Sedation of Pediatric Patients

Definition

Sedation may be described as a continuum of states of depressed consciousness. The American Academy of Pediatrics (AAP), the American Society of Anesthesiologists (ASA), and the Joint Commission (TJC) have agreed on standardized definitions to describe sedation depth including minimal sedation, moderate sedation, deep sedation, and general anesthesia. Definitions of sedation states and patient responsiveness are presented in Table 76.1 . The possible “states” or “depths” of sedation have been correlated to the risk of complications based on the extent to which natural airway/vascular tone and protective reflexes have been depressed. Deeper levels of sedation have greater likelihood of depressing airway tone, protective reflexes, respiratory drive, and cardiac function, inherently resulting in greater risks of complications.

Because sedation is a continuum and patient responses to sedating medications are unpredictable, emphasis has been placed on practitioners’ ability to rescue patients from at least one level of sedation deeper than intended. As such, practitioners who administer drugs to achieve minimal sedation must have the skills to rescue a patient who becomes moderately sedated, and practitioners who intend to achieve deep sedation must have the skills to rescue patients from a state of general anesthesia. Because most sedation-related adverse events in children are related to airway compromise or loss of respiratory effort, the most important skills are the appropriate recognition of inadequate ventilation and subsequent advanced airway management. For practical purposes, most children require deep sedation to produce acceptable conditions for prolonged diagnostic or therapeutic procedures. Therefore it is good practice to use the guidelines for deep sedation from the outset of the sedation process.

Sedation adverse events (complications) have been well documented in a number of studies, notably in a report from the Pediatric Sedation Research Consortium (PSRC). In a report of over 30,000 prospectively observed sedation encounters, this group reported the observed complications, which included (but were not limited to) apnea, airway obstruction, laryngospasm, hypoxia, prolonged recovery, and aspiration. There were also a small number of patients with hypotension and bradycardia ( Table 76.2 ). Although the rates for serious adverse events were low, the data confirm that sedation of children involves alterations of consciousness that are associated with partial or complete loss of protective reflexes and more profound changes in central nervous system and cardiopulmonary physiology.

TJC and the Centers for Medicare and Medicaid Services (CMS) have recognized anesthesiologists as experts in managing all levels of sedation/anesthesia, and both organizations have mandated that departments of anesthesia lead the way in developing institutional policies regarding the sedation of all patients, whether adult or pediatric. The intention is to create uniform standards of care regarding the management of patients undergoing sedation/anesthesia within each institution.