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Procedural sedation and analgesia, commonly referred to as “sedation,” is a treatment strategy to relieve pain, anxiety and suppress patient movements during diagnostic and therapeutic procedures by administering anxiolytic, sedative, analgesic, and/or dissociative drugs. The goal is to minimize patient awareness and discomfort while maintaining patient safety. Sedation depth should vary in accordance with the specific needs of the patient and procedure.

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Bottom Line Recommendations

Bottom Line Recommendations: Procedural Sedation

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Evered L, Bhatt M & TREKK Network

Bottom line recommendations for pediatric procedural sedation. Published online: March 2018.

Recommandations de Base: La Sédation Procédurale

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Evered L, Bhatt M & TREKK Network

Bottom line recommendations for the procedural sedation - French. Published online: March 2018.

Clinical guidelines

Clinical Guideline: Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

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Cot CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatr...

This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Clinical Guideline: Clinical policy: procedural sedation and analgesia in the emergency department

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Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM,...

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.

Video: Procedural sedation and analgesia in children

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Krauss BS, Krauss BA, Green SM.

This video describe procedural sedation and analgesia for children. Published: April 2014.

Clinical Guideline: Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update

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Green SM, Roback MG, Kennedy RM, Krauss B

This update of an evidence-based clinical practice guideline critically discusses indications, contrindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

Clinical Guideline: Sedation in children and young people: Sedation for diagnostic and therapeutic procedures in children and young people

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NICE National Institute for Health and Care Excellence

This clinical guideline covers the assessment, preparation, training and monitoring needed when using sedation in people under the age of 19. The aim is to help healthcare professionals decide when sedation is the most clinically and cost effective option for reducing pain and anxiety during operations for children and young people.

Clinical Practice Guideline: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update

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American Academy of Pediatrics, American Academy of Pediatric Dentistry, Cot ...

This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Overviews of systematic reviews

Overview of Systematic Reviews: What works and what's safe in pediatric emergency procedural sedation: an overview of reviews

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Hartling L, Milne A, Foisy M, Lang E, Sinclair D, Klassen TP, Evered L

This overview of systematic reviews examines the safety and efficacy of sedative agents commonly used for procedural sedation (propofol, ketamine, nitrous oxide, midazolam) in children in the ED or similar settings.

Systematic reviews

Systematic Review: Intranasal ketamine for procedural sedation and analgesia in children

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Poonai N, Canton K, Ali S, Hendrikx S, Shah A, Miller M, Joubert G, Rieder M,...

Evidence suggests ketamine can be administered intranasally. This study reviews the evidence for intranasal ketamine for procedural sedation and analgesia in children.

Review: Update on pharmacological management of procedural sedation in children

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Roback MG, Carlson DW, Babl FE, Kennedy RM

This review provides an update on pharmacological techniques for procedural sedation for children outside the operating room.

Systematic Review: Nitrous oxide provides safe and effective analgesia for minor paediatric procedures--a systematic review

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Pedersen RS, Bayat A, Steen NP, Jacobsson ML

The aim of this review was to investigate the safety and efficacy of nitrous oxide during brief, but painful paediatric procedures and to compare nitrous oxide with some of the commonly used pharmacological and non-pharmacological treatments for relieving anxiety and mild to moderate pain in Denmark.

Systematic Review: Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review

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Deasy C, Babl FE

This review investigated existing evidence to determine whether ketamine should be best administered intravenously or intramuscularly.

Systematic Review: Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature

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Leroy PL, Schipper DM, Knape HJ

This review investigated which skills and competence were imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and analyzed the underlying levels of evidence.

Systematic Review: Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children

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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss...

Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.

Systematic Review: Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss...

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Systematic Review: Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review

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Migita RT, Klein EJ, Garrison MM

This review assessed the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Systematic Review: Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department

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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, ...

This document is a clinical policy on pediatric procedural sedation.

Key studies

Key Study: Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium

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Beach ML, Cohen DM, Gallagher SM, Cravero JP

This study evaluated aspiration episodes and a combined outcome of major adverse events (aspiration, death, cardiac arrest, or unplanned hospital admission) with respect to NPO status, American Society of Anesthesiologists physical status, age, propofol use, procedure types, and urgency of the procedure.

