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"Conscious sedation": Time for this oxymoron to go away!
... Like the individuals discussed above, the victims of cancel culture reflect the interplay of morality, power, and public accountability. These individuals' ability to navigate the public sphere and sometimes return to prominence after being "cancelled" reflects a cultural contradiction (Coté, 2001). Here are some of the victims of cancel culture of public figures in Indonesia: Table 3. Insulted a bride-to-be on Facebook in 2023. ...
Several public figures have controversies, so the public responds negatively. On the other hand, an Islamic communication perspective is necessary to analyze this phenomenon. Therefore, this research aimed to uncover the dynamics and oxymora cancel culture in virtual media in Indonesia, especially in the context of Islamic communication. Using a netnography approach, this study analyses various cases involving public figures such as Ahmad Dhani, Luna Maya, Gisel Anastasya, Rizki Billar, Tuan Guru Mizan Qudsiyah, and Panji Gumilang on the YouTube platform. The study results show that cancel culture in Indonesia reflects social complexity, where religious values face modern demands for social justice. On the one hand, cancel culture functions as a social control mechanism to maintain religious norms and public ethics, providing a role for society in correcting behavior that is considered deviant. On the other hand, this phenomenon risks creating an intolerant environment, limiting the space for forgiveness and improvement, and potentially violating the principles of compassion and justice in Islam. This research contributes to a deeper understanding of the role of Islamic communication in responding to the phenomenon of cancel culture, emphasizing the importance of a wise and contextual approach in integrating religious values and the demands of modernity in the digital space.
... However, soon it was acknowledged that the terminology of conscious sedation could not be used for pediatric population especially the young children. 12 Sedation in general is defined as "a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be performed." 13 Three levels of sedation are defined in addition to GA. ...
Objective In this article we will try and provide a comprehensive literature review on the use of sedation and general anesthesia (SAGA) in pediatric population for diagnostic studies and the salient differences in practices worldwide particularly with regards to the practice differences in developed versus developing countries.
Methods The key articles we obtained were primarily from Indian Journal of Anesthesia, Local NHS Trust protocols, PubMed, MEDLINE, NICE Evidence, UptoDate (Wolters Kluwer), and The Cochrane Library.
Results In the last two decades pediatric radiology has seen a huge increase in volume of procedures with a proportional increase in SAGA. The duration being dependent on the modality (for example, few minutes for computed tomography scan and up to an hour for magnetic resonance imaging particularly if there are multiple studies). SAGA has an extensive list of adverse effects that could be due to the underlying drug or due to wrong patient selection. The principles for safe use of the drugs remain the same just like any other medical or surgical procedure and include meticulous assessments of children and ruling out the contraindications, obtaining parental consent, deciding the drugs which can be given, ascertain the duration of procedure after communication with the radiologist, monitor closely before, during, and after the procedure, discharge, and after the discharge criteria are met. All the above criteria depend on the local guidelines and therefore vary from not only one country to the other but also from one institution to the other within the same country.
Conclusion As expected, the SAGA techniques, drugs, and personnel involved in delivering the care vary from country to country. However, the final and desired outcome remains the same that is to deliver safe care with acquisition of optimal images that serve the purpose of arriving at the correct diagnosis.
... This situation is similar to that of procedure-related pain for children undergoing dental procedures, where only a minority of states cover dental anesthesia and then only for those with underlying medical conditions. 20 It is apparent that interventions are available to reduce pain and distress in children with cancer undergoing repeated painful procedures. However, even as recognition of ineffective strategies and clinician education appears to be gaining momentum, 20 significant obstacles remain. ...
To compare the efficacy of 3 different pharmacologic regimens to relieve pain and distress in children with cancer undergoing bone marrow aspirations (BMAs) and lumbar punctures (LPs).
Retrospective cohort study with crossovers for some patients.
The pain and distress ratings of patients undergoing BMAs (n = 73) and LPs (n = 105) were examined in a comparison of 3 different interventions: (1) a topical eutectic mixture of lidocaine and prilocaine (EMLA cream), (2) oral midazolam and EMLA cream, or (3) propofol/fentanyl general anesthesia. The choice of the intervention depended on patient/parent request. A validated faces pain scale was completed by the child or parent following each BMA or LP. The faces pain scale includes ratings of the severity of pain (from 0 = none to 5 = severe) and ratings of how frightened (from 0 = not scared to 5 = scared) the child was prior to each procedure. Comparisons of the pain and distress ratings were made among all patients for their first procedure and also within individual patients who had received >1 of the 3 interventions. Independent comparisons between the first treatments received by each patient were analyzed using Kruskal-Wallis tests. Comparisons of different crossover treatments received by individual patients were analyzed using Wilcoxon tests.
For all first procedures, mean +/- SD pain and distress ratings during LPs were significantly lower when propofol/fentanyl was used (n = 43; 0.4 +/- 1.0 and 1.4 +/- 1.7) versus either EMLA (n = 29; 2.4 +/- 1.7 and 2.9 +/- 1.9) or midazolam/EMLA (n = 33; 2.4 +/- 1.8 and 2.7 +/- 1.8), respectively. Pain and distress ratings during BMAs were also significantly lower with propofol/fentanyl (n = 29; 0.5 +/- 1.0 and 1.2 +/- 1.7) versus EMLA (n = 21; 3.5 +/- 1.6 and 3.3 +/- 1.8) or midazolam/EMLA (n = 23; 3.3 +/- 1.5 and 3.0 +/- 1.9), respectively. When data were analyzed within each patient, these differences were also present.
