PROCEDURAL SEDATION AND IN THE PEDIATRIC PATIENT Are You Prepared to be the Child’s Safety Net? Michele Prior, RN, MSN Allegheny General Hospital Pittsburgh, PA.

OBJECTIVES PROCEDURAL SEDATION

• Define the levels of procedural sedation • Refers to the broad spectrum of interventions that can be used to alter patient response so that tests and procedures • Identify guidelines for monitoring and can be accomplished managing children receiving procedural • Was formerly called “conscious sedation” sedation • It facilitates the performance of procedures that are painful • Discuss the onset, duration and side effects or require the child to have limited motion of medications commonly used for children • Clinicians must determine the appropriate level of sedation during procedural sedation for the procedure and the appropriate medication(s) • Describe non-pharmacologic approaches to managing pain and anxiety in children

WHAT SEDATION IS COMMONLY DEFINITIONS USED FOR? MINIMAL SEDATION

• CT Scan • MRI Sedation Level Patient Cardiorespiratory Responsiveness Effects • Bone marrow aspirations • Lumbar punctures Minimal (Anxiolytics) Normal response to Patient can protect own verbal commands airway • Fracture reductions Cognitive functions Ventilation and • Suturing and coordination may cardiovascular functions • Dressing changes be impaired are unaffected • PICC line insertions • GI procedures • Cardiac catheterization DEFINITIONS DEFINITIONS MODERATE SEDATION DEEP SEDATION

Sedation Level Patient Cardiorespiratory Sedation Level Patient Cardiorespiratory Responsiveness Effects Responsiveness Effects Moderate (Conscious) Purposeful response Patient can protect own Deep Not easily arousal Patient may need help in Drug induced state to verbal commands or airway even with painful protecting airway light tactile stimulation Cardiovascular function Drug induced stimuli  is usually maintained depression of Cardiovascular function consciousness may be impaired

DEFINITIONS CAUTION GENERAL ANESTHESIA • Note that conscious sedation and deep sedation lie along a continuum anchored at Sedation Level Patient Cardiorespiratory one end by full alertness and reflexes and at Responsiveness Effects the other end by general anesthesia and loss Anesthesia Not arousal even Patient needs help in with painful stimuli maintaining airway of protective reflexes Positive pressure ventilation may be needed Cardiovascular function may be impaired

HISTORICAL BACKROUND RESCUE

• Practitioners of sedation must have the • 1983-AAP raises concern about 3 deaths of children in skills to rescue patients from deeper levels dentists’ office during/following sedation • 1985-AAP publishes its first guidelines for monitoring and than intended for the procedure management of children receiving sedation • Must be able to recognize the various levels • 1992-AAP revises the guidelines of sedation and have skills necessary to • 2002-AAP, the Joint Commission and the AADP (American Association of Pediatric Dentists) use the same provide appropriate cardiopulmonary terminology support • 2006-AAP publishes “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” SETTING STANDARDS FOR SCOPE OF RN PRACTICE PROCEDURAL SEDATIONS

• American Academy of Pediatrics • Procedural sedation requires the nurse to • The Joint Commission have specific knowledge and skills that • American Society of Anesthesiologists were once the sole domain of certified • Individual hospitals and institutions Nurse Anesthetists and Anesthesiologists • State Boards of may determine what procedural sedation medications fall within the RN’s scope of practice regarding administration

GOALS PRE-PROCEDURAL PATIENT EDUCATION • Maintain child’s safety and welfare • Minimize physical discomfort or pain • Objectives for sedation • Control movement during the procedure • Sedation medications, possible side effects • Minimize anxiety and negative psychological response to the treatment or procedure and anticipated changes in the child’s • Gain the child’s cooperation behavior • Assure timely patient recovery • What happens before, • Improve patient/parent satisfaction during and after the sedation • Discharge criteria

