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  • Continuous monitoring of oxygen saturation and heart rate will identify the most common serious risk of sedation, hypoxia.

  • Combinations of drugs may increase adverse effects of each, such as respiratory depression; consider reducing dosing when combining sedation medications.

  • Avoid ketamine in infants younger than 3 months due to the risk of airway complications.

  • Emergence reactions associated with ketamine appear to be related to the pretreatment anxiety level of the patient.

  • Obesity is an independent risk factor for adverse events. Extra caution should be taken when sedating these patients.

Acknowledgment of the presence and importance of pediatric pain has transformed the management of ill and injured patients.1 Procedural sedation and analgesia (PSA) are now an integral component of pediatric emergency care.2 Increased availability of emergent imaging has expanded the emergency physician’s role to include MRI and CT scan sedation.

Sedatives with or without analgesics are given for tedious, precise, or painful procedures, resulting in a level of consciousness depressed enough to accomplish the procedure while maintaining respiratory drive. The previous misnomer conscious sedation has been replaced by four levels of procedural sedation, each with increasing risk of loss of protective and cardiorespiratory functions.3 Anxiolysis, or “minimal sedation,” impairs coordination and cognitive function but allows patients to respond normally to verbal stimuli. “Moderate sedation” is a drug-induced depression of consciousness (profound relaxation) but retains purposeful response to verbal or light stimuli. With “deep sedation,” patients are not easily aroused, yet repeated painful stimulation yields purposeful response at doses “not likely” to depress ventilatory function. “General anesthesia” is the state where painful stimuli do not evoke a response, and the corresponding lack of tone can compromise airway reflexes, airway patency, and cardiorespiratory function.

The Joint Commission and the American Academy of Pediatrics recognize that sedation is a continuum; therefore, safety and monitoring guidelines focus on the ability to rescue a patient from a deeper level of sedation than intended.2,4 Studies show that many children enter a deeper level of sedation than initially intended.5 Safety guidelines encompass patient assessment, personnel and monitoring equipment, medication familiarity, discharge criteria, and quality assurance. Knowledge of specific medications is critical, but guidelines leave specific requirements to individual hospital credentialing committees.


The analgesic or sedative need is determined by the patient complaint, the status and responses of the child, the preference of the treating clinician, and, when appropriate, family. Prior to moderate or deep procedural sedation, children should undergo a focused history pertinent to their chief complaint using a modified SAMPLE approach6 (Table 13-1). In addition to obstructive airway concerns such as snoring, other factors which have been associated with an increased risk of adverse events or the need for intervention include recurrent or current stridor, obstructive sleep apnea, obesity (BMI >95%), symptomatic asthma or heart disease, gastroesophageal reflux, or ...

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