Sedation in

Pediatric
Patients

•Dr Reeta Singh

Consultant Anesthesiologist
Awali Hospital, BAPCO
Kingdom of Bahrain
 Definition

 Continuum of depth of sedation ASA 2014

?  Preparation
 Precautions
 Monitoring
 Competences

Risks
www.asahq.org
 5

Main Resources/Disclosures

The following publications were the central sources of information

and will be referenced :

 American Academy of Pediatrics. American Academy of Pediatric

Dentistry. Work Group on Sedation. Guidelines for Monitoring and
Management of Pediatric Patients During and After Sedation for
Diagnostic and Therapeutic Procedures: An Update1
 American Society of Anesthesiologists. Task Force on Sedation and
Analgesia by Non-anesthesiologists. Practice Guidelines for Sedation
and Analgesia by Non-anesthesiologists2
 American College of Emergency Physicians. Clinical Policy for
Procedural Sedation and Analgesia in the Emergency Department3
 Joint Commission Resources: Comprehensive Accreditation Manual for
Hospitals: The Official Handbook.4
 Introduction

• Sedation is a depression of CNS and/or airway protective reflexes by the administration of drugs
by any route to decrease patient discomfort without producing unintended loss of consciousness
• Achieved by sedatives and analgesics which reduce anxiety and pain during procedures with an
intent to
• Decrease the length of time needed to perform the procedure
• Increase the likelihood of success
• Reduce the risk of injury to patient or health worker because of uncontrolled movement.
• Minimize the risk of psychological trauma
• Maximize the potential for Amnesia
 6

Introduction

• In the past decade, the use of sedatives and analgesics to relieve pain and anxiety
associated with invasive diagnostic and therapeutic/painful procedures on pediatric
patients in non-traditional settings (i.e., Emergency Department, Radiology, EEG lab,
etc.) has substantially increased.
• Increased awareness of the importance of anxiolysis, amnesia and analgesia
• Increased numbers and diverse short diagnostic and therapeutic procedures which
require sedation
• Further complicating matters, there is very little existing conformity in the diverse
practitioners and providers’ choice of technique, medication(s) and depth of
sedation/anesthesia to accomplish the same procedure.
• Importance thereby to unify guidelines for the Monitoring and Management of
pediatric patients undergoing Sedation
• Need for Systematic Approach Before, During and After Sedation to promote safe
and effective sedation for children
 Paediatric Sedation
 Special understanding of the anatomic, physiological and psychological differences between the developing
neonate, infant, child and adolescent
 Unique application of airway equipment, tools, monitors In the pediatric age groups
 Pediatric Anaesthesia experience (Auroy and Ecoffey, Anesth Analg1997)

Number of children anesthetized/year Complications

1-100 7/1000

100-200 2.8/1000

More than 200 1.3/1000

 Paediatric Airway- not a miniature
version of adult
 Differences from the adult
 Large occiput
 Cephalad larynx C3-4 compared to C5-6 in adult
 Hypertrophied tonsils and adenoids
 Narrow, floppy, Omega shaped epiglottis
 Straight laryngoscope blade preferred
 Cone shaped- narrowest at cricoid
 Shorter trachea- endobronchial intubation
 Minor trauma can cause oedema
 Presedation Evaluation

 Assess anxiety levels of both child and parent/ caregiver

 Establish rapport with child
 Explain clearly- reassure and gain confidence and
cooperation of parent
 Assess how cooperative child will be
 Predictors of Difficult airway- dysmorphic facies, snoring,
obesity, loose teeth
 Ensure adequate fasting
 Procedures Requiring Sedations

Diagnostic Therapeutic
Distressful
(Minimum Pain) Invasive (Painful)
Noninvasive
VCUG Wound Care
(Non-Painful)
IV placements Laceration Repair
MRI
Injections Oncology
CT Procedures-BM
Blood Samples
Evoked Potentials biopsy
GI Endoscopy
Nuclear Medicine Biopsies
Studies LP
Examination of a Fracture
child with sexual Reductions
assault Chest Tube Drains
 Pain in Pediatrics

• Lower Pain Threshold

• Pain if untreated pain or inadequately treated can
lower threshold for pain permanently due to brain
changes – descending inhibitory pathways are
immaturely developed in small children
• Smaller the child –higher the risk of long-term
sequelae
• Wherever there is a nerve try to block it
• Use multimodal analgesia
 7

Focus of Presentation

 Familiarize with the principles and standards underlying safe and effective
pediatric moderate sedation,
 review optimal pre-sedation patient evaluation,
 review commonly used sedative/analgesic drugs,
 review potential patient complications and
 provide resources to improve patient safety and outcomes.

