Keywords

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  1. 1.

    Procedural sedation:

    1. (a)

      The use of procedural sedation outside the operating room to minimize or alleviate pain and/or anxiety has become commonplace in most children’s hospitals.

    2. (b)

      The approach should be well thought out ahead of time and the person providing sedation should be qualified to handle any situation that may arise during the sedation, including respiratory or cardiac decompensation, anaphylactic reaction and vomiting with aspiration to name a few.

    3. (c)

      The process of providing procedural sedation can be divided into the following three components which will be discussed later in detail:

      1. (i)

        Pre-sedation.

      2. (ii)

        Intra-procedure.

      3. (iii)

        Post-sedation.

  2. 2.

    Definitions and levels of sedation:

    1. (a)

      The approach to the child and use of medications may vary greatly, i.e. intramuscular midazolam to relieve anxiety for a brief non-painful procedure versus intravenous fentanyl and propofol to achieve deep sedation for a procedure that is both painful and noxious.

    2. (b)

      The term “conscious sedation”, while still present in the medical vernacular, is a misnomer and should be replaced with “procedural sedation”. A child is either conscious and receiving medications to relieve pain and/or anxiety, or they are sedated, with a correspondingly altered mental status (see Tables 1 and 2).

      Table 1 Common definitions used in procedural sedation
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      Table 2 Levels of sedation
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  3. 3.

    Pre-Sedation Assessment:

    1. (a)

      History:

      1. (i)

        A general history of each child should be known prior to administering sedative and analgesic medications. Important historical information that may impact the choice of medications administered is summarized in Table 3.

      2. (ii)

        NPO guidelines per Table 4.

      Table 3 Pre-sedation assessment
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      Table 4 NPO guidelines
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    2. (b)

      Physical Exam:

      1. (i)

        A focused physical exam should include assessment of vital signs, cardiopulmonary function and baseline neurological status.

      2. (ii)

        Airway.

        1. 1.

          The pediatric airway is anatomically different than the adult.

          Fig. 1
          figure 1

          Pediatric airway, as compared to the adult. The narrowest part of the pediatric airway is the cricoid ring (Included with permission from Susan Gilbert as published at http://www.medartist.com/emergency_pediatrics.html. Downloaded 28 Apr 2013)

          Full size image
        2. 2.

          A child’s tongue is relatively larger compared to the space it occupies in the oropharynx.

          1. (a)

            Children with macroglossia, micrognathia or retrognathia may have even more limited space relative to the oropharynx.

        3. 3.

          Larynx is more anterior and superior.

        4. 4.

          Relative to adult’s epiglottis, a child’s is longer, more narrow and more floppy.

        5. 5.

          Children younger than 8-years-old have the narrowest part of their upper airway located in the subglottic region at level of cricoid cartilage.

          1. (a)

            Any obstruction in this area will significantly impair airflow.

          2. (b)

            When supine, care should be taken to ensure the airway remains aligned and excess flexion or extension of the neck does not occur.

        6. 6.

          A roll under the neck and/or shoulders should be utilized to create a “sniffing” position, whereby the horizontal plane of the ears (with patient lying supine) is anterior to the shoulders

        7. 7.

          Mallampati classification may be performed to assist in predicting a difficult intubation but has not been shown to affect risk stratification for children undergoing procedural sedation.

      3. (iii)

        In addition to the airway assessment, attention should be paid to any physical attributes the child may have that would put him/her at risk for complications, such as:

        1. 1.

          Obesity or failure to thrive.

        2. 2.

          Scoliosis or other skeletal abnormalities.

        3. 3.

          Baseline neurologic impairment.

      4. (iv)

        A brief examination of the chest with auscultation of lungs and heart should be performed.

      5. (v)

        After completion of physical exam, assignment of ASA score may be helpful in stratifying the child’s relative risk of sedation (Table 5)

        Table 5 ASA classification
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  4. 4.

    Intra-procedure:

    1. (a)

      Informed consent must be obtained for all sedated procedures.