Children receiving propofol/fentanyl general anesthesia experienced significantly less procedure-related pain and distress than did those receiving either EMLA or oral midazolam/EMLA.
... Las guías propuestas por la American Academy of Pediatrics (AAP) y la American Association of Anestesiology para la preparación preoperatoria del paciente así como los equipos y personal requeridos para la inducción de la sedación y reanimación 47,48 , están siendo actualmente revisadas. Así, se proponen nuevas terminologías (sedación mínima [ansiólisis], sedación-analgesia moderada, sedación-analgesia profunda y anestesia general), y nuevos requerimientos (el personal debe ser aquel capaz de manejar adecuadamente el estado de sedación profunda instituido y de reconocer y tratar con rapidez las complicaciones) 49 . ...
There is considerable interhospital variability in the practice of flexible bronchoscopy in children. The present report aims to provide some recommendations that are supported by the Spanish Society of Pediatric Pulmonologists. We review the indications, contraindications, equipment, setting and personnel involved in flexible bronchoscopy, as well as the pre-procedure preparation of the patient, medications, post-procedure monitoring, complications, care and maintenance of instruments, and informed consent. These recommendations may be adopted, modified or rejected according to clinical needs and constraints.
... Soon it became clear that this conceptual state of sedation is often not adequate for children and they often need deeper sedation (9). Many feel that the term "conscious sedation" is indeed oxymoronic in children (10). Consequently, there has been a revised levels of sedation proposed by American Society of Anesthesiologists and adopted by the American Academy of Pediatrics in 1999(11) ( Table I). ...
... The term conscious sedation continues to be used in both the anesthesia and non-anesthesia literature (6). However, this term is no longer included in standards of the American Society of Anesthesiologists (ASA) (10), and its use is being discouraged because it is imprecise and potentially misleading (24-26). ...
The purpose of this study was to prospectively characterize the safety and effectiveness of moderate sedation/analgesia for performing radiologic non-vascular abdominal intervention.
During a 3-month period, a total of 63 adult patients with a mean age of 64 years (range: 27-82) underwent moderate sedation for 72 radiologic non-vascular interventional procedures. A combination of fentanyl citrate and midazolam hydrochloride, based on the patient's body weight, was intravenously administered until the patient was drowsy and tranquil. The adverse events associated with this moderate sedation were assessed. The visual analog scale format was used to measure the subjective feelings of the patient's pre-procedural anxiety and intraprocedural pain.
The mean total dose per kilogram of body weight of fentanyl used in PTBD was 1.148 microg, it was 1.157 microg for PTGBD, 1 microg for AD, 1 microg for PCN, 1.641 microg for TDC, 1 microg for DJS, 2 microg for BS, 1 microg for GS and 2 microg for RFA. The mean total dose per kilogram of body weight of midazolam was 0.035 mg in PTBD, PTGBD, AD, PCN, DJS, GS and RFA, 0.039 mg in TDC, and 0.043 mg in BS. A temporary reduction of systolic blood pressure to less than 80 mmHg was observed during 5 procedures (6.9%), whereas a temporary elevation of systolic blood pressure above 150 mmHg was observed during 10 procedures (13.8%). A reduction of arterial oxygen saturation to less than 90% was observed during 14 procedures (19.4%). None of the patients required pharmacologic reversal agents or cardiopulmonary resuscitation. The mean anxiety score recorded before all procedures was 5.2 (distressing). The mean pain score during the procedure, which was recorded after all procedures, was 2.9 (mild).
Moderate sedation allows performance of safe and effective radiologic non-vascular intervention, and it is also easy for an interventional radiologist to use. The patients should be continuously monitored to check their vital signs and arterial oxygen saturation during the procedures.
... In the case of the VCUG, a degree of consciousness is required. This may be defined as light sedation, and the use of oxymoron "conscious sedation" is being discouraged [98]. ...
Voiding cystourethrograms are distressing for children and parents. Nonpharmacological methods reduce distress. Pharmacological interventions for VCUG focus on sedation as well as analgesia, anxiolysis, and amnesia. Sedation has cost, time, and safety issues. Which agents and route should we use? Are we sure that sedation does not influence the ability to diagnose vesicoureteric reflux?
Literature search of Medline, EMBASE, and the Cochrane Database. Review of comparative studies found.
Seven comparative studies including two randomised controlled trials were reviewed. Midazolam given orally (0.5-0.6 mg/kg) or intranasally (0.2 mg/kg) is effective with no apparent effect on voiding dynamics. Insufficient evidence to recommend other sedating agents was found. Deeper sedating agents may interfere with voiding dynamics.
Midazolam reduces the VCUG distress, causes amnesia, and does not appear to interfere with voiding dynamics. Midazolam combined with simple analgesia is an effective method to reduce distress to children undergoing VCUG.
