Pediatric Procedural Sedation

Excerpt

Pediatric procedural sedation involves techniques and medications to minimize anxiety and pain during unpleasant or painful procedures. This procedure is used to manage unavoidable discomfort by integrating physical, psychological, and pharmacological interventions to enhance patient comfort. In pediatric patients, procedural pain and distress are not limited to major interventions requiring deep sedation. Routine procedures such as intravenous cannulation, venipuncture, urethral catheterization, and lumbar puncture may also cause significant discomfort and anxiety. In addition, pediatric patients may require anxiolysis during imaging procedures such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or echocardiography to reduce stress and ensure optimal image acquisition.

Pediatric procedural sedation may be performed in various settings and is not limited to anesthesia practitioners. The procedure is now routinely practiced by other specialists, including emergency and critical care clinicians, alongside nurse specialists. In 2019, the American College of Emergency Physicians (ACEP) developed an interprofessional consensus on unscheduled, time-sensitive procedural sedation. According to the ACEP, procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.

In 2018, the American Society of Anesthesiologists (ASA) established the Task Force on Moderate Procedural Sedation and Analgesia in collaboration with the American Association of Oral and Maxillofacial Surgeons, the American Dental Association, the American Society of Dentist Anesthesiologists, the American College of Radiology, and the Society of Interventional Radiology. Published guidelines vary slightly depending on the procedural environment. The ACEP guidelines emphasize pain and anxiety management in patients with emergent or urgent conditions in the emergency department and in high-risk patients to ensure the successful completion of procedures.

Understanding the terminology related to sedation, analgesia, and dissociation is imperative. Sedation induces a state in which a patient can remain still. Analgesia refers to pain relief, typically achieved through local or central interventions. Dissociation produces a trance-like mind-body separation. Pediatric procedural sedation is performed along a continuum, using interventions to provide the appropriate level of sedation and analgesia for the required procedure. The techniques may range from anxiolysis for imaging or minor nonpainful procedures to moderate sedation for more painful interventions, such as fracture reduction. The approach is tailored to each patient's anxiety and pain levels. According to published guidelines, pediatric procedural sedation may be safely performed outside the operating room in settings such as the emergency department, dentistry, gastrointestinal endoscopy, and radiology.

The ASA defines sedation as a continuum of states ranging from minimal to moderate and deep sedation, followed by general anesthesia. Minimal sedation, also called anxiolysis, allows the patient to respond normally to verbal commands. Cognitive function and physical coordination may be impaired, but airway reflexes remain intact, and cardiovascular and ventilatory functions are unaffected. Moderate sedation, also known as conscious sedation, results in a depressed level of consciousness. The patient responds purposefully to verbal commands alone or when accompanied by tactile stimuli. The airway remains intact without the need for intervention, spontaneous ventilation is adequate, and cardiovascular function is typically maintained.

Deep sedation leads to a depressed level of consciousness where the patient cannot be easily aroused but responds purposefully to repeated or painful stimulation. Airway support may be required, spontaneous ventilation may be inadequate, and cardiovascular function is typically maintained. General anesthesia results in a complete loss of consciousness, where the patient is not arousable even with painful stimuli. Independent ventilatory function is impaired, often requiring airway assistance and positive pressure ventilation. Cardiovascular function may also be compromised.

Pediatric patients have a higher risk of unintentionally progressing to a deeper state of sedation than intended. Performing pediatric procedural sedation requires healthcare providers to possess sufficient airway management skills and certification in Pediatric Advanced Life Support (PALS).