Procedural sedation in children: Preparation

INTRODUCTION — This topic reviews the preparation for pediatric procedural sedation including assessment of American Society of Anesthesiologists (ASA) physical status classification and fasting status, and assurance of necessary personnel, equipment, and monitoring.

Performance of procedural sedation, properties of specific agents, and strategies for selecting medications for pediatric procedural sedation outside of the operating room are discussed separately:

●(See "Procedural sedation in children: Approach".)

●(See "Pediatric procedural sedation: Pharmacologic agents".)

●(See "Procedural sedation in children: Selection of medications".)

TOPIC SCOPE — This topic provides guidance for emergency and scheduled (elective) pediatric procedural sedation performed by sedation providers from a variety of disciplines including general and pediatric emergency medicine, pediatric critical care medicine, pediatric hospital medicine, and general pediatrics.

BACKGROUND — The performance of diagnostic and therapeutic procedures in children is safer and more likely to be successful when the patient's motion is controlled and when associated pain and anxiety are effectively controlled. Pharmacologic and nonpharmacologic interventions that consider the child's age, developmental status, and clinical circumstances are required to meet these goals [1]. In addition, attention to the treatment of pain and anxiety associated with the child's condition is a requisite of acceptable and compassionate patient care. Specific issues related to the importance of addressing pain and anxiety in emergency medical systems have been emphasized in a clinical report from the American Academy of Pediatrics (AAP) [2].

The increased availability of short-acting sedatives along with accurate noninvasive monitoring and sedation-specific training of providers has enabled effective and safe management of sedation and analgesia outside of the operating room [3]. Procedural sedation is an evolving field practiced by a diverse group of multidisciplinary practitioners in an expanding variety of clinical settings [4]. Among the challenges that must be addressed, the development of standardized definitions of sedation terminology designed to facilitate the tracking and reporting of patient-centered outcomes is essential to ensure safe and efficacious sedation practice [5,6]. In addition, there remains a number of guidelines for sedation promulgated by various specialty societies [7-11].

GOALS OF SEDATION AND ANALGESIA — Goals of sedation and analgesia for painful procedures are to [7]:

●Maintain patient safety and welfare

●Minimize physical pain and maximize patient comfort

●Control anxiety, minimize psychological trauma, maximize amnesia

●Control behavioral movement to allow safe performance of procedures

The clinician must determine the appropriate level of sedation and/or analgesia required for a particular procedure. In addition to medications, age-appropriate, nonpharmacologic interventions should always be employed to maximize patient comfort. (See "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions'.)

DEFINITIONS — The American College of Emergency Physicians (ACEP)defines "procedural sedation" as the use of anxiolytic, sedative, analgesic, or dissociative drugs to attenuate pain, anxiety, and motion to facilitate the performance of a necessary diagnostic or therapeutic procedure, provide an appropriate degree of amnesia or decreased awareness, and ensure patient safety [1,4]. The consensus expert definition provided by the International Committee for the Advancement of Procedural Sedation (ICAPS) is consistent with the ACEP definition but further defines safety as preservation of airway patency and reflexes, spontaneous breathing, and hemodynamic stability [12].

The progression from minimal sedation to general anesthesia is a continuum, and patients can easily move from one "level" of sedation to another. Attempts to codify sedation "states" have evolved over the last 30 years. The American Academy of Pediatrics (AAP), the American Society of Anesthesiologists (ASA), the American Academy of Pediatric Dentists, and the Joint Commission use the following definitions to describe the depth of sedation [4,7,13,14]:

●Analgesia – Relief of pain without intentionally producing a sedated state. Altered mental status may be a secondary effect of medications administered for analgesia.

●Minimal sedation – The patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular function is unaffected.

●Moderate sedation/analgesia – The patient responds purposefully to verbal commands either alone or accompanied by light touch. Maintains airway and adequate ventilation without intervention. Cardiovascular function is maintained.

●Deep sedation/analgesia – The patient cannot be easily aroused but responds purposefully to noxious stimulation. May require assistance to maintain airway and adequate ventilation. Cardiovascular function is usually maintained.

●General anesthesia – The patient cannot be aroused. Often requires assistance to maintain airway and positive pressure ventilation. Cardiovascular function may be impaired.