PRE-PROCEDURE EVALUATION PRESCRIPTIONS • Age and weight • Medical history • Administration of sedation medications at • History of snoring or sleep apnea home poses unacceptable risks for infants and children traveling in car safety seats • History of prior sedations • Procedural medications must be • Family history of adverse reactions to sedation administered under the direct supervision of or analgesia trained medical personnel • Physical exam and review of systems • Time of last fluid/food intake AMERICAN SOCIETY OF MINIMUM FASTING GUIDELINES ANESTHESIOLOGIST (ASA) (AMERICAN SOCIETY OF PHYSICAL STATUS CLASSIFICATION ANESTHESIOLOGISTS) Class I -Healthy patient Class II -Mild systemic disease – no functional limitation Class III -Severe systemic disease – definite functional Clear Liquids Breast Foods/Solids limitation Milk/Formula Class IV -Severe systemic disease that is a constant threat to 2 hours 4 hours for 6 hours life and Class V -Moribund patient who is not expected to survive 24 hours with or without the operation 5 hours for -Patient declared brain dead whose organs are being formula Class VI removed for donation An “E” after the class indicates an emergency procedure

MONITORING & MANAGEMENT FASTING AND ASPIRATION RISK GUIDELINES PRE-PROCEUDRE RESPONSIBILITIES • Goal is to reduce risk of pulmonary aspiration of gastric contents • Assure that a consent has been signed – risks and • If fasting guidelines can not be met due to benefits explained emergent need for sedation must balance the risks • Obtain and document baseline heart rate, and benefits respiratory rate, blood pressure and temperature • Consider: • Assure that a pre-sedation assessment is 1. Delaying the procedure performed and documented by a Licensed 2. Reducing the level of sedation Independent Practitioner immediately before 3. Protecting the airway with intubation beginning moderate or deep sedation

MONITORING &MANAGEMENT PRE-PROCEDURE GUIDELINES RESPONSIBILITIES INTRA-PROCEDURE •Suction • According to the Joint Commission, “The individual administering moderate or deep sedation and anesthesia •Oxygen must be qualified and have credentials to manage and •Airway resolve patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.” •Pharmacy • In addition to the person performing the procedure, a •Monitor sufficient number of qualified staff must be present to evaluate the patient, to provide the sedation, to help with •Equipment the procedure and to monitor and recover the patient Standard PC.03.01.01 MONITORING & MANAGEMENT GUIDELINES MONITORING LEVEL OF INTRA-PROCEDURE CONSCIOUSNESS

• The American Academy of Pediatrics states that a minimum of two personnel are required to be present The level of consciousness must be during the procedure: the practitioner performing the documented procedure and a support person to monitor the child. The support personnel may be certified at the very minimum in Pediatric BLS and be knowledgeable of emergency equipment • The ASA also states that a person with advanced life support skills be available within 5 minutes or present in the room if deep sedation is being administered.

MONITORING PAIN MONITORING

• According to the Joint Commission, during the administration of moderate or deep sedation or anesthesia, the patient’s oxygenation, ventilation and circulation are to be monitored continuously • The American Academy of Pediatrics states that there must be continuous monitoring of oxygen saturation and heart rate and intermittent recording of blood pressure and respiratory rate • Documentation must be time based and include oxygen flow rate if applicable

SUPPLEMENTAL OXYGEN CAPNOGRAPHY MONITORING

• Significant practice variation exists on the use of • Measuring expired CO 2 is the only direct, non-invasive oxygen both pre and intra procedure way to measure ventilation status and is recommended for all procedural sedations • Advantage includes maximizing bloodstream • End total CO2 measures correlate closely with arterial oxygenation during the procedural sedation CO2 • Disadvantage is there may be a delay in noting • Capnography can provide an early sign of desaturation/apnea as measured by pulse oximetry hypoventilation especially if oxygen is used • It is an important adjunct to visual observation and pulse oximetry RESUSCITATIVE EQUIPMENT POST-PROCEDURE • Resuscitator bag and mask in appropriate size MONITORING • Oxygen delivery system able to administer at least • Perform continuous monitoring of pulse 90% oxygen for at least 60 minutes oximetry, respiratory and cardiac rates until • Suction apparatus and catheters the child meets the predetermined discharge • Emergency cart with proper airway equipment criteria • Cardiac defibrillator (in vicinity) • Pulse oximeter • Document vital parameters as per hospital • Automated or manual blood pressure cuff policy • Resuscitation and reversal medications

RECOMMENDED DISCHARGE RECOMMENDED DISCHARGE CRITERIA CRITERIA • Cardiovascular function and airway patency are satisfactory and stable • The child can sit up unaided (if age- • The child is easily arousable, and protective appropriate) reflexes are intact • For a very young or handicapped child, incapable of the usually expected responses, • The child can talk (if age-appropriate) the pre-sedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved • The state of hydration is adequate

