Differences between outpatient and inpatient sedation

Within the PICU, intensivists have the luxury of assistance from multiple team members, including nurses, respiratory therapists, an intravenous catheter placement team, and back-up emergency services (such as rapid response or the resource nurse). In addition, the PICU is equipped with advanced airway equipment, capnography, and extensive hemodynamic monitoring capabilities. In contrast, in the outpatient setting, the sedationist is usually partnered with a single nurse who is exclusively dedicated to the sedation. An additional nurse may be assisting the proceduralist and not directly involved with the process of sedation.

A goal of outpatient sedation is maintenance of the natural airway during sedation. Thus, the need for intubation may be deemed as a failure. Monitoring of exhaled end-tidal carbon dioxide with capnography may not be readily available, though highly recommended. Physical access to the patient may be particularly challenging in certain locations, such as magnetic resonance imaging (MRI) suites. Given the distinctive challenges that arise from outpatient procedural sedation, the intensivist must be trained to perform sedation safely in a variety of clinical settings.

Outpatient procedural sedation training during pediatric critical care fellowship

As the demand for procedural sedation outside the PICU increases, so does the need for the intensivist to demonstrate proficiency in outpatient procedural sedation management and monitoring. A recent article describing trends in outpatient procedural sedation reports a consistent intensivist presence in the provision of procedural sedation over the last 10 years. Despite the important role of the intensivist in procedural sedation, a recent survey of pediatric critical care medicine (PCCM) fellowship directors reported that only one-third of PCCM fellowship trainees received formal procedural sedation training during their fellowship. Additionally, only 61% of fellows felt adequately prepared to provide procedural sedation on their own after finishing fellowship. Current training for procedural sedation in most PCCM fellowship programs appears to be inconsistent and optional, highlighting a training gap that must be addressed. Given that most PCCM fellows likely will be required to perform procedural sedation outside the PICU, it is imperative that fellowship programs incorporate outpatient procedural sedation training in their academic and training curricula. The SPS ( www.pedsedation.org ) provides simulation-based training in procedural sedation during its annual conference. Simulation has been shown to be effective in teaching sedation competencies and enhancing team dynamics; it should be routinely employed to train providers of procedural sedation.

Sedation team structure

Considering the increasing role of the intensivist in procedural sedation outside the PICU, the newly graduated PCCM fellow will likely be required to incorporate this practice into clinical service. Some institutions allow intensivists to “moonlight” in the sedation service for compensation in addition to their PICU responsibilities. Transition to being a sedationist (part time or even full time) may also appeal to senior intensivists trying to decrease PICU clinical service or on-call duties before retirement or those experiencing burnout or moral distress while working in the PICU. Some programs use a hybrid of full-time sedationists (usually senior physicians from PCCM or Pediatric Emergency Medicine) and other intensivist and emergency medicine specialists who cover sedation shifts when not working in their primary clinical sites.

In addition to the intensivist, most sedation programs allow a dedicated trained sedation nurse to assist mostly with sedation monitoring. An observer (usually another nurse) may be involved in monitoring but may also help with interruptible tasks. All personnel providing procedural sedation must have training in pediatric advanced life support.

Classification of sedation

The American Society of Anesthesiology (ASA) classifies sedation as mild, moderate, deep, and general anesthesia. The classification is based on responsiveness to voice, touch, painful stimulus, and the ability to maintain airway reflexes and cardiovascular function. The type of medication used does not define the level of sedation. Mild sedation is a drug-induced state in which the patient responds to verbal commands. For example, mild sedation may be employed in a child to reduce anxiolysis before a nonpainful imaging study. Moderate sedation is a state of depressed consciousness in which the patient may respond to verbal commands or tactile stimulation. No airway interventions are required, and cardiovascular function is maintained. For example, moderate sedation may be appropriate in a cooperative adolescent during suture repair of a laceration. Deep sedation is defined as a depression of consciousness in which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The patient may require assistance in maintaining a patent airway, but the cardiovascular system is usually maintained. In outpatient procedural sedation, the intensivist commonly induces deep sedation, typically with propofol. The sedation specialist must have in-depth knowledge of monitoring as well as rescue of pediatric patients undergoing deep sedation. Last, general anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to maintain ventilatory function is commonly impaired and patients often require positive-pressure ventilation. Neuromuscular and cardiovascular functions may also be impaired. For these reasons, general anesthesia is reserved for operating rooms and not performed in the outpatient procedural sedation setting. It is important to recognize that sedation is a continuum and that any child can slip from moderate sedation to deep sedation, making airway rescue skills paramount.

Equipment, monitoring, and rescue drugs

Essential components that must be available in any outpatient sedation location include an emergency cart, hemodynamic monitoring devices, and rescue drugs. Equipment in emergency carts must include bag-valve-mask devices, oral and nasopharyngeal airways, laryngeal mask airways (LMAs), endotracheal tubes, laryngoscopy blades, and intravenous lines. In addition to these lifesaving devices, sedation specialists should have access to portable telemetry, pulse oximetry, capnography, blood pressure monitoring, and defibrillators. Last, common rescue medications—such as albuterol, atropine, diphenhydramine, dextrose, epinephrine, flumazenil, lidocaine, lorazepam, methylprednisolone, naloxone, oxygen, racemic epinephrine, and sodium bicarbonate—should be readily available. Pediatric intensivists are trained to rescue a child using these tools, making them uniquely suited to provide outpatient sedation for diagnostic and therapeutic procedures.

Sedation prescreening

Not all patients are candidates for procedural sedation. Pediatric intensivists should be aware that certain conditions necessitate the services of a pediatric anesthesiologist. Children with difficult airway (determined by history or physical examination), microcephaly, micrognathia, retrognathia, mandibular/midface hypoplasia, or genetic syndromes with known complex airway anatomy are best referred to the anesthesiologist. In addition, patients with ASA physical status classification of IV or higher ( Table 135.1 ), severe obstructive sleep apnea (apnea-hypopnea index >10), morbid obesity (body mass index >95th percentile), and complex cardiopulmonary disease (such as unrepaired congenital heart disease) may not be suitable candidates for outpatient procedural sedation and are best discussed with the anesthesiologist.

Once a patient is deemed to be a candidate for natural airway sedation, instructions for nil per os (NPO; nothing by mouth) status should be given. Most institutions follow the American Academy of Pediatrics (AAP) fasting guidelines for procedural sedation. Table 135.2 shows the modified NPO guidelines commonly used in this setting. Recent evidence reporting minimal to no aspiration risk with a reduced fasting duration prior to procedural sedation will likely result in future changes in NPO guidelines. On the day of sedation, the pediatric intensivist must perform a focused medical history that, at a minimum, includes history of current illness, past medical history, current medications, allergies, adherence to fasting guidelines, and a family history of adverse reactions to anesthesia. An informed consent should be obtained from the parents or the legal guardian prior to procedural sedation.

TABLE 135.2

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