Pediatric Sedation: An Overview of Best Practices (April 2004)
Not so long ago, in order to perform certain medical procedures, pediatricians had to restrain young children on a firm wooden board, using heavy cloth bands to hold the children in place. The unfortunate patients would scream and struggle, and be left with terrible memories of their hospital stay.
Today, the increasing use of pediatric procedural sedation has markedly reduced the traumatic effects of these procedures on our young patients and their families. Pediatric sedation guidelines from the American Academy of Pediatrics detail a meticulous level of care, covering patient preparation, equipment, personnel, monitoring and record keeping. The following brief discussion will highlight some of our experiences sedating thousands of children at California Pacific Medical Center, emphasizing items of interest to general pediatricians counseling patients and families about proposed sedated procedures.
Non-Pharmacologic Sedation
The best sedation may be no sedation. If a procedure can be done without sedating medication, then the small risks of sedation can be avoided. Specific features of the planned procedure, the child’s age, developmental stage and personality are all considered when deciding whether a non-pharmacologic approach is worth trying.
Generally, this approach is only considered for procedures that are not painful and when some patient movement is tolerable. The child may eat and drink normally. The procedure is performed in a calm and supportive setting. The family can hold the patient if the procedure allows. Sleep deprivation may help. A feeding may encourage a young baby to sleep long enough to complete a non-noxious study. Clearly, the child’s personality may make a big difference. While many two year olds require sedation to place scalp EEG leads, for example, other children in the same age group are quite relaxed by nature, and in a supportive environment will tolerate a stranger playing with their hair for the half hour needed to place the leads. Our Child Life Service is quite helpful with these non-sedated procedures. They can provide distracting toys, music and videotapes, and help families and staff to create a non-threatening environment.
Pharmacologic Sedation
If pharmacologic sedation will be used, important safeguards apply. Elective sedation and anesthesia are always done on an empty stomach to reduce the risks of regurgitation and aspiration while airway protective reflexes may be attenuated. In general, no solid foods are permitted after midnight the night before, and only clear fluids are allowed up to 3 hours prior to sedation. For younger children unable to tolerate prolonged periods without eating, milk and formula are allowed until 6 hours before the scheduled procedure, and clear fluids until 3 hours before. Breast milk is considered a clear fluid. Patients with delayed gastric emptying or other medical conditions may need more stringent precautions. Normal oral medications may be given with a small amount of clear fluid up to 3 hours before. If a non-pharmacologic technique has been attempted and included feeding, then no sedating medications should be given until the NPO guidelines have been met.
The risks of sedation are in part related to the inherently unpredictable response to sedation medicines. The goal is always to sedate patients as lightly as needed to perform a procedure reliably, but a child can inadvertently pass from a shallow level of sedation to a deeper one, with increased risk of airway compromise, hypoventilation or cardiovascular instability. We therefore monitor all patients fully; from before the first dose of medicine to the time the children waken completely, with continuous pulse oxymetry, noninvasive blood pressure monitoring, EKG and direct observation by a trained individual not participating in the procedure itself. We use end-tidal or transcutaneous CO2 monitoring for selected patients. An anesthesia bag and mask, oxygen, and large bore suction are at the bedside, with other emergency equipment rapidly accessible.
Choosing the sedating agent or agents, the route of administration, and the desired depth of sedation varies based on many factors. An uncomfortable procedure might require analgesia in addition to pure sedation. Brief procedures demand short-acting drugs. Benzodiazepines, barbiturates and several other classes of drugs should be avoided if an EEG is to be done, as brain wave activity will be affected. Patients with cardiovascular instability should get drugs with minimal effects on blood pressure or cardiac rhythm. Unstable asthmatics should avoid histamine-releasing medicines. If the patient has an evolving neurologic problem, any sedation will obscure clinical evaluation; long-acting agents should be avoided and pharmacologically reversible agents may be desirable.
In recent years, the most popular sedating agent used by the PICU physicians at California Pacific Medical Center for procedural sedation has become Propofol (Diprivan). Given intravenously, it works rapidly and reliably, with a short duration of action. It can be given in repeated small, titrated doses for longer procedures, or as a continuous infusion. Older patients report they waken refreshed, without the persistent dysphoria that follows many other sedating drugs.
Clearly, pediatric procedures have been made much easier in recent years, using careful sedation. The children, their families, and the medical team have benefited greatly. Children who require repeated noxious procedures may have benefited the most. For example, children with acute lymphocytic leukemia require multiple lumbar punctures and bone marrow aspirations in the early phases of their treatment. Routine sedation for these recurrent procedures, particularly with the associated amnesia, represents a tremendous improvement in their care.
Pediatric Intensive Care Unit
Physicians: John Tsukahara, M.D. and Anne Tseng, M.D.
Tel. (415) 600-3420