Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures Charles J. Coté, MD, FAAP, Stephen Wilson, DMD, MA, PhD, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

The safe sedation of children for procedures requires a systematic approach abstract that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed for underlying medical or surgical conditions that would place the child at conflict of interest statements with the American Academy of increased risk from sedating medications, appropriate fasting for elective Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of procedures and a balance between the depth of sedation and risk for those Pediatrics has neither solicited nor accepted any commercial who are unable to fast because of the urgent nature of the procedure, involvement in the development of the content of this publication. a focused airway examination for large (kissing) tonsils or anatomic airway Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external abnormalities that might increase the potential for airway obstruction, a clear reviewers. However, clinical reports from the American Academy of understanding of the medication’s pharmacokinetic and pharmacodynamic Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. effects and drug interactions, appropriate training and skills in airway The guidance in this report does not indicate an exclusive course of management to allow rescue of the patient, age- and size-appropriate treatment or serve as a standard of medical/dental care. Variations, equipment for airway management and venous access, appropriate taking into account individual circumstances, may be appropriate. medications and reversal agents, sufficient numbers of appropriately trained All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, staff to both carry out the procedure and monitor the patient, appropriate revised, or retired at or before that time. physiologic monitoring during and after the procedure, a properly equipped DOI: https://doi.org/10.1542/peds.2019-1000 and staffed recovery area, recovery to the presedation level of consciousness PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). before discharge from medical/dental supervision, and appropriate discharge Copyright © 2019 by the American Academy of Pediatric Dentistry and instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics. This report is also being published in American Academy of Pediatrics and the American Academy of Pediatric Pediatr Dent 2019;41(4): in press. The articles are identical. Either citation can be used when citing this report. Dentistry to offer pediatric providers updated information and guidance in FINANCIAL DISCLOSURE: The authors have indicated they do not have delivering safe sedation to children. a financial relationship relevant to this article to disclose.

FUNDING: No external funding.

To cite: Coté CJ, Wilson S. AMERICAN ACADEMY OF INTRODUCTION PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. The number of diagnostic and minor surgical procedures performed on Guidelines for Monitoring and Management of Pediatric pediatric patients outside of the traditional operating room setting has Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019;143(6):e20191000 increased in the past several decades. As a consequence of this change and

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019:e20191000 FROM THE AMERICAN ACADEMY OF PEDIATRICS the increased awareness of the these safety principles have been Pediatric Sedation Research importance of providing analgesia and widely implemented and shown to Consortium has improved the anxiolysis, the need for sedation for reduce morbidity.† These practice sedation knowledge base, procedures in physicians’ offices, recommendations are proffered with demonstrating the marked safety dental offices, subspecialty procedure the awareness that, regardless of the of sedation by highly motivated suites, imaging facilities, emergency intended level of sedation or route of and skilled practitioners from departments, other inpatient hospital drug administration, the sedation of a variety of specialties practicing settings, and ambulatory surgery a pediatric patient represents the above modalities and skills – centers also has increased markedly.1 52 a continuum and may result in that focus on a culture of sedation In recognition of this need for both respiratory depression, laryngospasm, safety.45,83,95,128–138 However, these elective and emergency use of impaired airway patency, apnea, loss of groundbreaking studies also show sedation in nontraditional settings, the patient’sprotectiveairwayreflexes, a low but persistent rate of potential the American Academy of Pediatrics and cardiovascular instability.‡ sedation-induced life-threatening (AAP) and the American Academy of events, such as apnea, airway Pediatric Dentistry (AAPD) have Procedural sedation of pediatric obstruction, laryngospasm, x published a series of guidelines for patients has serious associated risks. pulmonary aspiration, desaturation, the monitoring and management of These adverse responses during and and others, even when the sedation pediatric patients during and after after sedation for a diagnostic or is provided under the direction of – sedation for a procedure.53 58 The therapeutic procedure may be a motivated team of specialists.129 purpose of this updated report is to minimized, but not completely These studies have helped define the unify the guidelines for sedation used eliminated, by a careful preprocedure skills needed to rescue children by medical and dental practitioners; review of the patient’s underlying experiencing adverse sedation to add clarifications regarding medical conditions and consideration events. monitoring modalities, particularly of how the sedation process might regarding continuous expired carbon affect or be affected by these The sedation of children is different dioxide measurement; to provide conditions: for example, children with from the sedation of adults. Sedation updated information from the developmental disabilities have been in children is often administered to medical and dental literature; and to shown to have a threefold increased relieve pain and anxiety as well as to suggest methods for further incidence of desaturation compared modify behavior (eg, immobility) so improvement in safety and outcomes. with children without developmental as to allow the safe completion of 74,78,103 This document uses the same disabilities. Appropriate drug a procedure. A child’s ability to language to define sedation selection for the intended procedure, control his or her own behavior to categories and expected physiologic a clear understanding of the sedating cooperate for a procedure depends responses as The Joint Commission, medication’s pharmacokinetics and both on his or her chronologic age the American Society of pharmacodynamics and drug and cognitive/emotional Anesthesiologists (ASA), and the interactions, as well as the presence development. Many brief procedures, – AAPD.56,57,59 61 of an individual with the skills needed such as suture of a minor laceration, to rescue a patient from an adverse may be accomplished with This revised statement reflects the response are critical.# Appropriate distraction and guided imagery current understanding of appropriate physiologic monitoring and techniques, along with the use of monitoring needs of pediatric patients continuous observation by personnel topical/local anesthetics and both during and after sedation for not directly involved with the minimal sedation, if needed.175–181 a procedure.* The monitoring and care procedure allow for the accurate and However, longer procedures that outlined may be exceeded at any time rapid diagnosis of complications and require immobility involving on the basis of the judgment of the initiation of appropriate rescue children younger than 6 years or responsible practitioner. Although interventions.** The work of the those with developmental delay intended to encourage high-quality oftenrequireanincreaseddepthof † patient care, adherence to the Refs 11, 23, 24, 27, 30–33, 35, 39, 41, 44, 47, 51, sedation to gain control of their – recommendationsinthisdocument and 74 84 behavior.86,87,103 Children younger ‡ – cannot guarantee a specificpatient Refs 38, 43, 45, 47, 48, 59, 62, 63, and 85 112 than 6 years (particularly those x Refs 2, 5, 38, 43, 45, 47, 48, 62, 63, 71, 83, 85, outcome. However, structured sedation younger than 6 months) may be at 88–105, and 107–138 protocols designed to incorporate 129 # Refs 42, 48, 62, 63, 92, 97, 99, 125–127, 132, 133, greatest risk of an adverse event. and 139–158 Childreninthisagegroupare * Refs 3, 4, 11, 18, 20, 21, 23, 24, 33, 39, 41, 44, 47, ** Refs 44, 63, 64, 67, 68, 74, 90, 96, 110, and particularly vulnerable to the 51, and 62–73 159–174 sedating medication’s effects on

