Pediatric sedation is a challenge which spans all continents and has grown to encompass specialties outside of anesthesia, radiology and emergency medicine. All sedatives are not universally available and local and national regulations often limit the sedation practice to specific agents and those with specific credentials. Some specialties have established certification and credentials for sedation delivery whereas most have not. Some of the relevant sedation guidelines and recommendations of specialty organizations worldwide will be explored. The challenge facing sedation care providers moving forward in the 21st century will be to determine how to apply the local, regional and national guidelines to the individual sedation practices. A greater challenge, perhaps impossible, will be to determine whether the sedation community can come together worldwide to develop standards, guidelines and recommendations for safe sedation practice. 1. Introduction Pediatric sedation is a challenge which spans all continents. Over the past decade, sedation has grown to encompass specialties outside of anesthesia, radiology, and emergency medicine. Until the 1990s, sedation in the United States was limited predominantly to delivery by anesthesiologists, radiologists, dental medicine, and emergency medicine physicians. It now encompasses other specialties which include gastroenterology, intensive care medicine, hospital medicine, pediatric medicine, and nursing [1–3]. Worldwide, however, the majority of pediatric sedation is still administered by anesthesiologists. All sedatives are not universally available and local and national regulations often limit the sedation practice to specific agents and those with specific credentials. Some specialties have established certification and credentials for sedation delivery whereas most have not [4–10]. The challenge is that there is no standardization of sedation practice, guidelines, and credentialing: Many specialties have guidelines and recommendations for their own practice, which may in fact contradict the guidelines set forth by other specialty societies [5, 11–13]. The challenge facing sedation care providers moving forward in the 21st century will be to determine how to apply the local, regional, and national guidelines to the individual sedation practices. A greater challenge, perhaps impossible, will be to determine whether the sedation community can come together worldwide to develop standards, guidelines, and recommendations for safe sedation practice. Some of the relevant sedation guidelines and recommendations of
References
[1]
J. P. Cravero, M. L. Beach, G. T. Blike, S. M. Gallagher, and J. H. Hertzog, “The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the pediatric sedation research consortium,” Anesthesia and Analgesia, vol. 108, no. 3, pp. 795–804, 2009.
[2]
K. P. Mason, “Sedation trends in the 21st century: the transition to dexmedetomidine for radiological imaging studies,” Paediatric Anaesthesia, vol. 20, no. 3, pp. 265–272, 2010.
[3]
J. P. Cravero, “Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room,” Current Opinion in Anaesthesiology, vol. 22, no. 4, pp. 509–513, 2009.
[4]
“Guidelines for the Use of Sedation and General Anesthesia by Dentists? As adopted by the October 2007 ADA House of Delegates. The American Dental Association.,” http://www.ada.org/sections/professionalResources/pdfs/statements_anesthesia.pdf.
[5]
D. O. Faigel, T. H. Baron, and T. H. Baron, “Guidelines for the use of deep sedation and anesthesia for GI endoscopy,” Gastrointestinal Endoscopy, vol. 56, no. 5, pp. 613–617, 2002.
[6]
A. Riphaus, T. Wehrmann, and T. Wehrmann, “S3 Guideline: sedation for gastrointestinal endoscopy 2008,” Endoscopy, vol. 41, no. 9, pp. 787–815, 2009.
[7]
S. A. Godwin, D. A. Caro, S. J. Wolf, A. S. Jagoda, R. Charles, B. E. Marett, and J. Moore, “Clinical policy: procedural sedation and analgesia in the emergency department,” Annals of Emergency Medicine, vol. 45, no. 2, pp. 177–196, 2005.
[8]
Personal correspondence from: Samir Haddad, “Sedation by non-Anesthesiologists (Appendix A-G),” National Guard Health Affairs, Kingdom of Saudia Arabia.
[9]
Scottish Intercollegiate Guidelines Network, “Guideline 58: safe sedation of children undergoing diagnostic and therapeutic procedures,” 2004.
[10]
A. Reed, R. O. Gray, M. de Kock, J. Thomas, J. Piercy, and J. Roelofse, “Personal Correspondence from: Professor James Roelofse, Paediatric Procedural Sedation and Analgesia (PSA) Guidelines,” South African Society of Anaesthesiologists, 2010.
