Appendices

Appendix

Page

A. Non-pharmacological Techniques in Procedural Sedation 28 - 30

B. Drugs Used in Procedural Sedation

31 - 49

Nitrous Oxide

31 - 35

Benzodiazepines

36 - 38

Ketamine

39 - 44

Propofol

45 - 47

Opioids

48 - 49

C. Procedural sedation Record

50 - 51

D. Patient Advice Pre Procedure Paediatric & Adult

52 - 53

E. Patient consent form

54

F. Discharge advise for both adults and children

55 - 59

G. References

60 - 62

Appendix A: Non-pharmacological Techniques in Procedural Sedation

Role of Staff

Team members need to know their role in the procedure, in particular who can function as a “safe” person who provides emotional/social support to the patient and the family.

Role of the parents or support person

Invite the parents and child to be part of the team as active participants and not just passive recipients. Most children want their parents present and most parents want to be there. Research has identified behaviours which promote coping and behaviours which promote distress (see below). It is effective for staff to model coping promoting behaviours, especially if there is not enough time or resources to coach parents directly.

Preparation

Find out a bit about them, their likes and dislikes. Ask them what they would be doing if they were at home. Find out what knowledge and expectations they have about the procedure. Let them ask questions, be honest about what will happen and answer any misconceptions. Provide age appropriate information about the procedure, including any sensation to expect (smells, noises and physical sensations). Children need to know what they will feel like after the procedure (e.g. Intravenous cannula (IV) or IV fluids, plaster, bandage). Tell the child when the procedure will happen, giving them enough time to prepare but not so long that increases anticipatory anxiety. Tell the child how they can be helpful to increase his/her sense of competency.

Environment

The child should be attended to by calm, friendly adults. Remember children may see you as big and threatening, so be small and gentle. Do not get equipment ready in front of children but they may need to see and touch it to feel less anxious. Keep unexpected events to a minimum and explain any surprises, like a loudspeaker noise.

Holding

Use positioning for comfort and avoid forceful restraint. Have the child sitting rather than lying wherever possible. Do not use parents for restraint, only comfort holding.

Language including choice and control

Choices of words/phrases/imagery in the first seconds of the therapeutic encounter may set the stage for the child’s response to pain. It is very important to comment positively on some aspect of the child’s physical state e.g. “your blood looks very rich and strong.” Be very careful with your choice of words. Use language to suggest that the child will get well and will return home. For example “when you get home what is the first thing you will do?” Acknowledge what is happening and suggest its positive side. Make positive suggestions related to treatment procedures and imply change, possibly for the better.

Emphasise the qualitative sensations that the child may experience such as cold, tingling and pressure so that the child focuses on what he/she is feeling and not just on a hurting aspect.

When talking to a child in pain it is important to acknowledge their pain and anxiety but not make it worse. If a child asks if it will hurt, be honest with them. If the procedure is likely to cause some pain, describe the pain in familiar terms that he/she will understand. The parents will have some examples of pain that their child has experienced during play or may have observed someone else experience without distress. Aim to keep their brain busy and distracted by talking or telling stories so the pain messages can’t get through.

Avoid deceptive statements such as “this shouldn’t hurt”. Children do not forgive or forget dishonest statements easily. Rather provide suggestions for coping e.g. “I wouldn’t be surprised if this hardly bothers you, especially when you see what’s happening in the video cartoon.”

Immediately before

Remain calm and firm. Do not focus on feelings once the procedure is imminent. Do not bargain, negotiate or apologise, as it increases distress. Do not give the child a choice about when to start the procedure as it increases anticipatory anxiety. However you can give children a sense of control by involving them in some decisions such as: where to sit for the procedure, which hand to use for the IV insertion. Just before the procedure, stop talking about the procedure or focusing on it in any way and encourage the use of relaxation and distraction.

During Procedure

Distraction is actively engaging the child onto a positive focus away from the negative focus without tricking the child. Find out from the child what he or she likes doing best: if sport, which one; if the X Box, which game; if playing with a pet, what name (so you can engage them). Use age appropriate distraction such as bubbles, windmills, stories, music, toys, electronic games, non-procedural talk or imagery. To promote relaxation encourage breathing exercises, muscle relaxation and imagining a favourite place, sport or activity. Maintain verbal contact unless child needs quiet to concentrate.

Continue the verbal distraction/imagery even if the child’s distress increases during the procedure and do not revert to reassurance or apologising. Prompt the child to use coping behaviours and praise all attempts.

After Procedure

Only say “it’s finished” at the very end of the procedure. Focus on positive coping efforts and continue distraction. Allow the child time to recover. Be sensitive to the child’s needs. Instill a sense of achievement no matter what happened. Start normal pleasant conversation and activities. Use pain medication as required. Avoid focusing on any further procedures till nearer the time.

If the child is too sedated to remember much, you still need to instill a sense of achievement by reminding the child of positive aspects of the procedure. Reframing memory may be the key to coping with subsequent procedure.

Appendix B: Drugs Used in Procedural Sedation

NITROUS OXIDE

Background

Nitrous oxide is an anaesthetic gas, which provides analgesia and sedation and is delivered in variable concentration with oxygen. The exact mechanism of action of nitrous oxide is unknown however it is thought to work by stabilising neuronal as well as other membranes and therefore causing general depression of the whole CNS. The gas is non allergenic and not flammable or explosive.

At TPCH we have 2 options for delivering nitrous:-

1. Entonox: a 50-50 premix nitrous oxide and oxygen.

2. Quantiflex: a device allowing delivery of a variable quantity of nitrous mixed with Oxygen up to 70% Nitrous concentration

Indications

Studies in children have shown nitrous oxide to be an effective, painless and safe agent for reducing pain and anxiety when performing painful procedures. It has both analgesic and sedative properties. Its quick onset of action and recovery makes it ideal for use in the emergency department.

It is useful in such interventions as:

· Suturing and wound management

· IV insertion – particularly in acutely painful conditions e.g. burns

· Removal of foreign bodies from ear/soft tissue

· Fracture manipulation

· Reduction of digit dislocations

· Simple moulding of plaster of Paris casts to fractures

· Burns dressings

· Injection of local anaesthetic

· Abscess incision and drainage

· Other painful/uncomfortable procedures

It is less useful for:

· Very painful or prolonged procedures

· Facial (perioral) lacerations

· Procedures requiring immobility

The recommended youngest age to attempt administration of Entonox is 4 years of age. Younger children usually require sedation by other means as they are unable to cooperate to self-administer the Entonox.

Quantiflex has the advantage that it may be used in younger children with a firm mask seal. However if this procedure is to be performed the monitoring should be as for IV sedation as deep sedation is possible.

Pharmacology

Nitrous oxide has a short duration of action. It takes approximately 1-3 minutes to induce these effects with a nitrous oxide-oxygen mixture and about 4-5 minutes for them to wear off. There are no drug interactions – nitrous is eliminated unchanged from the lungs.

