Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0032
Jennifer K. Gillen, J. Hojsak
Cerebral palsy is a nonprogressive disorder resulting from an injury to the brain before, during, or slightly after birth that affects motor function. Patients with cerebral palsy have a wide range of symptomatology that can affect their risk for complications during anesthesia and procedural sedation. The inherent issues of spasticity and hypotonia affecting skeletal muscle, oropharyngeal muscle function, and gut motility create an increased risk for airway-related adverse events in particular. Contractures may affect the positioning requirements of any procedure or test, thereby affecting the level of sedation needed for patient comfort and procedure completion. Careful preprocedure planning is crucial.
{"title":"The Child with Cerebral Palsy","authors":"Jennifer K. Gillen, J. Hojsak","doi":"10.1093/MED/9780190659110.003.0032","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0032","url":null,"abstract":"Cerebral palsy is a nonprogressive disorder resulting from an injury to the brain before, during, or slightly after birth that affects motor function. Patients with cerebral palsy have a wide range of symptomatology that can affect their risk for complications during anesthesia and procedural sedation. The inherent issues of spasticity and hypotonia affecting skeletal muscle, oropharyngeal muscle function, and gut motility create an increased risk for airway-related adverse events in particular. Contractures may affect the positioning requirements of any procedure or test, thereby affecting the level of sedation needed for patient comfort and procedure completion. Careful preprocedure planning is crucial.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"31 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125139498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0038
J. Biber, J. Wheeler
While solid organ biopsies are routinely done on adults with only local anesthesia or minimal sedation, children frequently require deep sedation or general anesthesia to achieve acceptable conditions (stillness, anxiolysis, analgesia) to facilitate these procedures. This is more frequently being done with pediatric sedation/anesthesia outside the operating room. Issues unique to sedation for these procedures are pain, the need for relative patient immobility (both during the procedure and following it), and the nonstandard positioning required during the procedure. Regardless of the medications chosen, adequate monitoring should occur during the procedure as well as during the recovery period. With a good sedation plan for both sedation and analgesia, adequate monitoring, and contingency planning for adverse events, this can safely be performed in institutions with highly motivated and organized sedation services.
{"title":"Solid Organ Biopsies","authors":"J. Biber, J. Wheeler","doi":"10.1093/MED/9780190659110.003.0038","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0038","url":null,"abstract":"While solid organ biopsies are routinely done on adults with only local anesthesia or minimal sedation, children frequently require deep sedation or general anesthesia to achieve acceptable conditions (stillness, anxiolysis, analgesia) to facilitate these procedures. This is more frequently being done with pediatric sedation/anesthesia outside the operating room. Issues unique to sedation for these procedures are pain, the need for relative patient immobility (both during the procedure and following it), and the nonstandard positioning required during the procedure. Regardless of the medications chosen, adequate monitoring should occur during the procedure as well as during the recovery period. With a good sedation plan for both sedation and analgesia, adequate monitoring, and contingency planning for adverse events, this can safely be performed in institutions with highly motivated and organized sedation services.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127676514","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0027
A. Stormorken
The goals of sedation for both diagnostic and therapeutic procedures are to manage preprocedural anxiety, minimize pain, and allow for successful completion of the procedure without adverse patient outcomes. To plan the appropriate way to achieve these goals, the sedationist must decide whether the procedure will cause the patient pain (invasiveness), the degree of immobility required for the procedure to be completed effectively, and the duration of time for which sedation is needed. If systemic medications are needed to manage the patient and procedural goals, they should be selected based on the duration of sedation necessary. Pain control can often be effectively managed with local injectable or topical techniques. It is the sedationist’s responsibility to choose a medication, or combination of medications, that allows for administration of the lowest dose of drug(s) possible while providing the greatest effective therapeutic effect.
{"title":"Procedural Aspects Affecting Sedation Care","authors":"A. Stormorken","doi":"10.1093/MED/9780190659110.003.0027","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0027","url":null,"abstract":"The goals of sedation for both diagnostic and therapeutic procedures are to manage preprocedural anxiety, minimize pain, and allow for successful completion of the procedure without adverse patient outcomes. To plan the appropriate way to achieve these goals, the sedationist must decide whether the procedure will cause the patient pain (invasiveness), the degree of immobility required for the procedure to be completed effectively, and the duration of time for which sedation is needed. If systemic medications are needed to manage the patient and procedural goals, they should be selected based on the duration of sedation necessary. Pain control can often be effectively managed with local injectable or topical techniques. It is the sedationist’s responsibility to choose a medication, or combination of medications, that allows for administration of the lowest dose of drug(s) possible while providing the greatest effective therapeutic effect.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"281 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116073974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0036
Patricia D. Scherrer, Laura Bredbenner
The voiding cystourethrogram (VCUG), which involves bladder catheterization and then fluoroscopic imaging of bladder filling and voiding, is the “gold standard” procedure for the diagnosis of vesicoureteral reflux in children. However, it can be associated with significant distress and discomfort for children. Child Life Specialists are essential to preprocedure preparation and coping strategies for all children, but some patients may also require procedural sedation. Oral or intranasal midazolam and nitrous oxide are the two most commonly used agents, each with its own advantages. Some children may benefit from even deeper levels of sedation, including dissociative sedation/analgesia with oral or intravenous ketamine, deep sedation with intravenous propofol, or even general anesthesia with inhaled anesthetics such as sevoflurane. The choice of regimen should be a joint decision among the multidisciplinary team members to best meet the needs of the child.