Guidelines and regulatory agencies also use these sedation depth descriptions to describe the relative risk state for a given patient; thus, the level of provider care and monitoring varies with the sedation level [4]. As a general rule, the Joint Commission recommends that providers have the capability of managing patients one level deeper than the targeted depth.

Sedation with ketamine represents an exception to the sedation continuum, whereby increasing doses result in deeper levels of sedation and increased risk for respiratory suppression. Members of ACEP and the Society for Pediatric Sedation (SPS) describe dissociative sedation as being characterized by a trance-like, cataleptic state in which the patient experiences profound analgesia and amnesia but generally retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability [15-17]. Respiratory adverse events such as apnea or laryngospasm, although uncommon, may still occur, and providers must always be prepared to rescue the patient from a deep sedation state anytime ketamine is administered [18-20]. Some experts (ACEP and SPS) have suggested that this state should be considered distinct from the sedation spectrum outlined above and called "dissociative sedation" [10,17]. However, this categorization of ketamine sedation is not part of the standard definitions of sedation used by the ASA, AAP, and the Joint Commission. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Ketamine'.)

"Conscious sedation" is an outdated term that is sometimes used to refer to minimal or moderate sedation. Because effective sedation usually impairs consciousness, this term has is not used when referring to sedation states in children.

PRE-SEDATION EVALUATION — All patients should undergo evaluation for their suitability for sedation prior to the procedure. Specific details of the patient history that increase the frequency of adverse events and should be obtained are listed in the sections that follow. The history of previous exposure to sedation or general anesthesia is especially important because the outcome of any specific sedation/anesthesia encounter is likely best predicted by previous outcomes and experiences. Relevant family history and the time (and content) of their last oral intake should also be documented.

Physical examination should, at minimum, include auscultation of the heart and lungs and evaluation of the neck and airway for conditions that might interfere with bag-mask ventilation, endotracheal intubation, or resuscitation.

Focused medical history — The clinician should obtain a medical history that identifies potential sedation risks, including the following [8,21,22]:

●History of lower respiratory tract infection within the last two weeks [23]

●Major medical illnesses, especially those affecting the respiratory, cardiovascular, and neurologic systems

●History of snoring or central or obstructive sleep apnea

●History of prior sedation or general anesthesia including any prior complications

●History of prematurity [24]

●Family history of an adverse reaction to sedation, analgesia, or general anesthesia

●Pregnancy status, if applicable

●Drug or food allergies

●Current medications, including prescription, over-the-counter, and herbal preparations

●Recent illicit drug use

●Review of systems that evaluate cardiac, pulmonary, renal, bowel, and hepatic function

Fasting and aspiration risk — The purpose of fasting prior to sedation is to reduce the risk of pulmonary aspiration of gastric contents. Aspiration of gastric contents during pediatric sedation is a rare though much-feared complication. Based upon one prospective observational study of over 139,000 elective pediatric sedations performed by organized sedation services participating in the Pediatric Sedation Research Consortium, aspiration occurred in approximately 1 in 10,000 sedations. NPO status for liquids and solids was not found to be an independent predictor of major complications or aspiration in this study [25]. Patients undergoing emergency procedures that require sedation are thought by many experts to be at increased risk of aspiration because fasting has often not occurred and the procedure cannot be delayed [4,7]. However, in a cohort of almost 6200 children who received procedural sedation for emergency procedures, half of whom did not meet American Society of Anesthesiologists (ASA) fasting guidelines, none experienced pulmonary aspiration [26]. In addition, no association between fasting duration and any type of adverse event was detected.

Gastric point of care ultrasound (POCUS) has been proposed as an alternate means of assessing aspiration risk in infants and children. In an observational of gastric POCUS performed in 103 children prior to procedures for traumatic injuries in the emergency department, gastric volume could be measured in 85 percent of patients but was not strongly correlated with fasting time [27]. Small observational studies in infants and children have also documented the ability to measure preoperative gastric volume and contents with POCUS. In experienced hands, gastric POCUS is quick and noninvasive. However, results of gastric POCUS have not been associated with the risk of aspiration; further study is required before using gastric ultrasound to guide clinical decisions. (See "Preoperative fasting in children and infants", section on 'Preoperative gastric ultrasound'.)

