27. Procedural Sedation: Anesthesia and Sedation of Children Away from the OR
KeywordsPediatric gastroscopySedation of childrenKetamine sedationPediatric MRI anesthesiaNitrous oxide sedation
Young children often need sedation for diagnostic or therapeutic procedures. The number of procedures is increasing as technology improves and many are performed in areas away from the operating room. Demand for sedation is also increasing because of cultural changes suggesting it is not acceptable to restrain children or subject them to frightening or painful procedures whilst awake. In addition, children presenting for some diagnostic procedures may have poorly delineated pathology and be quite unwell. The demand for sedation places pressure on the resources of anesthetic services, and techniques that do not require an anesthetist are often used. This chapter discusses the issues and techniques to safely sedate children for medical procedures.
27.1 Remote Location
Many diagnostic or therapeutic procedures are performed remote from the OR in areas as diverse as radiology, neurophysiology or oncology wards. These areas are usually poorly designed for anesthesia, with bulky equipment, poor lighting and often limited access to the child. Staff in these locations may be unfamiliar with anesthetic protocols and priorities. Extra vigilance is required when checking patient preparation and fasting, equipment, emergency supplies and the recovery area. Occasionally, procedures on children are carried out in adult hospitals due to limited facilities and expertise in smaller children’s hospitals. The lack of assistance and equipment on site and the transfer to and from the parent hospital add another element of risk.
27.2 Typical Procedures Requiring Sedation
Procedures such as echocardiograms, MRI scans and EEGs are not painful, but require the child to remain still for extended periods of time in an uncomfortable and frightening environment. Older children can cooperate, particularly if they are distracted. Babies up to 3 months old can usually be fed and wrapped up warmly—most will fall asleep (incredibly!) during the examination. Some children, especially preschool aged, can be difficult to image adequately while awake. Other diagnostic and therapeutic procedures such as lumbar punctures, bone marrow biopsies, nephrostomy insertion, and endoscopies are painful and require analgesia as well as sedation. These procedures, particularly those that are intermittently painful, are more difficult to provide safe sedation for—doses of agents sufficient to make the child comfortable during painful stimulation may then leave them excessively sedated or even apneic when the stimulation is removed.
It is difficult to safely provide sedation for painful procedures in children, particularly when the pain is intermittent.
27.3 Sedation Versus General Anesthesia
Levels of sedation in children (based on American Academy of Pediatrics guidelines 2016)
Level of sedation
Anxiolysis only (e.g. state induced by nitrous oxide at less than 50%)
Purposeful response to verbal command (also termed ‘conscious sedation’)
Purposeful response after repeated verbal or painful stimuli. At risk of airway obstruction
At risk of airway obstruction and may need ventilatory support
The level of sedation is more difficult to assess in children—young children cannot talk and rousing a child to assess level might wake them completely. At the same time, they are more at risk of respiratory problems if sedation is not closely monitored.
Minimal and moderate sedation are rarely effective in children—small doses of sedation do not change a tired and hungry toddler into an awake yet co-operative patient. There is a tendency, especially in younger children, toward deeper sedation to produce the desired conditions. The increased risk of airway obstruction and cardiopulmonary depression, combined with problems associated with remote location and inexperienced staff can sometimes mean that general anesthesia is a safer option than sedation. This is especially pertinent for long procedures, medically compromised patients, or if procedures are painful or distressing.
Sedation versus general anesthesia for medical procedures-their advantages and disadvantages
Less staff and equipment required
May need less preparation of child
May have faster recovery with less PONV or drowsiness
More reliable airway control
Movement less likely and procedure always completed
Child may need preparation
More staff and equipment
May take time to titrate sedation to correct level
Extensive training required for personnel
Procedure not always completed
Greater propensity for PONV