Analgesia and Procedural Sedation Module

Cite this article as:
Team DFTB. Analgesia and Procedural Sedation Module, Don't Forget the Bubbles, 2020. Available at:
TopicAnalgesia and procedural sedation
AuthorLauren Shearer
DurationUp to 2 hours
Equipment requiredNone
  • Pre-reading
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline for sharing admission criteria.

Lily, 4 years old, presents to the ED with her mother after falling from a scooter whilst in the park. She is holding her arm and not using it. There is no obvious gross deformity.

How would you do a pain assessment in this age category?

What would be the optimum analgesia choice based on a severe pain score?

What other methods or non-pharmacological adjuncts can be used?

When should we reassess the pain?

See RCEM Pain in Children – Best Practice Guidance for a guide on how to assess pain.

Consider different assessment tools:

  • FLACC (Face, legs, activity, cry, and consolability)
  • Wong Baker Faces
  • Visual analogue scale

See the analgesic ladder (RCEM guidance above and the WHO pain ladder).

Adjuvants should be considered in all steps of the ladder.

Bottom of the ladder is the most commonly used paracetamol (at 15mg/kg/dose) and non-steroidal anti-inflammatory drugs (NSAIDs). Paracetamol is an antipyretic and weak analgesic. It is used for the treatment of mild pain and fever associated with a sore throat or illness. But we should avoid oligo-analgesia and use the right drug for the right kind of pain.

Moving up the ladder are weak opioids like codeine. Codeine (an inactive compound of morphine) is no longer recommended for the management of acute moderate pain, particularly in children under 12 years with obstructive sleep apnoea or for post tonsillectomy procedures. Codeine must be metabolised by the cytochrome P450 enzyme 2D6 to the active compound, morphine, to relieve pain. Poor metabolisers of codeine may metabolise only up to 15% of the morphine concentration, receiving little or no analgesia from codeine. Ultra rapid metabolisers may metabolise up to 50% more morphine than normal metabolisers – which is potentially life threatening.

Children with moderate to severe pain should receive opioids together with non opioids. Morphine, oxycodone, hydromorphone are all active compounds that do not require the enzyme conversion to provide analgesia. Fentanyl, a synthetic opioid, has few, if any cardiovascular side effects. This is in contrast to morphine which may exacerbate hypotension with its vasodilatory effects. So in haemodynamically unstable children, fentanyl may be the preferred choice for acute pain management.

It’s easy to use, it’s needle-less, and decreases the overall need for utilisation of IV or IM routes which is a positive change in parent and patient satisfaction. It bypasses first pass metabolism permitting rapid and predictable bioavailability (compared with oral and intramuscular routes) and offers direct CSF delivery via the nose- brain pathway route

The maximum volume of IN medication permitted is 1ml per nostril and in cases of nasal trauma or septal defects, IN Fentanyl of course cannot be used. Rule of thumb, the IN dose is 2-3 times the IV dose.

Administer intranasal medications in the sniffing position. Lie the patient flat with occiput posterior, put patient in the sniffing position, seat the mucosal atomizing device cushion in the nostril, aim toward the pinna of the ear, and shoot fast – you have to push the drug as fast as you can to atomize the solution.

IN medication can be used for sedation, anxiolysis, pain control and seizure management. A 2014 Cochrane review on intranasal fentanyl concluded that it can be an effective analgesic for children aged 3 years and above with acute moderate to severe pain. Studies have demonstrated INF to result in decreased time to medication administration and equivalent pain control when compared to IV morphine, oral morphine or IV Fentanyl. IN Fentanyl (1.5mcg/kg) has become an excellent alternative to morphine in the ED, it has a greater safety profile and is easily available in the ED.

How does it compare to IN Fentanyl? One study demonstrated a similar pain reduction in children with moderate to severe pain from an isolated limb injury in the Paediatric ED, although the sample size was small and there was no comparator or placebo group. Adverse effects were more frequent with ketamine; however, these were all relatively mild (drowsiness and dizziness). Also, practically speaking, pain control doses for the IN Ketamine route at 1mg/kg mean that volumes for most children weighing above 10kg will exceed 1ml per naris if the ketamine concentration 10mg/ml is used.

An alpha-2 receptor agonist (like clonidine), does not markedly decrease blood pressure. Dexmedetomidine targets receptors in the CNS and spinal cord, and so it provides deep sedation, with very minimal blood pressure effects. It induces a sleep-like state. In fact, EEGs done under dex show the same pattern as seen in stage II sleep. Dexmedetomidine is safe, if titrated, and does not depress airway reflexes or respiration. Dose is 2.5 mcg/kg IN, and can add another 1 mcg/kg if needed. The downside is that it can last 30 minutes or more, but it may be a good choice for an abdominal ultrasound or CT head.Inflicting Pain with an IV to relieve pain is not something that makes sense to young children. IN medication offers pain relief prior to getting intravenous access and can even obviate the need for IV access if definitive care such as a cast, suturing, reduction of bony injuries can be done during the duration of action of the IN medication.

It is important these are thought about in conjunction with pharmacological techniques. These include:
Play specialists

  • Distraction techniques
  • Music
  • Games
  • Don’t forget the Bubbles

Immobilisation of injuries


  • Right people
  • Right place  
  • Right time

Parental/carer anxiety

Sucrose, and non-nutritive sucking interventions exert analgesic effects independent of the opioid pathway. Swaddling/facilitated tucking (preterm) and skin to skin care significantly increase B-endorphin levels.

Rocking/holding neonates and breastfeeding during minor procedures have all been shown to decrease objective measures of pain such as heart rate and crying.

Pain should be assessed on arrival and then monitored throughout their time in the emergency department and if appropriate beyond. Children in moderate and severe pain should have their pain reassessed within 60 minutes of receiving analgesia.

Frank, 8-years-old, was playing in the street with friends and fell over. He cut his knee on some broken glass and sustained a 4 cm laceration over his patella. An x-ray shows no foreign body and no fractures. The knee is swollen and the laceration requires suturing. On pain assessment he is reporting mild pain.

What are your initial considerations?

What are the options for cleaning and closing?

Don’t forget oral analgesics (as above) and a full assessment for other injuries.

  • Unsuitable for under 1s
  • Takes 20-30 minutes to work
  • Skin will blanch when ready
  • Max dose: 2 mls for 1 -3 year; 3 mls for >3 years
  • Not for use on: mucous membranes; extremities; wounds >8 hours old
  • Can be used in conjunction with local anaesthetic infiltration
  • Max dose not to exceed 5mg/kg
  • Inject slowly to reduce pain
  • Small gauge needle to reduce pain
  • Doses: 3mg/kg lidocaine

EMLA cream (lidocaine 2.5% and prilocaine 2.5%) is effective at numbing the tissue below intact skin to a depth of 6-7mm if left on for 30-60 min but does cause vasoconstriction which can be problematic if looking to cannulate.

LMX4, a topical liposomal 4% lidocaine cream like EMLA has full effectiveness by 30 minutes.

  • Play specialist
    Distraction techniques appropriate to age
  • Preparation of the child and area
  • Quiet setting
  • Parental/carer involvement
  • Using appropriate language

Freddie, 9 years old, attends the emergency department after falling from the monkey bars. He has sustained a displaced and angulated supracondylar fracture. He has some tingling at the fingers in the ulna distribution and therefore requires urgent manipulation. You decide to use nitrous oxide.

Do you need any pharmacological adjuncts?

What about non pharmacological?

