- Email: [email protected]
Clinical Policy on Pediatric Procedural Sedation
Correspondence
Figure 1. Rumack-Matthew nomogram. Modified from Rumack BH, Peterson RC, Koch GC, et al. Acetaminophen overdose: 662 cases with oral acetylcysteine therapy. Arch Intern Med. 1981;141:380-385.2
t in terms of acetaminophen level A to determine the earliest time that an acute ingestion could have been taken without likely toxicity, given a measured level of acetaminophen: t ¼ 32:9155 13:2878ðlog AÞ t ¼ 33 13:3ðlog AÞ where A is measured acetaminophen level in mg/mL and t is time interval in hours, within which acetaminophen level is likely to be nontoxic. The simplified versions of these 2 equations are relatively easy to memorize and can be solved on any calculator with ‘‘x^y’’ (x to the y power) and ‘‘log’’[log-base 10] keys. Such a calculator is available on any computer running under the Windows (Microsoft Corporation, Redmond, WA) operating system (Figure 2). In addition, the precise forms of the equations can be used within a computer spreadsheet or can be programmed into a handheld personal digital assistant. The equations can also be incorporated within a hospital’s informatics system in such a way that customized treatment guidelines could be reported to the clinician in conjunction with the acetaminophen laboratory results. However, as with the Rummack-Matthew nomogram, these equations should not substitute for judicious consultation with a regional poison control center. Steven J. White, MD Departments of Emergency Medicine and Pediatrics Vanderbilt University Medical Center Nashville, TN Barry H. Rumack, MD Rocky Mountain Poison and Drug Center University of Colorado School of Medicine Denver, CO doi:10.1016/j.annemergmed.2004.11.033
564 Annals of Emergency Medicine
Figure 2. Sample calculation using Windows operating system calculator (scientific view) for known ingestion with level drawn at 7 hours and 20 minutes after acute ingestion. 1. Watson WA, Litovitz TL, Rodgers GC, et al. 2002 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2003;21: 353-421. 2. Rumack BH, Peterson RC, Koch GC, et al. Acetaminophen overdose: 662 cases with oral acetylcysteine therapy. Arch Intern Med. 1981; 141:380-385. 3. Smilkstein MJ, Knapp GL, Kulig KW, et al. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med. 1988;319:1557-1562. 4. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975;55:871-876. 5. Rumack BH. Acetaminophen hepatic toxicity: the first 35 years. Clin Toxicol. 2002;40:3-20.
Clinical Policy on Pediatric Procedural Sedation To the Editor: I applaud Mace et al1 for the ‘‘Clinical Policy: EvidenceBased Approach to Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department,’’ published in the October 2004 issue of Annals. However, in addition to identifying potential agents for emergency department (ED) pediatric sedation, I believe it is equally important to note those drugs that should not be considered for this procedure. For example, chloral hydrate, diphenhydramine, meperidine, and the ‘‘DPT cocktail’’ (demerol-phenergan-thorazine) have been used for decades for pediatric sedation, despite their adverse risk profiles and absence of supporting data.2-5 Although many emergency physicians choose better regimens (such as those described in the clinical policy), these less-desirable agents of habit are still used in many Volume 45, no. 5 : May 2005
Correspondence settings, including both teaching and community EDs. This persists because the ‘‘evidence base’’ of procedural sedation often consists of clinical anecdotes that have become ingrained in daily practice. Strongly stated consensus recommendations are an excellent way to initiate the flow of information regarding good (and bad) clinical practices, but these statements must address the profiles and needs of the potential end-users. Identifying suboptimal common practice is as important as recognizing ‘‘best practice.’’ The clinical policy by Mace et al1 omits important information that could potentially alter practice in many teaching and community EDs. Henry E. Wang, MD, MPH Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh, PA doi:10.1016/j.annemergmed.2004.10.041 1. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44: 342-377. 2. Polaner DM, Houck CS, Rockoff MA, et al. Sedation, risk, and safety: do we really have data at last? Pediatrics. 2001;108: 1006-1008. 3. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine. Pediatr Emerg Care. 2001;17:351-353. 4. Reappraisal of lytic cocktail/demerol, phenergan, and thorazine (DPT) for the sedation of children. American Academy of Pediatrics Committee on Drugs. Pediatrics. 1995;95:598-602. 5. Leelataweedwud P, Vann WF Jr. Adverse events and outcomes of conscious sedation for pediatric patients: study of an oral sedation regimen. J Am Dent Assoc. 2001;132:1531-1539, 1596.
