27. Procedural Sedation: Anesthesia and Sedation of Children Away from the OR

Tanya Farrell¹

(1)

Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia

Tanya Farrell

Email: Tanya.Farrell@health.wa.gov.au

Keywords

Pediatric 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.

Keypoint

It is difficult to safely provide sedation for painful procedures in children, particularly when the pain is intermittent.

27.3 Sedation Versus General Anesthesia

The aims of sedation are to safely reduce fear and anxiety, increase compliance with the procedure and to control pain if necessary. Sedation has traditionally been described as a continuum from consciousness to unconsciousness (Table 27.1). The endpoints of the different levels of this continuum however, are arbitrary and subjective. Personnel involved in monitoring sedation may not appreciate the levels are not discrete and are difficult to assess in young children who are also susceptible to fluctuations between the levels. There is also a dilemma in assessing sedation in children—rousing a settled child to assess the level of sedation may cause the procedure to be abandoned if the child then doesn’t settle again. Sometimes even inflating a blood pressure cuff may rouse the child, and so monitoring is sometimes more restricted than it might be for an adult. The development of a more objective model for sedation levels based upon cardiorespiratory monitoring rather than response to verbal or physical stimuli would allow closed medication loops and self-correction with automated algorithms. However, interindividual variation and argument over what constitutes moderate, deep sedation and general anesthesia have hampered progress in this area.

Table 27.1

Levels of sedation in children (based on American Academy of Pediatrics guidelines 2016)

Level of sedation	Characteristics
Minimal sedation	Anxiolysis only (e.g. state induced by nitrous oxide at less than 50%)
Moderate sedation	Purposeful response to verbal command (also termed ‘conscious sedation’)
Deep sedation	Purposeful response after repeated verbal or painful stimuli. At risk of airway obstruction
Anesthesia	At risk of airway obstruction and may need ventilatory support

Note

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.

There is an impression among non-anesthetists that sedation is safer than anesthesia. Many proceduralists will persist with attempts at deeper and deeper sedation, compromising safety that could otherwise be gained with more tightly controlled conditions and a protected the airway. Nevertheless, sedation, including sedation provided by non-anesthetic personnel, has advantages over general anesthesia in many children and for many procedures (Table 27.2).

Table 27.2

Sedation versus general anesthesia for medical procedures-their advantages and disadvantages

	Sedation	General anesthesia
Advantages	Less staff and equipment required	May need less preparation of child
	May have faster recovery with less PONV or drowsiness	More reliable airway control
	May have faster recovery with less PONV or drowsiness	Movement less likely and procedure always completed
Disadvantages	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

The actual levels of staffing and equipment required for sedation depends on the level of sedation used

Patient selection is critical to the success of sedation techniques (Table 27.3). In some cases, general anesthesia a quicker alternative than the preparation for sedation and the slow onset of sedation agents. Some studies have compared anesthesia with sedation and concluded that anesthesia is more cost effective when the total time for induction, procedure and recovery is considered. On the other hand, the supply of highly trained personnel required for provision of anesthesia or deep sedation is far outstripped by demand in most hospitals.

Table 27.3

Contraindications to sedation (based on SIGN guidelines)

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