What other considerations should be made?

Nitrous oxide provides anaesthesia, anoxiolysis and some mild amnesia but offers limited analgesia. Administration of analgesic supplements is recommended. Many papers including the FAN study demonstrate the safety and efficacy of co-administering intranasal fentanyl. Other analgesics can also be safely used.

There are two methods of delivering nitrous oxide, piped nitrous oxide and Entonox. Piped nitrous oxide can provide variable concentrations and can be titrated to response, whereas entonox is a fixed 50/50 mix of nitrous and oxygen and comes in canisters. The canister is set up with a demand value that needs to be overcome with a deep breath; this can be difficult for under 5’s.  You should see onset of effect in 30-60 seconds with the peak effect at 2-5 minutes. Offset of effects is similar at 2-5minutes, 100% oxygen should be applied during this time post procedure to avoid diffusion hypoxia.

Side effects are minor and transient but include:

  • Nausea
  • Vomiting (6-10% children receiving 50% dose). Increases incidence with higher dose, longer duration and concurrent opioid use. Consider prophylactic antiemetic if child has history of nausea or vomiting.
  • Dizziness
  • Nightmares

Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air containing spaces within the body, so it is contraindicated in:

  • Pneumothorax
  • Pneumocephalus
  • After diving
  • Gastrointestinal obstruction

Nitrous oxide inactivates the vitamin B12 dependent enzyme, methionine synthase and can deplete the B12 stores.  Therefore caution is advised in those at risk of vitamin B12 deficiency (vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptors and proton pump inhibitors)

Despite the absence of use of intravenous sedative drugs, it is best practice to manage this patient in a high dependency setting, with monitoring including; respiratory rate, heart rate and oxygen saturations and at least 2 members of staff where one’s job is entirely focused on the sedation and monitoring of the child.

Guided imagery would work well in this setting with a trained practitioner.  This is a process where a variety of techniques can be used such as simple visualisation, story telling, direct suggestion imagery and fantasy exploration to elicit a physical response such as a reduction in pain, stress or anxiety.

Lola, 2 years old, has fallen in the playground and sustained a laceration to the forehead. Lola had an ice cream after the incident in an attempt to settle her. She has no past medical history and was born at term. Can she have procedural sedation in the department? What are the considerations?

What drugs do you need for the sedation? Should you use any adjuncts with the ketamine? Are there any emergency drugs you should have available?

There are no contraindications and you decide to go ahead with ketamine sedation, during the procedure whilst full monitoring in place the CO2 trace is lost.  What is your structured approach to management of this scenario?

A through pre sedation assessment is required to assess ASA grade, examine airway anatomy and illicit any contraindications listed below

Multiple studies have shown that fasting does not reduce the risk of aspiration or increase the risk of adverse events and the 2020 updated guidelines for ketamine sedation in the ED have echoed this. They advised that the fasting state should be considered in relation to the urgency of the procedure, but recent food intake should not be considered a contraindication to ketamine use. 

RCEM states the procedure should be carried out in an area with immediate access to full resuscitation facilities; three practitioners should be present throughout, one for the sedation, one for the procedure and one for monitoring and assistance. The updated 2020 guidance has included capnography in the mandatory monitoring required along with heart rate, ECG, blood pressure, respiratory rate and oxygen saturations. While there is no evidence that shows that capnography reduces the incidence of adverse events, there are studies that show capnography decreased the incidence of hypoxia and respiratory events. 

Oxygen should be given prior to the procedure if possible and during to reduce the time to de-saturation should an adverse event occur.

Ketamine is a NMDA receptor antagonist. It is a dissociative anaesthetic, a potent analgesic and amnesic. Ketamine induces a trance like state, often with the eyes open. It maintains the airway reflexes and maintains cardiovascular stability.

The RCEM accepted dose is 1mg/kg over 60 seconds. A rate of 60 seconds reduces the incidence of adverse events such as laryngospasm. A top up dose of 0.5mg/kg can be used if necessary. Onset is within 1 minute and will elicit a horizontal nystagmus and a loss of response to verbal stimuli. The HR, BP and RR may increase slightly. Sedation will wear off after 20 minutes and full recovery should occur by 60-120 minutes. RCEM no longer advise the use of IM ketamine as they suggest it is safer to have IV access available from the start of the procedure should an adverse event occur.

Midazolam: a 2018 BestBets review looking at 6 studies including 2 RCTs has shown that prophylactic benzodiazepines do not significantly decrease the incidence of emergence delirium and they in fact can increase the risk of adverse events, so they should not routinely be given prophylactically. However, midazolam can be used to treat severe emergence, especially in older children. (Aliquots of IV 0.05-0.1mg/kg can be given)

Atropine: atropine was previously used prophylactically to reduce secretions however there is no evidence to support its routine use to prevent laryngospasm or other adverse airway events and again it may increase the rate or adverse events. (Green et al)

Ondansetron: may be appropriate for patients at high risk of vomiting due to ketamine’s emetogenic properties. High-risk groups include those with previous nausea/vomiting during sedation/anaesthesia, older children, those who have received opioids or where ketamine is given intramuscularly. Caution should be used in those at risk of long QT.

Emergency drugs: RCEM suggests key resuscitation drug dose calculations should be done prior to the procedure and these should be accessible, however, no specific drugs are recommended. We suggest that WETFLAG dosing should be done along with the dose calculated for suxamethonium (1.5mg/kg for RSI).

Complications are rare with ketamine. A recent study by Bhatt et al in 2017 (6,760 patients across 5 sites in Canada) looking at propofol, ketamine, propofol/ketamine and ketamine/fentanyl, ketamine alone recorded the lowest serious adverse events at 0.4%. Green et al (2009) showed a 1% risk of noisy breathing requiring airway repositioning, a 0.3% risk of laryngospasm and 0.02% risk of intubation being required.

The capnography trace is there to provide early warning of potential or impending airway and respiratory adverse events. A loss of capnography trace indicates apnoea or obstruction. First check the equipment and monitoring is still in place then check for chest wall movement. If the chest wall is not moving then there is central apnoea. If there is chest wall movement there is obstruction. Airway manoeuvres will relieve obstructive apnoea but will not relieve laryngospasm.

10-year-old boy fell from the top of the climbing frame, landed awkwardly on his left ankle. Primary survey shows no other injuries except obvious deformity of the left ankle.

Summary: procedure appropriate for sedation – post procedure simple airway issues due to obesity

Faculty required: operator/Voice of patient/Nurse in scenario

Vitals: HR 120, BP 105/60, Sats 99%, RR 20, ETCO2 4.2, ECG NSR

Neurovascular compromise of the foot, CRT delayed

PMH: nil

BH: term, nil complications

DH: nil

NKDA, UTD with immunisations

Last ate 2 hours prior

  • Check full medical history
  • ASA status
  • Airway assessment (loose tooth, excess body fat)
  • Ensure appropriate setting (RESUS)
  • Appropriate equipment and monitoring (ECG, EtCO2, Sats, HR, RR, BP, suction, tilting table, resuscitation facilities)
  • Describe consent
  • WETFLAG calculations plus emergency drug calculations
  • Choice of appropriate drugs and dosing for sedation
  • Ensure appropriate staff
  • Pre-oxygenation
  • Checks patient during procedure
  • Checks equipment
  • Chest wall movement
  • Simple patient positioning and airway manoeuvre opens the airway and CO2 trace returns  
  • Describes post procedure monitoring
  1. Emphasis on appropriate preparation
  2. Systematic approach to adverse events and when to anticipate them

When should you assess a child’s pain and document a pain score in the emergency department when they present with an injury?

