acting out in an aggressive manner.  Most often these requests tend to focus on the PRN medication plan should a child become aggressive or upset.  However, most successful agitation plans begin well before any medication needs to be administered.

Aggressive behavior is most often a means of communicating something that an individual feels incapable of conveying in any other manner.  Whether it is a child who is retaliating after being bullied or one who has not eaten all day, the act of striking another person is a declaration of displeasure at the current situation.  Understanding the finer details of a child’s past history of aggressive behavior can feel like an arduous task in busy emergency rooms, but the benefits of doing so include reduction in the need for PRN medication, decreased episodes of restraints, and reducing barriers to vital medical care that is being provided.

The best “agitation plans” are not those that deal with aggressive behavior after they happen but those that address a child’s needs before any aggressive behavior has occurred.  Effective history taking combined with practical measures can be extremely effective in stopping aggressive behavior before they start.  Obtaining a complete history should pay special attention to past episodes of aggressive behavior as well as common triggers as these are key in building a plan of care.  For example, a child who is triggered by hunger and needs to be kept NPO to receive anesthesia for an MRI could be scheduled for the first case of the day in order to receive their scan in the morning, as opposed to being kept NPO throughout the entire day.  Communication between staff members regarding a patient’s specific needs is also very important in terms of having those needs met throughout an ER visit.  If a family tells a physician that their child does better when given a warning before anyone approaches them, that information should be passed along to nursing staff prior to their checking the patient’s vital signs.

At The Children’s Hospital of Philadelphia we have developed clinical pathways to optimize patient care from the time they arrive in the emergency room to their discharge.  These pathways primarily focus on a patient’s environment, and emphasizing effective communication and behavioral strategies for managing behaviors before discussing effective PRN usage if those avenues are not successful.  Ultimately successful management of aggressive behavior in an emergency room is a team effort relying on commitment and proactive problem solving from everyone who interacts with a patient and their family throughout their hospital stay.


The Children’s Hospital of Philadelphia ED Pathway for Evaluation/Treatment of Children with

Behavioral Health Issues:


The Children’s Hospital of Philadelphia Pathway for the Approach to Managing Behaviors in Children with Autism Spectrum Disorder (ASD)/Developmental Disorders:


Anik Jhonsa, MD

Children’s Hospital of Philadelphia

Medical Director of Emergency Psychiatric Services

Assistant Training Director Child and Adolescent Psychiatry Fellowship Program

Clinical Associate in Department of Psychiatry Perelman School of Medicine at the University of Pennsylvania

A Case for Ketofol in the Pediatric ED

Imagine it’s a warm day in June when an 18-month old male with a complicated facial laceration involving the oral mucosa from a dog bite presents to your emergency department (ED). His parents are requesting that his lacerations be repaired by a plastic surgeon.   You recognize their concern and are happy to oblige. You want to ensure the best outcome so you decide to do procedural sedation for the repair. You reach for your handy dandy procedural sedation hammer Ketamine. However, while your patient has obviously achieved a dissociative state, he seems to be periodically moving and tongue thrusting. Your consultant is not very pleased at that thought of attempting a delicate repair on a moving child. What can be done?



Ketamine is a dissociative anesthetic that has been increasing in popularity as an ED procedural sedation agent since the 1990s1-3. Ketamine is best utilized for short painful procedures such as orthopedic reduction, abscess drainage, laceration repair or burn debridement. A common loading dose of ketamine for the pediatric patient is 1.5 mg/kg – 2mg/kg if given IV. Subsequent doses of 0.5 mg/kg – 1 mg/kg of ketamine can be given to maintain a dissociative state. Intravenous ketamine should be administered slowly over 30-60 seconds to avoid respiratory depression and apnea that has been associated with rapid administration. Ketamine can also be given IM if a procedure is short and an IV unnecessary or if the patient is unable to safety cooperate with IV placement. IM ketamine dosing is generally 4 mg/kg – 5 mg/kg. IM ketamine has been associated with increased rates of vomiting. A recent review of literature suggests that Ketamine is widely utilized, consistently effective for procedural sedation and has a low risk of adverse events when administered by an experienced clinician5. On the con side, Ketamine has a relatively long recovery time with one study citing an average of 64 minutes4.



There are a few studies that examine the use of propofol in the pediatric ED primarily for non painful procedures or in conjunction with opiates for painful procedures. Propofol is a short acting non-opioid, non-barbiturate sedative hypnotic agent that has been gaining momentum outside the operating room. Propofol is contraindicated in patients with egg or soy allergies.

Current guidelines favor an induction dose of 1 mg/kg over 1-2 minutes with repeated aliquots of 0.5 mg/kg over 30-60 seconds until a relatively motionless state is achieved. Key benefits of propofol are its anti-emetic properties and its shorter recovery time and sedation time compared to similar sedatives 6-8. Important side effects of propfol are respiratory depression and hypotension. Propofol can be painful when injected which is why some studies suggest injecting a small amount of lidocaine into the vein 9.



