Procedural sedation (peds)

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Sedation levels

Sedation levels

Level Definition Comments
Minimal Sedation Standard pain medications
Moderate Sedation Awake and able to respond to questions use in: LP, I+D
Dissociative Sedation Trance-like state, airway reflexes preserved
Deep Sedation React purposefully to painful stimuli use in: Reduction
General Anesthesia Unarousable, requires intubation/advanced airway

Procedural Checklist[1]

  • Consent in chart
  • PIV with fluids running
  • ETCO2 and NC connected to patient
  • Airway preparation
    • Suction with Yankauer attached
    • BVM attached to wall oxygen
    • Oral/nasal airways
    • Mac/Miller blades
    • ET tubes with stylets
  • Meds at bedside
    • Sedation Meds
    • Narcan 0.4mg if opioid being used, not drawn up
    • Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
    • Glycopyrrolate, 1 vial; not drawn up
  • Strongly consider child life

Fasting

  • No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) [2]
  • Some specialty societies recommend:
    • 2-hour fasting time for clear liquids
    • 4-hour fasting time for breast milk
    • 6-hour fasting time for solids

Airway Monitoring

  • Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). [2]
  • Placing the patient on ETCO2 + SpO2 is ideal[3]
  • Position the patient in a position you would intubate if needed (ear at level of sternal notch)
  • Consider nasal airway in patients with likely OSA

Sedation Medications

Oral Sedation

  • Consider if only sedation without analgesia required
  • Midazolam 0.5-1mg/kg PO 10-20min prior to procedure
  • Chloral hydrate 50-75mg/kg PO 30min prior to procedure
    • May give additional 25-50mg/kg PO x 1 after 30min if needed

Intranasal sedation

  • Give 1mL at a time alternating nare. Contraindicated if significant URI
  • Midazolam 0.2mg/kg IN
  • Fentanyl 2mcg/kg IN

Cincinnati Children's Hospital Protocol

Peds Procedural Sedation.jpg [4]

Side Effects

  • Desaturation
    • Stimulate
      • Try pressure behind ear
    • Jaw thrust
    • Nasal airway
    • BVM
    • NIV
    • LMA
    • Intubation

Disposition

  • Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs [5]
  • Not necessary to tolerate oral challenge [6]


See Also

References

  1. http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
  2. 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  3. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
  4. Cincinnati Children's Hospital "The Pocket" 2010-2011
  5. Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91
  6. Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627

Authors:

Michael Holtz