A: Wait until the child is seen by a doctor before assessing pain

B: At triage

C: Immediately after giving oral analgesia

D: Within 60 minutes of receiving analgesia for moderate and severe pain

E: When the child or the child’s parents informs you they are in pain

The correct answer is B + D.

A child’s pain should be assessed on arrival in the emergency department, and should be treated appropriately in a timely manner (within 20 minutes for moderate and severe pain). Pain should also be re-evaluated within 60 minutes of receiving analgesia for moderate and severe pain. This process should be repeated for all subsequent doses of analgesia. Reviewing pain should take into account peak of onset for the analgesia given; as such oral analgesics will not work immediately.

Which of the following predict possible airway difficulties in children?

A: C-spine immobilisation

B: Premature birth requiring NICU

C: Trisomy 21

D: Mouth breathing or frequent drooling

E: Reduced mouth opening

All are true.

A through pre assessment prior to sedation should be done to elicit any potential complications and also decide on appropriateness of sedation in the emergency department.

A formal airway assessment should include:

  • Mouth opening
  • Assessment of dentition for loose and protruding teeth
  • Tongue size
  • Presence of soft tissue masses in the mouth
  • Mandible size
  • Neck mobility
  • Tempero-mandibular joint mobility

A review of the child’s medical history should also include, congenital abnormalities, birth complications, previous complications during anaesthetics or sedation, noisy breathing, sleep issues and concurrent upper respiratory tract infections.

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Procedural sedation

Cite this article as:
Tadgh Moriarty. Procedural sedation, Don't Forget the Bubbles, 2020. Available at:

Sometimes we have to do things that children don’t like. These procedures may be scary, or potentially painful. In this post, we’ll cover a few of the more common techniques.


Case one: Kayla

Earlier this month, the UK Royal College of Emergency Medicine, RCEM, published new guidance on the use of ketamine for procedural sedation in children in the emergency department, superseding their 2016 guidelines. Follow Kayla through her ED visit as she helps us explore the changes RCEM recommends.


It’s 3 pm on a busy Friday afternoon on your PEM shift. You have just seen Kayla, a 20-month-old girl who fell from onto a concrete step and sustained a nasty L-shaped laceration to her thigh. You have satisfied yourself that her joints are not involved, and an x-ray reveals no underlying fracture. You can see a large amount of debris within the wound. Her vaccines are up to date and she has no significant medical history. She is, however, eating a large ice cream cone that her parents had purchased to pacify her. You wonder how best to proceed as you have a nasty wound that needs thorough irrigation and closure. A toddler is unlikely to tolerate local anaesthetic infiltration as the primary means of anaesthetising the wound.


Does Kayla need procedural sedation?

Paediatric Procedural Sedation (PPS) aims to alleviate the distress around painful procedures but should not be viewed as a substitute for good pain relief. Maximize analgesia and recruit any distraction devices to hand (iPads / parents / play specialists – these are a particularly excellent resource and should be utilized wherever possible).

Is the wound suitable for ‘LAT gel’? This revolutionary gel which combines lignocaine, adrenaline and tetracaine can prevent many sedations when used correctly. It takes 30-60minutes to be fully effective after application so be sure to allow sufficient time. Even if the patient is progressing to procedural sedation this gel will help with local anaesthesia and analgesia.

The ability to perform PPS will be based on current acuity within the department, available resources, and appropriate staffing skill mix. The three main agents used for procedural sedation in paediatrics are midazolam, nitrous oxide, and ketamine.


Kayla’s LAT gel has been in situ for half an hour. You return to the cubicle armed with a play specialist and nurse, along with your irrigation and suturing materials. Despite a stellar sock puppet show by your play specialist, loud sing-along songs, and Peppa Pig showing on the iPad, your attempt at irrigation is futile; Kayla remains upset. You decide PPS is needed to ensure effective irrigation, neat wound closure, and avoiding further trauma to an upset child (and mother!)


Which agent is best suited?

You need to consider what you hope to achieve with sedation and what level of experience and resources are available currently in the department to aid in answering this question. The spectrum of use varies from diagnostic imaging, through minimally painful procedures (e.g. foreign body removal, vascular access), to painful procedures (e.g. fracture reduction, wound washout and closure). The choice of agent, therefore, will reflect the individual patient (anxiety, co-operative, parental preference), and the staff available at the time.


Kayla requires a short painful procedure to be carried out and nitrous oxide or ketamine would be suitable. As you start showing her the face mask for nitrous, Kayla freaks out – Kayla had a slightly traumatic experience with a bronchodilator and spacer, her mother explains. There’s no way you’re going to get Kayla to cooperate with the nitrous mask. So ketamine is selected as the agent of choice.

Just as you are about to begin the pre-procedure assessment one of the student nurses who will be observing the procedure tells you that she has seen a lot on Twitter about the new RCEM ketamine PPS guideline recently but is unclear as to exactly what ketamine is and why it’s useful in paediatrics.


Ketamine is an NMDA receptor antagonist. It is a dissociative anaesthetic and potent analgesic and amnesic. Rather than the typical ‘sleep‘ which results after administration of other anaesthetic agents, ketamine induces a trance-like state, oftentimes with the patient’s eyes open but ‘nobody home‘ (it is important to warn parents beforehand about this as it can be quite scary if unexpected). Some of the many benefits of ketamine are that airway reflexes are maintained, while is augmented heart rate and blood pressure (for the most part – in the compromised circulation bradycardia and hypotension can occur).


The pre-sedation assessment

You begin Kayla’s pre-sedation assessment. Your assessment includes a focussed history: has Kayla undergone any previous anaesthesia or PPS? If so, did she have any reactions or adverse events? Does she suffer from any chronic medical conditions, take any regular medications or have any drug allergies? Does Kayla have any concurrent medical conditions – especially active asthma, respiratory tract infection or tonsillitis?

You then examine Kayla, ensuring you conduct as cardiorespiratory exam and an assessment of her airway anatomy, including ASA grade. You need to assure yourself that no contraindications exist.


RCEM’s 2020 guidance is very specific about the need for conducting a thorough pre-sedation assessment, including assessing ASA grade, all of which should be thoroughly documented for clinical auditing and safety purposes. An example proforma template is provided at the end of their guideline. This contrasts with the 2016 guideline, which included a list of contraindications, but did not require documentation of ASA grade.


It’s time to consent Kayla and her mum for the procedure. You remember that ketamine is considered safer than other hypnotic drugs such as Propofol but need to remind yourself of the specifics, and the side-effect profile prior to consenting.


How safe is ketamine?

Does ketamine have side effects? Yes, but of all sedation agents studied by Bhatt et al in 2017 (6,760 patients across 5 sites in Canada), ketamine came out on top. This looked at ketamine/propofol, ketamine/fentanyl, propofol alone and ketamine alone. There were 831 adverse events across all agents (11.7%) – these included oxygen desaturation (5.6%) and vomiting (5.2%). There were 69 (1.1% of cases) serious adverse events (SAE). Ketamine as single-agent had the lowest SAEs at just 0.4%.

Pre-procedural opioids and laceration repair were associated with increased risk of emesis. Bhatt et al noted that prophylactic antiemetics reduce the risk of vomiting by half, but these were not needed in those under 5 years of age due to the low overall risk of emesis.

