Abstract

Background

Ketamine is growing in popularity for procedural sedation in the paediatric population, yet safety concerns remain. We performed a retrospective review of practice and outcomes of paediatric ketamine sedation using the World SIVA International Sedation Task Force reporting tool.

Methods

A retrospective inspection of the dedicated emergency department electronic sedation database and subsequent note and sedation chart review was performed for all paediatric sedations throughout a 7 yr period from September 2006. All adverse events were stratified.

Results

During the study period, procedural sedation was provided for a total of 243 children, of whom 215 were sedated with ketamine, most commonly for wound management ( n =131). The median patient age was 4 yr (14 months to 15 yr), and 63.7% were male. Of the total, 76.7% were discharged home either directly ( n =101) or after brief observation ( n =64). One patient required subsequent general anaesthesia after a failed sedation with paradoxical agitation. Of the total, 9.8% of patients had an adverse event, the most severe risk stratification being ‘minor risk’. All interventions were ‘minimal risk’. There were no ‘sentinel risk’ outcomes.

Conclusions

These data support the ongoing use of ketamine for paediatric procedural sedation in the emergency department by emergency physicians. Relatively high resource requirements mean that ensuring adequate numbers of procedures may prove challenging.

Editor's key points

  • The unique pharmacodynamic effects of ketamine offer many benefits for paediatric procedural sedation.

  • The authors evaluate the safety of 7 yr of paediatric procedural sedation with ketamine in their emergency department.

  • Outcomes were evaluated using a published sedation outcome reporting tool.

  • The incidence of adverse effects was low, and none was severe.

The phencyclidine derivative ketamine has a number of characteristics that make it popular for procedural sedation, particularly in the emergency department, where otherwise-painful procedures are performed. Unlike other general anaesthetic agents, ketamine causes a ‘dissociative anaesthesia’ as a result of a functional dissociation between the cortical and limbic systems. 1,2 As a result of its relative cardiovascular stability and maintenance of protective airway reflexes, 2,3 there has been a gradual increase in its use and popularity as a sedative agent, particularly within the paediatric population. 4

Historically, paediatric sedation using ketamine was introduced in radiotherapy and burns patients. 5–7 Evidence has subsequently built up supporting its use in the emergency department, 8–16 particularly in North America, where it is standard practice in many hospitals. 4,17–18 In comparison, the UK has been relatively slow to develop this technique into mainstream practice. 19,20 The Royal College of Emergency Medicine issued a guideline as early as 2004. The update in 2009 21 outlined several advantages, including a wide safety margin, avoidance of a general anaesthetic and physical restraint, and high efficacy. However, like all drugs, ketamine is not without side-effects, which include respiratory depression, airway compromise, hypersalivation, emesis, and emergence phenomena. 3,4

The debate around provision of sedation by emergency physicians is one that continues. 22–25 Proponents argue that ketamine is fundamentally different and should be treated as such. 26 Recently, in response to disparities in sedation adverse event reporting, 27 the World Society for Intravenous Anaesthesia (World SIVA) developed an adverse event reporting tool 28 with the intention of providing outcome standardization and aggregation, with subsequent transparent comparison of adverse sedation practice outcomes. This has been used in other emergency medicine settings. 29 In light of the availability of this tool, the ongoing debate around emergency physician-delivered paediatric sedation, and the need for continual scrutiny of our practice, we performed a retrospective review of paediatric ketamine sedation in our UK-based emergency department.

Methods

The Royal Devon and Exeter Hospital Emergency Department has maintained an electronic database of all procedural sedation undertaken since 2006. This was interrogated to identify all paediatric sedations throughout a 7 yr period. A retrospective note review, including the departmental ketamine sedation proforma of those patients identified, was performed. Any adverse events identified were scrutinized using paper and electronic records, and risk stratification was performed using the World SIVA adverse event reporting tool. 28

Information on patient characteristics was collected, alongside indications, sedation methods, and any adverse events. All data were anonymized, and subsequent statistical analysis was performed using Microsoft Excel (Professional Plus 2010). Statistical significance ( P ) was placed at 0.05. In accordance with local policy and after completion of the Health Research Authority/Medical Research Council decision tree, ethical approval was deemed unnecessary. Incomplete data domains were excluded from statistical analysis.

