Safe and Sound: Optimizing Pediatric Procedural Sedation in Emergency Departments — From High-resource Standards to Low-resource Adaptations

Abstract

Pediatric procedural sedation (PPS) is a common and essential component of emergency department practice, enabling painful, prolonged, or anxiety-producing procedures to be performed in children who are otherwise uncooperative. Over the past two decades, PPS has evolved from a primarily analgesic intervention to a structured process guided by safety protocols, standardized monitoring, and pharmacologic strategies. However, sedation practices vary considerably across regions, particularly between high-resource and resource-limited settings. This review aims to examine current evidence on PPS in the emergency department, with a focus on global practice patterns, safety, pharmacologic management, and monitoring requirements across different resource environments. PPS is widely utilized across emergency departments, with common indications including fracture reduction, laceration repair, diagnostic imaging, and other invasive bedside procedures. Evidence from large registries and multicenter studies indicates a low incidence of serious adverse events when sedation is performed by trained personnel using standardized protocols. Ketamine remains the most commonly used sedative agent worldwide, particularly in resource-limited settings, due to its reliable dissociative properties and favorable airway safety profile. In contrast, propofol and combination regimens are more frequently used in high-resource environments and are associated with a higher incidence of respiratory complications, necessitating advanced monitoring. PPS in the emergency department is generally safe and effective when guided by evidence-based practices, appropriate patient selection, and adequate monitoring. Adaptable sedation strategies that account for local resources, while maintaining core safety principles, may help optimize outcomes across diverse healthcare settings.