For deep sedation procedures, supplemental oxygen is usually administered via a nasal cannula to the patients. Non-invasive mechanical ventilation (NIMV) is the oxygenation method, especially used in the treatment of hypoxia. We aimed to compare the use of nasal cannula and NIMV applications as oxygenation methods for deep sedation procedures in the dental treatments of children, especially in terms of patient safety and the convenience of the dentist to apply the treatment. Patients were divided into two groups as the nasal mask group (M) and the nasal cannula group (N). For oxygenation, while a nasal cannula was used for group N, NIMV with a nasal mask was applied for group M. Hemodynamic parameters of the patients, complications and dentist's satisfaction degree were recorded and compared. Saturation of blood oxygen (SpO2) was significantly higher in group M after induction of anesthesia and in the fifth minute of the procedure. Hypoxia (SpO2 ≤90) event number during the procedure was significantly higher in group N. Surgeon satisfaction was significantly higher in group M. We concluded that, in children undergoing deep sedation for dental treatments, NIMV applied with a nasal mask reduces the risk of hypoxia and is safer than using a nasal cannula.
In a pediatrician’s practice, there are a number of indications for the provision of procedural sedation. This chapter aims to provide a framework for procedural sedation from a pediatrician’s point of view, including understanding the practice setting, the patients, and the procedures themselves. Although written from a pediatrician’s perspective, this chapter is designed to apply to all sedation providers across all specialties. Additionally, in trying to create an approach to procedural sedation, it is equally important to consider when the risks of the sedation outweigh the benefits.
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
Il dolore interessa oltre il 50% dei bambini che si presentano in Pronto Soccorso. Quando presente, deve essere valutato e trattato prontamente con mezzi farmacologici adatti alla sua intensità e alla sua eziologia. Il dolore residuo deve essere oggetto di un aggiustamento terapeutico. Lo scopo è di permettere al bambino di riprendere le sue attività. Quando è programmato un gesto doloroso a scopo diagnostico o terapeutico, può essere necessaria un’analgesia/sedazione. Per questo tipo di gestione, gli analgesici, in monoterapia come in associazione, devono essere somministrabili facilmente e senza dolore, avere un’azione rapida e prevedibile, un’emivita breve e una buona efficacia ed essere privi di effetti collaterali. Una tale gamma di molecole non esiste ed ogni analgesia/sedazione comporta un rischio, in particolare di ipossiemia. Tuttavia, al prezzo di un investimento umano e materiale, un dipartimento di emergenza deve essere in grado di fornire un supporto analgesico efficace in condizioni di sicurezza identiche a quelle di un’anestesia. La qualità di questo tipo di organizzazione è misurata attraverso l’identificazione dei bambini per i quali è, in principio, preferibile un’anestesia generale.
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
Dental caries, a common ailment in children, often requires sedation. A majority of these sedations are provided by the dentist and take place in their offices. Dentists undergo training to deliver moderate sedation. The American Academy of Pediatric Dentists has published guidelines and policies for dentists who administer sedation and anesthesia in their offices. Oral sedation is the most common sedation technique used for dental caries, historically in the form of a “cocktail.” However, safety concerns of the “cocktail” combined with the improved safety and efficacy of midazolam have shifted the sedation regimen toward midazolam. The intranasal route for moderate sedation is used increasingly in dental sedation. An anesthesiologist may provide moderate or deep IV sedation or general anesthesia in the office. Hospital-based anesthesia is also used, but access and cost restrict its use. Sedation is an important service, but patient safety always comes first.
There is considerable interhospital variability in the practice of flexible bronchoscopy in children. The present report aims to provide some recommendations that are supported by the Spanish Society of Pediatric Pulmonologists
We review the indications, contraindications, equipment, setting and personnel involved in flexible bronchoscopy, as well as the pre-procedure preparation of the patient, medications, post-procedure monitoring, complications, care and maintenance of instruments, and informed consent. These recommendations may be adopted, modified or rejected according to clinical needs and constraints
Procedural sedation offers an effective and humane way to deliver dental care to the young, anxious child and to those with extensive treatment needs. Delivery of sedation requires thorough understanding of its indications and contraindications, patient assessment, pharmacology, monitoring, and office protocol. Safe and successful outcomes depend on a systematic approach to care, and the ability to manage unintended cardiopulmonary events.
Health care professionals have a duty to advocate for the children in their care. Children are in delicate stages of their development and cannot be expected to act like little adults. A child may find it difficult to endure a painful procedure. Sedation should be contemplated for any procedure that would impose pain or anxiety on a child. The non-anesthesiologist can safely and effectively administer sedation to a child for diagnostic and therapeutic procedures when institutional policy and procedures are followed.
Sedation for children outside the operating room has been the subject of numerous discussions in the last 20 years, especially for pediatric anesthesiologists. Among the reasons why this was and continues to be an important topic (Fig. 15.1) for us are:
An increase in the number and type of procedures outside and inside the operating room (OR), versus a decreased or equal number of anesthesiologists available, all scheduled as day surgery
An increase in the demand for special conditions to produce better images/results (e.g. MRI, dentistry)
An Increase in the complexity of cases due to an increase in survival rates of children with complex pathology.
The demand of procedures performed on children outside the operating room setting often exceeds the capacity of anesthesia services. The number of children requiring sedation outside the traditional operating room is rapidly approaching the number of children requiring anesthesia in the operating room. We address some of the major issues and controversies in this continuously evolving field.
Pediatric sedation continues to be a challenging field. Recently, the Society of Pediatric Sedation has been created. In the last year, important issues have been raised among pediatric sedation providers, keeping on feeding the debate within all the recognized experts. Why worry about nihil per os status? Is bispectral index useful as a sedation monitor? Should there be standards for simulation-based training of nonanesthesiologists for delivery of sedation? Is propofol well tolerated? Is dexmedetomidine a good choice for painful procedures? What is the role of etomidate?