Adverse events and Contraindications

Nitrous oxide is usually well tolerated by patients in the emergency department. Most patients only have mild side effects such as vomiting, nausea, dizziness, light-headedness and occasionally nightmares and some children will not be able to tolerate the mask. Some side effects are further outlined below.

Vomiting: Parents should be warned that vomiting may occur both during and after the procedure and even after arrival home. Up to 5% of children may vomit after discharge and 7% may vomit in hospital8. Adults are less likely to vomit. Although vomiting is unpleasant it is not usually dangerous as cough and gag reflexes are maintained (Fleisher 2000).12 The exception to this is if patients have had previous or simultaneously administered opiates or benzodiazepines. Because the combination will result in deeper sedation there is a potential for aspiration if vomiting occurs.

Oversedation: The precautions of mandatory co-administration of oxygen and self-administration prevent over sedation. If a mask or mouthpiece is held on by another person there is a possibility of oversedation so this should be avoided unless the patient has monitoring and staffing requirements as per intravenous sedation and if the operator feels that the patient is becoming too sedated then they should remove the mask

Desaturation with respiratory difficulties. This is rare. In patients with concurrent URTI or history or airways disease or asthma there is an increase risk therefore care should be taken with these patients

Increased pressure – intracranial, intraocular and Pulmonary vascular Pressure: Nitrous oxide is therefore contraindicated in patients with pulmonary hypertension, glaucoma or anyone with known increased ICP or with ALOC after head injury

Increased volume in closed air spaces: Nitrous oxide is 35 times more soluble in blood than nitrogen causing it to diffuse into a closed air-containing cavity faster than nitrogen diffuses out. If the cavity does not have rigid walls, the volume increases. It should not be used in patients in whom there is a the possibility of closed air spaces such as pneumothorax , bowel obstruction, middle ear infection, or after SCUBA diving (12hours of a normal dive or 24hours of repeated or deep dives) or if any signs of decompression sickness.

History of Malignant hyperthermia: Nitrous oxide is possibly associated with malignant hyperthermia and should not be used in patients who are susceptible to this.

Staff requirements

Unlike other procedural sedation use of Entonox only requires 2 staff present:

· One doctor or other staff member to perform the procedure

· One nurse, or another doctor credentialed in Entonox use

The use of Quantiflex should be as per Intravenous procedural sedation with at least one medical officer present:

· One Registered nurse and doctor (both PS competent and at least one credentialed in Quantiflex use)

· One doctor/Staff member to perform the procedure

· A senior doctor notified of the procedure

Fasting state prior to procedure

There is no evidence that fasting state is related to adverse events – in particular there is no reported difference in vomiting or aspiration rates in children given N20 whether they have fasted or not.12

Equipment

Entonox/Quantiflex administration requires the preparation of the following equipment:

· Separate oxygen source with mask other than the nitrous oxygen source and also Bag valve mask available

Observations

· Documentation of vital signs and findings throughout the administration of nitrous oxide in the nursing observation chart

· Oxygen saturation needs to be monitored constantly and for five minutes post procedure

· Respiratory rate needs to be constantly monitored

· Conscious state must be constantly monitored by the administrator

· On completion of the procedure and administration of nitrous the patient needs to be monitored until their conscious state returns to the baseline. (if developmentally delayed, parents can aid in the assessment of baseline)

Administration

Trained nursing or medical staff are required to supervise the administration of nitrous oxide. Appropriately trained emergency nursing staff has been shown to provide high quality and safe procedural sedation with Entonox11

Quantiflex should be performed with medical staff present as there is a possibility of deep sedation with higher concentrations of N2O but may be administered by competent medical or nursing staff. Staff or persons who may be pregnant especially first trimester should avoid being present during nitrous oxide administration.

Guidelines for administration of Entonox

· Familiarise patient especially children with the equipment prior to the procedure – this increases effectiveness and compliance

· Appropriate mask to be attached to the circuit or mouthpiece if older

· Filter is needed in the Entonox circuit

· Use a new mouthpiece and filter for each administration

· Check level in the bottle – if less than ¼ then must be replaced

· Turn on the cylinder

· Allow patient to self-administer Entonox – a “Darth Vader” or hissing sound indicates the patient is activating the valve

· Administration should start 3 mins prior to the procedure

· Sedation score of 4 is the aim – if the patient becomes excessively drowsy remove the mask if it doesn’t automatically fall away.

· At the end of the procedure 100% oxygen should be delivered for 3 minutes and the cylinder turned off and mouthpiece and filter discarded

· Continue observations 15 minutely until the patient meets discharge criteria

Guidelines for use of Quantiflex machine

Quantiflex machine delivers a constant flow of oxygen/nitrous oxide mix and

has a failsafe delivery of a minimum of 30% Oxygen at all times. This continuous flow is generally used for young children.

Equipment assembly and check prior to procedure

· Check that the O2 and N2O hoses are connected to the cylinders and both cylinders are turned on

· Check the gauges to ensure that there is an adequate supply of oxygen and nitrous oxide (¼ % full minimum)

· Check the reservoir bag inflates with no leak

· Select the appropriate size face mask.

· Check the scavenging device is connected

· Prescribe on medication chart

During procedure

· Set the flow of O2/ N2O to desired concentration (usually 50-70% N2O)

· Apply face mask ensuring adequate seal

· Observe the reservoir to ensure there is a supply of nitrous oxide for the patient to breathe and to ensure that the bag does not overextend

· Nitrous oxide/oxygen mix should be applied for 3 minutes PRIOR to procedure to ensure sufficient analgesic effect is present.

· The patient should continue to breathe nitrous/oxygen mix for the duration of the procedure.

· The dose may be titrated upwards by increasing the nitrous flow by 1 l/min. - or by 10 % increase in nitrous to a maximum of 70% N2O

· Administration should be temporarily discontinued if the patient becomes excessively drowsy. Frequent communication with the patient allows titration of the N2O dose for effect.

· Monitor sedation levels and adjust % of N2O versus O2 as required

· Continuous monitoring and assessment of vital signs throughout the procedure (see observation recommendations)

· Administer 100% oxygen for 4-5 minutes after the procedure is finished to avoid diffusion hypoxia

Post Procedure

· Turn off Quantiflex

· Discard face mask and tubing

· Monitor patient until their conscious state returns to baseline

BENZODIAZEPINES

Benzodiazepines have been used in children and adults as adjuncts in procedural sedation. They are anxiolytic, sedative and result in amnesia for the procedure. They have no analgesic effects therefore for painful procedures they should only be used in conjunction with an opiate for analgesia.

Benzodiazepines act at the gamma amino butyric acid receptor (GABA). GABA receptor stimulators such as benzodiazepines potentiate the GABA effects of calming the patient, relaxing smooth muscle and producing sleep.