Royal Devon and Exeter Emergency Department has developed a paediatric ketamine procedural sedation protocol that has evolved during several years, and all sedations were performed according to this protocol. In accordance with this departmental protocol, all sedations were performed in the ‘Resus’ area of the department, with emergency drugs including suxamethonium, defibrillators, and advanced airway equipment available. All patients underwent close monitoring using ECG, blood pressure, oxygen saturation, and respiratory rate. Nasal capnography was introduced in the department in late 2011 and used routinely therein.

Local guidelines were updated in 2008 to mandate staffing to include at least one sedating doctor at consultant level, a procedure-tasked operator, and a nurse. These fulfil obligations set out in UK guidelines issued. 30

Discharge criteria after sedation include pre-procedure ambulation, adverse symptom resolution, and appropriate supervision. In addition, there must be no injury-related reason for ongoing observation or admission.

Results

From September 2006 to September 2013, a total of 243 children were sedated. Ketamine was used in 215 patients. All non-ketamine sedations were excluded from subsequent analysis but included both inhalational and i.v. techniques (see Table  1 ). After ketamine, the most common technique was nitrous oxide, in isolation ( n =9) or in combination with other techniques ( n =9).

Table 1

Methods used for paediatric sedations. Nitrous oxide refers to 70% nitrous oxide–30% oxygen mix

Sedation method Number performed 
Ketamine 208 
Ketamine and intranasal diamorphine 
Ketamine and morphine 
Nitrous oxide 
Nitrous oxide and midazolam 
Propofol 
Midazolam 
Morphine 
Propofol and morphine 
Propofol and intranasal diamorphine 
Alfentanil and nitrous oxide 
Midazolam and morphine 
Fentanyl and nitrous oxide 
 243 
Sedation method Number performed 
Ketamine 208 
Ketamine and intranasal diamorphine 
Ketamine and morphine 
Nitrous oxide 
Nitrous oxide and midazolam 
Propofol 
Midazolam 
Morphine 
Propofol and morphine 
Propofol and intranasal diamorphine 
Alfentanil and nitrous oxide 
Midazolam and morphine 
Fentanyl and nitrous oxide 
 243 

The median patient age was 4 yr (range 14 months to 15 yr). Of all patients undergoing ketamine sedation, 137 (63.7%) were male. The most common indication for ketamine sedation was wound management ( n =131), followed by management of fracture or dislocation, or both ( n =62; Table  2 ).

Table 2

Indications for paediatric ketamine sedation ( n =215)

Foreign body 19 
Dental procedure 
Fracture/dislocation management 62 
Wound management 131 
Foreign body 19 
Dental procedure 
Fracture/dislocation management 62 
Wound management 131 

In 187 patients (87.0%) i.v. sedation was used, whereas ketamine was administered i.m. in 28 patients. The median initial dose was 1.25 mg kg −1 i.v. or 3.94 mg kg −1 i.m. Supplemental doses were required in 70 patients; in 34.8% of patients dosed i.v. and 17.9% of patients dosed i.m. Supplemental doses were given for a prolonged procedure time ( n =32) or in response to inadequate sedation ( n =38). There was no difference between mean initial doses for those patients requiring additional sedation with i.v. ( P =0.07) or i.m. ( P =0.20) administration. Median (mean) total doses were 1.65 (1.5) mg kg −1 i.v. and 4.63 (4) mg kg −1 i.m.

Throughout the period examined, with the exception of 1 yr (September 2011–12), there was a decrease in the annual number of paediatric ketamine sedations performed. The mean year-on-year reduction in numbers performed was 10.9%. Throughout the entire study period, 186 sedations (86.5%) were performed with at least one consultant present. Of those performed without documented direct consultant involvement, 80% of those were before 2008.

Of all patients, 165 (76.7%) were discharged home. This includes 101 who were discharged directly, with a further 64 discharged after a brief period of observation. Patient destinations are shown in Figure 1 . In 2010, a paediatric assessment unit was introduced, from which 25 patients underwent transient post-sedation observation. Before this, 39 patients were briefly admitted to the general paediatric ward for observation under the care of the duty senior emergency physician before discharge. One patient was admitted for failed sedation, requiring a subsequent procedure under general anaesthesia. Forty-nine admissions (43.0%) were attributable to the injury itself and were unrelated to the sedation.

