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.