Elective procedures — For children undergoing sedation for scheduled elective procedures, fasting guidelines are usually created on an institutional basis and reflect multidisciplinary consensus among anesthesiology, sedation service physician leadership, and nursing services. We suggest fasting as follows:

●One hour after receiving clear liquids

●Four hours after breast feeding

●Six hours after ingesting nonfatty solid foods (eg, toast or bananas), formula, or milk other than human milk

●Eight hours after full meals

Increasingly, recommended fasting intervals for clear liquids are being reduced; fasting guidelines from many institution permit clear liquids up to one hour prior to procedural sedation for children. The suggested fasting times for the other liquids and foods are largely consistent with consensus guidelines developed by the ASA, the American Academy of Pediatrics (AAP), the National Institute of Clinical Excellence, and the American Academy of Dentistry guidelines [7-9].

Although fasting to reduce the risk of aspiration during procedural sedation makes intuitive sense, there is little evidence that this approach actually prevents aspiration [25,28,29]. For example, in a prospective observational study from the Pediatric Sedation Research Consortium of over 139,000 children undergoing elective sedation by a dedicated sedation service in the outpatient setting, of whom almost one-quarter did not meet ASA fasting criteria, 10 aspirations and 75 major complications occurred [25]. Fasting status was not an independent predictor of either aspiration (odds ratio [OR] 0.8, 95% CI 0.1-4.1) or major complications (OR 1.1, 95% CI 0.6-1.9). However, the relationship between fasting duration and aspiration or major complications remains uncertain given the low number of events despite a very large sample size.

Preoperative fasting in infants and children is discussed separately. (See "Preoperative fasting in children and infants".)

Urgent or emergency procedures — Several major organizations have provided guidance on fasting for procedural sedation, and important differences between these guidelines exist. The American College of Emergency Physicians recommends that procedural sedation not be delayed in adults or children receiving care in the emergency department based solely upon fasting time [11].

For children who need to undergo a painful procedure in urgent or emergency situations where complete gastric emptying is not possible, we suggest not delaying procedural sedation based upon fasting status alone. However, the provider should evaluate the timing and nature of the last oral intake, the urgency of the procedure, and the risk for aspiration based upon procedural and patient factors (eg, children with higher ASA levels or abnormal airways are at greater risk for adverse events) when determining the depth and length of procedural sedation [10,11].

We advise the following approach to reducing aspiration risk for children undergoing sedation for urgent or emergency procedures outside of the operating room (eg, fracture reduction, abscess incision and drainage, or laceration repair):

●Carefully consider the risks and benefits of performing the procedure in patients who have presumed full stomachs. Although there is no proof that longer fasting times reduce aspiration risk, if the procedure is not a true emergency, it is reasonable to delay sedation if the child has not fasted [7,30]. However, it is important to recognize that children who meet ASA elective procedure fasting guidelines were not less likely to experience serious adverse events or aspiration in two large cohorts of children who received elective and emergency sedation [25,26]. (See 'Elective procedures' above.)

●Decrease the targeted depth of sedation, when possible. Limited evidence in children has associated the risk of adverse effects with depth of sedation [31]. Minimal sedation may better permit the patient to maintain protective airway reflexes, which reduces risk. However, maintenance of a specific depth of sedation (eg, minimal or moderate sedation) is not always possible in individual patients, and minimal sedation is not adequate for many emergency procedures such as fracture reduction.

●In patients with significant aspiration risk (eg, ingestion of a large meal just prior to injury in a patient with other risk factors for aspiration) for whom deep sedation is necessary and procedural delay is not possible, providers must assess risks of aspiration with the benefits of a potentially life- or limb-saving procedure and be prepared to manage complications when sedation is administered. Some experts would suggest rapid sequence intubation prior to sedation, although evidence is lacking as to whether this approach reduces aspiration risk [28,32-36]. For these patients, consultation with an anesthesiologist or other sedation expert is strongly encouraged.

●Administration of preprocedural antacids or motility agents has not been shown to reduce aspiration risk and is not indicated [37].

