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Procedural sedation in children: Approach

Procedural sedation in children: Approach
Literature review current through: Jan 2024.
This topic last updated: Nov 18, 2022.

INTRODUCTION — This topic reviews the indications, contraindications, and steps for safe performance of procedural sedation in children undergoing diagnostic or therapeutic procedures, regardless of setting.

Preparation for procedural sedation, properties of specific agents, and strategies for selecting medications for pediatric procedural sedation are discussed separately:

(See "Procedural sedation in children: Preparation".)

(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.   

GOALS OF SEDATION AND ANALGESIA — Procedural sedation in children is performed by a wide range of providers, in a variety of settings, who use many different agents to facilitate the successful completion of diagnostic and therapeutic procedures. Outcomes for procedural sedation for elective and emergency procedures have been demonstrated to be excellent when performed by dedicated sedation providers and services [1-3].

Goals of sedation and analgesia for painful procedures are to [4]:

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

Control hyperdynamic or vagal response to painful interventions

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 [5-8]. (See 'Nonpharmacologic interventions' below.)

DEFINITIONS — For the purposes of this topic, we will use the following definitions regarding the depth of sedation (see "Procedural sedation in children: Preparation", section on 'Definitions'):

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 has depression of consciousness but can respond 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.

Dissociative sedation – Sedation with ketamine represents an exception to the above sedation continuum. In contrast to other sedatives where deeper sedation can lead to a higher risk of respiratory suppression, ketamine sedation is 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 [9,10]. (See "Procedural sedation in children: Preparation", section on 'Definitions'.)

"Procedural sedation" has been defined by the International Committee for the Advancement of Procedural Sedation, which includes representatives from anesthesia, emergency medicine, critical care, pediatrics, dentistry, and gastroenterology, as "the administration of one or more pharmacological agents to facilitate a diagnostic or therapeutic procedure while targeting a state during which airway patency, spontaneous respiration, protective airway reflexes, and hemodynamic stability are preserved, while alleviating anxiety and pain" [11]. The progression from mild sedation to general anesthesia is a continuum, and patients can easily move from one "level" of sedation to another.

"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 is no longer used when referring to sedation states in children.

INDICATIONS — There are no absolute indications for the performance of procedural sedation in children. It may be used for any procedure in which a child's pain or anxiety may be excessive and movement may impede safe performance of the procedure or cause significantly negative emotional sequelae. The need for sedation will vary greatly with a child's developmental or behavioral status. Procedural sedation (at deep levels of sedation) can result in profound muscle relaxation, thereby increasing the successful completion of certain procedures such as the closed reduction of a dislocated joint or displaced fracture.

The targeted depth of sedation and the selection of medications largely depend upon the procedure performed including expected duration of sedation, the anticipated degree of pain, the experience and credentials of the sedation provider, and patient factors [4,12]. It is important to note that the depth of sedation targeted may not be the depth of sedation actually achieved. All sedation providers must be prepared to rescue patients when the actual depth of sedation exceeds the targeted depth of sedation. (See "Procedural sedation in children: Selection of medications".)

The properties of the specific agents with respect to pediatric sedation are listed in the tables and discussed in detail separately (table 1 and table 2). (See "Pediatric procedural sedation: Pharmacologic agents".)

A wide range of procedures may warrant sedation in children, including nonpainful imaging procedures (that require no movement), mildly painful procedures (eg, laceration repair), and moderately to severely painful procedures (eg, fracture reduction).

CONTRAINDICATIONS AND PRECAUTIONS — There are no absolute contraindications to procedural sedation outside the operating room in children.

Precautions should be taken when preparing to provide procedural sedation to those patients with signs of a difficult airway or significant medical comorbidities (American Society of Anesthesiologists [ASA] classification III or higher). Those patients with ASA classes III, IV, and V (table 3), functional needs, or airway abnormalities warrant consultation with a pediatric anesthesiologist or clinician with similar pediatric sedation/anesthesia expertise. A history of severe sleep apnea or airway abnormality warrants special consideration when planning sedation care. Children who readily obstruct their airway when asleep may do so during sedation and are at risk for excessive response to sedative medications. (See "Procedural sedation in children: Preparation", section on 'Risk classification' and "Procedural sedation in children: Preparation", section on 'Airway assessment'.)