This endorsed previous data from a large case series by Green et al (2009) which demonstrated low rates of adverse events with ketamine PPS; most notably, noisy breathing (not requiring any intervention other than airway repositioning) occurred in 1%, laryngospasm in 0.3% and of these only 0.02% required intubation.

Both of these large studies demonstrate ketamine’s excellent safety profile when used with the appropriate preparation and patient selection.


Does Kayla need to have fasted?

Let’s have a look at the current guidelines and evidence. Several large studies have looked at this controversial issue: one study in a US PED in 2001/2002 where only 44% of patients met traditional fasting guidelines demonstrated no statistically nor clinically significant increase in adverse events in the unfasted population.

A series of over 30,000 children undergoing PPS by Cravero et al (2006) reported only 1 episode of aspiration – and this was in a fasted patient!

In 2016, Beach et al published a report based on 140,000 procedural sedation events, noting that aspiration was a rare event. Furthermore, they concluded that non-fasted patients were at no greater risk of major complications or aspiration than fasted patients.

In 2014 the American College of Emergency Physicians (ACEP) altered their national guidance stating that procedural sedation “should not be delayed for children in the ED who have not been fasted.” This was based on a systematic review including 3,000 sedation events showing that pre-procedural fasting failed to reduce the risk of emesis, aspiration, or other adverse events. They acknowledged that the current evidence does not support the rationale put forth in the non-emergency medicine guidelines that adherence to minimum fasting times decreased adverse events in ED procedural sedation.


This is reflected in RCEM’s 2020 guidance, which states that there is no evidence that complications are reduced if the child has fasted. They advised that the fasting state should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as a contraindication to ketamine use.*


*We cheered when we read this in the 2020 guideline. No more fasting – we’ve been saying this for years! But, a quick look back at the 2016 guideline shows that this was actually the recommendation back then too. Really careful scrutiny shows that a single word, “however”, has been removed from the start of the sentence, “traditional anaesthetic practice favours a period of fasting”, altering the tone of the recommendation to a much less dogmatic mandate about nil by mouth status.


Satisfied that the evidence does not suggest any advantage to fasting children before PPS (who, let’s face it, tend to be less cooperative when hungry anyway), you prepare the room, staff, and equipment for the procedure.


Where will Kayla’s procedure be carried out, how many staff do you require, and what equipment should get ready?


RCEM recommends at least three operators: the proceduralist (the clinician performing the procedure), the sedationist (clinician responsible purely for managing sedation) and a sedation assistant*. They specifically acknowledge that the clinician responsible for the sedation and the patient’s airway should be experienced in the use of ketamine, and capable of managing its complications. The 2020 guideline has elaborated further on this, coming with a recommendation for a need for suitable training, a minimum of six months’ experience in anaesthesia or intensive care medicine and an up-to-date APLS course.

*RCEM says ‘nurse’ for the third member of staff but really, it’s anyone who is experienced in monitoring children and supporting the sedationist – doctors can take on this role too.

ACEP’s 2014 position statement concurs with the need for three operators.

The recommendation is that the procedure should be carried out in a resuscitation bay or high dependency area with immediate access to full resuscitation facilities.

Monitoring (every five minutes) of heart rate, blood pressure, respiratory rate, and oxygen saturation is mandated. The American Academy of Pediatrics advised the use of capnography as an adjunct in order to detect hypoventilation and apnoea earlier than pulse oximetry or clinical assessment alone. While no evidence currently shows capnography reduces the incidence of serious adverse events, available studies show a decreased incidence of hypoxia and respiratory events.


The use of capnography during sedation has been affirmed by RCEM who have made it a mandatory minimal requirement in their most recent guideline iteration, in parallel with their previously recommended monitoring of respiratory rate, heart rate, oxygen saturations, ECG and BP.
The 2020 RCEM guideline also includes ‘degree of dissociative sedation’ as part of its recommended monitoring during the procedure, which is a new addition to their guidance. Ketamine is unique in that it does not conform to the ‘sedation continuum’ – the patient is either dissociated or not. This recommendation is perhaps aimed at prompting the sedation clinician and nursing colleague as to whether dissociation has occurred, and as to whether a top-up dose is required (more on that later).
The updated RCEM document specifically advises having key resuscitation drug dose calculations performed prior to the procedure and ready access to these, another new addition to their guidance, although no specific drugs are recommended.


Some doses you may find useful are:

As you’re checking the ketamine and emergency drug doses with your nursing colleague she asks whether you want her to draw up atropine and midazolam? She is a recent addition to the ED team and mentions that when she worked in theatre some years ago they frequently gave these medications together with ketamine.


Should any adjunctive agents be used with ketamine?

There was a previous vogue to co-administer a benzodiazepine to reduce the incidence of emergence. A 2018 BestBets review looked at this very question by studying 6 relevant studies (including 2 RCTs: Sherwin et al 2000, and Walthen et al 2000). These failed to demonstrate a significant difference in emergence between ketamine alone and ketamine with midazolam. In fact, the only difference demonstrated was increased rates of adverse advents when a benzo was co-administered. So, no prophylactic benzodiazepine required.

Having said this, if a child suffers severe emergence (older children, in particular, have increased risk of recovery agitation), then it is worth considering midazolam (aliquots of IV 0.05-0.1mg/kg) to treat (but not routinely or for minor / moderate emergence).

Another previous trend involved the co-administration of atropine to reduce the risk of aspiration. But the evidence does not support this practice, Green et al concluded “There is no evidence to support routine use of anticholinergic medication such as atropine to prevent laryngospasm or other adverse airway events.” Concurrent anticholinergics may actually increase the rate of airway and respiratory adverse events. There is a small increased risk of laryngospasm with oropharyngeal manipulation (including suctioning) so atropine (20 micrograms/kg IV) may be considered as rescue therapy if PPS is being used for intraoral laceration repair (although RCEM would recommend not using ketamine for these procedures for this precise reason).

A common side-effect of ketamine is vomiting. RCEM’s 2020 guidance recommends the use of IV ondansetron at 0.1mg/kg (max dose 4mg) to treat intractable vomiting.

Given ketamine’s emetogenic properties, is it worth giving an antiemetic prophylactically? It is worth considering ondansetron (0.1mg/kg IV) as prophylaxis in high risk groups: those with previous nausea/vomiting during sedation/anaesthesia, older children, or IM administration. The NNT depending on age of the patient will lie between Var7 and 9. This was further endorsed by a BestBets review published in the EMJ in 2018 which concluded that ondansetron should be considered when using ketamine for PPS, especially in older children or for those receiving preprocedural opioids. As with any drug, however, you’ll need to balance the risk-benefit ratio in your mind. Some would prefer not to use ondansetron prophylactically because of the risk of arrhythmias in children with undiagnosed long QT. But, again, long QT is rare…


A resus bay is prepped. Kayla and her mother are ready. Roles have been allocated; your nursing colleague is ready and is just removing the Ametop from Kayla’s hands which had been applied when PPS was considered; one of the ANPs will be the procedural clinician and your consultant will supervise you as the sedation clinician. You cannulate first go, while Kayla is distracted by Peppa Pig on screen. It’s time to dissociate.


But what dose will you give Kayla?

Various opinions exists regarding the exact or perfect dose; the most commonly accepted dosing schedule is 1-1.5mg/kg for intravenous (IV) administration.


RCEM’s guideline recommends a starting dose of 1mg/kg over 60 seconds (to reduce adverse events such as laryngospasm). This can be supplemented with top-up doses of 0.5mg/kg. This has not changed from their previous guidance.


