Conscious sedation isn't always appropriate
Because conscious sedation presents risks including airway obstruction, cardiopulmonary impairment, and hypoventilation, clinicians must take care to ensure that the procedure is appropriate to the situation, says Steven Weber, RN, CEN, CFRN, MICN, manager of the children's ED at WakeMed in Raleigh, NC. "Keep in mind that conscious sedation can result in complications," he stresses. "When children go home, they may seem to be awake and alert, but there is always the chance they will have a reaction."
Because the procedure is labor-intensive, current ED volume and staff resources need to be considered. "Depending on what drug you give, the child may need to stay in the ED for a long period of time, which ties up a nurse," notes Weber.
Performing two conscious sedations simultaneously ties up additional staff. "You may have orthopedics and the ED doing one at the same time, which ties up two nurses and also possibly two ancillary people," notes Weber.
Still, the procedure isn't always time-consuming. "Once the child can sit up and start talking, it's amazing how quickly they wake up. When we ask if they want a popsicle and their eyes light up, it's usually only 10-15 minutes before they're out the door," says Lynn Daum, RN, an emergency nurse at Children's Hospital Medical Center in Cincinnati, OH. "Often after you give the last dose, you're taking down the vital signs while you're on your way to x-ray, so it doesn't prolong their stay much."
While some procedures necessitate conscious sedation, others don't. "With a nondisplaced fracture, sometimes we will, sometimes we won't, depending on the severity of it," explains Daum. "It does tie up a nurse, and you have to weigh what is best for the patient. Staff need to be very conscientious about which patients they choose to sedate."
Risks and benefits must be weighed. "Any child undergoing a painful or frightening procedure should be properly sedated or medicated," says Alfred Sacchetti, MD, FACEP, an emergency physician at Our Lady of Lourdes Medical Center in Camden, NJ. To repair a complex laceration by strapping a screaming child down for a half an hour without sedation is unacceptable, he emphasizes.
On the other hand, there are times when sedation is clearly not called for. "Not every pediatric procedure that makes a child unhappy requires sedation," Sacchetti says. "To sedate a 14-month old with a 5 mm laceration on the chin which will require one suture and less than five minutes of firm restraint is counter-productive."
The decision should be made solely on the basis of what is best for the child, Sacchetti stresses. "I do believe that the dangers have been grossly overexaggerated and have been used to intimidate many clinicians from using it when it should be applied," he notes. "[Conscious sedation] should be very liberally used, but must be applied in the context of the situation."
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