Guidelines for Monitoring and Management of Pediatric Patients ...

Guidelines for Monitoring and Management of Pediatric Patients During andAfter Sedation for Diagnostic and Therapeutic Procedures: An UpdateAmerican Academy of Pediatrics, American Academy of Pediatric Dentistry, CharlesJ. Coté and Stephen WilsonPediatrics 2006;118;2587DOI: 10.1542/peds.2006-2780The online version of this article, along with updated information and services, islocated on the World Wide Web at:http://pediatrics.aappublications.org/content/118/6/2587.full.htmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned,published, and trademarked by the American Academy of Pediatrics, 141 Northwest PointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

CLINICAL REPORTGuidelines for Monitoring andManagement of Pediatric PatientsDuring and After Sedation forDiagnostic and TherapeuticProcedures: An UpdateGuidance for the Clinician in RenderingPediatric CareAMERICAN ACADEMY OF PEDIATRICSAMERICAN ACADEMY OF PEDIATRIC DENTISTRYCharles J. Coté, MD, Stephen Wilson, DMD, MA, PhD, the Work Group on SedationABSTRACTThe safe sedation of children for procedures requires a systematic approach thatincludes the following: no administration of sedating medication without thesafety net of medical supervision; careful presedation evaluation for underlyingmedical or surgical conditions that would place the child at increased risk fromsedating medications; appropriate fasting for elective procedures and a balancebetween depth of sedation and risk for those who are unable to fast because of theurgent nature of the procedure; a focused airway examination for large tonsils oranatomic airway abnormalities that might increase the potential for airway obstruction;a clear understanding of the pharmacokinetic and pharmacodynamiceffects of the medications used for sedation, as well as an appreciation for druginteractions; appropriate training and skills in airway management to allow rescueof the patient; age- and size-appropriate equipment for airway management andvenous access; appropriate medications and reversal agents; sufficient numbers ofpeople to carry out the procedure and monitor the patient; appropriate physiologicmonitoring during and after the procedure; a properly equipped and staffedrecovery area; recovery to presedation level of consciousness before dischargefrom medical supervision; and appropriate discharge instructions. This report wasdeveloped through a collaborative effort of the American Academy of Pediatricsand the American Academy of Pediatric Dentistry to offer pediatric providersupdated information and guidance in delivering safe sedation to children.INTRODUCTIONInvasive diagnostic and minor surgical procedures on pediatric patients outside thetraditional operating room setting have increased in the last decade. As a consequenceof this change and the increased awareness of the importance of providinganalgesia and anxiolysis, the need for sedation for procedures in physician offices,dental offices, subspecialty procedure suites, imaging facilities, emergency departments,and ambulatory surgery centers has also markedly increased. 1–37 In recognitionof this need for both elective and emergency use of sedation in nontraditionalsettings, the American Academy of Pediatrics (AAP) and American Academywww.pediatrics.org/cgi/doi/10.1542/peds.2006-2780doi:10.1542/peds.2006-2780All clinical reports from the AmericanAcademy of Pediatrics automaticallyexpire 5 years after publication unlessreaffirmed, revised, or retired at orbefore that time.The guidance in this report does notindicate an exclusive course of treatmentor serve as a standard of medical care.Variations, taking into account individualcircumstances, may be appropriate.Key Wordssedation, guidelines, procedures, adverseevents, outcomes, accidents, prevention,monitoring, drug interactions, pediatric,childrenAbbreviationsAAP—American Academy of PediatricsAAPD—American Academy of PediatricDentistryASA—American Society ofAnesthesiologistsEMS—emergency medical servicesECG—electrocardiographyLMA—laryngeal mask airwayPEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics and theAmerican Academy of Pediatric DentistryPEDIATRICS Volume 118, Number 6, December 2006 2587Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

of Pediatric Dentistry (AAPD) have published a series ofguidelines for the monitoring and management of pediatricpatients during and after sedation for a procedure.38–42 The purpose of this updated statement is tounify the guidelines for sedation used by medical anddental practitioners, add clarifications regarding monitoringmodalities, provide new information from medicaland dental literature, and suggest methods for furtherimprovement in safety and outcomes. With the revisionof this document, the Joint Commission on Accreditationof Healthcare Organizations, the American Societyof Anesthesiologists (ASA), the AAP, and the AAPD willuse similar language to define sedation categories andthe expected physiologic responses. 41–44This revised statement reflects the current understandingof appropriate monitoring needs both duringand after sedation for a procedure. 4,5,12,19,21,22,26,45–53 Themonitoring and care outlined in these guidelines may beexceeded at any time on the basis of the judgment of theresponsible practitioner. Although intended to encouragehigh-quality patient care, adherence to these guidelinescannot guarantee a specific patient outcome. However,structured sedation protocols designed toincorporate the principles in this document have beenwidely implemented and shown to reduce morbidity.29,32–34,37,54,55 These guidelines are proffered with theawareness that, regardless of the intended level of sedationor route of administration, the sedation of a pediatricpatient represents a continuum and may result inrespiratory depression and loss of the patient’s protectivereflexes. 43,56–59Sedation of pediatric patients has serious associatedrisks, such as hypoventilation, apnea, airway obstruction,laryngospasm, and cardiopulmonary impairment.2,6,22,45,46,54,60–69 These adverse responses during andafter sedation for a diagnostic or therapeutic proceduremay be minimized, but not completely eliminated, by acareful preprocedure review of the patient’s underlyingmedical conditions and consideration of how the sedationprocess might affect or be affected by these conditions.54 Appropriate drug selection for the intended procedureas well as the presence of an individual with theskills needed to rescue a patient from an adverse responseare essential. Appropriate physiologic monitoringand continuous observation by personnel not directlyinvolved with the procedure allow for accurate and rapiddiagnosis of complications and initiation of appropriaterescue interventions. 46,51,54The sedation of children is different from the sedationof adults. Sedation in children is often administered tocontrol behavior to allow the safe completion of a procedure.A child’s ability to control his or her own behaviorto cooperate for a procedure depends both on his orher chronologic and developmental age. Often, childrenyounger than 6 years and those with developmentaldelay require deep levels of sedation to gain control oftheir behavior. 57 Therefore, the need for deep sedationshould be anticipated. Children in this age group areparticularly vulnerable to the sedating medication’s effectson respiratory drive, patency of the airway, andprotective reflexes. 46 Studies have shown that it is commonfor children to pass from the intended level ofsedation to a deeper, unintended level of sedation. 