Pediatric Sedation

Paul D. Cooper, MD
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Subject: Pediatric Sedation

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Introduction

There are a number of reasons for sedating a child in medicine. Reduction or cessation of pain and/or anxiety is the most common grounds. In fact, The Joint Commission is so concerned about patient pain they recently designated pain as being the “fifth” vital sign. Sedation, especially in the outpatient setting, is used mainly to facilitate a better outcome for a procedure or an imaging study as well as to provide as comfortable an environment as possible for the patient. The levels of sedation are not exact states but rather a continuum from minimal sedation to deep sedation and general anesthesia. It is very easy for a child to slip into a deeper state of sedation, especially after anxiolysis has been achieved; therefore, great attention and care need to be exercised when sedating a pediatric patient. The overall goal is to adjust the sedation medication(s) in such a way as to provide adequate anxiolysis, sedation, and analgesia, but at a level that does not compromise respiratory or cardiovascular function (i.e. “deep enough but not too deep.”) Table 122-1 describes the levels of pediatric sedation. 
 
TABLE 122-1.
Definitions of Levels of Pediatric Sedation
For a pediatric sedation procedure, it is important to have a provider who is trained in, and responsible for, the sedation procedure—not splitting their concentration between the sedation and the other procedure that requires sedation. The sedation provider should also be versed in methods to rescue the patient including advanced pediatric airway management. The provider may be the person administering the sedation; however, an independent support person must be present to document as above as well as monitor the patient’s condition. For moderate sedation, it is strongly recommended to have an independent trained provider to administer the sedation and this is mandatory for sedation greater than moderate sedation. 
When the patient arrives for the sedation/procedure, there are a number of important items that need to be addressed. First, always obtain an informed consent from the parent or guardian. Second, there are important minimum fasting periods before elective sedation. When clear liquids are ingested (e.g., water, oral electrolyte solutions, fruit juice, tea, coffee) 2 hours should elapse before sedation is attempted. That interval is extended to 4 hours for breast milk, 6 hours for infant formula or nonhuman milk, and 6 to 8 hours for solid food. Third, provide instructions and information to the person who will be responsible for taking care of the child after the sedation. 
If a patient is being sedated for an imaging study, an immobilization device (i.e., a papoose board) may be considered for infants and small children. Most papoose boards are x-ray and magnetic resonance imaging safe, but be sure to confirm that this is the case with the one you are using. 

Equipment (SOAPME)

  • S (suction)

  • O (oxygen)

  • A (Airway): Size-appropriate airway equipment, laryngoscope blades, endotracheal tubes, stylets, face mask, bag-valve-mask

  • P (Pharmacy): Drugs for the sedation as well as emergency drugs including “rescue/reversal” drugs).

  • M (Monitors)

    • Blood pressure

    • Cardiorespiratory monitor

    • Expired carbon dioxide monitor

    • Pulse oximeter

  • E (Equipment): An IV and possibly an emergency cart with medicines and defibrillator.

Indications

  • Any procedure that elicits pain or anxiety. (This includes young children who need magnetic resonance imaging or computed tomography scans.)

  • In an outpatient or non–operating room setting, patients who are in American Society of Anesthesiologists (ASA) Physical Status Classification Class I and II are usually acceptable patients (see Step 3).

Contraindications (Relative)

  • Patients in ASA Class III-V (Table 122-2) require an experienced team for sedation, such as PICU staff or an anesthesiologist.

  • For children with certain conditions such as a mediastinal mass, airway abnormalities (including tonsillar hypertrophy) and obstructive sleep apnea, the physician must weigh the risks of sedation versus the benefit of the procedure or imaging study.

The Procedure

Step 1

Review dietary precautions with the person who had been taking care of the child and confirm that the recommended time has elapsed since the last ingestion. 
  • PITFALL: Never prescribe a sedative medication for the parent to administer at home prior to the procedure.

 
Minimum Fasting Periods

Step 2

Obtain IV access if required by the drugs and route of administration being planned. Although IV access is not mandatory for administration of all medications, it is strongly suggested to have IV access for any sedation in children. 
  • PITFALL: Because sedation is a continuum, it is in the best interest of the child to have IV access available, as in the event that the patient goes into a deeper state of sedation than intended or expected.

Step 3

Before starting sedation, always document the patient’s history and physical examination, including medical problems, prior surgeries, any history of anesthesia complications, allergies, and medicines. Also, document the patient’s baseline mental status, baseline vitals, accurate weight, and ASA classification. 
  • PEARL: Do not forget about herbal medicines, as some may affect sedation drug half-life!

