Procedural sedation in children outside of the operating room
- Deborah C Hsu, MD, MEd
Deborah C Hsu, MD, MEd
- Associate Professor of Pediatrics, Section of Emergency Medicine
- Baylor College of Medicine
- Joseph P Cravero, MD
Joseph P Cravero, MD
- Associate Professor of Anesthesia
- Harvard Medical School
- Boston Children's Hospital
- 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
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 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 and improved sedation training programs 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 are the development of standardized definitions of outcomes, particularly with respect to what constitutes satisfactory sedation and what is an adverse event. In addition there remain a number of guidelines for sedation promulgated by a various specialty societies. Unified guidelines would encourage consistent care across specialties .
This topic reviews the indications, contraindications, and steps for safe performance of procedural sedation in children undergoing diagnostic or therapeutic procedures, regardless of setting.
Pre-sedation evaluation, preparation for procedural sedation, properties of specific agents used for pediatric procedural sedation, strategies for selecting medications for pediatric procedural sedation, pediatric airway management, and sedation in adults are discussed separately:
- 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.
- Chen E, Joseph MH, Zeltzer LK. Behavioral and cognitive interventions in the treatment of pain in children. Pediatr Clin North Am 2000; 47:513.
- Young KD. Pediatric procedural pain. Ann Emerg Med 2005; 45:160.
- Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics 2008; 122 Suppl 3:S134.
- 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.
- Grunwell JR, McCracken C, Fortenberry J, et al. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care 2014; 30:381.
- Shavit I, Leder M, Cohen DM. Sedation provider practice variation: a survey analysis of pediatric emergency subspecialists and fellows. Pediatr Emerg Care 2010; 26:742.
- Campbell IT, Beatty PC. Monitoring preoxygenation. Br J Anaesth 1994; 72:3.
- HELLER ML, WATSON TR Jr, IMREDY DS. APNEIC OXYGENATION IN MAN: POLAROGRAPHIC ARTERIAL OXYGEN TENSION STUDY. Anesthesiology 1964; 25:25.
- Fu ES, Downs JB, Schweiger JW, et al. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest 2004; 126:1552.
- Green SM, Krauss B. Supplemental oxygen during propofol sedation: yes or no? Ann Emerg Med 2008; 52:9.
- Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2014; 63:247.
- Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006; 117:e1170.
- Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006; 13:500.
- Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med 2002; 9:275.
- Langhan ML, Shabanova V, Li FY, et al. A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Am J Emerg Med 2015; 33:25.
- Malviya S, Voepel-Lewis T, Tait AR, et al. Effect of age and sedative agent on the accuracy of bispectral index in detecting depth of sedation in children. Pediatrics 2007; 120:e461.
- de Bie HM, Boersma M, Wattjes MP, et al. Preparing children with a mock scanner training protocol results in high quality structural and functional MRI scans. Eur J Pediatr 2010; 169:1079.
- French GM, Painter EC, Coury DL. Blowing away shot pain: a technique for pain management during immunization. Pediatrics 1994; 93:384.
- Sinha M, Christopher NC, Fenn R, Reeves L. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics 2006; 117:1162.
- McQueen A, Cress C, Tothy A. Using a tablet computer during pediatric procedures: a case series and review of the "apps". Pediatr Emerg Care 2012; 28:712.
- Committee on Hospital Care and Child Life Council. Child life services. Pediatrics 2014; 133:e1471.
- Wolfer J, Gaynard L, Goldberger J, et al. An experimental evaluation of a model child life program. Child Health Care 1988; 16:244.
- de Amorim e Silva CJ, Mackenzie A, Hallowell LM, et al. Practice MRI: reducing the need for sedation and general anaesthesia in children undergoing MRI. Australas Radiol 2006; 50:319.
- Raschle NM, Lee M, Buechler R, et al. Making MR imaging child's play - pediatric neuroimaging protocol, guidelines and procedure. J Vis Exp 2009.
- Khan JJ, Donnelly LF, Koch BL, et al. A program to decrease the need for pediatric sedation for CT and MRI. Appl Radiol 2007; 36:30.
- Duff AJ. Incorporating psychological approaches into routine paediatric venepuncture. Arch Dis Child 2003; 88:931.
- American Academy of Pediatrics. Committee on Hospital Care. Child life services. Pediatrics 2000; 106:1156.
- Krauss BS, Krauss BA, Green SM. VIDEOS IN CLINICAL MEDICINE. Managing Procedural Anxiety in Children. N Engl J Med 2016; 374:e19.
- 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.
- Newman DH, Azer MM, Pitetti RD, Singh S. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med 2003; 42:627.
- Walther-Larsen S, Rasmussen LS. The former preterm infant and risk of post-operative apnoea: recommendations for management. Acta Anaesthesiol Scand 2006; 50:888.
- Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118:1087.
- Coté CJ, Notterman DA, Karl HW, et al. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000; 105:805.
- Coté CJ, Karl HW, Notterman DA, et al. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics 2000; 106:633.
- Pitetti R, Davis PJ, Redlinger R, et al. Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines. Arch Pediatr Adolesc Med 2006; 160:211.
- GOALS OF SEDATION AND ANALGESIA
- CONTRAINDICATIONS AND PRECAUTIONS
- PERFORMING PROCEDURAL SEDATION
- Informed consent
- Nonpharmacologic interventions
- Medication administration
- DISCHARGE CRITERIA
- ADVERSE OUTCOMES
- CLINICAL PRACTICE GUIDELINES
- SUMMARY AND RECOMMENDATIONS