Downloaded from www.aappublications.org/news by guest on October 4, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS respiratory drive, airway patency, activation of emergency medical and protective airway reflexes.62,63 services (EMS) may be required in Other modalities, such as careful such settings, but the practitioner preparation, parental presence, is responsible for life-support hypnosis, distraction, topical local measures while awaiting EMS anesthetics, electronic devices with arrival.63,214 Rescue techniques age-appropriate games or videos, require specific training and guided imagery, and the techniques skills.63,74,215,216 The maintenance of advised by child life specialists, the skills needed to rescue a child with may reduce the need for or the apnea, laryngospasm, and/or airway needed depth of pharmacologic obstruction include the ability to – sedation.29,46,49,182 211 open the airway, suction secretions, provide continuous positive airway Studies have shown that it is pressure (CPAP), perform successful common for children to pass from bag-valve-mask ventilation, insert the intended level of sedation to an oral airway, a nasopharyngeal a deeper, unintended level of airway, or a laryngeal mask airway sedation,85,88,212,213 making the (LMA), and, rarely, perform tracheal concept of rescue essential to safe FIGURE 1 intubation. These skills are likely sedation. Practitioners of sedation Suggested management of airway obstruction. best maintained with frequent must have the skills to rescue the simulation and team training patient from a deeper level than that for the management of rare conditions, and patients in hospice intended for the procedure. For – events.128,130,217 220 Competency care are beyond the scope of this example, if the intended level of with emergency airway management document. sedation is “minimal,” practitioners procedure algorithms is fundamental must be able to rescue from for safe sedation practice and “moderate sedation”; if the intended successful patient rescue (see GOALS OF SEDATION level of sedation is “moderate,” – Figs 1, 2, and 3).215,216,221 223 The goals of sedation in the pediatric practitioners must have the skills to patient for diagnostic and rescue from “deep sedation”;ifthe Practitioners should have an in-depth therapeutic procedures are as intended level of sedation is “deep,” knowledge of the agents they intend follows: (1) to guard the patient’s practitioners must have the skills to to use and their potential safety and welfare; (2) to minimize rescue from a state of “general complications. A number of reviews physical discomfort and pain; (3) anesthesia.” The ability to rescue and handbooks for sedating pediatric to control anxiety, minimize means that practitioners must be †† patients are available. There are psychological trauma, and maximize able to recognize the various levels specific situations that are beyond the the potential for amnesia; (4) to of sedation and have the skills and scope of this document. Specifically, age- and size-appropriate equipment guidelines for the delivery of general necessary to provide appropriate anesthesia and monitored anesthesia cardiopulmonary support if needed. care (sedation or analgesia), outside These guidelines are intended for all or within the operating room by venues in which sedation for anesthesiologists or other a procedure might be performed practitioners functioning within (hospital, surgical center, a department of anesthesiology, are freestanding imaging facility, dental addressed by policies developed by facility, or private office). Sedation the ASA and by individual 234 andanesthesiainanonhospital departments of anesthesiology. In environment (eg, private physician’s addition, guidelines for the sedation or dental office, freestanding of patients undergoing mechanical imaging facility) historically have ventilation in a critical care been associated with an increased environment or for providing incidence of “failure to rescue” from analgesia for patients postoperatively, adverse events, because these patients with chronic painful settings may lack immediately FIGURE 2 available backup. Immediate †† Refs 30, 39, 65, 75, 171, 172, 201, 224–233 Suggested management of laryngospasm.

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 3 amnesia are additional goals that GENERAL GUIDELINES should be considered in the selection of agents for particular patients. Candidates However, the potential for an adverse Patients who are in ASA classes I and outcome may be increased when 2 or II are frequently considered more sedating medications are appropriate candidates for minimal, administered.62,127,136,173,235 moderate, or deep sedation Recently, there has been renewed (Supplemental Appendix 2). Children interest in noninvasive routes of in ASA classes III and IV, children medication administration, including with special needs, and those with intranasal and inhaled routes (eg, anatomic airway abnormalities or nitrous oxide; see below).236 moderate to severe tonsillar hypertrophy present issues that Knowledge of each drug’s time of require additional and individual onset, peak response, and duration of consideration, particularly for action is important (eg, the peak moderate and deep sedation.68,244–249 electroencephalogram (EEG) effect of Practitioners are encouraged to intravenous midazolam occurs at consult with appropriate ∼4.8 minutes, compared with that of subspecialists and/or an – diazepam at ∼1.6 minutes237 239). anesthesiologist for patients at Titration of drug to effect is an increased risk of experiencing FIGURE 3 important concept; one must know adverse sedation events because of Suggested management of apnea. whether the previous dose has taken their underlying medical/surgical full effect before administering conditions. 237 modify behavior and/or movement additional drugs. Drugs that have Responsible Person so as to allow the safe completion of a long duration of action (eg, the procedure; and (5) to return the intramuscular pentobarbital, The pediatric patient shall be patient to a state in which discharge phenothiazines) have fallen out of accompanied to and from the from medical/dental supervision is favor because of unpredictable treatment facility by a parent, legal safe, as determined by recognized responses and prolonged recovery. guardian, or other responsible criteria (Supplemental Appendix 1). The use of these drugs requires person. It is preferable to have 2 a longer period of observation even adults accompany children who are These goals can best be achieved by after the child achieves currently still in car safety seats if selecting the lowest dose of drug with used recovery and discharge transportation to and from – the highest therapeutic index for the criteria.62,238 241 This concept is a treatment facility is provided by 1 of procedure. It is beyond the scope of particularly important for infants and the adults.250 this document to specify which drugs toddlers transported in car safety are appropriate for which seats; re-sedation after discharge Facilities procedures; however, the selection of attributable to residual prolonged The practitioner who uses sedation the fewest number of drugs and drug effects may lead to airway must have immediately available matching drug selection to the type obstruction.62,63,242 In particular, facilities, personnel, and equipment and goals of the procedure are promethazine (Phenergan; Wyeth to manage emergency and rescue essential for safe practice. For Pharmaceuticals, Philadelphia, PA) situations. The most common serious example, analgesic medications, such has a “black box warning” regarding complications of sedation involve as opioids or ketamine, are indicated fatal respiratory depression in compromise of the airway or for painful procedures. For children younger than 2 years.243 depressed respirations resulting in nonpainful procedures, such as Although the liquid formulation of airway obstruction, hypoventilation, computed tomography or magnetic chloral hydrate is no longer laryngospasm, hypoxemia, and apnea. resonance imaging (MRI), sedatives/ commercially available, some hospital Hypotension and cardiopulmonary hypnotics are preferred. When both pharmacies now are compounding arrest may occur, usually from the sedation and analgesia are desirable their own formulations. Low-dose inadequate recognition and treatment (eg, fracture reduction), either single chloral hydrate (10–25 mg/kg), in of respiratory compromise.‡‡ Other agents with analgesic/sedative combination with other sedating rare complications also may include properties or combination regimens medications, is used commonly in are commonly used. Anxiolysis and pediatric dental practice. ‡‡ Refs 42, 48, 92, 97, 99, 125, 132, and 139–155

