Safety of pediatric procedural sedation in a Canadian emergency department

To assess the safety of pediatric procedural sedation performed by emergency physicians working within a structured sedation protocol. A retrospective review of all children undergoing emergency department (ED) procedural sedation during a 2-year period after the institution of a structured sedation protocol. 167 children underwent procedural sedation, primarily for orthopedic manipulation, wound management and foreign body removal. Of these, 82% received ketamine, 17% received fentanyl and midazolam and 1% received midazolam alone. Sedation was adequate in all but 6 patients, who required supplemental ketamine for orthopedic manipulation. Vomiting after arousal occurred in 17 children (10%), but no episodes of clinical aspiration occurred. One child became agitated during recovery and another experienced a transient visual hallucination. There were no cases of laryngospasm, apnea or cardiorespiratory compromise, and no mortality or significant morbidity occurred. Emergency physicians using a structured sedation protocol can safely perform ED pediatric procedural sedation. Where intravenous access is not already present, intramuscular ketamine, administered in the doses described, is a safe and effective agent for pediatric sedation.