Procedural sedation and analgesia in children

doi:10.1016/S0140-6736(06)68230-5

The Lancet

Volume 367, Issue 9512, 4–10 March 2006, Pages 766-780

https://doi.org/10.1016/S0140-6736(06)68230-5 Get rights and content

Summary

Procedural sedation and analgesia for children—the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures—is now widely practised by a diverse group of specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in practice are described along with current areas of controversy and future directions.

Section snippets

Underlying principles

The principles of the procedure, including presedation assessment, continuous monitoring during the procedure, and recovery scoring systems, mirror longstanding anaesthesia practices.

Presedation assessment

The practice of procedural sedation and analgesia has three components done in sequence: presedation assessment, sedation for the procedure, and post-procedure recovery and discharge. A directed history and physical examination should precede the process, and if additional risk is discovered, the advisability of sedation should be reconsidered. High-risk cases might be better postponed or managed in theatre.

Presedation assessments are a JCAHO requirement in the USA, and hospitals have developed

Personnel and interactive monitoring

Continuous observation of patients by a health-care provider capable of recognising adverse sedation events is essential. This person must be able to continuously observe the patient's face, mouth, and chest-wall motion, allowing rapid detection of respiratory depression, apnoea, partial or complete airway obstruction, laryngospasm, emesis, and hypersalivation. Procedural sedation and analgesia personnel should be proficient at maintaining airway patency and assisting ventilation if needed.

Equipment and mechanical monitoring

The use of mechanical monitoring has greatly enhanced the safety of procedural sedation and analgesia. Continuous oxygenation (pulse oximetry with an audible signal), ventilation (capnography), and haemodynamics—blood pressure and ECG—can all be monitored non-invasively in spontaneously breathing patients. Pulse oximetry is not a substitute for monitoring ventilation, as there is a variable lag time (depending on age, physical status, and use of supplemental oxygen) between the onset of

Post-procedure assessment

Children should be monitored until they are no longer at risk for cardiorespiratory depression, their vital signs are stable, they are alert and at age-appropriate baseline level of consciousness, and they can talk and sit unaided, according to age. It is not a requirement that young children be able to walk unaided.²¹ Many hospitals use standardised recovery-scoring systems similar to those used in surgical post-anaesthesia recovery.⁵³ A reliable adult should be given discharge instructions

Indications

Indications for procedural sedation and analgesia can be divided into three categories: minor trauma, instrumentation, and diagnostic imaging (panel 3). Many such procedures do not require procedural sedation and analgesia and can be accomplished with psychological techniques that can also reduce adverse responses to painful or frightening procedures.54, 55, 56, 57 A multifactorial decision-making process is used to determine the appropriate drugs, dosing, and sedation endpoint.53, 58 Selection

Classes of drugs

The five classes of procedural sedation and analgesia drugs are sedative-hypnotics, analgesics, dissociative sedatives, inhalational agents, and antagonists (table 2). The most widely used are sedative-hypnotics, including benzodiazepines (eg, midazolam, diazepam), barbiturates (eg, pentobarbital, methohexital, thiopental), and several drugs in their own pharmacological class (eg, chloral hydrate, etomidate, propofol). Propofol, etomidate, methohexital, and thiopental are referred to as

International differences in practice

The practice of procedural sedation and analgesia internationally can be divided into three categories: (1) anaesthetists are the sole practitioners, with most procedures happening in the operating theatre or day surgery units (eg, most of Europe, Africa, Latin America, and Asia); (2) a few trained practitioners outside of anaesthesia undertake procedural sedation and analgesia in well-defined circumstances and locations (eg, UK, Singapore, Hong Kong, South Korea, Taiwan, Philippines); (3)

Areas of controversy

There are two general areas of controversy in the practice of procedural sedation and analgesia: practitioner skills (who is qualified to undertake the procedure) and practise standards (what are they qualified to practise).

