• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 2004 Oct;44(4):342-77. [83 references] PubMed



• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Emerg Nurs 2004 Oct;30(5):447-61. PubMed



• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Pediatr Surg 2004 Oct;39(10):1472-84. PubMed

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the "Major Recommendations" field.

Etomidate

Is etomidate effective for providing procedural sedation in children in the emergency department (ED)?

• Level A recommendations. None specified.
• Level B recommendations. None specified.
• Level C recommendations. Etomidate is an effective agent for procedural sedation in the pediatric patient population within the ED.

Is etomidate safe for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. None specified.
• Level C recommendations. Etomidate is a safe agent for procedural sedation in the pediatric patient population within the ED.

Fentanyl/Midazolam

Are fentanyl and midazolam effective for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Intravenous use of fentanyl and midazolam is effective for pediatric sedation during painful procedures in the ED.
• Level C recommendations. None specified.

Is the use of fentanyl and midazolam safe for providing procedural sedation for painful procedures in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. The combination of fentanyl and midazolam appears to result in a greater risk of respiratory depression; therefore, the clinician should take particular care to monitor the patient for signs of respiratory depression and should have appropriate training and support to treat apnea.
• Level C recommendations. None specified.

Ketamine

Is ketamine effective for providing procedural sedation in children in the ED?

• Level A recommendations. Ketamine is effective either as a sole agent or in combination with a benzodiazepine for brief painful procedures in children.
• Level B recommendations. None specified.
• Level C recommendations. None specified.

Is ketamine safe for providing procedural sedation in children in the ED?

• Level A recommendations. Ketamine can be safely used for procedural sedation in children in the ED, but may require head positioning, supplemental oxygen, occasional bag-valve-mask ventilatory support, and measures to address laryngospasm.
• Level B recommendations. None specified.
• Level C recommendations. None specified.

Does the addition of midazolam as an adjunct to ketamine for procedural sedation for children in the ED reduce recovery agitation or vomiting?

• Level A recommendations. The addition of midazolam as an adjunct to ketamine for procedural sedation for children in the ED does not decrease the incidence of emergent reactions.
• Level B recommendations. The addition of midazolam as an adjunct to ketamine for procedural sedation for children decreases the incidence of emesis.
• Level C recommendations. None specified.

Methohexital

Is methohexital effective for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Methohexital administered by either the intravenous, intramuscular, or rectal routes can provide effective sedation for children undergoing painless diagnostic studies.
• Level C recommendations. None specified.

Is methohexital safe for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Methohexital can be safely used for procedural sedation but may require head positioning, supplemental oxygen, and occasional bag-valve-mask ventilatory support.
• Level C recommendations. None specified.

Pentobarbital

Is pentobarbital effective for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Pentobarbital alone is effective in producing cooperation for painless diagnostic procedures. Best sedation results are seen in children younger than 8 years.
• Level C recommendations. None specified.

Is pentobarbital safe for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Pentobarbital can be safely used for procedural sedation but may require head positioning, supplemental oxygen, and occasional bag-valve-mask ventilatory support.
• Level C recommendations. None specified.

Propofol

Is propofol effective for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Propofol combined with opiate agents is effective in producing cooperation for painful therapeutic or diagnostic studies.
• Level C recommendations. Propofol alone, without the concomitant use of opiate agents, is likely to be effective in producing sedation for painless diagnostic studies in ED patients.

Is propofol safe for providing procedural sedation in children in the ED?

• Level A recommendations. None specified.
• Level B recommendations. Propofol combined with opiate agents can be safely used for procedural sedation but may require head positioning, supplemental oxygen, and occasional bag-valve-mask ventilatory support.
• Level C recommendations. Propofol alone, without the concomitant use of opiate agents, can be safely used for procedural sedation but may require head positioning, supplemental oxygen, and occasional bag-valve-mask ventilatory support.

Definitions:

Strength of Evidence

Strength of evidence Class I - Interventional studies including clinical trials, observational studies including prospective cohort studies, aggregate studies including meta-analyses of randomized clinical trials only

Strength of evidence Class II - Observational studies including retrospective cohort studies, case-controlled studies, aggregate studies including other meta-analyses

Strength of evidence Class III - Descriptive cross-sectional studies, observational reports including case series and case reports, consensus studies including published panel consensus by acknowledged groups of experts

Strength of Recommendation

Level A recommendations - Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all the issues)

Level B recommendations - Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)

Level C recommendations - Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 2004 Oct;44(4):342-77. [83 references] PubMed



• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Emerg Nurs 2004 Oct;30(5):447-61. PubMed



• Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Pediatr Surg 2004 Oct;39(10):1472-84. PubMed

Electronic copies: Available in Portable Document Format (PDF) from the American College of Emergency Physicians Web site.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please refer to the American College of Emergency Physicians (ACEP) Web site.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.