A standard approach (adequate preparation, clinical assessment of the child, fasting as required and right sedation plan) is mandatory to provide safety and efficiency. Sedation is a continuum, and it can be easy to advance from one level to the next and even reach a state of general anesthesia. Newer modalities such as end-tidal CO2 and, maybe, bispectral index monitoring are indeed enhancing the safety of procedural sedation and analgesia.
Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.
Rodent and monkey research has shown that ketamine can induce accelerated programmed nerve cell death (apoptosis) when administered in high doses, for prolonged periods, or both. Concern about similar neurotoxicity with human therapeutic use has prompted ongoing investigations by the Food and Drug Administration and National Institutes of Health. If the results of these inquiries are unfavorable to ketamine, such action could ultimately lead to restricted availability of this drug or even its discontinuation from the market. This article discusses the limitations of the published animal research, the challenges in extrapolating such data to humans, the need for further animal and human investigations, and the potential adverse effect on current clinical practice that might result, should the use of ketamine be restricted or the drug removed from the market.
[Green SM, Krauss B. Procedural sedation terminology: moving beyond “conscious sedation.” Ann Emerg Med. April 2002;39:433-435.]
Flexible airway endoscopy has been used in clinical and research investigations of pediatric airway and pulmonary disorders for nearly 25 years. Not only has clinical use of the flexible bronchoscope improved our evaluation and management of a variety of airway and pulmonary diseases in children, but also research investigations using lavage and biopsy specimens obtained with the flexible bronchoscope have contributed extensively to our understanding of lung inflammation and infection. Improvements and new developments in fiberoptic endoscope technology, training of airway endoscopists, preoperative and sedative medications, patient monitoring, and airway endoscopic techniques, as well as adjunctive minimally invasive and noninvasive diagnostic modalities, continue to refine and enhance the pediatric clinical and research applications of flexible airway endoscopy.
The application of sedation/analgesia in paediatric patients is rapidly expanding as less invasive, non-operative techniques of diagnosis and treatment are applied to the paediatric population. Medical providers who are asked to provide sedation may include radiologists, paediatricians, nurses and emergency physicians, as well as anaesthesiologists and intensive care physicians. At the same time, the range of drugs used in these settings has expanded considerably. As there is no single drug fulfilling the criteria for the ideal sedative (rapid-onset, rapid recovery, no adverse effects, immobility appropriate to procedure being performed), multiple drugs may be used in combination. It is imperative that practitioners using drugs for sedation/analgesia in children be aware of the adverse effect profile(s) of these drugs, both individually and in combination. The purpose of this review is to describe the adverse effects of sedative and reversal agents currently used in paediatric sedation/analgesia.
Administration of sedation and analgesia in the interventional radiology suite is often necessary during painful diagnostic and therapeutic procedures. Although sedative and analgesic agents are generally safe, catastrophic complications related to their use can occur, often as a result of incorrect drug administration or inadequate patient monitoring. The incidence of adverse outcomes related to provision of sedation and analgesia can be reduced with improved understanding of the pharmacology of these medications, by providing adequate monitoring to sedated patients, by recognizing patients who are at increased risk of experiencing an adverse drug reaction, and by early and appropriate management of complications.
Pain concerns more than 50% of the children cared in the emergency unit. After evaluation, it has to be cured with drugs adapted to its level and its origin. Residual pain needs therapeutic adjustment. The goal is to allow the child to restart his activities. A preventive sedation analgesia is necessary when a painful exam is to be performed, either for diagnosis or therapeutic purpose. For this goal ideal analgesics, either for monotherapy or associated, are easily and painlessly administered. They have rapid onset of action, brief half-life, predictable, effective analgesic properties without side effects and they are quickly reversible. These drugs do not exist and every sedation procedure has a risk of hypoxemia. With the human and equipment's investment an emergency department should be able to ensure that procedures are performed in children under sedation with a standard of safety that is similar to general anaesthesia. The main drawback in a well-organised system should be a significant children's rate for which general anaesthesia is preferred.
Summarizing the discussion of the previous pages, we can point out the main guidelines that were followed, i.e. safety for the child and the operators, and the efficacy of an anesthesia intervention based on the application of protocols that require maximum attention to patient preparation, to defining the anesthesia plan and to detailing the monitoring and evaluation criteria.7,8 In recent years, the number of anesthesia techniques has grown 9-11 and been refined. The best technique remains the one the anesthetist is best at in relation to the specifics of the individual case. For this reaason no indications are given for selecting a certain technique or drug, but rather indications are suggested for adopting those behaviors in the pre, intra- and postsedation phases that will ensure maximum safety.12,13 Hence, the recommendations are, on the one hand, addressed to the less expert anesthetist to provide him or her with useful tools for facing new challenges and determining a safe method, and on the other hand, they are directed at the expert anesthetist so that he or she can compare them with his or her own setting and have criteria that may help standardize working methods across various institutions. In either instance, by taking a common approach to the problem, we may be better able to work safely, speak the same language and compare the results of our work.