True allergic reactions to commonly used sedation medications are rare. However, caregivers may report adverse events with specific classes of agents as follows [12]:

Paradoxical reactions (patient becomes more agitated rather than sedated) may occur with benzodiazepines and barbiturates, especially in younger children.

Morphine administration is associated with histamine release that may produce hives, especially in regions of the body where it is administered. Nasal pruritus is described with fentanyl.

Fentanyl is rarely associated with chest wall rigidity.

Agitation with emergence, diplopia, nausea, and/or vomiting has been described with ketamine.

Of these, prior paradoxical reactions with benzodiazepines or emergence phenomenon after ketamine may warrant avoidance of these agents for sedation in individual patients.

Fasting status is not an absolute contraindication to sedation for urgent or emergency procedures such as laceration repair, fracture reduction, or abscess drainage. 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). All of these factors should be taken into consideration when determining the depth and length of procedural sedation. The evaluation of fasting status and impact on timing and depth of sedation for urgent or emergency procedures is discussed in greater detail separately. (See "Procedural sedation in children: Preparation", section on 'Urgent or emergency procedures'.)

PERFORMING PROCEDURAL SEDATION

Informed consent — Before performing procedural sedation, the clinician should obtain written informed consent from the caregiver. Key components of this consent include the following:

Proposed benefits, typically the ability to perform a procedure effectively while minimizing pain, anxiety, and psychological trauma

Possible risks, which are often agent specific, but commonly include potential for airway compromise, hypoxia, and vomiting

The consent process should include specific discussion of the drug options and potential routes of administration for procedural sedation as well as alternatives including local or regional anesthesia and, when appropriate, general anesthesia.

Preparation — Preparation for procedural sedation in children outside of the operating room is discussed in detail separately. (See "Procedural sedation in children: Preparation".)

Children undergoing procedural sedation should have assessment of the following (see "Procedural sedation in children: Preparation", section on 'Pre-sedation evaluation'):

Fasting status

Focused medical examination with specific attention to the airway

American Society of Anesthesiologists classification

Previous history of sedation or general anesthesia and outcome

Clinicians who administer sedation must understand the pharmacology of the drugs they use and be comfortable choosing a procedural sedation plan for the patient. Because depression of consciousness is a continuum and responses to medications vary, clinicians must recognize that targeted and achieved depths of sedation may differ and be prepared to manage complications in patients whose level of sedation becomes deeper than intended or who experience an adverse reaction to medication. Competence in definitive emergency airway management is mandatory if deep sedation is intended or possible and is strongly advised for lighter levels.

Prior to the start of procedural sedation, the clinician should ensure that monitoring devices are present and functioning properly and that oxygen, oxygen delivery devices, suction equipment, pediatric airway equipment, an emergency cart with appropriate medications, and a defibrillator are immediately available. (See "Procedural sedation in children: Preparation", section on 'Equipment'.)

Administration of sedation requires personnel with appropriate experience and training. (See "Procedural sedation in children: Preparation", section on 'Personnel'.)

Preoxygenation — We suggest the use of supplemental oxygen with continuous capnography during procedural sedation. The accuracy of capnography in reflecting the patient's true partial pressure of carbon dioxide (PaCO2) is variable and depends on positioning of the sensor, the nature of the patient's breathing (mouth versus nose), and the rapidity with which oxygen is being administered. However, capnography provides early warning of respiratory depression and apnea during procedural sedation. (See 'Monitoring' below.)

Significant practice variation exists regarding the use of preoxygenation and continuous supplemental oxygenation during procedural sedation. Although it is recommended for moderate sedation by the American Society of Anesthesiology [13,14], evidence is limited to show that preoxygenation or continuous administration of supplemental oxygen in children undergoing procedural sedation is associated with improved safety [15].

