In this post, I link to and excerpt from PedsCases‘ Procedural Sedation in Infants, Children, and Adolescents, by Summer Hudson Aug 22, 2021.
All that follows is from the podcast and show notes.
This PedsCases podcast will explore approaches to procedural sedation in infants, children, and adolescents undergoing common diagnostic and therapeutic procedures requiring sedation and analgesia outside the operating room by non-anesthesiologists / non-intensivist clinicians. It will specifically focus on the prevention of sedation-related adverse events. The podcast was developed by Summer Hudson and Katie Gourlay, second-year medical students at the University of Alberta, in collaboration with Dr. Kristina Krmpotic, a pediatric intensivist at IWK Health.
Here are excerpts from the script.
Let’s review some take-home points to summarize:
1. The main goals of procedural sedation are to maximize patient comfort and safety, while minimizing movement and anxiety to ensure procedural success. 2. When considering a child for procedural sedation, you should perform a detailed history and physical exam. Consider the factors that place a child at increased risk for procedural sedation and their ASA classification, in determining whether
procedural sedation can be administered safely by a non-anesthesiologist.
3. Emergency preparedness is imperative for the procedural sedation of any child. The clinician must ensure the appropriate personnel, monitoring equipment, and rescue medications are immediately available prior to commencing any procedural sedation in case the child deteriorates and resuscitation is required.
In this PedsCases podcast we will explore approaches to procedural sedation in infants, children, and adolescents undergoing common diagnostic and therapeutic procedures
requiring sedation and analgesia outside the operating room by non-anesthesiologists / non-intensivist clinicians. For the purposes of this podcast and the position statement,the term “Procedural Sedation” refers to the administration of pharmacologic agents for the purpose of sedation, allowing the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function2. For a detailed review of the management of distress and pain in children, please review the PedsCases podcast created by Drs. Anastasia Zello, Evelyn Trottier, and Samina Ali.
Goals for Procedural Sedation
There are many reasons a child may require procedural sedation. The main goal of procedural sedation, as outlined by the CPS guideline, is to “minimize distress, physical discomfort, and pain while maintaining airway reflexes, adequate oxygenation and ventilation, and cardiopulmonary stability, reflected by limited deviation from baseline vital signs.” These goals fit our aims for Abdul – we want to keep him comfortable and still during the CT scan, so we can obtain a high-quality image.
Skills & Training
Now that we’ve identified the goal of procedural sedation, let’s talk about moving forward with procedural sedation.
First, it is essential to be aware of the necessary skills and training a clinician requires to perform safe and effective procedural sedation.
Non-anesthesiologist clinicians can perform procedural sedation safely, in both tertiary care and community hospitals, with individual physician competency determining the success of the procedure.
The CPS guideline states that the clinician administering
sedation must be prepared to manage emergencies including but not limited to: airway obstruction, laryngospasm, aspiration, apnea, hypoxia, hypoventilation, bradycardia,
arrhythmias, hypotension, cardiac arrest, seizures, allergic reactions and paradoxical reactions.
The clinician should be prepared to manage the patient at any depth of sedation.
Selection & Evaluation For Procedural Sedation
In evaluating a child for procedural sedation, always conduct a thorough history. As outlined by the American Society of Anaesthesiologists (ASA for short), key elements to identify on history include:
● Demographic data (including name, age, and weight);
● Recent or current symptoms of acute illness (like upper respiratory tract infection)
or active chronic conditions (like a recent asthma exacerbation);
● Past medical history (including acute and chronic medical conditions, previous
sedations and anaesthetics, and a thorough review of systems);
● Family history of anesthetic complications;
● Social history; and
● Fasting status.
As a note, if the child is not currently fasting, the clinician should provide recommendations prior to the procedure, consistent with institutional guidelines and practices. Current guidelines ASA recommend a fasting period of at least 1 hour for clear liquids, 4 hours for human milk, and 6 hours for formulas and solid foods.
In addition to a detailed history, a focused physical exam is another critical component of the pre-evaluation for sedation. This should include baseline vital signs, cardiopulmonary exam, and airway assessment to identify barriers to intubation.
The history and physical exam in combination will allow you to classify the patient by the ASA Physical Status Classification System. This system scores children on a scale of 1 to 5 based on the severity of their symptoms.
ASA I status is assigned to healthy children with no underlying conditions.
ASA II status is assigned to children with only mild systemic disease (such as well-controlled diabetes or asthma).
ASA III status applies to those children with severe systemic disease, such as asthma accompanied by active wheeze or complicated diabetes.
ASA IV is assigned to those children with severe systemic disease that is a constant threat to life (e.g. sepsis or severebronchopulmonary dysplasia).