[11]
American Society of Anesthesiologists. ASA Task Force on Sedation and Analgesia by Non-anesthesiologists, “Practice guidelines for sedation and analgesia by non-anesthesiologists: an updated report by the American Society of Anesthesiologists task force on sedation and analgesia by non-anesthesiologists,” Anesthesiology, vol. 96, no. 4, pp. 1004–1017, 2002.
[12]
J. J. Vargo, L. B. Cohen, D. K. Rex, and P. Y. Kwo, “Position statement: nonanesthesiologist administration of propofol for GI endoscopy,” Hepatology, vol. 50, no. 6, pp. 1683–1689, 2009.
[13]
FDA Docket 2005P-0267, American Society of Anesthesiologists: Comments Opposing Citizen Petition Requesting Change in Propofol Labeling, 2005, http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/~/media/For%20the%20Public%20and%20Media/Press%20Room/News%20Archives/FDArePropofol101905.ashx.
[14]
D. Gozal, B. Drenger, P. D. Levin, A. Kadari, and Y. Gozal, “A pediatric sedation/anesthesia program with dedicated care by anesthesiologists and nurses for procedures outside the operating room,” Journal of Pediatrics, vol. 145, no. 1, pp. 47–52, 2004.
[15]
C. J. Coté, S. Wilson, and Work Group on Sedation, “Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update,” Paediatric Anaesthesia, vol. 18, no. 1, pp. 9–10, 2008.
[16]
J. A. Walker, R. D. McIntyre, and R. D. McIntyre, “Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center,” American Journal of Gastroenterology, vol. 98, no. 8, pp. 1744–1750, 2003.
[17]
J. J. Vargo, L. B. Cohen, D. K. Rex, and P. Y. Kwo, “Position statement: nonanesthesiologist administration of propofol for GI endoscopy,” Gastrointestinal Endoscopy, vol. 70, no. 6, pp. 1053–1059, 2009.
[18]
M. E. Fredette and J. R. Lightdale, “Endoscopic sedation in pediatric practice,” Gastrointestinal Endoscopy Clinics of North America, vol. 18, no. 4, pp. 739–751, 2008.
[19]
S. M. Green, M. Klooster, T. Harris, E. L. Lynch, and S. G. Rothrock, “Ketamine sedation for pediatric gastroenterology procedures,” Journal of Pediatric Gastroenterology and Nutrition, vol. 32, no. 1, pp. 26–33, 2001.
[20]
L. Julián-Gómez, J. Barrio, and J. Barrio, “A retrospective study of pediatric endoscopy as performed in an adult endoscopy unit,” Revista Espanola de Enfermedades Digestivas, vol. 102, no. 2, pp. 100–107, 2010.
J. J. Vargo, L. B. Cohen, D. K. Rex, and P. Y. Kwo, “Position statement: nonanesthesiologist administration of propofol for GI endoscopy,” Gastroenterology, vol. 137, no. 6, pp. 2161–2167, 2009.
[23]
http://www.drnaps.org/.
[24]
G. T. Bosslet, M. L. Devito, T. Lahm, F. D. Sheski, and P. N. Mathur, “Nurse-administered propofol sedation: feasibility and safety in bronchoscopy,” Respiration, vol. 79, no. 4, pp. 315–321, 2010.
[25]
D. K. Rex, C. Overley, and C. Overley, “Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases,” American Journal of Gastroenterology, vol. 97, no. 5, pp. 1159–1163, 2002.
[26]
L. B. Cohen, A. N. Dubovsky, J. Aisenberg, and K. M. Miller, “Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist,” Gastrointestinal Endoscopy, vol. 58, no. 5, pp. 725–732, 2003.
[27]
V. P. Deenadayalu, E. F. Eid, J. S. Goff, J. A. Walker, L. B. Cohen, et al., “Non-anesthesiologist administered propofol sedation for endoscopic procedures: a worldwide safety review,” Gastrointestinal Endoscopy, vol. 67, article no. AB107, 2008.
[28]
R. Kaddu, D. Bhattacharya, K. Metriyakool, R. Thomas, and V. Tolia, “Propofol compared with general anesthesia for pediatric GI endoscopy: is propofol better?” Gastrointestinal Endoscopy, vol. 55, no. 1, pp. 27–32, 2002.
