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Subject: Pediatric Sedation
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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).
Expired carbon dioxide monitor
E (Equipment): An IV and possibly an emergency cart with medicines and defibrillator.
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).
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.
PITFALL: Never prescribe a sedative medication for the parent to administer at home prior to the procedure.
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.
PEARL: Do not forget about herbal medicines, as some may affect sedation drug half-life!
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.
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.
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
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.