Pediatric sedation is an evolving field performed by an extensive list of specialties. Well-defined sedation systems within pediatric facilities are paramount to providing consistent, safe sedation. Pediatric sedation providers should be trained in the principles and practice of sedation, which include patient selection, pre-sedation assessment to determine risks during sedation, selection of optimal sedation medication, monitoring requirements, and post-sedation care. Training, credentialing, and continuing sedation education must be incorporated into sedation systems to verify and monitor the practice of safe sedation. Pediatric hospitalists represent a group of providers with extensive pediatric knowledge and skills who can safely provide pediatric sedation.
Key points
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The roles, responsibilities, and skills of providers administering pediatric sedation continue to advance globally.
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Pediatric sedation providers should be trained in the principles and practice of sedation, which include patient selection, performing pre-sedation assessments to determine risks during sedation, selection of optimal of sedation medication, monitoring requirements, and post-sedation care.
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Collaboration with other sedation providers to partner in the training, certification, and ongoing maintenance of sedation skills are important in creating safe systems for pediatric sedation to be performed by pediatric hospitalists.
Introduction
The roles, responsibilities, and skills of providers administering pediatric sedation continue to advance globally. Pediatric sedation is a growing field involving not only new pharmacologic innovation but also the emerging roles of the sedation provider. Across the world, several different practitioners are currently providing pediatric sedation. This extensive list includes anesthesiologists, emergency medicine physicians, dentists, intensivists, pediatric hospitalists, pediatric subspecialists, radiologists, surgeons, nurse anesthetists, advanced nurse practitioners, and nurses. Each of these specialties carries their own skill set for providing mild, moderate, and deep pediatric sedation. Providers of pediatric sedation must adhere to the principles and practices of pediatric sedation and maintain the skills necessary to provide safe sedation and recovery. In the United States several groups have published guidelines regarding the practice of pediatric sedation, including the American Academy of Pediatrics, the American Academy of Pediatric Dentistry, the American College of Emergency Physicians, and the American Society of Anesthesiologists (ASA). Accordingly, the Joint Commission of Healthcare Organization has incorporated these sedation guidelines into their Comprehensive Accreditation Manual for Hospitals. Sedation services should be governed by institutional standards that incorporate national guidelines for pediatric sedation. Quality improvement measures must be used to monitor and review sedation practices. Credentialing and training programs should be available to non-Anesthesia providers to assure safe sedation practices.
Introduction
The roles, responsibilities, and skills of providers administering pediatric sedation continue to advance globally. Pediatric sedation is a growing field involving not only new pharmacologic innovation but also the emerging roles of the sedation provider. Across the world, several different practitioners are currently providing pediatric sedation. This extensive list includes anesthesiologists, emergency medicine physicians, dentists, intensivists, pediatric hospitalists, pediatric subspecialists, radiologists, surgeons, nurse anesthetists, advanced nurse practitioners, and nurses. Each of these specialties carries their own skill set for providing mild, moderate, and deep pediatric sedation. Providers of pediatric sedation must adhere to the principles and practices of pediatric sedation and maintain the skills necessary to provide safe sedation and recovery. In the United States several groups have published guidelines regarding the practice of pediatric sedation, including the American Academy of Pediatrics, the American Academy of Pediatric Dentistry, the American College of Emergency Physicians, and the American Society of Anesthesiologists (ASA). Accordingly, the Joint Commission of Healthcare Organization has incorporated these sedation guidelines into their Comprehensive Accreditation Manual for Hospitals. Sedation services should be governed by institutional standards that incorporate national guidelines for pediatric sedation. Quality improvement measures must be used to monitor and review sedation practices. Credentialing and training programs should be available to non-Anesthesia providers to assure safe sedation practices.
Patient selection and pre-sedation assessment
Appropriate patient selection is a critical element in providing safe sedation. A thorough pre-sedation assessment must be completed for every pediatric patient before sedation. This evaluation should be focused on identifying potential risks for sedation and difficulty with airway management, and should include the reason for the sedation, active medical problems, and past medical problems ( Box 1 ).