 
American Society of Anesthesiologists Physical Status Classification Physical Status Classification

Step 4

During the sedation procedure, continuously monitor and document the patient’s vital signs, including their heart rate and oxygen saturation. Use a time based and start with a “time out” to confirm right patient right procedure. Blood pressure and respiratory rate should be monitored intermittently and all vitals should be recorded every 5 minutes until the patient returns to presedation baseline level of consciousness. Assess the airway throughout the procedure by direct observation and auscultation. Record all medications, including concentration, time of each administration, and the dose (both amount as well as amount per kilogram of body weight) and route of administration. Of course, clearly record any complications. 

Step 5

As with all medications, it is important for the provider to fully know the route of administration, dose, maximum dose, common side effects, onset of action, duration of action, and reversibility. 
 
Commonly Used Drugs and Their Properties

Step 6

Use the minimum amount of medication necessary to adequately meet the goals of sedation, anxiolysis, and/or analgesia. It is also usually important to use the shortest acting medication(s) available both for expedient recovery as well as rescuing the patient from unintended deeper sedation. 
  • Pearl: Frequently used combinations include midazolam + fentanyl and ketamine + midazolam + atropine.

  • PITFALL: Combining sedative drugs is helpful in sedation, but be careful because the side effects of respiratory and cardiovascular compromise may be potentiated with the use of multiple of drugs.

  • PITFALL: The end of the procedure, especially a painful one, is not a time for the physician to be any less vigilant about monitoring the patient. Frequently, after the painful stimulus has been removed, the patient may progress into a deeper state of sedation.

 
Common Drugs and Doses

Step 7

Reversal drugs may be used to rescue a patient who has become apneic. However, reversal drugs are not to be used just to “wake” the patient after the sedation is complete. 
  • PITFALL: Remember to monitor for the return of respiratory depression for at least 2 hours after administration of a reversal agent because the half-life of the reversal agent may be shorter than the sedation drug.

 
Rescue/Reversal Drugs

Complications

  • The most common complication during pediatric sedation is to have the patient unintentionally progress into a state of sedation that is deeper than intended. Many of the drugs used depress respiratory drive and/or may precipitate airway compromise or obstruction. The first 5 to 10 minutes and the end of the procedure are two of the most critical times. At the beginning of a procedure, the provider is trying to get the procedure underway and may not have allowed enough time for the onset of action of the sedation medications before administering more. At the end of the procedure, after the painful stimulus has been removed, the patient may progress into a deeper state of sedation. Therefore, it is always important to remember the ABCs (Airway, Breathing, and Circulation) of life support as well as the reversal/antagonist drugs.

  • Respiratory compromise: Hypoventilation, hypoxemia, apnea, airway obstruction

  • Cardiovascular compromise: Hypotension and cardiopulmonary arrest, arrhythmia

  • Seizures

  • Allergic reactions/anaphylaxis

  • Vomiting

  • Hypothermia

Postprocedure Instructions

After the procedure, the patient should be followed closely. The following are the recommended discharge criteria. Each criteria as well as the general condition of the patient needs to be documented as well as the time of discharge. A good “rule of thumb” is for the patient to be able to stay awake on his or her own for at least 30 minutes. 

Recommended Discharge Criteria

  • Cardiovascular function and airway patency are satisfactory and stable.

  • The patient is easily aroused, and protective reflexes are intact.

  • The patient can talk (if age appropriate).

  • For a very young or handicapped child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved.

  • Adequate hydration.

Coding Information and Supply Sources

Most of the drugs and equipment may be purchased from hospital supply sources. 

Bibliography

American Society of Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology.  2002;96:1004.
Cote CJ, Wilson S. American Academy of Pediatrics Clinical Report: Guidelines for monitoring and management of pediatric patients during and after sedation of diagnostic and therapeutic procedures: an update. Pediatrics.  2006;118:2587. [View Abstract]
Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet.  2006;367:766.
Robertson J, Shilkofski N. Analgesia and Sedation. In: Custer JW, Rau RE Eds. The Harriet Lane Handbook , 17th ed. Philadelphia: Elsevier Mosby;  2006.
Robertson J, Shilkofski N. Formulary. In: Custer JW, Rau RE Eds. The Harriet Lane Handbook , 17th ed. Philadelphia: Elsevier Mosby;  2006.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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