• Cases that require a relatively motionless child in order to provide adequate working conditions.
• Invasive procedures, such as laceration repair, lumbar puncture, and orthopedic procedures.
• Diagnostic imaging studies.
• Due to the risk of oversedation or an allergic response to a sedative, sedation is indicated only if absolutely necessary.
| • Although there are few absolute contraindications, the points presented here are important to consider when weighing the risks and benefits of the sedation procedure. |
• History of an allergy or other untoward reaction to previous sedation attempts.
• Facial dysmorphism or deformity or anatomic variation that would make maintaining airway competency difficult (ie, Pierre Robin syndrome or Goldenhar syndrome). In these cases, consultation with an anesthesiologist is warranted.
• The presence of upper respiratory infection.
• Although not an absolute contraindication, sedation should be approached with caution.
• In a patient with clear lung fields but rhinorrhea, glycopyrrolate or atropine can be used prior to sedation to aid in drying secretions.
• The presence of lower airway symptoms, such as wheezing.
• For nonemergent sedations, rescheduling should be strongly considered.
• For emergent sedations, pretreatment with nebulized albuterol and use of ketamine should be considered.
• Vital signs must be assessed before, during, and after the sedation process.
• Pulse oximetry should be recorded regularly.
• Derangements in pulse oximetry may be the first sign of a problem, perhaps stemming from hypoventilation or laryngospasm.
• Capnography, while not widely used, had been studied recently as an adjuvant in monitoring patients during sedation.
• There is some evidence that elevation of carbon dioxide as measured by inline capnography may be a reliable early indicator of respiratory compromise from oversedation.
• Loss of airway patency; if unrecognized, hypoventilation or upper airway obstruction can lead to hypoxemia and respiratory arrest.
• Circulatory collapse can be induced by peripheral vasodilation and direct myocardial effects of some drugs.
• Potential for aspiration is increased with deep sedation because the gag reflex is lost.
• Allergic reactions are uncommon but do occur. The physician must be able to quickly diagnose and intervene if anaphylaxis begins.
• Terms such as “conscious sedation” and “twilight sleep” are misleading as any degree of sedation has potential to change to deep anesthesia and must be approached with this in mind.
• Practitioners who sedate patients must be skilled in advanced airway management, pediatric advanced life support, and in assessment of patients for changing levels of sedative effects.
• Trained support staff and resuscitation equipment and drugs must also be immediately available.
• Sedation should be initiated in a controlled environment. No sedation medications should be given by the parents on the way to the hospital or office, as was once common.
• Although complications from sedation are infrequent, the physician must be prepared for any clinical situation.
• In addition to being prepared for airway and cardiovascular emergencies, the qualified sedation practitioner must supervise or perform the following:
• Adequate presedation clinical evaluation.
• Formulation of a sedation plan.
• Adequate monitoring during and after the sedation process.
• Documentation, including details of drug administration, monitoring record, and occurrence of any complications (eg, airway obstruction, emesis, allergic reactions, paradoxical reactions to sedatives).
• Fulfillment of preestablished criteria before discharge from a monitoring environment.
• Appropriate management of pain.
• A thorough presedation evaluation is necessary before any drug administration. This screening process concentrates on past and current medical conditions, previous reactions to sedatives or to general anesthetics, and known drug allergies.
• A history of snoring, mouth breathing, asthma, or recent upper respiratory tract infections suggests possible airway obstruction or increased secretions.
• A history of difficult intubations or sleep apnea may require referral for consultation with an anesthesiologist or otolaryngologist (or both) prior to the procedure.
• A focused inspection of the airway must explore potential airway difficulties due to adenotonsillar hypertrophy, micrognathia, or other abnormal airway anatomy.
• The cardiovascular assessment should elicit information about the following:
• Congenital heart defects.
• Heart murmurs.
• Presence of a pacemaker.
• Previous cardiovascular surgical procedures.
• Cyanosis.
• Fatigue.
• Failure of growth.
• Neurologic evaluation includes notation of shunts, neurologic abnormalities, and seizure disorder.
• Important gastrointestinal issues to address are reflux and liver disease.
• Compromise of renal function and the frequency of dialysis should be noted.
• Exposure to infectious diseases should be recorded.
• The presence of an organ transplant must be documented.
• Finally, endocrine screening must evaluate the possibility of diabetes and questions should be asked about pituitary and thyroid dysfunction.
• Patients with pituitary dysfunction routinely are given stress-dose corticosteroids prior to sedation under the guidance of an endocrinologist.
• The patient’s fasting status should be reviewed before drug administration.
• Children aged younger than 6 months should not ingest milk or solids for 4 hours before elective sedation.
• Children older than 6 months should not ingest milk for 6 hours before elective sedation.
• Clear liquids may be given up to 2 hours prior to sedation in all age groups.
• Patients at risk for regurgitation or aspiration (eg, children with known reflux or extreme obesity) may benefit from prolonged fasting or pharmacologic therapy to reduce gastric volume and acidity.
• Hydration with intravenous fluids is often necessary after prolonged fasting, particularly in young infants.
• In an emergency department, waiting many hours prior to sedation may not be an option.
• Although fasting is preferred, there is little evidence to show patients who have not fasted have worse outcomes, such as aspiration, than those who fasted.
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