Pain management and sedation for children in the emergency department

We would like to thank those who have responded to our article on
pain management and sedation for children in the emergency department.(1)

Crawford and Kapur have stated their concern regarding the widespread
use of “intravenous anaesthetic induction drugs” by appropriately trained
doctors, and also state that they believe a fasting time of six hours is
necessary for general anaesthesia. We clearly stated that general
anaesthesia is an alternative that should be considered, not an option to
be undertaken by emergency physicians. It is unfortunate that they have
failed to appreciate the advances made in the field of safe sedation in
emergency departments over the past two decades. This has now become
established practice and there is a growing body of evidence supporting
its safety when used appropriately.
There are a number of factors that have led to these developments
including cost pressures and admissions avoidance. Why admit every child
requiring a procedure for a general anaesthetic if the alternative is
timely, cost effective, more child friendly and at the same time safe?
Paediatric sedation in the emergency departments has been an evolving but
managed process which is reflected by the available guidance from
professional bodies.(2)

They mention international guidelines (without reference) for fasting
for six hours before general anaesthesia. There are however no guidelines
for sedation that recommend such a long period and there is increasing
recognition that the appropriate fasting time depends on a number of
factors including individual patient risk, urgency and target depth of
sedation. In particular for ketamine sedation, where airway reflexes are
protected, there is now good evidence to support much shorter fasting
times. An in depth discussion of these issues was beyond the scope of our
review and we recommend a recent review which addresses this in more
detail.(3)

We do agree with Crawford and Kapur that sedation in children should
be carried out by senior, appropriately trained doctors. Out of hours
consultant presence is commonplace in emergency departments – there is no
argument for leaving such procedures to unsupervised trainees who have not
proven their competence, whether they be from an emergency medicine or
anaesthetic background.

Thanks to Sen for highlighting some further issues with the dosing of
analgesia in the ED. We agree that appropriate doses must be used and that
titration to effect is important with opiates. Although intramuscular
Ketamine is an alternative to intravenous injection, its prolonged
recovery time due to the higher dose and the higher incidence of emesis
make it a lesser choice.(4) Arguably, children in whom intravenous access
cannot be easily obtained probably should not be sedated in the emergency
department.

De Cunto and colleagues highlight the use of intranasal midazolam.
Whilst we agree that there is evidence supporting its use, it does not
provide any analgesia, rather amnesia for painful procedures. It’s effects
are less predictable. We do recognise that it is an acceptable alternative
where intravenous access is difficult and where clinicians lack experience
with the use of drugs such as ketamine.

We believe we have provided an evidence-based approach that is
commonly used worldwide in EDs for the management of pain and provision of
safe sedation in children. We acknowledge that other approaches are also
in common use. We hope that all such approaches will lead to less pain for
children presenting to emergency departments.

1. Atkinson PR, Chesters a, Heinz P. Pain management and sedation for
children in the emergency department. BMJ 2009;339:b4234

2 . American College of Emergency Physicians. Clinical policy:
procedural sedation and analgesia in the emergency department. Ann Emerg
Med. 2005;45:177-196.

3. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and
emergency department procedural sedation and analgesia: a consensus-based
clinical practice advisory. Ann Emerg Med. 2007 Apr;49(4):454-61

4. Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D,
McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia
Pena BM, Gerber AC, Losek JD; Emergency Department Ketamine Meta-Analysis
Study Group. Predictors of emesis and recovery agitation with emergency
department ketamine sedation: an individual-patient data meta-analysis of
8,282 children. Ann Emerg Med. 2009 Aug;54(2):171-80.

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