You should notice onset of action within a minute. It is easy to spot as the child will develop horizontal nystagmus coupled with a loss of response to verbal stimuli. The heart rate, blood pressure and respiration rate may all increase slightly. Sedation will start to wear off after 20 minutes, with full recovery should occur by about 60 to 120 minutes.

Many departments are still using intramuscular (IM) ketamine. This can be particularly helpful in certain situations such as where IV access is difficult.


Due to its variable onset and offset time, longer time to recovery and increased risk of emesis, however, RCEM have now advised against IM except where senior decision-makers deem it necessary. The advice is that “clinicians should be mindful of the perceived safety benefits of having intravenous access from the start of the procedure to mitigate a rare adverse event.” This is the biggest change in their new guidance; the 2016 guideline included dosing and top-up recommendations for IM ketamine.


There are still some children who would benefit from IM ketamine, so if choosing the IM option, consider a dose of 2-4mg/kg, with senior clinical support. Ideally IV access could be achieved once the child is dissociated and the IV top-up dose can be administered if required. However if IV access is impossible or not obtained the IM top-up dose is 1-2mg/kg. You can expect a slightly slower onset at about 3-5 minutes with its duration extended from 15-30minutes. Recovery is variable occurring anywhere between 60-120 minutes.


As you walk over to the drug cupboard to collect your syringes with carefully calculated doses, your consultant asks, “Are you confident in managing any potential airway complications?”


Airway complications with ketamine PPS

Thankfully complications with ketamine are rare. Most events such as noisy breathing or stridor, and minor desaturation will respond to simple airway manoeuvres to ensure the airway is open, plus the use of high-flow oxygen via a mask with a reservoir bag. The most feared complication, laryngospasm, is extremely rare and most often will respond to simple airway manoeuvres. But sedationists must be competent in managing this prior to administering the first dose of ketamine. If laryngospasm is suspected, stop the procedure and call for help. Ensure 100% oxygen is administered if not already in situ. Gently suction any visible secretions. If this fails to improve the situation begin manual ventilation with ventilation via a bag-valve-mask or, if you are comfortable using an anaesthetic circuit, apply PEEP. Some guidelines (and anaesthetists) suggest applying pressure to Larson’s point, very similar to performing a strong jaw thrust. If there is no response at this point, with critical airway compromise, then RSI is required. Administer the pre-calculated dose of paralytic and intubate. Remember, Green’s reported incidence of intubation secondary to laryngospasm was only 0.02%.

The flowchart below may be of benefit – it formed part of my quality improvement project on PPS and was used as a wall chart in the sedation cubicle and included in each sedation proforma booklet. When emergencies occur, being able to cognitively offload by following step by step aide memoires and having pre-calculated doses to hand can be immensely comforting and helpful.



Kayla’s procedure is completed without difficulty and the nurse enquires as to how long Kayla needs to remain monitored for?


Children should remain monitored until their conscious state, level of verbalization and ambulation is back at pre sedation levels. They should be able to tolerate oral fluids. Prior to discharge, a final set of observations should be within normal limits for their age. Consider the need for a prescription (antibiotics or analgesia) prior to discharge.


Kayla successfully underwent ketamine PPS, allowing a thorough wash out of her wound and suturing which provided a tidy end result. She was later discharged with an antibiotic prescription and a teddy which the play specialist had found in the toy room for her. Delighted with your chance to use “Special K”, you quickly took out your phone to tweet about the latest changes in RCEM guidance in ketamine for procedural sedation in children in the ED (along with the endless uses of ketamine!)


The new RCEM guidance has come at an interesting time – how might it change our practice in PPS in the ED? PERUKI are soon to launch a two-level paediatric procedural sedation survey (name PoPSiCLE – we all know that a good study needs a catchy name) to inform the current status and variations in the practice of PPS in PERUKI , to provide baseline information for developing a network-wide training resource and patient registry. Watch this space…


Case two: Ronan


It’s a sunny Saturday afternoon. The smell of BBQ and summer is wafting through some open windows in the department. On your way to work, you noticed plenty of bouncy castles and trampolines in use. It’s not surprising your first patient is an 8-year-old boy who has fallen awkwardly while trying to impress some other kids at his birthday party. After examining him and his xray you see he has a midshaft radius and ulnar fracture with some angulation. Thankfully his DRUJ (distal radio-ulnar joint) appears intact, and his radial head is in joint. He needs manipulation of the fractures and application of a backslab. He’s in a lot of pain, despite the paracetamol and ibuprofen he had at triage. He tells you his favourite birthday cake is at home waiting for him and he wants to get home to blow out all the candles. You wonder if you can avoid him a trip to the operating room for a general anaesthetic. Would PPS perhaps be a safe alternative?


Nitrous oxide provides anaesthesia, anxiolysis, and also some mild amnesia. However, it offers limited analgesia and so co-administration of an analgesic is recommended. Several key papers, including the FAN study (2017) and Seith et al (2012) have demonstrated the safety and efficacy of co-administrating intranasal fentanyl (INF) with nitrous oxide.

Once you’re ready to go, move the child into the dedicated resus bay or sedation room. If using piped nitrous oxide with a variable concentration flow meter (ensuring the scavenging system is switched on) titrate the dose from 30-70% according to clinical response. The alternative is Entonox (a 50/50 mix of nitrous and oxygen) which usually comes in portable canisters but requires the child to be able to take a deep breath to overcome a demand valve circuit, usually tricky for the under-fives. You should notice the onset of effect in 30-60 seconds, but its peak effect will be 2-5 minutes so best to wait for this before commencing the procedure. Once the intervention or procedure is completed it is important to administer 100% oxygen for 3-5minutes post-procedure to avoid diffusion hypoxia. The offset of effects should occur within 2-5 minutes.

Does nitrous oxide have any side effects? While well tolerated by most children, transient minor side effects such as nausea, dizziness and occasionally nightmares can occur. It can cause vomiting in 6-10% of children receiving 50% nitrous dose. This rate increases with higher concentration and can increase up to 25% if an opioid is co-administered. Be sure to warn parents about this relative frequency of vomiting when using nitrous oxide, both during and after sedation. The risk of vomiting also increases with a longer duration of nitrous administration. Consider a prophylactic antiemetic if the child has a history of nausea or vomiting.

Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air-containing spaces within the body. This makes it contraindicated for use in patients with gastrointestinal obstruction, pneumocephalus, pneumothorax and after diving.

Nitrous oxide inactivates the vitamin B12-dependent enzyme, methionine synthase, and so can deplete vitamin B12 stores. Because of this, caution is advised in those at risk of vitamin B12 deficiency such as vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptor blockers and proton pump inhibitors. Nitrous should also be avoided in those with metabolic diseases especially methionine synthase deficiency, methymalonic acidaemia, and homocysinuria (because inactivation of methionine synthase can affect homocysteine metabolism). There’s a theoretical risk to pregnancies in the first trimester and so guidance often suggests avoiding nitrous oxide exposure in early pregnancy.

During administration monitor heart rate, respiratory rate and oxygen saturations. At least two staff members are required; a sedationist and a proceduralist.


