Acknowledgment of the presence and importance of pediatric pain has transformed the management of ill and injured patients.¹ Procedural sedation and analgesia (PSA) are now an integral component of pediatric emergency care.² Increased availability of emergent imaging has expanded the emergency physician’s role to include MRI and CT scan sedation.

Sedatives with or without analgesics are given for tedious, precise, or painful procedures, resulting in a level of consciousness depressed enough to accomplish the procedure while maintaining respiratory drive. The previous misnomer conscious sedation has been replaced by four levels of procedural sedation, each with increasing risk of loss of protective and cardiorespiratory functions.³ Anxiolysis, or “minimal sedation,” impairs coordination and cognitive function but allows patients to respond normally to verbal stimuli. “Moderate sedation” is a drug-induced depression of consciousness (profound relaxation) but retains purposeful response to verbal or light stimuli. With “deep sedation,” patients are not easily aroused, yet repeated painful stimulation yields purposeful response at doses “not likely” to depress ventilatory function. “General anesthesia” is the state where painful stimuli do not evoke a response, and the corresponding lack of tone can compromise airway reflexes, airway patency, and cardiorespiratory function.

The Joint Commission and the American Academy of Pediatrics recognize that sedation is a continuum; therefore, safety and monitoring guidelines focus on the ability to rescue a patient from a deeper level of sedation than intended.^2,4 Studies show that many children enter a deeper level of sedation than initially intended.⁵ Safety guidelines encompass patient assessment, personnel and monitoring equipment, medication familiarity, discharge criteria, and quality assurance. Knowledge of specific medications is critical, but guidelines leave specific requirements to individual hospital credentialing committees.

The analgesic or sedative need is determined by the patient complaint, the status and responses of the child, the preference of the treating clinician, and, when appropriate, family. Prior to moderate or deep procedural sedation, children should undergo a focused history pertinent to their chief complaint using a modified SAMPLE approach⁶ (Table 13-1). In addition to obstructive airway concerns such as snoring, other factors which have been associated with an increased risk of adverse events or the need for intervention include recurrent or current stridor, obstructive sleep apnea, obesity (BMI >95%), symptomatic asthma or heart disease, gastroesophageal reflux, or swallowing problems.⁷ The obesity epidemic is now a common problem in childhood, and the practitioner should be vigilant when sedating these patients.⁸ Increase in adverse events such as hypoxia or hypoventilation may occur, as well as oversedation when medication is dosed on the obesity weight. Using ideal body weight instead of actual weight for medication dosing has been recommended for many medications in the obese patient.⁹

The importance of recent food intake is balanced in the emergency department (ED) by the urgency of the procedure. One emergency clinical practice guideline takes urgency, sedative type, and recent literature into account to determine reasonable fasting times (Fig. 13-1).^1,10–12

Document vital signs, including baseline blood pressure, oxygen saturation, and temperature, as well as a brief examination of the oropharynx, posterior pharynx, and chest. Because of the relatively larger tongue and more reactive tonsils and adenoids in children, positional respiratory compromise is more of a concern in children undergoing PSA than adults. Larger tonsils or a history of snoring or apnea should prompt the clinician to have a nasopharyngeal airway at the bedside. Evaluate the airway using a Mallampati score or other method to assess ease of emergent intubation (Fig. 13-2).¹³ Consider risk–benefit and potential general anesthesia consultation for any patient anticipated to be a difficult intubation, that is, those with craniofacial abnormalities, past reconstruction of the trachea, or atlantoaxial instability.

Assign any child undergoing PSA in the ED an American Society of Anesthesiologists (ASA) score. ASA 1 or 2 patients are generally healthy children who are good candidates for PSA in the ED; ASA 4 or 5 patients are generally better treated in a formal operating room or procedural unit. ASA 3 patients may be managed in either area depending on the nature of the problem and the capabilities of the treating physician. Rating of ASA category may be subjective; a low ASA score does not override a concerning airway evaluation.

Immediately prior to sedation, Joint Commission requirements state that patients must be reassessed to ensure that their physical condition has not deteriorated since the initial examination. The AAP guidelines call for a “time out,” documenting the patient’s name, procedure, and reason for procedure.²

The mnemonic “Soap Me!” includes all aspects of equipment that should be immediately available during deep sedation (Table 13-2). Suction, oxygen, and monitoring equipment should be set up and running in the room prior to initiation of sedation, and an airway crash cart can be readily available but not opened. A bag-valve-mask setup may be left unopened in the room for moderate sedation, but should be open and ready to use for anticipated deep sedation.

Use of supplemental oxygen is controversial, perhaps because of early association with adverse events in dental clinics where its use is routine.¹¹ Although critics argue it may mask hypoventilation, studies of ED sedations where supplemental O₂ is supplied have fewer hypoxia events than when it is withheld. Optimizing airway patency during the procedure can be assisted by using a towel roll under the shoulders as well as elevating the head of the bed.

The degree of monitoring required is determined by the intended depth of sedation and the intended procedure. The best monitor is a skilled dedicated observer who is not involved in the procedure and who can observe the child’s level of consciousness, airway patency, response to stimulation, respiratory function, and perfusion. Patients receiving analgesia alone for an acute painful condition or minimal sedation/anxiolysis generally do not require additional monitoring.

