Chapter 14. Sedation and Pain Management

• Cases that require a relatively motionless child in order to provide adequate working conditions.

• Invasive procedures, such as laceration repair, lumbar puncture, and orthopedic procedures.

• Diagnostic imaging studies.

• Due to the risk of oversedation or an allergic response to a sedative, sedation is indicated only if absolutely necessary.

• History of an allergy or other untoward reaction to previous sedation attempts.

• Facial dysmorphism or deformity or anatomic variation that would make maintaining airway competency difficult (ie, Pierre Robin syndrome or Goldenhar syndrome). In these cases, consultation with an anesthesiologist is warranted.

• The presence of upper respiratory infection.

• • Although not an absolute contraindication, sedation should be approached with caution.

  • In a patient with clear lung fields but rhinorrhea, glycopyrrolate or atropine can be used prior to sedation to aid in drying secretions.

• The presence of lower airway symptoms, such as wheezing.

• • For nonemergent sedations, rescheduling should be strongly considered.

  • For emergent sedations, pretreatment with nebulized albuterol and use of ketamine should be considered.

• Vital signs must be assessed before, during, and after the sedation process.

• Pulse oximetry should be recorded regularly.

• • Derangements in pulse oximetry may be the first sign of a problem, perhaps stemming from hypoventilation or laryngospasm.

• Capnography, while not widely used, had been studied recently as an adjuvant in monitoring patients during sedation.

• There is some evidence that elevation of carbon dioxide as measured by inline capnography may be a reliable early indicator of respiratory compromise from oversedation.

• Loss of airway patency; if unrecognized, hypoventilation or upper airway obstruction can lead to hypoxemia and respiratory arrest.

• Circulatory collapse can be induced by peripheral vasodilation and direct myocardial effects of some drugs.

• Potential for aspiration is increased with deep sedation because the gag reflex is lost.

• Allergic reactions are uncommon but do occur. The physician must be able to quickly diagnose and intervene if anaphylaxis begins.

• Terms such as “conscious sedation” and “twilight sleep” are misleading as any degree of sedation has potential to change to deep anesthesia and must be approached with this in mind.

• Practitioners who sedate patients must be skilled in advanced airway management, pediatric advanced life support, and in assessment of patients for changing levels of sedative effects.

• Trained support staff and resuscitation equipment and drugs must also be immediately available.

• Sedation should be initiated in a controlled environment. No sedation medications should be given by the parents on the way to the hospital or office, as was once common.

• Although complications from sedation are infrequent, the physician must be prepared for any clinical situation.

• In addition to being prepared for ...