The prototypical benzodiazepine, diazepam, has been replaced in procedural sedation by midazolam due to its shorter half-life and water solubility.

Midazolam can be administered IV, IM, orally, rectally and nasally. Absorption varies with route of administration. In addition oral dosages are in part metabolised by the liver (first pass effect).

Effects of benzodiazepines can be reversed by Flumazenil, a benzodiazepine antagonist although this should not be administered to patients who have a history of chronic benzodiazepine use as they are at risk of seizures with reversal

Formulation of Midazolam

· ORAL/BUCCAL: The oral route is the most convenient and easiest route of administration. However, the IV preparation used is bitter and children sometimes refuse it or spit it out. The taste can be disguised by using 5-15mls of undiluted cordial/other flavouring.

· INTRAVENOUS: The advantage of IV midazolam is ease of administration and titration. Disadvantage is insertion of an IV line.

· INTRANASAL: IN midazolam has a rapid onset and may be used however children may become upset because the formulation stings the mucosa. One drop of 5mg/ml solution contains about 0.3mg of midazolam – one drop per nostril over 15sec until full dose applied. A single spray of Intranasal lignocaine spray per nostril administered immediately prior to the IN midazolam solution has been found to reduce the discomfort.

· RECTAL and INTRAMUSCULAR: Rectal and IM administration of midazolam are generally not recommended for procedural sedation in the emergency department.

· Blood levels after rectal administration are variable. The onset is slower than with intranasal route.

· The main problem with IM midazolam is the pain associated with injection.

Indications for use

Relieve anxiety regarding procedures and in conjunction with opiates to achieve sedation for procedures

Benzodiazepines have no analgesic effect

Adverse reactions

Major side effects are:

1. Cardiorespiratory depression (hypotension, bradycardia and respiratory depression)

2. Paradoxical excitement (10-15%)

3. Emergence delirium

Side effects are dose related and vary with route of administration.

· The highest risk of major side effects is IV administration. 13 Rapid IV administration simultaneously with opioids increases the risk of respiratory depression.

· Higher doses of intranasal midazolam can lead to prolonged elimination, delayed recovery and respiratory depression. All patients receiving this sedative intra-nasally must be monitored closely.

· No serious respiratory depression has been reported in oral administration at 0.5mg/kg except if other sedative drugs are co-administered.

Considerations for use

· Patients with previous adverse events to midazolam sedation – this is the only true contraindication. Also should not be used in children aged less than 1 year due to increased risk of airway complications.

· Patients with swallowing difficulties, airway difficulties or sleep disorders can develop airway obstruction and hypoxemia from relaxation of upper airway muscles

· Consider reduced doses in renal hepatic and cardiac impairment

· Consider reduced doses in the elderly

· Myasthenia gravis.

· Acute glaucoma

Equipment, staffing and set up are as per general module see previous

Doses

1. Oral midazolam: 0.5mg/kg with sedation in 30-45 minutes (max 15mg). Higher doses of 0.75-1mg/kg are associated with increased side effects.

2. Buccal Midazolam: 0.3mg/kg of IV formulation – onset 10-15mins but may be earlier.

3. IV Midazolam: 0.05-0.1mg/kg with onset 1 minute. IV midazolam should be given slowly and titrated to effect in adults <5mg is recommended regardless of weight dosing.

4. IN Midazolam: 0.2-0.4mg/kg of IV formulation (max 10mg) intra-nasally sedation is usually within 10-15 minutes but may be earlier and may last up to 2 hours

Reversal agent Flumazenil

Overdose symptoms of midazolam can be reversed by flumazenil, a benzodiazepine antagonist. Flumazenil is administered IV. It has a short duration of action and might require several doses or an infusion. It should never be required if careful titrated sedation is undertaken.

· Children: 5mcg/kg every 60 seconds to a total dose of 40mcg/kg (max 1mg)

· Adult dose: 300-600mcg repeat as necessary up to a total of 2mg

· Maintenance dose if indicated – half the dose required to waken the patient given every hour by continuous infusion

Ketamine

Ketamine is an analgesic and a dissociative anaesthetic agent. It is fundamentally different from other procedural sedation and analgesia agents and is the exception to the sedation continuum tenet. Ketamine exerts its effect by ‘‘disconnecting’’ the thalamo-neocortical and limbic systems (through simultaneous depression of the cortex and stimulation of the limbic system), effectively dissociating the central nervous system from outside stimuli (e.g., pain, sight, sound). The resulting ‘‘sensory isolation’’ of this trancelike cataleptic state is characterized by potent analgesia, sedation, and amnesia while cardiovascular stability is maintained and spontaneous respirations and protective airway reflexes are usually preserved 14

The complete analgesia typical of the dissociative state permits extremely painful procedures to be performed that would otherwise be difficult using traditional moderate or deep sedation with benzodiazepines and opioids. Rather than displaying the dose-response continuum observed with all other procedural sedation and analgesia agents, Ketamine dissociation is either present or absent with a narrow transition zone. This dissociative state, once achieved, has no observable progressive depth or level, and administration of

additional Ketamine to an already dissociated patient does not enhance or deepen sedation, as would be the case with opioids, sedative-hypnotics, or inhalational agents. For non-dissociative agents, the more drug given, the more the patient progresses along the sedation continuum, with increasing probability of impaired independent airway function and respiratory control. In

contrast, the absolute amount of Ketamine given has no clinically important impact on respirations and airway integrity within the range of clinically administered doses and using standard administration methods. Accordingly, dissociative sedation can be readily begun by administration of a single intravenous or intramuscular loading dose, and the only need for titration, in marked contrast to other sedatives, is to maintain the dissociative state over time.

Ketamine is an ideal agent to facilitate short painful procedures, especially in children, which might otherwise require general anaesthesia. It has many features that are attractive in the outpatient setting: rapid onset (less than 5 minutes IM or IV and up to 25min Oral or IN), consistently effective analgesia and amnesia, airway stability and acceptable recovery duration (70 –140 mins depending on route of administration).

Its safe use in children has been documented in numerous series14,15,16 and the literature supports the safety and efficacy of ketamine for a large variety of brief, painful or emotionally disturbing procedures – most typically fracture reduction and laceration repair in children. Its use in adults has been increasing in recent years and evidence is appearing that it is safe and effective in this age group also.

A study by Green et al15 of ketamine use in 1022 children in the emergency department produced acceptable sedation in 98% of patients; airway complications occurred in 1.4% but were transient, quickly identified and did not require intubation. Vomiting occurred in 6.7% and emergence phenomena at 19.3%. A study of 266 children receiving IV ketamine reported an adverse respiratory event in 4.5%, vomiting in 18.7% and emergence phenomena in 26.7% (Wathern, 2000)26

It is also used extensively in developing countries for major and minor surgery and in disaster and battlefield settings where no anaesthetist or facilities are available.