The potential benefits of preoxygenation include:

Maximizing bloodstream oxygenation during procedural sedation [16]

Maximizing lung storage of oxygen [16]

Maintenance of oxygenation during periods of apnea [17]; for example, children who experience hypopnea or apnea during sedation will have a two- to four-minute delay in oxygen desaturation if they have received preoxygenation [18]

Potential harms of preoxygenation include:

Unless capnography or direct visualization of chest wall movement occurs continuously throughout sedation, continuous supplemental oxygen [17]:

Delays desaturation as measured by pulse oximetry

Permits patients to maintain acceptable oxygen saturation despite significant hypoventilation

May delay recognition of apnea unless capnography or direct visualization of chest wall movement occurs continuously throughout sedation

For these reasons, when preoxygenation and continuous supplemental oxygen is provided, then the patient also requires monitoring with continuous capnography or direct visualization of chest wall movement throughout sedation.

Administration of supplemental oxygen to infants and young children may also increase anxiety prior to sedation caused by discomfort associated with the mode of delivery (eg, nasal prongs or face mask). This problem can be overcome by applying the capnography canula or face mask and providing oxygen delivery shortly after sedation has begun.

The use of oxygen in adults undergoing procedural sedation is discussed separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications", section on 'Monitoring'.)

Monitoring — Recommended monitoring during moderate to deep procedural sedation includes [4,12,18]:

Continuous visual observation of face, mouth, and chest wall movement when feasible

Initial and repeated measures of vital signs including repeated blood pressure measurements in patients receiving moderate or deep sedation or agents known to cause hemodynamic instability

Continuous measurement of heart rate and pulse oximetry

End tidal-carbon dioxide (ETCO2) detection for moderate sedation (when tolerated) and deep sedation

For children receiving moderate or deep sedation, we recommend capnography (ETCO2) throughout the procedure and during recovery. ETCO2 monitoring is readily available in most settings for nonintubated patients and may be helpful to assess ventilation during sedation and analgesia. Based upon trials in children, increases or decreases in ETCO2 may be detected in patients with respiratory depression before hypoventilation or hypoxemia is noted, particularly in those who are receiving supplemental oxygen [19,20]. Although not always reflective of the patient's true PaCO2, ETCO2 permits more rapid detection of hypoventilation and apnea than clinical assessment alone [19,20].

Vital signs consisting of heart rate, respirations, and blood pressure should be recorded at specific intervals, including [12]:

Before starting the procedure

After the administration of the sedative agent(s)

At completion of the procedure

During early recovery

At completion of recovery

If deep sedation is targeted or if a patient has significant underlying illness, vital signs should be measured at least every five minutes.

Complications from sedation such as respiratory depression are most likely to occur within 5 to 10 minutes after administration of intravenous medication and immediately after the procedure when stimuli associated with the procedure are removed [12]. Thus, attention to the patient's breathing and monitoring should be especially close during these periods.

Bispectral index (BIS) is a measure of consciousness obtained by continuous electroencephalographic (EEG) monitoring of probes placed on the forehead. The EEG signal is processed by a proprietary computer algorithm. BIS was derived in adults and is used in some settings to monitor for awareness to anesthesia. It has a range of 0 (no brain activity) to 100 (alert). (See "Accidental awareness during general anesthesia", section on 'Brain monitoring'.)

BIS is not routinely recommended for monitoring of pediatric sedations outside of the operating room.

BIS is of uncertain value in monitoring children during procedural sedation because it varies in its prediction of sedation depth by patient age and sedative agent. As an example, in a combined analysis of four observational studies, BIS was found to differentiate light from moderate or deep sedation in children with reasonable sensitivity (74 to 83 percent) and specificity (78 to 84 percent). However, BIS differentiated moderate from deep sedation with poor sensitivity (58 to 71 percent) and specificity (57 to 66 percent) [21]. BIS values in children were lower in infants and patients who received opioids. BIS values did not correlate with sedation depth in children receiving ketamine.

