Pediatric Procedural Sedation, Analgesia, and Anxiolysis

Minimal Sedation. Formally referred to as anxiolysis, minimal sedation is a state in which the patient is responsive but somewhat cognitively impaired, while maintaining all other functions rated in the sedation continuum.

Moderate Sedation. Previously referred to as “conscious sedation,” moderate sedation is a state of drug-induced depression of consciousness that still enables the patient to maintain purposeful responses to age-appropriate verbal commands and tactile stimulation, spontaneous ventilation, and CV integrity.

Deep Sedation. Deep sedation causes a drug-induced depression of consciousness that may potentially impair spontaneous ventilation and independent airway patency, while maintaining CV function. A deeply sedated patient is usually arousable with repeated painful stimulation.

Dissociative Sedation. This level of sedation induces a unique, trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. The dissociative state can facilitate the performance of moderate-to-severe painful procedures, as well as procedures requiring immobilization in uncooperative patients.⁴

Contraindications to Procedural Sedation

Though there are no absolute contraindications to procedural sedation in children, its use is generally determined based on ASA’s patient physical status classification system. In this grading system, procedural sedation is appropriate for pediatric patients with a physical status of Class I (normally healthy patient) or Class II (a patient with mild systemic disease—eg, mild asthma).⁵ The EP should consult with a pediatric anesthesiologist prior to sedating a patient with an ASA status of Class II or higher, or a patient with a known laryngotracheal pathology.¹

Pre- and Postsedation Considerations

History and Physical Examination

Prior to patient sedation, the EP should perform a focused history, including a determination of the patient’s last meal and/or drink, and a physical examination. The history should also include known allergies and past or current medication use—specifically any history of adverse events associated with prior sedation. Pregnancy status should be determined in every postpubertal female patient.

The physical examination should focus on the cardiac and respiratory systems, with particular attention to any airway abnormalities or possible sources of obstruction.^1,3

Fasting

A need for fasting prior to procedural sedation remains controversial: Current ASA guidelines for fasting call for fasting times of 2 hours for clear liquids, 4 hours after breastfeeding, 6 hours for nonhuman milk or formula feeding, and 8 hours for solids.⁶

Fasting prior to general anesthesia has become a common requirement because of the risk of adverse respiratory events, including apnea, stridor, bronchospasm, emesis, and pulmonary aspiration of gastric contents. However, these events rarely occur during pediatric procedural sedation in the ED, and it is important to note that the American College of Emergency Physicians’ standards do not require delaying procedural sedation based on fasting times. There is no strong evidence that the duration of preprocedural sedation-fasting reduces or prevents emesis or aspiration.⁷

Equipment

In 2016, the American Academy of Pediatrics (AAP) updated its “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures,”¹ including the essential equipment required for the safe administration of sedation, which can be remembered using the following “SOAPME” mnemonic:

Size: appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction);

Oxygen: An adequate oxygen supply and functioning flow meters or other devices to allow its delivery;

Airway: Size-appropriate equipment (eg, bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, laryngeal mask airway, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask;

Pharmacy: All the basic drugs needed to support life during an emergency, including antagonists as indicated;

Monitors: Functioning pulse oximeter with size-appropriate oximeter probes, end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, electrocardiogram, stethoscope); and

Equipment: Special equipment or drugs for a particular case (eg, defibrillator).¹

Personnel

The 2016 AAP guidelines¹ also indicate the number and type of personnel needed for sedation—in addition to the physician performing the procedure—which is primarily determined by the intended level of sedation as follows:

Minimal Sedation. Though there are no set guidelines for minimal sedation, all providers must be capable of caring for a child who progresses to moderate sedation.

Moderate Sedation. Intentional moderate sedation necessitates two practitioners: one practitioner to oversee the sedation and monitor the patient’s vital signs, who is capable of rescuing the patient from deep sedation if it occurs; and a second provider proficient at least in basic life support to monitor vital signs and assist in a resuscitation as needed.

Deep Sedation. For patients requiring deep sedation, the practitioner administering or supervising sedative drug administration should have no other responsibilities other than observing the patient. Moreover, there must be at least one other individual present who is certified in advanced life support and airway management.¹