A comprehensive “Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation in Children” was published in 2004, and this module is largely based on this practice guideline.19

Indications for use

1. very painful procedures

2. laceration repair -complex or cosmetic laceration repair

3. wound exploration – foreign body

4. reduction and immobilisation of fracture or dislocation

5. incision and drainage procedures

6. need for immobilisation

7. removal of foreign bodies from eye, ear, nose and skin

Adverse Reactions and Contraindications

Previous allergy or anaphylaxis to ketamine

Ketamine use is obviously contraindicated in this case

Respiratory depression

Ketamine uncommonly causes respiratory depression. Severe respiratory depression is rare but is increased in frequency if ketamine is pushed by rapid IV bolus achieving rapid peak CNS levels, or when CNS abnormalities are present or in young infants. Neonates and small infants have greater difficulty maintaining a patent airway with any sedative agent. Therefore, in the Emergency Department, ketamine is contraindicated in infants less than 3 months of age and relatively contraindicated between 3-12months of age.

Airway malposition

Occasional malposition of the airway can occur especially if the patient exhibits random purposeless motion. It is critical to continuously pay attention to airway patency and reposition head or jaw if snoring respirations or stridor develop.

Hypersalivation

Ketamine stimulates salivary and tracheobronchial secretions. Some experts recommend concurrent use of an anticholinergic such as atropine (0.01-0.02/kg, max dose 0.6mg) to inhibit these secretions, particularly when the procedure may involve the mouth and airway. Newer studies have failed to show a benefit from co administered atropine and its use in combination with ketamine is dropping.20

Laryngospasm

A series of 1022 paediatric patients who received IM ketamine reported four episodes of laryngospasm; all were transient and without sequelae19. Generally with anaesthesia young age and respiratory infections increase the risk of laryngospasm. Clinicians need to be prepared to treat laryngospasm with oxygen and assisted ventilation until the episode subsides.

Ketamine is relatively contraindicated for use in conditions with increased risk of laryngospasm. These include

· Procedures involving laryngeal stimulation

· History of Airway instability, stenosis, tracheomalacia, trachea surgery

· Active asthma, current Upper respiratory tract infection

Cardiovascular stimulation

Ketamine is sympathomimetic and can produce mild to moderate increases of blood pressure, heart rate, cardiac output and oxygen consumption. Therefore it is relatively contraindicated in patients with significant cardiovascular disease.

Musculoskeletal effects and Ataxia

Skeletal muscle hypertonicity and random movement of head and extremities are often observed. Ataxia can be pronounced during recovery. Ambulation must be avoided until full equilibrium is restored.

Intracranial pressure elevation

Ketamine may increase intracranial pressure especially in patients with preexisting neurological conditions such as hydrocephalus and CNS lesions.

Whilst ketamine had previously been contraindicated in head trauma, a recent review has challenged the basis for this21. Recent case studies showed it to be safe prehospital though further studies should be done22. ICU studies have found it to be a safe sedative agent in already intubated patients with head injury21.

Intraocular pressure elevation

Ketamine may increase intraocular pressure so is contraindicated in cases of glaucoma or penetrating eye injury

Recovery reactions

Emergence Reactions and issues

Ketamine can stimulate hallucinatory reactions during recovery, which may be either pleasant or unpleasant. A recent published study by Treston et al found that over 5yrs and 745 ketamine sedations only 16 patients experienced unpleasant perceptions (2.1%) and all except one settled without treatment within 20mins23. Although these so-called ‘‘emergence reactions’’ are rarely unpleasant in children their incidence in adults is highly variable, with reported incidences ranging from 0% to 30%. When Ketamine is administered in adults, clinicians should be aware of the rare potential for pronounced reactions, including nightmares, delirium, excitation, and physical combativeness. Titrated benzodiazepines appear to consistently and rapidly pacify such reaction.

Recovery agitation without an apparent hallucinatory component is not uncommon after dissociative sedation. It appears to be a separate entity from the Ketamine specific hallucinatory reactions and is also associated with Midazolam administration. Mild recovery agitation occurs more frequently in children aged less than 5 years of age and in patients with underlying medical problems.

Also, in contrast to all other sedative drugs, when a patient who is agitated prior to the drug has a sedated CNS and awakes gradually, ketamine is a dissociative drug and when the dissociative effect wears off the patient awakes as agitated as before the sedation. It is therefore essential to ensure the patient is calm and relaxed, thinking pleasant thoughts and to focus on what vivid dreams they would like to have before administering ketamine.

Although evidence is insufficient to mandate it, whenever possible provide a well monitored location with muted lighting, noise, and physical contact until wakefulness is well established.

Co-administration of low dose benzodiazepines was often recommended to prevent ketamine emergence reactions. Two randomised controlled trials of ketamine used in children with or without low dose midazolam failed to show any difference in the rate of recovery agitation.25, 26 and given the potential of respiratory depression from concurrent benzodiazepines there is no evidence to support their routine co administration.

When Ketamine is administered without prophylactic benzodiazepines and rare unpleasant recovery reactions do occur, titrated benzodiazepines appear rapidly and consistently effective in alleviating or substantially mitigating such reactions.

Vomiting

Vomiting is reported in 7-14% of children prior to leaving the ED following ketamine. When vomiting occurs, it is typically late during the recovery phase when the patient is alert and can clear the airway without assistance. It occurs more frequently in older children (12.1% in those aged >5 years) compared with younger children (3.5% in those <5 years) 27 and may also be dose related as it has recently been reported to occur more frequently following IM administration– which is typically a higher dose of 4 mg/kg compared with an IV dose of 1.5 mg/kg.

Length of sedation

Roback’s28 study showed length of sedation was significantly longer in IM group compared to the IV group (Median 129 versus 80 min)

The trance like state, open eyes and occasional random movements seen during ketamine administration can be frightening for parents. Therefore it is important to explain the effects of ketamine to the parent. The sedation handout provides good talking points in the discussion with parents about the expected events during the sedation and possible sequelae after the procedure.

Ketamine Doses and routes of Administration

Ketamine may be safely and effectively administered by either the intramuscular or intravenous route, and the choice should be based on practical considerations. The following table summarises the main features of the two methods of administration. Note that if IM ketamine is to be used then expertise to promptly achieve IV access must be present until full recovery of the patient. There is no reversal agent for ketamine.

Route of Administration

Intramuscular (IM)

Intravenous (IV)

Advantages

No IV necessary

Ease of repeat dosing, faster recovery

Clinical onset

5 minutes

1-2 minutes

Duration of effective dissociative sedation

20-25 minutes

5-10 -minutes

Recovery time

100 – 140 minutes

70 – 100 - minutes

Initial dose

2-4mg/kg

0.5 - 1mg/kg

Subsequent dose

Insert IV and give further doses 0.25 – 0.50 mg/kg IV

0.25 – 0.50 mg/kg

Maximum dose

5mg/kg

2mg/kg

Warning

IV administration must always be given over a period of greater than 60 seconds. Rapid IV administration is associated with transient respiratory depression including apnoea

Drug preparation

IM administration

· Ampoules 200mg in 2 ml.

