Pediatric Procedural Sedation And Analgesia

 

Definition: “A technique of administering one or more sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant therapeutic or diagnostic procedures while maintaining cardiorespiratory function”

Provide the optimal amount of sedation and analgesia for the procedure that needs to be performed.

 

Indications

·       Drugs used can be changed based upon the Indications.

·       Both diagnostic and therapeutic procedures and it may be urgent or elective or painful or painless

·       Diagnostic imaging- CT / MRI / USG / ECHO / Endoscopy

·       Diagnostic Procedures - LP, Bone Marrow, Biopsy

·       Therapeutic - I &D / Fracture Reduction /Dislocation, Wound / Laceration Repair

·       Common procedures, such as IV cannulation, venipuncture, urethral catheterization, CVC

3PHASES

1.PRESEDATION

A. Patient Assessment

 

Sedation is contraindicated or inadvisable when the risk of adverse events is high.

Obtain comprehensive health evaluation to determine baseline status and identify any specific health conditions that require additional considerations or consultation. This includes sex, age, weight, current medications, allergies, and relevant personal or family medical history.

Patient's vital signs and overall stability

Focused History – history of chronic disease or genetic abnormalities (e.g., cardiovascular, respiratory disease, Down syndrome, cerebral palsy)

Medication history, and allergies

The physical status evaluation of the airway is based on Five-point Physical Status Classification System of the American Society of Anaesthesiologists.

 Procedural sedation is only done in ASA Class I and Class II . III or more is a contraindication.

 Assess airway patency using the Mallampati score and assess mouth opening, tonsillar hypertrophy, mandibular anomalies, lingual anomalies, and cervical spine mobility.

·       Consider the NPO status of the patient in the context of the urgency of the indicated procedure.

Fasting Guidelines for Procedural sedation

 B. Equipment and Personal

Ensure equipment is available, appropriately sized, and functional – SOAP ME

 • Suction apparatus and catheter

• Oxygen supply that is flowing with adequate administration equipment ranging from a nasal cannula to a nonrebreather mask

 • Airway equipment including bag valve mask, appropriately sized oral and nasal airways, laryngeal mask airway, direct and video-assisted laryngoscope with correctly sized blades, appropriately sized endotracheal tube, surgical and needle airway.

• Pharmacologic agents including anxiolytic, analgesic, dissociative, and reversal agents

• Monitoring devices including a pulse oximeter, ET Co2, NIBP, ECG leads, respirations. • IV, running, or functional saline lock if administering IV medications or risk of progressing to a deeper level of sedation

• Medications and equipment for cardiac resuscitation.

At least two providers to perform PPS - Should be trained in advance airway management and completed PALS Course.

Clinicians must have the requisite skills to effectively manage potential adverse events, such as respiratory depression or upper-airway obstruction.

C. OBTAINE INFORMED CONSENT

Discuss the risks, benefits, and limitations of procedural sedation, as well as any alternatives, with the parent or guardian and with the patient, if capable

D.  AGE-SPECIFIC PSYCHOLOGICAL TECHNIQUES

Can help children control their anxiety.

For distress oral or intranasal midazolam is a common choice

For pain, oral oxycodone or intranasal fentanyl can be used.

2.SEDATION

Sedation is best understood as a continuum, ranging from lighter to deeper sedation and, finally, to general anesthesia.

All sedating agents, apart from ketamine, fall into this category.

RESPONSIVE-BASED SEDATION DEFINITIONS:

Sedation Level	Description
Minimal (Anxiolysis)	- Drug-induced state during which patients respond normally to verbal commands. - May experience drowsiness and impaired coordination. - Normal ventilation is maintained.  - Adequate for brief minor procedures or motion inhibition during diagnostic imaging.
Moderate (Conscious Sedation)	- Patients respond purposefully to verbal commands alone or with light tactile stimulation. - Expected to open eyes or take deep breaths on command. - Maintain a patent airway and adequate respirations without assistance. - Suitable for motion control during imaging. And procedures with local anaesthesia
Deep	- Patients cannot be easily aroused but respond purposefully after repeated or painful stimulation. - Close monitoring required due to potential airway and respiratory issues.  - Used for painful procedures where local anaesthetics are insufficient (e.g., fracture reduction).
General Anaesthesia	- Unresponsive to painful stimulation. - High risk of airway obstruction and apnoea. - Immediate rescue measures needed to support airway and ventilation. - Used when deep sedation limits are exceeded.
Dissociative sedation	- Occurs in patients who receive ketamine. - Trance-like state.  - Amnestic to the event. - Patients enter a cataleptic state with functional dissociation of     higher cortical centres from outside stimuli. - Unlike other sedating agents, patients are unresponsive to pain -Retain protective airway reflexes and spontaneous respirations, and cardiopulmonary stability

