Pediatrics
When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 pediatric procedural sedations

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Abstract

Study objectives

The optimal timing of discharge from the emergency department (ED) after pediatric procedural sedation and analgesia has not been well studied. Because concern about delayed adverse effects commonly delays discharge after sedation, we attempted to establish the timing of adverse effects in our cohort of procedural sedations.

Methods

We analyzed data from a prospectively generated database comprising consecutive sedation events throughout a 2-year period. We determined the timing of serious (eg, hypoxia, stridor, hypotension) and other adverse effects from final medication administration and calculated adverse effect risk ratios in relation to sedation characteristics.

Results

In 1,341 sedation events, there were 184 (13.7%) adverse effects, of which 159 (11.9%) were serious. The median age of children with and without adverse effects was similar (64 months in both groups). Most adverse effects occurred during the procedure (92%) rather than after the procedure (8%). Serious adverse effects occurred a median of 2 minutes after final medication dose (range –106 to +40 minutes). One hypoxic episode occurred each at 26, 30, and 40 minutes after final medication administration; all were repeated occurrences in children who had experienced previous hypoxia during the expected peak drug effect.

Conclusion

Adverse effects were common; however, serious adverse effects rarely occurred after 25 minutes from the final medication administration. Those that did occur this late were all preceded by a separate similar adverse effect during the expected peak drug effect, which suggests that when similar medication regimens are used, discharge from the ED may be safe at approximately 30 minutes after final sedation medication administration if no adverse effects have occurred.

Introduction

The ability of emergency physicians to provide safe and effective pediatric procedural sedation and analgesia is well established.1, 2, 3, 4, 5, 6 Extended emergency department (ED) recovery monitoring after procedural sedation and analgesia is commonplace because the occurrence of a serious adverse effect (eg, respiratory depression) without monitoring or after discharge may have dire and therefore unacceptable consequences. However, these lengthy recoveries require significant ED and personnel resources. The most appropriate duration of stay after a completed ED procedure has not been studied.

Using a prospectively collected database of procedural sedation and analgesias completed in our pediatric ED throughout a 2-year period, we attempted to determine the timing of adverse effects relative to drug administration and to identify factors that increase or decrease the risk of an adverse effect. We hope that delineation of the periods in which serious effects are most likely to occur will allow improvement in the standardization, development, and safety of procedural sedation and analgesia discharge criteria.

Section snippets

Materials and methods

Between May 1, 1997, and April 30, 1999, we prospectively accrued a database of 1,367 consecutive procedural sedation and analgesia events in a pediatric academic tertiary care medical center with an ED census of more than 50,000 patients annually. We have previously described the safety, efficacy, and resource use of this procedural sedation and analgesia sample.1, 2 The hospital's institutional review board reviewed and approved all data collection before the study period. A separate approval

Results

There were 1,367 procedural sedation and analgesia events performed during the study period, of which 26 were excluded because of subsequent patient hospitalization. No children were admitted to the hospital because of an adverse effect of the procedural sedation and analgesia or procedure. Characteristics of the remaining patients are shown in Table 1. We found adequate documentation about the timing and nature of adverse effects in 160 children (Figure 1).

The distribution of adverse effects

Discussion

Although adverse events in pediatric procedural sedation and analgesia have been reported and studied in the medical literature, our study specifically examines the timing of these events in relation to the procedure and the timing of medication administration. Safety must be the first concern in undertaking procedural sedation and analgesia, and the relevant literature to date has appropriately focused on attempts to characterize, identify, and reduce factors that may increase the risk of

Acknowledgements

We would like to acknowledge Henry E. Wang, MD, for his assistance in data analysis and in the preparation of this manuscript.

References (21)

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Author contributions: SS and RDP designed and implemented the initial data collection and related training, designed the procedural sedation data sheet, and completed the first phase of data abstraction from the initial charts and data sheets. MMA and DHN conceived the study concept and design, abstracted the data in the second phase, and completed all data analysis and general study organization. DHN takes responsibility for the paper as a whole.

Presented in abstract form at the American College of Emergency Physicians Scientific Assembly, Chicago, IL, October 2001.

The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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