Agitation, thrashing movements requiring restraint, is a known risk of procedural sedation and analgesia (PSA) in children. Although agitation may indicate patient discomfort and compromise procedural success, no formal studies have previously been done on its rate of incidence. During 5,045 nonsurgical procedures performed in a pediatric hospital, 433 (8.6 percent) children experienced agitation, according to a team of researchers led by Dr. Jenifer R. Lightdale, M.D., of the Children's Hospital of Boston. Reports of agitation were based on nursing documentation that described the child as "agitated," "struggling," "requiring restraint," etc.
Most children (81 percent) were undergoing PSA for imaging procedures, particularly MRI. Other procedures included in the study were a variety of invasive imaging procedures as well as nonimaging procedures, both painful and nonpainful, such as fracture splinting and electroencephalography. Among children undergoing complete, uninterrupted procedures, there was a higher adverse event rate if they were found to be agitated (6.2 percent) than if they were not (2.3 percent).
Adverse events, most of which were not considered serious, included vomiting (0.86 percent) and waking before the end of the procedure (2.36 percent). School-aged children of both sexes appeared at risk for agitation during nonpainful procedures, especially if they were taking many medications. Children were also at higher risk if the sedation level ultimately achieved was not as deep as the targeted level, if PSA regimens involved two sedatives, or if midazolam and fentanyl were used, especially in high doses.
The procedures studied came from a complete database of all procedures occurring with PSA at a large pediatric tertiary care hospital during 2003. The study was funded by the Agency for Healthcare Research and Quality (HS13675).
See "Agitation during procedural sedation and analgesia in children," by Dr. Lightdale, Clarissa Valim, M.D., Lisa B. Mahoney, B.S., and others in Clinical Pediatrics 49(1), pp. 35-42, 2010.