Downloaded from www.aappublications.org/news by guest on October 4, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS seizures, vomiting, and allergic immediately available at all sedation associates shall be provided to all reactions. Facilities providing locations; they can be obtained from patients and their families. pediatric sedation should monitor for, http://www.pedsanesthesia.org/. Instructions shall include and be prepared to treat, such limitations of activities and complications. Documentation appropriate dietary precautions. Back-up Emergency Services Documentation prior to sedation shall include, but not be limited to, the Dietary Precautions A protocol for immediate access to following recommendations: Agents used for sedation have the back-up emergency services shall be potential to impair protective airway clearly outlined. For nonhospital 1. Informed consent: The patient reflexes, particularly during deep facilities, a protocol for the immediate record shall document that sedation. Although a rare occurrence, activation of the EMS system for life- appropriate informed consent pulmonary aspiration may occur if threatening complications must be was obtained according to local, the child regurgitates and cannot established and maintained.44 It state, and institutional 251,252 protect his or her airway.95,127,258 should be understood that the requirements. Therefore, the practitioner should availability of EMS does not replace 2. Instructions and information evaluate preceding food and fluid the practitioner’s responsibility to provided to the responsible intake before administering sedation. provide initial rescue for life- person: The practitioner shall It is likely that the risk of aspiration threatening complications. provide verbal and/or written during procedural sedation differs instructions to the responsible from that during general anesthesia On-site Monitoring, Rescue Drugs, person. Information shall include involving tracheal intubation or other and Equipment objectives of the sedation and airway manipulations.259,260 An emergency cart or kit must be anticipated changes in behavior – However, the absolute risk of immediately accessible. This cart or during and after sedation.163,253 255 aspiration during elective procedural kit must contain the necessary age- Special instructions shall be given sedation is not yet known; the and size-appropriate equipment (oral to the adult responsible for infants reported incidence varies from ∼1in and nasal airways, bag-valve-mask and toddlers who will be 825 to ∼1in30037.95,127,129,173,244,261 device, LMAs or other supraglottic transported home in a car safety Therefore, standard practice for devices, laryngoscope blades, tracheal seat regarding the need to fasting before elective sedation tubes, face masks, blood pressure carefully observe the child’s head generally follows the same cuffs, intravenous catheters, etc) to position to avoid airway guidelines as for elective general resuscitate a nonbreathing and obstruction. Transportation in anesthesia; this requirement is unconscious child. The contents of the a car safety seat poses a particular particularly important for solids, kit must allow for the provision of risk for infants who have received because aspiration of clear gastric continuous life support while the medications known to have a long contents causes less pulmonary patient is being transported to half-life, such as chloral hydrate, injury than aspiration of particulate a medical/dental facility or to another intramuscular pentobarbital, or gastric contents.262,263 area within the facility. All equipment phenothiazine because deaths and drugs must be checked and after procedural sedation have For emergency procedures in 62,63,238,242,256,257 maintained on a scheduled basis (see been reported. children undergoing general Supplemental Appendices 3 and 4 for Consideration for a longer period anesthesia, the reported incidence of suggested drugs and emergency life of observation shall be given if the pulmonary aspiration of gastric support equipment to consider before responsible person’s ability to contents from 1 institution is ∼1in the need for rescue occurs). observe the child is limited (eg, 373 compared with ∼1 in 4544 for Monitoring devices, such as only 1 adult who also has to drive). elective anesthetics.262 Because there electrocardiography (ECG) machines, Another indication for prolonged are few published studies with pulse oximeters with size-appropriate observation would be a child with adequate statistical power to provide probes, end-tidal carbon dioxide an anatomic airway problem, an guidance to the practitioner regarding monitors, and defibrillators with size- underlying medical condition such the safety or risk of pulmonary appropriate patches/paddles, must as significant obstructive sleep aspiration of gastric contents during have a safety and function check on apnea (OSA), or a former preterm procedural sedation,xx it is unknown a regular basis as required by local or infant younger than 60 weeks’ whether the risk of aspiration is state regulation. The use of postconceptional age. A 24-hour emergency checklists is telephone number for the xx Refs 95, 127, 129, 173, 244, 259–261, and recommended, and these should be practitioner or his or her 264–268

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 5 reduced when airway manipulation is TABLE 1 Appropriate Intake of Food and Liquids Before Elective Sedation not performed/anticipated (eg, Ingested Material Minimum moderate sedation). However, if Fasting a deeply sedated child requires Period, h intervention for airway obstruction, Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black 2 apnea, or laryngospasm, there is coffee concern that these rescue maneuvers Human milk 4 Infant formula 6 could increase the risk of pulmonary Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, 6 aspiration of gastric contents. For the amount ingested must be considered when determining an appropriate fasting children requiring urgent/emergent period. sedationwhodonotmeetelective Light meal: a light meal typically consists of toast and clear liquids. Meals that include 6 fasting guidelines, the risks of fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate sedation and possible aspiration are fasting period. as-yet unknown and must be fi Source: American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic balanced against the bene ts of agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. An performing the procedure promptly. updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Available For example, a prudent practitioner at: https://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx. For emergent sedation, the practitioner must balance the depth of sedation versus the risk of possible aspiration; see also Mace et al272 and Green would be unlikely to administer deep et al.273 sedation to a child with a minor condition who just ate a large meal; conversely, it is not justifiable to with a sip of clear liquid or water on reflexes, such as ketamine, or withhold sedation/analgesia from the day of the procedure. moderate sedation, which would also the child in significant pain from maintain protective reflexes, may be adisplacedfracturewhohadasmall For the Emergency Patient preferred.276 Some emergency snack a few hours earlier. Several patients requiring deep sedation The practitioner must always balance emergency department studies have (eg, a trauma patient who just ate the possible risks of sedating reported a low to zero incidence of afullmealorachildwithabowel nonfasted patients with the benefits pulmonary aspiration despite obstruction) may need to be of and necessity for completing the variable fasting periods260,264,268; intubated to protect their airway procedure. In particular, patients with however, each of these reports has, before they can be sedated. a history of recent oral intake or with for the most part, clearly balanced other known risk factors, such as the urgency of the procedure with Use of Immobilization Devices trauma, decreased level of the need for and depth of (Protective Stabilization) consciousness, extreme obesity (BMI sedation.268,269 Although emergency Immobilization devices, such as $95% for age and sex), pregnancy, or medicine studies and practice papoose boards, must be applied in bowel motility dysfunction, require guidelines generally support a less such a way as to avoid airway careful evaluation before the – restrictive approach to fasting for obstruction or chest restriction.277 281 administration of sedatives. When brief urgent/emergent procedures, The child’s head position and proper fasting has not been ensured, such as care of wounds, joint respiratory excursions should be the increased risks of sedation must dislocation, chest tube placement, checked frequently to ensure airway be carefully weighed against its etc, in healthy children, further patency. If an immobilization device is benefits, and the lightest effective research in many thousands of used, a hand or foot should be kept sedation should be used. In this patients would be desirable to better exposed, and the child should never circumstance, additional techniques define the relationships between be left unattended. If sedating for achieving analgesia and patient various fasting intervals and medications are administered in cooperation, such as distraction, sedation complications.262–270 conjunction with an immobilization guided imagery, video games, device, monitoring must be used at topical and local anesthetics, Before Elective Sedation a level consistent with the level of hematoma block or nerve blocks, Children undergoing sedation for sedation achieved. and other techniques advised elective procedures generally should by child life specialists, are follow the same fasting guidelines as Documentation at the Time of particularly helpful and should be Sedation those for general anesthesia – considered.29,49,182 201,274,275 (Table 1).271 It is permissible for 1. Health evaluation: Before sedation, routine necessary medications (eg, The use of agents with less risk of a health evaluation shall be antiseizure medications) to be taken depressing protective airway performed by an appropriately

