Procedural Sedation and Analgesia in Children

Overview
Procedural sedation and analgesia involve the use of one or more sedative and analgesic
agents to relieve pain and anxiety and to control motor activity in patients undergoing diagnostic
and therapeutic procedures. We have the capability to safely and effectively relieve children of
the pain and distress associated with medical procedures. Accordingly, procedural sedation and
analgesia have become the standard of care for children and are widely practiced worldwide by a
diverse group of specialists in both inpatient and outpatient settings. As the multidisciplinary
field of procedural sedation has evolved and matured, indications for the use of sedation have
grown.1,2
The video shows the technique of procedural sedation and analgesia in children. This
supplement reviews the information presented there, including indications, patient assessment,
the use of sedative and analgesic drugs, potential adverse events, recovery, and discharge from
the hospital.

Indications
Procedural sedation is frequently used for both diagnostic and therapeutic procedures,
whether urgent or elective. Typical indications include diagnostic imaging, fracture reduction or
dislocation, wound care and repair of a laceration, incision and drainage of an abscess, lumbar
puncture, bone marrow aspiration and biopsy, placement of a central venous catheter, and
gastrointestinal endoscopy.2

Patient Assessment
Sedation is contraindicated or inadvisable when the risk of adverse events is high.
Carefully evaluate each patient to assess his or her suitability for sedation. Obtain a directed
history and perform a physical examination that will help you identify factors that may be
relative or absolute contraindications to sedation, such as obesity, sleep apnea, allergies to
medications, previous problems with sedation or anesthesia, the presence of a difficult or
potentially difficult airway, and an active respiratory infection or respiratory disease.3,4
Risk assessment should include a general assessment of underlying health, such as the
five-point Physical Status Classification System of the American Society of Anesthesiologists.
Procedural sedation is often performed only in patients whose status is Class I (a normal, healthy
patient) or Class II (a patient with mild systemic disease), except in urgent or special situations
(Table 1). Assess and document the time at which the patient last ate or drank. For elective
procedures, follow established fasting guidelines, such as those of the American Academy of
Pediatrics. For urgent or emergency procedures, a risk–benefit assessment should be performed
(Table 2).5,6 If during assessment you identify a child who is at high risk for adverse events
during sedation, postpone the sedation, if possible, or consult an anesthesiologist.

After completing the presedation assessment, 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. Then obtain appropriate consent or assent.
Before the procedure, children may be distressed or in pain. Age-specific psychological
techniques can help children control their anxiety. Many procedures can be performed without
sedation or with minimal sedation if the child can cooperate. In selected circumstances,
premedication may be warranted; for distress, oral or intranasal midazolam is a common choice,
and for pain, oral oxycodone or intranasal fentanyl can be used.
The use of a topical anesthetic to minimize procedural sensations is an essential
component of procedural sedation in children. It is useful before placement of an intravenous
catheter, lumbar puncture, and laceration repair. To ensure patient safety, perform sedation only
when you have the necessary age-appropriate emergency equipment. This equipment would
include a ventilation bag and mask, oxygen, and a suction device. Clinicians must have the
requisite skills to effectively manage potential adverse events, such as respiratory depression or
upper-airway obstruction. Either you or an immediately available colleague must be able to
perform the maneuvers required for airway alignment, deliver positive pressure ventilation with
a bag and mask effectively, and initiate any other rescue measures that may be needed.
Resuscitation equipment and medications, including reversal agents, must be immediately
available.
Intravenous access is often unnecessary when the route of sedation is oral, intranasal,
rectal, intramuscular, or inhalational. However, you must be able to establish access for
intravenous administration, which is strongly preferred when sedation is deep or prolonged.