56,59,70For older and cooperative children, other modalities,such as parental presence, hypnosis, distraction, topicallocal anesthetics, and guided imagery, may reduce theneed for or the needed depth of pharmacologic sedation.31,71–81The concept of rescue is essential to safe sedation.Practitioners of sedation must have the skills to rescuethe patient from a deeper level than that intended forthe procedure. For example, if the intended level ofsedation is “minimal,” practitioners must be able to rescuethe patient from “moderate sedation”; if the intendedlevel of sedation is “moderate,” practitionersmust have the skills to rescue the patient from “deepsedation”; and if the intended level of sedation is “deep,”practitioners must have the skills to rescue the patientfrom a state of “general anesthesia.” The ability to rescuemeans that practitioners must be able to recognizethe various levels of sedation and have the skills necessaryto provide appropriate cardiopulmonary supportif needed. Sedation and anesthesia in a nonhospital environment(private physician or dental office or freestandingimaging facility) may be associated with anincreased incidence of “failure to rescue” the patientshould an adverse event occur, because the only backupin this venue may be to activate emergency medicalservices (EMS). 46,82 Rescue therapies require specifictraining and skills. 46,54,83,84 Maintenance of the skillsneeded to perform successful bag-valve-mask ventilationis essential to successfully rescue a child who hasbecome apneic or developed airway obstruction. Familiaritywith emergency airway management procedurealgorithms is essential. 83–87 Practitioners should have anin-depth knowledge of the agents they intend to use andtheir potential complications. A number of reviews andhandbooks for sedating pediatric patients are available.32,48,55,88–93 These guidelines are intended for all venuesin which sedation for a procedure might be performed(hospital, surgical center, freestanding imagingfacility, dental facility, or private office).There are other guidelines for specific situations andpersonnel that are beyond the scope of this document.Specifically, guidelines for the delivery of general anesthesiaand monitored anesthesia care (sedation or analgesia),outside or within the operating room by anesthesiologistsor other practitioners functioning within adepartment of anesthesiology, are addressed by policiesdeveloped by the ASA and by individual departments ofanesthesiology. 94 Also, guidelines for the sedation of patientsundergoing mechanical ventilation in a critical2588 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

care environment or for providing analgesia for patientspostoperatively, patients with chronic painful conditions,and hospice care are also beyond the scope of thisdocument.DEFINITION OF TERMS USED IN THIS REPORT● Pediatric patients: all patients through 21 years of age,as defined by the AAP.● Must/shall: an imperative need or duty that is essential,indispensable, or mandatory.● Should: the recommended need and/or duty.● May/could: freedom or liberty to follow a suggested orreasonable alternative.● Medical supervision/medical personnel: a currently licensedpractitioner of medicine, surgery, or dentistrytrained in the administration of medications used forprocedural sedation and the management of complicationsassociated with these medications.● Encouraged: a suggested or reasonable action to betaken.● ASA physical status classification: guidelines for classifyingthe baseline health status according to the ASA(see Appendix 1).● Minimal sedation (formerly anxiolysis): a drug-inducedstate during which patients respond normally toverbal commands; although cognitive function andcoordination may be impaired, ventilatory and cardiovascularfunctions are unaffected.● Moderate sedation (formerly conscious sedation orsedation/analgesia): a drug-induced depression ofconsciousness during which patients respond purposefullyto verbal commands (eg, “open your eyes,”either alone or accompanied by light tactile stimulation,such as a light tap on the shoulder or face, not asternal rub). For older patients, this level of sedationimplies an interactive state; for younger patients, ageappropriatebehaviors (eg, crying) occur and are expected.Reflex withdrawal, although a normal responseto a painful stimulus, is not considered as theonly age-appropriate purposeful response (ie, it mustbe accompanied by another response, such as pushingaway the painful stimulus, to confirm a higher cognitivefunction). With moderate sedation, no interventionis required to maintain a patent airway, and spontaneousventilation is adequate. Cardiovascularfunction is usually maintained. However, in the caseof procedures that may themselves cause airway obstruction(eg, dental or endoscopic), the practitionermust recognize an obstruction and assist the patient inopening the airway. If the patient is not making spontaneousefforts to open their airway to relieve theobstruction, then the patient should be considered tobe deeply sedated.● Deep sedation (deep sedation/analgesia): a drug-induceddepression of consciousness during which patientscannot be easily aroused but respond purposefully(see discussion of reflex withdrawal above) afterrepeated verbal or painful stimulation (eg, purposefullypushing away the noxious stimuli). The ability toindependently maintain ventilatory function may beimpaired. Patients may require assistance in maintaininga patent airway, and spontaneous ventilation maybe inadequate. Cardiovascular function is usuallymaintained. A state of deep sedation may be accompaniedby partial or complete loss of protective airwayreflexes.● General anesthesia: a drug-induced loss of consciousnessduring which patients are not arousable, even bypainful stimulation. The ability to independentlymaintain ventilatory function is often impaired. Patientsoften require assistance in maintaining a patentairway, and positive-pressure ventilation may be requiredbecause of depressed spontaneous ventilationor drug-induced depression of neuromuscular function.Cardiovascular function may be impaired.GOALS OF SEDATIONThe goals of sedation in the pediatric patient for diagnosticand therapeutic procedures are to (1) guard thepatient’s safety and welfare; (2) minimize physical discomfortand pain; (3) control anxiety, minimize psychologicaltrauma, and maximize the potential for amnesia;(4) control behavior and/or movement to allow the safecompletion of the procedure; and (5) return the patientto a state in which safe discharge from medical supervision,as determined by recognized criteria, is possible(Appendix 2).These goals can best be achieved by selecting the lowestdose of drug with the highest therapeutic index for theprocedure. It is beyond the scope of this document tospecify which drugs are appropriate for which procedures;however, the selection of the fewest number of drugs andmatching drug selection to the type and goal of the procedureare essential for safe practice. 53,88,91–93,95–97 For example,analgesic medications such as opioids are indicated forpainful procedures. For nonpainful procedures, such ascomputed tomography or MRI, sedatives/hypnotics arepreferred. When both sedation and analgesia are desirable(eg, fracture reduction), either single agents with analgesic/sedative properties or combination regimens are commonlyused. Anxiolysis and amnesia are additional goalsthat should be considered in selection of agents for particularpatients. However, the potential for an adverse outcomemay be increased when 3 or more sedating medicationsare administered. 45,98 Knowledge of each drug’s timeof onset, peak response, and duration of action is essential.Although the concept of titration of drug to effect is critical,one must know whether the previous dose has taken fullPEDIATRICS Volume 118, Number 6, December 2006 2589Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