Evidence suggests that fasting does not reduce adverse events during procedural sedation in the emergency department and that pulmonary aspiration is a rare event in this setting [26,31,38-40]. For example, in a multicenter prospective observational study of over 6100 children who were ASA level I or II and received emergency department sedation, the rates of any adverse event (11.6 percent) and serious adverse events (5.1 percent) did not differ significantly between children who did and did not meet ASA fasting guidelines [26]. No cases of pulmonary aspiration occurred. Almost 3000 children did not meet fasting guidelines for solids, and 310 did not meet guidelines for liquids. These sedations were performed by practitioners with a high level of pediatric airway and resuscitation expertise in settings that encouraged careful assessment and close monitoring. In addition, these studies are observational in nature and tend to categorize patients as "fasted" or "not fasted" rather than according to a spectrum of risk that takes into account the exact timing and nature of enteral intake as well as the underlying pathology present in each patient. As a result, these studies are not definitive in nature and, in our view, their results should not be interpreted as "fasting makes no difference at all" in terms of the risk of sedation for urgent or emergency procedures.

In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has provided guidance for sedation in children that addresses fasting as follows [9]:

●Fasting is not needed for:

•Sedation with 50 percent nitrous oxide (in oxygen) alone

•Moderate sedation where the child maintains verbal contact

According to the ASA and AAP guidelines, both of these are considered types of minimal sedation for which fasting is not necessary.

●Fasting that corresponds to the ASA guideline (two hours for clear liquids, four hours for breast milk, and six hours for formula, nonhuman milk, and solids) is advised for patients undergoing the following types of sedation for elective procedures:

•Moderate sedation where the child might not maintain verbal contact

•Deep sedation

Regardless of which fasting guidelines are used in children undergoing urgent or emergency procedures, clinicians who perform pediatric sedation should use fasting status and urgency of the procedure to decide the timing of sedation relative to last oral intake, the target depth of sedation, and the specific medications used [41].

Risk classification — The ASA classification allows providers to place patients in general categories of health from normal health to near death [7]. As part of the pre-sedation evaluation, an ASA classification should be given to each patient as follows:

●Class I – A normally healthy patient

●Class II – A patient with mild systemic disease (eg, mild asthma, controlled diabetes mellitus)

●Class III – A patient with severe systemic disease (eg, moderate to severe asthma, poorly controlled diabetes mellitus, pneumonia)

●Class IV – A patient with severe systemic disease that is a constant threat to life (eg, severe bronchopulmonary dysplasia, advanced cardiac disease)

●Class V – A moribund patient who is not expected to survive without the operation (eg, septic shock, severe trauma)

Although the ASA classification was not specifically designed to rate sedation risk, the ASA classification does appear to correlate with appropriateness for sedation. Children with ASA classes I and II are generally reasonable candidates for mild, moderate, and deep sedation outside of the operating room. In most instances, those patients with ASA classes III, IV, and V, functional needs, or airway abnormalities warrant consultation with a pediatric anesthesiologist or clinician with specific pediatric sedation expertise (eg, emergency physician, pediatric intensivist) who regularly provides sedation for children with severe systematic disease [7]. Having noted that the ASA status can be used as a general indicator of sedation requirements and risk, specific coexisting pathology (such as airway configuration) is much more important in predicting the patient response to sedation than the general ASA classification.

Young children, especially infants less than one year of age, require sedation for procedures in the emergency department setting much less commonly than older children [18]. While evidence is lacking it is logical that sedation this age group should be delivered by providers who are experienced with the unique physiologic and pharmacologic aspects of sedation in infants. Whether young children are at increased risk of adverse effects during procedural sedation is unclear. In an individual-patient data meta-analysis of over 8,250 children who received ketamine sedation for emergency department procedures, children under two years of age were found to have twice the odds of an airway or respiratory adverse event [42]. In a more recent, secondary analysis of a prospective patient cohort of nearly 6300 children who received emergency sedation, no significant difference in the incidence of adverse events in children 13 to 24 months of age was detected [43]. This study was not able to analyze the risk of adverse events in infants as the sample size in the first year of life was not sufficient. Due to the infrequent occurrence of sedation for emergency procedures in the very young, the true risk of adverse events is not known, and sedation should be administered accordingly.

