Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children

Published:April 28, 2018DOI:



      Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED.


      To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores.


      A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction.


      112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale.


      Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Krauss B.
        • Green S.M.
        Procedural sedation and analgesia in children.
        Lancet. 2006; 367: 766Y780
        • Pena B.M.
        • Krauss B.
        Adverse events of procedural sedation and analgesia in a pediatric emergency department.
        Ann Emerg Med. 1999; 34 ((4 pt 1):483Y491)
        • Lane R.D.
        • Schunk J.E.
        Intranasal midazolam use for minor procedures in the pediatric emergency department.
        Pediatr Emerg Care. 2008; 24: 300-303
        • Walbergh E.J.
        • Eckert J.
        Pharmacokinetics of intravenous (IV) and intranasal (IN) midazolam in children.
        Anesthesiology. 1989; 71: A1066
        • Rey E.
        • Delaunay L.
        • Pons G.
        • et al.
        Pharmacokinetics of midazolam in children: comparative study of intranasal and intravenous administration.
        Eur J Clin Pharmacol. 1991; 41: 355-357
        • Knoester P.D.
        • Jonker D.M.
        • van der Hoeven R.T.M.
        • et al.
        Pharmokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers.
        J Clin Pharmacol. 2002; : 501-507
        • Harbord M.G.
        • Kyrkou N.E.
        • Jyrkou M.R.
        • et al.
        Use of intranasal midazolam to treat acute seizures in paediatric community settings.
        J Paediatr Child Health. 2004; 40: 556-558
        • American Society of Anesthesiologists Committee
        Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.
        Anesthesiology. 2016; 126: 376-393
        • Godwin S.A.
        • Burton J.H.
        • Gerardo C.J.
        • et al.
        Clinical policy: procedural sedation and analgesia in the emergency department.
        Ann Emerg Med. 2014; 63: 247
        • Coté C.J.
        • Wilson S.
        • American Academy Of Pediatrics
        • American Academy Of Pediatric Dentistry
        Guidelines for monitoring and management of pediatric patients before, during and after sedation for diagnostic and therapeutic procedures: update 2016.
        Pediatrics. 2016; : 138
        • Agrawai D.
        • Manzi S.F.
        • Gupta R.
        • et al.
        Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department.
        Ann Emerg Med. 2003; 42: 636-646
        • Treston G.
        Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation.
        Emerg Med Australas. 2004; 16: 145-150
        • Ghaffar S.
        • Haverland C.
        • Ramasciotti C.
        • et al.
        Sedation for pediatric echocardiography: evaluation of preprocedure fasting guidelines.
        J Am Soc Echocardiogr. 2002; 15: 980-983
        • Kennedy R.M.
        • Porter F.L.
        • Miller P.
        • et al.
        Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopaedic emergencies.
        Pediatrics. 1998; 102: 956-963
        • Roback M.G.
        • Bajaj L.
        • Wathen J.E.
        • et al.
        Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?.
        Ann Emerg Med. 2004; 44: 454-459
        • Babl F.E.
        • Puspitadewi A.
        • Barnett P.
        • et al.
        Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and alalgesia.
        Pediatr Emerg Care. 2005; 21: 736-743
        • Mondello E.
        • Siliotti R.
        • Noto G.
        • Cuzzocrea E.
        • Scollo G.
        • Trimarchi G.
        • et al.
        Bispectral index in ICU: correlation with Ramsay score on assessment of sedation level.
        J Clin Monit Comput. 2002; 17: 271-277
        • Margaret N.D.
        • Clark T.A.
        • Warden C.R.
        • et al.
        Patient satisfaction in the emergency department – a survey of pediatric patients and their parents.
        Acad Emerg Med. 2002; 9: 1379-1388
        • Pagnamenta R.
        • Benger J.R.
        Factor influencing parent satisfaction in a children's emergency department prospective questionnaire-based study.
        Emerg Med J. 2008; 24: 417-419
        • Locke R.
        • Stefano M.
        • Koster A.
        • et al.
        Optimizing patient/caregiver satisfaction through quality of communication in the pediatric emergency department.
        Pediatr Emerg Care. 2001; 27: 1016-1021
        • Byckowski T.L.
        • Fitzgerald M.
        • Kennebeck S.
        • et al.
        A comprehensive view of parental satisfaction with pediatric emergency department visits.
        Ann Emerg Med. 2013; 62: 340-350
        • Institute of Medicine
        Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains.
        National Academies Press, Washington, DC2007
        • Pang P.S.
        • McCarthy D.
        • Schmidt M.
        • et al.
        440 factors associated with perfect press ganey satisfaction scores for discharged emergency department patients.
        Ann Emerg Med. 2011; 58(: S327-28
        • Nichol J.
        • Robert B.S.
        • Fu R.
        • et al.
        Association between patient and emergency department operational characteristics and patient satisfaction scores in a pediatric population.
        Pediatr Emerg Care. 2016; 32: 139-141
        • Green S.M.
        • Rothrock S.G.
        • Lynch E.L.
        • et al.
        Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases.
        Ann Emerg Med. 1998; 31: 688-697
        • Ramaswamy P.
        • Babl F.
        • Deasy C.
        • et al.
        Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration.
        Acad Emerg Med. 2008; 16: 101-107