[29]
J. R. Lightdale, C. Valim, A. R. Newburg, L. B. Mahoney, S. Zgleszewski, and V. L. Fox, “Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study,” Gastrointestinal Endoscopy, vol. 67, no. 7, pp. 1067–1075, 2008.
[30]
J. L. Koh, D. D. Black, I. K. Leatherman, R. D. Harrison, and M. L. Schmitz, “Experience with an anesthesiologist interventional model for endoscopy in a pediatric hospital,” Journal of Pediatric Gastroenterology and Nutrition, vol. 33, no. 3, pp. 314–318, 2001.
[31]
T. E. Terndrup, R. M. Cantor, and C. M. Madden, “Intramuscular meperidine, promethazine, and chlorpromazine: analysis of use and complications in 487 pediatric emergency department patients,” Annals of Emergency Medicine, vol. 18, no. 5, pp. 528–533, 1989.
[32]
W. G. Barsan, D. Seger, D. F. Danzl, L. J. Ling, R. Bartlett, R. Buncher, and C. Bryan, “Duration of antagonistic effects of nalmefene and naloxone in opiate-induced sedation for emergency department procedures,” American Journal of Emergency Medicine, vol. 7, no. 2, pp. 155–161, 1989.
[33]
K. O. Cutler, A. J. Bush, S. A. Godambe, and B. Gilmore, “The use of a pediatric emergency medicine-staffed sedation service during imaging: a retrospective analysis,” American Journal of Emergency Medicine, vol. 25, no. 6, pp. 654–661, 2007.
[34]
W. K. King, J. A. Stockwell, M. A. DeGuzman, H. K. Simon, and N. S. Khan, “Evaluation of a pediatric-sedation service for common diagnostic procedures,” Academic Emergency Medicine, vol. 13, no. 6, pp. 673–676, 2006.
[35]
J. Pershad and B. Gilmore, “Successful implementation of a radiology sedation service staffed exclusively by pediatric emergency physicians,” Pediatrics, vol. 117, no. 3, pp. e413–e422, 2006.
[36]
S. Ratnapalan and S. Schneeweiss, “Guidelines to practice: the process of planning and implementing a pediatric sedation program,” Pediatric Emergency Care, vol. 23, no. 4, pp. 262–266, 2007.
[37]
S. Schneeweiss and S. Ratnapalan, “Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines,” Canadian Journal of Emergency Medicine, vol. 9, no. 2, pp. 93–100, 2007.
[38]
L. A. Pollauf, R. E. Lutes, M. L. Ramundo, and N. C. Christopher, “The educational experience of pediatric emergency medicine fellows in the use and application of procedural sedation/analgesia,” Pediatric Emergency Care, vol. 20, no. 1, pp. 12–16, 2004.
[39]
G. M. Hoffman, R. Nowakowski, T. J. Troshynski, R. J. Berens, and S. J. Weisman, “Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model,” Pediatrics, vol. 109, no. 2 I, pp. 236–243, 2002.
[40]
K. Ilkhanipour, C. R. Juels, and M. I. Langdorf, “Pediatric pain control and conscious sedation: a survey of emergency medicine residencies,” Academic Emergency Medicine, vol. 1, no. 4, pp. 368–372, 1994.
[41]
S. M. Green, M. G. Roback, and M. G. Roback, “Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children,” Annals of Emergency Medicine, vol. 54, pp. 158–168, 2009.
[42]
S. M. Green, S. G. Rotbrock, and S. G. Rotbrock, “Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases,” Annals of Emergency Medicine, vol. 31, no. 6, pp. 688–697, 1998.
[43]
R. M. Kennedy, F. L. Porter, J. P. Miller, and D. M. Jaffe, “Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies,” Pediatrics, vol. 102, no. 4 I, pp. 956–963, 1998.
[44]
J. L. Anderson, E. Junkins, C. Pribble, and E. Guenther, “Capnography and depth of sedation during propofol sedation in children,” Annals of Emergency Medicine, vol. 49, no. 1, pp. 9–13, 2007.
[45]
J. R. Miner, M. H. Biros, W. Heegaard, and D. Plummer, “Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department,” Academic Emergency Medicine, vol. 10, no. 6, pp. 638–643, 2003.
[46]
E. Guenther, C. G. Pribble, E. P. Junkins Jr., H. A. Kadish, K. E. Bassett, and D. S. Nelson, “Propofol sedation by emergency physicians for elective pediatric outpatient procedures,” Annals of Emergency Medicine, vol. 42, no. 6, pp. 783–791, 2003.
