Chapter 20

• Delaying sedation because of recent food/drink intake must be balanced by the urgency of the procedure and the risk to the patient imposed by such a delay.
• Any patient who could be a “difficult intubation” (craniofacial abnormalities, atlantoaxial instability, and prior tracheal reconstruction) merits consultation with anesthesia.
• Continuous monitoring of oxygen saturation and heart rate will identify the most common serious risk of sedation, hypoxia.
• Intravenous administration of sedative agents offers the greatest flexibility for titrating doses and for deep sedation.
• Infants younger than 3 months should not get ketamine due to the high risk of airway complications.
• Pressure applied to the “laryngospasm notch” (see Figure 20–3) may reverse laryngospasm.
• Emergence reactions associated with ketamine appear to be related to the pretreatment anxiety level of the patient.
• Deep sedation for painless procedures can be achieved by a variety of drugs; the clinician should become familiar with one or two and understand fully the risks and dosing.
• Etomidate as a sedative is associated with very few airway events, and can be used in the hypotensive patient.
• Combinations of drugs may potentiate desired properties of each, but it may also increase adverse effects such as respiratory depression.

Over the last two decades, acknowledgment of the presence1 and importance of pediatric pain2 has transformed the management of ill and injured patients. Procedural sedation and analgesia (PSA) are now an integral component of pediatric emergency care.3 Increased availability of emergent imaging has expanded the emergency physician's role to include magnetic resonance imaging (MRI) and computed tomography (CT) scan sedation.4 With the corresponding increase in research, the ability of emergency medicine practitioners to safely control pain and produce sedation is now established and expected.57

Sedatives with or without analgesics are given for tedious, precise, or painful procedures, resulting in a level of consciousness depressed enough to accomplish the procedure while maintaining respiratory drive. The previous misnomer conscious sedation has been replaced by four levels of procedural sedation, each with increasing risk of loss of protective and cardiorespiratory functions.8 Anxiolysis or “Minimal Sedation” impairs coordination and cognitive function, but allows patients to respond appropriately to verbal stimuli. “Moderate sedation” retains purposeful response to verbal or light stimuli, but with profound relaxation. Under “deep sedation,” repeated painful stimulation yields purposeful response, at doses “not likely” to depress ventilatory function. “General anesthesia” is the state where painful stimuli do not evoke a response, thus the corresponding lack of tone can compromise both airway reflexes and cardiorespiratory function.

The Joint Commission and the American Academy of Pediatrics recognize that sedation is a continuum; therefore, safety and monitoring guidelines focus on the ability to rescue a patient from a deeper level of sedation than intended.3,9 Cooperation for a painless diagnostic study, such as MRI, requires a different degree and duration of sedation than a painful fracture reduction. Safety guidelines encompass patient assessment, personnel and monitoring equipment, ...

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