Ronan and his mum are happy for you to use nitrous oxide and eagerly his mum signs the consent form. While setting up the sedation room and recruiting a nursing colleague to assist, you administer intranasal fentanyl. Ronan successfully undergoes manipulation of his fractures and an above elbow backslab is applied. His post-reduction x-ray shows you performed a pretty awesome reduction and, in consultation with your orthopaedic colleagues, you are happy for Ronan to be discharged to return to their fracture clinic in a few days’ time. This delights Ronan, as he gets to return home to his birthday party (with strict instructions to remain off the trampoline) and he promises to bring you back some of his birthday cake later!



Case three: Chantelle

Your junior colleague has come to you for advice. She has just seen a 4-year-old girl who was hard at work in her playroom creating unicorn pictures. Her mum had given her lots of colourful supplies including some glittery sequins and beads. Chantelle became adventurous and decided to decorate herself rather than the unicorns. Unfortunately, one of the beads has become lodged in her ear and despite an attempt by your colleague using both parents, and a play specialist, the removal of the foreign body was unsuccessful. You believe the use of PPS will be required and begin pondering which agent to use.


Midazolam is a hypnotic agent providing anxiolysis and amnesia. It does not have analgesic properties, which is why it is important to co-administer with analgesia for any painful procedure. It can be administered by many routes, the two commonest for PPS being intranasal (IN) and orally. If used intranasally, a dose of 0.3-0.5mg/kg is suggested. You should notice its onset within 10-15 minutes, lasting about 60 minutes. This route of administration can cause some nasal irritation and burning, so some clinicians prefer to use it orally. With an oral dose of 0.5mg/kg you should notice onset at 15-30 minutes with a duration of effect for 60-90 minutes. Midazolam tastes bitter – so give it with some juice or squash to make it more palatable. Midazolam can be given intramuscularly (IM) and intravenously (IV), but it is less likely to be used in this fashion for PPS.

Does midazolam have any side effects? Yes! It can cause hypoventilation and apnoea – be aware that this risk is increased if co-administered with an opioid such as fentanyl or diamorphine. A reversal agent does exist: flumazenil (0.01mg/kg, max dose 1mg) but this is rarely required, and oftentimes using basic airway manoeuvres is sufficient. Paradoxical excitatory or agitation reactions can occur in up to 15% of children. Do warn parents of this possibility prior to administration. The best course of action if it does occur is to let the child “ride it out”. Because of this, many ED clinicians will choose ketamine or nitrous oxide as their PPS agent of choice over midazolam.

With these side effects in mind, it is prudent to ensure basic monitoring includes heart rate, respiratory rate, and oxygen saturation monitoring. At least two staff are required; proceduralist and sedationist.


Having obtained informed consent from Chantelle’s mother, you decide to give her intranasal midazolam. 45 minutes later you remove the mischievous bead from her left ear. Her parents are thrilled, but before you leave the room you remember the mantra of “always check the other ear”. So before packing up your tools and leaving her with your sedation nurse, you decide to check her other ear. Interesting you find two glittery sequins hiding in her right ear canal. Phew, that saved a second sedation event!



Ketamine Procedural sedation for children in the emergency department. The Royal College of Emergency Medicine. Best Practice Guideline. February 2020.

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009; 54(2):158-168.e1-4

Agrawal D, Manzi S, Gupta R, Krauss B. Pre-procedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a paediatric ED. Annals of Emergency Medicine. 2003; 42(5): 636-646

Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/ anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006; 118(3):1087-1096

Beach ML, Cohen DM, Gallagher SM, Cravero JP. 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. Anesthesiology 2016;124(1):80-8

Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine 2014;63(2):247-58.e18

Sherwin TS, Green SM, Khan A, et al.Does adjuctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomised, double-blind, placebo-controlled trial. Ann Emerg Med 2000;35:229–38.

Walthen J, Roback M, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in Children? A double-blind, randomized, controlled, emergency department trial. Annals of emergency medicine 2000;36(6): 579-587

Green SM, Roback M, Kennedy R et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Annals of emergency medicine 2011; 57(5): 449-461

Dunlop L, Hall D. Antiemetic use in paediatric sedation with ketamine. Emerg Med J 2018; 35:524-525

Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367(9512):766-80

Nickson C. Paediatric Procedural sedation with Ketamine. Life in the Fast Lane. March 2019

Zier ZL, Liu M. Safety of high concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011 Dec;27(12):1107-12

Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989; 18:177-181

Comfort Kids Programme. Royal Children’s Hospital Melbourne. 2016

Peyton PJ, Wu CY. Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure. Anesthesiology. 2014;120(5):1137–1145

Baum VC. When nitrous oxide is no laughing matter: nitrous oxide and pediatric anesthesia. Paediatric Anaesthesia 2007;17(9):824-30

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence.: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2005

Axelsson G, Ahlborg G, Jr., Bodin L. Shift work, nitrous oxide exposure, and spontaneous abortion among Swedish midwives. Occupational & Environmental Medicine 1996;53(6):374-8

Hoeffe J et al. Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study. Am J Emerg Med. 2017;35(5):710-715.

Seith RW, Theophilos T, Bable FE. Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation. Acad Emerg Med. 2012;19(1):31-6

Kennedy RM, Porter FL, Miller JP, Jaffe DM. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics. 1998;102:956–63

Pena, B.M. and Krauss, B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999; 34: 483–491

Wright, S.W., Chudnofsky, C.R., Dronen, S.C. et al. Midazolam use in the emergency department. Am J Emerg Med. 1990; 8: 97–100

Davies FC, Waters M. Oral midazolam for conscious sedation of children during minor procedures. J Accid Emerg Med. 1998;15(4):244–248. doi:10.1136/emj.15.4.244

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Bailey, P.L., Pace, N.L., Ashburn, M.A. et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology. 1990; 73: 826–830

Gregory GA. Pediatric Anesthesia. 4th ed. Philadelphia, PA: Churchill Living- stone; 2002


The 32nd Bubble Wrap

Cite this article as:
Grace Leo. The 32nd Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:


Article 1: Should we worry about fever after Meningococcal B immunisations?

Campbell G, Bland RM, Hendry SJ. Fever after meningococcal B immunisation: A case series. J Paediatr Child Health. 2019; 55: 932-937. doi:10.1111/jpc.14315

Why does it matter?

Meningococcal meningitis and septicaemia remain is one of the most serious bacterial infections (SBI). In Australia, the government subsidised vaccine schedule includes Meningococcal ACWY however Meningococcal B vaccine (Bexsero) can be purchased ($250-$500) for children 6 weeks to 11 years. It is an immunogenic vaccine, and paracetamol is recommended on the day of immunisation, but how can we be sure the fever is due to the infection and not something more sinister?

What’s it about?

A prospective case series from the ED at Royal Hospital for Children, Glasgow was performed on patients presenting between 2016-17. They identified 92 eligible infants under 3 months presenting with fever within 72 hours of Bexsero immunisations. The youngest infant was 7 weeks old.

Of these patients, 76 infants were discharged within 24 hours with majority undergoing at least one investigation (FBC, CRP, Urine MCS, NPA). Only 16 children of the 66 admitted remained in hospital for > 24 hours, with 12 undergoing an LP and completing 48 hours of IV antibiotics.

In this study, 26 children had an NPA performed with 12 positive for at least 1 virus, and one child represented with bronchiolitis.

Only one child in the cohort had SBI with an E.coli UTI. This infant also had a significantly elevated CRP and WCC compared with the other patients, and their fever started 54 hours after immunisation. The remainder had negative CSF, urine and blood cultures.