Goal: Help participants and organizations assess and improve their pediatric
moderate sedation processes.
 10

Procedural Sedation in Children

Children receive sedation more frequently than adults (largely

due to diagnostic procedures that require controlled/no
movement).

To meet necessary goals, sedation/analgesia usually must be

deeper than given to adults.

Due to physiologic differences, children are at higher risk for

respiratory depression and life-threatening hypoxia.5

Technically, providers with the intent to practice “moderate

sedation” may be closer to the definition of “general
anesthesia” because children can easily slip from one level to
another.6
 15

Slippery Slope of Procedural Sedation

Minimum Moderate Dissociative Deep General

Anesthesia

Remember: Levels of sedation are considered to be

on a continuum because a sedated child can go in
and out of an intended level quite rapidly.
 18

Continuum – Dissociative Sedation

Dissociative Sedation = (Ketamine) A trancelike, cataleptic state occurs with both profound analgesia
and amnesia while maintaining protective airway reflexes, spontaneous respirations, and
cardiopulmonary stability.8
 Child’s eyes remain open with nystagmic gaze; may exhibit random tonic movements of extremities.
 Causes hyperactive airway reflexes, with a risk of larynogspasm.
 Does not blunt protective airway reflexes to the same degree as other sedatives (e.g., opioids, benzodiazepines).

Deep Sedation

Minimal Sedation
Due to Ketamine’s markedly different clinical
Dissociative
effect, it does not officially fit the ASA
Unconsciousness
Consciousness

sedation continuum. However, it is generally

recognized to produce a level of sedation
between moderate and deep sedation.

Moderate Sedation
General Anesthesia
 12

Potential to Harm
The Pediatric Sedation Research Consortium (an international
collaborative of 35 institutions dedicated to improving pediatric
sedation/anesthesia care) conducted a study to determine the incidence
and nature of adverse events for procedures outside the OR.
Reviews of over 30,000 records revealed the following:6
 Serious adverse events were rare – no deaths reported; CPR was required
in one case
 However, the following adverse events were more common:
 02 desaturation (below 90% > 30 seconds)
 Stridor
 Laryngospasm
 Unexpected apnea Conclusion: While serious adverse events
 Excessive secretions were low, reported events with the
 Vomiting
 Prolonged sedation/recovery
potential to harm, and that require timely
 “Failed” sedation rescue interventions, are significant.
 One in every 200 sedations required airway and ventilation interventions
ranging from bag mask ventilation, oral airway placement, and/or emergency
intubation.
 13

Potential to Harm (cont.)

In another recent study, researchers reviewed sedative drug -

related adverse events reported to the FDA.7
Notable findings included:
 Negative outcomes were often associated with:
 Drug combinations and interactions
 Use of 3 or more sedating medications (compared with 1 or 2
medications)
 Drug overdose (esp. prescription/transcription errors)
 Drugs administered by nonmedically trained personnel
 Drugs administered at home (before scheduled procedures)

 No relationship between outcome and drug class nor route of

administration

PATIENT MONITORING AND AIRWAY SKILLS ARE THE KEYS TO SAFETY

 22

Goals of Effective Sedation

Guard the patient’s safety & welfare

Minimize physical discomfort & pain

Control anxiety, minimize psychological trauma, and

maximize the potential for amnesia

Control behavior and/or movement to allow the safe

completion of the procedure

Return the patient to a state in which safe discharge from

medical supervision (as determined by recognized criteria)
is possible1
 23

Strike a Balance

MAXIMIZE benefits while minimizing the associated risks

Laryngospasm Maximiz
Minimize e Minimize
Airway pain & psychological
Hypoventilation Death obstruction amnesia
discomfor trauma/anxiet
t y
Cardiac
depression Apnea Control
movement
BENEFIT
RISK
 28

Foundation for Safe Sedation

Guiding Principles – Supervision & Training

Patient evaluation

Monitoring Rescue Skills

 Checklist for Safe Sedation

• Easy Access to patient

• Age-appropriate airway devices
• ECG and Defibrillator with size appropriate
patches/paddles
• Oxygen, Suction devices
• Extensive patient Monitoring
• Understanding the importance of Ventilation
Monitoring with Capnography
• Drugs to manage sedation, reverse, treat
complications
• Staffing
• Properly equipped Recovery Area
• Back up EMS service
 Checklist of the Physician Doing
sedation?