Single smaller doses of non-parenteral medications separated in time typically result in minimal sedation/anxiolysis. The sedation level anticipated with combinations and dosages given concurrently is often addressed in individual hospital policies. When 0.1 mg/kg of morphine is inadequate for severe fractures or when adjunct parenteral benzodiazepines are needed (e.g., femur fracture), monitoring with a minimum of continuous pulse oximetry is warranted.¹⁴

Patients undergoing moderate or deep procedural sedation require continuous cardiac and pulse oximetry monitoring, with intermittent blood pressure and respiratory rate checks. Generally, electronic monitoring should be in place prior to sedation initiation. In difficult circumstances, PSA may begin with bedside monitoring by an appropriately trained nurse or physician after a check to ensure the electronic equipment works. A child who continually screams and thrashes from the blood pressure cuff, oximetry, or an end-tidal CO₂ monitor is in danger of laryngospasm or post-sedation emergence. The offending monitor can be removed after baseline vitals immediately prior to sedation and replaced when the child is asleep.

Deep sedation requires an additional person whose sole responsibility is to monitor the patient. Using moderate sedation, the sedationist can perform a procedure with a person monitoring who can intermittently assist with the procedure. The sedationist should understand monitoring equipment, recognize the signs and symptoms of respiratory depression, and be able to provide effective bag-valve-mask ventilation should apnea occur.

The most common serious risk of PSA is hypoxia from respiratory depression. Transient self-resolving hypoxia may be an expected PSA effect in contrast to hypoxia that requires an intervention to reverse (i.e., bag-mask-ventilation). Continuous pulse oximetry can provide both an ongoing assessment of oxygenation as well as a continuous display of heart rate. Pulse oximetry may not reflect hypoventilation, particularly if supplemental oxygen is being provided. For children in whom concerns for adequate ventilation exist, continuous end-tidal capnometer (ETCO₂) should be added to the monitoring equipment. In addition to providing information about apnea and obstruction in advance of oximetry, the ETCO₂ wave form shows each exhalation, giving information about perfusion, shallow breathing, coughing, or erratic breaths suggesting waking or obstruction.¹⁵ It has been shown that providers with access to ETCO₂ provide less frequent but more timely interventions to hypoventilation.¹⁶ Provide ETCO₂ monitoring for patients who are physically removed from the ED (i.e., to radiology). In cases where the patient’s respiratory effort is difficult to assess even at the bedside (e.g., the obese patient with a gluteal abscess to be sedated prone), ETCO₂ may also be useful.

Determine the timing and duration of patient monitoring by both the agent used and the procedure performed. Sedation clinical monitoring can also be based on sedation phase. Phase I sedation is when the patient is receiving or has received a drug that is achieving its peak clinical effect. During this time, 1:1 level clinical monitoring needs to occur. At a minimum, monitor any sedated children until the clinical effects of their drug therapy have dissipated, the pharmacologic peak is past, and the child’s respiratory and mental status have approached baseline. This is extremely important in children undergoing acute painful procedures such as fracture reductions. The greatest risk of hypoventilation in these children may occur after the painful stimuli of the procedure have ceased. Conversely, children who initially present extremely agitated and crying vigorously may exhaust themselves and remain sleeping long after the pharmacologic effects of a sedative have passed. Patients receiving long-acting medications, or for whom reversal agents were required, may require monitoring until peak medication action is passed. Determine the duration of patient monitoring individually.

Discharge of children undergoing PSA should not occur until the child has normal vital signs, has returned to an appropriate pre-sedation mental and physical baseline, and is able to sit without assistance or maintain head control if they are still in a child seat. Aftercare instructions should reflect the fact that the child has received an agent that may alter mental status and must therefore receive close supervision and have limited high-risk play/recreation.

Properly staffed and prepared EDs have demonstrated low complication rates for all PSA patients. Implementation of current guidelines has further improved hospital sedation safety.^17–19

Intravenous (IV) administration offers the greatest flexibility in terms of titrating medications to a specific patient response, and is the preferred route for a child when medication titration is anticipated or deep sedation is planned. Intramuscular (IM) and subcutaneous (SQ) injections provide reliable delivery but should be reserved for drugs with well-established dose–response relationships (e.g., ketamine) to avoid repeated administration. Oral (PO) administration should be reserved for drugs with predictable actions, or in cases when placement of an IV is not possible until oral sedatives take effect (e.g., strong, combative patients with autism). The timing of repeat doses can be difficult to determine due to delays in absorption and onset of action.

Transmucosal (TM) drug administration provides quicker onset than PO administration but is slow enough to make titration of medications difficult. Newer mucosal atomizer devices have enhanced medication delivery. Analgesic and sedative medications such as methohexital, midazolam, dexmedetomidine, and fentanyl have been successfully delivered transmucosally through the oral, buccal, intranasal, and rectal routes.^20–23 Aerosolized intranasal midazolam delivery provides effective and well-tolerated TM delivery, making it ideal for short procedural sedation situations, such as simple laceration repair in young children.²⁴

Inhalation of nitrous oxide (N₂O) and methoxyflurane has been described in children in the ED setting and is a safe and relatively well tolerated route of delivery.^25–27 Advantages of this route include ease of delivery and painless administration; the disadvantages are the need for specialized equipment and patient cooperation.

Clinicians using common sedative and analgesic agents for PSA should be familiar with their indications, actions, relative contraindications, and potential alternatives (Table 13-3).²⁸