· Carefully measure the dose of ketamine required using a 1 ml insulin syringe for accuracy.

· The final volume may be transferred into a different syringe to allow IM administration.

IV administration

· Ampoules 200mg in 2 ml.

· Dilute with18 ml of H2O or NaCl to achieve concentration of 10 mg/ml

· Or take 1ml of ketamine (100mg) and dilute up to 10mls

· Ketamine and Atropine should be administered separately.

· Atropine is given before Ketamine

PROPOFOL

Background

Propofol is an intravenous ultra-short acting sedative/hypnotic agent used for the induction and maintenance of sedation and anaesthesia. The amassed emergency medical experience using Propofol to induce deep sedation has shown this agent to be relatively safe and without serious sequelae. This ultra-short agent can occasionally transiently overshoot deep sedation but this appears to lack clinical significance. Adverse reactions can be reduced by slower induction titrating to the lowest dose producing optimal sedation. Transient cardio-respiratory depression can be safely managed in clinical practice.

It has no analgesic action thus mandating co-administration of opioid analgesics for painful procedures. It has the advantage of being a known antiemetic with minimum emergence reactions.

Propofol use for procedural sedation in paediatrics has been increasing in recent years with a number of published studies indicating its safety and efficacy in this age group. 30

Combination of propofol with ketamine in a 1:1 mix “ketafol” or as combination therapy is also becoming popular for use in procedural sedation in emergency. Preliminary studies appear to show reduction of overall dose required when the drugs are used in combination with minimal adverse events. 31,32 At this stage this combination should only be used by consultants familiar with its use.

Pharmacology

A therapeutic dose of Propofol produces hypnosis with minimal excitation in approximately forty seconds from the start of the injection. As with other rapidly acting IV anaesthetic agents, the half time blood-brain equilibration is approximately 1 to 3 minutes, this accounts for the rapid induction of sedation/anaesthesia. Elimination can be 2 – 24 hours.

Indications for use

Short term for moderate and deep procedural sedation e.g.

· Removal of foreign bodies

· Cardioversion

· Relocation of joint e.g. shoulder or hip

· Fracture manipulation

· Short laceration repair

Adverse Reactions

A prospective study of 392 patients aged 1-18 years found minimal significant adverse reactions using recommended doses 33

Possible adverse events outlined below

Bradycardia/asystole

Propofol has been associated with reports of bradycardia (occasionally profound) and asystole. Atropine must be rapidly available to treat these adverse effects.

Hypotension

Cardiovascular effects range from minimal reduction in blood pressure to significant arterial hypotension. Slow induction and minimising dose requirements reduces the incidence of these untoward side effects. IV fluids should be available for management. Inotropes are not usually required as propofol is short acting and hypotension usually resolves with ceasing of further infusion of propofol however they should be available.

Pain on injection / thrombophlebitis

Lee and Russell have shown that pain on injection can be reduced by adding 2 ml 2% lignocaine (incidence 8%) added to the Propofol. Pre-treatment with lignocaine offers no advantage (incidence 28%) 340 The addition of lignocaine significantly decreases the incidence of excitatory side-effects. This is an OFF LABEL use of lignocaine but is a widespread practice in emergency departments and by anaesthetists.

Excitatory side-effects

Epileptiform movements, including convulsions & opisthotonos have occurred.

Anaphylactoid reactions

Propofol has been reported to occasionally cause severe allergic reactions with angioedema, bronchospasm, erythema and hypotension. These reactions respond to adrenaline.

Flushing / rash

This is a not uncommon reaction and is due to histamine release. It is self-limiting.

Contraindications

Propofol has been found to be relatively safe however the following contraindications should be noted.

· Anaphylaxis is rare but should not be used in patients with propofol, egg, lecithin, glycerol, and soya oil allergies.

· Pregnancy (no direct harm to foetus but increased rate of maternal death)

· CVS instability – other agents are more CVS stable

· Relative contraindications

· Epilepsy : the following details should be considered prior to using propofol for epileptic patients

· Epileptic patients were thought to have had an increased risk of seizure in the recovery phase. This is currently being challenged in the literature.

· A study of conscious sedation with propofol for epileptic patients having dental procedures found no enhanced epileptiform activity or seizures. 35

· There may be some increase in seizures in the subsequent weeks which is thought to be due to a proconvulsant metabolite.

· Status epilepticus is treated with propofol.

Propofol dose

· Adults Induction for deep sedation 0.5-1.0 mg/kg bolus (titrate slowly) and 0.5 mg/kg subsequent boluses. Suggested dose up to 3mg/kg and should be titrated to effect.

· Children >2 Induction for deep sedation NB An emergency consultant must be present for any sedation of children with propofol

· Initial dose IV Propofol 0.5- 1mg/kg (max 40mg) over 1 min

· Suggest additional doses of 0.5mg/kg up to 3mg/kg can be used. Note that research is coming out that the doses for paediatric sedation with propofol are likely to be higher than that required for adults. 36

Opioids

Introduction

Opioid analgesics are excellent agents for procedural sedation especially for patients who have significant pain before, during and after a procedure e.g. relocation of a dislocated shoulder. Analgesics are often given in the pre-hospital environment prior to presentation to the ED and the sedationist needs to consider this when giving other subsequent sedating medications. Morphine and fentanyl are used in combination with N2O, benzodiazepines and Propofol. Multimodal use of procedural sedation and analgesic (PSA) agents allows creation of a better sedation experience while reducing the dose of each agent.

Indications

Analgesia for any painful procedure especially where the sedative agent has no analgesic properties

Considerations

· Myasthenia gravis

· Opioid hypersensitivity usually alternative opioid is available.

Precautions

Using combinations of opioid and other agents have accumulative effects on the depth of sedation and care must be taken to avoid adverse side effects.

Reduced doses are needed with the elderly, debilitated & patients with renal & hepatic dysfunction. Atopic patients may have increase histamine release.

Adverse Reactions

· Respiratory depression

· Histamine release

· Local rash

· Urticaria/wheeze

· Nausea/vomiting

· Muscle rigidity (High dose fentanyl in infants)

Dosage of Common agents

· Panadeine forte (codeine is a pro-drug of morphine) 30mg codeine with 500mg paracetamol usual dose for adult is 2 tablets

· Morphine 0.05-0.15 mg/kg IV

· Fentanyl 1-2 mcg/kg IV

· Fentanyl 1.5 mcg/kg Intra nasal (IN) (see protocol for subsequent doses)

Reversal Agent

Naloxone is a pure antagonist. This agent should not be needed if appropriate dose regimens are used. Abrupt reversal can cause sudden emergence with severe pain and massive catecholamine output which can precipitate ischaemic chest pain, arrhythmias and acute heart failure in the elderly. It can also cause seizures in patients who take regular doses of opiates including codeine and may cause pulmonary oedema in larger doses.