effect before administering additional drug. Such managementwill improve safety and outcomes. Drugs with longdurations of action (eg, chloral hydrate, intramuscular pentobarbital,phenothiazines) will require longer periods ofobservation even after the child achieves currently usedrecovery and discharge criteria. 45,99,100 This concept is particularlyimportant for infants and toddlers transported incar safety seats who are at risk of resedation after dischargebecause of residual prolonged drug effects with the potentialfor airway obstruction. 45,46GENERAL GUIDELINESCandidatesPatients who are in ASA classes I and II (Appendix 1) arefrequently considered appropriate candidates for minimal,moderate, or deep sedation. Children in ASA classesIII and IV, children with special needs, and those withanatomic airway abnormalities or extreme tonsillar hypertrophypresent issues that require additional and individualconsideration, particularly for moderate anddeep sedation. 51 Practitioners are encouraged to consultwith appropriate subspecialists and/or an anesthesiologistfor patients at increased risk of experiencing adversesedation events because of their underlying medical/surgical conditions.Responsible PersonThe pediatric patient shall be accompanied to and fromthe treatment facility by a parent, legal guardian, orother responsible person. It is preferable to have 2 ormore adults accompany children who are still in carsafety seats if transportation to and from a treatmentfacility is provided by one of the adults. 101FacilitiesThe practitioner who uses sedation must have immediatelyavailable facilities, personnel, and equipment tomanage emergency and rescue situations. The mostcommon serious complications of sedation involve compromiseof the airway or depressed respirations resultingin airway obstruction, hypoventilation, hypoxemia, andapnea. Hypotension and cardiopulmonary arrest mayoccur, usually from inadequate recognition and treatmentof respiratory compromise. Other rare complicationsmay also include seizures and allergic reactions.Facilities that provide pediatric sedation should monitorfor, and be prepared to treat, such complications.Back-up Emergency ServicesA protocol for access to back-up emergency services shallbe clearly identified with an outline of the proceduresnecessary for immediate use. For nonhospital facilities, aprotocol for ready access to ambulance service and immediateactivation of the EMS system for life-threateningcomplications must be established and maintained. Itshould be understood that the availability of EMS servicesdoes not replace the practitioner’s responsibility toprovide initial rescue in managing life-threatening complications.On-Site Monitoring and Rescue EquipmentAn emergency cart or kit must be immediately accessible.This cart or kit must contain equipment to providethe necessary age- and size-appropriate drugs and equipmentto resuscitate a nonbreathing and unconsciouschild. The contents of the kit must allow for the provisionof continuous life support while the patient is beingtransported to a medical facility or to another areawithin a medical facility. All equipment and drugs mustbe checked and maintained on a scheduled basis (seeAppendices 3 and 4 for suggested drugs and emergencylife support equipment to consider before the need forrescue occurs). Monitoring devices, such as electrocardiography(ECG) machines, pulse oximeters (with sizeappropriateoximeter probes), end-tidal carbon dioxidemonitors, and defibrillators (with size-appropriate defibrillatorpaddles), must have a safety and function checkon a regular basis as required by local or state regulation.DocumentationDocumentation before sedation shall include, but not belimited to, the guidelines that follow.1. Informed consent: the patient record shall documentthat appropriate informed consent was obtained accordingto local, state, and institutional requirements.1022. Instructions and information provided to the responsibleperson: the practitioner shall provide verbaland/or written instructions to the responsible person.Information shall include objectives of the sedationand anticipated changes in behavior during and aftersedation. Special instructions shall be given to theresponsible adult for infants and toddlers who will betransported home in a car safety seat regarding theneed to carefully observe the child’s head position toavoid airway obstruction. Transportation in a carsafety seat poses a particular risk for infants who havereceived medications known to have a long half-life,such as chloral hydrate, intramuscular pentobarbital,or phenothiazine. 45,46,100,103 Consideration for a longerperiod of observation shall be given if the responsibleperson’s ability to observe the child is limited (eg,only 1 adult who also has to drive). Another indicationfor prolonged observation would be a child withan anatomic airway problem or a severe underlyingmedical condition. A 24-hour telephone number forthe practitioner or his or her associates shall be providedto all patients and their families. Instructionsshall include limitations of activities and appropriatedietary precautions.2590 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

Dietary PrecautionsAgents used for sedation have the potential to impairprotective airway reflexes, particularly during deep sedation.Although a rare occurrence, pulmonary aspirationmay occur if the child regurgitates and cannot protecthis or her airway. Therefore, it is prudent that,before sedation, the practitioner evaluate preceding foodand fluid intake. It is likely that the risk of aspirationduring procedural sedation differs from that during generalanesthesia involving tracheal intubation or otherairway manipulation. 104,105 However, because the absoluterisk of aspiration during procedural sedation is notyet known, guidelines for fasting periods before electivesedation should generally follow those used for electivegeneral anesthesia. For emergency procedures in childrenwho have not fasted, the risks of sedation and thepossibility of aspiration must be balanced against thebenefits of performing the procedure promptly (see below).Additional research is needed to better elucidatethe relationships between various fasting intervals andsedation complications.Before Elective SedationChildren receiving sedation for elective proceduresshould generally follow the same fasting guidelines asthose for general anesthesia (Table 1). It is permissiblefor routine necessary medications to be taken with a sipof water on the day of the procedure.TABLE 1 Appropriate Intake of Food and Liquids Before ElectiveSedationIngested MaterialMinimum FastingPeriod, hClear liquids: water, fruit juices without2pulp, carbonated beverages, clear tea,black coffeeBreast milk 4Infant formula 6Nonhuman milk: because nonhuman milk6is similar to solids in gastric emptyingtime, the amount ingested must beconsidered when determining anappropriate fasting periodLight meal: a light meal typically consists6of toast and clear liquids. Meals thatinclude fried or fatty foods or meat mayprolong gastric emptying time; boththe amount and type of foods ingestedmust be considered when determiningan appropriate fasting periodSource: American Society of Anesthesiologists. Practice guidelines for preoperative fasting andthe use of pharmacologic agents to reduce the risk of pulmonary aspiration: application tohealthy patients undergoing elective procedures—a report of the American Society of Anesthesiologists.Available at: www.asahq.org/publicationsAndServices/NPO.pdf.Before Emergency SedationThe practitioner must always balance the possible risksof sedating nonfasted patients with the benefits andnecessity for completing the procedure. In this circumstance,the use of sedation must be preceded by anevaluation of food and fluid intake. There are few publishedstudies with adequate statistical power to provideguidance to the practitioner regarding safety or risk ofpulmonary aspiration of gastric contents during proceduralsedation. 