Lastly, ASA V status is assigned to children who are not
expected to survive past 24 hours with or without the procedure in question, such as those with severe traumatic brain injury or severe septic shock.
Other children may also be at increased risk of complications and should be referred to anaesthesia for consultation prior to administering procedural sedation.
This includes children with a potentially difficult airway, as indicated by previous difficulties or phenotypic features, such as craniofacial abnormalities or obesity, as well as children with pulmonary hypertension, or existing respiratory disease. It also includes children with obesity or obstructive sleep apnea.
Preterm infants should also receive consultation, as this group is susceptible to post-anaesthetic apneas until age 60 weeks post conceptual age.
It is important to note that all infants less than 6 months of age
also have an increased risk of adverse events.
Overall, pediatric considerations for sedation will be different than those for adults. Because children are more likely to demonstrate spontaneous behaviors and movements, they can require deeper sedation levels. It is not uncommon for children to have varied responses to medications and progress to a deeper level of sedation than intended. As a result, clinicians administering procedural sedation must be prepared to manage children at any level of sedation.
Children also consume more oxygen than adults, so hypoxia can develop much more quickly during periods of respiratory depression. Respiratory depression is a serious concern in patients undergoing sedation, and must be recognized quickly so that immediate interventions can be performed.
Anatomical differences in the pediatric airway include a larger tongue or narrower airway, which may make airway management more difficult. Other patients at risk for difficult airway management include obese patients and patients with a historically difficult airway.
Having reviewed the potential complications of procedural sedation, what can clinicians and institutions do to remain vigilant in the prevention of adverse events?
Most adverse events can be prevented through proper patient selection, preparation, monitoring, and emergency management.
The first key step in emergency preparedness is proper selection and classification of patients for procedural sedation, as previously discussed.
Next, prior to beginning sedation, clinicians must ensure availability of appropriate personnel, monitoring equipment, emergency equipment, and rescue medications.
Adequate monitoring includes continuous pulse oximetry, intermittent blood pressure monitoring every 5 minutes, continuous 3-lead electrocardiography, and end-tidal
carbon dioxide monitoring when available. The latter is specifically important for procedures requiring moderate to deep procedural sedation. Pulse oximetry is insufficient because normal saturations may be maintained long after the onset of
Intermittent auscultation should also be performed to assess airflow and mitigate risk of respiratory failure through early recognition of hypoventilation or airway obstruction.
Finally, let’s talk about the final important component of our emergency preparedness strategy: emergency equipment and rescue medications.
Before administering procedural sedation, the clinician responsible should ensure availability of age- and size-appropriate emergency equipment, and immediate access
to rescue medications including resuscitation drugs and reversal agents.
These include Atropine, Epinephrine, Flumenazil, Naloxone, and Succinylcholine. We encourage you to read the CPS guideline* for dosing recommendations.
A handy mnemonic for the checklist of emergency equipment is SOAPME:
● The S stands for suction catheters and apparatus.
● O stands for oxygen supply and delivery equipment, which includes flow meters,
tubing, and nasal prongs.
● A stands for airway equipment – including face masks for various face sizes, both nasopharyngeal and oropharyngeal airways, laryngoscope handles and blades,
endotracheal tubes, and stylets. ● The P stands for positive-pressure delivery system – for example, a bag-valve-mask apparatus.
● The M stands for monitors – like the O2 saturation monitors and ECG leads we
● Lastly, the E stands for emergency cart – containing all necessary resuscitation equipment including alternate airways, tools for achieving vascular access, and associated medications.
It is important to note that specific medications for procedural sedation are numerous and distinct. Medication choices vary widely based on patient characteristics, procedure type and duration, as well as institutional availability and practitioner familiarity. and are thus beyond the scope of this podcast. Clinicians administering procedural sedation should have a comprehensive understanding of agent onset, mechanism of action, and adverse effects for all medications they are administering.*
Documentation, Monitoring and Recovery
Once emergency measures are in place and sedation agents are chosen and the team is ready to proceed, one team member should be assigned the task of monitoring and documenting throughout the procedure.
Real-time vital signs should be recorded every 5 minutes throughout the sedation and every 15 minutes during recovery, until the patient has returned to baseline. Medications used, side effects experienced, and use of any emergency intervention previously mentioned, should also be documented. The
efficacy of sedation used can be recorded using a formal scoring system. In addition to documentation of the pre-sedation evaluation and informed consent, discharge instructions should also be specified and recorded.*
*Validation of the Pediatric Sedation State Scale [Full-Text PDF]. PEDIATRICS Volume 139, number 5, May 2017:e20162897.
*Pediatric Sedation Scales: Using the Right One When It Counts
By Suzan Miller-Hoover DNP, RN, CCNS, CCRN. 2016