Airway assessment — Despite the importance of identifying children with potentially difficult airways prior to sedation, evidence specific to this goal is limited. Nevertheless, a reasonable, systematic approach for children can be developed from experience with adult patients in the operating room and emergency department using the mnemonic LEMON (table 1) (see "The difficult pediatric airway for emergency medicine", section on 'Identification of the difficult pediatric airway'):

●L: Look externally for indicators of a difficult airway (eg, a misshapen head, facial abnormalities, or neck masses).

●E: Evaluate mouth opening, thyromental distance, and the distance between the mandible and the thyroid cartilage (this correlates with the distance between the base of the tongue and the larynx) (picture 1). Adequate mouth opening and thyromental distance should be the width of three of the patient's fingers. The distance between the mandible and thyroid cartilage should be the width of two fingers.

●M: Mallampati score (figure 1): When applying the Mallampati score to airway assessment of children prior to procedural sedation, important limitations of the score must be considered. The Mallampati score was originally devised to identify patients for whom tracheal intubation may be difficult [44]. Considering that tracheal intubation is only rarely required as a result of procedural sedation in children (11.4 per 10,000 in the largest elective sedation cohort [45] and 0 of 6,295 in the largest emergency sedation cohort [18]), extrapolating Mallampati score to patient risk in procedural sedation is fraught with challenges. In one study of emergency department sedation, higher Mallampati scores in children were not associated with increased risk for adverse events [46]. In addition, assigning a Mallampati score may be difficult and unreliable in young children and any patient unable to cooperate due to their underlying condition. Thus, some pediatric sedation experts do not recommend the use the Mallampati score in children.

●O: Obstruction: Signs of airway obstruction (eg, stridor, a muffled voice, or difficulty handling secretions) always indicate that airway management may be difficult. Upper airway obstruction can interfere with bag-mask ventilation as well as with laryngoscopy and intubation.

●N: Neck mobility: Conditions that limit neck mobility (eg, congenital anomalies or cervical spine immobilization) can usually be identified by observation.

In considering these physical attributes, children with a severe anatomical abnormality (eg, micrognathia or a previously healthy child with signs of upper airway obstruction) or a combination of more than one of the above abnormalities are most likely to be challenging to manage if airway or respiratory complications develop secondary to procedural sedation. Prior to administering sedation to children with potentially difficulty airways, consider the risks, benefits, and need for anesthesiology and/or otolaryngology consultation prior to sedating.

PREPARATION — Prior to performing urgent or elective procedural sedation, the clinician should obtain informed assent or consent from the patient and, if indicated, informed consent from the primary caregiver and ensure that the proper personnel, monitoring capability, and equipment are present to perform the procedure in a safe manner. Whenever possible, informed consent should also be obtained prior to sedation for emergency conditions, although in some instances, the patient's condition may not allow delay for informed consent.

Informed consent — Components of the informed consent for procedural sedation should include:

●The specific medications that will be administered, potential side effects (eg, vomiting, respiratory depression, laryngospasm, emergence reaction), and the likely duration of sedation

●Precautions taken to manage adverse effects that might occur, including frequent assessment, continuous monitoring, personnel dedicated to performing the sedation, and immediate availability of resuscitation equipment and (if applicable) reversal agents

●Alternative agents and why they are not being used

In agreement with the American Academy of Pediatrics (AAP), we support family presence for procedures; however, care must be taken to ensure that appropriate personnel are available to prepare and guide parent(s) or guardian(s) through the procedural sedation experience [47,48]. Caregivers who choose to remain with the child during sedation should be informed that their child's appearance during sedation may be upsetting (eg, blank stare or nystagmus with ketamine) and that the child may vocalize or have other nonspecific behaviors that indicate discomfort despite effective procedural sedation.

Personnel — Clinicians who administer sedation must understand the pharmacology of the drugs they use and be comfortable choosing a procedural sedation plan for the patient [9]. Because depression of consciousness is a continuum (except for ketamine) and responses to medications vary, clinicians must be able to deal with complications in patients whose level of sedation becomes deeper than intended or who experience an adverse reaction to medication. Competence in emergency airway management is mandatory if deep sedation is intended or possible and is strongly advised for lighter levels [9].

Administration of moderate sedation requires at least two individuals, typically an advanced practice clinician (eg, physician, physician's assistant, advanced practice registered nurse, nurse anesthetist) and an assistant (typically a registered nurse). At least one person present should have training in pediatric resuscitation and be skilled in airway management and cardiopulmonary resuscitation (CPR).