In reply: I would like to thank Dr. Wang for his letter. I, like Dr. Wang, want to encourage the use of appropriate drugs for emergency department (ED) procedural sedation. The pharmacologic agentsdetomidate, fentanyl/midazolam, ketamine, methohexital, pentobarbital, and propofoldreviewed in the referenced clinical policy were chosen as ones commonly used in the ED.1 Providing information to potential users regarding the safety and efficacy of these 6 agents is an excellent method for encouraging the use of appropriate drugs for ED procedural sedation. There is evidence that the use of various drugs for ED procedural sedation by emergency physicians has changed now that additional pharmacologic agents are available and that information regarding the safety and efficacy of these agents is available. Earlier surveys (1 done in 1989, and 2 done in 1991) did indicate the widespread use of demerol-phenerganthorazine.2-4 However, later surveys (done in 1994, in 1998 to 2000, and 2003 [RD Goldman et al, unpublished data]) show a dramatic decline in the use of demerol-phenerganVolume 45, no. 5 : May 2005
thorazine and other sedative agents.5,6 In these 3 recent surveys, the use of demerol-phenergan-thorazine was less than 5%, 0%, and 0%, respectively.5,6 In addition to appropriate selection of a given pharmacologic agent for a specific patient, another critical component for limiting and/or eliminating problems or untoward events during ED procedural sedation is appropriate patient monitoring by qualified ED personnel. This is delineated in the American College of Emergency Physicians’ clinical policy on procedural sedation.7 There was also a practical consideration. Because of space (policy length), time, and other constraints, the development panel was not able to review all of the possible pharmacologic agents available for ED procedural sedation; therefore, we decided to emphasize the most commonly used choices. Other agents, such as demerol-phenergan-thorazine and chloral hydrate, are included in discussions in other resources.8,9 Sharon E. Mace, MD Department of Emergency Medicine Ohio State University School of Medicine Faculty, MetroHealth Medical Center Emergency Medicine Residency Observation Unit Pediatric Education/Quality Improvement Cleveland Clinic Foundation Cleveland, OH doi:10.1016/j.annemergmed.2004.11.032
1. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44: 342-377. 2. Hawk W, Crockett RK, Ochsenchlager DW, et al. Conscious sedation of the pediatric patient for suturing: a survey. Pediatr Emerg Care. 1992;6:84-88. 3. Cook BA, Bass JW, Nomizu, et al. Sedation for children for technical procedures: current standard of practice. Clin Pediatr. 1992;31: 137-142. 4. Ilkanipour K, Jeuls CR, Langdorf MI. Pediatric pain control and conscious sedation. A survey of emergency medicine residencies. Acad Emerg Med. 1994;1:368-372. 5. Krauss B, Zurakowski D. Sedation patterns in pediatric and general community hospital emergency departments. Pediatr Emerg Care. 1998;14:99-103. 6. Cimpello LB, Khine H, Aoner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care. 2004;20:228-232. 7. American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Approved by ACEP Board of Directors, October 20, 2004. 8. Mace SE. Chloral hydrate. Pediatric pain management and procedural sedation. In: Mace SE, DuCharme J, Murphy MF, eds. Pain Management and Sedation in the Emergency Department. New York, NY: McGraw-Hill; 2005. 9. Mace SE. Pediatric procedural sedation. Pediatric pain management and procedural sedation. In: Mace SE, DuCharme J, Murphy MF, eds. Pain Management and Sedation in the Emergency Department. New York, NY: McGraw-Hill; 2005.
