Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0017
D. Faulk
Assessing a child’s level of sedation is critical to the safe provision of sedation for diagnostic and therapeutic procedures. Providers must recognize when patients enter deeper than intended levels of sedation where cardiorespiratory compromise can occur and promptly intervene to prevent clinical deterioration. Observational scales and processed EEG monitors have been used to assess levels of sedation. In circumstances where there is physical separation of provider and patient, increased vigilance and frequency of monitoring physiologic parameters is critical. The use of capnography to monitor respiratory function should be employed in these situations.
{"title":"Observation","authors":"D. Faulk","doi":"10.1093/med/9780190659110.003.0017","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0017","url":null,"abstract":"Assessing a child’s level of sedation is critical to the safe provision of sedation for diagnostic and therapeutic procedures. Providers must recognize when patients enter deeper than intended levels of sedation where cardiorespiratory compromise can occur and promptly intervene to prevent clinical deterioration. Observational scales and processed EEG monitors have been used to assess levels of sedation. In circumstances where there is physical separation of provider and patient, increased vigilance and frequency of monitoring physiologic parameters is critical. The use of capnography to monitor respiratory function should be employed in these situations.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"420 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":"121823239","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/9780190659110.003.0009
Feifei Z. Williams, Michael Wolf
Children with congenital heart disease (CHD) are at an increased risk for sedation-related complications. The number of these patients with unrepaired or palliated disease requiring procedural sedation outside of the operating room continues to increase as staged surgeries and techniques are associated with better survival. CHD patient characteristics associated with the highest risk of sedation-related complications include age less than 2 years; single-ventricle physiology, including hypoplastic left heart syndrome; left ventricular outflow tract obstruction; cardiomyopathy with impaired ventricular function; and pulmonary hypertension. Before sedating a child with CHD, providers must recognize the anatomic variations, surgical history, and physiologic implications for each individual patient. An understanding of the hemodynamic principles involved in managing intracardiac shunts is essential. Commonly used sedation medications in patients with CHD and their potential adverse effects are discussed, as well as presedation and postsedation considerations.
{"title":"Congenital Heart Disease Considerations","authors":"Feifei Z. Williams, Michael Wolf","doi":"10.1093/MED/9780190659110.003.0009","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0009","url":null,"abstract":"Children with congenital heart disease (CHD) are at an increased risk for sedation-related complications. The number of these patients with unrepaired or palliated disease requiring procedural sedation outside of the operating room continues to increase as staged surgeries and techniques are associated with better survival. CHD patient characteristics associated with the highest risk of sedation-related complications include age less than 2 years; single-ventricle physiology, including hypoplastic left heart syndrome; left ventricular outflow tract obstruction; cardiomyopathy with impaired ventricular function; and pulmonary hypertension. Before sedating a child with CHD, providers must recognize the anatomic variations, surgical history, and physiologic implications for each individual patient. An understanding of the hemodynamic principles involved in managing intracardiac shunts is essential. Commonly used sedation medications in patients with CHD and their potential adverse effects are discussed, as well as presedation and postsedation considerations.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"10 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":"121972972","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/9780190659110.003.0031
L. Burton, P. Kamat
Children with autism spectrum disorders (ASD) require procedural sedation for a variety of diagnostic and therapeutic reasons. Patients with ASD present a challenge to the sedationist due to a variety of issues, including impairment in social interaction, barriers to communication, complex behavioral patterns, stereotyped repetitive behavior, mental health issues, and a need for consistency in terms of environment and caregivers. Children with ASD, especially teenagers, can exhibit aggressive behavior, self-injury, and temper tantrums, which can lead to issues with efficient and safe preparation for procedural sedation. Other challenges include the need for additional resources, difficulties in approaching the patient to perform a physical examination, delays in administering premedications, and difficulty obtaining intravenous access prior to the procedure. Children with ASD are more likely to be referred for general anesthesia due to these problems. This chapter discusses the role of the sedationist in the procedural sedation of these children.