The magnetic resonance imaging suite is a challenging environment for the anaesthesiologists, and carries inherent risks. Several factors account for this, including the remote location, the unique features of the magnetic resonance imaging scanner and patient-related factors. A systematic approach, similar to that of anesthesia provided in the operating room (i.e. proper fasting, informed consent, focused airway examination, medical and surgical history, family history, previous sedation experiences) is mandatory. Understanding the implications of the magnetic resonance imaging environment will facilitate ensuring the safety of the patient. A well-equipped anesthesia machine, standard monitoring (electrocardiogram, oxygen saturation and non-invasive blood pressure), trained personnel and adequate planning should be standard for all out of the operating room procedures. Finally, rigorous discharge criteria are recommended to detect residual sedation.
We have come a long way in sedation accident prevention, and we need to continue to improve. Although the systems approach has made flying very safe, accidents can and will continue to occur. Fortunately, when sedating a child, we can rescue the patient if we have the skills to do it. It is our obligation to provide the safety net needed to achieve the goal of accomplishing sedation safely, painlessly, and returning the child safely to a pre-sedation level of consciousness.
Pediatric procedural sedation has evolved rapidly over the last decade because of the increased awareness about the presence of procedure-related anxiety and pain in even the youngest children. The increased demands in varied situations, new definitions of the levels of sedation, new regulatory requirements, and the development of short-acting titratable sedatives have stimulated the development of new paradigms of safe, effective, and resource-efficient systems of providing procedural sedation.
The purpose of the present review is to provide the reader with a synopsis of the recent literature on sedation of children by non-anesthesiologists.
Health care centers are experiencing an increasing demand for sedation of pediatric patients. Whether provided by physician anesthesiologists, nurse anesthetists, or appropriately credentialed non-anesthesia clinicians, this increase is a reflection of new advances in the area of diagnostic imaging, better pharmacologic agents, and a heightened awareness of the psychologic needs of children. By definition anesthesiologists are the experts when it comes to providing sedation to patients. For pediatric patients, pediatric anesthesiologists provide the most appropriate specialization. However, because of insufficient manpower, anesthesiologists cannot adequately meet the increasing workload of providing sedation for each child in need.
In some circumstances the incidence of adverse events when sedation is provided by non-anesthesiologist can be high. Predicators of adverse outcome have been identified. Given strict adherence to sedation guidelines and appropriate credentialing of the sedation provider, non-anesthesiologists can safely provide sedation for children.
Voiding cystourethrography (VCU) is a distressing procedure for children. Conscious sedation using oral midazolam may reduce this distress, but its use may also alter the ability of the VCU to show vesicoureteric reflux (VUR). The objectives of our study were to assess the effectiveness of conscious sedation using oral midazolam when administered routinely in children undergoing VCU and to ensure that conscious sedation using oral midazolam does not alter the ability of VCU to show VUR.
Our study was a randomized double-blind controlled trial performed at a university teaching hospital; our study group consisted of children over the age of 1 year who been referred for their first VCU examination from July 2001 to July 2003. Participants were randomized to receive a placebo or midazolam syrup (0.5 mg/kg) before the examination. The primary outcome measures were the Groningen Distress Rating Scale (GDRS) and grading of VUR, as defined by the international grading system established by the International Reflux Study Group.
There were no serious adverse events. One hundred thirty-nine children were randomized in the study, and 117 underwent complete assessment. Eight who underwent VCU after the study day were included in a "complete case" intention-to-treat analysis. In the placebo group, 34 children (61%) experienced serious distress or severe distress (GDRS score, 3 or 4). In the midazolam group, 16 children (26%) experienced the same degree of distress. There was a significant difference between the GDRS scores (nonlinear mixed-model analysis, p < 0.001) of the two study groups. The number needed to treat to reduce serious or severe distress in one child was 2.9 (95% CI, 1.9-5.5). VUR was identified in 16% of all children. There was no difference in VUR grading between the groups (nonlinear mixed-model analysis, p = 0.31).
Routine use of oral midazolam (0.5 mg/kg) for conscious sedation of children undergoing VCU reduces distress and does not alter the ability of VCU to show VUR well enough to allow diagnosis.
Emergency department procedural sedation practices for children have been reported for pediatric tertiary care centers. This report describes these same practice patterns and outcomes for community hospital-based general emergency physicians (EPs) in their treatment of pediatric patients.
The Procedural Sedation in the Community Emergency Department registry is a prospective observational database composed of consecutive EP-directed procedural sedation cases in community hospitals. Information on sedation cases is collected at the time of the patient encounter and entered into an Internet-accessed database.
A total of 1028 procedural sedations were performed on 977 patients at 14 study sites, with 341 procedures performed in 339 patients younger than 21 years. The most common specified pediatric procedures performed included laceration repairs (n = 86, 25%), shoulder relocations (n = 78, 23%), and fracture care of the upper extremity (n = 56, 16%). Medications used included ketamine (n = 141, 41%), midazolam (n = 10, 32%), etomidate (n = 54, 16%), fentanyl (n = 51, 15%), and propofol (n = 47, 14%). Complications were reported in 2 cases (0.6%), 1 episode of apnea requiring a reversal agent and 1 episode of hypoxia responsive to supplemental oxygen. Of procedures attempted, 339 (99.4%) were successfully completed. Emergency physicians both directed the sedation and performed the procedure in 252 cases (74%), whereas in another 69 cases (20%), they directed the sedation for another physician performing the procedure. In 20 cases (5.8%), the EP directed sedation for a painless diagnostic study.