Downloaded from www.aappublications.org/news by guest on October 4, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS licensed practitioner and reviewed interactions.305–314 Therefore, prematurity (may be associated with by the sedation team at the time of a careful drug history is a vital part of subglottic stenosis or propensity to treatment for possible interval the safe sedation of children. The apnea after sedation); (6) history of changes.282 The purpose of this practitioner should consult various any seizure disorder; (7) summary evaluation is not only to document sources (a pharmacist, textbooks, of previous relevant hospitalizations; baseline status but also to determine online services, or handheld (8) history of sedation or general whether the patient has specificrisk databases) for specific information on anesthesia and any complications or – factors that may warrant additional drug interactions.315 319 The US Food unexpected responses; and (9) consultation before sedation. This and Drug Administration issued relevant family history, particularly evaluation also facilitates the a warning in February 2013 related to anesthesia (eg, muscular identification of patients who will regarding the use of codeine for dystrophy, malignant hyperthermia, require more advanced airway or postoperative pain management in pseudocholinesterase deficiency). children undergoing tonsillectomy, cardiovascular management skills or The review of systems should focus particularly those with OSA. The alterationsinthedosesortypesof on abnormalities of cardiac, safety issue is that some children medications used for procedural pulmonary, renal, or hepatic function have duplicated cytochromes that sedation. that might alter the child’s expected allow greater than expected responses to sedating/analgesic An important concern for the conversion of the prodrug codeine to medications. A specific query practitioner is the widespread use of morphine, thus resulting in potential regarding signs and symptoms of medications that may interfere with overdose; codeine should be avoided – sleep-disordered breathing and OSA drug absorption or metabolism and for postprocedure analgesia.320 324 may be helpful. Children with severe therefore enhance or shorten the The health evaluation should include OSA who have experienced repeated effect time of sedating medications. the following: episodes of desaturation will likely Herbal medicines (eg, St John’s wort, have altered mu receptors and be ginkgo, ginger, ginseng, garlic) may • age and weight (in kg) and analgesic at opioid levels one-third to alter drug pharmacokinetics through gestational age at birth (preterm one-half those of a child without inhibition of the cytochrome P450 infants may have associated – OSA325 328,339,340; lower titrated system, resulting in prolonged drug sequelae such as apnea of doses of opioids should be used in effect and altered (increased or prematurity); and this population. Such a detailed decreased) blood drug concentrations • health history, including (1) food history will help to determine which (midazolam, cyclosporine, and medication allergies and – patients may benefit from a higher tacrolimus).283 292 Kava may increase previous allergic or adverse drug level of care by an appropriately the effects of sedatives by reactions; (2) medication/drug skilled health care provider, such as potentiating g-aminobutyric acid history, including dosage, time, an anesthesiologist. The health inhibitory neurotransmission and route, and site of administration for evaluation should also include: may increase acetaminophen-induced prescription, over-the-counter, 293–295 • liver toxicity. Valerian may herbal, or illicit drugs; (3) relevant vital signs, including heart rate, itself produce sedation that diseases, physical abnormalities blood pressure, respiratory rate, apparently is mediated through the (including genetic syndromes), room air oxygen saturation, and modulation of g-aminobutyric acid neurologic impairments that might temperature (for some children neurotransmission and receptor increase the potential for airway who are very upset or – function.291,296 299 Drugs such as obstruction, obesity, a history of noncooperative, this may not be erythromycin, cimetidine, and others snoring or OSA,325–328 or cervical possible and a note should be may also inhibit the cytochrome P450 spine instability in Down written to document this system, resulting in prolonged syndrome, Marfan syndrome, circumstance); sedation with midazolam as well as skeletal dysplasia, and other • physical examination, including other medications competing for the conditions; (4) pregnancy status a focused evaluation of the airway – same enzyme systems.300 304 (as many as 1% of menarchal (tonsillar hypertrophy, abnormal Medications used to treat HIV females presenting for general anatomy [eg, mandibular infection, some anticonvulsants, anesthesia at children’s hospitals hypoplasia], high Mallampati score immunosuppressive drugs, and some are pregnant)329–331 because [ie, ability to visualize only the hard psychotropic medications (often used of concerns for the potential palate or tip of the uvula]) to to treat children with autism adverse effects of most sedating determine whether there is an spectrum disorder) may also produce and anesthetic drugs on the increased risk of airway clinically important drug-drug fetus329,332–338; (5) history of obstruction74,341–344;

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 7 • physical status evaluation (ASA concentrations of oxygen and re-sedation62,104,256,349,350 and classification [see Appendix 2]); inhalation sedation agents and the because some patients will have and duration of their administration shall complex multiorgan medical • name, address, and telephone be documented. Before drug conditions, a longer period of number of the child’s home or administration, special attention observation in a less intense parent’s, or caregiver’s cell phone; must be paid to the calculation of observation area (eg, a step-down additional information such as the dosage (ie, mg/kg); for obese observation area) before discharge patient’s personal care provider or patients, most drug doses should from medical/dental supervision 239 medical home is also encouraged. likely be adjusted lower to ideal may be indicated. Several scales body weight rather than actual to evaluate recovery have been For hospitalized patients, the current weight.345 When a programmable devised and validated.212,346–348,351,352 fi hospital record may suf ce for pump is used for the infusion of A simple evaluation tool may be adequate documentation of sedating medications, the dose/ the ability of the infant or child to presedation health; however, a note kilogram per minute or hour and the remain awake for at least 20 minutes shall be written documenting that the child’sweightinkilogramsshouldbe when placed in a quiet fi chart was reviewed, positive ndings double-checked and confirmed by environment.238 were noted, and a management plan a separate individual. The patient’s was formulated. If the clinical or chart shall contain documentation at emergency condition of the patient the time of treatment that the CONTINUOUS QUALITY IMPROVEMENT precludes acquiring complete patient’s level of consciousness and The essence of medical error information before sedation, this responsiveness, heart rate, blood reduction is a careful examination of health evaluation should be obtained pressure, respiratory rate, expired index events and root-cause analysis as soon as feasible. carbon dioxide values, and oxygen of how the event could be avoided in 2. Prescriptions. When prescriptions saturation were monitored. Standard the future.353–359 Therefore, each are used for sedation, a copy of the vital signs should be further facility should maintain records that prescription or a note describing the documented at appropriate intervals track all adverse events and content of the prescription should be during recovery until the patient significant interventions, such as in the patient’schartalongwith attains predetermined discharge desaturation; apnea; laryngospasm; a description of the instructions that criteria (Appendix 1). A variety of need for airway interventions, were given to the responsible sedation scoring systems are including the need for placement of person. Prescription medications available that may aid this supraglottic devices such as an oral – intended to accomplish process.212,238,346 348 Adverse airway, nasal trumpet, or LMA; procedural sedation must not be events and their treatment shall be positive-pressure ventilation; administered without the safety documented. prolonged sedation; unanticipated net of direct supervision by use of reversal agents; unplanned or Documentation After Treatment trained medical/dental personnel. prolonged hospital admission; The administration of sedating A dedicated and properly equipped sedation failures; inability to medications at home poses an recovery area is recommended (see complete the procedure; and unacceptable risk, particularly for Appendices 3 and 4). The time and unsatisfactory sedation, analgesia, or infants and preschool-aged children condition of the child at discharge anxiolysis.360 Such events can then be traveling in car safety seats because from the treatment area or facility examined for the assessment of risk deaths as a result of this practice shall be documented, which should reduction and improvement in have been reported.63,257 include documentation that the patient/family satisfaction. child’s level of consciousness and Documentation During Treatment oxygen saturation in room air have The patient’schartshallcontain returned to a state that is safe for PREPARATION FOR SEDATION a time-based record that includes the discharge by recognized criteria (see PROCEDURES name, route, site, time, dosage/ Appendix 1). Patients receiving Part of the safety net of sedation is kilogram, and patient effect of supplemental oxygen before the using a systematic approach so as to administered drugs. Before sedation, procedure should have a similar not overlook having an important a “time out” should be performed to oxygen need after the procedure. drug, piece of equipment, or monitor confirm the patient’s name, Because some sedation medications immediately available at the time of proceduretobeperformed,and are known to have a long half-life a developing emergency. To avoid this laterality and site of the procedure.59 and may delay a patient’scomplete problem, it is helpful to use an During administration, the inspired return to baseline or pose the risk of acronym that allows the same setup