DISCHARGE DISCHARGE INSTRUCTIONS RESPONSIBILITES

• Offer clear liquids when the patient is awake, but • Preferable to have two adults to accompany do not force the child to drink the infant/child home if still in a car safety • Give parents both verbal and written discharge seat to observe child’s head position and instructions avoid airway compromise • Document time and condition of child upon • Review medication side effects, discharge and that instructions were given complications and limitation of activities • Make sure the parents have a 24 hour phone number to call if complications or questions SELECTION OF MEDICATIONS • Painfulness of the procedure • Duration of the procedure • Degree of immobility required • Underlying medical conditions • Need for sedation, analgesia or anxiolytics or a combination • Risk of adverse events or side effects

IDEAL AGENT MEDICATION COMBINATIONS • Provides analgesia and sedation • Sometimes procedural medication classes are • Has amnesic properties combined for a more efficient sedation • Has few or no side effects • When two or more conscious sedation • Works quickly and has a short duration of action medications are given, the potential for respiratory depression is heightened • Consider decreasing the initial doses by 25-50%

TRANSMUCOSAL TRANSMUCOSAL ADMINISTRATION ADMINISTRATION • Oral, nasal or rectal routes may be the • The effectiveness of medications easiest way to give a medication, but administered orally depends on medication absorption across mucous gastrointestinal functioning membranes provides less control over the • Medications administered nasally are medication’s effects onset and duration absorbed more reliably, but children may sneeze and expel the solution • Compared with oral administration, the rectal route provides better drug absorption INTRAVENOUS ADMINISTRATION INTRAMUSCULAR ADMINISTRATION • Only route that allows titrating the drug dosage to gain the desired degree of sedation or analgesia • Offers more complete drug delivery than • Has the fastest onset transmucosal route • Greater care must be taken when determining • May be simpler to perform than intravenous access doses • On the negative side, IM’s are painful • Recommended for all sedations requiring more • Absorption rates vary, so the interval from the time than one medication of injection to onset of action is difficult to predict

DOCUMENTATION OF BENZODIAZEPINES MEDICATIONS • Anxiolytics that produce amnesia and mild hypnosis Must include: but no analgesia •Date • Used primarily during painless diagnostic or therapeutic procedures •Time • Pure sedatives, such as Benzodiazepines and •Medication Barbiturates, do nothing to inhibit pain and thus should not be used as agents for pain relief •Dose • Cimetidine and Erythromycin can increase sedative •Route effects

MIDAZOLAM (VERSED®) INTRANASAL MIDAZOLAM COMMENTS • Appears to be safe with minimal respiratory • One of the most frequently used sedation depression and no effect on blood pressure medications in children • Avoids the necessity of intravenous access • The most rapid and short acting Benzodiazepine • Appears to cause sedative effects within 5-10 • It produces anxiolytics, sedation and amnesia minutes and lasts about 30 minutes • It is a good choice for short procedures that are • More rapid onset and shorter duration than oral painless, but require potent sedation route, but the acidity of the preservative (benzyl • Can be administered IV, IM, PO or intranasal alcohol) can cause burning in some children INTRANASAL MIDAZOLAM MIDAZOLAM DOSES • The most effective dose is 0.25-0.5 mg/kg (of the 5 mg/mL solution) dripped slowly • IM/IV 0.06-0.1 mg/kg/dose into alternating nares with a TB syringe attached to an intravenous catheter • May repeat with 0.1-0.2 mg/kg in 5-10 minutes • May cause local irritation and may cause the child to cough or sputter • Max per dose is 2 mg and should be administered over a period of 2 minutes • Oral dose is 0.5 mg/kg

MIDAZOLAM DIAZEPAM (VALIUM®) CAUTIONS COMMENTS

• May cause respiratory depression, dizziness and hypotension Well suited for more lengthy diagnostic • If narcotics or other CNS depressants are procedures such as angiography or to administered, the Midazolam dose should be provide muscle relaxation for orthopedic decreased by 30% procedures. • If used alone for a painful procedure it may increase sensitivity to pain

DIAZEPAM DIAZEPAM DOSES CAUTIONS • PO/PR 0.2-0.3 mg/kg/dose given 45-60 • Incomplete and erratic absorption via IM route minutes prior to the procedure (Max • Make sure that the line is patent – can cause 10mg/dose) burning and phlebitis • Can not be diluted as it will precipitate • IV: 0.1-0.2 mg/kg/dose (Max 10 mg/dose) • Administer as close as possible to the IV insertion Do not exceed 1-2 mg/minute IV site • Children may complain of dizziness LORAZEPAM (ATIVAN®) LORAZEPAM COMMENTS DOSING

• Effects are similar to those of Diazepam • The recommended Pediatric dose is 0.05- • Longer duration so it is better suited when 0.1mg/kg/dose to a total of 4 mg longer periods of sedation are needed • Dilute with equal volume of NSS, D5W or sterile water.