{"title":"The Child with Autism Spectrum Disorder","authors":"L. Burton, P. Kamat","doi":"10.1093/MED/9780190659110.003.0031","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0031","url":null,"abstract":"Children with autism spectrum disorders (ASD) require procedural sedation for a variety of diagnostic and therapeutic reasons. Patients with ASD present a challenge to the sedationist due to a variety of issues, including impairment in social interaction, barriers to communication, complex behavioral patterns, stereotyped repetitive behavior, mental health issues, and a need for consistency in terms of environment and caregivers. Children with ASD, especially teenagers, can exhibit aggressive behavior, self-injury, and temper tantrums, which can lead to issues with efficient and safe preparation for procedural sedation. Other challenges include the need for additional resources, difficulties in approaching the patient to perform a physical examination, delays in administering premedications, and difficulty obtaining intravenous access prior to the procedure. Children with ASD are more likely to be referred for general anesthesia due to these problems. This chapter discusses the role of the sedationist in the procedural sedation of these children.","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":"127523767","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/9780190659110.003.0022
C. Chumpitazi
The incidence of sedation-related adverse events depends on the medications administered, the characteristics of the procedure, and preexisting patient factors. Minor adverse sedation-related events may present inconvenience or transient discomfort to the patient and, if recognized and supported in a timely manner by the sedationist, will not usually result in physiologic or psychological harm to the patient. Postprocedure vomiting, transient hypoxemia, mild hypotension, emergence reactions, and prolonged recovery times are examples of minor events. The relative likelihood of events of this type (1 of every 200 sedation episodes) provides significant impetus for effective preparation and training for sedationists to effectively respond to or preempt them. These “minor” events can still progress to more significant harm.
{"title":"Minor Adverse Events","authors":"C. Chumpitazi","doi":"10.1093/med/9780190659110.003.0022","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0022","url":null,"abstract":"The incidence of sedation-related adverse events depends on the medications administered, the characteristics of the procedure, and preexisting patient factors. Minor adverse sedation-related events may present inconvenience or transient discomfort to the patient and, if recognized and supported in a timely manner by the sedationist, will not usually result in physiologic or psychological harm to the patient. Postprocedure vomiting, transient hypoxemia, mild hypotension, emergence reactions, and prolonged recovery times are examples of minor events. The relative likelihood of events of this type (1 of every 200 sedation episodes) provides significant impetus for effective preparation and training for sedationists to effectively respond to or preempt them. These “minor” events can still progress to more significant harm.","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":"128802889","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/9780190659110.003.0056
U. Tirodker
In the past several decades the practice of procedural sedation and analgesia has evolved into a distinct skill set and a service that has rapidly grown in terms of indications, need, practitioner types, and practice settings. The scope of non-anesthesiology sedation providers includes but is not limited to intensivists, emergency medicine physicians, hospitalists, dentists, gastroenterologists, pulmonologists, cardiologists, advanced practice providers, and nursing. Several subspecialty societies and regulatory institutions have published and revised guidelines and standards to enhance patient safety by standardizing various aspects related to patient evaluation, personnel, monitoring, and management of procedural sedation and analgesia and its recovery. The American Academy of Pediatrics, American Society of Anesthesiologists, and the American College of Emergency Physicians are the groups that have published the most widely disseminated, comprehensive guidelines. This chapter gives an overview of these societies’ guidelines.
