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Review Procedural Sedation and Analgesia in Children Review Procedural sedation and analgesia in children Baruch Krauss, Steven M Green Procedural sedation and analgesia for children—the use of sedative, analgesic, or dissociative drugs to relieve anxiety Published Online and pain associated with diagnostic and therapeutic procedures—is now widely practised by a diverse group of February 21, 2006 specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and DOI:10.1016/S0140-6736(06) 68230-5 analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used Division of Emergency to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural Medicine, Children’s Hospital sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in and Harvard Medical School, practice are described along with current areas of controversy and future directions. 300 Longwood Avenue, Boston, MA 02115, USA (B Krauss MD); and Department Procedural sedation and analgesia is the use of sedative, essential and clinicians must be prepared to rescue of Emergency Medicine, Loma analgesic, and dissociative drugs to provide anxiolysis, patients from levels of sedation deeper than intended. Linda University Medical Center analgesia, sedation, and motor control during painful or and Children’s Hospital, Loma unpleasant diagnostic and therapeutic procedures. During Initial guidelines and terminology Linda, CA, USA (S M Green MD) the past 20 years, this procedure has evolved into a distinct In 1985, the National Institutes of Health and the Correspondence to: Dr Baruch Krauss skill set with a growing number of indications and practice American Academy of Pediatrics issued guidelines for baruch.krauss@childrens. settings. Given the logistical and economic advantages of procedural sedation and analgesia in response to several harvard.edu not requiring the operating theatre, procedures once sedation-related deaths.1,2 These documents defined three restricted to the theatre are now done by many different levels of sedation: conscious sedation, deep sedation, and practitioners (cardiologists, dentists, emergency physi- general anaesthesia. The language has evolved and the cians, gastroenterologists, intensive care doctors, oncol- misleading term conscious sedation3–5 has been replaced by ogists, plastic surgeons, and radiologists) in inpatient and moderate sedation.3,6,7 Unfortunately, responsiveness is a outpatient settings. The rapid growth of procedural crude surrogate marker for respiratory drive and retention sedation and analgesia has been fuelled by new drug and of protective airway reflexes.8,9 Despite better terminology, monitoring technology, expanded practitioner skills, the there is still no objective way to describe sedation depth, need to shift procedural work to outpatient settings, and and titration to a precise endpoint can be difficult. widespread acceptance of the ethical imperative to treat pain and anxiety in children. We review the state of Current guidelines and standards international paediatric procedural sedation and analgesia, Many specialty societies and regulatory bodies have highlighting the relevant principles, indications, and published guidelines for procedural sedation and pharmacopoeia, as well as current controversies and analgesia, each designed to address their specific future directions. perspectives (panel 1).1,3,5–7,10–33 The most widely disseminated were published by the American Academy Underlying principles of Pediatrics,2,5 the American Society of Anesthesiologists The principles of the procedure, including presedation (ASA),3 and the American College of Emergency assessment, continuous monitoring during the Physicians.6 Guidelines are intended to standardise the procedure, and recovery scoring systems, mirror longstanding anaesthesia practices. Search strategy and selection criteria Sedation continuum We searched the Cochrane Library, MEDLINE, and relevant specialty journals (all from Progression from minimum sedation to general 1980 to June, 2005). We used the search terms “procedural sedation and analgesia” or anaesthesia does not lend itself to arbitrary division. Low “conscious sedation” or “sedation and analgesia for procedures”. We largely selected doses of opioids or sedative-hypnotics induce mild publications in the past 15 years with an emphasis on the past 5 years, but did not analgesia or sedation respectively, with little danger of exclude commonly referenced and highly regarded older publications. We only searched adverse events. Higher doses provide progressively deeper articles in the English language or those translated into English. We also searched the sedation, increasing the risk of respiratory and airway reference lists of articles identified by this strategy and selected those we judged relevant. compromise. Almost all non-dissociative drugs for We included four types of studies: randomised controlled trials, observational studies, procedural sedation and analgesia in common use, retrospective studies, and meta-analyses. Abstracts and case reports were excluded and, including opioids, benzodiazepines, barbiturates, when cited, small preliminary studies were noted as such. However, we searched the etomidate, and propofol, can induce a state of general entire published work, including abstracts and case reports, when attempting to anaesthesia with loss of protective airway reflexes. determine whether a specific adverse event or complication had been reported. Some Additionally, sedation depth will drift during any given small studies from under-represented countries were included to give an international procedure. Noxious stimuli can lighten sedation, and the perspective. Several review articles, editorials, and book chapters were included because withdrawal of external stimuli at the end of a procedure they provided comprehensive overviews that were beyond the scope of this Review. can deepen it. Accordingly, continuous monitoring is www.thelancet.com Published online February 21, 2006 DOI:10.1016/S0140-6736(06)68230-5 1 Review between the operating theatre, emergency department, or Panel 1: Guidelines and standards for procedural sedation endoscopy suite. Accordingly, US hospitals must develop and analgesia and enforce institution-wide protocols for this procedure, Australia and New Zealand although there is some flexibility based upon specific G Australasian College for Emergency Medicine, Australian needs and available expertise. Among other things, and New Zealand College of Anaesthetists10 JCAHO standards require that practitioners can manage a G New Zealand College of Anaesthetists, Royal Australian compromised airway, that those who administer deep College of Dental Surgeons, New Zealand Dental sedation can rescue patients from inadvertent general Association11 anaesthesia, and that those administering moderate sedation can rescue patients from inadvertent deep Canada sedation (panel 2).6,7,34,35 G Canadian Association of Emergency Physicians12 Italy Presedation assessment G Società Italiana di Anestesia Analgesia13 The practice of procedural sedation and analgesia has three components done in sequence: presedation South Africa assessment, sedation for the procedure, and post- 14 G Medical Association of South Africa procedure recovery and discharge. A directed history and UK physical examination should precede the process, and if G British Society of Gastroenterology15 additional risk is discovered, the advisability of sedation G General Dental Council16 should be reconsidered. High-risk cases might be better G Scottish Intercollegiate Guidelines Network17 postponed or managed in theatre. G Standing Dental Advisory Committee18 Presedation assessments are a JCAHO requirement in G United Kingdom National Clinical Guidelines in Paediatric the USA, and hospitals have developed specific forms to Dentistry19 facilitate consistent documentation. The risks, benefits, and limitations of the procedure should be discussed with Netherlands the patient (or their parent or guardian) and verbal 20 G National Organisation for Quality Assurance in Hospitals agreement obtained. Written consent is not required USA unless it is a local institutional requirement. G American Academy of Pediatrics2,21 G American Academy of Pediatric Dentistry22 General G American Academy of Periodontology23 Physicians should assess the type and severity of G American Association of Critical-Care Nurses24 underlying medical problems. These can be quantified G American College of Critical Care Medicine25 with the ASA physical status classification, used for G American College of Emergency Physicians6 preoperative risk stratification (table 1). Although most G American Nurses Association26 procedural sedation and analgesia will be of healthy G American Society for Gastrointestinal Endoscopy27,28 patients (ASA class I and II), data suggest that it could be 36–38 G American Society of Anesthesiologists3 safe for patients with comorbidity (ASA class III). G American Society of Plastic and Reconstructive Surgeons29 Current medications and allergies should be verified and G Association of Operating Room Nurses30 inquiry made about previous adverse experiences with G Emergency Nurses Association31 procedural sedation and analgesia or anaesthesia. G Joint Commission on Accreditation of Healthcare Organizations7 Airway G National Institutes of Health1 The airway should be inspected for
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