Continuous Monitoring vital signs ensures patient safety during procedural sedation, allowing timely intervention when needed.

vital signs should be measured at baseline, after drug administration, on completion of the procedure, during early recovery, and at completion of recovery before discharge.

During deep sedation, vital signs are often recorded every 5 minutes. 

Vital Sign	Description
Pulse Oximetry	- Continuous monitoring of oxygen saturation (SpO₂). - Mandatory for detecting hypoxemia.
Blood Pressure	- Periodic measurement to verify hemodynamic stability. - Typically recorded during baseline, after drug administration, completion of the procedure, early recovery, and before discharge.
Electrocardiography (ECG)	- Continuous monitoring to assess cardiac function. - Helps detect any adverse cardiovascular events.
Capnography	- Recommended, especially during deep sedation.  - Provides early warning of respiratory depression. - Depicts carbon dioxide levels as a waveform.  - Combined with clinical observations to identify respiratory issues.

·       With or without supplemental oxygen?

Administering supplemental oxygen before and during deep sedation has been shown to reduce the frequency of hypoxemia. However, such administration renders pulse oximetry ineffective as a means of early warning for respiratory depression. Thus, the use of capnography is strongly recommended if supplemental oxygen is used, since capnography readings are not affected by the presence or absence of additional oxygen.

3.POST SEDATION

A.  Post Procedure Monitoring

Sufficient time, or a minimum of 1.5 hours, should have elapsed following the administration of reversal agents to ensure that patients do not become re-sedated after reversal agent effects have abated.

a. Vital signs, B/P, oxygen saturation, ETCO2, and cardiac rhythm are monitored every 15 minutes or less until the patient meets discharge criteria.

 b. Oxygen Saturation is monitored until it is maintained by patient at pre-procedure level for a minimum of 15 minutes without supplemental oxygen.

c. Inpatients may be monitored and maintained at level with supplemental oxygen as ordered by physician.

d. The Aldrete Score is monitored and recorded every 15 minutes or less.

B. When to Discharge

A child will be discharged at pre-procedural level A

1. Have pre-procedural vital signs

 2. Be able to follow commands and verbalize appropriately

3. Demonstrate baseline motor function appropriate for age

 4. Be able to take popsicle or liquids

5. Recognize, interact with, or is consolable by parent or caregiver

 6. Have responsible parent or guardian

 

C. Aldrete scoring for discharge of procedural sedation. 

 If score is more than 9 patients can be safely discharged.

DRUGS FOR PROCEDURAL SEDATION IN CHILDREN

 short-acting sedative-hypnotic and analgesic medications are available for paediatric procedural sedation.

choice of drug is based upon the type of procedure and the patient's underlying medical condition. anticipated degree of pain.

PPSA the route administration is not always Intravenous it can be

•        Intravenous
•        Inhalational
•        Intranasal
•        Intramuscular

• DRUGS USED IN PPSA

Agent Type	Drug
Sedative-Hypnotic Agents
	Propofol
	Dexmedetomidine
	Etomidate
	Midazolam
	Short-Acting Barbiturates (Pentobarbital, Thiopental, Methohexital)
Other Agents
	Ketamine
	Ketamine with Propofol (Ketofol)
	Nitrous Oxide
Analgesic Agents
	Fentanyl
	Oral Sucrose
	Topical, Local, and Regional Anesthesia

References

 1. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med 2000;342:938-45. 2. Idem. Procedural sedation and analgesia in children. Lancet 2006;367:766-80. 3. Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation — an examination of the role of fasting and sedation depth. Acad Emerg Med 2002;9:35-42. 4. Bhatt M, Kennedy RM, Osmond MH, et al. Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med 2009; 53:426-35, e4. 5. Agrawal D, Manzi S, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003;42:636-46. 6. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus-based cl

inical practice advisory. Ann Emerg Med 2007; 49:454-61.