Dosage of Naloxone

ADULTS:

· Aliquots of 0.1-0.2mg should be given IV every 2-3 minutes until rousable with an adequate respiration rate.

· An infusion at 2/3 the initial resuscitation dose / hour should then be implemented.

CHILDREN

· Initial dose of 0.01mg/kg IV

· Repeat every 2-3 minutes

Procedural Sedation Record

Adults and Paediatrics

THE PRINCE CHARLES HOSPITAL

NORTHSIDE HEALTH SERVICE DISTRICT

(form needs to be used in conjunction with competency package)

(Affix patient identification label here)

URN:

Family Name:

Given Names:

Address:

Date of Birth: Sex: FORMCHECKBOX M FORMCHECKBOX F

Date: _____________ Start time: _____________

Procedural type: _________________________

Sedation administered by: ____________________

Consultant involved: ______________________

PRE-SEDATION CHECKLIST

· Written Consent Obtained

· Information

· Written/Verbal (please circle)

· DVD (Research)

· Allergies: ______________________

· Previous Anaesthetic Risk __________________

· Pre–Procedural analgesia given: ( Y (time _____ )( N

· Fasting Risk Assessment

· Last ate (Type)__________(time)______

· Last drank (Type)_______(time)_______

· Pre-anaesthetic Examination

· Cardiovascular

· Respiratory

· Airway MP Score: ____

· Weight: __________kg

· Equipment Check

· No contraindications to Anaesthesia

· Morphine _______mg

· Fentanyl ________mcg

·

· Oral analgesia

· Others __________

·

PROCEDURAL OBSERVATIONS

(record until sedation score= 5 for at least 3min)

Duration of Sedation

Post Sedation

Minutes

0

3

6

9

0

15

30

45

60

Time

Drugs (Specify doses)

1.

2.

3

Observations

O2 L/min

SaO2

ETCO2

RR

HR

BP

Sedation score

POST-PROCEDURE CHECKLIST

Adverse Events: ( YES (please document) ( NIL Adverse Events ( This Requires Audit

· Apnoea > 30s

· Bradycardia (Age specific)

· Vomiting

· Emergence Agitation

· Desaturation (<94%)

· Aspiration of stomach contents

· Laryngospasm

· Hypotension (Age specific)

· Excess Salivation

· Others ____________

Management of adverse event: __________________________________________________________________

POST-PROCEDURE ORDERS

DISCHARGE CHECKLIST

· RR, PR, BP, SS q15min for 1hr

· Pulse Oximetry 1 hr post

· Oxygen if Sats < 95% and notify MO

· Normal Gait, speech. Conscious level, no nystagmus

· Tolerating light diet/Fluids

· Post-procedure advise sheet given

· Responsible person available

Appropriate follow up made:__________________________________________________________________

Doctor:

Signature:

Date/Time:

RN:

Signature:

Date/Time:

Procedural Sedation Record

Adults and Paediatrics

THE PRINCE CHARLES HOSPITAL

NORTHSIDE HEALTH SERVICE DISTRICT

(Affix patient identification label here)

URN:

Family Name:

Given Names:

Address:

Date of Birth:Sex: FORMCHECKBOX M FORMCHECKBOX F

PREDICATORS OF DIFFICULT INTUBATION

MALLAMPATTI SCORE

· Mallampati Score III and IV

· Inability to open mouth > 4cm

· Thyro-mental distances < 6cm

· Limitation of neck movement

· Difficulty in protruding lower jaw

· History of difficult intubation

WISCONSIN SEDATION SCALE *

Sedation Classification

Sedation Score

Description

Inadequate

6

Anxious, agitated, or in pain

Minimal – conscious

5

Spontaneously awake without stimulus

Conscious – moderate

4

Drowsy, eyes open or closed, but easily arouses to consciousness with verbal stimulus

Moderate – deep

3

Arouses to consciousness with moderate tactile or loud verbal stimulus

Deep

2

Arouses slowly to consciousness with sustained painful stimulus

1

Arouses, but not to consciousness, with painful stimulus

Anesthesia

0

Unresponsive to painful stimulus

*Requires assessment of sedation depth by quantitative score every 5 minutes until a sedation score of 4 or greater is achieved

SUGGESTED PAEDIATRIC (per kg) IV DRUG DOSES (please refer to competency package) ED consultant must be present

DRUG

INITIAL

DOSE RANGE (titrate to effect)

COMMENTS

Fentanyl

0.5 - 1 mcg/kg

0.5 - 2 mcg/kg

Use in Children > 6 months age and no contraindications

Morphine

0.05 mg/kg

0.05 - 0.1 mg/kg

If no contraindications

Propofol

0.5 - 1mg/kg

0.5 - 3 mg/kg

Use in Children > 2 years age and no contraindications

Ketamine

0.5 - 1mg/kg

0.5 - 2 mg/kg child

Use in Children > 6 months age and no contraindications

SUGGESTED ADULT (70 kg) IV DRUG DOSES # (please refer to competency package)

DRUG

INITIAL

INCREMENTS (titrate to effect)

DOSE RANGE

Morphine

2.5 -5mg

2.5 mg

2.5 - 10 mg

Fentanyl

25 -50 mcg

25 mcg

25 - 100 mcg

Midazolam

1 – 3 mg

1 mg

1 - 5 mg

Propofol

30 – 70 mg

20 – 30 mg

50 - 200 mg

Ketamine

40-50 mg

25 mg

50 - 100 mg

# Consider lower doses in the Elderly

The Prince Charles Hospital

Emergency Department

INFORMATION FOR PARENTS/GUARDIANS OF CHILDREN REQUIRING PROCEDURAL SEDATION

Please read the information contained in this leaflet prior to your child’s procedural sedation

This handout explains:

· What is procedural sedation

· The risks of procedural sedation

· How you can help your child before, during and after sedation

What is procedural sedation?

Your child has an injury or condition that your doctor feels would be appropriately managed by giving procedural sedation.

Procedural sedation involves giving medication by injection to your child to reduce their pain and distress so that they can receive the treatment they require as quickly and as safely as possible.

In addition, sedation often avoids admission and the need for general anaesthesia.

The medication will make your child sleepy so that they move less and the treatment they require can be done without awareness and anxiety. The medication given will also relieve your child’s pain.

Prior to starting the procedure

1. We will need to know about your child’s health. In particular, if your child has any allergies to medications or if they have any breathing problems or have ever had a problem with an anaesthetic.