    2. (b)

      A time out should occur prior to administering any medications or starting the procedure.

      1. (i)

        Monitoring and equipment.

        1. 1.

          All children undergoing sedation to facilitate invasive or non-invasive procedures require continuous cardiopulmonary monitoring including pulse oximetry.

        2. 2.

          Capnography, a tool that measures exhaled CO2, can be very useful in monitoring airway patency and ventilation in the sedated child.

        3. 3.

          The mnemonic SOAPME can help the provider ensure he/she has the appropriate equipment in place prior to starting the procedure.

          1. (a)

            S (suction).

          2. (b)

            O (oxygen).

          3. (c)

            A (airway).

          4. (d)

            P (pharmacy).

          5. (e)

            M (monitors).

          6. (f)

            E (extra equipment).

      2. (ii)

        Sedative medications (Table 6)

        1. 1.

          There are many sedatives that are currently used for procedural sedation. Some have purely sedative effects while others also provide analgesia. When used in conjunction with a narcotic or another sedative, dosing should be decreased to minimize the chance of over-sedation.

        2. 2.

          Combinations that are often used include versed/fentanyl, versed/ketamine, propofol/fentanyl and propofol/ketamine.

        3. 3.

          Midazolam (Versed) is a benzodiazepine that has sedative, hypnotic, amnestic and anxiolytic properties. It produces its effects by enhancing the inhibitory action of GABA.

          1. (a)

            Commonly used as intramuscular (IM) injection for the child who either needs a brief procedure where complete stillness is not an issue, or as premed to relieve anxiety for IV placement. Recommended max dosing is 10–15 mg total.

          2. (b)

            May also be given oral or nasal, but sneezing or coughing will limit its effectiveness and may require redosing.

          3. (c)

            Flumazenil is a GABA receptor antagonist and can reverse the clinical effects of any benzodiazepine if overdose is suspected.

        4. 4.

          Lorazepam (Ativan) has similar clinical effects as midazolam.

          1. (a)

            Rarely used for procedural sedation and cannot be given IM.

          2. (b)

            Duration much longer.

        5. 5.

          Ketamine is a PCP derivative that has sedative, amnestic and analgesic effects. It produces its effects by blocking NMDA receptors, leading to inhibition of glutamate mediated transmission.

          1. (a)

            Can be used as IM or IV injection alone to achieve both anxiolysis and analgesia, such as is needed for fracture reductions.

          2. (b)

            May cause tachycardia and hypertension.

          3. (c)

            Can increase airway secretions and cause airway bronchodilation.

          4. (d)

            Emergence reaction can occur as hallucinations, confusion and/or agitation. Benzodiazepines in small doses may be given to help minimize this response.

        6. 6.

          Propofol (Diprivan) is an anesthetic medication that has sedative, hypnotic and amnestic effects. It is thought to produce its effect via the GABA pathways.

          1. (a)

            Most commonly used sedative medication in procedural sedation.

          2. (b)

            Typically used as bolus injections until induction occurs, then as IV infusion to maintain the desired level of sedation.

            1. (i)

              Infusion rates for procedural sedation range from 75 to 200 mcg/kg/min.

            2. (ii)

              Lidocaine (10 mg in 1 ml) can be left to dwell in PIV for one minute before injection to alleviate local burning sensation.

          3. (c)

            Very rapid onset of action.

          4. (d)

            May cause hypotension and/or apnea, especially with rapid bolus.

        7. 7.

          Dexmedetomidine (Precedex) is an extremely potent alpha 2 receptor agonist with preference for centrally mediated activity via GABA activity. It produces sedation and analgesia.

          1. (a)

            Typically used as a bolus followed by infusion.

          2. (b)

            Boluses should be given very slowly and not more frequent than every 10 min.

          3. (c)

            Rapid bolus can lead to dramatic bradycardia and hypotension.

          Table 6 Sedative medications
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      3. (iii)

        Analgesic medications (Table 7).

        1. 1.

          The majority of analgesics used for procedural sedation are opioid based. Non opioid based analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are typically reserved for use after the procedure.

