Overview of Pediatric Procedural Sedation
Pediatric procedural sedation, or PPS for short, is a set of techniques and medications used to reduce anxiety and pain in children during unpleasant or painful medical procedures. This becomes necessary when a procedure that may cause discomfort or pain can’t be avoided. The aim of PPS is to make the procedure as bearable as possible for the young patient. This doesn’t just cover major procedures, but also common ones like inserting an IV, drawing blood, inserting a urinary catheter, or performing a spinal tap, which can all cause significant discomfort or fear in children. PPS can also be used to help children stay calm and still during imaging tests like CT scans, MRIs, ultrasounds, and heart scans.
Several kinds of doctors and nurses can perform PPS in different settings – it’s not only done by anesthesiologists. In fact, emergency and critical care doctors, as well as certain types of nurses, regularly use PPS. In 2019, the American College of Emergency Physicians developed guidelines on how to use sedatives along with painkillers to help patients tolerate discomfort during urgent procedures, while maintaining heart and lung function.
Multiple organizations, such as the American Society of Anesthesiologists, the American Association of Oral and Maxillofacial Surgeons, the American Dental Association, the American Society of Dentist Anesthesiologists, the American College of Radiology, and the Society of Interventional Radiology, have also crafted similar guidelines tailored to their respective fields.
It’s important to understand the different terms related to PPS. Sedation refers to putting the patient into a state where they are calm and stationary. Analgesia is a term for pain relief. Dissociation creates a state where the patient separates their mind from their body, almost like a trance. The goal with PPS is to find the right mix of sedation and analgesia for each procedure. This balance can range from mild anxiety relief for simple, painless procedures, to moderate sedation for more painful procedures.
Sedation can be measured on the Ramsey scale, which assigns a score based on patient responses. The higher the score, the deeper the level of sedation, with general anesthesia being the deepest level. In simpler terms, sedation levels can be described as follows:
– Minimal, or anxiolysis: The patient is awake and relaxed, and can respond normally to voices.
– Moderate, or conscious sedation: The patient is somewhat sleepy but can still respond to voices or touch. They can breathe normally without needing any help.
– Deep: The patient is very sleepy and may only respond to repeated or painful stimuli. They might need some help to keep their airway open for breathing.
– Dissociative: The patient is in a trance-like state where they are unaware of pain and won’t remember the procedure, but they are still awake and breathing normally with a stable heart rate.
– General anesthesia: The patient is unconscious and doesn’t respond to painful stimuli. They may need help to breathe and might require positive pressure ventilation.
When performing PPS on pediatric patients, it’s important to be careful to avoid sedating them too deeply. Healthcare providers should have the necessary skills to manage a patient’s airway and should be certified in Pediatric Advanced Life Support to ensure they can properly perform PPS.
Anatomy and Physiology of Pediatric Procedural Sedation
The most serious problem that can occur with PPS (Procedural Sedation in Pediatrics) is breathing problems. This could either be due to shallow breathing or a blocked airway, and it often occurs when a child is overly sedated. Therefore, it’s extremely important to pay attention to a child’s airway and any past issues it has had. Fortunately, kids generally don’t have the same complications as adults when it comes to airways, and their differences are generally more predictable.
In infancy, there are a few key characteristics to note about a child’s airway. For example, babies have larger heads and back of the skull, a large tongue and smaller jaw, and their larynx or voice box is situated higher and more forward than in adults. This angle makes it harder to see, but this can usually be fixed by tilting the neck back or by placing a small roll under the shoulders to help extend it – unless there’s a risk of neck injury.
Young children also have a more flexible epiglottis – the flap that covers the windpipe while swallowing – which may make it difficult to view the larynx. Additionally, their large adenoids and tonsils can block the upper airways, and they have small cricoid cartilage, making it tricky to surgically open up the windpipe from the neck, a procedure called cricothyrotomy. Skilled practitioners often use a straight laryngoscope, a tool to view the throat, to move the flexible epiglottis out of the way for a clearer view.