Community EPs in the Procedural Sedation in the Community Emergency Department registry deliver safe and effective pediatric sedation using a broad selection of agents.
The purpose of this study was to identify factors that may influence current American Academy of Pediatric Dentistry (AAPD) members' definitions of a successful oral sedation.
Surveys were electronically mailed to all AAPD members with registered e-mail addresses, and printed surveys were sent via postal mail to all other members. The survey included: (1) items on demographic variables; and (2) questions on sedation methods and definition of success.
The following response rates were recorded: (1) electronic survey = 26%; (2) printed = 45%; and (3) diplomate = 53%. The majority of members (55%) characterized their patient management style as being authoritarian. Sixty-seven percent agreed that the need to employ restraints when using sedation does not necessarily indicate that sedation is inadequate or unacceptable. When asked if such a sedation outcome could be defined as being successful, however, the agreement dropped to 47%. When defined as optimal, the respondents' agreement was further reduced to 36%.
The practitioner's management style and use of restraint significantly influence how a dentist defines a successful sedation.
Factors that contribute to adverse sedation events in children undergoing procedures were examined using the technique of critical incident analysis.
We developed a database that consists of descriptions of adverse sedation events derived from the Food and Drug Administration's adverse drug event reporting system, from the US Pharmacopeia, and from a survey of pediatric specialists. One hundred eighteen reports were reviewed for factors that may have contributed to the adverse sedation event. The outcome, ranging in severity from death to no harm, was noted. Individual reports were first examined separately by 4 physicians trained in pediatric anesthesiology, pediatric critical care medicine, or pediatric emergency medicine. Only reports for which all 4 reviewers agreed on the contributing factors and outcome were included in the final analysis.
Of the 95 incidents with consensus agreement on the contributing factors, 51 resulted in death, 9 in permanent neurologic injury, 21 in prolonged hospitalization without injury, and in 14 there was no harm. Patients receiving sedation in nonhospital-based settings compared with hospital-based settings were older and healthier. The venue of sedation was not associated with the incidence of presenting respiratory events (eg, desaturation, apnea, laryngospasm, approximately 80% in each venue) but more cardiac arrests occurred as the second (53.6% vs 14%) and third events (25% vs 7%) in nonhospital-based facilities. Inadequate resuscitation was rated as being a determinant of adverse outcome more frequently in nonhospital-based events (57.1% vs 2.3%). Death and permanent neurologic injury occurred more frequently in nonhospital-based facilities (92.8% vs 37.2%). Successful outcome (prolonged hospitalization without injury or no harm) was associated with the use of pulse oximetry compared with a lack of any documented monitoring that was associated with unsuccessful outcome (death or permanent neurologic injury). In addition, pulse oximetry monitoring of patients sedated in hospitals was uniformly associated with successful outcomes whereas in the nonhospital-based venue, 4 out of 5 suffered adverse outcomes. Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient.
This study-a critical incident analysis-identifies several features associated with adverse sedation events and poor outcome. There were differences in outcomes for venue: adverse outcomes (permanent neurologic injury or death) occurred more frequently in a nonhospital-based facility, whereas successful outcomes (prolonged hospitalization or no harm) occurred more frequently in a hospital-based setting. Inadequate resuscitation was more often associated with a nonhospital-based setting. Inadequate and inconsistent physiologic monitoring (particularly failure to use or respond appropriately to pulse oximetry) was another major factor contributing to poor outcome in all venues. Other issues rated by the reviewers were: inadequate presedation medical evaluation, lack of an independent observer, medication errors, and inadequate recovery procedures. Uniform, specialty-independent guidelines for monitoring children during and after sedation are essential. Age and size-appropriate equipment and medications for resuscitation should be immediately available regardless of the location where the child is sedated. All health care providers who sedate children, regardless of practice venue, should have advanced airway assessment and management training and be skilled in the resuscitation of infants and children so that they can successfully rescue their patient should an adverse sedation event occur.
To perform a systematic investigation of medications associated with adverse sedation events in pediatric patients using critical incident analysis of case reports.
One hundred eighteen case reports from the adverse drug reporting system of the Food and Drug Administration, the US Pharmacopoeia, and the results of a survey of pediatric specialists were used. Outcome measures were death, permanent neurologic injury, prolonged hospitalization without injury, and no harm. The overall results of the critical incident analysis are reported elsewhere. The current investigation specifically examined the relationship between outcome and medications: individual and classes of drugs, routes of administration, drug combinations and interactions, medication errors and overdoses, patterns of drug use, practitioners, and venues of sedation.
