The goals of sedation and analgesia are to relieve pain and suffering and to allow diagnostic and therapeutic procedures to proceed with comfort, safety, efficacy, and efficiency. The needs of the patient and the specific goals of sedation must be considered on an individual basis, with attention to patient safety and minimization of anxiety, pain, and memory. Adherence to the guidelines for the monitoring of sedated patients developed by the American Academy of Pediatrics (AAP), the American Society of Anesthesiologists (ASA), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is essential.^1-4 Please note that the information provided in this chapter is not sufficient guidance for the safe administration of procedural sedation. Each institution should have its own training and certification requirement as well as a procedure for maintaining competence in providing procedural sedation. It is our responsibility as hospitalists to ensure that our patients are cared for in systems that provide for safe, efficient and effective sedation.

The following definitions for the level of sedation have been adopted by the AAP, ASA, and JCAHO.^1-4

Minimal sedation (anxiolysis): A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are usually maintained.

Moderate sedation or analgesia: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light to moderate tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep sedation or analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to maintain independent ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General anesthesia: A drug-induced loss of consciousness during which patients cannot be aroused, even by painful stimulation. The ability to maintain independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or depression of neuromuscular function.

It is important to note that patients’ responses to medications and doses can vary tremendously. Thus healthcare providers intending to achieve moderate sedation should be prepared to manage unintended deep sedation, and during attempts to achieve deep sedation, the provider should be capable of managing a brief period of general anesthesia, including maintaining a patent airway, effective ventilation, and cardiovascular function.

HISTORY AND PHYSICAL EXAMINATION

All children scheduled to undergo sedation should be screened for potential adverse events during sedation and recovery. A presedation evaluation includes a focused history and physical examination, with attention to the airway and cardiorespiratory status. A focused history can be guided by the mnemonic AMPLE (Table 184-1).

The evaluation of a potentially difficult airway includes a history of previous problems with sedation or anesthesia, stridor, snoring, sleep apnea, and any recent respiratory illness. Patients with significant obesity, short neck, small mandible, dysmorphic facial features, small mouth opening, large tongue or tonsils, or nonvisible uvula are at increased risk of airway obstruction even with moderate sedation.

The patient’s physical status as classified by the ASA can be useful in assessing sedation risk (Table 184-2).³ ASA class I and II children are at low risk for adverse events during sedation when they are carefully monitored. Anesthesiology consultation should be considered when planning the sedation of an ASA class III patient.

PRESEDATION FASTING

There is no proven relationship between the duration of fasting before sedation and the risk of aspiration in humans. However, the general consensus is that fasting likely reduces the risk of aspiration. For elective procedures, the ASA consensus recommendations should be followed (Table 184-3).⁵ For nonelective procedures, the patient should be fasted as soon as the potential need for sedation is identified. Although the risk of clinically significant aspiration is low, it should be weighed carefully against the need to perform a diagnostic or therapeutic procedure quickly. The lightest effective sedation should be used.

SELECTION OF AN AGENT

The selection of medications is guided by the desired effect: analgesia, anxiolysis, amnesia, or some combination. Desired depth of sedation must be considered carefully. The lightest effective sedation is preferred, but because of the wide variety of individual responses, clinicians should be trained and prepared to administer increasingly deeper sedation, guided by the patient’s response. The clinician should consider using effective nonpharmacologic techniques such as distraction, imagery, and parental involvement whenever possible.

PERSONNEL

For minimal and moderate sedation, one person with the appropriate training and experience is responsible for the procedural sedation and analgesia. This person may be the same individual who will be performing the procedure. A second person who is knowledgeable in basic pediatric life support is also required. That person is responsible for monitoring the patient’s cardiopulmonary status and for recording these data on a sedation record; he or she may also assist in brief, interruptible tasks once the level of sedation is stabilized.

For deep sedation, a provider with training in advanced pediatric life support must be in the room. The person administering deep sedation should perform direct monitoring of the patient and should not be the person primarily responsible for the procedure. The sedation provider can offer brief assistance with the procedure, as long as attention is still being paid to the patient’s physiologic status. Problems with ventilation and oxygenation are easily managed when they are recognized quickly. Because deeper than intended sedation may occur in any patient, it is generally recommended that the sedation provider be prepared to manage deep sedation even when only moderate sedation is intended.

MONITORING

For minimal and moderate sedation, a minimum of pulse oximetry is strongly recommended.^1-4 In addition, continuous monitoring of the heart rate and respiratory rate and intermittent noninvasive blood pressure measurements are generally recommended. If intravenous access is not otherwise established, it is not required but should be carefully considered.

For deep sedation, continuous electrocardiographic heart rate and respiratory rate as well as pulse oximetry and noninvasive blood pressure monitoring are strongly recommended.^1-4 If available, end-tidal carbon dioxide monitoring is also recommended throughout the sedation and recovery. Intravenous access is also recommended. In addition to electrophysiologic monitoring, the child’s color, airway patency, and rate and depth of respiration should be monitored by direct observation. This is especially important when giving additional medicine and immediately after the procedure. Completion of the painful parts of the procedure may cause children to experience deepening of the sedated state.