Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0015
S. Liebling, Melissa L. Langhan
This section focuses on the use of pulse oximetry during procedural sedation and analgesia (PSA). Pulse oximetry is the most common monitoring method used during PSA. It is a noninvasive method for monitoring a patient’s peripheral oxygen saturation (SpO2) of hemoglobin. Its use is recommended in the monitoring of children undergoing various levels of sedation as a means to detect hypoxemia and decrease the likelihood of adverse outcomes, including cardiopulmonary arrest and death. It is a highly reliable modality for detecting oxygen desaturation events. However, understanding its indications and limitations will allow the user to properly identify and manage a desaturation event during PSA.
{"title":"Pulse Oximetry","authors":"S. Liebling, Melissa L. Langhan","doi":"10.1093/med/9780190659110.003.0015","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0015","url":null,"abstract":"This section focuses on the use of pulse oximetry during procedural sedation and analgesia (PSA). Pulse oximetry is the most common monitoring method used during PSA. It is a noninvasive method for monitoring a patient’s peripheral oxygen saturation (SpO2) of hemoglobin. Its use is recommended in the monitoring of children undergoing various levels of sedation as a means to detect hypoxemia and decrease the likelihood of adverse outcomes, including cardiopulmonary arrest and death. It is a highly reliable modality for detecting oxygen desaturation events. However, understanding its indications and limitations will allow the user to properly identify and manage a desaturation event during PSA.","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":"132313945","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/9780190659110.003.0050
D. Tsze, J. Reynolds
The intranasal route is an effective means of administering sedatives and analgesics. It is a needle-free alternative to intravenous or intramuscular routes, it is not subject to first-pass metabolism, and its efficacy approaches that of intravenous administration. There is absorption through the highly vascular nasal mucosa, as well as utilization of the nose–brain pathway that bypasses systemic circulation and the blood–brain barrier and transports medications directly to the brain. Intranasal administration of sedative and analgesic medications has been shown to be safe and effective for children in a variety of settings. It provides an opportunity to avoid intravenous line placement in many situations, which may reduce the pain and anxiety associated with many diagnostic and therapeutic procedures in children. More studies are needed to compare important sedation outcomes between intranasal sedation regimens and the more common intravenous sedation regimens in order to guide best practice.
{"title":"Intranasal Medications","authors":"D. Tsze, J. Reynolds","doi":"10.1093/med/9780190659110.003.0050","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0050","url":null,"abstract":"The intranasal route is an effective means of administering sedatives and analgesics. It is a needle-free alternative to intravenous or intramuscular routes, it is not subject to first-pass metabolism, and its efficacy approaches that of intravenous administration. There is absorption through the highly vascular nasal mucosa, as well as utilization of the nose–brain pathway that bypasses systemic circulation and the blood–brain barrier and transports medications directly to the brain. Intranasal administration of sedative and analgesic medications has been shown to be safe and effective for children in a variety of settings. It provides an opportunity to avoid intravenous line placement in many situations, which may reduce the pain and anxiety associated with many diagnostic and therapeutic procedures in children. More studies are needed to compare important sedation outcomes between intranasal sedation regimens and the more common intravenous sedation regimens in order to guide best practice.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"49 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":"115389732","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/9780190659110.003.0006
Mary F Landrigan-Ossar, Samuel M. Vanderhoek
In order to safely provide sedation, the practitioner must have a complete understanding of the range of effects of the medication regimens. While these drugs provide anxiolysis, hypnosis and analgesia, these actions come at a price. Sedatives and analgesics have specific, generally depressive effects on the central nervous control of respiratory drive. Peripherally they act on the control and tone of airway musculature and depress airway reflexes. These actions vary according to class of drug and may act in synergy. This section will review some of the common effects on the airway of most sedation medications. A brief discussion of patients with special airway considerations is also included.