104–109 When protective airway reflexes arelost, gastric contents may be regurgitated into the airway.Therefore, patients with a history of recent oralintake or with other known risk factors, such as trauma,decreased level of consciousness, extreme obesity, pregnancy,or bowel motility dysfunction, require carefulevaluation before administration of sedatives. Whenproper fasting has not been ensured, the increased risksof sedation must be carefully weighed against its benefits,and the lightest effective sedation should be used.The use of agents with less risk of depressing protectiveairway reflexes may be preferred. 110 Some emergencypatients requiring deep sedation may require protectionof the airway before sedation.Use of Immobilization DevicesImmobilization devices such as papoose boards must beapplied in such a way as to avoid airway obstruction orchest restriction. The child’s head position and respiratoryexcursions should be checked frequently to ensureairway patency. If an immobilization device is used, ahand or foot should be kept exposed, and the childshould never be left unattended. If sedating medicationsare administered in conjunction with an immobilizationdevice, monitoring must be used at a level consistentwith the level of sedation achieved.Documentation at the Time of Sedation1. Health evaluation: before sedation, a health evaluationshall be performed by an appropriately licensedpractitioner and reviewed by the sedation team at thetime of treatment for possible interval changes. Thepurpose of this evaluation is to not only documentbaseline status but also determine if patients presentspecific risk factors that may warrant additional consultationbefore sedation. This evaluation will alsoscreen out patients whose sedation will require moreadvanced airway or cardiovascular managementskills or alterations in the doses or types of medicationsused for procedural sedation.A new concern for the practitioner is the widespreaduse of medications that may interfere withdrug absorption or metabolism and, therefore, enhanceor shorten the effect time of sedating medications.Herbal medicines (eg, St John’s wort or echinacea),may alter drug pharmacokinetics throughinhibition of the cytochrome P450 system, resultingin prolonged drug effect and altered (increased ordecreased) blood drug concentrations. 111–116 Kava mayincrease the effects of sedatives by potentiatingPEDIATRICS Volume 118, Number 6, December 2006 2591Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

-aminobutyric acid inhibitory neurotransmission,and valerian may itself produce sedation that apparentlyis mediated through modulation of -aminobutyricacid neurotransmission and receptor function.117,118 Drugs such as erythromycin, cimetidine,and others may also inhibit the cytochrome P450system, resulting in prolonged sedation with midazolamas well as other medications competing for thesame enzyme systems. 119–122 Medications used to treatHIV infection, some anticonvulsants, and some psychotropicmedications may also produce clinically importantdrug-drug interactions. 123–125 Therefore, carefullyobtaining a drug history is a vital part of the safe sedationof children. The clinician should consult varioussources (a pharmacist, textbooks, online services, orhandheld databases) for specific information on druginteractions. 126The health evaluation should include:● obtaining age and weight● obtaining a health history, including (1) allergiesand previous allergic or adverse drug reactions; (2)medication/drug history, including dosage, time,route, and site of administration for prescription,over-the-counter, herbal, or illicit drugs; (3) relevantdiseases, physical abnormalities, and neurologicimpairment that might increase the potentialfor airway obstruction, such as a history of snoringor obstructive sleep apnea 127,128 ; (4) pregnancy status;(5) a summary of previous relevant hospitalizations;(6) history of sedation or general anesthesiaand any complications or unexpected responses;and (7) relevant family history, particularly thatrelated to anesthesia● a review of systems with a special focus on abnormalitiesof cardiac, pulmonary, renal, or hepaticfunction that might alter the child’s expected responsesto sedating/analgesic medications● determination of vital signs, including heart rate,blood pressure, respiratory rate, and temperature(for some children who are very upset or noncooperative,this may not be possible, and a noteshould be written to document this occurrence)● a physical examination, including a focused evaluationof the airway (tonsillar hypertrophy, abnormalanatomy [eg, mandibular hypoplasia]) to determineif there is an increased risk of airwayobstruction 54,129,130● a physical status evaluation (ASA classification [seeAppendix 1])● obtaining name, address, and telephone number ofthe child’s medical homeFor hospitalized patients, the current hospitalrecord may suffice for adequate documentation ofpresedation health; however, a brief note shall bewritten documenting that the chart was reviewed,positive findings were noted, and a management planwas formulated. If the clinical or emergency conditionof the patient precludes acquiring complete informationbefore sedation, this health evaluationshould be obtained as soon as is feasible.2. Prescriptions: when prescriptions are used for sedation,a copy of the prescription or a note describingthe content of the prescription should be in the patient’schart along with a description of the instructionsthat were given to the responsible person. Prescriptionmedications intended to accomplish proceduralsedation must not be administered without the benefit ofdirect supervision by trained medical personnel. Administrationof sedating medications at home poses anunacceptable risk, particularly for infants and preschool-agedchildren traveling in car safety seats. 46Documentation During TreatmentThe patient’s chart shall contain a time-based record thatincludes the name, route, site, time, dosage, and patienteffect of administered drugs. Before sedation, a “timeout” should be performed to confirm the patient’s name,procedure to be performed, and site of the procedure. 43During administration, the inspired concentrations ofoxygen and inhalation sedation agents and the durationof their administration shall be documented. Before drugadministrations, special attention must be paid to calculationof dosage (ie, mg/kg). The patient’s chart shallcontain documentation at the time of treatment that thepatient’s level of consciousness and responsiveness,heart rate, blood pressure, respiratory rate, and oxygensaturation were monitored until the patient attainedpredetermined discharge criteria (see Appendix 2). Avariety of sedation-scoring systems are available andmay aid this process. 70,100 Adverse events and their treatmentshall be documented.Documentation After TreatmentThe time and condition of the child at discharge from thetreatment area or facility shall be documented; thisshould include documentation that the child’s level ofconsciousness and oxygen saturation in room air havereturned to a state that is safe for discharge by recognizedcriteria (see Appendix 2). Patients receiving supplementaloxygen before the procedure should have asimilar oxygen need after the procedure. Because somesedation medications are known to have a long half-lifeand may delay a patient’s complete return to baseline orpose the risk of resedation, 45,103,131,132 some patients mightbenefit from a longer period of less-intense observation(eg, a step-down observation area) before dischargefrom medical supervision. 133 Several scales to evaluaterecovery have been devised and validated. 70,134,135 A re-2592 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