Active Medical Problems
Fever
Head/facial trauma
Depressed level of consciousness
Obesity
Reduced intravascular volume
Symptoms of sleep apnea
Snoring
Upper/lower airway issues
Upper respiratory infection (URI) symptoms
Uncontrolled seizures
Unfasted
Unstable psychiatric disorder
Past Medical Problems
Apnea
Craniofacial abnormalities
Genetic syndromes (eg, Down syndrome)
Hematologic/oncologic disease
History of postoperative nausea/vomiting
History of prior sedation complications
Liver dysfunction
Metabolic disorders
Myopathy or neurologic condition
Prematurity
Renal disease
Risk of aspiration
Significant cardiac disease
Significant dental problems/devices
Significant gastrointestinal condition
Tracheal abnormalities
Upper/lower airway issues
Certain patients have medical conditions that put them at high risk for complications during sedation. In general, patients with significant craniofacial abnormalities or history of upper airway abnormalities may have anatomic alterations to upper airway structures that would put them at risk for respiratory complications and difficult intubation. Recognition of the increased risks of sedation in young infants must be appreciated. Infants younger than 6 months are at risk for respiratory depression and apnea. Infants younger than 3 months should be sedated by anesthesiologists or intensivists. Given the same concerns with infants 3 to 6 months old, careful assessment and monitoring should be performed in this age group. Caution should be exercised with obese patients whose body mass index is greater than 95% on standard pediatric growth curves. These children can be subject to reduction in lung volumes and compliance, are at risk for upper airway obstruction, can be difficult to ventilate using a bag-valve mask (BVM) technique, and can be difficult to intubate. Obese children also may have cardiac complications including hypertension and increased left ventricular mass/hypertrophy. Obese children who have significant symptoms or a diagnosis of obstructive sleep apnea should be sedated by an anesthesiologist or intensivist.
The patients’ family history in relation to anesthesia/sedation complications or psychiatric history should also be obtained. It is important to document any allergies or sensitivities to medications and to list all current medications the patient is taking. Postmenarchal females and any girl 12 years and older should have a documented negative human chorionic gonadotropin before sedation.
Elective and urgent sedation cases should adhere to individual institution guidelines, which vary among pediatric facilities. Most institutions adopt standard ASA nil-by-mouth (NPO) guidelines for elective cases of 2 hours for liquids, 4 hours for breast milk, and 6 hours for formula/nonhuman milk in infants 6 months and younger, and 6 hours for solids for infants older than 6 months. NPO status is controversial in the urgent setting. The risks and benefits must be considered before attempting to sedate patients in urgent situations. Consideration must be made for available resources should complications arise during sedations performed for relatively urgent procedures. Anesthesia consultation should be sought if the procedure must happen emergently, NPO guidelines are not met, and there is a high risk for aspiration.
ASA classification should be determined for each patient to determine his or her current disease state ( Table 1 ). It is important to identify which patients require further Anesthesia consultation or are more appropriate to be sedated by an anesthesiologist or intensivist. In general, patients with an ASA classification of I or II are appropriate for sedation by a trained sedation provider. ASA class III patients should require a minimum of an anesthesiologist/intensivist consultation, and are best served by sedation providers with advanced training in sedation. Patients with ASA classification of IV or more should be sedated by an anesthesiologist or intensivist.
| Status | Disease State |
|---|---|
| I | A normal healthy patient |
| II | A patient with mild systemic disease |
| III | A patient with severe systemic disease |
| IV | A patient with severe systemic disease that is a constant threat to life |
| V | A moribund patient who has little chance of survival but is submitted to surgery as a last resort |
| VI | A declared brain-dead patient whose organs are being removed for donor purposes |
A detailed physical examination should be performed before any sedation, focusing on key elements that could pose potential risks or complications to the patient while under sedation. It is equally important to obtain baseline vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, weight, and pain score. The physical examination should include a thorough examination of the head and neck. Specific attention should be paid to craniofacial characteristics such as a short neck, small mandible, dysmorphic features, small mouth opening, large tongue, and enlarged tonsils. This evaluation will help to determine which patients are at more risk for difficult intubation or airway complications arising from sedation.