BARBITURATES PENTOBARBITAL (NEMBUTAL®) • Have no inherent analgesic properties COMMENTS • Usually combined with an analgesic when given in advance of a painful procedure • Short to intermediate acting barbiturate effective for non-painful pediatric • Because of their lipid solubility, barbiturates offer a wide variety of routes procedures such as radiographic procedures for administration • Pentobarital has the best efficacy and fewest • Used most commonly for children having adverse effects in this medication class diagnostic imaging

PENTOBARBITAL PENTOBARBITAL DOSES CAUTIONS • Do not inject >50 mg/min; IV titration • Initial IV dose is 1-2 mg/kg (max single preferred dose is 100mg) • May cause respiratory depression, apnea, laryngospasm, bronchospasm and • IV dose can be repeated every 3-5 minutes hypotension for a total dose of 6 mg/kg • Avoid in patients who have hemodynamic • Oral and rectal dose vary by age-under 4 instability years of age 3-6 mg/kg is recommended and over 4 years the dose is 1.5 to 3 mg/kg (max single dose is 100 mg) MORPHINE OPIOIDS COMMENTS Because of their ability to provide analgesia without loss of consciousness, opioids have Provides excellent analgesia as well as mild to long been the mainstay for relieving peri- moderate sedation procedural pain in adults and children

MORPHINE DOSES AND CAUTIONS FENTANYL (SUBLIMAZE®) • May affect systemic vascular resistance COMMENTS causing hypotension • Lipid soluble opioid that is 10 times more potent • May also cause respiratory depression, than Morphine nausea and vomiting • The rapid onset and short duration make it ideal for short, painful procedures either alone or • IM/SQ/IV dose is 0.05-0.2 mg/kg/dose up combined with a sedative to a total of 15 mg • Can be given orally, IV or IM • Should be diluted to a concentration of 1:1 and administered over 4-5 minutes

FENTANYL DOSES AND CAUTIONS CO-ADMINISTRATION OF • All routes may cause respiratory depression MIDAZOLAM AND FENTANYL • The oralet has a high incidence of nausea and • In settings where ultra short-acting agents vomiting are not available, this combination is • IM/IV dose is 1-2 mcg/kg/dose-may repeat after 10 minutes times five sometimes used for procedural sedation • Infuse IV over 2-5 minutes and titrate by doses of • Respiratory depression can occur 1 mcg/kg • Midazolam should be administered first and • Rapid IV injection may produce skeletal and chest wall rigidity necessitating a muscle relaxant and and Fentanyl titrated thereafter tracheal intubation KETAMINE (KETALAR®) CO-ADMINSTRATION OF COMMENTS MIDAZOLAM AND FENTANYL • Ketamine produces a trance-like cataleptic • Give Midazolam first 0.02 mg/kg state in which the child experiences (maximum 2 mg) analgesia and amnesia • Wait two minutes and observe patient • Airway protective reflexes and respirations response give second dose of midazolam if are maintained necessary • There is a minimal effect on the • Give fentanyl 0.5 mcg/kg cardiovascular system • Observe patient may repeat fentanyl dose every two minutes, titrate to effect

KETAMINE KETAMINE DOSES CAUTIONS Be aware that the medication can cause: • PO: 6-8 mg/kg/dose • Laryngospasm • Emergence reactions/hallucinations • IM: 1-4 mg/kg/dose • Increased oral secretions • IV: 0.2 -2 mg/kg/dose • Increased ICP (Total IV dose not to exceed 3 mg/kg) • Increased blood pressure, heart rate and cardiac output • Nausea • Nystagmus