Anxious or agitated child — As a practical consideration, unnecessary stimulation such as inflation of a blood pressure cuff, premature initiation of a painful procedure, or familial separation may hinder the induction of sedation in a young or anxious child. For children unable to cooperate, our approach is to maximize nonpharmacological measures to comfort children first. As sedative drugs are administered, obtain a complete set of vital signs and monitor the child visually until the sedative drugs have begun to take effect. At this point, we begin monitoring of pulse oximetry, heart rate, and for children undergoing moderate or deep sedation, capnography with administration of nasal cannula oxygen. (See 'Preoxygenation' above.)

Sedation state — The "state" of a patient during a sedation refers to their overall status and multiple goals of sedation. Specifically, is the patient awake and crying/moving, or is the patient in a quiet, nonstressed state during the procedure? We suggest the use of the Pediatric Sedation State Scale (PSSS) (table 4) to provide a simple means of effectively documenting and rapidly communicating the quality of pediatric sedation relative to the goals of sedation [22]. Derived from expert opinion and validated using a small sample of patients and observers with high inter- and intra-observer agreement, the PSSS takes no more than 10 minutes to teach and consists of six levels of sedation that report on patient behavior, patient interference with the procedure, need for restraint, and physiologic parameters.

Assignment of scores may occur at regular intervals (eg, every 5 to 10 minutes). If the PSSS is used routinely for specific procedures, it has the potential to confirm that conditions were acceptable for each patient’s sedation strategy. It may also offer a means to objectively compare different sedation techniques, including nonpharmacologic interventions, as part of quality improvement and clinical research efforts.

By contrast, scales that simply measure the depth of sedation track only one aspect of this practice because a patient does not necessarily need to be sedated deeply or at all to meet the goals of procedural sedation (see 'Goals of sedation and analgesia' above). Many of these scales also do not permit the definition of "dangerous" states where patient physiology is not under good control such as hypoxia, hypotension, or bradycardia.

Nonpharmacologic interventions — Nonpharmacologic interventions include behavioral and cognitive approaches [6,23-25]. For many children, the use of nonpharmacologic interventions, in addition to effective analgesia for painful procedures, may prevent the need for procedural sedation. In situations where the patient is conscious during the sedation, behavioral and cognitive approaches are complementary to pharmacologic interventions and should be used. These techniques also help to reduce preprocedural agitation, which permits an easier transition to sedation, may reduce the amount of medication required for effective sedation, and may decrease the frequency of adverse events, including emergence phenomena. (See "Procedural sedation in children: Selection of medications", section on 'Nonpharmacologic interventions'.)

Behavioral treatments include the techniques of desensitization, distraction, reinforcing coping skills, positive reinforcement, and relaxation [5,7].

Desensitization allows for gradual, increasing exposure to the procedure over a period of time. This technique maintains anxiety at low levels and lessens the learned fear associated with the procedure. For example, children could be exposed to a "mock" magnetic resonance imaging (MRI) scanner progressively over time to provide desensitization without the expense of reducing the availability of an actual MRI machine [26].

Distraction techniques involve an age appropriate stimulus to use during the procedure, such as non-nutritive sucking in infants, bubble blowing, party blowers, listening to a book, counting, interactive toys, playing music through headphones, video games, video, or virtual reality [6,27-29]. In a randomized trial that included 240 children requiring laceration repair in an emergency department, distraction techniques were associated with a significant reduction in situational anxiety among older children and lower parental perception of pain and distress among younger children [30]. In a separate case series, the use of tablet computers with age-appropriate applications has been described as another distraction technique that is effective for completing short procedures in the emergency department [31]. These tablets have multi-touch displays capable of presenting various audiovisual media in the forms of books, movies, music and games in an intuitive, interactive format. They can be used for children of all developmental levels and abilities, with or without child life support, prior to and during the performance of a potentially painful or frightening procedure.