{"title":"Sedation Effects","authors":"Mary F Landrigan-Ossar, Samuel M. Vanderhoek","doi":"10.1093/med/9780190659110.003.0006","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0006","url":null,"abstract":"In order to safely provide sedation, the practitioner must have a complete understanding of the range of effects of the medication regimens. While these drugs provide anxiolysis, hypnosis and analgesia, these actions come at a price. Sedatives and analgesics have specific, generally depressive effects on the central nervous control of respiratory drive. Peripherally they act on the control and tone of airway musculature and depress airway reflexes. These actions vary according to class of drug and may act in synergy. This section will review some of the common effects on the airway of most sedation medications. A brief discussion of patients with special airway considerations is also included.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"126 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":"115239779","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/9780190659110.003.0053
Andrea R. Carberry, G. Hollman
Institutions vary in their requirements for determining competency and granting privileges for providing moderate and deep procedural sedation. Several specialties outside of anesthesiology routinely provide pediatric procedural sedation services. Attaining sedation competency requires a multitiered approach to education, training, and assessment that encompasses factual knowledge and higher-level cognitive functioning such as clinical decision-making, communication skills, psychomotor skills, and ability to function as a member of a multidisciplinary team. Educational and training methods used to teach procedural sedation include written materials, didactic lectures, interactive small-group sessions, medical simulation, and clinical experience with mentoring. Assessment of procedural sedation knowledge and skills includes written examinations, medical simulation, proctoring, and multisource evaluations.
{"title":"Physician Training and Perspective","authors":"Andrea R. Carberry, G. Hollman","doi":"10.1093/MED/9780190659110.003.0053","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0053","url":null,"abstract":"Institutions vary in their requirements for determining competency and granting privileges for providing moderate and deep procedural sedation. Several specialties outside of anesthesiology routinely provide pediatric procedural sedation services. Attaining sedation competency requires a multitiered approach to education, training, and assessment that encompasses factual knowledge and higher-level cognitive functioning such as clinical decision-making, communication skills, psychomotor skills, and ability to function as a member of a multidisciplinary team. Educational and training methods used to teach procedural sedation include written materials, didactic lectures, interactive small-group sessions, medical simulation, and clinical experience with mentoring. Assessment of procedural sedation knowledge and skills includes written examinations, medical simulation, proctoring, and multisource evaluations.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"7 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":"122517435","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/9780190659110.003.0021
David Fagin
To perform effective and safe procedural sedation, one must be knowledgeable about the adverse events that can occur with the administration of various sedatives and analgesics. Adverse events (sometimes thought of as complications of care) are often predictable if the sedationist properly assesses the patient’s physiologic and psychological conditions and understands the side effects of the medications administered and the procedural conditions that may exacerbate risk. With such preparation, the sedationist can monitor for the event and can either prevent it or provide supportive care in a timely manner. The American Academy of Pediatrics and other national organizations have developed guidelines for caring for patients requiring procedural sedation with the intent of informing sedationists of the risks involved in sedation care and the skills and equipment needed to ameliorate or prevent patient harm. Adverse events can be classified as minor, moderate, and major.
为了进行有效和安全的程序性镇静，必须了解使用各种镇静和镇痛药可能发生的不良事件。如果镇静师正确评估患者的生理和心理状况，了解所给药物的副作用和可能加剧风险的程序条件，通常可以预测不良事件(有时被认为是护理并发症)。有了这样的准备，镇静师可以监测事件，既可以预防它，也可以及时提供支持性护理。美国儿科学会(American Academy of Pediatrics)和其他国家组织已经制定了护理需要程序性镇静的患者的指南，目的是告知镇静医师镇静护理所涉及的风险，以及改善或预防患者伤害所需的技能和设备。不良事件可分为轻微、中度和严重。
{"title":"Definition and Incidence of Adverse Events","authors":"David Fagin","doi":"10.1093/med/9780190659110.003.0021","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0021","url":null,"abstract":"To perform effective and safe procedural sedation, one must be knowledgeable about the adverse events that can occur with the administration of various sedatives and analgesics. Adverse events (sometimes thought of as complications of care) are often predictable if the sedationist properly assesses the patient’s physiologic and psychological conditions and understands the side effects of the medications administered and the procedural conditions that may exacerbate risk. With such preparation, the sedationist can monitor for the event and can either prevent it or provide supportive care in a timely manner. The American Academy of Pediatrics and other national organizations have developed guidelines for caring for patients requiring procedural sedation with the intent of informing sedationists of the risks involved in sedation care and the skills and equipment needed to ameliorate or prevent patient harm. Adverse events can be classified as minor, moderate, and major.","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":"129946741","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/9780190659110.003.0048
M. Sury, S. Greenaway
Pediatric procedural sedation is required for children across the globe in a wide variety of circumstances. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) is a government organization whose purpose is to provide guidelines to help ensure that patients receive effective, good-value healthcare across the whole of the National Health Service. In 2010 NICE published a guideline for the use of pediatric sedation. The overarching aims were to review the safety and efficacy of sedation for common procedures and to form a consensus view on the necessary resources to do this safely. This chapter summarizes the key recommendations and describes how pediatric sedation has since evolved in the UK.
