Preparation for pediatric procedural sedation outside of the operating room
- Joseph P Cravero, MD
Joseph P Cravero, MD
- Associate Professor of Anesthesia
- Harvard Medical School
- Boston Children's Hospital
- Deborah C Hsu, MD, MEd
Deborah C Hsu, MD, MEd
- Associate Professor of Pediatrics, Section of Emergency Medicine
- Baylor College of Medicine
- Section Editors
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic reviews the preparation for pediatric procedural sedation, regardless of setting, including assessment of American Society of Anesthesiologists classification and fasting status, and assurance of necessary personnel, equipment, and monitoring.
A discussion of the nonpharmacologic and pharmacologic interventions for pediatric procedural sedation as well as pediatric airway management and rapid sequence intubation are discussed separately. (See "Procedural sedation in children outside of the operating room" and "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children".)
The performance of diagnostic and therapeutic procedures in children is safer and more likely to be successful when the patient does not move and when any associated pain and anxiety are effectively controlled. Pharmacologic and nonpharmacologic interventions that consider the child's age, developmental status, and the clinical circumstances are often required to meet these goals . 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 has been emphasized in a clinical report from the American Academy of Pediatrics .
The increased availability of short-acting sedatives along with accurate noninvasive monitoring has enabled effective and safe management of sedation and analgesia outside the operating room . Procedural sedation is an evolving field practiced by a diverse group of practitioners in an expanding variety of clinical settings . Among the challenges that must be addressed, the development of standardized definitions of outcomes, particularly with respect to what constitutes satisfactory fasting for sedation is essential. In addition, there remains a number of guidelines for sedation promulgated by various specialty societies. Unified multidisciplinary guidelines would encourage consistent care across specialties and sedation settings .
GOALS OF SEDATION AND ANALGESIA
Goals of sedation and analgesia for painful procedures are to :
- Bhatt M, Kennedy RM, Osmond MH, et al. Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med 2009; 53:426.
- Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004; 114:1348.
- Howard RF. Current status of pain management in children. JAMA 2003; 290:2464.
- Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 367:766.
- Cravero JP, Blike GT. Review of pediatric sedation. Anesth Analg 2004; 99:1355.
- Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138.
- Sacchetti A, Schafermeyer R, Geradi M, et al. Pediatric analgesia and sedation. Ann Emerg Med 1994; 23:237.
- Coté CJ. "Conscious sedation": time for this oxymoron to go away! J Pediatr 2001; 139:15.
- Green SM, Krauss B. The semantics of ketamine. Ann Emerg Med 2000; 36:480.
- American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96:1004.
- Mandt MJ, Roback MG. Assessment and monitoring of pediatric procedural sedation. Clin Ped Emerg Med 2007; 8:223.
- Havidich JE, Beach M, Dierdorf SF, et al. Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk. Pediatrics 2016; 137:e20150463.
- Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003; 42:636.
- Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Anesthesiology 2016; 124:80.
- Warner MA, Warner ME, Warner DO, et al. Perioperative pulmonary aspiration in infants and children. Anesthesiology 1999; 90:66.
- Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth. Acad Emerg Med 2002; 9:35.
- Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; :CD004423.
- Miner JR, Burton JH. Clinical practice advisory: Emergency department procedural sedation with propofol. Ann Emerg Med 2007; 50:182.
- Sandhar BK, Goresky GV, Maltby JR, Shaffer EA. Effect of oral liquids and ranitidine on gastric fluid volume and pH in children undergoing outpatient surgery. Anesthesiology 1989; 71:327.
- Green SM, Roback MG, Miner JR, et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med 2007; 49:454.
- Søreide E, Eriksson LI, Hirlekar G, et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand 2005; 49:1041.
- Brady M, Kinn S, O'Rourke K, et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev 2005; :CD005285.
- Splinter WM, Stewart JA, Muir JG. Large volumes of apple juice preoperatively do not affect gastric pH and volume in children. Can J Anaesth 1990; 37:36.
- Green SM. Fasting is a consideration--not a necessity--for emergency department procedural sedation and analgesia. Ann Emerg Med 2003; 42:647.
- Ljungqvist O, Søreide E. Preoperative fasting. Br J Surg 2003; 90:400.
- Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2014; 63:247.
- Bassett KE, Anderson JL, Pribble CG, Guenther E. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 2003; 42:773.
- Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth 1999; 83:453.
- Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related? Ann Emerg Med 2004; 44:454.
- Babl FE, Puspitadewi A, Barnett P, et al. Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia. Pediatr Emerg Care 2005; 21:736.
- Olsson GL, Hallen B, Hambraeus-Jonzon K. Aspiration during anaesthesia: a computer-aided study of 185,358 anaesthetics. Acta Anaesthesiol Scand 1986; 30:84.
- Blitt CD, Gutman HL, Cohen DD, et al. "Silent" regurgitation and aspiration during general anesthesia. Anesth Analg 1970; 49:707.
- Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005; 45:177.
- Sury M, Bullock I, Rabar S, et al. Sedation for diagnostic and therapeutic procedures in children and young people: summary of NICE guidance. BMJ 2010; 341:c6819.
- Coté CJ, Notterman DA, Karl HW, et al. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000; 105:805.
- Murphy, MF, Walls, RM. Identification of the difficult and failed airway. In: Manual of emergency airway management, 2nd, Walls, RM (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.74.
- GOALS OF SEDATION AND ANALGESIA
- PRE-SEDATION EVALUATION
- Focused medical history
- Fasting and aspiration risk
- - Elective procedures
- - Urgent or emergent procedures
- Risk classification
- Airway assessment
- Informed consent
- Vascular access
- SUMMARY AND RECOMMENDATIONS