• Who have achieved Anaesthetists- familiar with pediatric

essential training anaesthesia
and skills Pediatricians -trained in Emergency
• Familiar with the Rescue and Airway Management
Pharmacological Critical Care Physicians
Emergency Physicians trained in
agents
pediatric airway management, and use of
• Prepared to manage monitoring mandated for Sedation
the complications. Dentists trained in pediatric sedations –
usually use of nitrous oxide
 Essential Training and Skills-
Competencies

• Skills for pre-procedure history taking, counseling, informed consent, including risks / benefits and alternatives to the
administration of analgesics and sedative drugs for deep sedation.
• Knowledge of Pharmacology of sedative/ analgesic drugs and antagonists
• Risks/ benefits of supplemental oxygen
• Levels of sedation, monitoring
• Recognition of adequacy of ventilation and proficiency in airway and ventilation Rescue
• Monitoring of physiological variables, pre/intra and post sedation – SPO2, Capnography, ECG, RR and NIBP,
Importance of using audible alarms and setting the limits of alarms
• Documentation- drugs, physiological variables and level of sedation
• Qualifications in ACLS and PALS, awareness of an effective rescue plan of the unit
• Awareness of the related policies of the hospital related to sedation and participation in quality improvement system
to track any unusual or adverse outcomes and any deficiencies in the process and care of sedation patients .
 34

Support Personnel & Training

 At least 1 more person dedicated to constantly monitor appropriate
physiologic parameters and assist in any supportive or
resuscitation measures

 Be trained in, and capable of providing, pediatric basic life support

 Know how to use resuscitation equipment & supplies in the

event of an emergency
 Successfully complete institutional training on
sedation/analgesia and recovery care
 Be aware of and follow your institution’s sedation policy

The recent EMSC Survey results showed a THIS PERSON SHOULD

higher than expected percentage (> 27%) of HAVE NO OTHER
staff being allowed to assist beyond what SIGNIFICANT
the national guidelines recommend. RESPONSIBILITIES
 24

Before You Begin…

Each sedation should be tailored to the
individual child considering the following factors:

Select the lowest drug dose with the highest therapeutic

index for the procedure - consider if agent(s) can be reversed

Consider whether the procedure could be accomplished

without sedation by engaging alternative modalities
(e.g., Child Life services, distraction techniques, comfort positions, etc.)

Alternatively, do not undertreat the child when

sedation/analgesia is appropriate & necessary
Preoxygenation
 37

Sedation Considerations
Consider each of these factors when planning for sedation
 Procedural issues:
 What type -- therapeutic (painful) vs. diagnostic (non-painful)?
 What is the child’s health status, age/development level & personality type?
 How stressful/anxiety-producing is the procedure (e.g., sexual abuse evaluation)?
 Is immobility/behavior control required?
 What position will the child be in during the procedure?
 How much time will it take to complete the procedure?
 How quickly can rescue resources be available?

 Medication issues:
What is the mechanism of action?
How is the sedating/analgesic agent metabolized?
 What is the duration of action? (avoid dose stacking)
 Potential adverse reactions/monitoring issues :
 Need for appropriate reversal agent
 Medication side effects/allergic reactions
 Oxygen desaturation
 Laryngospasm
 Hypotension
 38

Equipment & Supplies

To ensure systematic & thorough preparation

for every sedation, the AAP1 recommends S O A P M E
 Suction – age/size-appropriate suction catheters and suction apparatus
(Yankauer-type)
 Oxygen – adequate O2 supply, working flow/delivery devices
 Airway – age/size-appropriate airway equipment (e.g., ET tubes, LMAs,
oral and nasal airways, laryngoscope blades, stylets, bag mask)
 Pharmacy – all basic life-saving drugs, including reversal agents (Naloxone,
Flumazenil)
 Monitors – pulse oximeter, BP monitor, ECG, stethoscope, thermometer,
cardiac monitor, end-tidal carbon dioxide (EtCO2) monitor/detector
 Equipment – special equipment/drugs for particular child (e.g., crash cart w/
defibrillator, respiratory box, IV access equipment) should be readily
available

MOST IMPORTANT PERSONNEL SKILLED IN ADVANCED LIFE SUPPORT!