Ninety-five incidents fulfilled study criteria and all 4 reviewers agreed on causation; 60 resulted in death or permanent neurologic injury. Review of adverse sedation events indicated that there was no relationship between outcome and drug class (opioids; benzodiazepines; barbiturates; sedatives; antihistamines; and local, intravenous, or inhalation anesthetics) or route of administration (oral, rectal, nasal, intramuscular, intravenous, local infiltration, and inhalation). Negative outcomes (death and permanent neurologic injury) were often associated with drug overdose (n = 28). Some drug overdoses were attributable to prescription/transcription errors, although none of 39 overdoses in 34 patients seemed to be a decimal point error. Negative outcomes were also associated with drug combinations and interactions. The use of 3 or more sedating medications compared with 1 or 2 medications was strongly associated with adverse outcomes (18/20 vs 7/70). Nitrous oxide in combination with any other class of sedating medication was frequently associated with adverse outcomes (9/10). Dental specialists had the greatest frequency of negative outcomes associated with the use of 3 or more sedating medications. Adverse events occurred despite drugs being administered within acceptable dosing limits. Negative outcomes were also associated with drugs administered by nonmedically trained personnel and drugs administered at home. Some injuries occurred on the way to a facility after administration of sedatives at home; some took place in automobiles or at home after discharge from medical supervision. Deaths and injuries after discharge from medical supervision were associated with the use of medications with long half-lives (chloral hydrate, pentobarbital, promazine, promethazine, and chlorpromazine).
Adverse sedation events were frequently associated with drug overdoses and drug interactions, particularly when 3 or more drugs were used. Adverse outcome was associated with all routes of drug administration and all classes of medication, even those (such as chloral hydrate) thought to have minimal effect on respiration. Patients receiving medications with long plasma half-lives may benefit from a prolonged period of postsedation observation. Adverse events occurred when sedative medications were administered outside the safety net of medical supervision. Uniform monitoring and training standards should be instituted regardless of the subspecialty or venue of practice. Standards of care, scope of practice, resource management, and reimbursement for sedation should be based on the depth of sedation achieved (ie, the degree of vigilance and resuscitation skills required) rather than on the drug class, route of drug administration, practitioner, or venue.
ANESTHESIOLOGISTS possess specific expertise in the pharmacology, physiology, and clinical management of patients receiving sedation and analgesia. For this reason, they are frequently called on to participate in the development of institutional policies and procedures for sedation and analgesia in nonoperating-room settings. To assist in this process, the American Society of Anesthesiologists developed these Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines are systematically developed recommendations that assist practitioners in making decisions about health care. These recommendations may be adopted, modified, exceeded, or rejected according to clinical needs and constraints, and they are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. Practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. The practice guidelines enumerated below have been developed using systematic literature summarization techniques. Results of the literature analyses have been supplemented by the opinions of the Task Force members and a panel of more than 60 consultants, drawn from a variety of medical specialties in which sedation and analgesia are commonly provided. In those instances when the literature does not provide conclusive data, there is an explicit statement that the guidelines are based on the opinion of the consultants or the consensus of the Task Force members. A detailed description of the analytic methods is included in appendix 1.
These therapeutic approaches to the premedication of children, in our opinion, offer a more rational, probably safer, and at least equally efficacious treatment regimen as the DPT/lytic cocktail. It is understood that controlled, double-blind comparative clinical trials in children are needed of these or other potential premedicant regimens for specific pediatric procedures (e.g., cardiac catheterization, CT scans, bone marrow aspiration, gastrointestinal endoscopy, pleural taps, etc.) to establish the premedication treatment(s) with the greatest benefit-to-risk ratio. Until these data are available, we must maintain prudence in the selection (design) of premedicant regimens and carefully monitor all children receiving these "cocktails."
Most errors that lead to disaster have precursors. Few occur in unique or unfamiliar ways, even in aviation where efforts to eradicate familiar problems are so intense. If a certain type of incident that could lead to patient injury recurs sporadically, it is reasonable to assume that some day one of the recurrences actually will lead to injury. Therefore, action must be taken to stop recurrence of such incidents. Although an incident might appear to be minor, one should realize that most tragedies are the result of an improbable string of minor events, each of which may not be so improbable when considered by itself. The 30-minute refractory period described above provides a noteworthy mechanism for such minor incidents to compound each other in a type of chain reaction that can lead to disaster. Procedures must be established which will guarantee corrective responses to recurring incidents - even when seemingly insignificant - and which will assure that these corrective responses are well conceived. Because so few passive incident-reporting mechanisms will collect the type of information needed to achieve these results, active effort must be exerted to obtain prompt, meaningful reports on these errors which are the precursors to disaster. In addition, to ensure that the established reporting system is effective, protection of confidentiality and positive reinforcement must be key features of the system. The data collected in the study described here are still being analyzed for further insight into error patterns. Analysis of specific types of errors and problems should continue to lead to a greater understanding of how preventable mishaps occur and how they can be prevented.
The Committee on Drugs (COD) of the American Academy of Pediatrics (AAP), along with its many consultants, has spent considerable time addressing the difficult issue of appropriate care for sedated pediatric patients. The Committee's concern has been the continued appearance of reports, nearly always from nonmedical journal sources ("word of mouth", newspapers), of children suffering adverse events (morbidity and mortality) after sedation for procedares that in themselves should not result in any such complications, eg, radiologic investigations.1-4
The original "Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients" were published in 1985.5 These were constructed because of concern regarding a number of deaths that occurred in the dental office.6
Safe sedation of a pediatric patient requires a thorough knowledge of the pharmacokinetics and pharmacodynamics of the drugs used to sedate the patient and the skills necessary to deal effectively with potential adverse events as a result of the sedation. The Sedation Guidelines of the American Academy of Pediatrics are reviewed. Emphasis is placed on monitoring and appropriate selection of drugs.
To compare the effectiveness of intramuscular meperidine (2 mg/kg) and promethazine (1 mg/kg) with chlorpromazine (MPC) or without chlorpromazine (MP) (1 mg/kg) for sedation of children undergoing emergency department procedures.