{"title":"Society Guidelines","authors":"U. Tirodker","doi":"10.1093/med/9780190659110.003.0056","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0056","url":null,"abstract":"In the past several decades the practice of procedural sedation and analgesia has evolved into a distinct skill set and a service that has rapidly grown in terms of indications, need, practitioner types, and practice settings. The scope of non-anesthesiology sedation providers includes but is not limited to intensivists, emergency medicine physicians, hospitalists, dentists, gastroenterologists, pulmonologists, cardiologists, advanced practice providers, and nursing. Several subspecialty societies and regulatory institutions have published and revised guidelines and standards to enhance patient safety by standardizing various aspects related to patient evaluation, personnel, monitoring, and management of procedural sedation and analgesia and its recovery. The American Academy of Pediatrics, American Society of Anesthesiologists, and the American College of Emergency Physicians are the groups that have published the most widely disseminated, comprehensive guidelines. This chapter gives an overview of these societies’ guidelines.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"43 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":"127695439","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/9780190659110.003.0008
J. Linzer
While respiratory concerns tend to be the first consideration with sedation medications, many can have important effects on the cardiovascular system that need to be managed. Changes in heart rate, blood pressure, and cardiac work have to be considered. While most of these medications will affect arterial blood pressure in one way or another, some will have no effect on heart rate. While one agent may work well in majority of patients, that same medication could have potentially devastating effects because of a patient’s underlying condition. Additionally, simply changing the rate of drug administration can potentially reduce or increase the cardiovascular effects.
{"title":"Sedation Effects","authors":"J. Linzer","doi":"10.1093/med/9780190659110.003.0008","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0008","url":null,"abstract":"While respiratory concerns tend to be the first consideration with sedation medications, many can have important effects on the cardiovascular system that need to be managed. Changes in heart rate, blood pressure, and cardiac work have to be considered. While most of these medications will affect arterial blood pressure in one way or another, some will have no effect on heart rate. While one agent may work well in majority of patients, that same medication could have potentially devastating effects because of a patient’s underlying condition. Additionally, simply changing the rate of drug administration can potentially reduce or increase the cardiovascular effects.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"65 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":"130861877","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/9780190659110.003.0020
Lorie Reilly
Follow-up is an important part of the pediatric sedation process. Follow-up may be performed in several different ways, such as a telephone call, direct contact with the patient and family, a mailed questionnaire, or an in-person visit (e.g., inpatient). Adverse events that occur after the postsedation discharge and are reported during the follow-up process should be documented in the medical record, because this is important and useful information for future sedation encounters. During follow-up some of the topics for discussion with the parent may include any change in the child’s activity level, appetite, sleep pattern, or behavior. An evaluation of patient/family satisfaction may be incorporated into the follow-up.
{"title":"Follow-up","authors":"Lorie Reilly","doi":"10.1093/med/9780190659110.003.0020","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0020","url":null,"abstract":"Follow-up is an important part of the pediatric sedation process. Follow-up may be performed in several different ways, such as a telephone call, direct contact with the patient and family, a mailed questionnaire, or an in-person visit (e.g., inpatient). Adverse events that occur after the postsedation discharge and are reported during the follow-up process should be documented in the medical record, because this is important and useful information for future sedation encounters. During follow-up some of the topics for discussion with the parent may include any change in the child’s activity level, appetite, sleep pattern, or behavior. An evaluation of patient/family satisfaction may be incorporated into the follow-up.","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":"114093982","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/9780190659110.003.0047
J. Unkel
A contemporary dental practice offers a variety of sedation medications and routes of administration. Most dental sedation is delivered to children by inhalational and oral routes, although the nasal route is gaining acceptance. Minimal and moderate sedation are the levels that the dentist, acting as both the sedationist and the proceduralist, will wish to achieve in the dental office. Combinations of medications offer the ability to achieve ideal moderate sedation. Nitrous oxide, benzodiazepines, antihistamines, and other agents are discussed. Dental procedures are invasive and unique in that they occur in the oral airway. To achieve a successful outcome, sedationists and proceduralists must take into account instrumentation, loud noises, treatment duration, delivery of local anesthetics, and oropharyngeal protective barriers. Local anesthetic administration can be painful when delivered in the oral cavity. As this is the initial invasive step the child will encounter during the dental experience, providing sedation care may be of value in addition to topical anesthetic.