In children less than 10 years old, a surgical cricothyrotomy is not advised because the membrane around the voice box is too small. Instead, a needle cricothyrotomy, a method of creating an opening in the neck for breathing, is used when an airway below the vocal cords is needed. Bag mask ventilation (BMV) is often used before placing a tube into the windpipe for airflow (intubation). Sometimes, BMV is all that is needed to help a child breathe better, especially when a quick recovery is expected, like during deep sedation. The aim during BMV is to provide a breath volume of 8 mL/kg, squeezing the bag just enough to see the chest rise, to avoid lung injury or stomach inflation.
Why do People Need Pediatric Procedural Sedation
If a child needs a medical procedure that might be uncomfortable or cause anxiety, they may be given medication to help them relax and reduce their pain. This can range from light sedation to help them stay calm for a CT or MRI scan, to deeper sedation for more painful procedures like setting a broken bone or stitching up a complex cut. The amount of sedation given depends on how much pain or anxiety the procedure might cause and whether the child needs to be still during the procedure.
Before giving sedation, doctors consider the child’s vital signs like heart rate and breathing rate, how stable their condition is, and other factors. These can include whether the child has a chronic disease or genetic condition, like heart or lung disease, Down syndrome, or cerebral palsy, their medication history, and any allergies they may have.
The doctor also evaluates the child’s physical condition, particularly their airway, using a system called the American Society of Anesthesiologists (ASA) classification. This system has six levels:
- ASA Class I: The child is healthy, with no acute or chronic disease, and a normal Body Mass Index (BMI) for their age.
- ASA Class II: The child has a mild systemic disease but is not currently experiencing any worsening symptoms. This could include congenital heart disease, a well-managed heart rhythm problem, well-controlled epilepsy, or asthma without a recent flare-up.
- ASA Class III: The child has severe systemic disease but is not in immediate danger. For example, a stable congenital heart abnormality, poorly controlled epilepsy, cystic fibrosis, severe obesity, metabolic disease, or a history of organ transplantation.
- ASA Class IV: The child has severe disease that constantly threatens their life, such as a symptomatic congenital heart abnormality, severe trauma, sepsis, severe breathing problems, congestive heart failure, or an acute shortage of oxygen to the brain.
- ASA Class V: The child is at extreme risk and is not expected to survive without surgery. This could include massive trauma, needing a machine called ECMO to keep their heart and lungs working, a brain hemorrhage causing pressure, respiratory failure, or multiple organ dysfunction.
- ASA Class VI: The child has been declared brain dead, and organs are being removed for transplant.
In emergency situations, sedation should generally only be given to children in ASA classes I or II. For children in ASA classes III or IV, or those with abnormalities in their neck or airway, it’s recommended to consult with an anesthesiologist or other specialist.
When a Person Should Avoid Pediatric Procedural Sedation
There are certain situations where PPS, a type of procedure that helps manage pain and calm a patient during operations, might not be the best option. For example:
If the necessary equipment for monitoring the patient’s heart rate, blood pressure, and breathing during the procedure isn’t available, PPS can’t be used. Likewise, if the healthcare professional doesn’t have specific training or certifications, such as being PALS certified or knowing how to handle a difficult to maintain airway in emergency situations, they should not perform PPS.
It’s also important to consider the patient’s allergies or past reactions to medications, as these can influence whether PPS should be used. Also, if the procedure is going to be particularly long or painful, requiring the patient to be completely unconscious, then they would need to go to an operating room for general anesthesia instead of PPS.
Also, if a patient’s health condition puts them at a high risk for complications during sedation (known as ASA class III and above), it might be safer for them to be cared for by a specialist or an anesthesiologist.
Guidelines usually suggest that a patient should not consume any clear liquids for 2 hours, breast milk for 4 hours, and solid food for 6 hours before an operation. In the past, it used to be thought that being at a high risk of inhalation of stomach content into the lungs, or aspiration, was a reason not to use PPS, but recent studies have shown that the risk of complications isn’t higher based on fasting times for procedures that weren’t scheduled ahead of time. So, sticking to these fasting guidelines might just cause unnecessary stress for children and their families, especially in emergency situations.