[47]
K. E. Bassett, J. L. Anderson, C. G. Pribble, and E. Guenther, “Propofol for procedural sedation in children in the emergency department,” Annals of Emergency Medicine, vol. 42, no. 6, pp. 773–782, 2003.
[48]
D. Agrawal, S. F. Manzi, R. Gupta, and B. Krauss, “Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department,” Annals of Emergency Medicine, vol. 42, no. 5, pp. 636–646, 2003.
[49]
B. M. G. Pena and B. Krauss, “Adverse events of procedural sedation and analgesia in a pediatric emergency department,” Annals of Emergency Medicine, vol. 34, no. 4, pp. 483–491, 1999.
[50]
S. M. Green, “Research advances in procedural sedation and analgesia,” Annals of Emergency Medicine, vol. 49, no. 1, pp. 31–36, 2007.
[51]
I. Keidan, D. Gravenstein, H. Berkenstadt, A. Ziv, I. Shavit, and A. Sidi, “Supplemental oxygen compromises the use of pulse oximetry for detection of apnea and hypoventilation during sedation in simulated pediatric patients,” Pediatrics, vol. 122, no. 2, pp. 293–298, 2008.
[52]
M. Vespasiano, M. Finkelstein, and S. Kurachek, “Propofol sedation: intensivists' experience with 7304 cases in a children's hospital,” Pediatrics, vol. 120, no. 6, pp. e1411–e1417, 2007.
[53]
P. A. Sanborn, E. Michna, D. Zurakowski, P. E. Burrows, P. J. Fontaine, L. Connor, and K. P. Mason, “Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations,” Radiology, vol. 237, no. 1, pp. 288–294, 2005.
[54]
A. W. Pruitt and W. R. Anyan Jr., “Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients,” Pediatrics, vol. 76, no. 2, pp. 317–321, 1985.
[55]
C. J. Coté, S. Wilson, P. Casamassimo, P. Crumrine, R. L. Gorman, and M. Hegenbarth, “Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update,” Pediatrics, vol. 118, no. 6, pp. 2587–2602, 2006.
R. E. Primosch, I. M. Buzzi, and G. Jerrell, “Monitoring pediatric dental patients with nasal mask capnography,” Pediatric Dentistry, vol. 22, no. 2, pp. 120–124, 2000.
[58]
J. R. Miner, W. Heegaard, and D. Plummer, “End-tidal carbon dioxide monitoring during procedural sedation,” Academic Emergency Medicine, vol. 9, no. 4, pp. 275–280, 2002.
[59]
L. A. Vascello and E. A. Bowe, “A case for capnographic monitoring as a standard of care,” Journal of Oral and Maxillofacial Surgery, vol. 57, no. 11, pp. 1342–1347, 1999.
“Practice guidelines for sedation and analgesia by non-anesthesiologists: an updated report by the American Society of Anesthesiologists task force on sedation and analgesia by non-anesthesiologists,” Anesthesiology, vol. 96, no. 4, pp. 1004–1017, 2002.
Sedation and Anesthesia Care Standards, Joint Commission on Accreditation of Healthcare Organizations; Oakbrook Terrace, Ill, USA http://www.jointcommission.org/.
R. S. Hockberger, L. S. Binder, and L. S. Binder, “The model of the clinical practice of emergency medicine,” Annals of Emergency Medicine, vol. 37, no. 6, pp. 745–770, 2001.
[68]
J. P. Waring, T. H. Baron, W. K. Hirota, et al., “Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy,” Gastrointestinal Endoscopy, vol. 58, pp. 317–322, 2003.
[69]
J. R. Lightdale, D. A. Goldmann, H. A. Feldman, A. R. Newburg, J. A. DiNardo, and V. L. Fox, “Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial,” Pediatrics, vol. 117, no. 6, pp. e1170–e1178, 2006.
[70]
D. B. Nelson, M. L. Freeman, and M. L. Freeman, “A randomized, controlled trial of transcutaneous carbon dioxide monitoring during ERCP,” Gastrointestinal Endoscopy, vol. 51, no. 3, pp. 288–295, 2000.