Fig. 1

Overview of patient destinations and outcomes

Fig. 1

Overview of patient destinations and outcomes

According to the specified adverse event tool, 21 patients (9.8%) had an ‘adverse outcome’ (Table  3 ). The most common of these were agitation and apnoea. Of all adverse events documented, the most severe according to the greatest risk posed were ‘apnoea’ and ‘desaturation’. These were both classified as being of ‘minor risk’ as a result of the transient nature of the events. With the exception of one paradoxical agitation requiring admission and a subsequent general anaesthetic, all outcomes fell into the ‘minimal risk’ category. All interventions were ‘minimal risk’, with the single most frequent intervention being ‘none required’. There were no ‘sentinel risk’ (i.e. critical enough to represent real or serious imminent risk of serious and major patient injury) descriptors, interventions, or outcomes throughout the 7 yr period.

Table 3

Adverse events and outcomes stratified using the World SIVA reporting tool 28

Adverse events Minimal risk descriptors Minor risk descriptors 
Recovery agitation 
Apnoea (not prolonged, <60 s) 
Paradoxical response 
Desaturation (75–90%, <60 s) 
Failed i.v. access 
Rash 
Vomiting/retching 
Hypersalivation 
Interventions Minimal risk intervention Minor risk intervention 
Supplemental oxygen, new or increased 
Airway repositioning 
Tactile stimulation 
None required 11 
Outcome Minimal risk outcome Moderate risk outcome 
 20 
Adverse events Minimal risk descriptors Minor risk descriptors 
Recovery agitation 
Apnoea (not prolonged, <60 s) 
Paradoxical response 
Desaturation (75–90%, <60 s) 
Failed i.v. access 
Rash 
Vomiting/retching 
Hypersalivation 
Interventions Minimal risk intervention Minor risk intervention 
Supplemental oxygen, new or increased 
Airway repositioning 
Tactile stimulation 
None required 11 
Outcome Minimal risk outcome Moderate risk outcome 
 20 

Discussion

We have demonstrated that paediatric procedural ketamine sedation appears safe in our department. Throughout a 7 yr period, there were no major or sentinel adverse events or outcomes in 215 consecutive children. This is the first time the World SIVA adverse event tool 28 has been used for paediatric ketamine sedation, although the tool has been used elsewhere in both adults and children. 25,29,31–35 There are many advantages to using an internationally recognized sedation reporting tool, including the standardization of terminology of adverse events and allowing ease of comparison between different centres. There are other paediatric sedation tools available, 36 but we found retrospective application of the World SIVA tool straightforward.

One advantage of this tool is that it clearly categorizes events and outcomes (Table  2 ) for subsequent analysis. In the present case series, the most severe events were both categorized as minor risk descriptors and were ‘apnoea (not prolonged, <60 s)’ and ‘oxygen desaturation (75–90%, <60 s)’. One episode of desaturation was attributable to partial airway obstruction, and the other was a probable measurement error with a documented rapid ‘jump’ to normal values. The interventions were also deemed ‘minimal risk’. It is worth noting that the majority of adverse effects demonstrated were recognized side-effects of ketamine itself.

No drug is without side-effects, and ketamine is no exception. Experience from North America has identified a number of predictors of airway complications, including age (<2 yr or >13 yr old), high doses, and co-administration of anticholinergics or benzodiazepines. 37 Likewise, patterns of postemergence agitation and emesis have been identified. 38 The encompassing nature of the World SIVA tool means that many recognized side-effects of ketamine, such as vomiting or hypersalivation, are included in the 9.8% overall adverse event rate. It is a therefore a strength of this tool that it can differentiate the degrees of severity of events.

Throughout the time period of this study, our emergency department admissions increased by more than 30%. It is perhaps surprising, therefore, that throughout the same time period the number of paediatric ketamine sedations decreased by a mean of 10.9% yr −1 . As with any procedure, maintaining patient safety is paramount, and because of the necessary patient safety precautions, procedural sedation is ‘resource heavy’ in its requirements for senior staff and a ‘Resus’ bay for appropriate monitoring. 30 With increasing pressures on emergency departments, it may be that providing this service becomes more challenging.

It has been argued that the different mechanism, clinical effects, and safety profile of ketamine mean that traditional definitions and sedation scales are inappropriate. 26 Furthermore, the lack of a defined dose–response continuum has led to the definition of dissociative sedation as achieving profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. 26 In the context of this definition, it is arguable that those patients requiring simple airway manipulation and becoming apnoeic were receiving general anaesthesia.