Equipment used for Pediatric Procedural Sedation
Before beginning Pediatric Procedural Sedation (PPS), your doctor will make sure that all the necessary tools are ready, are in working order and are suited for the size of the child. Here’s a simple overview of those tools:
1. A suction device and tube: This is used to clear out any blockages in the patient’s airway.
2. An oxygen supply with different tools to administer the oxygen, ranging from a small tube that fits by the nose (nasal cannula) to a mask that covers the mouth and nose (nonrebreather mask).
3. Specialized equipment for maintaining the breathing path. This includes a mask attached to a bag for manually helping with breathing (bag valve mask), small tubes suited to the size of the child’s mouth or nose (oral and nasal airways), a special mask used in the throat (laryngeal mask airway), and special tools for viewing the airway like a laryngoscope. They also have a tube to help with breathing (endotracheal tube), as well as equipment for surgical procedures.
4. Different types of medication including ones that reduce anxiety (anxiolytic), reduce pain (analgesic), create a trance-like state (dissociative), and those that can reverse the effects of other drugs (reversal agents).
5. Monitoring devices to keep track of heart rate (pulse oximeter and ECG leads), breathing rate, carbon dioxide levels in the lungs (end-tidal carbon dioxide), and blood pressure.
6. An intravenous (IV) line – This may already be inserted if IV medications need to be given or if there is a risk of needing a deeper level of sedation.
Finally, your doctor will also have medications and equipment ready for heart resuscitation, just in case something unexpected happens.
Who is needed to perform Pediatric Procedural Sedation?
Usually, two healthcare providers are required to undertake Procedural Sedation and Analgesia (PSA). This is a process to relax and sedate a patient so that a procedure can be conducted painlessly. One provider carries out the necessary procedure and the other is responsible for overseeing the sedation process and monitoring the patient’s condition.
There may be times, especially in emergencies for unplanned procedures, where having two providers isn’t possible. However, it’s still important for a nurse or another qualified individual to look after the patient while the procedure is taking place.
The person conducting the PSA needs to have a few crucial abilities. They need to know how to choose which patients are suitable for PSA and understand how to manage medications and reversal agents to end sedation when necessary. They should be able to observe and safeguard the patient’s airway, spotting any signs of blockage and identifying different types of sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).
Monitoring the patient’s breathing by looking at the motion of the patient’s chest and using devices to measure the oxygen levels (pulse oximetry) and carbon dioxide output (capnography) is also part of their role. They should also be able to track the patient’s heart stability using various techniques, including checking the heartbeat pattern, blood pressure, and a physical checkup. They must recognize when a child patient is either not sedated enough or sedated too much, and have advanced skills in managing a patient’s airway. Lastly, they need to be able to step in and manage any complications that may occur during the procedure.
Preparing for Pediatric Procedural Sedation
Before the doctors perform PPS (Procedural Pain Sedation), which is a technique to control pain during a medical procedure, they need to do a careful health check. This check helps to make sure that the procedure is as safe as possible for the patient. Doctors will follow a standard checklist and use guidelines from a respected medical association like the American Academy of Pediatrics.
The doctors will check the physical condition of the patient using a system called the ASA classification. This helps them understand how healthy the patient is before the procedure. Generally, PPS should only be done on emergency patients who are classified as ASA class I or II, meaning they’re relatively healthy. If a child is classed as ASA class III or higher, which means they have a more severe illness, or they have unusual features of their airway or neck bones, a specialist like an anesthesiologist should be consulted.
Also, the doctors need to get the patient’s informed consent. This means explaining the procedure clearly to the patient, or their parents if the patient is a child, so they understand what is about to happen and what the risks are.
Then, the doctors will gather a lot of health information about the patient. They’ll consider factors like the patient’s gender, age, weight, medication they’re taking, any allergies they have, and their personal and family medical history. They’ll also take into account if the patient has been fasting before the procedure, which could affect how their body responds to medication.
