December 2000 • Volume 7 Number 12
Pediatric procedural sedation: Don't shortchange kids in pain
As far as James Ducharme, M.D., is concerned, if a child feels pain during a clinical procedure, it's only because the physician lets it happen.
If you're having to pry kids down from the ceiling during clinical procedures, it's time to rethink your procedural sedation techniques, emergency physician James Ducharme, M.D., tells particpants at AAFP's emergency care course."You know how the pediatricians are always saying, 'Kids aren't little adults'? Well, that's true; they're not little adults. They're little patients. And there's no more reason for kids to suffer pain than there is for adults to," said Ducharme, professor of emergency medicine at Dalhousie University, Halifax, Nova Scotia. Ducharme spoke to FPs and ER physicians at AAFP's recent CME course on emergency and urgent care.
Too many physicians mistake fear for pain, Ducharme added. "We all tend to assume that a kid's crying because he's scared. No, it's because he's in pain. That tibia sticking out of his skin? He's not scared of it. It hurts."
A key component of adequate procedural sedation in children, said Ducharme, is realizing there's no single "magic bullet" for these patients. "I'd like to say I have the perfect drug for all pediatric procedures," he said, "but I can't -- much as I love ketamine. There are all kinds of scenarios, and there are different drugs for different durations."
When choosing medication and performing a procedure, follow these tips, said Ducharme:
- Avoid deep sedation and its attendant loss of protective reflexes.
- Use an area and equipment dedicated to procedural sedation, with supplies tailored to children as well as adults.
- Collaborate with a nurse skilled in dealing with these patients, or, as Ducharme put it, "one who can start an IV in a fat 2-year-old with no veins."
Several features of ketamine make it a solid choice in many pediatric situations, Ducharme said. This rapid-acting drug doesn't affect reflexes or vital signs. It is given as a single intramuscular or intravenous bolus, so there's no need for titration. It also has the advantage of providing anesthetic and amnesic effects.
Although there's a small risk of nausea and vomiting, said Ducharme, and the medical literature has raised the possibility of an emergence effect, ketamine is often the drug of choice both from an efficacy and a safety aspect.
For more articles on emergency/urgent care for the family physician, access http://www.aafp.org/fpr/20011200/ and click on stories listed under "Emergency and Urgent Care." For more information on AAFP's 2002 emergency and urgent care course, see "Quick Fax."
Nitrous oxide is another tried and true sedative in certain cases, said Ducharme. He cited the example of an 11-year-old mentally challenged patient who requires urinary catheterization. Because this patient receives daily phenothiazine therapy, certain sedating agents would be ineffective, rendering nitrous oxide a good choice.
Members of the fentanyl family likewise have their place in procedural sedation, Ducharme said, but these and other short-acting drugs should be used with caution. "The shorter acting they are, the greater their propensity is, and that propensity is to induce respiratory suppression," he said.
Above all, he advised, don't take risks with your patients; the operating room is always an option. Realize, too, that you need to treat the child's parents right along with the child.
"You have to tell them what you're going to do, how long it's going to take and what their child's going to be like after you do it," said Ducharme. "If you're going to reduce a fracture, you have to tell them what it's going to sound like. Otherwise, you have a pale, clammy person sliding down onto the floor."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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