The decreasing numbers of paediatric sedations performed poses an interesting dilemma regarding maintenance of skills. When a sedation goes unremarkably, as the vast majority of these did, there is little testing of the robustness of the rescue systems that are in place. It is when adverse events of an escalating severity occur that the systems are truly tested. In a review of 95 adverse paediatric sedation events (including 51 deaths), it was noted that severe complications are most often attributable to the skills of the practitioner in failing to rescue the patient. 39 This is not a new phenomenon, 40 and it has been argued that paediatric sedation outside large centres may result in poorer outcomes. 41 However, these data suggest that this may not be the case providing that ongoing training and continuous reviewing of practice occurs amidst a robust clinical governance strategy. For example, our current departmental strategy includes annual review of patients and physician caseload, an annual workshop on laryngospasm with senior anaesthetist input, and having the management of laryngospasm embedded within the ketamine sedation chart.

The same adverse events review noted that physician type was unrelated to complications; and certainly, this is an opinion that has been voiced vociferously elsewhere. 42 It has been argued that dividing providers into anaesthetist and non-anaesthetist subgroups does not account for the discrepancies in skills and training, and that instead, studies regarding complications should be stratified by skill level and competency to ensure rigorous safety standards. 41 A recent review of our emergency department adult propofol sedation practice, 29 and the debate that ensued, demonstrates the variety in acceptance and perceptions of emergency physician-delivered sedation. 22–24,43,44

Some anaesthetists will be more comfortable providing a general anaesthetic 45 for the paediatric population rather than sedation. In contrast, emergency physicians may be more frequently exposed to and potentially be more comfortable performing paediatric sedation.

In children undergoing magnetic resonance imaging and computed tomography, it has been demonstrated that a general anaesthetic provides better image quality and an improved safety profile. 46 Nonetheless, to our knowledge, no direct comparison studies in terms of safety or satisfaction, comparing general anaesthesia with sedation, have been performed in the emergency department setting.

Our results showed that 76.7% of patients were discharged home after a period of supervised recovery within the emergency department, in the paediatric assessment unit, or in the paediatric ward. Only one patient had a sedation that failed because of paradoxical agitation, requiring a subsequent general anaesthetic. The remainder of patients admitted were admitted for definitive management of their original injury after initial management performed under sedation. This equates overall to a total of 165 avoided general anaesthetics, providing a clear reduction of pressure on both theatre and anaesthetic services. In addition, there are other advantages, such as reducing admission times and minimizing further disruption to the lives of the parents and families.

These results are limited by the fact that they are from a single institution and are based upon a retrospective chart and notes review, from which extrapolation of quantitative data can be ‘fraught with error’. 47 However, the majority of reported outcomes, such as complications and discharge outcomes, are clear cut, and there was very limited abstraction or room for interpretation. Similar methods have been used previously in a multicentre study to demonstrate that ketamine procedural sedation provides a faster turnaround time in paediatric radial fractures when compared with a general anaesthetic. 48 This faster discharge time has benefits for both the child and their family in terms of minimizing disruption and loss of earnings.

We have demonstrated that an emergency department paediatric ketamine sedation programme can be delivered safely in a UK non-specialist tertiary paediatric centre. This will be no surprise to many, given the established safety profile of paediatric ketamine sedation elsewhere. 4,8–20 However, with increasing pressures on departments, maintaining safety standards is paramount. Sufficient numbers of procedures must be performed to maintain skills and procedural familiarity, and as such, efforts need to be made to ensure that procedural sedation continues to be carried out in a safe and timely manner, and in sufficient numbers to ensure continued safety of this valuable service that benefits children and their families.

Authors' contributions

Design, patient recruitment, and analysis: G.L.

Data collection and data analysis: L.R.K.

Manuscript preparation: L.R.K., S.C.L., G.L.

Declaration of interest

None declared.