{"title":"Voiding Cystourethrography","authors":"Patricia D. Scherrer, Laura Bredbenner","doi":"10.1093/med/9780190659110.003.0036","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0036","url":null,"abstract":"The voiding cystourethrogram (VCUG), which involves bladder catheterization and then fluoroscopic imaging of bladder filling and voiding, is the “gold standard” procedure for the diagnosis of vesicoureteral reflux in children. However, it can be associated with significant distress and discomfort for children. Child Life Specialists are essential to preprocedure preparation and coping strategies for all children, but some patients may also require procedural sedation. Oral or intranasal midazolam and nitrous oxide are the two most commonly used agents, each with its own advantages. Some children may benefit from even deeper levels of sedation, including dissociative sedation/analgesia with oral or intravenous ketamine, deep sedation with intravenous propofol, or even general anesthesia with inhaled anesthetics such as sevoflurane. The choice of regimen should be a joint decision among the multidisciplinary team members to best meet the needs of the child.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116443353","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0033
Jeana E. Havidich, R. Evans
Preterm and former preterm infants present unique challenges for sedation providers. These children represent a heterogeneous high-risk population who frequently require sedation or anesthesia for diagnostic and therapeutic procedures. They have limited physiologic reserve and immature metabolic functions. Prematurity is associated with an increased risk for sedation adverse events, including death. Understanding the anatomic and physiologic differences between preterm and term children is necessary for the development of a sedation plan. One of the most important differences pertains to the airway and respiratory system, so airway management is a critical component of the sedation plan. Preterm neonates have altered pharmacokinetics and pharmacodynamics, so titration of sedative drugs is recommended.
{"title":"The Premature Infant","authors":"Jeana E. Havidich, R. Evans","doi":"10.1093/med/9780190659110.003.0033","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0033","url":null,"abstract":"Preterm and former preterm infants present unique challenges for sedation providers. These children represent a heterogeneous high-risk population who frequently require sedation or anesthesia for diagnostic and therapeutic procedures. They have limited physiologic reserve and immature metabolic functions. Prematurity is associated with an increased risk for sedation adverse events, including death. Understanding the anatomic and physiologic differences between preterm and term children is necessary for the development of a sedation plan. One of the most important differences pertains to the airway and respiratory system, so airway management is a critical component of the sedation plan. Preterm neonates have altered pharmacokinetics and pharmacodynamics, so titration of sedative drugs is recommended.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"12 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131038463","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0051
R. Burger, Shobhit Jain
Midazolam, the most commonly used oral sedative in children, is used primarily as a premedication but can also be beneficial in brief, minimally invasive procedures, with few side effects. Ketamine can be used for brief, painful procedures but can cause vomiting. Dexmedetomidine can be used as a premedication but has not been extensively studied. Chloral hydrate is useful for imaging studies and noninvasive procedures but is limited by its prolonged sedative effects. Melatonin can be used for sedation and anxiolysis for imaging and noninvasive testing, but there is conflicting literature about its analgesic effects. There are limited studies on the use of meperidine and hydroxyzine for dental procedures. Ketamine and dexmedetomidine intravenous preparations have been administered enterally. Melatonin and clonidine are enteral medications that may prove useful in pediatric procedural sedation. In general, enteral administration is associated with preprocedural anxiolysis, uneven bioavailability, and unpredictable onset of action and recovery times.
{"title":"Oral Medications","authors":"R. Burger, Shobhit Jain","doi":"10.1093/med/9780190659110.003.0051","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0051","url":null,"abstract":"Midazolam, the most commonly used oral sedative in children, is used primarily as a premedication but can also be beneficial in brief, minimally invasive procedures, with few side effects. Ketamine can be used for brief, painful procedures but can cause vomiting. Dexmedetomidine can be used as a premedication but has not been extensively studied. Chloral hydrate is useful for imaging studies and noninvasive procedures but is limited by its prolonged sedative effects. Melatonin can be used for sedation and anxiolysis for imaging and noninvasive testing, but there is conflicting literature about its analgesic effects. There are limited studies on the use of meperidine and hydroxyzine for dental procedures. Ketamine and dexmedetomidine intravenous preparations have been administered enterally. Melatonin and clonidine are enteral medications that may prove useful in pediatric procedural sedation. In general, enteral administration is associated with preprocedural anxiolysis, uneven bioavailability, and unpredictable onset of action and recovery times.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131056668","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0018
Lorie Reilly
Recovery from sedation is a dynamic, multiphase process that warrants attentive monitoring by a team of knowledgeable, skillful providers. In addition to automated monitor interpretation and documentation, the team caring for the patient from the immediate postsedation phase through discharge to home or transfer back to the inpatient unit must be knowledgeable about the patient and comorbidities, the procedure just completed, the pharmacologic properties of the sedation regimen employed, and the adverse events that may occur as recovery unfolds, and they must have the necessary skills to navigate and rescue the patient from any such adverse events. Availability of basic and advanced airway equipment, reversal medications, and intravenous fluids is critical. Direct observation with attention to level of consciousness, cardiorespiratory status, temperature, and pain status is required. Monitoring must continue until the patient returns to the presedation baseline state prior to discharge. Written instructions and verbal, interpersonal communication with caregivers are essential to the conclusion of sedation recovery monitoring.