To decide if the patient’s airway is clear, the doctors will use a score called the Mallampati score. They’ll also check the patient’s mouth opening, size of the tonsils, jaw structure, tongue, and movement of the neck. They’ll make sure they have the right equipment on hand, in the right sizes, and that everything is working properly. This preparation is crucial to make the procedure safe and comfortable for the patient.
How is Pediatric Procedural Sedation performed
The type of medicine for patient-directed sedation relies on what kind of procedure the patient needs. This can range from a calming medicine for non-painful procedures to medicines that provide a higher level of sedation and pain relief for painful procedures. The medicine selected should have a fast onset and quick recovery time. Different types of medicines used for this kind of sedation include benzodiazepines, ketamine, propofol, ketamine with propofol, nitrous oxide, and etomidate.
For non-painful procedures, children typically require only calming medication. Benzodiazepines work well for this, in combination with emotional and physical support. For somewhat painful procedures like wound cleaning or repairing cuts, more significant pain relief and calming medication are needed. This may include nasal-administered fentanyl or dexmedetomidine, nitrous oxide, and a low dose of ketamine. For more painful procedures like setting broken bones, medicines are needed that bring about temporary memory loss and pain relief.
Here are some of the specific medications:
Midazolam can help to calm patients, but it can also cause a painful feeling when administered through the nose. Pentobarbital also acts as a sedative, but it has variable effectiveness and can lead to long recovery times. Nitrous Oxide is used as an inhaled sedative. It acts very quickly, but can lead to nausea and can’t be used with certain conditions like pneumothorax and bowel obstruction.
Fentanyl is an effective painkiller and can be administered via the nose. It typically has few side effects and only lasts for a short time. Ketamine in low doses can provide pain relief and temporary memory loss without completely disorienting the patient. Dexmedetomidine is also a calmer and sedative, providing pain relief without significant effects on breathing or heart function.
For more major painful procedures, Propofol can be used. This medicine is a potent sedative but doesn’t provide pain relief. Etomidate is another potent sedative with no pain relief. Ketamine in higher doses can provide strong pain relief by causing dissociative amnesia, but can lead to increased pressure in the eyes and head, and issues with the airway in younger patients. Combination of propofol and ketamine can be used to achieve the required level of sedation and pain relief, but it may increase the risk of low oxygen levels compared to using ketamine alone.
After the procedure, the patient’s vital signs should be closely observed till they regain their normal consciousness level.
Possible Complications of Pediatric Procedural Sedation
Each drug used in Procedural Sedation and Analgesia (or PPS, a technique used to help you relax and manage pain during certain medical procedures) can potentially cause side effects, as mentioned earlier. The objective of PPS is to choose the right drug for the right patient that would work best for the procedure being performed. Ideally, PPS should sedate the patient only for the shortest time necessary to carry out the procedure without any complications. The doctor should always be cautious about possible adverse events linked to the drugs administered and any specific risks of the patient. The most dreaded complication in PPS is difficulty in breathing, which may happen if the patient is over-sedated. The doctor should be able to recognize early signs of breathing problems and be equipped to manage the airway if needed.
What Else Should I Know About Pediatric Procedural Sedation?
Procedural sedation and analgesia (PPS), which is basically a medical way of saying “making a procedure less painful and stressful”, is very effective when used correctly for children who have to go through stressful or painful medical procedures. Not only does it make the process less painful, but it also helps children avoid bad memories connected to the procedure.
This method improves the effectiveness of both diagnosis and medical procedures, while reducing stress for the child. PPS can be planned ahead or done unexpectedly, but should always take place in a controlled environment. This means it should be performed by experienced healthcare providers with the right tools and facilities to ensure safety and effectiveness.
As with anything in medicine, it’s important for healthcare providers to know the potential risks, which can include throwing up or difficulty breathing, so they can immediately respond if these problems occur. But when administered correctly by skilled healthcare providers, PPS can help carry out procedures safely with a low chance of negative effects.