        2. 2.

          If an adverse effect such as respiratory depression is suspected in the child who received a narcotic, naloxone should be given. This will reverse the analgesic and sedative effect for a brief period of time. Be prepared for the child to awaken and be in obvious pain. Also be prepared to redose as necessary until the symptoms of overdose have resolved.

        3. 3.

          Morphine is the prototypic opiate and acts on the mu receptor to induce analgesia. Higher doses will also cause sedative and hypnotic effects. It can be given PO, PR, SQ, IM or IV. Dosing varies by route and should be verified prior to administration.

          1. (a)

            High doses in infants have been associated with prolonged apnea.

          2. (b)

            Histamine release may lead to local flushing and pruritus as well as systemic effects like wheezing or hypotension.

        4. 4.

          Fentanyl is a synthetic derivative of meperidine that acts at the mu receptor. It has less hypnotic and sedative effects than morphine.

          1. (a)

            As much as 100 times more potent than morphine.

          2. (b)

            Has a very rapid onset.

          3. (c)

            Should be bolused very slowly (over 2 to 5 min) to minimize the chance of chest wall rigidity and respiratory decompensation.

          4. (d)

            May be used in the child with suspected allergy to morphine.

        5. 5.

          Hydromorphone (Dilaudid) is a derivative of morphine that acts at the mu receptor.

          1. (a)

            As much as five times more potent than morphine.

          2. (b)

            Has the longest duration of the opioids.

          3. (c)

            Like fentanyl, causes less pruritus, nausea and dysphoria than morphine.

      Table 7 Analgesic medications
      Full size table
  5. 5.

    Post-Sedation:

    1. (a)

      The child should be monitored until they return to their pre-sedation baseline.

    2. (b)

      A child should not be discharged until certain criteria are met:

      1. (i)

        Stable vital signs.

      2. (ii)

        Return to baseline mental status.

      3. (iii)

        Head control and strength is appropriate to maintain a patent airway.

      4. (iv)

        Pain is well controlled.

      5. (v)

        Nausea is well controlled.

    3. (c)

      Special circumstances such as administering a reversal agent or a prolonged adverse event during the sedation may require the child to be monitored longer and/or admitted to the hospital for overnight observation.

    4. (d)

      Specific instructions should be given to the child’s family telling them what to do if the child has any medical problems immediately following the sedation.

  6. 6.

    Adverse events during procedural sedation:

    1. (a)

      Desaturation may occur from many causes and should be treated immediately. The most common cause is secondary to upper airway obstruction. However, lower airway obstruction, especially in the child with known asthma may occur suddenly and require treatment.

      1. (i)

        Check equipment to ensure oxygen is flowing and all tubes are connected and without obstruction.

      2. (ii)

        Apnea can be central or obstructive.

        1. 1.

          Central apnea is usually a result of over-sedation.

          1. (a)

            Treatment consists of supporting the child’s airway and breathing until the drug has worn off.

            1. (i)

              May require bag mask ventilation.

          2. (b)

            May consider reversal agent if prolonged.

        2. 2.

          Obstructive apnea is obvious by the observation that child has abdominal and/or chest movements but no air entry into the lungs.

          1. (a)

            Treatment is based on the specific causes that will be discussed below.

      3. (iii)

        Upper airway obstruction is the most common cause of desaturation and is usually due to hypotonia of soft palate and/or epiglottis as well as accumulation of secretions.

        1. 1.

          Audible stridor is likely due to secretions which should immediately be suctioned, using caution not to suction too deep and cause coughing or reflex gagging.

        2. 2.

          If pharyngeal hypotonia is suspected, reposition the head and neck to ensure midline position with slight extension of neck: Do not overextend.

          1. (a)

            “Sniffing position” as discussed earlier in the chapter is the desired position to maintain a patent airway.

          2. (b)

            If midline position is not successful, may try gently rotating child’s head to the side while maintaining slight extension of neck.

        3. 3.

          Provide chin lift followed by jaw thrust until obstruction has been relieved.

