Professional Skills and Competence for Safe and Effective Procedural Sedation in Children: Recommendations Based on a Systematic Review of the Literature
Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children. 1. Introduction Invasive diagnostic procedures are a part of daily pediatric practice. Many of these procedures are painful, stressful, and impossible to perform without immobilizing the patient. Therefore, procedural sedation (PS) is required to enable these procedures to be performed. PS can be defined as the use of sedative, analgesic, or dissociative drugs in order to provide anxiolysis, analgesia, sedation, and motor control during painful or unpleasant procedures [1]. Since anesthesiologists cannot cover the growing demand for PS, nonanesthesiologists have organized their own PS strategies [2, 3]. Historically, this resulted in a wide range of drugs and techniques for use in pediatric PS, involving a large variance of sedation levels, sedation level predictability, effectiveness, and associated risks. However, by the end of last century, PS by nonanesthesiologists was increasingly criticized by anesthesiologists for neglecting transparency and standard safety precautions. There are strong indications that within this criticism, a source could be found for PS-related accidents [4, 5]. About a decade ago, dedicated nonanesthesiology specialists, who recognized the urgent need to
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