Downloaded from www.aappublications.org/news by guest on October 4, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS and checklist for every procedure. A should this occur, then the guidelines advanced life support [PALS]); commonly used acronym useful in for moderate sedation apply.85,363 regular skills reinforcement planning and preparation for with simulation is strongly – a procedure is SOAPME, which Moderate Sedation encouraged.79,80,128,130,217 220,364 represents the following: Moderate sedation (old terminology, Support Personnel S = Size-appropriate suction catheters “conscious sedation” or “sedation/ and a functioning suction analgesia”) is a drug-induced The use of moderate sedation shall apparatus (eg, Yankauer-type depression of consciousness during include the provision of a person, in suction) which patients respond purposefully addition to the practitioner, whose O = an adequate Oxygen supply and to verbal commands or after light responsibility is to monitor functioning flow meters or other tactile stimulation. No interventions appropriate physiologic parameters devices to allow its delivery are required to maintain a patent and to assist in any supportive or airway, and spontaneous ventilation resuscitation measures, if required. A = size-appropriate Airway is adequate. Cardiovascular function This individual may also be equipment (eg, bag-valve-mask or is usually maintained. The caveat that responsible for assisting with equivalent device [functioning]), loss of consciousness should be interruptible patient-related tasks of nasopharyngeal and oropharyngeal unlikely is a particularly important short duration, such as holding an airways, LMA, laryngoscope blades aspect of the definition of moderate instrument or troubleshooting (checked and functioning), 60 sedation; drugs and techniques used equipment. This individual should endotracheal tubes, stylets, should carry a margin of safety wide be trained in and capable of providing face mask enough to render unintended loss of advanced airway skills (eg, PALS). P = Pharmacy: all the basic drugs consciousness unlikely. Because the The support person shall have needed to support life during an patient who receives moderate specific assignments in the event of emergency, including antagonists sedation may progress into a state of an emergency and current knowledge as indicated deep sedation and obtundation, the of the emergency cart inventory. The M = Monitors: functioning pulse practitioner should be prepared to practitioner and all ancillary oximeter with size-appropriate increase the level of vigilance personnel should participate in oximeter probes,361,362 end-tidal corresponding to what is necessary periodic reviews, simulation of rare carbon dioxide monitor, and other for deep sedation.85 emergencies, and practice drills of the monitors as appropriate for the facility’s emergency protocol to procedure (eg, noninvasive blood Personnel ensure proper function of the pressure, ECG, stethoscope) equipment and coordination of staff The Practitioner 133,365–367 E = special Equipment or drugs for roles in such emergencies. The practitioner responsible for the a particular case (eg, defibrillator) It is recommended that at least 1 treatment of the patient and/or the practitioner be skilled in obtaining administration of drugs for sedation vascular access in children. SPECIFIC GUIDELINES FOR INTENDED must be competent to use such LEVEL OF SEDATION techniques, to provide the level of Monitoring and Documentation monitoring described in these Baseline Minimal Sedation guidelines, and to manage Minimal sedation (old terminology, complications of these techniques (ie, Before the administration of sedative “anxiolysis”) is a drug-induced state to be able to rescue the patient). medications, a baseline determination during which patients respond Because the level of intended of vital signs shall be documented. normally to verbal commands. sedation may be exceeded, the For some children who are very upset Although cognitive function and practitioner must be sufficiently or uncooperative, this may not be coordination may be impaired, skilled to rescue a child with apnea, possible, and a note should be written ventilatory and cardiovascular laryngospasm, and/or airway to document this circumstance. functions are unaffected. Children obstruction, including the ability to who have received minimal sedation open the airway, suction secretions, During the Procedure generally will not require more than provide CPAP, and perform successful The physician/dentist or his or her observation and intermittent bag-valve-mask ventilation should the designee shall document the name, assessment of their level of sedation. child progress to a level of deep route, site, time of administration, Some children will become sedation. Training in, and and dosage of all drugs administered. moderately sedated despite the maintenance of, advanced pediatric If sedation is being directed by intended level of minimal sedation; airway skills is required (eg, pediatric a physician who is not personally

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 9 administering the medications, then Immobilization devices (protective depression of consciousness during recommended practice is for the stabilization) should be checked to which patients cannot be easily qualified health care provider prevent airway obstruction or chest aroused but respond purposefully administering the medication to restriction. If a restraint device is after repeated verbal or painful confirm the dose verbally before used, a hand or foot should be kept stimulation (eg, purposefully administration. There shall be exposed. The child’s head position pushing away the noxious stimuli). continuous monitoring of oxygen should be continuously assessed to Reflex withdrawal from a painful saturation and heart rate; when ensure airway patency. stimulus is not considered bidirectional verbal communication a purposeful response and is more between the provider and patient is After the Procedure consistent with a state of general appropriate and possible (ie, patient The child who has received moderate anesthesia. The ability to is developmentally able and sedation must be observed in independently maintain ventilatory purposefully communicates), a suitably equipped recovery area, function may be impaired. Patients monitoring of ventilation by (1) which must have a functioning may require assistance in capnography (preferred) or (2) suction apparatus as well as the maintaining a patent airway, and amplified, audible pretracheal capacity to deliver .90% oxygen and spontaneous ventilation may be stethoscope (eg, Bluetooth positive-pressure ventilation (bag- inadequate. Cardiovascular function technology)368–371 or precordial valve mask) with an adequate oxygen is usually maintained. A state of deep stethoscope is strongly capacity as well as age- and size- sedation may be accompanied by recommended. If bidirectional verbal appropriate rescue equipment and partial or complete loss of protective communication is not appropriate or devices. The patient’s vital signs airway reflexes. Patients may pass not possible, monitoring of should be recorded at specific from a state of deep sedation to the ventilation by capnography intervals (eg, every 10–15 minutes). state of general anesthesia. In some (preferred), amplified, audible If the patient is not fully alert, oxygen situations, such as during MRI, one is pretracheal stethoscope, or precordial saturation and heart rate monitoring not usually able to assess responses stethoscope is required. Heart rate, shall be used continuously until to stimulation, because this would respiratory rate, blood pressure, appropriate discharge criteria are met defeat the purpose of sedation, and oxygen saturation, and expired (see Appendix 1). Because sedation one should assume that such carbon dioxide values should be medications with a long half-life may patients are deeply sedated. recorded, at minimum, every delay the patient’s complete return to “General anesthesia” is a drug- 10 minutes in a time-based record. baseline or pose the risk of re- induced loss of consciousness during Note that the exact value of expired sedation, some patients might benefit which patients are not arousable, carbon dioxide is less important than from a longer period of less intense even by painful stimulation. The simple assessment of continuous observation (eg, a step-down ability to independently maintain respiratory gas exchange. In some observation area where multiple ventilatory function is often situations in which there is excessive patients can be observed impaired. Patients often require patient agitation or lack of simultaneously) before discharge assistance in maintaining a patent cooperation or during certain from medical/dental supervision (see airway, and positive-pressure procedures such as bronchoscopy, section entitled “Documentation ventilation may be required because dentistry, or repair of facial Before Sedation” above).62,256,349,350 of depressed spontaneous lacerations capnography may not be A simple evaluation tool may be the ventilation or drug-induced feasible, and this situation should be ability of the infant or child to remain depression of neuromuscular documented. For uncooperative awake for at least 20 minutes when function. Cardiovascular function children, it is often helpful to defer placed in a quiet environment.238 may be impaired. the initiation of capnography until the Patients who have received reversal child becomes sedated. Similarly, the agents, such as flumazenil or stimulation of blood pressure cuff naloxone, will require a longer period Personnel inflation may cause arousal or of observation, because the duration During deep sedation and/or general agitation; in such cases, blood of the drugs administered may exceed anesthesia of a pediatric patient in pressure monitoring may be the duration of the antagonist, a dental facility, there must be at counterproductive and may be resulting in re-sedation. least 2 individuals present with the documented at less frequent intervals patient throughout the procedure. (eg, 10–15 minutes, assuming the Deep Sedation/General Anesthesia These 2 individuals must have patient remains stable, well “Deep sedation” (“deep sedation/ appropriate training and up-to-date oxygenated, and well perfused). analgesia”) is a drug-induced certification in patient rescue, as