The Mallampati classification relates tongue size to pharyngeal size, and should be performed on every patient who is able to cooperate. This test is performed with the patient in the sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum, with no vocalization. The subsequent classification is assigned based on the pharyngeal structures that are visible ( Box 2 , Fig. 1 ). Infants and children who are uncooperative should undergo a visual inspection of the oropharynx with a tongue depressor for any abnormalities. Referral to an anesthesiologist for sedation should be considered for patients with a Mallampati classification of IV.
| Class | Structures Visualized |
|---|---|
| I | Soft palate, fauces, uvula, anterior and posterior pillars |
| II | Soft palate, fauces, uvula |
| III | Soft palate and base of the uvula |
| IV | Soft palate is not visible at all |
A focused clinical examination including the cardiovascular and pulmonary systems is crucial. Any significant or unexpected findings such as a pathologic murmur, significant wheezing, or respiratory distress should be evaluated and treated before providing sedation. After performing a thorough sedation history and physical examination, the sedation provider must assess the proposed procedure or study for guidance in the selection of appropriate sedation agents.
Indications for sedation
It is important to consider the need for sedation, and which properties of sedation or combination thereof will be required to perform a procedure or study. These properties include mild/moderate/deep sedation, analgesia, amnesia, anxiolysis, and degree of immobility. It is equally important to ascertain the anticipated length of the procedure, as this plays an important role in determining optimal medications, redosing, or combinations of sedation agents. The pre-sedation assessment and physical examination should alert the sedation provider as to which medications may pose greater sedation risks and complications, or which medications are contraindicated for specific patients. Providers who are relatively inexperienced should ask for assistance or Anesthesia consultation should they be asked to perform a sedation they think exceeds their abilities. The request for evening and overnight urgent sedations at risk for complications may be best delayed until appropriate personnel are available. Sedation providers must also be aware of institutional policies regarding which children are considered appropriate candidates for sedation, which targeted depth of sedation is acceptable, monitoring requirements, recovery and discharge criteria, and necessary documentation.
Choosing the optimal sedation agent
Common medications used for pediatric sedation include midazolam, nitrous oxide, ketamine, pentobarbital, dexmedetomidine, and propofol. Of importance is that some of these medications used alone may not achieve the level of sedation required to complete a procedure or study. Several of these medications are used in combination to achieve optimal sedation; it is imperative that experienced, advanced sedation providers provide this type of sedation. It has been shown that the use of multiple sedation medications significantly increases the rates of adverse events. Sedation providers must be aware of personal limitations in addition to those institutional policies and procedures that govern sedation. Sedation providers should have the ability to manage and rescue patients who progress to a deeper sedation level than was planned. Appreciation of these issues is an important element in providing consistently safe sedation. For sedation providers with less experience or training, a one-drug sedation plan should be adopted. Sedation is much more predictable using one medication only to complete a study or procedure. It is imperative that the sedation provider be in control of all sedation medications, and supervises or personally discards the unused medication. Boxes 3–8 summarize the general guidelines for medication selection for uncomplicated pediatric sedation.
| Sedation properties | Anxiolysis, mild sedation | ||
| Indications | Radiology examinations Brief studies/procedures (local anesthetic medications should be used for analgesia during procedures) |
| |
| Contraindications |
| ||
| Dosing | Inhaled 0.4 mg/kg | IV 0.05 to 0.2 mg/kg | By mouth (PO) 0.5 mg/kg |
| Adverse effects | Agitation, respiratory depression | ||
| Sedation properties | Anxiolysis, amnesia, mild analgesia, mild/moderate sedation, relative immobility | |
| Indications | Short painful procedures Painful/difficult examinations |
|
| Contraindications |
|
|
| Dosing | Inhaled 30% to 70% (higher concentrations provide enhanced analgesia and sedation) PO oxycodone 0.2 to 0.3 mg/kg (maximum 10 mg) given 60 minutes prior can augment analgesia and sedation | |
| Adverse effects | Nausea, vomiting, hallucinations, agitation | |
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