The future

The future of procedural sedation and analgesia will focus on enhancing training, safety, and effectiveness. Training issues include establishment of uniform minimum skill requirements, investigation of the effectiveness of simulation-based training in teaching and improving procedural sedation and analgesia skills, and development of curricula for training in countries where the practice is not well established. Safety issues involve defining the most appropriate monitoring for the different

Search strategy and selection criteria

We searched the Cochrane Library, MEDLINE, and relevant specialty journals (all from 1980 to June, 2005). We used the search terms “procedural sedation and analgesia” or “conscious sedation” or “sedation and analgesia for procedures”. We largely selected publications in the past 15 years with an emphasis on the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We only searched articles in the English language or those translated into English. We

References (126)

SM Green et al.
Procedural sedation terminology: moving past “conscious sedation”
Ann Emerg Med
(2002)
SM Green
Fasting is a consideration–not a necessity–for emergency department procedural sedation and analgesia
Ann Emerg Med
(2003)
JP Waring et al.
Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy
Gastrointest Endosc
(2003)
SM Green et al.
Clinical practice guideline for emergency department ketamine dissociative sedation in children
Ann Emerg Med
(2004)
SM Green et al.
The semantics of ketamine
Ann Emerg Med
(2000)
E Guenther et al.
Propofol sedation by emergency physicians for elective pediatric outpatient procedures
Ann Emerg Med
(2003)
D Agrawal et al.
NPO status and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department
Ann Emerg Med
(2003)
MG Roback et al.
Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?
Ann Emerg Med
(2004)
S Ghaffar et al.
Sedation for pediatric echocardiography: evaluation of preprocedure fasting guidelines
J Am Soc Echocardiogr
(2002)
MP Poirier et al.
Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps: a hyperoxemic animal model
Am J Emerg Med
(1998)

JJ Vargo et al.

Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy

Gastrointest Endosc

(2002)

D Agrawal et al.

Can bispectral index monitoring quantify depth of sedation during procedural sedation and analgesia in the pediatric emergency department?

Ann Emerg Med

(2004)

M Gill et al.

A study of the bispectral index monitor during procedural sedation and analgesia in the emergency department

Ann Emerg Med

(2003)

JE Wathen et al.

Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled emergency department trial

Ann Emerg Med

(2000)

DM Fatovich et al.

A randomized, controlled trial of oral midazolam and buffered lidocaine for suturing lacerations in children (the SLIC trial)

Ann Emerg Med

(1995)

K Connors et al.

Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair

Ann Emerg Med

(1994)

SM Green et al.

Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile with 1,022 cases

Ann Emerg Med

(1998)

SM Green et al.

Predictors of adverse events with ketamine sedation in children

Ann Emerg Med

(2000)

JD Luhmann et al.

A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair

Ann Emerg Med

(2001)

National Institutes of Health Consensus conference: anesthesia and sedation in the dental office

JAMA

(1985)

Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients

Pediatrics

(1985)

Practice guidelines for sedation and analgesia by non-anesthesiologists

Anesthesiology

(2002)

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum

Pediatrics

(2002)

Clinical policy: procedural sedation and analgesia in the emergency department

Ann Emerg Med

(2005)

Comprehensive accreditation manual for hospitals

(2005)

SM Green et al.

Pulmonary aspiration risk during ED procedural sedation: an examination of the role of fasting and sedation depth

Acad Emerg Med

(2002)

Faculty of Pain Medicine and Joint Faculty of Intensive Care Medicine. Statement on clinical principles for procedural sedation

Emerg Med

(2003)

Code of practice sedation for dental procedures

SAAD Dig

(1992)

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines

J Emerg Med

(1999)

A Levati et al.

SIAARTI-SARNePI Guidelines for sedation in pediatric neuroradiology

Minerva Anestesiol

(2004)

Conscious sedation clinical guideline

S Afr Med J

(1997)

Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy

Gut

(1991)

GDC new guidelines for sedation

SAAD Dig

(1999)

Sedation of children SIGN guidelines

SAAD Dig

(2002)

Conscious sedation in the provision of dental care: new guidelines

SAAD Dig

(2004)

Managing anxious children: the use of conscious sedation in paediatric dentistry

Int J Paediatr Dent

(2002)

JT Knape et al.