{"title":"Monitoring","authors":"Lorie Reilly","doi":"10.1093/med/9780190659110.003.0018","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0018","url":null,"abstract":"Recovery from sedation is a dynamic, multiphase process that warrants attentive monitoring by a team of knowledgeable, skillful providers. In addition to automated monitor interpretation and documentation, the team caring for the patient from the immediate postsedation phase through discharge to home or transfer back to the inpatient unit must be knowledgeable about the patient and comorbidities, the procedure just completed, the pharmacologic properties of the sedation regimen employed, and the adverse events that may occur as recovery unfolds, and they must have the necessary skills to navigate and rescue the patient from any such adverse events. Availability of basic and advanced airway equipment, reversal medications, and intravenous fluids is critical. Direct observation with attention to level of consciousness, cardiorespiratory status, temperature, and pain status is required. Monitoring must continue until the patient returns to the presedation baseline state prior to discharge. Written instructions and verbal, interpersonal communication with caregivers are essential to the conclusion of sedation recovery monitoring.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"3 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131569040","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0019
Michelle M. Rhoads, Tracy Campbell
Preparation for discharge should begin well before the patient arrives in the recovery room. To ensure a safe and timely discharge, goals must be established for each patient. Elements of a successful discharge include collaboration of team members, use of evidence-based policies and procedures, and adequate patient preparation. Readiness for discharge can be determined by using objective and measureable discharge criteria, taking into consideration the needs of the patient and family. Assessment for discharge readiness should include use of validated discharge criteria or sedation score, postoperative nausea and vomiting evaluation, management of pain, postprocedural/sedation care education, and an understanding of follow-up needs. Adherence to these essential criteria will not only help to ensure a timely and safe discharge but will also improve patient and family satisfaction.
{"title":"Discharge Considerations","authors":"Michelle M. Rhoads, Tracy Campbell","doi":"10.1093/med/9780190659110.003.0019","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0019","url":null,"abstract":"Preparation for discharge should begin well before the patient arrives in the recovery room. To ensure a safe and timely discharge, goals must be established for each patient. Elements of a successful discharge include collaboration of team members, use of evidence-based policies and procedures, and adequate patient preparation. Readiness for discharge can be determined by using objective and measureable discharge criteria, taking into consideration the needs of the patient and family. Assessment for discharge readiness should include use of validated discharge criteria or sedation score, postoperative nausea and vomiting evaluation, management of pain, postprocedural/sedation care education, and an understanding of follow-up needs. Adherence to these essential criteria will not only help to ensure a timely and safe discharge but will also improve patient and family satisfaction.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"35 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127868428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0001
L. Lowrie
The processes of care involved in providing sedation and analgesia for children undergoing diagnostic and therapeutic procedures have evolved from an afterthought necessary to accomplish a procedure humanely to almost a medical discipline of its own centering around patient physical and psychological comfort and safety. Many of the tests and procedures common to modern medical care are easily accomplished for a competent adult who is able to understand the advantages of holding still, the timeframe of brief painful injections, and the future benefits represented by accomplishing the unpleasant test. Infants and children developmentally cannot project such abstract thinking to rationalize an unpleasant experience and may experience potentially long-lasting psychological consequences unless healthcare professionals provide supportive and preventive care. In this sense, procedural sedation is a uniquely pediatric field. This chapter should serve to place the rapidly emerging arena of pediatric procedural sedation into an appropriate historical context from which the reader may better understand the current state of the art of pediatric sedation and recognize the gaps in understanding of best practice in the complex care required.
{"title":"Pediatric Sedation","authors":"L. Lowrie","doi":"10.1093/med/9780190659110.003.0001","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0001","url":null,"abstract":"The processes of care involved in providing sedation and analgesia for children undergoing diagnostic and therapeutic procedures have evolved from an afterthought necessary to accomplish a procedure humanely to almost a medical discipline of its own centering around patient physical and psychological comfort and safety. Many of the tests and procedures common to modern medical care are easily accomplished for a competent adult who is able to understand the advantages of holding still, the timeframe of brief painful injections, and the future benefits represented by accomplishing the unpleasant test. Infants and children developmentally cannot project such abstract thinking to rationalize an unpleasant experience and may experience potentially long-lasting psychological consequences unless healthcare professionals provide supportive and preventive care. In this sense, procedural sedation is a uniquely pediatric field. This chapter should serve to place the rapidly emerging arena of pediatric procedural sedation into an appropriate historical context from which the reader may better understand the current state of the art of pediatric sedation and recognize the gaps in understanding of best practice in the complex care required.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"2016 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128038886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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