Clinically Relevant Bottom Line

Fever in the first 24 hours following the 2 month Meningococcal B vaccine is expected, and depending on the clinical exam and partial septic work up results, may be discharged home with reassurance. The key is to always be weary of the unwell looking infant and those whose fevers persist, as a full septic work up and IV antibiotics should be considered.

Reviewed by: Tina Abi Abdallah


Article 2:  Does iron fortified formula for Infants make a difference?

Gahagan S, et al. Randomized Controlled Trial of Iron-Fortified versus Low-Iron Infant Formula: Developmental Outcomes at 16 Years. The Journal of Pediatrics. 2019 June [epub] doi: 10.1016/j.jpeds.2019.05.030

Why does it matter?

Iron deficiency anaemia in infancy has long-term effects on the developing brain.  It is the most common nutrition disorder in the world.  Therefore, many countries routinely supplement infant formula with iron.  Recommendations for iron concentrations in infant formulas differ between guidelines, ranging from 4-12mg/L.Australian formulas generally contain between 6.7-9 mg/L.  There has been no study comparing the effects of iron-fortified formula vs low-iron formula on cognitive outcomes. 

What’s it about? 

Six-month old infants who did not have iron deficiency anaemia, were recruited from community clinics in Santiago, Chile.  They were randomised to iron-fortified (12mg/L) or low-iron (2.3mg/L) formula for 6 months and were followed-up at 16 years of age.  Of the 405 participants, those who randomised to iron-fortified formula (n=216) had lower scores than those randomised to low-iron formula (n=189) in 8 of the 9 tests.  Three of the 8 were statistically significant, and were in the domains of visual memory (p=0.02), arithmetic achievement (p=0.02) and reading comprehension achievement (p=0.02).  For visual motor integration, it was found that those with low haemoglobin at 6-months of age who received iron-fortified formula, outperformed those with low-iron formula.  The opposite was also true, with those with high haemoglobin at 6 months, receiving iron-fortification underperforming those with low-iron formula.  Animal studies have shown concern regarding the possibility of iron neurotoxicity in the growing infant, as well as the effects of iron exposure in early life on brain aging and neurodegenerative disease outcomes.

Clinically Relevant Bottom Line

This study from Chile suggests that  adolescents who received iron-fortified formula as infants from 6 to 12 months of age had poorer cognitive outcomes compared with those who received a low-iron formula. This could be related to iron neurotoxicity and there is a need for further studies to investigate the optimal level of iron supplementation in infancy.  Although on a public health level it may not be feasible, it may be ideal to individualise the optimal amount of iron for supplementation based on baseline haemoglobin or iron measures. 

Reviewed by: Lorraine Cheung

  1. American Academy of Pediatrics Committee on Nutrition recommends 10-12mg/L from birth. European Society of Pediatric Gastroenterology, Hepatology and Nutrition recommends 4-7 mg/L.


Article 3: Introducing paediatric procedural sedation in low-resource countries

Schultz, M & Niescierenko, M. Guidance for Implementing Pediatric Procedural Sedation in Resource-Limited Settings. Clinical Pediatric Emergency Medicine, 2019 In Press; doi: 10.1016/j.cpem.2019.06.004

Why does it matter?

Since its introduction, much research has demonstrated the safety and benefit of paediatric procedural sedation (when used with the proper monitoring). The benefits of procedural sedation include reduced procedure time and error rates; increased comfort of patients, parents and health care professionals; and reduced need for general anaesthesia for minor procedures. While paediatric procedural sedation is part of routine practice in high-income countries (HIC), it is almost non-existent in low- and middle-income countries (LMIC). The paper claims this is mainly due to a lack of skilled providers, not for lack of need. Providing proper clinical training to health providers in LMIC would help provide safe and adequate analgesia for children undergoing minor procedures.

What’s it about?

The authors of the paper have devised a paediatric procedural sedation curriculum, which was piloted at John F. Kennedy Hospital in Monrovia, Liberia. The pilot curriculum focuses solely on the use of ketamine, as it is cheap, widely available in Africa, has multiple routes of administration and is safe for use in children. The curriculum also allows for a single-practitioner method of procedural sedation, which is key in LMIC where there are limited number of health providers compared to the patient load. The curriculum is divided in three 2-hour sessions which consist of (1) introduction to procedural sedation, (2) resuscitation and management of adverse effect, and (3) monitoring and conclusion. All required teaching supplies were restricted to printed handouts, poster paper, markers and low-fidelity simulation equipment, thus eliminating the need for computers, software and electricity. Participants of this curriculum were 15 paediatric and surgical residents.

Clinically relevant bottom line

I was  fascinated with how the authors came up with this pilot curriculum for the Liberian hospital. Not only did they have to think about the costs of the individual piece of equipment in the sedation kit, but they also took into consideration the variable availability of electricity, the type of possible monitoring during sedation, and the scarcity of personnel. Too often we forget how lucky we are to have access to so many resources! The rollout of safe and routine paediatric procedural sedation is ongoing in Liberia and this is an initial step toward enabling safe procedural sedation for children living in LMIC.

Reviewed by: Jennifer Moon


Article 4: Supporting parents to CEASE smoking

Nabi-Burza E, Drehmer JE, Hipple Walters B, et al. Treating Parents for Tobacco Use in the Pediatric Setting: The Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial. JAMA Pediatr. Published online August 12, 2019. doi:10.1001/jamapediatrics.2019.2639

Why does it matter?

Exposure of children to secondhand and even thirdhand smoke (from toxins absorbed in clothing, carseats) is a serious public health issue. Smoke from cigarette smoke contains about 4000 chemicals, over 50 of which are known carcinogens. Second hand smoke increases the risk of children having SIDS, ear and respiratory infections, asthma exacerbations and teeth problems.

What’s it about?
The CEASE intervention (Clinical Effort Against Secondhand Smoke Exposure Cluster Randomized Clinical Trial) was developed between the AAP  and Massachusetts Tobacco Cessation and Prevention Program, and the Massachusetts General Hospital Center for Child and Adolescent Health Research and Policy. It focuses on 3 of the 5 As of tobacco cessation – Ask, Assist and Arrange Follow Up.

In this cluster RCT study run by the AAP, the CEASE intervention was delivered in paediatric clinics in 5 American states. The CEASE intervention included a smart tablet questionnaire, educational pamphlets and aids and training for staff to help screen for tobacco use and offer treatment to parents. Treatments were referral to a Quitline and/or provision of nicotine replacement therapy.
The study looked at the effectiveness and sustainability of this CEASE intervention 2 weeks and 2 years post start of intervention.

In a population of 8184 parents screened, 27.1% in the intervention group and 23.9% in the control group were smokers. Engagement in a treatment practice was 44.3% in the group vs 0.1% in the control. In the 2 year follow up of 9794 parents screened, 24.4% and   of the parents were smoking in the intervention and control practices respectively. There was a reduction in smoking prevalence in the intervention practices of 2.7% compared to an increase of 1.1% in the usual care control group. The NNT to treat to reduce one smoker was 27 individuals. For confirmed cessation (saliva tested, at least quit for 1 week), the NNT was 18.

The bottom line

We might take a smoking history routinely, but how often do we reach the next step of advising or assisting parents to quit? This trial shows that simple interventions can help improve uptake of treatment. Every parent who quits is one less child exposed to dangerous chemicals from tobacco smoke. The CEASE resources are freely available for use and adaptation So why not move from contemplation to action and take the time to adopt a meaningful change in your own practice? There’s help on hand and it may be easier than you think to start!