2. We will explain to you the entire sedation process including possible risks/complications that can occur.

3. We will answer any questions or concerns that you may have prior to obtaining your written consent.

The risks of procedural sedation

· Sedation can fail and a full anaesthetic may be required

· Your child may remember nothing of the procedure and may not remember events shortly prior to the procedure

· The medication used may cause nausea or vomiting. This may occur during the procedure or up to half an hour after the procedure

· Rarely, vomit can be inhaled into the lungs (aspiration). This is usually managed with antibiotics

· Rarely, your child may require assistance with their breathing which usually is only repositioning of the mouth, neck and jaw or rarely assisted breaths with a bag-valve mask are necessary. Very rarely this support includes the placement of a breathing tube. The procedure is therefore performed in an area where this support is possible

· It is possible to be allergic to any of the medications used which will require treatment with extra medications

· Rashes that are self-limiting also may occur with some of the medications

· Rarely the medications given cause your child’s blood pressure to become too low. If that happens intravenous fluids will be given until the blood pressure is at a safe level

· Some of the medications cause pain at the injection site – this is short lived

The medication ketamine works in a different way than other sedation medication. If your child is given ketamine they are unlikely to feel any pain or be aware of the procedure however

· They may have their eyes open and their eyes may flicker

· They may be in a trance like state or may hallucinate

· They may have jerking movements of their arms and legs and may need to be held still

· They may drool a lot

· They may have vivid dreams on waking

· They may be unsteady for a period after the medication has worn off

Your child will be monitored by staff until they are fully awake and recovered from the medication

How you can help your child

· Before – Don’t hide the fact that your child may have some pain. Answer questions honestly with help from the doctors and nurses. Try and talk to your child about things that may distract them. Try not to be too upset.

· During – You are welcome to stay with your child during the procedure or at least until they are sleepy. Distract your child. Bargaining, criticising and apologies are strongly discouraged. Time frames such as “nearly finished” are not helpful.

· After – Stay with your child as they wake up and focus on the positives

· Going home – make sure you understand and have your discharge advice with you before you go home

Thank you for helping us care for your child

Please feel free to ask any questions you have prior to the procedure

A. INTERPRETER/ CULTURAL NEEDS

An Interpreter Service is required yes no

If yes, is a qualified Interpreter present yes no

A Cultural Support Person is required yes no

If yes, is a Cultural Support Person present

yes no

B. CONDITION AND PROCEDURE

The doctor has explained that I/my child has the following condition: (Doctor to document in patient’s own words)

____________________________________.

____________________________________.

____________________________________.

____________________________________.

The doctor has explained the I/my child requires the following procedure: (Doctor to document in the patient’s/parent’s own word, specifying side and site if applicable)

____________________________________.

____________________________________.

____________________________________.

____________________________________.

C. PROCEDURAL SEDATION RISKS

See the information sheet on procedural sedation and the risks involved. If you have any concerns, talk these over with your doctor.

If you have not been given an information sheet, please ask for one.

D. GENERAL RISKS OF A PROCEDURE

They include:

(a)Small areas of the lungs may collapse,

increasing the risk of chest infection. This

may need antibiotics and physiotherapy.

(b) Clots in the legs (deep vein thrombosis or

DVT) with pain and swelling. Rarely part of

this clot may break off and go to the lungs

which can be fatal.

(c) A heart attack because of strain on the

heart or a stroke.

(d) Death is possible due to the procedure.

E. RISKS OF THE SPECIFIC PROCEDURE BEING PERFORMED

___________________________________.

___________________________________.

___________________________________.

___________________________________.

___________________________________.

F. PATIENT CONSENT

The doctor has explained these risks and any complications and their management that may be required if they were to occur.

The doctor has explained treatment options including the results of NOT having the procedure.

The doctor has explained that I/my child needs procedural sedation analgesia in order to allow management of my/my child’s condition.

I have been given and read the information sheet on procedural sedation including the risks of procedural sedation.

I had any questions about the procedure or the sedation answered to my satisfaction.

The doctor has explained the other options available including no sedation and having procedure under general anaesthetic.

I am aware that if any immediately life threatening events occur during the procedure these will be dealt with accordingly.

I am also aware that there is no guarantee the procedure will improve my/my child’s condition and rarely, the condition may worsen. Further management will be arranged in these cases.

On the basis of the above statements, I CONSENT TO THE PROCEDURE AND THE PROCEDURAL SEDATION.

Name of Patient/Guardian:__________________________

Signature: ____________________________

Date: ____________________________

Witness name: ____________________________

Witness signature____________________________.

We wish you a speedy recovery

Attach patient label here

For more information contact

Your family doctor

Or

13 HEALTH (13432584)

THE PRINCE CHARLES HOSPITAL

________________________

INTRODUCTION

You have been given a sedative medication during your visit to hospital today.

The name of the medication is ________

The time it was given is ________

Please read the following information prior to leaving the hospital and ask the medical staff any further questions you have regarding this information.

common signs and symptoms after a sedation

Occasionally side effects occur after administration of sedative medication. For the next 12 -24 hours you may be:

· Drowsy and wanting to sleep more

· Not thinking clearly or able to concentrate

· Unsteady and more likely to fall or lose your balance

· Nauseous and may have less appetite or may vomit

These symptoms may last 8hours but if they persist we suggest seeking further medical advice

Because of these factors we advise the following :

For the Next 12 hours

Or until you feel fully recovered

· Eat a light diet. Clear fluids – water, juice, iceblocks, clear soup and then light meals. Avoid heavy fatty meals as this may worsen nausea and vomiting

· Do quiet activities

· Stay with someone particularly over night

· Take particular care when cooking and bathing

· Take care with your normal medications. If you are on medications that normally cause drowsiness, please discuss this with your medical team prior to leaving hospital

For the Next 24 hours

· Do not drive any motor vehicle

· Do not operate heavy machinery

· Do not swim or play any other water sports

· Do not participate in sporting activities

· Do not use any potentially dangerous equipment e.g. power tools

· Do not consume alcohol or use recreational drugs

If you need a medical certificate in order to follow these recommendations please discuss this with the medical staff prior to discharge today.

These recommendations are for your safety and wellbeing.

You should be able to resume normal activities after 24 hours.

If you or your family have any concerns about your recovery from this procedure or notice anything unusual please seek medical advice.

In an emergency Dial 000

We wish your child a speedy recovery

Attach patient label here

For more information contact

Your family doctor

Or

13 HEALTH (13432584)

The Prince CHarles hospital

INTRODUCTION

Your child has been given a sedative medication during their visit to hospital today.