{"title":"The NICE Guidelines and Pediatric Sedation in the United Kingdom","authors":"M. Sury, S. Greenaway","doi":"10.1093/MED/9780190659110.003.0048","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0048","url":null,"abstract":"Pediatric procedural sedation is required for children across the globe in a wide variety of circumstances. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) is a government organization whose purpose is to provide guidelines to help ensure that patients receive effective, good-value healthcare across the whole of the National Health Service. In 2010 NICE published a guideline for the use of pediatric sedation. The overarching aims were to review the safety and efficacy of sedation for common procedures and to form a consensus view on the necessary resources to do this safely. This chapter summarizes the key recommendations and describes how pediatric sedation has since evolved in the UK.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"3 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"113954468","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/9780190659110.003.0029
B. Jackson, Elysha Pifko
The emergency department (ED) commonly manages patients who require urgent/emergent painful or anxiety-provoking diagnostic or therapeutic procedures. Safe, appropriate, high-quality procedural sedation/analgesia (PSA) is an essential aspect of ED care of pediatric patients that increases the likelihood of procedural success and improves overall patient satisfaction. Emergency Medicine physicians are trained to stratify the risks and benefits of PSA and to manage any complications. Important factors to consider prior to PSA in the ED include patient selection, procedural complexity, procedural urgency, necessary personnel, and pharmacologic options. In general, performing simple procedures with few anticipated complications on patients with favorable cardiorespiratory anatomy and physiology without prior sedation complications is the ideal situation for PSA in the ED.
{"title":"Urgent Sedation (Unscheduled Procedural Sedation) in the Emergency Department","authors":"B. Jackson, Elysha Pifko","doi":"10.1093/med/9780190659110.003.0029","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0029","url":null,"abstract":"The emergency department (ED) commonly manages patients who require urgent/emergent painful or anxiety-provoking diagnostic or therapeutic procedures. Safe, appropriate, high-quality procedural sedation/analgesia (PSA) is an essential aspect of ED care of pediatric patients that increases the likelihood of procedural success and improves overall patient satisfaction. Emergency Medicine physicians are trained to stratify the risks and benefits of PSA and to manage any complications. Important factors to consider prior to PSA in the ED include patient selection, procedural complexity, procedural urgency, necessary personnel, and pharmacologic options. In general, performing simple procedures with few anticipated complications on patients with favorable cardiorespiratory anatomy and physiology without prior sedation complications is the ideal situation for PSA in the ED.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"7 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":"129616830","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/9780190659110.003.0004
J. Cravero
Pediatric procedural sedation is required for a wide variety of interventions ranging from nonstimulating imaging procedures to painful minor surgeries and other tests. The measurement of how well a given sedation strategy has met the requirements for a procedure is not well codified by simply noting the depth of sedation provided. Patients may be deeply sedated but thrashing about during a painful procedure, and they may be almost awake and perfectly tolerating a minor procedure. Procedural sedation must be measured using a rubric that appreciates the “state” of the patient and qualifies his or her movement, stress, pain, and safety at any specific time point during the procedure. The ability to control these factors and provide an acceptable state for the patient and the proceduralist should be the standard for measuring the quality of sedation provision for children.