 40

Capnograph
Non-invasive device that continually monitors EtCO2
 While pulse oximetry measures oxygen saturation, capnography monitors
the status of the child’s ventilation
 Pulse oximetry has a significant “lag time” between apnea and reading.
 Earliest indicator of airway or respiratory compromise (e.g. apnea, hypoxia,
upper airway obstruction, laryngospasm, bronchospasm, and respiratory
failure)9
 Is highly recommended for moderate & deep sedation performed outside of
the OR (e.g., ED, Radiology suite, etc.)

The use of precordial stethoscope or capnograph for patients who are difficult to
observe (e.g., MRI, darkened room) to aid in monitoring adequacy of ventilation is
encouraged. – AAP/AAFD (2006)

Ex. Normal Waveform = patent airway, patient breathing Ex. Curved Waveform denotes bronchospasm
 42

Airway Evaluation
Mallampati classification system10 is a standard airway
MALLAMPATI AIRWAY CLASSIFICATION
evaluation used as a method to predict difficult
intubation.
View = patient seated with mouth open
Class  Assess ability to open mouth and protrude tongue
as wide as possible

Soft palate, fauces, uvula,  Check for loose teeth

I
tonsillar pillars

II Soft palate, fauces, full uvula

 Assume that it may be necessary to establish an
artificial airway during any sedation.
III Soft palate only
 Anticipate any/all obstacles before the real time
IV Hard palate only occurrence.
 Class III & IV = potential difficult intubation (consider
anesthesia consult)

Airway safety is especially risky during

procedures involving the upper airways,
such as GI endoscopy or bronchoscopy.
 44

ASA/AAP NPO Guidelines

NPO Guidelines for Elective* Sedation

INGESTED TIME

Clear Liquids (water, fruit juices w/o pulp, carbonated beverages,

2 hours
clear tea, black coffee)

Breast milk 4 hours

Infant formula 6 hours

Nonhuman milk (similar to solids) 6 hours

Solids (light meal; if includes fatty/fried food, consider longer faster

6 hours
period)

*In emergency situations, carefully weigh the need for immediacy with the
increased risk of pulmonary aspiration. Use the lightest effective sedation possible.
 45

Documentation – Before & During

Before Sedation During Sedation

 Presedation health evaluation On a time-based flowsheet:
(include initial aldrete score)
 Drug name(s) & drug calculations
 Confirm staff privileges & universal  Route
procedures (i.e., “time out”)
 Site
 Drug calculations (include reversal  Time
agents and local anesthetics)  Dosage (titrated to desired effect)
 Informed consent (risks vs. benefits,
alternatives to planned sedation) During administration, record:
 Instructions to family:  Inspired concentrations of O2 &
 Objectives of sedation duration of sedating/analgesic agents
 Anticipated changes in behavior (during &
after)
 Level of consciousness
 Why/when to expect longer observation  Heart rate, respiratory rate, SpO2
time (drugs with long half-lifes; severe
underlying condition; neonates/preemies,  Adverse events and corrective
etc.) intervention/treatment given
 Special transport instructions for children
going home in car seat (child’s head
positioning) Document at least once every 5 minutes until
 24-hour emergency phone # child reaches predetermined discharge criteria
 Ideal Sedation Agent
Commonly Used today
• Midazolam
• Come on fast and go away fast • Propofol
• Doesn’t effect Blood Pressure • Etomidate
• Ketamine
• Very Few Side effects • Fentanyl
• Shouldn’t effect Respiration • Dexmedetomidine
• Nitrous Oxide
• Amnestic • Chloral Hydrate – no longer freely available
• Analgesic • Pethidine – no longer advised for children

REMEMBER: Ideally, pediatric sedation/analgesia should be

tailored to the child and the procedure to be performed
 66

Clinical Cautions

 Dose Stacking – term refers to what happens when you administer

medications so close together that the peak effects of each dose
coincide. This practice can result in an excessive total drug effect
over time.
 When two drugs are being used in sedation, titrate one of them to the desired
level before administering the second.
Example: If child is in pain, administer an analgesic to a desired level of pain
relief, then administer an anxiolytic to further enhance sedation.

