Pediatric Pearls - Ouchless ED: Part 2 - The Big Stuff

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Jason M. -

You were talking about IN verses and fentanyl for procedural sedation, but 2 chapters ago, those very agents were suggested as never to be used again. Can you explain the desperate views? Thank you.

ilene c. -

I believe you are talking about the Medzeppelin piece, and I am pasting the written summary of that. Let me know if I am thinking of the wrong piece or if I didn’t answer adequately:

Fentanyl and midazolam for procedural sedation: Your oxygen saturation will go down. Both of these agents are inappropriate for procedural sedation. They were commonly used back in the day and are perceived as safer than ketamine or propofol. This is wrong.
The effect of midazolam is unpredictable in procedural sedation: This is true for all benzodiazepines. Some patients you give a tiny dose and they become zonked and other require heroic doses and they still aren’t sedated. It has to do with liver metabolism and the sensitivity of the patient.
The fentanyl and midazolam combo needs to go away: It is associated with more hypoxia. Ketamine and propofol can do almost all procedural sedations.

I do agree with everything being said here. Let's start with fentanyl. This piece is discussing fentanyl for sedation, particularly in combination with midazolam. I agree with giving 2 parenteral agents both known for respiratory depression being a bad idea when better agents exist. But we still give fent liberally for analgesia. It often takes a village to get an IV into a kid, and if strong analgesia is needed, IN fentanyl is a quick, easy, safe and effective agent. Regarding midazolam, I agree that using high enough doses for a full procedural sedation when ketamine and propofol are available is silly. IN or oral midazolam is more used as an anxiolytic- to take the edge off for a slightly older child that has the potential to stay still or for a toddler getting a procedure for which adequate topical analgesia can be achieved and they can be restrained, not a major fracture, abscess or lac requiring a true sedation. I feel like people are mixed on oral/ IN midazolam. Sol likes it much more than I do. I have had a number of kids with paradoxical reactions who act like evil, violent, disinhibited drunks on it. But some people love it. Maybe Sol just likes disinhibited drunks more than I do….

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