Pediatric Procedural Sedation and Analgesia

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Definitions

Procedural sedation, as defined by the American Society of Anesthesiologists, occurs on a continuum, ranging from minimal sedation or anxiolysis to general anesthesia (Table 1). Anxiolysis refers to a drug-induced state in which cognitive and motor functions may be impaired. Moderate sedation and analgesia, also known as conscious sedation, is a state of moderate sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation. Ventilatory and

Sedation by the nonanesthesiologist

Several groups have published recommendations and guidelines directed toward the nonanesthesiologist who may perform procedural sedation [1], [2], [3]. Specific pediatric guidelines are published by the American Academy of Pediatrics (AAP) [4], [5]. The most important recommendation common to all guidelines relates to the person performing the sedation. This person must be qualified to manage all potential complications, including hemodynamic instability, respiratory depression, and airway

Equipment and monitoring

The practice guidelines and clinical policies cited above describe the supportive equipment and monitors that must be available when performing pediatric procedural sedation. Equipment must be age- and size-appropriate and include oxygen, suction, medications, a bag-mask ventilation device, and intubation equipment. Necessary monitors include pulse oximetry and cardiac monitors with appropriate alarms. Blood pressure should be determined before sedation begins and at 5-minute intervals during

Sedation for a painful procedure

There are many options available to the practitioner who needs to perform sedation and analgesia for a painful procedure on a child. One option is to use a combination of intravenous medications to create a sedative and analgesic cocktail. It is important to remember the class effects of the drugs. Opioids provide pain relief but may only provide adequate sedation when used at high dosages. Using higher dosages obviously increases the risk of unwanted side effects such as respiratory depression

Sedation for nonpainful procedures

Adequate sedation allows children to tolerate unpleasant procedures and may expedite conducting procedures that require the uncooperative child not to move. A common arena for minimal sedation is the radiology suite. Cooperation for a diagnostic study such as MRI is a frequent indication for pediatric procedural sedation. MRI scans can cause anxiety in even the most cooperative child or adult. These scans require the patient to lie still in a closed cylinder for 30 to 90 minutes, which promotes

Safe sedation

The Joint Commission on Accreditation of Health care Organizations (JCAHO) mandates that the standard of care for sedated children be uniform throughout an institution [33]. Although delegating the care of sedated children to a pediatric anesthesiologist may be optimal, it is not practical or cost effective. Sedation by nonanesthesiologists is safe and acceptable as long as the standards of care are met, including identifying appropriate candidates for safe PSA to decrease the incidence of

Fasting guidelines

The practice of prolonged fasting (NPO) from solids and liquids originates from the work of Mendelson in 1946 [36]. In Mendelson's investigation, aspiration occurred in 66 of 44,016 nonfasted obstetric patients over a 13-year period. He described the risk of gastric acid aspiration during obstetric anesthesia with the consequent development of pneumonitis. Since Mendelson's article, NPO recommendations have been extrapolated to all patients requiring general anesthesia and even parenteral

Discharge criteria

After procedural sedation, children should not be discharged from the medical facility until they have awakened to their baseline mental and ambulatory status. Discharge instructions should be reviewed with parents or other responsible adults before the sedation and before discharge. An emphasis should be placed on the importance of watching carefully for signs of respiratory distress. Children should not be left unattended in a car seat, and a sleeping child should not be left alone. They

Summary

Procedural sedation and analgesia is a safe and effective means to manage a child's pain and anxiety. When the practitioner is deciding which methods of PSA to use, it is important to determine whether the intended goal is sedation or analgesia or both and to consider the adverse reactions and side effects of each agent. Appropriate safety measures should be undertaken, including supportive equipment, monitors, and a presedation assessment. End-tidal carbon dioxide levels and bispectral index

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