PROPOFOL (DIPRIVAN®) COMMENTS PROPOFOL DOSES • Extremely short-acting intravenous sedative-hypnotic agent used primarily for • IV 0.5-1.5 mg/kg/dose initial bolus induction and maintenance of anesthesia followed by 0.5 mg/kg over 3-5 minutes for • Has no analgesic properties induction and maintenance of sedation • Must be administered by clinicians trained in deep sedation/anesthesia and airway management PROPOFOL KETOFOL CAUTIONS COMMENTS • Expect loss of consciousness and deep • Combining Ketamine and Propofol can sedation immediately produce effective sedation for brief and • Requires intensive patient monitoring painful procedures • May cause hypotension • Decreased likelihood of vomiting than with • Should not be used in children who are Ketamine alone allergic to eggs as Propofol contains egg • Less respiratory depression and hypotension yokes than with Propofol alone

KETOFOL ETOMIDATE (AMIDATE®) DOSES • Propofol (10mg/mL) is mixed in a 1:1 COMMENTS volume with Ketamine (10mg/mL) • Non-barbiturate hypnotic agent with an ultra- short onset and duration of action • The median recovery time is 14 minutes • It has no analgesic effect and often requires • Clinician must be trained in the provision of administration of a short acting opioid for deep sedation or anesthesia painful procedures • Myoclonus is a potential side effect

ETOMIDATE ETOMIDATE DOSES CAUTIONS • Must be administered by clinicians trained May cause: in deep sedation/anesthesia and airway •Nausea management •Vomiting • IV dose is 0.1-0.2 mg/kg/dose over 30-60 •Myoclonus seconds •Adrenocortical suppression • Causes pain during IV administration and pretreatment with Lidocaine may be helpful DEXMEDETOMIDINE (PRECEDEX®, DEXMEDETOMIDINE DEXDOR®) DOSES/CAUTTIONS • Recently received approval by the USA • Dose is 2-3 mcg/kg IV bolus followed by a Food and Drug Administration for continuous infusion of 1-2 mcg/kg/hour procedural sedation • Adverse effects include initial hypotension • Alpha-2 adrenergic receptor that offers followed by bradycardia and hypertension potent sedation effects along with some • It should be avoided in children with analgesia cardiac conduction disorders • It has been found to be effective for use in children with autism and behavioral disorders

NITROUS OXIDE COMMENTS NITROUS OXIDE DELIVERY • Nitrous oxide is an anesthetic gas that provides mild analgesia, sedation, amnesia • Minimal sedation is determined as a rate of and anxiolysis 50% nitrous oxide or less with the balance • Onset of action and recovery are very rapid of the mixture being oxygen • Spontaneous respirations, airway protective • Equipment must have a scavenger system reflexes and hemodynamic status is for waste maintained

NITROUS OXIDE CHLORAL HYDRATE COMMENTS COMMENTS • Sedative hypnotic agent with no analgesic •Alleviates the need for an intravenous line properties •Has an excellent safety record in children • Long history of use in infants and children •The major adverse events are nausea and • Popular sedative for non-painful procedures vomiting that require a motionless patient •It is contraindicated in patients with trapped • Onset of action is prolonged (up to 60 minutes) gas within body cavities • Administered orally or rectally CHLORAL HYDRATE CHLORAL HYDRATE CAUTIONS DOSES • Major drawback is the prolonged onset and • PO/PR: 50-75 mg/kg/dose given 30-60 duration of effect minutes prior to procedure • Chloral hydrate should never be given at home • Max: 1 gram/dose for infants, 2 grams/dose • Higher doses can cause respiratory depression for children • There is a decreased efficacy in children over 3 years of age • Can cause “explosive stools”

ORAL SUCROSE COMMENTS ORAL SUCROSE • Oral sucrose can reduce procedural pain and have DOSES a calming effect in Pediatric patients up to 18 • Only small volumes of sucrose are required months of age • The recommended dose for infants up to 1 • The analgesic effect lasts 5-8 minutes month of age is 0.2-1 mL and for infants up • The sucrose is more effective when given with a to 18 months of age it is 1-2 mLs pacifier as it promotes non-nutritional sucking • The sucrose should be drawn up in an oral syringe and given 2 minutes prior to the procedure