[71]
J. J. Vargo, G. Zuccaro Jr., J. A. Dumot, D. L. Conwell, J. B. Morrow, and S. S. Shay, “Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy,” Gastrointestinal Endoscopy, vol. 55, no. 7, pp. 826–831, 2002.
[72]
G. Koshy, S. Nair, E. P. Norkus, H. I. Hertan, and C. S. Pitchumoni, “Propofol versus midazolam and meperidine for conscious sedation in gi endoscopy,” American Journal of Gastroenterology, vol. 95, no. 6, pp. 1476–1479, 2000.
[73]
J. Metzner, K. L. Posner, and K. B. Domino, “The risk and safety of anesthesia at remote locations: the US closed claims analysis,” Current Opinion in Anaesthesiology, vol. 22, no. 4, pp. 502–508, 2009.
[74]
M. G. Roback, L. Bajaj, J. E. Wathen, and J. Bothner, “Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?” Annals of Emergency Medicine, vol. 44, no. 5, pp. 454–459, 2004.
[75]
M. G. Roback, J. E. Wathen, L. Bajaj, and J. P. Bothner, “Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs,” Academic Emergency Medicine, vol. 12, no. 6, pp. 508–513, 2005.
[76]
A. Sacchetti, E. Stander, N. Ferguson, G. Maniar, and P. Valko, “Pediatric procedural sedation in the community emergency department: results from the ProSCED registry,” Pediatric Emergency Care, vol. 23, no. 4, pp. 218–222, 2007.
[77]
A. Bell, G. Treston, C. McNabb, K. Monypenny, and R. Cardwell, “Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation,” Emergency Medicine Australasia, vol. 19, no. 5, pp. 405–410, 2007.
[78]
C. Wood, C. Hurley, J. Wettlaufer, M. Penque, S. H. Shaha, and K. Lillis, “Retrospective comparison of emergency department length of stay for procedural sedation and analgesia by nurse practitioners and physicians,” Pediatric Emergency Care, vol. 23, no. 10, pp. 709–712, 2007.
[79]
R. D. Pitetti, S. Singh, and M. C. Pierce, “Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department,” Archives of Pediatrics and Adolescent Medicine, vol. 157, no. 11, pp. 1090–1096, 2003.
[80]
R. O. Cummins, D. A. Chamberlain, and D. A. Chamberlain, “Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the utstein style: a statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, and Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council,” Circulation, vol. 84, no. 2, pp. 960–975, 1991.
[81]
A. H. Idris, R. A. Berg, and R. A. Berg, “Recommended guidelines for uniform reporting of data from drowning the "Utstein Style",” Circulation, vol. 108, no. 20, pp. 2565–2574, 2003.
[82]
W. F. Dick, P. J. F. Baskett, and P. J. F. Baskett, “Recommendations for uniform reporting of data following major trauma—the Utstein style. An International Trauma Anaesthesia and Critical Care Society (ITACCS) initiative,” British Journal of Anaesthesia, vol. 84, no. 6, pp. 818–819, 2000.
[83]
J. E. Hollander, A. L. Blomkalns, and A. L. Blomkalns, “Standardized reporting guidelines for studies evaluating risk stratification of ED patients with potential acute coronary syndromes,” Academic Emergency Medicine, vol. 11, no. 12, pp. 1331–1340, 2004.
[84]
M. Bhatt, R. M. Kennedy, and R. M. Kennedy, “Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children,” Annals of Emergency Medicine, vol. 53, no. 4, article no. e4, p. 426, 2009.
[85]
http://an.hitchcock.org/PediatricSedationRC/.
[86]
Consensus conference, “Anesthesia and sedation in the dental office,” Journal of the American Medical Association, vol. 254, pp. 1073–1076, 1985.
[87]
D. Wengrower, E. Goldin, and D. Gozal, “Re: Editorial—where is the line between deep sedation and general anesthesia?” American Journal of Gastroenterology, vol. 98, no. 7, p. 1667, 2003.
[88]
E. Barbi, I. Bruno, A. Ventura, D. Gozal, and Y. Gozal, “Widening sedation availability,” Journal of Pediatrics, vol. 146, no. 3, pp. 438–439, 2005.
[89]
S. M. Green and K. P. Mason, “Reformulation of the sedation continuum,” Journal of the American Medical Association, vol. 303, no. 9, pp. 876–877, 2010.
