Postintubation Sedation of Pediatric Patients in the Emergency Department: A Systematic Review and Meta-Analysis

Context Postintubation sedation is a critical intervention for patients undergoing mechanical ventilation. Research in the intensive care unit (ICU) and adult emergency department (ED) demonstrates that appropriate postintubation sedation has a significant impact on patient outcomes. There are minimal published data regarding postintubation sedation for pediatric ED patients. Objective To identify, describe, and critique published literature on postintubation sedation in pediatric ED patients. Data Sources Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.Gov. Study Selection Studies describing postintubation sedation in the ED for pediatric patients (<18 years of age) intubated in the ED via rapid sequence intubation (RSI) were included. Studies reporting intubation outside the ED, intubation not by RSI, or nonpediatric patients were excluded, as were studies not reporting novel human clinical research. Data Extraction Data were abstracted by 2 authors using a standardized worksheet. Data included study design & setting, demographics, medications for RSI and postintubation sedation, administration of any or appropriately timed postintubation sedation, and predictive factors for postintubation sedation-related outcomes. Results A total of 10 studies were included, all of which were nonrandomized; there was significant heterogeneity and many key variables and outcomes were not consistently reported. Meta-analysis of eligible studies demonstrated pooled estimates of 77.3% (95% confidence interval [CI]: 62.5-92.0) for proportion of patients receiving any postintubation sedation, 43.5% (95% CI: 29.3-57.6) for proportion of patients receiving appropriately timed postintubation sedation, and 18.6 minutes (95% CI: 12.5-24.7) for median time to postintubation sedation, all with significant heterogeneity. Conclusions Data on postintubation sedation in pediatric ED patients are limited. Administration of postintubation sedation is inconsistent and may be substantially delayed. Further high-quality research into the use of postintubation sedation in this setting is needed, and appropriate postintubation sedation should be a target for quality improvement.