Annals of Emergency Medicine 565
Figure 1. Rumack-Matthew nomogram. Modified from Rumack BH, Peterson RC, Koch GC, et al. Acetaminophen overdose: 662 cases with oral acetylcysteine therapy. Arch Intern Med. 1981;141:380-385.2
t in terms of acetaminophen level A to determine the earliest time that an acute ingestion could have been taken without likely toxicity, given a measured level of acetaminophen: t ¼ 32:9155 13:2878ðlog AÞ t ¼ 33 13:3ðlog AÞ where A is measured acetaminophen level in mg/mL and t is time interval in hours, within which acetaminophen level is likely to be nontoxic. The simplified versions of these 2 equations are relatively easy to memorize and can be solved on any calculator with ‘‘x^y’’ (x to the y power) and ‘‘log’’[log-base 10] keys. Such a calculator is available on any computer running under the Windows (Microsoft Corporation, Redmond, WA) operating system (Figure 2). In addition, the precise forms of the equations can be used within a computer spreadsheet or can be programmed into a handheld personal digital assistant. The equations can also be incorporated within a hospital’s informatics system in such a way that customized treatment guidelines could be reported to the clinician in conjunction with the acetaminophen laboratory results. However, as with the Rummack-Matthew nomogram, these equations should not substitute for judicious consultation with a regional poison control center. Steven J. White, MD Departments of Emergency Medicine and Pediatrics Vanderbilt University Medical Center Nashville, TN Barry H. Rumack, MD Rocky Mountain Poison and Drug Center University of Colorado School of Medicine Denver, CO doi:10.1016/j.annemergmed.2004.11.033
564 Annals of Emergency Medicine
Figure 2. Sample calculation using Windows operating system calculator (scientific view) for known ingestion with level drawn at 7 hours and 20 minutes after acute ingestion. 1. Watson WA, Litovitz TL, Rodgers GC, et al. 2002 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2003;21: 353-421. 2. Rumack BH, Peterson RC, Koch GC, et al. Acetaminophen overdose: 662 cases with oral acetylcysteine therapy. Arch Intern Med. 1981; 141:380-385. 3. Smilkstein MJ, Knapp GL, Kulig KW, et al. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med. 1988;319:1557-1562. 4. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975;55:871-876. 5. Rumack BH. Acetaminophen hepatic toxicity: the first 35 years. Clin Toxicol. 2002;40:3-20.
Clinical Policy on Pediatric Procedural Sedation To the Editor: I applaud Mace et al1 for the ‘‘Clinical Policy: EvidenceBased Approach to Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department,’’ published in the October 2004 issue of Annals. However, in addition to identifying potential agents for emergency department (ED) pediatric sedation, I believe it is equally important to note those drugs that should not be considered for this procedure. For example, chloral hydrate, diphenhydramine, meperidine, and the ‘‘DPT cocktail’’ (demerol-phenergan-thorazine) have been used for decades for pediatric sedation, despite their adverse risk profiles and absence of supporting data.2-5 Although many emergency physicians choose better regimens (such as those described in the clinical policy), these less-desirable agents of habit are still used in many Volume 45, no. 5 : May 2005
Correspondence settings, including both teaching and community EDs. This persists because the ‘‘evidence base’’ of procedural sedation often consists of clinical anecdotes that have become ingrained in daily practice. Strongly stated consensus recommendations are an excellent way to initiate the flow of information regarding good (and bad) clinical practices, but these statements must address the profiles and needs of the potential end-users. Identifying suboptimal common practice is as important as recognizing ‘‘best practice.’’ The clinical policy by Mace et al1 omits important information that could potentially alter practice in many teaching and community EDs. Henry E. Wang, MD, MPH Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh, PA doi:10.1016/j.annemergmed.2004.10.041 1. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44: 342-377. 2. Polaner DM, Houck CS, Rockoff MA, et al. Sedation, risk, and safety: do we really have data at last? Pediatrics. 2001;108: 1006-1008. 3. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine. Pediatr Emerg Care. 2001;17:351-353. 4. Reappraisal of lytic cocktail/demerol, phenergan, and thorazine (DPT) for the sedation of children. American Academy of Pediatrics Committee on Drugs. Pediatrics. 1995;95:598-602. 5. Leelataweedwud P, Vann WF Jr. Adverse events and outcomes of conscious sedation for pediatric patients: study of an oral sedation regimen. J Am Dent Assoc. 2001;132:1531-1539, 1596.
