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Capnography during sedation/analgesia in the pediatric emergency department
1Hasbro Children's Hospital, Department of Pediatrics, Brown University, Providence, Rhode Island, USA. mcquik@mail.mmc.org
Insights
Pediatric sedation with common agents significantly increases end-tidal carbon dioxide (ETCO2). Monitoring ETCO2 is valuable for assessing ventilation during procedural sedation in children.
Area of Science:
- Pediatric Emergency Medicine
- Anesthesiology
- Respiratory Physiology
Background:
- Procedural sedation and analgesia are frequently used in pediatric emergency departments.
- Monitoring ventilation is crucial during sedation to ensure patient safety.
Purpose of the Study:
- To measure changes in end-tidal carbon dioxide (ETCO2) levels during sedation/analgesia in pediatric patients.
- To describe ETCO2 changes associated with different sedation strategies.
Main Methods:
- Prospective observational study of 106 pediatric patients in a PED.
- Continuous ETCO2 and SpO2 monitoring before and after sedation.
- Analysis of ETCO2 changes with various sedative agents (fentanyl, morphine, ketamine, midazolam).
Main Results:
- Mean ETCO2 increase of 6.7 mmHg (P < 0.00001).
- Greater ETCO2 increases observed with midazolam/opiate combinations.
- Two patients experienced transient SpO2 desaturations, resolving with stimulation.
Conclusions:
- Commonly used pediatric sedation agents cause significant ETCO2 increases.
- ETCO2 monitoring is a useful adjunct for assessing ventilation during pediatric sedation.
- ETCO2 can serve as an objective tool for evaluating sedation strategies.
Objective:
To measure changes in end-tidal carbon dioxide levels (ETCO2) during sedation/analgesia in pediatric patients and to describe ETCO2 changes associated with different sedation strategies.
Methods:
This was a prospective, observational patient series in an urban pediatric emergency department (PED). Participants included 106 children with a mean age of 6.8 years. (range 1.2-16.6 years). Sedation/analgesia was given for fracture reduction (55%), laceration repair (37%), abscess incision and drainage (4%), and lumbar puncture (LP) (4%). Medications included fentanyl, morphine, ketamine, and midazolam. Continuous ETCO2 waveforms were recorded via a Capnogard ETCO2 Monitor. Oxygen saturation was recorded using a Nelcor N-200 pulse oximeter. Recording began prior to sedation and continued until the patient was awake or when it was necessary to remove the patient from the monitor for further medical care. Each record was analyzed for peak ETCO2 and averaged over five consecutive breaths, before and after the administration of medications. The main outcome measure was the change in ETCO2 levels.
Results:
The mean increase in ETCO2 was 6.7 mmHg (P is included in, 0.00001; range: +0.16 to +22.3). ETCO2 increased by 3.2 mmHg (95% CI = 2.2-4.2) for midazolam alone, 5.4 mmHg (95% CI = 4.5-6.4) for midazolam and ketamine, and 8.8 mmHg (95% CI = 7.4-10.2) for midazolam and opiate. Two patients had transient SpO2 desaturations below 93%, which corrected with stimulation.
Conclusions:
Commonly used agents for pediatric sedation result in significant increases in ETCO2. ETCO2 is a useful adjunct in assessing ventilation and may serve as an objective research tool for assessing different sedation strategies.