cently described and simple evaluation tool may be theability of the infant or child to remain awake for at least20 minutes when placed in a quiet environment. 100CONTINUOUS QUALITY IMPROVEMENTThe essence of medical error reduction is a careful examinationof index events and root-cause analysis ofhow the event could be avoided in the future. 136–140Therefore, each facility should maintain records thattrack adverse events such as desaturation, apnea, laryngospasm,the need for airway interventions includingjaw thrust or positive pressure ventilation, prolongedsedation, unanticipated use of reversal agents, unintendedor prolonged hospital admission, and unsatisfactorysedation/analgesia/anxiolysis. Such events can thenbe examined for assessment of risk reduction and improvementin patient satisfaction.PREPARATION AND SETUP FOR SEDATION PROCEDURESPart of the safety net of sedation is to use a systematicapproach so as to not overlook having an importantdrug, piece of equipment, or monitor immediately availableat the time of a developing emergency. To avoid thisproblem, it is helpful to use an acronym that allows thesame setup and checklist for every procedure. A commonlyused acronym that is useful in planning andpreparation for a procedure is SOAPME:S (suction)—size-appropriate suction catheters and a functioningsuction apparatus (eg, Yankauer-type suction)O (oxygen)—adequate oxygen supply and functioningflow meters/other devices to allow its deliveryA (airway)—size-appropriate airway equipment (nasopharyngealand oropharyngeal airways, laryngoscopeblades [checked and functioning], endotracheal tubes,stylets, face mask, bag-valve-mask or equivalent device[functioning])P (pharmacy)—all the basic drugs needed to support lifeduring an emergency, including antagonists as indicatedM (monitors)—functioning pulse oximeter with sizeappropriateoximeter probes 141,142 and other monitors asappropriate for the procedure (eg, noninvasive blood pressure,end-tidal carbon dioxide, ECG, stethoscope)E (equipment)—special equipment or drugs for a particularcase (eg, defibrillator)SPECIFIC GUIDELINES FOR INTENDED LEVEL OF SEDATIONMinimal SedationMinimal sedation (formerly anxiolysis) is a drug-inducedstate during which patients respond normally toverbal commands. Although cognitive function and coordinationmay be impaired, ventilatory and cardiovascularfunctions are unaffected. Children who have receivedminimal sedation generally will not require morethan observation and intermittent assessment of theirlevel of sedation. Some children will become moderatelysedated despite the intended level of minimal sedation;should this occur, the guidelines for moderate sedationwill apply. 56Moderate SedationModerate sedation (formerly conscious sedation or sedation/analgesia)is a drug-induced depression of consciousnessduring which patients respond purposefullyto verbal commands or light tactile stimulation (see“Definition of Terms Used in This Report”). No interventionsare required to maintain a patent airway, andspontaneous ventilation is adequate. Cardiovascularfunction is usually maintained. The caveat that loss ofconsciousness should be unlikely is a particularly importantaspect of the definition of moderate sedation. Thedrugs and techniques used should carry a margin ofsafety wide enough to render unintended loss of consciousnesshighly unlikely. Because the patient who receivesmoderate sedation may progress into a state ofdeep sedation and obtundation, the practitioner shouldbe prepared to increase the level of vigilance correspondingto what is necessary for deep sedation. 56PersonnelThe PractitionerThe practitioner responsible for the treatment of thepatient and/or the administration of drugs for sedationmust be competent to use such techniques, provide thelevel of monitoring provided in these guidelines, andmanage complications of these techniques (ie, to be ableto rescue the patient). Because the level of intendedsedation may be exceeded, the practitioner must be sufficientlyskilled to provide rescue should the childprogress to a level of deep sedation. The practitionermust be trained in, and capable of providing, at theminimum, bag-valve-mask ventilation to be able tooxygenate a child who develops airway obstruction orapnea. Training in, and maintenance of, advanced pediatricairway skills is required; regular skills reinforcementis strongly encouraged.Support PersonnelThe use of moderate sedation shall include provisionof a person, in addition to the practitioner, whose responsibilityis to monitor appropriate physiologic parametersand to assist in any supportive or resuscitationmeasures if required. This individual may also be responsiblefor assisting with interruptible patient-relatedtasks of short duration. 44 This individual must be trainedin and capable of providing pediatric basic life support.The support person shall have specific assignments inthe event of an emergency and current knowledge of theemergency cart inventory. The practitioner and all ancillarypersonnel should participate in periodic reviewsand practice drills of the facility’s emergency protocol toensure proper function of the equipment and coordinationof staff roles in such emergencies.Monitoring and DocumentationBaselineBefore administration of sedative medications, a baselinedetermination of vital signs shall be documented.PEDIATRICS Volume 118, Number 6, December 2006 2593Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

For some children who are very upset or noncooperative,this may not be possible, and a note should bewritten to document this happenstance.During the ProcedureThe practitioner shall document the name, route, site,time of administration, and dosage of all drugs administered.There shall be continuous monitoring of oxygensaturation and heart rate and intermittent recording ofrespiratory rate and blood pressure; these should berecorded in a time-based record. Restraining devicesshould be checked to prevent airway obstruction orchest restriction. If a restraint device is used, a hand orfoot should be kept exposed. The child’s head positionshould be checked frequently to ensure airway patency.A functioning suction apparatus must be present.After the ProcedureThe child who has received moderate sedation mustbe observed in a suitably equipped recovery facility (ie,the facility must have functioning suction apparatus aswell as the capacity to deliver more than 90% oxygenand positive-pressure ventilation [eg, bag and mask withoxygen capacity as described previously]). The patient’svital signs should be recorded at specific intervals. If thepatient is not fully alert, oxygen saturation and heartrate monitoring shall be used continuously until appropriatedischarge criteria are met (see Appendix 2). Becausesedation medications with a long half-life maydelay the patient’s complete return to baseline or posethe risk of resedation, some patients might benefit froma longer period of less-intense observation (eg, a stepdownobservation area in which multiple patients can beobserved simultaneously) before discharge from medicalsupervision (see also “Documentation” for instructionsto families). 45,103,131,132 A recently described and simpleevaluation tool may be the ability of the infant or childto remain awake for at least 20 minutes when placed ina quiet environment. 