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  • • 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.

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• Although there are few absolute contraindications, the points presented here are important to consider when weighing the risks and benefits of the sedation procedure.

  • • 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 ...

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