Downloaded from www.aappublications.org/news by guest on October 4, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS delineated below, including drug least 2 individuals must be present shall include all parameters described administration and PALS or Advanced with the patient throughout the for moderate sedation. Vital signs, Pediatric Life Support (APLS). One of procedure with skills in patient including heart rate, respiratory rate, these 2 must be an independent rescue and up-to-date PALS (or APLS) blood pressure, oxygen saturation, observer who is independent of certification, as delineated above. One and expired carbon dioxide, must be performing or assisting with the of these individuals may either documented at least every 5 minutes dental procedure. This individual’s administer drugs or direct their in a time-based record. Capnography sole responsibility is to administer administration by the skilled should be used for almost all deeply drugs and constantly observe the independent observer. The skills of sedated children because of the patient’s vital signs, depth of the individual directing or increased risk of airway/ventilation sedation, airway patency, and administering sedation and/or compromise. Capnography may not adequacy of ventilation. The anesthesia medications must include be feasible if the patient is agitated or independent observer must, at those described in the previous uncooperative during the initial a minimum, be trained in PALS (or paragraph. Providers who may fulfill phases of sedation or during certain APLS) and capable of managing any the role of the skilled independent procedures, such as bronchoscopy or airway, ventilatory, or cardiovascular observer in a hospital or surgicenter, repair of facial lacerations, and this emergency event resulting from the as permitted by state regulation, must circumstance should be documented. deep sedation and/or general be a physician with sedation training For uncooperative children, the anesthesia. The independent observer and advanced airway skills, such as, capnography monitor may be placed must be trained and skilled to but not limited to, a physician once the child becomes sedated. Note establish intravenous access and anesthesiologist, an oral surgeon, that if supplemental oxygen is draw up and administer rescue a dentist anesthesiologist, or other administered, the capnograph may medications. The independent medical specialists with the requisite underestimate the true expired observer must have the training and licensure, training, and competencies; carbon dioxide value; of more skills to rescue a nonbreathing child; a certified registered nurse importance than the numeric reading a child with airway obstruction; or anesthetist or certified anesthesiology of exhaled carbon dioxide is the a child with hypotension, anaphylaxis, assistant; or a nurse with advanced assurance of continuous respiratory or cardiorespiratory arrest, including emergency management skills, such gas exchange (ie, continuous the ability to open the airway, suction as several years of experience in the waveform). Capnography is secretions, provide CPAP, insert emergency department, pediatric particularly useful for patients who supraglottic devices (oral airway, recovery room, or intensive care are difficult to observe (eg, during nasal trumpet, or laryngeal mask setting (ie, nurses who are MRI or in a darkened room).## airway), and perform successful bag- experienced with assisting the The physician/dentist or his or her valve-mask ventilation, tracheal individual administering or directing designee shall document the name, intubation, and cardiopulmonary sedation with patient rescue during route, site, time of administration, resuscitation. The independent life-threatening emergencies). and dosage of all drugs administered. observer in the dental facility, as Equipment If sedation is being directed by permitted by state regulation, must a physician who is not personally be 1 of the following: a physician In addition to the equipment needed administering the medications, then anesthesiologist, a certified registered for moderate sedation, an ECG recommended practice is for the nurse anesthetist, a second oral monitor and a defibrillator for use in nurse administering the medication surgeon, or a dentist anesthesiologist. pediatric patients should be readily to confirm the dose verbally before The second individual, who is the available. administration. The inspired practitioner in the dental facility Vascular Access concentrations of inhalation sedation performing the procedure, must be agents and oxygen and the duration trained in PALS (or APLS) and Patients receiving deep sedation of administration shall be capable of providing skilled should have an intravenous line documented. assistance to the independent placed at the start of the procedure or observer with the rescue of a child have a person skilled in establishing experiencing any of the adverse vascular access in pediatric patients Postsedation Care events described above. immediately available. The facility and procedures followed for postsedation care shall conform During deep sedation and/or general Monitoring anesthesia of a pediatric patient in A competent individual shall observe ## Refs 64, 67, 72, 90, 96, 110, 159–162, 164–170, a hospital or surgicenter setting, at the patient continuously. Monitoring and 372–375

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 11 TABLE 2 Comparison of Moderate and Deep Sedation Equipment and Personnel Requirements function may alter the ability to Moderate Sedation Deep Sedation metabolize and excrete sedating 376 Personnel An observer who will monitor An independent observer whose medications, resulting in the patient but who may also only responsibility is to prolonged sedation and the need for assist with interruptible tasks; continuously monitor the extended postsedation monitoring. should be trained in PALS patient; trained in PALS Former preterm infants have an Responsible practitioner Skilled to rescue a child with Skilled to rescue a child with increased risk of postanesthesia apnea, laryngospasm, and/or apnea, laryngospasm, and/or 377 airway obstruction including airway obstruction, including apnea, but it is unclear whether the ability to open the airway, the ability to open the airway, a similar risk is associated with suction secretions, provide suction secretions, provide CPAP, sedation, because this possibility has CPAP, and perform successful perform successful bag-valve- not been systematically bag-valve-mask ventilation; mask ventilation, tracheal investigated.378 recommended that at least 1 intubation, and cardiopulmonary practitioner should be skilled resuscitation; training in PALS is Other concerns regarding the effects in obtaining vascular access required; at least 1 practitioner of anesthetic drugs and sedating in children; trained in PALS skilled in obtaining vascular access in children immediately medications on the developing brain available are beyond the scope of this Monitoring Pulse oximetry Pulse oximetry document. At this point, the research ECG recommended ECG required in this area is preliminary and Heart rate Heart rate inconclusive at best, but it would Blood pressure Blood pressure Respiration Respiration seem prudent to avoid unnecessary Capnography recommended Capnography required exposure to sedation if the procedure Other equipment Suction equipment, adequate Suction equipment, adequate is unlikely to change medical/dental oxygen source/supply oxygen source/supply, management (eg, a sedated MRI defibrillator required purely for screening purposes in Documentation Name, route, site, time of Name, route, site, time of 379–382 administration, and dosage of administration, and dosage of preterm infants). all drugs administered all drugs administered; Continuous oxygen saturation, continuous oxygen saturation, Local Anesthetic Agents heart rate, and ventilation heart rate, and ventilation (capnography recommended); (capnography required); All local anesthetic agents are cardiac parameters recorded every parameters recorded at least depressants and may cause central 10 minutes every 5 minutes nervous system excitation or Emergency checklists Recommended Recommended depression. Particular weight- Rescue cart properly stocked Required Required with rescue drugs and age- based attention should be paid and size-appropriate to cumulative dosage in all – equipment (see Appendices children.118,120,125,383 386 To ensure 3 and 4) that the patient will not receive an Dedicated recovery area with Recommended; initial recording Recommended; initial recording of excessive dose, the maximum rescue cart properly of vital signs may be needed vital signs may be needed for at stocked with rescue drugs at least every 10 minutes until least 5-minute intervals until the allowable safe dosage (eg, mg/kg) and age- and size- the child begins to awaken, child begins to awaken, then should be calculated before appropriate equipment (see then recording intervals may recording intervals may be administration. There may be Appendices 3 and 4) and be increased increased to 10–15 minutes enhanced sedative effects when dedicated recovery the highest recommended doses personnel; adequate oxygen supply of local anesthetic drugs are used in Discharge criteria See Appendix 1 See Appendix 1 combination with other sedatives or opioids (see Tables 3 and 4 for limits and conversion tables of commonly to those described under “moderate requirements for moderate and used local anesthetics).118,125,387–400 sedation.” The initial recording of deep sedation. In general, when administering local vital signs should be documented at anesthetic drugs, the practitioner least every 5 minutes. Once the Special Considerations should aspirate frequently to child begins to awaken, the minimize the likelihood that the recording intervals may be Neonates and Former Preterm Infants needle is in a blood vessel; lower increasedto10to15minutes. Neonates and former preterm infants doses should be used when injecting Table2summarizestheequipment, require specific management, because into vascular tissues.401 If high doses personnel, and monitoring immaturity of hepatic and renal or injection of amide local anesthetics

