The Children’s Hospital of Chongqing Medical University has approximately 1,400 beds and performs more than 30,000 operations annually. It is considered to be one of the top three childrens’ hospitals in China and the largest center in southwest China. Anesthesiologists lead the sedation services for invasive procedures, which include bronchoscopy, gastroscopy, ultrasound-guided biopsies, renal, liver, cardiac catheterization and intervention, change of burn dressings, and other minor surgeries. Attending pediatricians, radiologists, and intensive care medicine physicians are responsible for sedation for non-painful procedures (CT/MRI, ultrasound, and echocardiography). There is an institutional guideline for providing sedation to children. These guidelines specify that only attending anesthesiologists (trained anesthesiologists who can work independently) who are trained in pediatric sedation have privileges to perform sedation outside the operating theater. All children must have pre-sedation assessment and evaluation. Patients with significant comorbidities and at high risk for sedation are identified, informed consent obtained from the legal guardian, and patients fasted (nil per os, NPO). Physiologic monitoring, resuscitation equipment and emergency medications, reversal agents for sedatives, and analgesia are available. Discharge criteria and recovery facilities are adopted to facilitate safe discharge. Commonly used sedatives by non-anesthesiologists include oral chloral hydrate and intramuscular phenobarbital. Anesthesiologists often use intravenous drugs, which include propofol, midazolam, sufentanil and remifentanil.

There are many challenges to providing a high standard of pediatric sedation. In the Children’s Hospital of Chongqing Medical University, anesthesiologists provide sedation at four sedation centers. These centers are often remote and distant from the operating theater. Often, only one anesthesiologist is available for providing the sedation service in each center. The sedation volume is extremely high and it is, therefore, not unusual for one anesthesiologist to be responsible for 30 endoscopy sedations in a 2–3 h period: His responsibilities would include pre-sedation evaluation, sedative preparation and administration, physiological monitoring, and documentation. The specialty nurses are responsible for recovery and discharge. With such a large sedation volume in such a short time frame, the anesthesiologist may not have adequate time to perform or document a detailed pre-sedation evaluation, particularly on complicated inpatients, many of whom have significant comorbidities. This busy environment creates a significant potential for risk and errors as the workload and demand is high. This is especially hazardous when working alone in remote areas. With this high patient volume, there is significant potential should one wish to review sedation practice, outcomes, and clinical research. Unfortunately, however, data collection and review is virtually impossible due to insufficient manpower. Training provided to non-anesthesiologists who practice sedation is often inadequate. There is, in general, no formal training of these practitioners on emergency identification, management, and airway resuscitation skills.

Guangzhou Women and Children’s Medical Center is the largest pediatric hospital in south China. An anesthesiologist-led pediatric sedation service for moderate to deep sedation was established here in January 2012, following a recommendation by the Joint Commission International (JCI), which subsequently accredited them in 2013. This hospital has approximately 1,300 beds and 60,000 operations performed annually. More than 20,000 sedations were provided by the anesthesiology department in 2012. The sedation service includes sedation for CT, MRI, ultrasound, echocardiograph, ABR, VEP, endoscopies, interventional procedures, dental procedures, biopsies, and minor surgeries. There are a number of sedation units within the hospital that are responsible for providing sedation for different procedures. Each unit is led by one anesthesiologist and one nurse, both of whom are credentialed by the hospital to provide sedation. There is a comprehensive institutional guideline available for providing moderate to deep sedation. The guideline adopts recommendations that are similar to that of the American Academy of Pediatrics and includes pre-sedation evaluation, informed consent, fasting and preparation, monitoring and documentation, as well as equipment and drugs for both sedation and resuscitation. Similar to the Children’s Hospital of Chongqing Medical University, the patient volume is very high and each anesthesiologist delivers sedation care for up to 50 patients per day. For invasive and painful procedures, intravenous analgesics and sedatives include sufentanil and propofol. For non-painful procedures, chloral hydrate is still the most commonly used sedative.

Even though a dedicated team and anesthesiologist-led sedation service is available in this center, the very high patient-to-anesthesiologist ratio makes it difficult to administer intravenous sedation to each patient for all non-painful procedures. Recently, dexmedetomidine has been introduced via the intranasal route in order to supplement or provide anxiolysis or sedation. Oral chloral hydrate with intranasal dexmedetomidine has been associated with a success rate of greater than 90 %, a combination that has become the primary mode of sedation [1]. After pre-sedation evaluation and informed consent, sedative(s) are prescribed by the attending/staff anesthesiologist. When the depth of sedation is assessed by the anesthesiologist to be adequate, the parent carries the child to the waiting area and waits with him until the procedure is ready to be performed. The success rate of chloral hydrate at 50 mg/kg is approximately 77–86 % for non-painful procedures in this center. Since chloral hydrate has an unpleasant taste, often children are encouraged to ingest it with other fluids such as fruit juice or a dairy drink. Therefore, children are, in fact, not fasted (not NPO) when chloral hydrate is used as the primary sedative. Subjectively, the author (Yuen) and anesthesiologists from this center observe that ingestion of chloral hydrate with a dairy drink tends to decrease irritability and hasten the onset of sedation. Nevertheless, this is only anecdotal experience and there are no such published reports to substantiate this. In this center, the anesthesiologist-led pediatric sedation service has been in operation for 2 years and to date there have been no cases of clinical aspiration nor aspiration-related events. In cases of failed chloral hydrate sedation after a first dosage, a repeat dose of 25 mg/kg is administered. The success rate after this repeat dose is 89–93 %. Only after a “failed” (unsuccessful at achieving adequate sedation conditions) oral sedation is intravenous sedation with propofol used for non-painful procedures. However, since these patients have consumed an oral drink with chloral hydrate, they are not meeting NPO guidelines for intravenous sedation, and the procedure is subsequently rescheduled or delayed until sufficient fasting time is achieved.

All sedated children are recovered in a post-sedation recovery room. Parents are encouraged to stimulate and wake up their children after sedation. Vital signs—which include SpO₂, blood pressure and respiratory rate—are monitored and recorded every 10 min. When the Aldrete score is greater than or equal to 9, the children would be discharged after parents are given post-discharge instruction (Table 23.1). (Refer to Chap. 5.) Inpatient and critically ill patients are often discharged to the inpatient ward or intensive care unit directly after the procedures with physiologic monitors for transport and escort by their attending medical officer.