Reviewed by: Grace Leo


If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to. 

Deb Shellshear: Procedural sedation at DFTB17

Cite this article as:
Team DFTB. Deb Shellshear: Procedural sedation at DFTB17, Don't Forget the Bubbles, 2018. Available at:

This talk was recorded live on the second day at DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at


Cite this article as:
Jess Longmore. Ketamine, Don't Forget the Bubbles, 2016. Available at:

You can keep staring at the 3 year old’s deep eyebrow laceration, desperate to glue it, but you know it needs to be sutured. Now what?

Injured or distressed children present us with difficulties in the emergency department. Children experience a more intense physical and emotional reaction to painful or threatening procedures than adults. The goals of sedation of children in the emergency department include minimizing pain, anxiety, movement which may jeopardize the procedure, and maximizing the chances of success for the procedure performed, returning the patient to his or her pre-sedated state as quickly as possible while assuring the patient’s safety. In addition to minimizing the negative psychological experience for the child, sedation will reduce fear and distress in subsequent presentations to health care facilities.

Paediatric procedural sedation has become a domain of expertise in emergency medicine. As emergency physicians, we should be aware of the pros and cons of the different options within paediatric sedation, and not only skilled in the technicalities of each but in the non-clinical aspect of ensuring both the child and the caregiver have as pleasant an experience as possible.

Choice of sedation

There are no hard and fast rules on what sedation to use. One must take into account many variables, including the age (and temperament) of the child, the proposed procedure, fasting time, co-morbidities, and levels of parental anxiety. If a patient or a parent is extremely anxious, or if the procedure has the potential to be very long, complex or painful, it may be more appropriate or kinder for the child to have their procedure done in theatre under general anaesthetic. In a compliant child with a laceration away from the face needing sutures, Nitrous Oxide may be ideal.

Prior to any form of sedation

  • Take time to discuss the options with the parents.
  • Remember to consider systemic pain relief. If using ketamine it is important that the patient is comfortable before the drug is administered – if they are uncomfortable or agitated during administration they are more likely to have nightmares or a scary emergence.
  • ALA (or similar) should be used around wound edges, and AnGel/LMX on potential cannulations sites.
  • Local anaesthetic should be used where appropriate as the analgesic effect will outlast the ketamine.

Ketamine sedation

Ketamine has been described as the “ideal” agent for paediatric sedation, and has rapidly become the drug of choice for short, painful procedures in the ED due to its rapid onset of action, and anxiolytic, analgesic and amnesic properties. Ketamine dissociation results in a lack of response to painful or noxious stimuli, whilst preserving respiratory and cardiovascular stability.

Ketamine use has previously been restricted to anaesthetists, but emergency physicians are using it more and more frequently; ACEM and ACEP both have formal guidelines for emergency physicians especially for ketamine sedations, and most departments will have a local protocol. It should, however, only ever be used in a resuscitation area by an airway trained doctor in case of laryngospasm. It is mandatory to have a separate doctor performing the procedure itself and a nurse credentialed in ketamine sedation. Local policies may specify PLS/APLS certification or similar. This may mean delaying the procedure until daylight hours or calling in the consultant if there is an urgent clinical need.

Absolute contraindication

infants less than 6 months (due to increased risk of airway compromise and recent animal studies which have found that ketamine is involved in neuronal degeneration within the developing brain)

Relative contraindications

  • age less than 12 months
  • high risk of laryngospasm (e.g. asthma, active URTI)
  • significant cardiac disease
  • reduced loc or recent head injury
  • previous psychosis
  • prior adverse reaction to ketamine

Examples of appropriate procedures

  • Suturing
  • Reduction of fractures/dislocations
  • Burn debridement
  • Lumbar Puncture
  • Abscess drainage

For the parents

For successful sedation, it is integral to involve the parents or caregivers and keep them on side. Take the time to explain the procedure to them and gain informed consent. I often given them a leaflet to read about ketamine sedation and then come back ten minutes later to answer any questions they may have. Ensure to go over what will happen, what they will see and what the child will experience.


  • Your child may seem to be awake after receiving ketamine, their eyes might flicker from side to side or they might twitch – this is normal
  • They may develop a rash
  • They may vomit
  • They may drool
  •  Sometimes as your child wakes up they may be agitated or appear to be having hallucinations or nightmares. These can normally be helped by minimizing sensory input (e.g. talking softly and dimming the lights), but if required we can give a drug that will help to minimize these.
  • In very few cases, we may have to give extra Oxygen or extra drugs
  • Be reassured that your child will not remember the procedure

How parents can help:

Keep calm themselves, reassure the child, talk softly and smoothly and describe a pleasant scene to them as they are given the drug. Remain with the child throughout the procedure and provide positive

Routes of administration

Ketamine can be used intravenously or intra-muscularly, if access is likely to be problem. Studies have concluded that IV ketamine is similar to IM ketamine in terms of efficacy and safety, with no significant difference in the rates of adverse respiratory events, however higher rates of vomiting were found in intramuscular administration.

IM has also been found to last slightly longer, and time to discharge was therefore longer (129 minutes from administration to discharge with intra-muscular ketamine, versus 80 minutes with IV).


Dissociation can usually be achieved with:

1-1.5mg/kg iv (given over 1-2 mins to avoid apnoea); top up dose of 0.5mg/kg iv can be given if required

4mg/kg im, a repeat dose of 2-4mg/kg can be given after 10 minutes if sedation inadequate

Note – Several studies have shown that higher ketamine doses are required for smaller children

It is normally good practice to site a cannula when the child is dissociated if using the IM route, in case the procedure takes longer or any other drugs are required, and in order to titrate any top-up doses more accurately.

During the procedure

Talk gently and tell the child to choose a dream as they drift off to sleep. You can also describe (or get the parent to describe) a pleasant scene as you are administering the drug.

Adequate sedation is usually indicated by a lack of response to verbal stimuli and nystagmus.Be patient. The effects of ketamine are usually apparent 1-2 minutes after an intravenous dose, and 5 minutes after an intramuscular dose (this can seem a long time with the orthopaedic surgeon staring at you!) Top-up doses can be given as above, but ensure you have waited sufficient time before topping up.

Atropine 0.02mg/kg up to a maximum of 0.6mg can be used to reduce the hypersalivation caused by ketamine which can lead to larynogospasm or aspiration. Recent studies have shown no benefit to routine co-administration of atropine, though prophylactic administration may be considered in procedures in which minimising oral secretions is important, such as lip or tongue wounds. It is worth having it drawn up to be administered in the event of concerns surrounding hypersalivation during the procedure.

Midazolam has previously been used for emergence phenomena, but it should be noted that unpleasant reactions are uncommon and there is no benefit from the routine prophylactic administration of midazolam in children. There is significant variation in the literature with regards to dose, ranging from 0.02mg/kg to 0.1mg/kg. I favour a dose of 0.05mg/kg, but this can be repeated if necessary. I normally don’t draw this up, but have the dose required in my head and the vial nearby should unpleasant reactions arise.

Ondansetron 0.15mg/kg would be the drug of choice for the vomiting child; some clinicians opt to give it prophylactically although there is minimal evidence to support routine use.

After the procedure

Ensure to put the lights down, talk in whispers, and leave the child to wake up

Regular observations are required post procedure until the child is fully awake

Prior to discharge

Ensure the child is fully awake and give them something to eat and drink

Discharge home with parents when able to mobilise and verbalise

Ensure to give appropriate post-procedure advice