Factors Associated With Use of Procedural Sedation in Pediatric Facial Laceration Repair in the Emergency Department

OBJECTIVE: To identify factors associated with the utilization of procedural sedation during pediatric facial laceration repair. METHODS: We performed a retrospective cross-sectional study at a tertiary care pediatric ED from 2016 to 2020 of patients aged 0 to 18 with facial lacerations repaired with sutures. Our primary outcome was utilization of procedural sedation (ketamine, propofol alone or plus fentanyl or ketamine, midazolam plus fentanyl), with a secondary outcome of utilization of anxiolysis (intranasal midazolam). We measured the association of covariates, including provider subspecialty and patient age, sex, race and ethnicity, insurance status, time and day, laceration characteristics, mechanism, and layers of repair in a multivariate analysis and multinomial logistic regression. RESULTS: We identified 4943 patient visits, with 3859 (78.8%) laceration repairs performed by emergency medicine providers and 1084 (21.9%) performed by plastic surgery. Procedural sedation was used in 373 (7.6%) visits. Lacerations repaired by plastic surgery were 25 times more likely to involve procedural sedation compared with those repaired by emergency medicine providers [adjusted odds ratio (aOR): 25.0, 95% CI: 17.1-36.5]. Additional factors included: laceration length (≥5 vs. <2.5 cm, aOR: 3.87, 95% CI: 1.88, 7.94), laceration complexity (complex vs. simple aOR: 2.50, 95% CI: 1.75, 3.57), and time of presentation (overnight vs. day, aOR: 2.58, 95% CI: 1.36, 4.91). CONCLUSION: Provider specialty was the strongest independent predictor of procedural sedation use, even after adjustment for wound characteristics. These findings highlight substantial practice variation and suggest an opportunity to develop standardized, clinically driven approaches to sedation decision-making for pediatric facial lacerations.