Links To And Excerpts From The Candian Paediatric Society’s Position Statement”Recommendations for procedural sedation in infants, children, and adolescents”

In this post, I link to and excerpt from The Candian Paediatric Society’s Position Statement “Recommendations for procedural sedation in infants, children, and adolescents“. Posted: Mar 12, 2021.

All that follows is from the above resource.

This statement provides best practice guidance for the development of institutional standards surrounding safe procedural sedation for infants, children and adolescents (Figure 1).

The term ‘procedural sedation’ refers here to the administration of any pharmacologic agent(s) for the purpose of sedation. Guidance in this document does not necessarily apply to patients receiving medications for anxiolytic purposes or analgesic drugs for pain. Such cases are described in another Canadian Paediatric Society statement on managing pain and distress in children undergoing brief diagnostic and therapeutic procedures.

Clinician skills, training, and credentialing

Procedural sedation can be safely administered by non-anesthesiologist clinicians in both tertiary care and community hospitals [8]-[11][14]. Safety and effectiveness relate primarily to individual clinicians’ skills [15], and a practitioner competent in airway management and the resuscitation and stabilization of critically ill paediatric patients must be immediately available at all times [12].

The clinician responsible for administering sedation must be prepared to manage emergency situations including aspiration, airway obstruction, laryngospasm, apnea, hypoventilation, hypoxia, hypotension, bradycardias, arrhythmias, cardiac arrest, seizures, allergic reactions, and paradoxical reactions [6][8][9][11][12].

There is significant institutional variation in credentialing requirements for clinicians who provide procedural sedation [16]. Many institutions have developed formal training programs demonstrating improvements in the quality and safety of sedation services [17][20]. Participation in a formal training course is likely more effective in improving physician knowledge than self-directed learning [21]. Recommended core competencies can be found at High-fidelity simulation team-based training may assist in training and maintaining the skills of health care providers (HCPs) to respond more effectively in emergency situations that could arise [22][24].

Table 1. Key elements of the pre-sedation evaluation
  1. Demographic data
    • name, age, weight
  2. Details of procedure
    • type, duration, urgency
  3. Past medical history
    • acute medical conditions/current illnesses
    • comorbid medical conditions
    • review of systems
    • previous sedations/anesthetics
  4. Allergies
  5. Medications
  6. Family history of anesthetic complications
  7. Social history
  8. Fasting status
    • current or provide recommendations before procedure
  9. Physical examination
    • baseline vital signs
    • airway assessment for features of a difficult airway (e.g., craniofacial anomalies, abnormal neck mobility, small oral aperture or cavity, large tongue, neck masses, laryngeal and subglottic abnormalities)
    • cardiopulmonary examination
  10. Other investigations as required
  11. Summary
    • ASA physical status assessment
    • sedation plan and rationale
    • planned disposition
  12. Informed consent
ASA American Society of Anesthesiologists
Table 2. American Society of Anesthesiologists (ASA) Physical Status Classification System
Healthy, normal child
Child with mild systemic disease
Controlled asthma, controlled diabetes
Child with severe systemic disease
Active wheezing, diabetes with complications, heart disease that limits activity
Child with severe systemic disease that is a constant threat to life
Status asthmaticus, severe bronchopulmonary dysplasia, sepsis
Child who is moribund who is not expected to survive 24 h with or without an operative procedure
Severe traumatic brain injury, septic shock
* Modified from reference [28] to provide paediatric-specific examples
ASA American Society of Anesthesiologists

Although recent studies have demonstrated no statistically significant association between pre-procedural fasting of any duration and any type of adverse event in children who undergo procedural sedation in the emergency department (ED) [34][35], ASA fasting guidelines recommend a minimum fasting period of 1 h for clear liquids, 4 h for human milk, and 6 h for infant formula, nonhuman milk, and light meals [36]. Children undergoing procedural sedation should be fasted according to institution-specific general anesthesia fasting guidelines and practices.