COMPLICATIONS OF PROCEDURAL REVERSAL AGENTS SEDATIONS • The use of reversal agents requires • Respiratory depression/apnea establishment of an appropriate recovery • Aspiration time (usually 2-4 hours) to ensure that • Airway obstruction resedation does not occur • Cardiopulmonary impairment • Hypotension • Reversal agents wear off more quickly than • Vomiting the medications they are reversing • Emergence reactions • Additional reversal agents may be needed • Anaphylaxis • Seizures • Death NALOXONE (NARCAN®) COMMENTS/DOSES FLUMAZENIL (ROMAZICON®) COMMENTS/DOSES • For reversal of opioid induced CNS and respiratory depression • For reversal of sedative effects of the Benzodiazepines; it may not reduce the respiratory • Naloxone’s effects may wear off before that depression of the opioid; be aware of the possible re- • Because the duration of the Benzodiazepines is emergence of respiratory depression longer than the duration of Flumazenil, resedation may occur • The dose is 0.1 mg/kg IV • Can lower the seizure threshold in children with • Minimum dose is 0.5 mg/dose and the max seizure disorders dose is 2 mg/dose • The dose is 0.01 mg/kg/dose IV

ADDITIONAL RESCUE ADVERSE OUTCOMES FROM MEDICATIONS PROCEDUAL SEDATION • Albuterol • Serious complications are unlikely to occur • Atropine in children who receive sedation in the • Diphenhydramine hospital setting due to early recognition of • Epinephrine (1:1000 and 1:10,000) and rapid response to cardiopulmonary • Glucose compromise • Methylprednisolone • Untoward reactions may occur with all • Racemic Epinephrine routes of administration and all classes of • Succinylcholine medications

CONTINUOUS QUALITY PSYCHOSOCIAL INTERVENTIONS IMPROVEMENT • Be honest Track and report any adverse events per hospital policy: • Encourage expression of feelings and fears •Laryngospasm/Apnea • Provide opportunities for safe and therapeutic •Need advanced airway management •Prolonged sedation play •Use of reversal agents • Ascertain the child’s level of understanding and •Transfer to an ICU correct misconceptions •Inadequate sedation /analgesia/ anxiolysis • Avoid medical jargon and words that may provoke negative fantasies PSYCHOSOCIAL INTERVENTIONS

• Explain procedures and treatments, in terms of what the child will see, feel and hear at his level of understanding • Be aware of the importance of timing when giving information • Be sensitive to the amount of information that a child can handle

PSYCHOSOCIAL INTERVENTIONS THANK YOU • Direct information and questions to the child as well as to the parents • Allow the child to participate in care and make choices when possible • Let the child know how he can cooperate

REFERENCES REFERENCES

1.American Academy of Pediatrics. (2006) “Guidelines for the 6.Hockenberry, M., and Wilson, D. (2011) Wong’s Nursing Monitoring and Management of Pediatric Patients During and After Care of Infants and Children. 9th ed. St. Louis: Mosby . Sedation for Diagnostic and Therapeutic Procedures.” Pediatrics . Vol.118 (6), 2587-2602. 7. Hsu, D., et al. (2013) “Pharmacologic Agents for 2.Chiaretti, A. et al. (2011) “Intranasal Lidocaine and Midazolam for Procedural Sedation Outside of the Operating Room.” Procedural Sedation in Children.” Archives of Diseases in Children . Vol. UptoDate. www.uptodate.com 96, 160-163. 8.Koh, J., and Palermo, T. (2013) “Conscious Sedation: 3.Cravero, J. (2012) “Pediatric Sedation with Propofol-Continuing Reality or Myth?” Pediatrics in Review . Vol. 28 (7), 243- Evolution of Procedural Sedation Practice.” The Journal of Pediatrics . Vol. 160 (5), 714-716. 248. 4.Hall, J., and Collyer, T. (2007) “Ketamine Sedation in Children.” 9.McMorrow, S. (2012) “Dexmedetomidine Sedation.” Emergency Nurse . Vol. 15 (5), 24-27. Pediatric Emergency Care . Vol. 28 (3), 292-296. 5.Hsu, D., et al. (2013) “Procedural Sedation in Children Outside of the Operating Room.” UpToDate. www.uptodate.com REFERENCES

10. Srinivasan, M. et al. (2012) “Procedural Sedation for Diagnostic Imaging in Children by Pediatric Hospitalists Using Propofol.” The Journal of Pediatrics. Vol. 160 (5) 801-806 . 11. Steurer, L.,and Luhmann, J. (2007) “Adverse Effects of Pediatric Emergency Sedation After Discharge.” Pediatric Nursing . Vol. 33 (5), 403-407. 12. Suddaby, B., and Mowery, B. (2008) “The Art of Procedural Sedation and Analgesia.” Pediatric Nursing. Vol. 34 (6), 490-492.