In reply: I would like to thank Dr. Wang for his letter. I, like Dr. Wang, want to encourage the use of appropriate drugs for emergency department (ED) procedural sedation. The pharmacologic agentsdetomidate, fentanyl/midazolam, ketamine, methohexital, pentobarbital, and propofoldreviewed in the referenced clinical policy were chosen as ones commonly used in the ED.1 Providing information to potential users regarding the safety and efficacy of these 6 agents is an excellent method for encouraging the use of appropriate drugs for ED procedural sedation. There is evidence that the use of various drugs for ED procedural sedation by emergency physicians has changed now that additional pharmacologic agents are available and that information regarding the safety and efficacy of these agents is available. Earlier surveys (1 done in 1989, and 2 done in 1991) did indicate the widespread use of demerol-phenerganthorazine.2-4 However, later surveys (done in 1994, in 1998 to 2000, and 2003 [RD Goldman et al, unpublished data]) show a dramatic decline in the use of demerol-phenerganVolume 45, no. 5 : May 2005
thorazine and other sedative agents.5,6 In these 3 recent surveys, the use of demerol-phenergan-thorazine was less than 5%, 0%, and 0%, respectively.5,6 In addition to appropriate selection of a given pharmacologic agent for a specific patient, another critical component for limiting and/or eliminating problems or untoward events during ED procedural sedation is appropriate patient monitoring by qualified ED personnel. This is delineated in the American College of Emergency Physicians’ clinical policy on procedural sedation.7 There was also a practical consideration. Because of space (policy length), time, and other constraints, the development panel was not able to review all of the possible pharmacologic agents available for ED procedural sedation; therefore, we decided to emphasize the most commonly used choices. Other agents, such as demerol-phenergan-thorazine and chloral hydrate, are included in discussions in other resources.8,9 Sharon E. Mace, MD Department of Emergency Medicine Ohio State University School of Medicine Faculty, MetroHealth Medical Center Emergency Medicine Residency Observation Unit Pediatric Education/Quality Improvement Cleveland Clinic Foundation Cleveland, OH doi:10.1016/j.annemergmed.2004.11.032
1. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44: 342-377. 2. Hawk W, Crockett RK, Ochsenchlager DW, et al. Conscious sedation of the pediatric patient for suturing: a survey. Pediatr Emerg Care. 1992;6:84-88. 3. Cook BA, Bass JW, Nomizu, et al. Sedation for children for technical procedures: current standard of practice. Clin Pediatr. 1992;31: 137-142. 4. Ilkanipour K, Jeuls CR, Langdorf MI. Pediatric pain control and conscious sedation. A survey of emergency medicine residencies. Acad Emerg Med. 1994;1:368-372. 5. Krauss B, Zurakowski D. Sedation patterns in pediatric and general community hospital emergency departments. Pediatr Emerg Care. 1998;14:99-103. 6. Cimpello LB, Khine H, Aoner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care. 2004;20:228-232. 7. American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Approved by ACEP Board of Directors, October 20, 2004. 8. Mace SE. Chloral hydrate. Pediatric pain management and procedural sedation. In: Mace SE, DuCharme J, Murphy MF, eds. Pain Management and Sedation in the Emergency Department. New York, NY: McGraw-Hill; 2005. 9. Mace SE. Pediatric procedural sedation. Pediatric pain management and procedural sedation. In: Mace SE, DuCharme J, Murphy MF, eds. Pain Management and Sedation in the Emergency Department. New York, NY: McGraw-Hill; 2005.
Annals of Emergency Medicine 565