        4. 4.

          Consider nasal trumpet or oral airway as adjuncts.

      4. (iv)

        Laryngospasm is a spasm of the glottic structure and can be an emergency if complete; partial obstruction allows some air entry.

        1. 1.

          Typically occurs during induction or emergence but can occur at any time.

        2. 2.

          Stridor may be heard and is often pre-empted by coughing.

        3. 3.

          Child will be attempting to breath but no air entry is occurring.

          1. (a)

            Prolonged attempts to breath with sudden release of glottic obstruction can cause pulmonary edema.

        4. 4.

          Treatment is multifactorial and stepwise including:

          1. (a)

            Increase in oxygen supply immediately.

          2. (b)

            Jaw thrust with suctioning of mouth and oropharynx.

          3. (c)

            Deepen sedation with bolus of IV sedative.

          4. (d)

            Pressure on the “laryngospasm notch”, an area just anterior to the mastoid process and below the earlobe, can be effective while performing a jaw thrust.

          5. (e)

            If none of the above are successful within 15–30 s, bag mask ventilation must be applied starting with continuous positive airway pressure (CPAP) and administering positive pressure breaths if necessary.

          6. (f)

            May require muscle relaxant such as succinylcholine.

      5. (v)

        Aspiration of oropharyngeal or gastric contents can occur at any time during the procedural sedation.

        1. 1.

          Proactive suctioning of secretions immediately upon hearing airway noises may be preventative.

        2. 2.

          Minor aspiration will not require treatment other than the patient clearing his/her airway with a productive cough.

        3. 3.

          A major aspiration, especially with evident vomitus, will likely require abortion of the procedure with subsequent treatment including:

          1. (a)

            Increased oxygen supply including bag-valve-mask.

          2. (b)

            Albuterol treatment may help with airway clearance.

          3. (c)

            Monitoring after the child has awakened may include hospital admission and observation for signs and symptoms of aspiration pneumonia or pneumonitis.

      6. (vi)

        Hypotension may occur as a direct result of the sedative medications, as a secondary result of the child’s underlying medical condition, or a combination of both. Hypotension may be a result of peripheral vasodilatation, direct myocardial depression or both. Changes in cardiac output from changes in intra-thoracic pressure during sedation may also occur.

        1. 1.

          A drop in BP from baseline is extremely common when using propofol and will be exacerbated by any adjunct medications such as an opioid.

        2. 2.

          Generally responds well to a decrease in the sedative infusion rate and a fluid bolus, i.e. 10–20 mL/kg NSS.

          1. (a)

            Re-assessment of the child including palpation of pulses and examination of skin should occur to ensure perfusion is maintained.

      7. (vii)

        Anaphylaxis or allergic reaction is rare but can be life threatening. Any existing allergies should be identified during the pre-assessment phase.

        1. 1.

          Urticaria with or without redness that was not present prior to the procedure along with any signs or symptoms of respiratory distress, swelling of face and/or tongue should be considered an allergic reaction.

        2. 2.

          Hypotension may not be present but can occur and be very severe due to significant vasodilatation.

        3. 3.

          Treatment consists of the following:

          1. (a)

            Abort the procedure and administer 100 % oxygen.

          2. (b)

            Stop administering the sedative/analgesic.

          3. (c)

            Administer epinephrine 0.01 mg/kg of 1:1,000 concentration IM into the lateral thigh, may need to repeat.

          4. (d)

            Give 10–20 mL/kg NSS bolus, may repeat if necessary.

          5. (e)

            Consider antihistamines (H1 and H2 blockers).

          6. (f)

            Consider IV corticosteroids.

          7. (g)

            If not responding immediately, get help and provide cardiopulmonary support until help arrives.

  7. 7.

    Procedural sedation for children can be done safely and with great success. The key is to be thoroughly prepared for any eventuality. Know your equipment, know your medications and know the personnel you are working with. Finally, knowledge about your patient and his/her medical history is a must. Remember, safety first, before, during and after the procedure!