A number of physiologic parameters should be monitored to ensure the safety of the patient. The most recent guidelines from the AAP state that there should be a “functioning pulse oximeter with size-appropriate oximeter probes and other monitors as appropriate for the procedure (e.g., noninvasive blood pressure, respiratory rate, heart rate, electrocardiogram [ECG], capnography and a precordial stethoscope is encouraged in those circumstances in which the patient is not easily visible)” [5]. In July 2011, the American Society of Anesthesiologists updated the Standards for Basic Anesthetic Monitoring. These standards specify that “during moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment” [12].

Protocols or algorithms for how to activate back-up emergency services are essential for every setting where procedural sedation is practiced [5]. For nonhospital facilities, this includes the activation of the Emergency Medical Service (EMS) system and ambulance/transport services to the receiving hospital. It is implicit that the availability of EMS services does not obviate the practitioner’s responsibility in providing initial management and rescue of the potential complications of the sedation.

There need to be written guidelines and protocols for the preprocedure assessment as well as for the monitoring of the patient during and following the procedure. Table 3.2 lists the information that should be obtained in a preprocedure assessment [5]. Documentation during the procedure should be a time-based record of the monitored physiologic parameters and the timing, dosage, and effect of the administered drugs. This should start with the “time out,” during which time the patient’s name, procedure to be performed, and the site of the procedure are confirmed [10]. All complications, unanticipated patient reactions, and ensuing treatment should be documented. Finally, there must be instructions for patients and families for care of the patient postprocedure and following discharge, including contact information should there be a concern after the patient is discharged.

The practice of pediatrics is dependent on having an understanding of how patients change over time. From infancy to adolescence, children undergo tremendous physical, cognitive, and mental development. Where a patient is in his/her development will alter how we as physicians interact with our patients. An understanding of the child’s cognitive development is paramount to effectively manage a patient who is about to undergo a medical procedure.

While the pain from a medical procedure may be short-lived, there is recent data to suggest that there are long-term detrimental effects on neuronal development, pain threshold and sensitivity, coping strategies, and pain perception [13]. While procedural sedation may remove the acute pain, the anxiety surrounding the procedure may actually heighten the pain experience or the patient’s response to pain [13]. As such, how we prepare a patient for a medical procedure may have tremendous subsequent impact [14]. Recommendations regarding preparation for the procedure can be partitioned into timing, format, and content.

Timing refers to when one informs a patient about the procedure that is going to happen. Data suggest that information provided too far in advance of a procedure may serve to increase anxiety: Children may dwell on or exaggerate the anticipated pain or forget the pertinent information completely [13]. On the other hand, inadequate time to process the information about a procedure may heighten stress. Patients undergoing a major medical procedure (e.g., surgery) will need more advanced timing as compared to something more routine, such as the administration of a vaccine. The timing will also be influenced by the developmental stage of the patient. In general, children who cannot reason or think abstractly will benefit less from early advanced information.

Format refers to how information about a procedure is conveyed. Examples of various formats include models, puppets, schematic drawings, etc. The appropriate format to be used depends greatly on one’s cognitive development. For instance, young children who are at an egocentric phase of their development may not have the cognitive maturity to understand role playing with a puppet or doll.

The content about a procedure should relay information about the procedure itself and what the patient can expect. Accurate expectations will allow a patient to gain a sense of self-control and better cope with what is about to happen. As with timing and format, the content is greatly influenced by the developmental stage of the patient. Table 3.3 presents the sequential stages of cognitive development and the accompanying strategies to prepare a patient for a medical procedure [15].