Downloaded from www.aappublications.org/news by guest on October 4, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Commonly Used Local Anesthetic Agents for Nerve Block or Infiltration: Doses, Duration, and Calculations Local Anesthetic Maximum Dose With Maximum Dose Without Duration of Action,b min Epinephrine,a mg/kg Epinephrine, mg/kg Medical Dental Medical Dental Esters Procaine 10.0 6 7 6 60–90 Chloroprocaine 20.0 12 15 12 30–60 Tetracaine 1.5 1 1 1 180–600 Amides Lidocaine 7.0 4.4 4 4.4 90–200 Mepivacaine 7.0 4.4 5 4.4 120–240 Bupivacaine 3.0 1.3 2.5 1.3 180–600 Levobupivacainec 3.0 2 2 2 180–600 Ropivacaine 3.0 2 2 2 180–600 Articained — 7 — 760–230 Maximum recommended doses and durations of action are shown. Note that lower doses should be used in very vascular areas. a These are maximum doses of local anesthetics combined with epinephrine; lower doses are recommended when used without epinephrine. Doses of amides should be decreased by 30% in infants younger than 6 mo. When lidocaine is being administered intravascularly (eg, during intravenous regional anesthesia), the dose should be decreased to 3 to 5 mg/kg; long- acting local anesthetic agents should not be used for intravenous regional anesthesia. b Duration of action is dependent on concentration, total dose, and site of administration; use of epinephrine; and the patient’s age. c Levobupivacaine is not available in the United States. d Use in pediatric patients under 4 years of age is not recommended.

(bupivacaine and ropivacaine) into oximeters that do not contain department found that the use of vascular tissues is anticipated, then updated software.416–420 Oximeters capnography reduced the incidence of the immediate availability of a 20% that change tone with changes in hypoventilation and desaturation lipid emulsion for the treatment hemoglobin saturation provide (7% to 1%).174 The use of expired of local anesthetic toxicity is immediate aural warning to everyone carbon dioxide monitoring devices is recommended (Tables 3 and 5).402–409 within hearing distance. The oximeter now required for almost all deeply Topical local anesthetics are probe must be properly positioned; sedated children (with rare commonly used and encouraged, but clip-on devices are easy to displace, exceptions), particularly in situations the practitioner should avoid which may produce artifactual data in which other means of assessing the applying excessive doses to mucosal (under- or overestimation of oxygen adequacy of ventilation are limited. surfaces where systemic uptake and saturation).361,362 Several manufacturers have produced possible toxicity (seizures, nasal cannulae that allow methemoglobinemia) could result Capnography simultaneous delivery of oxygen and and to remain within the Expired carbon dioxide monitoring is measurement of expired carbon 421,422,427 manufacturer’s recommendations valuable to diagnose the simple dioxide values. Although regarding allowable surface area presence or absence of respirations, these devices can have a high degree 410–415 application. airway obstruction, or respiratory of false-positive alarms, they are also very accurate for the detection of Pulse Oximetry depression, particularly in patients sedated in less-accessible locations, complete airway obstruction or 164,168,169 Newer pulse oximeters are less such as in MRI machines or darkened apnea. Taping the sampling susceptible to motion artifacts and rooms.*** In patients receiving line under the nares under an oxygen may be more useful than older supplemental oxygen, capnography face mask or nasal hood will provide facilitates the recognition of apnea or similar information. The exact measured value is less important than TABLE 4 Local Anesthetic Conversion Chart airway obstruction several minutes before the situation would be the simple answer to the question: Is Concentration, mg/ the child exchanging air with each % mL detected just by pulse oximetry. In this situation, desaturation would be breath? 4.0 40 delayed due to increased oxygen 3.0 30 Processed EEG (Bispectral Index) 2.5 25 reserves; capnography would enable 161 2.0 20 earlier intervention. One study in Although not new to the anesthesia 1.0 10 children sedated in the emergency community, the processed EEG 0.5 5 (bispectral index [BIS]) monitor is 0.25 2.5 *** Refs 64, 66, 67, 72, 90, 96, 110, 159–162, slowly finding its way into the 0.125 1.25 164–170, 372–375, and 421–427 sedation literature.428 Several studies