References

1
Corssen
G
,
Miyasaka
M
,
Domino
EF
.
Changing concepts in pain control during surgery – dissociative anesthesia with CI-581
.
Anesth Analg
 
1969
;
47
:
746
59
2
White
PF
,
Way
WL
,
Trevor
AJ
.
Ketamine—its pharmacology and therapeutic uses
.
Anesthesiology
 
1982
;
56
:
119
36
3
Reich
DL
,
Silvay
G
.
Ketamine: an update on the first twenty-five years of clinical experience
.
Can J Anaesth
 
1989
;
36
:
186
97
4
Green
SM
,
Roback
MG
,
Kennedy
RM
,
Krauss
B
.
Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update
.
Ann Emerg Med
 
2011
;
57
:
449
61
5
Cronin
MM
,
Bousfield
JD
,
Hewett
EB
,
McLellan
I
,
Boulton
TB
.
Ketamine anaesthesia for radiotherapy in small children
.
Anaesthesia
 
1972
;
27
:
135
42
6
Bennett
JA
,
Bullirnore
JA
.
The use of ketamine hydrochloride anaesthesia for radiotherapy in young children
.
Br J Anaesth
 
1973
;
45
:
197
201
7
Byer
DE
,
Gould
AB
Jr.
Development of tolerance to ketamine in an infant undergoing repeated anesthesia
.
Anesthesiology
 
1981
;
54
:
255
6
8
McGlone
R
,
Ranasinghe
S
,
Durham
S
.
An alternative to “brutacaine”: a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing
.
J Accid Emerg Med
 
1998
;
15
:
231
6
9
McGlone
R
,
Fleet
T
,
Durham
S
,
Hollis
S
.
A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing
.
Emerg Med J
 
2001
;
18
:
34
8
10
Acworth
JP
,
Purdie
D
,
Clark
RC
.
Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency pediatric procedural sedation
.
Emerg Med J
 
2001
;
18
:
39
45
11
Younge
PA
,
Kendal
JM
.
Sedation for children requiring wound repair: a randomised, controlled double blind comparison of oral midazolam and oral ketamine
.
Emerg Med J
 
2001
;
18
:
30
3
12
Green
SM
,
Rothrock
SG
,
Lynch
EL
et al
.
Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases
.
Ann Emerg Med
 
1998
;
31
:
688
97
13
Chudnofsky
CR
,
Weber
JE
,
Stoyanoff
PJ
et al
.
A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients
.
Acad Emerg Med
 
2000
;
7
:
228
35
14
Priestly
SJ
,
Taylor
J
,
McAdam
CM
,
Francis
P
.
Ketamine sedation for children in the emergency department
.
Emerg Med
 
2001
;
13
:
82
90
15
Dachs
RJ
,
Innes
GM
.
Intravenous ketamine sedation of pediatric patients in the emergency department
.
Ann Emerg Med
 
1997
;
29
:
146
50
16
Howes
MC
.
Ketamine for paediatric sedation/analgesia in the emergency department
.
Emerg Med J
 
2004
;
21
:
275
80
17
Green
SM
,
Nakamura
R
,
Johnson
NE
,
Linda
L
.
Ketamine sedation for paediatric procedures: part 1, a prospective series
.
Ann Emerg Med
 
1990
;
19
:
1024
32
18
Green
SM
,
Johnson
NE
.
Ketamine sedation for paediatric procedures: part 2, review and implications
.
Ann Emerg Med
 
1990
;
19
:
1033
44
19
Morton
NS
.
Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective
.
Paediatr Anaesth
 
2008
;
18
:
25
9
20
Holloway
VJ
,
Husain
HM
,
Saetta
JP
,
Gautam
V
.
Accident and emergency department led implementation of ketamine sedation in paediatric practice and parental response
.
J Accid Emerg Med
 
2000
;
17
:
25
8
21
Benger
J
,
Berry
A
,
Frampton
A
et al
.
Ketamine
 
sedation of children in emergency departments
  .
College of Emergency Medicine
.
Ketamine Sedation of Children in Emergency Departments
.
London
:
CEM
,
2009
.
22
Lamb
AR
,
Harper
M
.
Procedural sedation: it is not what you do, it is how you do it
.
Br J Anaesth
 
2014
;
112
:
939
40
23
Webb
ST
,
Hunter
DN
.
Is sedation by non-anaesthetists really safe?
Br J Anaesth
 
2013
;
111
:
136
8
24
Wade
CN
.
Journal club response
.
Br J Anaesth
 
2014
;
112
:
939
939
25
Kaye
P
,
Govier
M
.
Procedural sedation with propofol for emergency DC cardioversion
.
Emerg Med J
 
2014
;
31
:
904
8
26
Green
SM
,
Krauss
B
.
The semantics of ketamine
.
Ann Emerg Med
 