Positive reinforcement involves providing patients with positive statements and rewards after undergoing a procedure.

Relaxation techniques can be taught to reduce children's anxiety associated with procedures.

Child life specialists may be particularly helpful in the execution of some of the above techniques. They can [32]:

Aid in the formation of trusting relationship between the patient, family, and health care providers.

Facilitate psychological preparation of pediatric patients for diagnostic/therapeutic procedures through provision of developmental appropriate information.

Encourage questions and emotional expression.

Coach children in the use of strategies such as breathing techniques, distraction and visual imagery, to decrease behavioral distress and pain experience.

Child life intervention has been shown to reduce anxiety, improve coping, provide a more positive experience for the patient and family, and decrease the need for sedation in procedures, resulting in lower risks for the patient and cost savings for the hospital [33-36].

Parental involvement enhances the impact of behavioral pain management if the parent/primary caregiver is properly prepared for a positive role (eg, coached on language to use, taught distraction and coping skills techniques) [6,37,38]. In addition, parental anxiety is a predictor of child anxiety. Thus, management of parental anxiety is an important element in allaying a child's fears [7].

Cognitive approaches are also used to manage pain [5,37]. Providing the child with information about the procedure before it is started may help allay anxiety. The content of this preparation needs to be age appropriate. Child life programs frequently use "medical play," including exploration of medical equipment and dramatic play enacting clinical situations, to help patients cope with painful treatments [39].

Concrete hypnosis can also be used to help direct the patient's attention away from the procedure, and children can be taught positive statements that they can repeat to themselves when they feel anxious.

The reference provides a video demonstrating the use of nonpharmacologic approaches to reduce preprocedure anxiety [23]. Regardless the resources available, we recommend that all children receive assessment of their pre-sedation state and nonpharmacologic interventions to comfort them prior to a procedure and sedation.

Medication administration — The choice of agent and mode of administration vary according to patient factors, the type of procedure performed, and the anticipated degree of pain. (See "Procedural sedation in children: Selection of medications".)

Careful titration of the chosen medication is often necessary to safely achieve the desired depth of sedation. The dosing and method of administration for the medications commonly used for procedural sedation in children outside of the operating room are presented in the tables (table 1 and table 2) and discussed in detail separately. (See "Pediatric procedural sedation: Pharmacologic agents".)

RECOVERY CARE AND DISCHARGE CRITERIA — Monitoring should continue until the child meets criteria for safe discharge [40]. These criteria include:

Airway patency and stable cardiovascular function

Easy arousability with intact protective reflexes

Ability to talk (if age-appropriate)

Ability to sit up unaided (if age-appropriate) and maintain wakefulness

Adequate hydration with management of any nausea or vomiting

Appropriate management of any continued pain

Young infants or children who are developmentally delayed should return to the level of responsiveness observed before sedation. The exact duration of recovery time will vary depending upon patient characteristics (eg, age or body mass index) and the sedative agent or agents and doses administered (table 1 and table 2). Of note, serious adverse effects, including hypoxia, stridor, or hypotension have been described during the recovery phase of procedural sedation [41]. Thus, close monitoring is required until these discharge criteria are met. Furthermore, the recovering child should be able to maintain the recovered, wakeful state for approximately 15 minutes prior to discharge to assure discharge is appropriate [42].

Because of the significant risk of apnea after sedation, term infants with postconceptual ages (PCA) ≤45 weeks and former premature infants with PCA <60 weeks should undergo prolonged observation of respiratory status prior to discharge [43]. The minimum duration of observation is derived from postanesthesia experience in term and preterm infants and varies depending upon PCA, the medications used, and patient comorbidities (eg, anemia, apnea of prematurity, chronic lung disease, or neurologic disease):

All infants term or preterm with PCA ≤45 weeks – 12 hours

Preterm infants with PCA 46 to 60 weeks and significant comorbidities – 12 hours

Healthy preterm infants with PCA 46 to 60 weeks – 6 hours (12 hours if given opioids or other medications with significant respiratory depressant effects)

Patients, who develop apnea during observation, warrant prolonged observation until they are free of apnea for at least 12 hours. In some patients with frequent apneic episodes, caffeine administration may be appropriate. (See "Management of apnea of prematurity", section on 'Caffeine'.)