Phases of Sedation
There are three phases of procedural sedation: presedation, sedation, and postsedation.
Sedation is best understood as a continuum, ranging from lighter to deeper sedation and, finally,
to general anesthesia. All sedating agents, with the exception of ketamine, fall into this category.
For convenience, this continuum has been arbitrarily divided into a series of progressive stages.
The sedation nomenclature most often used worldwide is also used here (Fig. 1).
At the lightest end of the sedation continuum is minimal sedation, a drug-induced state
during which patients respond normally to verbal commands. Although patients at this level of
sedation may have drowsiness and impaired coordination, normal ventilation is maintained.
Minimal sedation of the patient may be adequate to allow brief minor procedures to be
performed or to inhibit movement to the extent required to perform diagnostic imaging.
The next level is moderate sedation, during which patients respond purposefully to verbal
commands alone or when the commands are accompanied by light tactile stimulation. At this
level of sedation, children can usually be expected to open their eyes or take a deep breath on
command. It is expected that patients at this level of sedation will maintain a patent airway and
adequate respirations without assistance. Moderate sedation is sufficient for motion control
during diagnostic imaging and for many painful procedures in which local or topical anesthetic
agents can be used (e.g., laceration repair).
The third level of sedation is deep sedation, in which patients cannot be easily aroused
but can respond purposefully after repeated or painful stimulation. Since children sedated to this
level may not always maintain a patent airway and adequate respirations, they must be monitored
closely. Deep sedation is often used for painful procedures for which local or topical anesthetic
agents are not sufficient (e.g., fracture reduction or bone marrow aspiration). Deep sedation may
also be indicated if complete motion control is essential during diagnostic imaging.
When the bounds of deep sedation are exceeded, the patient has reached the state of
general anesthesia. In this state, the patient is unresponsive to painful stimulation and is at high
risk for airway obstruction and apnea. Immediate rescue measures may be indicated to support
airway patency and ventilatory function until the patient returns to a lighter level of sedation.
 Patients will often move up and down the continuum during the course of a procedure. It
is therefore critical to monitor patients continuously and to be prepared to rescue them from
levels of sedation that are deeper than intended.
Dissociative sedation does not fit into the continuum described in the video; this type of
sedation occurs in patients who receive ketamine. In dissociative sedation, patients enter a
cataleptic state in which there is functional dissociation of the higher cortical centers from
outside stimuli. The typical response to other sedating agents is central nervous system
depression, in which the patient is unresponsive to pain but almost always retains protective
airway reflexes and spontaneous respirations.7
The monitoring of vital signs, including pulse oximetry, electrocardiography, and blood-
pressure measurement, is an essential part of procedural sedation and enhances safety.
Continuous pulse oximetry is mandatory for the detection of hypoxemia.Periodic measurement
of blood pressure and continuous electrocardiography are typically used to verify hemodynamic
stability. Serious adverse cardiovascular events are extremely rare in children who do not have
underlying cardiovascular disease.
Capnography is recommended, especially during deep sedation, because it provides the
earliest possible advance warning of respiratory depression. Capnography depicts the carbon
dioxide level during each breath as a waveform. Characteristic changes in the waveform
combined with clinical observations can be used to quickly identify respiratory depression,
apnea, and airway obstruction (Fig. 2).8
In general, 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. They should also be measured as indicated on the basis of individual condition and
level of sedation. During deep sedation, vital signs are often recorded every 5 minutes. Patients
are at highest risk for respiratory depression shortly after the administration of intravenous
medications and when procedural stimuli are discontinued.
Safe sedation requires a minimum of two experienced practitioners — typically, a
physician to perform the procedure and a nurse to continuously monitor the patient and
document vital signs. Depending on the anticipated level of sedation and on the practice setting
(specialty type, procedure type, and location), two physicians may be strongly preferred — one
to administer medications and monitor the patient, and the other to perform the procedure.
Sedation may be performed with or without supplemental oxygen, and clinicians must
carefully weigh the potential advantages and disadvantages of this adjunct. 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 capnographic readings are not affected by the presence or
absence of additional oxygen.

Use of Sedative and Analgesic Drugs

The drugs used in procedural sedation and analgesia fall into five general classes: opioids
for analgesia, sedatives for anxiety reduction and sedation, dissociative agents for analgesia and
sedation, inhalational gases for mild analgesia and sedation, and opioid and benzodiazepine
antagonists to reverse the effects of these agents, when necessary. Various agents can be
administered through multiple routes — oral, intranasal, rectal, intramuscular, intravenous, and
inhalational (Table 3).1,2
 For procedures that are not painful (e.g., diagnostic imaging, in which the primary intent
of sedation is motion control), options for medication include intravenous pentobarbital,
intravenous fentanyl combined with intravenous midazolam, or intravenous propofol. For
minimally painful procedures that require varying levels of motion control, such as minor
laceration repair, drug options include oral or intranasal midazolam, intranasal fentanyl, nitrous
oxide, intramuscular or intravenous ketamine, intravenous propofol, or intravenous fentanyl
combined with intravenous midazolam. For painful procedures, such as fracture reduction or
bone marrow aspiration, drug options include intravenous fentanyl combined with intravenous
midazolam, intramuscular or intravenous ketamine, intravenous propofol combined with
intravenous fentanyl, or intravenous propofol combined with intravenous ketamine (Table 4).
(More specific information on the selection of drug regimens for sedation is beyond the scope of
the video. Several sources are listed in the reference section of this supplement.)
To administer medications for sedation safely and effectively, it is important to
understand their basic pharmacokinetics. Knowledge of the time of onset, time of peak effect,
and duration of effect for each drug allows safe administration, without any overlapping of peak
effects when multiple agents are used and with less potential for oversedation. Many procedures
will require repeat dosing to achieve and maintain the chosen sedation end point, particularly
when the agents used are short-acting, such as propofol.

Recovery and Discharge

After the procedure is completed, monitoring should be continued until the patient returns to the
age-appropriate baseline state and meets local criteria for safe discharge. The child should be
alert, should have stable vital signs, and should be able to talk and to sit unaided as appropriate
for age. However, the child does not need to be able to walk unaided before discharge or to be
able to drink fluids; fluid intake may induce vomiting if allowed too early, prolonging the
recovery period. Standardized recovery scoring systems are widely used to objectively determine
a safe time for discharge. The time to recovery of baseline state varies with the drugs used, but
most patients can be discharged within 1 to 2 hours. The caregiver should be provided with
discharge instructions that contain information about the appropriate diet, medications, and
activity level for the child and about whom to contact if questions or problems arise within the
24 hours after sedation.

Summary
Pediatric procedural sedation and analgesia is a multidisciplinary technique that is used to
manage procedural anxiety and pain. It is effective and generally safe when performed by
appropriately trained practitioners. The ultimate goal of procedural sedation is to provide a
painless, nontraumatic experience for children who are undergoing diagnostic or therapeutic
procedures.

Dr. Krauss reports receiving consulting fees from Oridion Medical and being named in four
patents held by Boston Children’s Hospital — one patent related to respiratory analysis with
capnography (U.S. patent 6,648,833), two patents related to a waveform interpreter for
respiratory analysis (U.S. patents 6,997,880 and 6,428,483), and one patent related to an
automated interpretive medical care system and methodology (U.S. patent 8,147,419). No other
potential conflict of interest relevant to this article was reported. Disclosure forms provided by
the authors are available with the full text of this article at NEJM.org.