For deep sedation outside of the operating room and in hospital-based settings, our practice is to have an advanced practice clinician or a nurse with extensive experience in airway management and resuscitation (such as an emergency department, intensive care unit [ICU], or post-anesthesia care unit [PACU]-experienced registered nurse) to monitor the patient's sedation. In all cases, there should be at least one advanced practice clinician present during the procedure who is qualified and experienced in definitive management of the pediatric airway, including bag-mask ventilation, the placement of supraglottic devices, and endotracheal intubation.

For deep sedation provided in a free-standing outpatient facility, the person monitoring the patient should be fully capable of managing and recovering a patient from general anesthesia. In these settings, the proceduralist should be qualified to assist in resuscitating a pediatric patient from respiratory or cardiac arrest as well.

Monitoring — The temperature, heart rate, respirations, and blood pressure should be measured and recorded prior to initiating procedural sedation. For patients undergoing moderate or deep sedation, appropriate monitoring consists of pulse oximetry, capnography, heart rate, respirations, and blood pressure. Because the exact depth of sedation is uncertain when providing moderate or deep sedation, our approach is to routinely apply end-tidal carbon dioxide (ETCO₂) monitoring. If ETCO₂ monitoring is not available or is logistically difficult (eg, sedation for repair of nasal, lip, or other oral wounds), constant observation of breathing, auscultation of the chest, or the use of any reliable monitor of respiration is imperative.

Depth of sedation monitoring using bispectral index (BIS) or other sedation depth monitors is not currently recommended during pediatric procedural sedation outside of the operating room. Although some sedation studies have found these monitors to have good correlation with clinical depth of sedation scales, most have found poor differentiation between moderate and deep sedation, issues with motion artifact, lack of standardization in infants, and no correlation with sedation depth for children receiving ketamine. (See "Procedural sedation in children: Approach", section on 'Preparation'.)

Vascular access — Patients receiving deep sedation should have an intravenous (IV) catheter in place for administration of multiple doses of medication or for resuscitation, if needed. Although desirable, IV access is not mandatory for lighter levels of sedation or when sedative agents are given by oral, nasal, rectal, or intramuscular (IM) routes. For example, IM ketamine has been used safely and effectively for sedation, although recovery times are typically longer than when ketamine is given via IV [49,50]. If the procedure is performed without an IV catheter, equipment, and personnel capable of establishing vascular access should be immediately available.

Equipment — In addition to the monitoring devices mentioned above (pulse oximeter, electrocardiograph monitor, and, whenever possible, ETCO₂ monitoring), equipment of appropriate size must be immediately accessible for management of the airway and resuscitation. This equipment includes:

●Oxygen

●Bag-mask system for positive pressure ventilation

●Laryngoscope with appropriately sized blades and endotracheal tubes and appropriate rescue airway devices (eg, laryngeal mask airway) (see "Supraglottic airway devices in children with difficult airways")

●Suction catheters and apparatus

●Emergency resuscitation cart with medications and supplies

●Defibrillator

When not in use, emergency equipment and medications must be checked on a routine basis to ensure they are available and function properly when needed.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Procedural sedation in children".)

SUMMARY AND RECOMMENDATIONS

●Definition – "Procedural sedation" is performed by a multidisciplinary group of practitioners and describes the broad spectrum of interventions that can be used to alter patient response so that tests and procedures can be accomplished while ensuring patient safety and comfort. (See 'Definitions' above.)

This topic provides guidance for emergency and scheduled (elective) pediatric procedural sedation performed by sedation providers from a variety of disciplines including general and pediatric emergency medicine, pediatric critical care medicine, pediatric hospital medicine, and general pediatrics. (See 'Topic scope' above.)