ADVERSE OUTCOMES — Adverse outcomes associated with procedural sedation for children are significantly reduced when standardized safe practices are observed [4]. The estimated rates of adverse events are provided below. They reflect the results from institutions with well-organized pediatric sedation services that have demonstrated high-quality performance and are staffed by experienced and highly trained physicians; these rates do not apply to settings where these safeguards are not present.

Minor adverse events – In a report describing over 30,000 prospectively collected hospital-based pediatric sedation/anesthesia encounters from sedation services at multiple institutions with 77 percent of the sedations performed by anesthesiologists, emergency physicians, or intensivists, the overall incidence of adverse events (primarily transient oxygen desaturation, vomiting, and excessive secretions) was 3 percent [1]. Thus, minor adverse events are relatively common in pediatric procedural sedation, but when personnel rapidly respond and reverse the adverse event, serious outcomes are rare.

Failed sedation – Failed sedation that prevents completion of the procedure is another important adverse event. The frequency of failed sedation varies among studies and depends upon multiple factors. For example, inadequate sedation that prevented completion of the procedure occurred in 1 out of 338 sedations in a registry study of over 30,000 sedations performed in a variety of hospital settings at multiple centers [1]. A separate study that used the same registry found that the frequency of failed sedation with propofol during almost 50,000 procedures was 0.6 percent. Finally, in a study of almost 6300 pediatric sedations performed in the emergency department, 0.9 percent of procedures failed due to inadequate sedation, and in 4 percent of patients whose procedures were successful, the children actively resisted and were considered sedation failures.

Although evidence is limited, several patient factors may be associated with failed sedations, including presence of an upper respiratory tract infection, a history of obstructive sleep apnea or snoring, ASA class III status, older age, and obesity [44]. However, selection of medication and provider decisions about administration also are important factors.

Major adverse events – When procedural sedation is performed by dedicated and experienced providers outside of the operating room, major adverse events such as aspiration, laryngospasm, cardiac arrest, permanent neurologic injury, and death are rare:

Aspiration – The risk of aspiration is very low (approximately 1 in 10,000 sedations) as described separately. (See "Procedural sedation in children: Preparation", section on 'Fasting and aspiration risk'.)

Laryngospasm – Laryngospasm in children receiving procedural sedation occurs more commonly than aspiration but is still a rare event. For example, in a registry study of prospectively collected data from over 275,000 pediatric sedations (almost all elective) occurring outside of the operating room in the United States, the unadjusted prevalence of laryngospasm was 3.3 per 1000 cases [45]. On adjusted analysis, intravenous (IV) ketamine alone (predicted probability 1.7 per 1000 cases [95% CI 0.6 to 2.8/1000]) and IV propofol alone (predicted probability 3.0 per 1000 cases [95% CI 2.2 to 3.9/1000]) had similar rates of laryngospasm. An increased probability of laryngospasm occurred in individuals with a concurrent upper respiratory infection (predicted probability 12.2 per 1000 cases [95% CI 6.3 to 18.1/1000]), and those undergoing airway procedures (predicted probability 9.6 per 1000 cases [95% CI 5.2 to 13.9/1000]). Compared with IV propofol alone, propofol combined with ketamine (7.5 per 1000 cases [95% CI 3.1 to 12/1000]) or propofol combined with dexmedetomidine (6.3 per 1000 [95% CI 3.7 to 8.9/1000]) were associated with increased risk. For the factors with the highest likelihood of laryngospasm (concurrent upper respiratory infection or airway procedures), the number needed to harm is estimated at >100 sedations to experience one instance of laryngospasm [45]. Emergency airway intervention was required in 10 percent of the 913 patients with laryngospasm; 5.3 percent underwent endotracheal intubation, and 2.3 percent of patients required an unplanned admission or an increase in level of care. Thus, although the risk of laryngospasm is low and most patients developing it have good clinical outcomes, these data provide a strong rationale for all pediatric sedation providers to have airway management expertise. Furthermore, sedation providers should be aware of factors associated with laryngospasm present in individual patients when determining their sedation plan.