Key Study: Characteristics of and Predictors for Apnea and Clinical Interventions During Procedural Sedation

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Krauss BS, Andolfatto G, Krauss BA, Mieloszyk RJ, Monuteaux MC

This study aims to describe the characteristics of and predictors for apnea and clinical interventions during emergency department (ED) procedural sedation.

Key Study: Safety and efficacy of propofol administered by paediatricians during procedural sedation in children

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Chiaretti A, Benini F, Pierri F, Vecchiato K, Ronfani L, Agosto C, Ventura A,...

The aim of this study was to determine the safety and the efficacy of paediatrician-administered propofol in children undergoing different painful procedures.

Key Study: Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium

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Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J

This study aimed to describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation and to describe the variations of monitoring and whether or not sedations meet monitoring guidelines.

Key Study: A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children

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Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M

This study compared total sedation time when ketamine/ propofol was used compared with ketamine alone for pediatric procedural sedation and analgesia.

Key Study: The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium

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Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH,

This study aims to delineate the nature and frequency of adverse events associate with propofol-based sedation/anesthesia care using prospectively collected data on pediatric sedation/anesthesia outside the operating room (OR).

Key Study: Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial

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Langston, WT, Wathen, JE, Roback, MG, Bajaj, L,

This study investigated the effect of ondansetron on the incidence of vomiting in children who received intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED).

Key Study: Etomidate versus midazolam for procedural sedation in pediatric outpatients: a randomized controlled trial

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Di Liddo L, D'Angelo A, Nguyen B, Bailey B, Amre D, Stanciu C

The objective of this study was to compare the efficacy of etomidate and midazolam for achieving procedural sedation and analgesia in children.

Key Study: A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures

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Roback MG, Wathen JE, MacKenzie T, Bajaj L

This study compared adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED).

Key Study: Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium

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Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B

The objective of this study was to use a large database of prospectively collected data on pediatric sedation and/or anesthesia for diagnostic and therapeutic procedures to delineate the nature and the frequency of adverse events that are associated with sedation/anesthesia care for procedures that are performed outside the operating room in children.

Key Study: The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis

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McGlone RG, Howes MC, Joshi M

The aims of this study were to report the experience of using intramuscular ketamine 2.0 or 2.5 mg/kg for minor painful procedures in children in a medium sized district general hospital accident and emergency department, and to demonstrate the safety and acceptability of ketamine and determine if the incidence of adverse effects is related to dose or other variables.

Key Study: Pretreatment with intravenous ketamine reduces propofol injection pain

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Barbi E, Marchetti F, Gerarduzzi T, Neri E, Gagliardo A, Sarti A, Ventura A

The aim of the study was to investigate whether pretreatment with ketamine would reduce infusion line pain in propofol sedation in children.

Key Study: Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department

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Godambe SA, Elliot V, Matheny D, Pershad J

This study compared the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation.

Key Study: Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation

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Acworth JP, Purdie D, Clark RC

This study compared intranasal midazolam (INM) with a combination of intravenous ketamine and intravenous midazolam (IVKM) for sedation of children requiring minor procedures in the emergency department.

Key Study: A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair

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Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM,

This study compared the efficacy and complication profile of oral midazolam therapy and continuous-flow 50% nitrous oxide in alleviating anxiety during laceration repair in children 2 to 6 years old.

Key Study: Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial

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Sherwin TS, Green SM, Khan A, Chapman DS, Dannenberg B

This study characterized the nature and severity of recovery agitation after ketamine sedation in children treated in the emergency department and determined whether the addition of adjunctive midazolam reduced the magnitude of such recovery agitation.

Key Study: Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial

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Wathen JE, Roback MG, Mackenzie T, Bothner JP,

This study was conducted to investigate the frequency and severity of adverse effects, specifically emergence phenomena, experienced by patients receiving intravenous ketamine with or without midazolam for sedation in a pediatric emergency department.

Key Study: Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies

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Kennedy RM, Porter FL, Miller JP, Jaffe DM

Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. This study compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

Key Study: Administration of nitrous oxide to pediatric patients provides analgesia for venous cannulation

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Henderson JM, Spence DG, Komocar LM, Bonn GE, Stenstrom RJ

This study aimed to determine whether administration of nitrous oxide, 50% and 70%, could provide analgesia and anxiolysis during venous cannulation in pediatric patients.