{"title":"Assessing Patient State and Efficacy","authors":"J. Cravero","doi":"10.1093/med/9780190659110.003.0004","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0004","url":null,"abstract":"Pediatric procedural sedation is required for a wide variety of interventions ranging from nonstimulating imaging procedures to painful minor surgeries and other tests. The measurement of how well a given sedation strategy has met the requirements for a procedure is not well codified by simply noting the depth of sedation provided. Patients may be deeply sedated but thrashing about during a painful procedure, and they may be almost awake and perfectly tolerating a minor procedure. Procedural sedation must be measured using a rubric that appreciates the “state” of the patient and qualifies his or her movement, stress, pain, and safety at any specific time point during the procedure. The ability to control these factors and provide an acceptable state for the patient and the proceduralist should be the standard for measuring the quality of sedation provision for children.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"131 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":"122488312","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/9780190659110.003.0030
J. Hertzog
Given that the incidence of obesity is increasing worldwide for both adults and children, sedationists will encounter obese children in their practice. Understanding the obesity-related risks of pediatric procedural sedation will assist the sedationist in managing and mitigating these risks. Obesity is associated with an increase in airway-related adverse events and the need for airway interventions during sedation. Obese patients also need modifications in the dosing of sedative and analgesic agents. Obstructive sleep apnea is commonly associated with obesity and should be identified during the presedation evaluation. With proper screening and preparation, obese patients may be safely and successful sedated for diagnostic and therapeutic interventions.
{"title":"The Obese Child","authors":"J. Hertzog","doi":"10.1093/med/9780190659110.003.0030","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0030","url":null,"abstract":"Given that the incidence of obesity is increasing worldwide for both adults and children, sedationists will encounter obese children in their practice. Understanding the obesity-related risks of pediatric procedural sedation will assist the sedationist in managing and mitigating these risks. Obesity is associated with an increase in airway-related adverse events and the need for airway interventions during sedation. Obese patients also need modifications in the dosing of sedative and analgesic agents. Obstructive sleep apnea is commonly associated with obesity and should be identified during the presedation evaluation. With proper screening and preparation, obese patients may be safely and successful sedated for diagnostic and therapeutic interventions.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"57 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":"124390220","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/9780190659110.003.0016
Kevin G. Couloures
A variety of monitoring techniques can be used to ensure adequate ventilation during sedation. Three of the methods are direct observation, precordial/pretracheal stethoscope, and end-tidal CO2 monitoring. Direct observation is simple and effective but may miss subtle changes and is difficult when the room is darkened or the patient is covered. Precordial stethoscopes are frequently utilized during dental procedures and can help detect changes in respiration or the need for suctioning. MRI-compatible versions are available, but the practitioner needs to be within 4 feet of the patient. End-tidal CO2 monitoring gives the most information about the adequacy of ventilation but requires costly equipment and placement of a specialized nasal cannula or mask on the child’s face. The benefit of utilizing any of these modalities is that changes in ventilation will precede changes in oxygenation. Hence, early recognition of change can help prevent respiratory compromise.
{"title":"Ventilation—Observation, Capnography, and Precordial Stethoscope","authors":"Kevin G. Couloures","doi":"10.1093/MED/9780190659110.003.0016","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0016","url":null,"abstract":"A variety of monitoring techniques can be used to ensure adequate ventilation during sedation. Three of the methods are direct observation, precordial/pretracheal stethoscope, and end-tidal CO2 monitoring. Direct observation is simple and effective but may miss subtle changes and is difficult when the room is darkened or the patient is covered. Precordial stethoscopes are frequently utilized during dental procedures and can help detect changes in respiration or the need for suctioning. MRI-compatible versions are available, but the practitioner needs to be within 4 feet of the patient. End-tidal CO2 monitoring gives the most information about the adequacy of ventilation but requires costly equipment and placement of a specialized nasal cannula or mask on the child’s face. The benefit of utilizing any of these modalities is that changes in ventilation will precede changes in oxygenation. Hence, early recognition of change can help prevent respiratory compromise.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"33 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":"126524688","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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