Cardiac arrest, permanent neurologic injury, and mortality – When performed by dedicated pediatric sedation services that are operating in institutions with an established record of safe sedation practice, cardiac arrest, permanent neurologic injury, or death during pediatric sedation is much rarer than aspiration, although precise estimates are lacking. For example, in a report of over 30,000 pediatric sedation/anesthesia encounters, CPR was required in one patient, and there were no deaths [1].

Lack of recognition and timely treatment of an adverse airway event such as hypoxemia, apnea, or laryngospasm appear to be major contributing factors when these devastating events do occur [46]. For example, in one retrospective report describing adverse sedation events in children, permanent neurologic injury or death was associated with sedations that occurred in nonhospital-based facilities and adverse events for which resuscitative efforts were inadequate [46]. Other factors that contributed to adverse outcomes were:

-Inadequate and inconsistent physiologic monitoring

-Inadequate medical evaluation before sedation

-No independent observer

-Medication errors

-Inadequate recovery procedures

Major adverse sedation events occur with all routes of administration and classes of medication, including those considered to have minimal effect on breathing. Poor outcomes also have been associated with excessive doses, drug interactions, administration by personnel without medical training, and, after discharge, drugs with long half-lives [47].

EFFICACY OF SEDATION — We recommend using tools that, in addition to successful completion of the procedure, also take into account the patient and family experience such as the Pediatric Sedation State Scale (PSSS) (table 4) [22] or Tracking and Reporting Outcomes of Procedural Sedation (TROOPS) to assess and document the quality and efficacy of sedation provided [48].

Previous studies have used successful completion of the procedure as the definition of "successful sedation." We feel that this definition fails to acknowledge the importance of the patient experience. In addition to completion of the procedure without adverse outcomes, high-quality sedation can only be achieved if the patient does not have unpleasant recall of the procedure and does not actively resist or require physical restraint [49]. Although a wide range of measures have been used to assess the efficacy and effectiveness of procedural sedation for children, outcomes that are valid and reliable have not been consistently employed [50].

Sedation providers should recognize that there is ample evidence in the pediatric anesthesia literature involving behavior changes in children after surgery. These changes are assumed to be associated with the stress and pain that accompany surgical experiences. There is no literature to specifically describe the incidence of nature of behavior changes after procedural sedation, but it would be logical to assume that children who have extreme anxiety/stress or pain during a procedure due to inadequate sedation would be at significant risk for prolonged behavioral changes after procedures [51-57].

CLINICAL PRACTICE GUIDELINES — Limited evidence suggests that implementation of hospital-wide guidelines for procedural sedation and analgesia may decrease the incidence of adverse events and adverse outcomes. As an example, hospital-wide implementation of national sedation and analgesia guidelines in one children's hospital resulted in a significant reduction in monthly adverse events during pediatric procedural sedation from 11 to 5 percent over three years (p <0.001) [58]. In order to make pediatric procedural sedation as safe as possible, institutions should develop protocols that specify a pre-sedation evaluation, including a sedation plan, monitoring during the procedure and recovery, discharge and follow-up criteria, credentialing for personnel, and a quality improvement monitoring mechanism.

Detailed and effective communication between healthcare providers and across services is also essential to the safe practice of procedural sedation. Protocols should include procedures for transferring care of sedated children. Specific information regarding medications received during the sedation with doses, times, and response should be included with the usual details of the medical history, daily medications, allergies and vital signs.

