Pediatric Procedural Sedation

Excerpt

Pediatric procedural sedation (PPS) refers to techniques and medications used to minimize anxiety and pain associated with unpleasant or painful procedures. PPS is used when painful or uncomfortable procedures are unavoidable and incorporates physical, psychological, and pharmacologic interventions to minimize discomfort. In the pediatric population, PPS is not limited to major painful procedures requiring deeper levels of sedation. Common procedures, such as IV cannulation, venipuncture, urethral catheterization, and lumbar puncture, can be associated with significant distress or pain in pediatric patients. Many pediatric patients may require anxiolysis to have CT or MRI imaging, ultrasound, or echocardiography to ensure adequate imaging is obtained and minimize patient stress.

PPS can be performed skillfully in various settings and is not exclusively practiced by anesthesia practitioners but is now practiced routinely by other specialists, such as emergency and critical care clinicians, along with several nurse specialists. In 2019, the American College of Emergency Physicians (ACEP) developed a multidisciplinary consensus on unscheduled, time-sensitive procedural sedation. According to 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 organized the task force on Moderate Procedural Sedation and Analgesia along with the American Association of Oral and Maxillofacial Surgeons (AAOMS), the American Dental Association (ADA), the American Society of Dentist Anesthesiologists (ASDA), the American College of Radiology (ACR), and the Society of Interventional Radiology (SIR). There are slight differences in the published guidelines based on the environment the procedure is performed. ACEP guidelines emphasize urgent and emergent procedures that require management of the sedation encounter along with treatment of the anxiety, pain, and acute pathology necessitating treatment.

It is imperative first to understand the terminology regarding sedation, analgesia, and dissociation. Sedation induces the patient into a state in which they are able to lie still. Analgesia is pain relief typically by local or central interventions. Dissociation is the production of a trance-like mind-body separation. PPS is practiced on a continuum using interventions to provide the optimal amount of sedation and analgesia for the procedure that needs to be performed. This can vary from anxiolysis for imaging or minor nonpainful procedures to moderate sedation for more painful procedures, such as fracture reduction. The approach is tailored to the specific patient depending on their level of anxiety and pain. Per published guidelines, PPS can be performed safely outside of the operating room in settings such as the emergency department, dentistry, gastrointestinal endoscopy, and radiology.

Different evaluation methods have been developed to define the degree of sedation. The most commonly used is the Ramsey scale that scores on eight characteristics, and a score indicates anxiolysis (2 to 3), moderate sedation (4 to 5), deep sedation (6), and general anesthesia (7 to 8). More practical terms of sedation are the responsive-based sedation definitions:

1. Minimal: also called anxiolysis; patient awake and relaxed, able to respond normally to verbal stimuli

2. Moderate: also called conscious sedation; The patient has a depressed level of consciousness, able to respond purposefully to verbal stimuli alone or accompanied by tactile stimuli. The airway remains intact, and no interventions to maintain the airway needed.

3. Deep: The patient has a depressed level of consciousness and cannot be easily aroused but does respond purposefully following repeated or painful stimuli. Patients may need support to maintain a patent airway.

4. Dissociative: The patient is in a trance-like state wherein they are unaware of the pain and amnestic to the event but remain awake with intact respirations, airway reflexes, and cardiopulmonary stability.

5. General anesthesia: The patient has a loss of consciousness and is not arousable even to painful stimuli. The patient has an impaired ability to maintain independent ventilatory function and often needs assistance in maintaining a patent airway along with requiring positive pressure ventilation.

Pediatric patients are at higher risk of unintentionally moving to a deeper state of sedation than desired. The provider must have sufficient airway management skills and be Pediatric Advanced Life Support (PALS) certified to perform PPS.