100 Patients who have received reversalagents, such as flumazenil or naloxone, will alsorequire a longer period of observation, because the durationof the drugs administered may exceed the durationof the antagonist, which can lead to resedation.Deep SedationDeep sedation is a drug-induced depression of consciousnessduring which patients cannot be easilyaroused but respond purposefully after repeated verbalor painful stimulation (see “Definition of Terms Used inThis Report”). The state and risks of deep sedation maybe indistinguishable from those of general anesthesia.PersonnelThere must be 1 person available whose only responsibilityis to constantly observe the patient’s vital signs,airway patency, and adequacy of ventilation and to eitheradminister drugs or direct their administration. Atleast 1 individual must be present who is trained in, andcapable of, providing advanced pediatric life support andwho is skilled in airway management and cardiopulmonaryresuscitation; training in pediatric advanced lifesupport is required.EquipmentIn addition to the equipment previously cited for moderatesedation, an ECG monitor and a defibrillator foruse in pediatric patients should be readily available.Vascular AccessPatients receiving deep sedation should have an intravenousline placed at the start of the procedure or havea person skilled in establishing vascular access in pediatricpatients immediately available.MonitoringA competent individual shall observe the patient continuously.The monitoring shall include all parameters describedfor moderate sedation. Vital signs, including oxygensaturation and heart rate, must be documented atleast every 5 minutes in a time-based record. The use ofa precordial stethoscope or capnograph for patients whoare difficult to observe (eg, during MRI or in a darkenedroom) to aid in monitoring adequacy of ventilation isencouraged. 143 The practitioner shall document thename, route, site, time of administration, and dosage ofall drugs administered. The inspired concentrations ofinhalation sedation agents and oxygen and the durationof administration shall be documented.Postsedation CareThe facility and procedures followed for postsedationcare shall conform to those described for moderate sedation.SPECIAL CONSIDERATIONSLocal Anesthetic AgentsAll local anesthetic agents are cardiac depressants andmay cause central nervous system excitation or depression.Particular attention should be paid to dosage insmall children. 64,66 To ensure that the patient will notreceive an excessive dose, the maximum allowable safedosage (eg, mg/kg) should be calculated before administration.There may be enhanced sedative effects whenthe highest recommended doses of local anesthetic drugsare used in combination with other sedatives or narcotics(see Tables 2 and 3 for limits and conversion tables ofcommonly used local anesthetics). 64,144–157 In general,when administering local anesthetic drugs, the practitionershould aspirate frequently to minimize the likelihoodthat the needle is in a blood vessel; lower dosesshould be used when injecting into vascular tissues. 1582594 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

TABLE 2Local AnestheticCommonly Used Local Anesthetic Agents: Doses,Duration, and CalculationsMaximum Dose WithEpinephrine, mg/kg aDuration of Action,min bMedical DentalEstersProcaine 10.0 6 60–90Chloroprocaine 20.0 12 30–60Tetracaine 1.5 1 180–600AmidesLidocaine 7.0 4.4 90–200Mepivacaine 7.0 4.4 120–240Bupivacaine 3.0 1.3 180–600Levobupivacaine 3.0 2 180–600Ropivacaine 3.0 2 180–600Articaine 7 60–230Maximum recommended doses and duration of action are shown. Note that lower dosesshould be used in very vascular areas.aThese are maximum doses of local anesthetics combined with epinephrine; lower doses arerecommended when used without epinephrine. Doses of amides should be decreased by 30%for infants younger than 6 months. When lidocaine is being administered intravascularly (eg,during intravenous regional anesthesia), the dose should be decreased to 3 to 5 mg/kg; longactinglocal anesthetic agents should not be used for intravenous regional anesthesia.bDuration of action depends on concentration, total dose, and site of administration; use ofepinephrine; and the patient’s age.Pulse OximetryThe new-generation pulse oximeters are less susceptible tomotion artifacts and may be more useful than older oximetersthat do not contain the updated software. 159–163 Oximetersthat change tone with changes in hemoglobin saturationprovide immediate aural warning to everyone withinhearing distance. It is essential that any oximeter probe isproperly positioned; clip-on devices are prone to easy displacement,which may produce artifactual data (underestimationor overestimation of oxygen saturation). 141,142CapnographyExpired carbon dioxide monitoring is valuable to diagnosethe simple presence or absence of respirations,airway obstruction, or respiratory depression, particularlyin patients sedated in less-accessible locations, suchas MRI or computerized axial tomography devices ordarkened rooms. 47,49,50,143,164–173 The use of expired carbondioxide monitoring devices is encouraged for sedatedchildren, particularly in situations where other means ofassessing the adequacy of ventilation are limited. Severalmanufacturers have produced nasal cannulae that allowsimultaneous delivery of oxygen and measurement ofexpired carbon dioxide values. 164,165 Although these devicescan have a high degree of false-positive alarms,they are also very accurate for the detection of completeairway obstruction or apnea. 166,168,173Adjuncts to Airway Management and ResuscitationThe vast majority of sedation complications can bemanaged with simple maneuvers, such as providingsupplemental oxygen, opening the airway, suctioning,and using bag-mask-valve ventilation. Occasionally,TABLE 3 Local Anesthetic Percent Concentration: Conversion tomg/mLConcentration, %mg/mL3.0 30.02.5 25.02.0 20.01.0 10.00.5 5.00.25 2.50.125 1.25endotracheal intubation is required for more prolongedventilatory support. In addition to standardendotracheal intubation techniques, a number of newdevices are available for the management of patientswith abnormal airway anatomy or airway obstruction.Examples include the laryngeal mask airway (LMA),the cuffed oropharyngeal airway, and a variety of kitsto perform an emergency cricothyrotomy.The largest clinical experience in pediatrics is with theLMA, which is available in a variety of sizes and caneven be used in neonates. Use of the LMA is now beingintroduced into advanced airway training courses, andfamiliarity with insertion techniques can be life-saving.174,175 The LMA can also serve as a bridge to secureairway management in children with anatomic airwayabnormalities. 176,177 Practitioners are encouraged to gainexperience with these techniques as they become incorporatedinto pediatric advanced life support courses.An additional emergency device with which to becomefamiliar is the intraosseous needle. Intraosseous needles arealso available in several sizes and can be life-saving in therare situation when rapid establishment of intravenousaccess is not possible. Familiarity with the use of theseadjuncts for the management of emergencies can be obtainedby keeping current with resuscitation courses, suchas Pediatric Advanced Life Support and Advanced PediatricLife Support or other approved programs.Patient SimulatorsAdvances in technology, particularly patient simulatorsthat allow a variety of programmed adverse events such asapnea, bronchospasm, laryngospasm, response to medicalinterventions, and printouts of physiologic parameters, arenow available. The use of such devices is encouraged tobetter train medical professionals to respond more appropriatelyand effectively to rare events. 178–180Monitoring During MRIThe powerful magnetic field and the generation of radiofrequency emissions necessitate the use of special equipmentto provide continuous patient monitoringthroughout the MRI procedure. Pulse oximeters capableof continuous function during scanning should be usedin any sedated or restrained pediatric patient. Thermalinjuries can result if appropriate precautions are notPEDIATRICS Volume 118, Number 6, December 2006 2595Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