Finally, health care providers who perform procedural sedation in children should have strong resuscitation and advanced pediatric life support skills, including advanced training in the assessment and management of the pediatric airway as well as specific training in pediatric procedural sedation.

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

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.   

Indications – There are no absolute indications for the performance of procedural sedation in children. It may be used for any procedure in which a child's pain or anxiety may be excessive and movement may impede performance. The need for sedation will vary greatly with a child's developmental or behavioral status. (See 'Indications' above.)

Relative contraindications – Relative contraindications to procedural sedation include signs of a difficult airway or significant medical comorbidities (American Society of Anesthesiologists Classification III or higher). Those patients with ASA classes III, IV, and V (table 3) due to conditions such as chronic respiratory disease, sleep apnea, decreased gastrointestinal motility, or airway abnormalities warrant consultation with a pediatric anesthesiologist or clinician with similar pediatric sedation expertise for consideration for general anesthesia. (See 'Contraindications and precautions' above.)

Targeted depth of sedation and selection of medications – The targeted depth of sedation and the selection of medications largely depend upon the procedure performed including expected duration of sedation, the anticipated degree of pain, the experience and credentials of the sedation provider, and patient factors. Guidance for selection of medications for pediatric sedation is provided separately. (See "Procedural sedation in children: Selection of medications".)

Nonpharmacologic interventions – Nonpharmacologic interventions, particularly distraction techniques, may relieve children's anxiety and pain distress before and during procedures and should be incorporated into pediatric procedural sedation plans whenever possible. (See 'Nonpharmacologic interventions' above.)

Preparation – The necessary preparation for safely performing procedural sedation in children is discussed separately. (See "Procedural sedation in children: Preparation".)

Preoxygenation – We suggest the use of supplemental oxygen with continuous capnography prior to and during procedural sedation (Grade 2C). (See 'Preoxygenation' above.)

Monitoring – Appropriate monitoring during pediatric sedation includes visual observation, initial and repeated measurements of vital signs, and continuous measurement of heart rate and pulse oximetry. We recommend that patients receiving moderate or deep procedural sedation also undergo monitoring with end-tidal carbon dioxide (ETCO2) detection throughout the procedure and during recovery whenever possible. (See 'Monitoring' above and "Carbon dioxide monitoring (capnography)", section on 'Procedural sedation'.)

We suggest the use of the Pediatric Sedation State Scale (table 4) to provide a simple means of effectively documenting and rapidly communicating the quality of pediatric sedation. (See 'Sedation state' above.)

Medication administration – Careful titration of the chosen medication is often necessary to safely achieve the desired depth of sedation. The dosing and method of administration for the medications commonly used for procedural sedation in children are presented in the tables (table 1 and table 2) and discussed in detail separately. (See "Pediatric procedural sedation: Pharmacologic agents".)

Recovery and safe discharge – Monitoring should continue until the child meets criteria for safe discharge. The criteria are provided above. Young infants or children who are handicapped should return to the level of responsiveness observed before sedation. The exact duration of recovery time will vary with the nature of the patient (eg, age or body mass index) and the sedative agent or agents used (table 1 and table 2). (See 'Recovery care and discharge criteria' above.)

Because of the significant risk of apnea after sedation, term infants with postconceptual ages (PCA) ≤45 weeks and former premature infants with PCA <60 weeks should undergo prolonged observation of respiratory status prior to discharge. (See 'Recovery care and discharge criteria' above.)

Clinical practice guidelines – In order to perform pediatric procedural sedation as safely as possible, institutions should develop guidelines that specify (see 'Clinical practice guidelines' above):

Pre-sedation evaluation, including a sedation plan

Monitoring during the procedure and recovery

Discharge and follow-up criteria

Development of dedicated sedation teams

Credentialing for personnel and a quality improvement monitoring mechanism

When performed by dedicated and experienced sedation providers engaged in standardized safe practices, serious adverse outcomes associated with pediatric procedural sedation are unlikely. (See 'Adverse outcomes' above.)

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

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Topic 6330 Version 39.0

References

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