Randomized, double-blind trial.
A community and university hospital ED.
Eighty-seven hemodynamically and neurologically stable children less than 16 years old.
IM sedation followed by intended procedure.
Children receiving either combination were not significantly different with regard to age, sex, weight, chronic illness, and indications. Procedures included laceration repair (46), fracture reduction (25), and others (16). Mean onset of action was similar (16 +/- 12 minutes), whereas the duration of action was significantly longer after MPC (63 +/- 57 minutes [mean +/- SD] compared with MP 29 +/- 36 minutes; P < .05, Student's t-test). Paradoxical hyperactivity occurred only after MP (three of 43 cases; P = NS, Fisher's exact test), whereas transient oxygen desaturation occurred only after MPC (one of 44 cases; P = NS). No other serious complications were observed. Three observers rated the effectiveness of sedation and analgesia on separate 10.2-cm visual-analog scales. Overall, MPC received significantly better ratings (7.4 +/- 2.1 cm) than MP (5.7 +/- 3.0 cm; P < .05, Mann-Whitney U test). Parents believed sedation worked well in 90% of cases. Their children had bad memories of the procedure in only 9% of cases.
Elimination of chlorpromazine from the IM combination of meperidine and promethazine for pediatric sedation during ED procedures results in a significant reduction in efficacy.
A previous report suggested that airway compromise without self-correction may occur in pediatric dental patients sedated with chloral hydrate (CH) and nitrous oxide (N2O) and may be interpreted as "deep" sedation. The purpose of this institutionally approved study was to determine 1) the association between the size of the tonsils and 2) the degree of expired carbon dioxide (CO2) and oxygen saturation (SaO2) changes to simulated airway obstruction using the Moore head-tilt maneuver for 30 sec or less. Thirty healthy children (ASA I), aged 22-40 months, were evaluated for tonsil size and sedated with CH (50 mg/kg) and hydroxyzine (2 mg/kg) and supplemented with N2O. Pulse oximetry and capnography were used to monitor the child. During the restorative phase when the patient appeared asleep, the head was rolled forward with the chin touching the chest for a period of 30 sec. Changes in SaO2 and CO2 waveform were observed during this period. The results indicated that seven children who had enlarged tonsils had blocked airways (as determined by capnography) lasting approximately 15 sec. The remaining children did not have enlarged tonsils and continued to exchange air appropriately. O2 levels did not change during this period. The results suggest that the likelihood of airway blockage increases with enlarged tonsils. In children without airway blockage, ventilation occurs unimpeded, and attempts to readjust the head may not occur. The association between airway blockage and patient responsiveness is discussed in relation to sedation levels.
Recent media attention has focused the public's attention on issues surrounding pediatric oral conscious sedation. Under a law passed in 1998 and taking affect on Jan. 1, 2000, California dentists will be subject to certification and procedural provisions designed to ensure the educational qualification of the provider and the standards under which the procedure is performed. This article discusses the history of concern and regulation regarding sedation of children in the dental office.
The purpose of this study was to evaluate the potential of using capnography to analyze respiratory samples taken from a scavenging nitrous oxide nasal hood during routine pediatric dental procedures.
Twenty-two subjects, aged 60-116 months, were administered alternately either 40% nitrous oxide/60% oxygen or 100% oxygen during two sequential restorative appointments. All subjects were monitored continuously for end-tidal carbon dioxide and respiratory rate using a capnograph whose sampling line was attached directly to the nitrous oxide nasal hood. The subject's breath sound, displayed behavior, type of dental procedure being performed, and presence of rubber dam isolation were recorded every minute throughout the two appointments.
Values for end-tidal carbon dioxide and respiratory rate were displayed on the capnograph when administering either oxygen or a combination of nitrous oxide/oxygen inhalation through the nasal hood. These respiratory values were lowered significantly when comparing 40% nitrous oxygen-60% oxygen to 100% oxygen inhalation. They were not significantly altered by the type of breath sound, patient behavior, dental procedure, or presence of rubber dam isolation, with the exception of some dental procedures which significantly lowered end-tidal carbon dioxide. The apnea alarm on the capnograph occurred during 5% of the total treatment time, but its occurrence represented a 97% false positive rate. The occurrence of the apnea alarm was significantly associated with the type for breath sound, patient behavior, and dental procedure. When used in this manner, the capnograph was effective in alerting the practitioner to potential apneic events, but likely has limited value in monitoring valid end-tidal carbon dioxide levels due to limitations in the sampling technique.
This study demonstrated the potential of the capnograph as a respiratory monitor for pediatric dental patients when the sampling line was attached to a scavenging nitrous oxide nasal hood.
Sedatives are an important and necessary management technique for some children during dental procedures. Sedation can be administered safely and efficiently by competent practitioners who have special training in the use of the technique in children and who adhere to sedation guidelines. Nonetheless, some children present with special needs, such as medically compromising conditions, or multiple carious teeth in a child who is fearful or whose family must travel a long distance for care. Sedation cannot always safely and adequately meet the needs of these children. In these cases, general anesthesia in a hospital, ambulatory care facility, or office is indicated and must be provided by an appropriately licensed and trained physician or dentist.
Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures
- Committee on Drugs American Academy of Pediatrics
Use of pediatric sedation and analgesia
- American College of Emergency Physicians