The name of the medication is ________

The time it was given is ________

Please read the following information prior to leaving the hospital and ask the medical staff any further questions you have regarding this information.

common signs and symptoms after a sedation

Occasionally side effects occur after administration of sedative medication. For the next 12 -24 hours your child may be:

· Drowsy and wanting to sleep more

· Not thinking clearly or able to concentrate

· Unsteady and more likely to fall or lose their balance

· Nauseous and may have less appetite or may vomit

Because of these factors we advise the following:

For the Next 12 hours

Or until your child appears fully recovered

· Give your child a light diet. Clear fluids – water, juice, iceblocks, clear soup and then light meals. Avoid heavy fatty meals as this may worsen nausea and vomiting

· Encourage quiet activities and allow your child to rest

· Supervise your child if they are playing outside.

· Supervise your child in the bath or shower

For the Next 24 hours

· Your child should not take part in activities that require normal childhood co-ordination such as bicycle-riding, skating, rollerblading, or playing on swings or monkey bars

· Your child should not swim or play any other water sports

· Supervise your child doing any activities requiring normal co-ordination

· Your child should not use any potentially dangerous equipment e.g. powertools

· Your child should not do any cooking

Please consider the safety of your child at childcare or school. If you think they may need a medical certificate discuss this with your doctor before you leave today.

If you have any concerns about your child’s recovery from this procedure or notice anything unusual about your child please seek medical advice.

In an emergency Dial 000

References

1. Babl F, McGowan V, Priestley S and Krieser D Sedation of Children in the Emergency Department at Sunshine Hospital and Royal Children’s Hospital. Education and guideline modules for nurses and doctors Version 2.2, 2004

2. American College of Emergency Physicians. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med 2005; 45(2):177-196.

4. American Society of Anesthesiologists. Practice Guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology 1999; 90:896-905.

5. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002:96:1004-1017.

6. Agrawal D, Manzi SF, Gupta R, Krauss B, Pre-procedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a paediatric emergency department. Ann Emerg Med 2003; 42(5):636-46.

7. Treston G. Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation. Emerg Med Australasia 2004; 16:145-150.

8. Babl FE, Puspitadewi A, Barnett P et al Pre-procedural Fasting State and Adverse Events in Children Receiving Concentration Nitrous Oxide in the Paediatric Emergency Department, Pedi Emerg Care 2005;21:736-743.

9. Green S, Roback MG, Miner J, Burton J, Krauss B. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory Ann Emerg Med 2006.

10. Clinical Practice Guideline for Emergency Department dissociative sedation in children. Ann Emerg Med 2004; 44(5); 460-71.

11. Quality of Sedation Score Wisconsin Score (Hoffman 2002) Hoffman GM, Nowakowski R, Troshynski TJ,Berens RJ, Weisman, SJ. Risk reduction in Paediatric procedural sedation by application of an American Academy of Paediatrics/American Society of Anaesthesiologists Process Model. Paediatrics 109:236 – 243, 2002

12. Selbst SM, Sedation and Analgesia. 64-64 In: Fleisher GR, Ludwig S (eds) Textbook of Pediatric Emergency Medicine, 4th ed. Lippincott Williams & Wilkins, Philadelphia, 2000.

13. Watcha, M Krauss B, Brustowicz (eds) Benzodiazepines In: Pediatric procedural sedation and anesthesia Lippincott Williams & Wilkins, Philadelphia 1999

14. Green SM, Nakamura R, Johnson NE. Ketamine sedation for pediatric procedures, part 1: a prospective series. Ann Emerg Med. 1990; 19:1024-1032.

15. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile with 1,022 cases. Ann Emerg Med. 1998; 31:688-697.

16. Dachs RJ, Innes GM. Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med. 1997; 29:146-150

17. Green SM, Johnson NE. Ketamine sedation for pediatric procedures: part 2, review and implications. Ann Emerg Med. 1990; 19:1033-1046.

18. Priestley,SJ.,Taylor,J.,McAdam,CM.,Francis,P. Ketamine sedation for children in the emergency department Emergency Medicine 2001; 13, 82-90.

19. Green SM and Krauss B, Clinical practice Guideline for Emergency Department Ketamine Dissociative Sedation in Children. Anne Emerg Med. 2004; 44; 460-471

20. Brown L, Green SM, Sherwin TS, et al. Ketamine with and without atropine: what’s the risk of excessive salivation? Acad Emerg Med. 2003; 10:482-483.

21. Sehdar R, Symons, D, Kindl K Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australasia 2006; 18: 37-44.

22. Bredmose P et al, Prehospital use of ketamine for analgesia in procedural sedation Emerg Med J 2009;26:62–64

23, Treston G, Bell A, Cardwell R, Fincher G, Chand D, Cashion, G What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation? Emerg Med Australasia 2009: 21,315-322

24. Green SM, Rothrock SG, Lynch EL et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile of 1022 cases. Ann Emerg Med 1998; 31:688-697

25.Sherwin,TS.,Green,SM.,Khan,A.,Chapman,DS.,Dannenber,B Does adjuvant midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double blind, placebo controlled trial Ann Emerg Med 2000; 35:239-244.

26. Wathen,JE.,Roback,MG.,Mackenzie,T.,Bothner,J. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind randomized, controlled emergency department trial Ann Emerg Med 2000; 36(6); 579-88.

27. Green, SM., Kuppermann, NK. Rothrock,SG et al Predictors of adverse events with intramuscular ketamine sedation in children, Ann Emerg Med 2000; 35:35-42.

28. Roback MG, Wathan JE, MacKenzie T, et al. A randomized, controlled trial of IV vs. IM ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006; 48:605-612.]

29. Alfaro-LeFevre, R., Blicharz, M., Flynn, N., Boyer, M Drug Hand Book, A nursing Process Approach. Addison-Wesley. 1992

30. Guenther, E., Pribble, C., Junkins Jr., E, Kadish, J, Bassett, K, Nelson, D, Propofol sedation by emergency physicians for elective pediatric outpatient procedures Ann Emerg Med 2003, Volume 42, Issue 6, Pages 783-791

31. Loh, G Dalen, D, Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department, Ann Pharmacotherapy 2007 Mar;41(3):485-92.

32. Willman, ED, Andolfatto, G, A prospective evaluation of “ketafol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency

33. Baskett KE Propofol for Procedural Sedation for Children in the ED Ann Emerg Med 2003; 42:773-82.

34. Lee P, Russell WJ. Preventing pain on the injection of propofol: a comparison between lignocaine pre-treatment and lignocaine added to propofol. Anaesth Intensive Care 2004; 32(4):482-4

35. Oei-Lim VL, et al. A comparison of the effects of propofol and nitrous oxide on the electroencephalogram in epileptic patients during conscious sedation for dental procedures. Anesth Analg 1992;75:708–714.

36. Patel KN, Simon HK, Stockwell CA, et al. Pediatric procedural sedation by a dedicated nonanesthesiology pediatric sedation service using propofol. Pediatr Emerg Care2009; 25:133-138.

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