{"title":"Sedation in the Pediatric Dental Practice","authors":"J. Unkel","doi":"10.1093/MED/9780190659110.003.0047","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0047","url":null,"abstract":"A contemporary dental practice offers a variety of sedation medications and routes of administration. Most dental sedation is delivered to children by inhalational and oral routes, although the nasal route is gaining acceptance. Minimal and moderate sedation are the levels that the dentist, acting as both the sedationist and the proceduralist, will wish to achieve in the dental office. Combinations of medications offer the ability to achieve ideal moderate sedation. Nitrous oxide, benzodiazepines, antihistamines, and other agents are discussed. Dental procedures are invasive and unique in that they occur in the oral airway. To achieve a successful outcome, sedationists and proceduralists must take into account instrumentation, loud noises, treatment duration, delivery of local anesthetics, and oropharyngeal protective barriers. Local anesthetic administration can be painful when delivered in the oral cavity. As this is the initial invasive step the child will encounter during the dental experience, providing sedation care may be of value in addition to topical anesthetic.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"90 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":"116825586","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/9780190659110.003.0007
Mary F Landrigan-Ossar, Samuel M. Vanderhoek
Most if not all sedation medications negatively affect the patency of the airway, most commonly secondary to soft tissue obstruction, although central apnea may also occur. The techniques available for managing the pediatric airway during sedation are myriad, and deciding which one to use depends on a variety of considerations. These include factors such as the level of sedation required for the procedure, the anticipated duration of the procedure, the remoteness of the patient from the provider, the child’s medical condition, and any airway conditions the child may have. The overarching goal is to maximize the child’s safety and mitigate the risk of airway consequences that the sedation may pose. This section discusses effective positioning, oxygen administration, chin left, jaw thrust, and use of oropharyngeal and nasopharyngeal airways, along with laryngeal mask airway placement and (briefly) endotracheal intubation.
{"title":"Techniques for Managing the Airway","authors":"Mary F Landrigan-Ossar, Samuel M. Vanderhoek","doi":"10.1093/med/9780190659110.003.0007","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0007","url":null,"abstract":"Most if not all sedation medications negatively affect the patency of the airway, most commonly secondary to soft tissue obstruction, although central apnea may also occur. The techniques available for managing the pediatric airway during sedation are myriad, and deciding which one to use depends on a variety of considerations. These include factors such as the level of sedation required for the procedure, the anticipated duration of the procedure, the remoteness of the patient from the provider, the child’s medical condition, and any airway conditions the child may have. The overarching goal is to maximize the child’s safety and mitigate the risk of airway consequences that the sedation may pose. This section discusses effective positioning, oxygen administration, chin left, jaw thrust, and use of oropharyngeal and nasopharyngeal airways, along with laryngeal mask airway placement and (briefly) endotracheal intubation.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"80 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":"115428802","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/9780190659110.003.0061
Michael Turmelle
The administrative organization of a pediatric procedural sedation service is guided by Center for Medicare and Medicaid Services (CMS) regulations. CMS specifically allows, within the broader regulations, institution-specific policies and structures to be developed and applied to the needs of the patient population served and institutional staff available. The sedation team approach has both advantages and disadvantages when compared to a sedation unit approach. A sedation team allows more flexibility to function outside the four walls of one set unit. The providers who deliver the sedation may vary within the team. Although there are many ways to structure a sedation team, the key to success is having a flexible yet well-organized approach that works in the given system and meets the needs of the patients who need procedural sedation care.
{"title":"A Sedation Team Approach","authors":"Michael Turmelle","doi":"10.1093/med/9780190659110.003.0061","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0061","url":null,"abstract":"The administrative organization of a pediatric procedural sedation service is guided by Center for Medicare and Medicaid Services (CMS) regulations. CMS specifically allows, within the broader regulations, institution-specific policies and structures to be developed and applied to the needs of the patient population served and institutional staff available. The sedation team approach has both advantages and disadvantages when compared to a sedation unit approach. A sedation team allows more flexibility to function outside the four walls of one set unit. The providers who deliver the sedation may vary within the team. Although there are many ways to structure a sedation team, the key to success is having a flexible yet well-organized approach that works in the given system and meets the needs of the patients who need procedural sedation care.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"16 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":"128112771","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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