Pediatric Procedural Sedation

Savithiri Ratnapalan

Pediatric Procedural Sedation and Analgesia

Procedural sedation is the technique of administering a single drug or a combination of drugs with sedative, analgesic, or dissociative properties to induce a state that allows children to:
- Tolerate painful or unpleasant procedures
- Stay still for some non-painful procedures
The most common reasons for pediatric procedural sedation are:
- Orthopedics (most common, and includes fracture reductions, dislocations, and immobilization/splinting)
- Laceration repair
- Foreign body removal
- Lumbar puncture
- CT scans

Challenges in Children

Assessing the level of sedation in a child may be harder than in adults.
- A child can easily move from moderate sedation to general anesthesia with minimal increases in sedative agents.
Children come in various sizes and need age-appropriate equipment.
- Ensure age- and size-appropriate equipment, including:
  - Blood pressure cuffs for different ages.
  - Doppler blood pressure monitors.
  - Pulse oximetry probes.
  - Intravenous canula.
  - Airway equipment – masks, resuscitation bags, and intubation equipment.
Children range from neonates to teenagers, and need specific dose calculations.
- Obtain accurate weight of patient of appropriate dosing.
- Drug doses should be calculated and checked by at least two healthcare professionals.
- Most common cause of drug error is dose inaccuracies.
Children should come with a parent or guardian.
- Consent from the parent and assent from child (as appropriate) should be obtained before the procedure.
Children need simple explanations and clear instructions.
Children need a calm monitored environment for procedural sedation and for recovery.

Pediatric Characteristics That Need Consideration

Young infants have relatively less oxygen reserve (greater oxygen consumption).
- Hypoxemia occurs more rapidly.
- Appropriate size bag and mask ventilation should be available.
Pediatric patient sizes may vary from 2.5–100 kg. The “pediatric crash cart” is bigger and should have age-appropriate equipment.
Airway sizes may vary unpredictably among pediatric patients of same age and weight.
At times, three different-sized endotracheal tubes should be available for the patients of the same age (the calculated size and a size smaller and larger).
- The appropriate uncuffed endo-tracheal-tube size may be determined by the following formula (age in years):
  - 4 + (1/4) (age)
  - Subtract 0.5 for the appropriate size cuffed ETT
    - For example, for a 4-year-old child: uncuffed ETT size = 4 + (1/4)4 = 5
    - So, cuffed ETT size = 5 – 0.5 = 4.5.
- The appropriate depth of ETT insertion can be approximated by:
  - Over 1 year of age:
    - Oral: 13 + (1/2)age
    - Nasal: 15 + (1/2)age
  - Infants (weight in kg):
    - Oral: 8 + (1/2)(weight)
    - Nasal: 9 + (1/2)(weight)
Small children have small airways.
- Since resistance to air flow is inversely proportional to the fourth power of the radius of the airway, 1 mm of concentric edema in a newborn trachea (radius ∼2 mm) increases resistance about 16 times.
- The presence of upper respiratory tract infection should be assessed prior to sedation, adjuvant agents to reduce secretions may have to be used, and vigilance in airway monitoring observed.
There are anatomic differences between the infant and the adult upper airway:
- Infant larynx:
  - More superior in neck.
  - Epiglottis shorter, angled more over glottis.
  - Vocal cords slanted: anterior commissure more inferior.
  - Larynx cone-shaped: narrowest at subglottic cricoid ring.
  - Softer, more pliable: may be gently flexed or rotated anteriorly.
- Infant tongue is relatively larger.
- Infant head is relatively larger: naturally flexed in supine position.
- Caution in intubation: extension of head may result in tracheal extubation, while flexion may lead to main stem intubation.
Young infants (less than approximately 2–3 months) are obligate nose breathers.
Infants and young children have limited hepatic glycogen storage and are more prone to hypoglycemia when fasted for prolonged periods.
- Consider starting an intravenous maintenance fluid such as D5% N Saline if the child has fasted or is expected to fast for a long period.
Gastroesophageal reflux is common in infants. Watch out for vomiting post sedation.

Policies and Protocols for a Safe Pediatric Sedation Within the ED

Trained personnel in pediatric sedation and airway management.
Accurate weight measurement, drug dose calculations, and a protocol mandating two persons sign-off on drugs.
Age-appropriate equipment to monitor and manage potential adverse effects of sedation in children.
Preprinted orders and monitoring sheets should be a requirement for any department performing PSA.
Documentation of consent.

Exclusion Criteria and Contraindications for ED Pediatric Sedation

Patient Criteria

ASA classification >II.
History of known airway problems: snoring, obstructive sleep apnea, large tonsils or adenoids, tracheomalacia, tracheostenosis, congenital abnormalities involving the airway (e.g., Down syndrome, Pierre Robin syndrome, Treacher Collins syndrome, and Crouzon’s disease).
Cardiovascular disease: repaired or unrepaired congenital heart disease and congestive heart failure.
Severe neurologic disease, severe hypotonia, and evidence of increased intracranial pressure.
Severe renal or liver disease.
Severe gastroesophageal reflux and previous esophageal surgery or injury.
Patients at increased risk of pulmonary aspiration of gastric contents (e.g., full stomach).
Potential neck injury, limitations in moving neck/opening mouth/jaw movement.
History of known sedation failure.
Home oxygen therapy/or home ventilation.
Sickle cell disease.
Baseline vital signs indicate SaO₂ <95% in room air.