taken; avoid coiling the oximeter wire and place theprobe as far from the magnetic coil as possible to diminishthe possibility of injury. Electrocardiogram monitoringduring MRI has been associated with thermal injury;special MRI-compatible ECG pads are essential to allowsafe monitoring. 181–184 Expired carbon dioxide monitoringis strongly encouraged in this setting.Nitrous OxideInhalation sedation/analgesia equipment that delivers nitrousoxide must have the capacity of delivering 100% andnever less than 25% oxygen concentration at a flow rateappropriate to the size of the patient. Equipment that deliversvariable ratios of nitrous oxide to oxygen and thathas a delivery system that covers the mouth and nose mustbe used in conjunction with a calibrated and functionaloxygen analyzer. All nitrous oxide-to-oxygen inhalationdevices should be calibrated in accordance with appropriatestate and local requirements. Consideration should begiven to the National Institute of Occupational Safety andHealth Standards for the scavenging of waste gases. 185Newly constructed or reconstructed treatment facilities, especiallythose with piped-in nitrous oxide and oxygen,must have appropriate state or local inspections to certifyproper function of inhalation sedation/analgesia systemsbefore any delivery of patient care.Nitrous oxide in oxygen with varying concentrationshas been successfully used for many years to provideanalgesia for a variety of painful procedures in children.15,186–210 The use of nitrous oxide for minimal sedationis defined as the administration of nitrous oxide(50% or less) with the balance as oxygen, without anyother sedative, narcotic, or other depressant drug beforeor concurrent with the nitrous oxide to an otherwisehealthy patient in ASA class I or II. The patient is able tomaintain verbal communication throughout the procedure.It should be noted that although local anestheticshave sedative properties, for purposes of this guideline,they are not considered sedatives in this circumstance. Ifnitrous oxide in oxygen is combined with other sedatingmedications, such as chloral hydrate, midazolam, or anopioid, or if nitrous oxide is used in concentrations morethan 50%, the likelihood for moderate or deep sedationincreases. 211,212 In this situation, the clinician must beprepared to institute the guidelines for moderate or deepsedation as indicated by the patient’s response. 213WORK GROUP ON SEDATIONPaul Casamassimo, DDS, MSCharles J. Coté, MDPatricia Crumrine, MDRichard L. Gorman, MDMary Hegenbarth, MDStephen Wilson, DMD, MA, PhDSTAFFRaymond J. Koteras, MHAREFERENCES1. Milnes AR. Intravenous procedural sedation: an alternative togeneral anesthesia in the treatment of early childhood caries.J Can Dent Assoc. 2003;69:298–3022. Law AK, Ng DK, Chan KK. Use of intramuscular ketamine forendoscopy sedation in children. Pediatr Int. 2003;45:180–1853. Rothermel LK. Newer pharmacologic agents for proceduralsedation of children in the emergency department: etomidateand propofol. Curr Opin Pediatr. 2003;15:200–2034. Flood RG, Krauss B. Procedural sedation and analgesia forchildren in the emergency department. Emerg Med Clin NorthAm. 2003;21:121–1395. Jaggar SI, Haxby E. Sedation, anaesthesia and monitoring forbronchoscopy. Paediatr Respir Rev. 2002;3:321–3276. de Blic J, Marchac V, Scheinmann P. Complications of flexiblebronchoscopy in children: prospective study of 1,328 procedures.Eur Respir J. 2002;20:1271–12767. Mason KP, Michna E, DiNardo JA, et al. Evolution of a protocolfor ketamine-induced sedation as an alternative to generalanesthesia for interventional radiologic procedures inpediatric patients. Radiology. 2002;225:457–4658. Houpt M. Project USAP 2000: use of sedative agents by pediatricdentists—a 15-year follow-up survey. Pediatr Dent. 2002;24:289–2949. Vinson DR, Bradbury DR. Etomidate for procedural sedationin emergency medicine. Ann Emerg Med. 2002;39:592–59810. Everitt IJ, Barnett P. Comparison of two benzodiazepines usedfor sedation of children undergoing suturing of a laceration inan emergency department. Pediatr Emerg Care. 2002;18:72–7411. Karian VE, Burrows PE, Zurakowski D, Connor L, PoznauskisL, Park MK. The development of a pediatric radiology sedationprogram. Pediatr Radiol. 2002;32:348–35312. Kaplan RF, Yang CI. Sedation and analgesia in pediatric patientsfor procedures outside the operating room. AnesthesiolClin North America. 2002;20:181–19413. Wheeler DS, Jensen RA, Poss WB. A randomized, blindedcomparison of chloral hydrate and midazolam sedation inchildren undergoing echocardiography. Clin Pediatr (Phila).2001;40:381–38714. Hain RD, Campbell C. Invasive procedures carried out inconscious children: contrast between North American andEuropean paediatric oncology centres. Arch Dis Child. 2001;85:12–1515. Kennedy RM, Luhmann JD. Pharmacological management ofpain and anxiety during emergency procedures in children.Paediatr Drugs. 2001;3:337–35416. Kanagasundaram SA, Lane LJ, Cavalletto BP, Keneally JP,Cooper MG. Efficacy and safety of nitrous oxide in alleviatingpain and anxiety during painful procedures. Arch Dis Child.2001;84:492–49517. Younge PA, Kendall JM. Sedation for children requiringwound repair: a randomised controlled double blind comparisonof oral midazolam and oral ketamine. Emerg Med J.2001;18:30–3318. Ljungman G, Gordh T, Sorensen S, Kreuger A. Lumbar puncturein pediatric oncology: conscious sedation vs. generalanesthesia. Med Pediatr Oncol. 2001;36:372–37919. Poe SS, Nolan MT, Dang D, et al. Ensuring safety of patientsreceiving sedation for procedures: evaluation of clinical practiceguidelines. Jt Comm J Qual Improv. 2001;27:28–4120. D’Agostino J, Terndrup TE. Chloral hydrate versus midazolamfor sedation of children for neuroimaging: a randomized clinicaltrial. Pediatr Emerg Care. 2000;16:1–42596 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

21. Green SM, Kuppermann N, Rothrock SG, Hummel CB, Ho M.Predictors of adverse events with intramuscular ketaminesedation in children. Ann Emerg Med. 2000;35:35–4222. Pena BM, Krauss B. Adverse events of procedural sedationand analgesia in a pediatric emergency department. AnnEmerg Med. 1999;34:483–49123. Hopkins KL, Davis PC, Sanders CL, Churchill LH. Sedation forpediatric imaging studies. Neuroimaging Clin N Am. 1999;9:1–1024. Bauman LA, Kish I, Baumann RC, Politis GD. Pediatric sedationwith analgesia. Am J Emerg Med. 1999;17:1–325. Bhatt-Mehta V, Rosen DA. Sedation in children: current concepts[published correction appears in Pharmacotherapy. 1998;18:1395]. Pharmacotherapy. 1998;18:790–80726. Morton NS, Oomen GJ. Development of a selection and monitoringprotocol for safe sedation of children. Paediatr Anaesth.1998;8:65–6827. Murphy MS. Sedation for invasive procedures in paediatrics.Arch Dis Child. 1997;77:281–28428. Webb MD, Moore PA. Sedation for pediatric dental patients.Dent Clin North Am. 2002;46:803–81429. Malviya S, Voepel-Lewis T, Tait AR, Merkel S. Sedation/analgesia for diagnostic and therapeutic procedures in children.J Perianesth Nurs. 2000;15:415–42230. Zempsky WT, Schechter NL. Office-based pain management:the 15-minute consultation. Pediatr Clin North Am. 2000;47:601–61531. Kennedy RM, Luhmann JD. The “ouchless emergencydepartment”: getting closer—advances in decreasing distressduring painful procedures in the emergency department. PediatrClin North Am. 1999;46:1215–124732. Rodriguez E, Jordan R. Contemporary trends in pediatricsedation and analgesia. Emerg Med Clin North Am. 2002;20:199–22233. Ruess L, O’Connor SC, Mikita CP, Creamer KM. Sedation forpediatric diagnostic imaging: use of pediatric and nursingresources as an alternative to a radiology department sedationteam. Pediatr Radiol. 2002;32:505–51034. Weiss S. Sedation of pediatric patients for nuclear medicineprocedures. Semin Nucl Med. 1993;23:190–19835. Wilson S. Pharmacologic behavior management for pediatricdental treatment. Pediatr Clin North Am. 2000;47:1159–117536. McCarty EC, Mencio GA, Green NE. Anesthesia and analgesiafor the ambulatory management of fractures in children. JAmAcad Orthop Surg. 1999;7:81–9137. Egelhoff JC, Ball WS Jr, Koch BL, Parks TD. Safety andefficacy of sedation in children using a structured sedationprogram. AJR Am J Roentgenol. 