The combination of ketamine and propofol, aka “ketofol,” was initially described in the surgical setting in the early 1990s. Ketofol has an advantage over ketamine alone with literature showing improved airway preservation, decreased vomiting and decreased need for opioids The combination also maintains more stable cardiovascular profile with fewer incidence of hypotension compared to propofol alone2. While no standard dosing regime has been established several articles use a 1:1 ratio2,10-11. Some institutions prefer a 0.5 mg/kg dose of ketamine followed by a 1mg/kg dose of propofol for induction. Ketofol has also been consistently associated with a high patient and physician satisfaction level. There are no systematic reviews of ketofol and most of current reported literature comes in the form of case series.


An Argument for Ketofol in Complex Lacerations

 Now that we have reviewed some of the literature let’s return to our patient. When selecting an appropriate sedative, the practitioner must keep in mind the desired sedation depth, duration of procedure, how painful the procedure is and individual patient characteristics.   Additionally, an agent’s efficacy and safety profile compared to other medications must be considered 5.   Because of its unique pharmacological properties, ketamine does not display a dose dependent continuum like other analgesia agents.   Once a patient reaches dissociative threshold additional does of ketamine does not enhance or deepen the sedation3. Complex facial lacerations especially those involving intraoral or perioral repair provide a large stimuli load. I have found in these incidences that a dissociative state does not confer stillness especially in the toddler age. Why not just use propofol alone you might ask?   Sedation with propofol alone in children requires total dosing between 2.8 to 3.5 mg/kg to achieve the desired level of sedation 10,12. The rate of adverse airway events with propofol are known to be dose-dependent. While larger studies are needed, one case series showed that the use of ketofol reduced the amount of propofol needed to achieve the desired level of sedation in pediatric patients13.   I therefore argue that when faced with a complex facial laceration in a younger patient, one should consider ketofol.   With a better safety profile, faster recovery time and a high patient and provider level of satisfaction, ketofol may just be the shiny new hammer my tool belt.


Article By:

Katharine Long, MD

Pediatric Emergency Fellow

The Children’s Hospital of Philadelphia



  • Melendez E, Bachur R. Serious adverse events during procedure sedation with ketamine. Pediatr Emerg Care. 2009;25:325-328.
  • Alletag MJ, Auerbach MA and Baum CR. Ketamine, Propofol, and Ketofol Use for Pediatric Sedation. Pediatr Emerg Care. 2012;28(12):1391-1395.
  • Green SM, Roback MG, Kennedy RM et al Clinical Practice Guideline for Emergency Department Ketamine Dissociated Sedation: 2011 Update. Ann of Emerg Med. 2011;57(5):449-461.
  • Sherwin TS, Green SM, Khan A, et al Does adjunctive midazolam reduce recover agitation after ketamine sedation for pediatric procedures? A randomized double-blind, placebo-controlled trial Ann Emerg Med. 2000; 35:229-238.
  • Hartling L, Milne A, Foise M et al. what Works and What’s Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews.   Acad Emerg Med. 2016; 23:519-530.
  • Migita RT, Klein EJ, Garrison MM. Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review. Arch Pediatr Adolesc Med. 2006;160:46-51.
  • National Clinical Guidelines Centre (UK). NICE Clinical Guidelines, No 112. Sedation in Children and Young People: Sedation for Diagnostic and Therapeutic Procedures in Children and Young People. London: Royal College of Physicians (UK), 2010.
  • Pershad J & Godambe SA. Propofol for Procedural Sedation in the Pediatric Emergency Department. J Emerg Med. 2004; 27(1): 11-14.
  • Jalota L, Kalira V, George E et al. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011; 342:d1110.
  • Anderson JL, Junkins E, Pribble C et al. Capnography and depth of sedation during propofol sedation in children. Ann Emerg Med. 2007;49:9-13
  • Green SM Andolfatto G, Krauss B. Ketofol for procedural sedation? Pro and con. Ann Emerg Med. 2011;57:444-448.
  • Guenther E, Pribble CG, Junkins EP Jr et al. Propofol sedation by emergency physicians for elective pediatric outpatient procedures. Ann Emerg Med. 2003;42:783-791.
  • Mourad M, El-Hamamsy M, Anware M et al. Low dose ketamine reduces sedative doses of propofol during ambulatory transesophageal echocardiography. Egypt J Anaes. 2004:20:41-46.
  • Shavit I, Bar-Yaakov N, Grossman L et al. Sedation for Children with Intraoral Injuries in the Emergency Department: A Case-Control Study. Pediatr Emerg Car 2014;30:805-807.
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