General Guidelines for Pediatric Procedural Sedation

Pediatric procedural sedation has a wide variety of applications. These include IV cannulation, obtaining CT imaging, urethral catheterization, and fracture or dislocation reduction to name a few. Before we delve further into this topic, it is important to discuss the goals of sedation and understand the commonly used terminology. 

The American Academy of Pediatrics noted the goals of sedation are: 1) guard the patient’s welfare; 2) minimize physical discomfort and pain; 3) control anxiety, minimize psychological trauma, and maximize the potential for amnesia; 4) modify behavior and/or movement to ensure safe completion of the procedure; and 5) return the patient to a state safe for discharge.

Now that these goals have been established, we can look at the differences between the achievable levels of sedation. With minimal sedation, our patient is able to respond to verbal stimuli, but is in a relaxed state. These patients will require minimal observation following completion of the procedure before they can be discharged. In moderate sedation, or procedural sedation, our patient will respond to verbal or tactile stimuli. However, they have a depressed level of consciousness. In both mild and moderate sedation, the patient will generally not require any interventions to maintain ventilatory or cardiovascular function. A patient that is in deep sedation has a depressed level of consciousness and cannot easily be aroused, but they do respond to painful stimuli. These patients may require support to maintain their airway. The patient that is in a state of general anesthesia is not arousable to even painful stimuli. These patients require help maintaining a patent airway with positive pressure ventilation.

It is important to understand that pediatric patients can unintentionally progress to deeper levels of sedation. Therefore, it is critical that the practitioner inducing any level of sedation be familiar with ways to rescue children that have progressed to deeper levels of sedation.

We know the goals of procedural sedation, and we know the different levels of sedation we can achieve. Now we need to think about indications for procedural sedation and appropriate pharmacological therapy. A thorough history and physical exam should be performed. Any comorbid conditions should be noted, as well as the patient’s ASA classification, with class I and II the most appropriate for minimal, moderate, or deep sedation.

Any procedure that will cause the patient significant discomfort or one for which will cause severe anxiety can be considered for procedural sedation. When thinking about which level of sedation we would like to achieve, we need to consider the amount of anxiety the procedure may incur, the level of pain expected of the procedure, and the necessity to keep the patient still for the procedure. While we will be discussing available options for sedation, this will be a brief overview

Ketamine will provide analgesia, amnesia, and sedation. As such, the IV form has become one of the most common drugs used for procedural sedation in the pediatric population. It has a relatively rapid onset of action, its onset and offset are predictable, and it does not decrease respiratory drive. Emesis, laryngospasms, and emergency reaction are the noted side effects.

Propofol and etomidate are two other common drugs used in procedural sedation. Propofol has a rapid onset and short duration but does not provide analgesia. When combined with an analgesic, it is ideal for shorter procedures. Similarly, etomidate has a short onset of action, but has a slightly longer duration of action. Like propofol, it does not have analgesic properties, but in combination with analgesics, is ideal for shorter procedures. Both etomidate and propofol can cause cardiorespiratory depression, so close monitoring of patients is necessary if used.

Finally, and most importantly, proper set up prior to administration of any medications is key. Suction, supplemental oxygen, any airway equipment must be on hand. The medication being used and, if available, reversal agent should be on hand. Pulse oximetry, end tidal carbon dioxide, cardiac monitoring, ECG, and blood pressure monitor should be available and in use. When setting up for the procedure, distraction techniques and parental involvement can be effective in calming the child.

In summary, consider the level of sedation required to ensure the most amnesia and analgesia, selecting an agent that will provide optimal sedation. Ketamine, with analgesic, amnestic, and sedative properties is one of the most commonly used. Ensure that you have properly set up for the procedure, with pulse oximetry, supplemental oxygen, cardiac monitoring, end tidal carbon dioxide, and suction readily available. Lastly, distraction techniques and parental involvement can help calm your patient and ensure the procedure proceeds as smoothly as possible.

Sources

1.     Stern J, Pozun A. Pediatric Procedural Sedation. 2023 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 34283466.

2.     Charles J. Coté, Stephen Wilson, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY; Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics June 2019; 143 (6): e20191000. 10.1542/peds.2019-1000

3.     Drendel, A, Helman, A. Pediatric Procedural Sedation. Emergency Medicine Cases. February, 2016. https://emergencymedicinecases.com/pediatric-procedural-sedation/. Accessed 07/26/2024