Downloaded from www.aappublications.org/news by guest on October 4, 2021 PEDIATRICS Volume 143, number 6, June 2019 13 TABLE 5 Treatment of Local Anesthetic Toxicity experience with these techniques as 1. Get help. Ventilate with 100% oxygen. Alert nearest facility with cardiopulmonary bypass capability. they become incorporated into PALS 2. Resuscitation: airway/ventilatory support, chest compressions, etc. Avoid vasopressin, calcium courses. channel blockers, b-blockers, or additional local anesthetic. Reduce epinephrine dosages. Prolonged effort may be required. Another valuable emergency 3. Seizure management: benzodiazepines preferred (eg, intravenous midazolam 0.1–0.2 mg/kg); avoid technique is intraosseous needle propofol if cardiovascular instability. placement for vascular access. ∼ 4. Administer 1.5 mL/kg 20% lipid emulsion over 1 minute to trap unbound amide local anesthetics. Intraosseous needles are available in Repeat bolus once or twice for persistent cardiovascular collapse. 5. Initiate 20% lipid infusion (0.25 mL/kg per minute) until circulation is restored; double the infusion several sizes; insertion can be life- rate if blood pressure remains low. Continue infusion for at least 10 minutes after attaining saving when rapid intravenous access circulatory stability. Recommended upper limit of ∼10 mL/kg. is difficult. A relatively new 6. A fluid bolus of 10–20 mL/kg balanced salt solution and an infusion of phenylephrine (0.1 mg/kg per intraosseous device (EZ-IO Vidacare, minute to start) may be needed to correct peripheral vasodilation. now part of Teleflex, Research Source: https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity. Triangle Park, NC) is similar to a hand-held battery-powered drill. It allows rapid placement with have attempted to use BIS it is still considered a research tool minimal chance of misplacement; it monitoring as a means of andnotrecommendedfor also has a low-profile intravenous noninvasively assessing the depth routine use. – adapter.445 450 Familiarity with the of sedation. This technology was use of these emergency techniques designed to examine EEG signals Adjuncts to Airway Management and can be gained by keeping current and, through a variety of algorithms, Resuscitation with resuscitation courses, such as correlate a number with depth of The vast majority of sedation PALS and advanced pediatric life unconsciousness: that is, the lower complications can be managed with support. the number, the deeper the sedation. simple maneuvers, such as Unfortunately, these algorithms are supplemental oxygen, opening Patient Simulators based on adult patients and have not the airway, suctioning, placement of High-fidelity patient simulators are been validated in children of varying an oral or nasopharyngeal airway, ages and varying brain development. now available that allow physicians, and bag-mask-valve ventilation. dentists, and other health care Although the readings correspond Rarely, tracheal intubation is quite well with the depth of propofol providers to practice managing required for more prolonged a variety of programmed adverse sedation, the numbers may ventilatory support. In addition to paradoxically go up rather than events, such as apnea, bronchospasm, standard tracheal intubation 133,220,450–452 fl and laryngospasm. down with sevo urane and ketamine techniques, a number of supraglottic because of central excitation despite The use of such devices is encouraged devices are available for the to better train medical professionals a state of general anesthesia or deep management of patients with sedation.429,430 Opioids and and teams to respond more effectively abnormal airway anatomy or airway 128,131,451,453–455 benzodiazepines have minimal and to rare events. obstruction. Examples include the One study that simulated the quality variable effects on the BIS. LMA, the cuffed oropharyngeal Dexmedetomidine has minimal effect of cardiopulmonary resuscitation airway, and a variety of kits to compared standard management of with EEG patterns, consistent with perform an emergency 431 ventricular fibrillation versus rescue stage 2 sleep. Several sedation cricothyrotomy.436,437 studies have examined the utility of with the EZ-IO for the rapid this device and degree of The largest clinical experience in establishment of intravenous access correlation with standard sedation pediatrics is with the LMA, which is and placement of an LMA for – scales.347,363,432 435 It appears that available in multiple sizes, including establishing a patent airway in there is some correlation with BIS those for late preterm and term adults; the use of these devices values in moderate sedation, but neonates. The use of the LMA is now resulted in more rapid establishment there is not a reliable ability to an essential addition to advanced of vascular access and securing of 456 distinguish between deep sedation airway training courses, and the airway. and moderate sedation or deep familiarity with insertion techniques sedation from general anesthesia.432 can be life-saving.438–442 The LMA Monitoring During MRI Presently, it would appear that BIS can also serve as a bridge to secure The powerful magnetic field and the monitoring might provide useful airway management in children with generation of radiofrequency information only when used for anatomic airway abnormalities.443,444 emissions necessitate the use of sedation with propofol363;ingeneral, Practitioners are encouraged to gain special equipment to provide

Downloaded from www.aappublications.org/news by guest on October 4, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS continuous patient monitoring nose must be used in conjunction for moderate or deep sedation throughout the MRI scanning with a calibrated and functional increases.107,197,492,494,495 In this procedure.457–459 MRI-compatible oxygen analyzer. All nitrous oxide-to- situation, the practitioner is advised pulse oximeters and capnographs oxygen inhalation devices should be to institute the guidelines for capable of continuous function calibrated in accordance with moderate or deep sedation, as during scanning should be used in appropriate state and local indicated by the patient’s any sedated or restrained pediatric requirements. Consideration should response.496 patient. Thermal injuries can result if be given to the National Institute of appropriate precautions are not Occupational Safety and Health taken; the practitioner is cautioned Standards for the scavenging of waste LEAD AUTHORS 464 to avoid coiling of all wires gases. Newly constructed or Charles J. Coté, MD, FAAP (oximeter, ECG) and to place the reconstructed treatment facilities, Stephen Wilson, DMD, MA, PhD oximeter probe as far from the especially those with piped-in nitrous magnetic coil as possible to diminish oxide and oxygen, must have AMERICAN ACADEMY OF PEDIATRICS the possibility of injury. ECG appropriate state or local inspections monitoring during MRI has been to certify proper function of associated with thermal injury; inhalation sedation/analgesia AMERICAN ACADEMY OF PEDIATRIC special MRI-compatible ECG pads are systems before any delivery of DENTISTRY essential to allow safe patient care. – monitoring.460 463 If sedation is STAFF achieved by using an infusion pump, Nitrous oxide in oxygen, with then either an MRI-compatible pump varying concentrations, has been Jennifer Riefe, MEd Raymond J. Koteras, MHA is required or the pump must be successfully used for many years situated outside of the room with to provide analgesia for long infusion tubing so as to a variety of painful procedures in 14,36,49,98,465–493 maintain infusion accuracy. All children. The use of ABBREVIATIONS equipment must be MRI compatible, nitrous oxide for minimal sedation is including laryngoscope blades and defined as the administration of AAP: American Academy of handles, oxygen tanks, and any nitrous oxide of #50% with the Pediatrics ancillary equipment. All individuals, balance as oxygen, without any other AAPD: American Academy of including parents, must be screened sedative, opioid, or other depressant Pediatric Dentistry for ferromagnetic materials, phones, drug before or concurrent with the ASA: American Society of pagers, pens, credit cards, watches, nitrous oxide to an otherwise healthy Anesthesiologists surgical implants, pacemakers, etc, patient in ASA class I or II. The BIS: bispectral index before entry into the MRI suite. patient is able to maintain verbal CPAP: continuous positive airway communication throughout the pressure Nitrous Oxide procedure. It should be noted that ECG: electrocardiography Inhalation sedation/analgesia although local anesthetics have EEG: electroencephalogram/ equipment that delivers nitrous oxide sedative properties, for purposes of electroencephalography must have the capacity of delivering this guideline they are not considered EMS: emergency medical services 100% and never less than 25% sedatives in this circumstance. If LMA: laryngeal mask airway oxygen concentration at a flow rate nitrous oxide in oxygen is combined MRI: magnetic resonance imaging appropriate to the size of the patient. with other sedating medications, such OSA: obstructive sleep apnea Equipment that delivers variable as chloral hydrate, midazolam, or an PALS: pediatric advanced life ratios of nitrous oxide .50% to opioid, or if nitrous oxide is used in support oxygen that covers the mouth and concentrations .50%, the likelihood

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Milnes AR. Intravenous procedural general anesthesia in the J Can Dent Assoc. 2003;69:298– sedation: an alternative to treatment of early childhood caries. 302

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/05/24/peds.2 019-1000 References This article cites 473 articles, 50 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/05/24/peds.2 019-1000#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Anesthesiology/Pain Medicine http://www.aappublications.org/cgi/collection/anesthesiology:pain_ medicine_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 4, 2021 Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures Charles J. Coté, Stephen Wilson, AMERICAN ACADEMY OF PEDIATRICS and AMERICAN ACADEMY OF PEDIATRIC DENTISTRY Pediatrics originally published online May 28, 2019;

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