[Guideline for administration of sedatives and analgesics by physicians who are not anesthesiologists. National Organization for Quality Assurance in Hospitals]

Ned Tijdschr Geneeskd

(1999)

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures

Pediatrics

(1992)

Clinical guideline on use of anesthesia-trained personnel in the provision of general anesthesia/deep sedation to the pediatric dental patient

Pediatr Dent

(2004)

Guidelines: in-office use of conscious sedation in periodontics

J Periodontol

(2001)

Consensus conference on sedation assessment

Crit Care Nurse

(2004)

SA Nasraway et al.

Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine and the American Society of Health-System Pharmacists, American College of Chest Physicians. Sedation, analgesia, and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2002

Crit Care Med

(2002)

ANA position statements. The role of the registered nurse in the management of patients receiving IV conscious sedation for short-term therapeutic, diagnostic, or surgical procedures

SCI Nurs

(1992)

DO Faigel et al.

Guidelines for the use of deep sedation and anesthesia for GI endoscopy

Gastrointest Endosc

(2002)

Sedation and analgesia in ambulatory settings

Plast Reconstr Surg

(1999)

Recommended practices. Monitoring the patient receiving i.v. conscious sedation

AORN J

(1993)

Conscious Sedation Position Statement

(2000)

SGNA position statement. Statement on the use of sedation and analgesia in the gastrointestinal endoscopy setting

Gastroenterol Nurs

(2004)

Procedure guideline for pediatric sedation in nuclear medicine

J Nucl Med

(1997)

SM Green et al.

Ketamine sedation for pediatric gastroenterology procedures

J Pediatr Gastroent Nutr

(2001)

Cited by (425)

Retrospective comparison between MRI examinations during radiographer-administered intranasal sedation or general anesthesia
2024, Radiography
In order for young children to be able to undergo a Magnetic Resonance Imaging (MRI) examination, general anesthesia is often required. The aim of this study was to compare the image quality, times, and costs of the examinations of infant brains performed with MRI either during sedation with dexmedetomidine administered by radiographers or anesthesia with propofol administered by anesthesia staff.
This study was a quantitative retrospective study of 27 consecutive standard brain examinations performed under sedation or anesthesia, involving 15 children under sedation and 12 under anesthesia. The age of the children was from 0.5 to five years old. The image quality was evaluated by three radiologists experienced in pediatric MRI examinations. Information such as examination time and the expense of the examination was also collected.
There was no statistically significant difference in the general image quality, but one image series was assessed to have significantly better image quality under sedation than under anesthesia, but all images had very high quality. However, it emerged that children under anesthesia were at the hospital on average 55 min longer and the scanner room was occupied 20 min longer on average. The anesthesia examinations were three times more expensive.
This study demonstrated equivalent image quality between sedation and anesthesia. In addition, sedation was less time-consuming and had a lower price, partly because no extra anesthetic staff were required. The use of intranasal sedation offers a possibility to expand the competence area for radiographers.
If radiographers learn to perform intranasal sedation, examinations can be performed in less time, at a third of the staff costs while maintaining image quality.
Higher anesthetic dose requirement for sedation in children with autism spectrum disorder compared to neuro-atypical controls- a prospective observational study
2023, Research in Autism Spectrum Disorders
Children with Autism Spectrum Disorders (ASD) are known to require general anesthesia or sedation for undergoing procedures like Magnetic Resonance Imaging (MRI). The dose required for sedation may vary depending on multiple factors. The aim of this study was to compare the sedative requirements of children with ASD with those who do not have ASD for undergoing MRI.
Thirty-four children with ASD and 31 neuro-atypical controls (children with other neurological disorders undergoing MRI) were recruited into the study. Children were premedicated with injection midazolam 0.1 mg/kg. This was followed by dexmedetomidine 2 mcg/kg over 2 min, followed by 2 mcg/kg/hour infusion inside the MRI gantry. If the above anesthetic was insufficient to make the child immobile, a bolus dose of thiopentone 3 mg/kg was supplemented and this was compared between the two groups. The children were monitored with ECG, and oxygen saturation. Since, these children were on sedative medications, each patient was given a sedation score depending on the number of sedative medications, the child was receiving.
Twenty one of 34 children in the ASD group required thiopentone for sedation while 5 of 31 in the control group required thiopentone supplementation (p < 0.001). The thiopentone requirement continued to be significantly different between the two groups at each level of sedation score (0, 1, 2 +) (p < 0.004).
Children with ASD required higher anesthetic dose for sedation compared to neuro-atypical controls for MRI. This study has shown that dexmedetomidine can be safely used for children with autism and additional sedatives are often required for imaging.
Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis
2023, British Journal of Anaesthesia
Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0–8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques.
Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0–8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events.
Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91–0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92–0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14–0.65); for oral pentobarbital 99% (95% CI: 0.90–1.00); for rectal thiopental 92% (95% CI: 0.85–0.96); for oral melatonin 75% (95% CI: 0.54–0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38–0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78–0.99); and for inhaled sevoflurane 98% (95% CI: 0.97–0.99).
We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.
Ambulatory sedation for children under 6 years with CHD in MRI and CT
2023, Cardiology in the Young
Efficacy of intranasal administration of dexmedetomidine in combination with midazolam for sedation in infant with cleft lip and palate undergoing CT scan: a randomized controlled trial
2024, BMC Anesthesiology
Efficacy and safety of esketamine for sedation among patients undergoing gastrointestinal endoscopy: a systematic review and meta-analysis
2023, BMC Anesthesiology