Emergency preparedness

Most adverse events are preventable, provided that patients have been appropriately selected, prepared, monitored, and managed in emergency situations [12]. Before commencing procedural sedation, the clinician should ensure the availability of:

  1. Appropriate personnel
  2. Monitoring equipment
  3. Emergency equipment and rescue medications

1) Appropriate personnel

Procedural sedation should only occur in the presence of at least two HCPs, including a clinician skilled in procedural sedation and advanced airway management and resuscitation. One HCP must be dedicated to continuously monitoring the patient and responding to physiological changes. When the clinician responsible for the sedation is also performing the procedure, continuous patient monitoring and directed administration of medications should be delegated to another highly qualified HCP, such as another physician, a nurse practitioner, an anesthesia assistant, or a nurse with advanced resuscitation skills (e.g., several years of experience in ED, intensive care, or post-anesthetic recovery).

2) Monitoring equipment

Monitoring should include continuous pulse oximetry and intermittent noninvasive blood pressure monitoring every 5 minutes. The AAP and the ASA recommend the use of continuous 3-lead electrocardiography (ECG) and end-tidal carbon dioxide monitoring (i.e., capnography) for moderate sedation because this technique is superior to clinical monitoring alone [1][37]. Pulse oximetry is essential but insufficient because normal saturations may be maintained after the onset of inadequate ventilation. Hypoventilation can be masked by the maintenance of normal saturations. Although ECG electrodes allow for transthoracic impedance monitoring, chest wall movement may continue to be interpreted as “normal” during episodes of obstructive apnea or laryngospasm. Air flow is best assessed by auscultation. The ability to immediately detect ventilatory failure secondary to hypoventilation, apnea, upper airway obstruction, or laryngospasm allows for timely intervention and avoidance of progression to cardiac arrest [12]. Hospitals should ensure that the necessary equipment and HCP skills required to perform and interpret capnography are available for moderate to deep procedural sedations.

3) Emergency equipment and rescue medications

Regardless of the anticipated level of sedation, age- and size-appropriate emergency equipment (Table 3) and rescue medications (Table 4) should be immediately available. The clinician administering the sedation and HCPs who are assisting must ensure familiarity with the location and functioning of equipment and weight-based doses of rescue medications, including those required for cardiopulmonary resuscitation and reversal agents.

Table 3. Emergency equipment (SOAPME)
S = suction catheters and apparatus
O = oxygen supply and delivery equipment (e.g., flow meters, tubing, prongs)
= airway equipment (e.g., face masks, nasopharyngeal/oropharyngeal airways, laryngoscope handles and blades, endotracheal tubes, stylets)
P = positive-pressure delivery system (i.e., bag-valve-mask ventilation)
M = monitors (e.g., pulse oximetry, end-tidal carbon dioxide, ECG leads, noninvasive blood pressure)
E = emergency cart with alternate airways (e.g., laryngeal mask airway), supplies for vascular access, and resuscitation drugs


Table 4. Rescue medications
Dose range and route Comments
Atropine 0.02 mg/kg IV (maximum 0.5 mg) May repeat dose once (maximum total dose 1 mg for child; 3 mg for adolescent)

(0.1 mg/mL)

0.01 mg/kg IV (maximum 1 mg) May repeat dose every 3 to 5 minutes

(benzodiazepine reversal)

0.01 mg/kg IV (maximum 0.2 mg) May repeat every 1 minute to a maximum total cumulative dose of 0.05 mg/kg or 1 mg total, whichever is less

Contraindicated in patients with underlying seizure disorder


(opioid reversal)

0.1 mg/kg IV (maximum 2 mg) Dilute and titrate to effect

May repeat every 2 to 3 minutes

Contraindicated in patients with chronic opioid exposure

Succinylcholine 1 to 2 mg/kg IV (maximum 150 mg)

2 to 4 mg/kg IM

Essential rescue medication that should be drawn up for the treatment of severe laryngospasm and to facilitate rapid intubation, when needed.

Repeat doses increase risk for bradycardia

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