●Pre-sedation evaluation – During pre-sedation evaluation, key history includes (see 'Pre-sedation evaluation' above):

•Timing and content of last oral intake

•Previous exposure to sedation or general anesthesia

•Medical conditions

•Current medications

•Allergies,

•Prior hospitalizations,

•Relevant family history

Essential physical examination includes

•Airway and neck assessment for conditions that might interfere with bag-mask ventilation, endotracheal intubation, or resuscitation (figure 1 and picture 1) (see "The difficult pediatric airway for emergency medicine", section on 'Identification of the difficult pediatric airway')

•Auscultation of the heart and lungs

●Risk classification – Children with the lowest risk for adverse events associated with procedural sedation are healthy or with mild systemic disease (American Society of Anesthesiologists [ASA] I and II), are not young infants, and have normal airways and empty stomachs. Patient conditions and high-risk procedures (eg, upper gastrointestinal endoscopy or bronchoscopy) increase risk. (See 'Risk classification' above.)

Pre-sedation evaluation should identify children who may experience serious adverse events with sedation in accordance with the ASA classification system and those with a potential difficult airway. Patients with severe or poorly controlled systemic disease (ASA class III, IV, or V) or a strong potential for a difficult airway warrant the involvement of a pediatric anesthesiologist or clinician with similar pediatric sedation expertise. (See 'Risk classification' above and 'Airway assessment' above.)

●Fasting – Aspiration is a rare but potentially life-threatening event after procedural sedation. Guidance for fasting depends upon the type of procedure (see 'Fasting and aspiration risk' above):

•Elective – We suggest that children undergoing sedation for scheduled elective procedures outside of the operating room fast as follows (Grade 2C):

-One hour for clear liquids

-Four hours for breast milk

-Six hours for formula, nonhuman milk, and nonfatty solids (eg, toast, bananas)

-Eight hours for full meals prior to sedation

The strength of this recommendation recognizes that guidelines for fasting and sedation for procedural sedation are based upon expert consensus and, for clear liquids, many institutions permit clear liquids up to one prior to procedural sedation. (See 'Elective procedures' above.)

•Urgent or emergency procedures – For children who need to undergo a painful procedure in urgent or emergency situations where complete gastric emptying is not possible, we suggest not delaying procedural sedation based upon fasting status alone (Grade 2C). However, the provider should evaluate the timing and nature of the last oral intake, the urgency of the procedure, and the risk for aspiration based upon the procedure to be performed and patient factors that may increase the risk of adverse events (eg, an ASA level of III, IV, or V or an abnormal airway) when determining the depth and length of procedural sedation. (See 'Urgent or emergency procedures' above.)

●Personnel – Clinicians providing pediatric sedation must be able to deal with complications in patients whose level of sedation becomes deeper than intended or who experience an adverse reaction to medication. Competence in emergency advanced airway management is mandatory if deep sedation is intended or possible and is strongly advised for lighter levels. Other requirements based upon the intended depth of sedation include (see 'Personnel' above):

•Moderate sedation – At least two individuals, a physician or other advanced practice provider (eg, physician's assistant, advanced practice registered nurse, or nurse anesthetist) and an assistant (typically a registered nurse). At least one person present should have training in pediatric resuscitation and be skilled in airway management and cardiopulmonary resuscitation (CPR).

•Deep sedation – For deep sedation in hospital-based settings, in addition to the advanced practice provider administering sedation, our practice is to have an advanced practice clinician or a nurse with extensive experience in pediatric airway management and resuscitation to monitor the patient's sedation. In all cases, there should be at least one advanced practice clinician present during the procedure who is qualified and experienced in definitive management of the pediatric airway.

For deep sedation provided in a free-standing outpatient facility, the person monitoring the patient should be fully capable of managing and recovering a patient from general anesthesia. In these settings, the proceduralist should be qualified to assist in resuscitating a pediatric patient from respiratory or cardiac arrest as well.

●Vascular access and equipment – Patients receiving deep sedation should have an intravenous (IV) catheter in place for administration of multiple doses of medication or for resuscitation, if needed.

Although desirable, IV access is not mandatory for lighter levels of sedation or when sedative agents are given by oral, nasal, rectal, or intramuscular routes. If the procedure is performed without an IV catheter, equipment, and personnel capable of establishing vascular access should be immediately available. In addition to the monitoring devices mentioned above (pulse oximeter, electrocardiograph monitor, and, whenever possible, end-tidal carbon dioxide [E_TCO₂] monitoring), resuscitation equipment and medications should be immediately accessible. (See 'Vascular access' above and 'Equipment' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Deborah C Hsu, MD, MEd, who contributed to earlier versions of this topic review.