View all citing articles on Scopus

View full text

ReviewProcedural sedation and analgesia in children

Summary

Section snippets

Underlying principles

Presedation assessment

Personnel and interactive monitoring

Equipment and mechanical monitoring

Post-procedure assessment

Indications

Classes of drugs

International differences in practice

Areas of controversy

The future

Search strategy and selection criteria

Ann Emerg Med

Ann Emerg Med

Gastrointest Endosc

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Am Soc Echocardiogr

Am J Emerg Med

Gastrointest Endosc

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

National Institutes of Health Consensus conference: anesthesia and sedation in the dental office

JAMA

Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients

Pediatrics

Practice guidelines for sedation and analgesia by non-anesthesiologists

Anesthesiology

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum

Pediatrics

Clinical policy: procedural sedation and analgesia in the emergency department

Ann Emerg Med

Comprehensive accreditation manual for hospitals

Pulmonary aspiration risk during ED procedural sedation: an examination of the role of fasting and sedation depth

Acad Emerg Med

Faculty of Pain Medicine and Joint Faculty of Intensive Care Medicine. Statement on clinical principles for procedural sedation

Emerg Med

Code of practice sedation for dental procedures

SAAD Dig

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines

J Emerg Med

SIAARTI-SARNePI Guidelines for sedation in pediatric neuroradiology

Minerva Anestesiol

Conscious sedation clinical guideline

S Afr Med J

Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy

Gut

GDC new guidelines for sedation

SAAD Dig

Sedation of children SIGN guidelines

SAAD Dig

Conscious sedation in the provision of dental care: new guidelines

SAAD Dig

Managing anxious children: the use of conscious sedation in paediatric dentistry

Int J Paediatr Dent

[Guideline for administration of sedatives and analgesics by physicians who are not anesthesiologists. National Organization for Quality Assurance in Hospitals]

Ned Tijdschr Geneeskd

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures

Pediatrics

Clinical guideline on use of anesthesia-trained personnel in the provision of general anesthesia/deep sedation to the pediatric dental patient

Pediatr Dent

Guidelines: in-office use of conscious sedation in periodontics

J Periodontol

Consensus conference on sedation assessment

Crit Care Nurse

Crit Care Med

ANA position statements. The role of the registered nurse in the management of patients receiving IV conscious sedation for short-term therapeutic, diagnostic, or surgical procedures

SCI Nurs

Guidelines for the use of deep sedation and anesthesia for GI endoscopy

Review
Procedural sedation and analgesia in children