The goals of sedation and analgesia are to relieve pain and suffering and to allow diagnostic and therapeutic procedures to proceed with comfort, safety, efficacy, and efficiency. The needs of the patient and the specific goals of sedation must be considered on an individual basis, with attention to patient safety and minimization of anxiety, pain, and memory. Adherence to the guidelines for the monitoring of sedated patients developed by the American Academy of Pediatrics (AAP), the American Society of Anesthesiologists (ASA), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is essential.1-4 Please note that the information provided in this chapter is not sufficient guidance for the safe administration of procedural sedation. Each institution should have its own training and certification requirement as well as a procedure for maintaining competence in providing procedural sedation. It is our responsibility as hospitalists to ensure that our patients are cared for in systems that provide for safe, efficient and effective sedation.
The following definitions for the level of sedation have been adopted by the AAP, ASA, and JCAHO.1-4
Minimal sedation (anxiolysis): A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are usually maintained.
Moderate sedation or analgesia: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light to moderate tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep sedation or analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to maintain independent ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General anesthesia: A drug-induced loss of consciousness during which patients cannot be aroused, even by painful stimulation. The ability to maintain independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or depression of neuromuscular function.
It is important to note that patients’ responses to medications and doses can vary tremendously. Thus healthcare providers intending to achieve moderate sedation should be prepared to manage unintended deep sedation, and during attempts to achieve deep sedation, the provider should be capable of managing a brief period of general anesthesia, including maintaining a patent airway, effective ventilation, and cardiovascular function.
HISTORY AND PHYSICAL EXAMINATION
All children scheduled to undergo sedation should be screened for potential adverse events during sedation and recovery. A presedation evaluation includes a focused history and physical examination, with attention to the airway and cardiorespiratory status. ...