 Synergism – the interaction of two or more agents so that their

combined effect is greater than the sum of their individual effects.
 Primary practitioners must recognize the risks associated with the use of
combinations of medications.
Example: When opiates are combined with benzodiazepines, respiratory
depression is much more likely than when either of these drug classes are used
by themselves.
Adapted from Dartmouth Hitchcock’s Pediatric Sedation Course (Cravero & Blike 2002)
 74

Comfort Positioning
Comfort positions are used by parents and caregivers to reduce stress
and anxiety to infants and children undergoing invasive medical
procedures.
 Why use positioning for comfort?
Example - Child  Fewer people are needed to complete a
procedure (in turn, less overwhelming for
straddling mom child)
during IV placement
 Sitting position promotes sense of control
 Child’s attention is for the child
focused on the toy
 Kicking is from knee  Reduces anxiety which promotes better
only cooperation from the child
 Upper body movement
is  Puts child in a secure, comforting hold
restricted
 Promotes close, physical contact with a
caregiver
Consider using comfort positioning during  Provides caregiver with an active role in
presedation procedures (e.g., IV placement) supporting child in a positive way

Photo: Children's Mercy Hospital – Kansas City

 75

Distraction Techniques

 This technique is most effective when

a child’s pain is mild to moderate (it is Box of
difficult to concentrate when pain is distraction
severe) supplies

Why Distraction?
 Child does not require training
 Works with infants and older children
 Involvement of parents Distraction
 Minimal training for staff technique
(w/ Child Life
What Works?
Specialist)
 Music & humor
 Non-procedural talk
 Relaxation/breathing techniques (e.g.,
guided imagery)
 Distraction boxes
 Not having parent hold child down Distraction
technique
w/ parents
Child should practice technique for
5-10 minutes before procedure
Photos: Cleveland Clinic
 76

Guided Imagery

Guided imagery helps children use their imagination to

divert their thoughts from the procedure to a more
pleasant experience.

 Supplies: creativity, a child’s imagination

 Suggestions:
 Help the child use his/her imagination to create a descriptive story
 Ask questions about a favorite place, upcoming events, vacations
to keep the child engaged in technique
 Guide the child through an experience that will tell him/her what to
imagine and what it will feel like (i.e., a magic carpet ride or a day
at the beach)
MRI Sedation
Thank You for your attention
Goals of Paediatric Procedural Sedation

• Guard the patient’s safety and welfare

• Minimize physical discomfort and pain
• Control anxiety, minimize psychological trauma, and maximize the potential for amnesia
• Control behaviour and/or movement to allow the safe completion of the procedure
• Return the patient to a state in which safe discharge from medical supervision is possible.
• The intent is to achieve these goals while ensuring that the patient is able to
independently maintain oxygenation, airway control, and cardiorespiratory function.
 79

References
1. American Academy of Pediatrics. American Academy of Pediatric Dentistry. Coté CJ.
Wilson S. Work Group on Sedation. Guidelines for monitoring and management of
pediatric patients during and after sedation for diagnostic and therapeutic procedures: an
update. Pediatrics. 2006;118(6):2587-2602.

2. American Society of Anesthesiologists. Task Force on Sedation and Analgesia by Non-

anesthesiologists. Practice guidelines for sedation and analgesia by non-
anesthesiologists. Anesthesiology. 2002;96:1004-1017.

3. American College of Emergency Physicians. Clinical policy for procedural sedation and
analgesia in the emergency department. Ann Emerg Med. 2005;45(2):177-196.

4. Joint Commission Resources: Comprehensive Accreditation Manual for Hospitals: The

Official Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare
Organizations, 2007, PC41-43.

5. Committee on Drugs, American Academy of Pediatrics. Guidelines for monitoring and

management of pediatric patients during and after sedation for diagnostic and
therapeutic procedures: addendum. Pediatrics. 2002;110:836-8.
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