2000
;
36
:
480
2
27
Roback
MG
.
Incidence and stratification of adverse events associated with sedation: Is there a benchmark?
In:
Mason
K
, ed.
Pediatric Sedation Outside the Operating Room: A Multispeciality International Collaboration
  .
New York, NY
:
Springer
,
2012
;
559
65
28
Mason
KP
,
Green
SM
,
Piacevoli
Q
;
International Sedation Task Force. Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force
.
Br J Anaesth
 
2012
;
108
:
13
20
29
Newstead
B
,
Bradburn
S
,
Appelboam
A
et al
.
Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases
.
Br J Anaesth
 
2013
;
111
:
651
5
30
Academy of Medical Royal Colleges
.
Safe Sedation Practice for Healthcare Procedures. Standards and Guidance
  .
October, 2013
.
London, UK
:
Academy of Medical Royal Colleges
.
31
Mekitarian Filho
E
,
de Carvalho
WB
,
Gilio
AE
,
Robinson
F
,
Mason
KP
.
Aerosolized intranasal midazolam for safe and effective sedation for quality computed tomography imaging in infants and children
.
J Paediatr
 
2013
;
163
:
1217
9
32
Hoyle
JD
Jr
,
Callahan
JM
,
Badawy
M
et al
.
Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma
.
Pediatr Emerg Care
 
2014
;
30
:
1
7
33
Mekitarian Filho
E
,
Robinson
F
,
de Carvalho
WB
,
Gilio
AE
,
Mason
KP
.
Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging
.
J Pediatr
 
2015
;
166
:
1313
5
34
Kouchaji
C
.
Complications of IV sedation for dental treatment in individuals with intellectual disability
.
Egypt J Anaesth
 
2015
;
31
:
143
8
35
Adams
L
,
Butas
S
,
Spurlock
D
Jr
.
Capnography (ETCO 2 ), respiratory depression, and nursing interventions in moderately sedated adults undergoing transesophageal echocardiography (TEE)
.
J Perianesth Nurs
 
2015
;
30
:
14
22
36
Bhatt
M
,
Kennedy
RM
,
Osmond
MH
et al
.
Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children
.
Ann Emerg Med
 
2009
;
53
:
426
35
37
Green
SM
,
Kuppermann
N
,
Rothrock
S
,
Hummel
C
,
Ho
M
.
Predictors of adverse events with intramuscular ketamine sedation in children
.
Ann Emerg Med
 
2000
;
35
:
35
42
38
Green
SM
,
Roback
MG
,
Krauss
B
et al
.
Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children
.
Ann Emerg Med
 
2009
;
54
:
158
68
39
Coté
CJ
,
Notterman
DA
,
Karl
HW
,
Weinberg
JA
,
McCloskey
C
.
Adverse sedation events in pediatrics: a critical incident analysis of contributing factors
.
Pediatrics
 
2000
;
105
:
805
14
40
Silber
JH
,
Williams
SV
,
Krakauer
H
,
Schwartz
JS
.
Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue
.
Med Care
 
1992
;
30
:
615
29
41
Krauss
B
,
Green
SM
.
Procedural sedation and analgesia in children
.
Lancet
 
2006
;
367
:
766
80
42
Green
SM
,
Krauss
B
.
Who owns deep sedation?
Ann Emerg Med
 
2011
;
57
:
470
4
43
Kakazu
CZ
,
Lippmann
M
.
Sedation: it is better to be safe than sorry
.
Br J Anaesth
 
2014
;
112
:
586
586
44
Sheahan
CG
,
Mathews
DM
.
Monitoring and delivery of sedation
.
Br J Anaesth
 
2014
;
113
(Suppl 2)
:
ii37
47
45
Crock
C
,
Olsson
C
,
Phillips
R
et al
.
General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family's perspective
.
Arch Dis Child
 
2003
;
88
:
253
7
46
Malviya
S
,
Voepel-Lewis
T
,
Eldevik
OP
,
Rockwell
DT
,
Wong
JH
,
Tait
AR
.
Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes
.
Br J Anaesth
 
2000
;
84
:
743
8
47
Gilbert
EH
,
Lowenstein
SR
,
Koziol-McLain
J
,
Barta
DC
,
Steiner
J
.
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
 
1996
;
27
:
305
8
48
Mitchell
L
,
Archer
E
,
Middleton
S
et al
.
Paediatric distal radial fracture manipulation: multicentre analysis of process times
.
Emerg Med J
 
2009
;
26
:
41
2

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