Pediatric Procedural Sedation and Analgesia
Section snippets
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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2018, Journal of Emergency MedicineCitation Excerpt :Additionally, parents and young children are often familiar with rectal temperature measurement and medications being given in suppository format in the ED setting, and may find PR sedation less threatening than the IN, IV, or IM route. However, the option of pediatric procedural sedation using medications delivered PR is mentioned only briefly in a few of the many review articles on the topic, and to date no synopsis on the spectrum or effectiveness of PR sedative medications has been published (2–8). Our goal is to review the medical literature and provide emergency physicians with an overview of the use of medications administered via the PR route for the purpose of procedural sedation in pediatric patients, particularly in the ED setting.
Soft tissue trauma and scar revision
2014, Facial Plastic Surgery Clinics of North AmericaCitation Excerpt :Procedural sedation is, therefore, an indispensable tool in this setting. Pediatric procedural sedation refers to the pharmacologic technique of managing a child’s pain and anxiety during an uncomfortable procedure.3 Procedures that are attempted in an uncooperative child often require restraints, which create adverse procedure outcomes and undue stress for patients and families.4
The Role of Sedation in Contemporary Pediatric Dentistry
2013, Dental Clinics of North America