1997;168:1259–126238. American Academy of Pediatrics, Committee on Drugs andSection on Anesthesiology. Guidelines for the elective use ofconscious sedation, deep sedation, and general anesthesia inpediatric patients. Pediatrics. 1985;76:317–32139. American Academy of Pediatric Dentistry. Guidelines for theelective use of conscious sedation, deep sedation, and generalanesthesia in pediatric patients. ASDC J Dent Child. 1986;53:21–2240. American Academy of Pediatrics, Committee on Drugs.Guidelines for monitoring and management of pediatric patientsduring and after sedation for diagnostic and therapeuticprocedures. Pediatrics. 1992;89:1110–111541. American Academy of Pediatrics, Committee on Drugs.Guidelines for monitoring and management of pediatric patientsduring and after sedation for diagnostic and therapeuticprocedures: addendum. Pediatrics. 2002;110:836–83842. American Academy of Pediatric Dentistry, Ad Hoc Committeeon Sedation and Anesthesia. Guidelines on the Elective Use ofMinimal, Moderate, and Deep Sedation and General Anesthesia forPediatric Dental Patients. Chicago, IL: American Academy ofPediatric Dentistry; 2004. Available at: www.aapd.org/media/PoliciesGuidelines/GSedation.pdf. Accessed February 7,200643. Joint Commission on Accreditation of Healthcare Organizations.Comprehensive Accreditation Manual for Hospitals: The OfficialHandbook by the JCAHO. Oakbrook Terrace, IL: JointCommission on Accreditation of Healthcare Organizations;200544. American Society of Anesthesiologists, Task Force on Sedationand Analgesia by Non-anesthesiologists. Practice guidelinesfor sedation and analgesia by non-anesthesiologists. Anesthesiology.2002;96:1004–101745. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskeyC. Adverse sedation events in pediatrics: analysis of medicationsused for sedation. Pediatrics. 2000;106:633–64446. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskeyC. Adverse sedation events in pediatrics: a critical incidentanalysis of contributory factors. Pediatrics. 2000;105:805–81447. Kim G, Green SM, Denmark TK, Krauss B. Ventilatory responseduring dissociative sedation in children: a pilot study.Acad Emerg Med. 2003;10:140–14548. Coté CJ. Sedation for the pediatric patient: a review. PediatrClin North Am. 1994;41:31–5849. Mason KP, Burrows PE, Dorsey MM, Zurakowski D, Krauss B.Accuracy of capnography with a 30 foot nasal cannula formonitoring respiratory rate and end-tidal CO 2 in children.J Clin Monit Comput. 2000;16:259–26250. McQuillen KK, Steele DW. Capnography during sedation/analgesia in the pediatric emergency department. PediatrEmerg Care. 2000;16:401–40451. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and riskfactors associated with the sedation of children by nonanesthesiologists[published correction appears in Anesth Analg.1998;86:227]. Anesth Analg. 1997;85:1207–121352. Coté CJ, Rolf N, Liu LM, et al. A single-blind study of combinedpulse oximetry and capnography in children. Anesthesiology.1991;74:980–98753. Scottish Intercollegiate Guidelines Network. Safe Sedation ofChildren Undergoing Diagnostic and Therapeutic Procedures: A NationalClinical Guideline. Edinburgh, Scotland: Scottish IntercollegiateGuidelines Network; 2003. Available at: www.sign.ac.uk/pdf/sign58.pdf. Accessed February 7, 200654. Hoffman GM, Nowakowski R, Troshynski TJ, Berens RJ,Weisman SJ. Risk reduction in pediatric procedural sedationby application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics.2002;109:236–24355. Krauss B. Management of acute pain and anxiety in childrenundergoing procedures in the emergency department. PediatrEmerg Care. 2001;17:115–12256. Dial S, Silver P, Bock K, Sagy M. Pediatric sedation for procedurestitrated to a desired degree of immobility results inunpredictable depth of sedation. Pediatr Emerg Care. 2001;17:414–42057. Maxwell LG, Yaster M. The myth of conscious sedation. ArchPediatr Adolesc Med. 1996;150:665–66758. Coté CJ. “Conscious sedation”: time for this oxymoron to goaway! J Pediatr. 2001;139:15–1759. Motas D, McDermott NB, VanSickle T, Friesen RH. Depth ofconsciousness and deep sedation attained in children as administeredby nonanaesthesiologists in a children’s hospital.Paediatr Anaesth. 2004;14:256–26060. Nahata MC, Clotz MA, Krogg EA. Adverse effects of meperidine,promethazine, and chlorpromazine for sedation in pediatricpatients. Clin Pediatr (Phila). 1985;24:558–56061. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopulmo-PEDIATRICS Volume 118, Number 6, December 2006 2597Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

nary arrest during pediatric sedation with meperidine,promethazine, and chlorpromazine. Pediatr Emerg Care. 2001;17:351–35362. Benusis KP, Kapaun D, Furnam LJ. Respiratory depression ina child following meperidine, promethazine, and chlorpromazinepremedication: report of case. ASDC J Dent Child. 1979;46:50–5363. Garriott JC, Di Maio VJ. Death in the dental chair: three drugfatalities in dental patients. J Toxicol Clin Toxicol. 1982;19:987–99564. Goodson JM, Moore PA. Life-threatening reactions after pedodonticsedation: an assessment of narcotic, local anesthetic,and antiemetic drug interaction. J Am Dent Assoc. 1983;107:239–24565. Jastak JT, Pallasch T. Death after chloral hydrate sedation:report of case. J Am Dent Assoc. 1988;116:345–34866. Jastak JT, Peskin RM. Major morbidity or mortality fromoffice anesthetic procedures: a closed-claim analysis of 13cases. Anesth Prog. 1991;38:39–4467. Kaufman E, Jastak JT. Sedation for outpatient dental procedures.Compend Contin Educ Dent. 1995;16:462, 464, 466passim; quiz 48068. Wilson S. Pharmacological management of the pediatric dentalpatient. Pediatr Dent. 2004;26:131–13669. Sams DR, Thornton JB, Wright JT. The assessment of two oralsedation drug regimens in pediatric dental patients. J DentChild. 1992;59:306–31270. Malviya S, Voepel-Lewis T, Tait AR, Merkel S, Tremper K,Naughton N. Depth of sedation in children undergoing computedtomography: validity and reliability of the University ofMichigan Sedation Scale (UMSS). Br J Anaesth. 2002;88:241–24571. Newton JT, Shah S, Patel H, Sturmey P. Non-pharmacologicalapproaches to behaviour management in children. Dent Update.2003;30:194–19972. Peretz B, Bimstein E. The use of imagery suggestions duringadministration of local anesthetic in pediatric dental patients.ASDC J Dent Child. 2000;67:263–26773. Iserson KV. Hypnosis for pediatric fracture reduction. J EmergMed. 1999;17:53–5674. Rusy LM, Weisman SJ. Complementary therapies for acutepediatric pain management. Pediatr Clin North Am. 2000;47:589–59975. Langley P. Guided imagery: a review of effectiveness in thecare of children. Paediatr Nurs. 1999;11(3):18–2176. Ott MJ. Imagine the possibilities! Guided imagery with toddlersand pre-schoolers. Pediatr Nurs. 1996;22:34–3877. Singer AJ, Stark MJ. LET versus EMLA for pretreatinglacerations: a randomized trial. Acad Emerg Med. 2001;8:223–23078. Taddio A, Gurguis MG, Koren G. Lidocaine-prilocaine creamversus tetracaine gel for procedural pain in children. AnnPharmacother. 2002;36:687–69279. Eichenfield LF, Funk A, Fallon-Friedlander S, CunninghamBB. A clinical study to evaluate the efficacy of ELA-Max (4%liposomal lidocaine) as compared with eutectic mixture oflocal anesthetics cream for pain reduction of venipuncture inchildren. Pediatrics. 2002;109:1093–109980. Shaw AJ, Welbury RR. The use of hypnosis in a sedation clinicfor dental extractions in children: report of 20 cases. ASDC JDent Child. 1996;63:418–42081. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of musicdistraction on pain, anxiety and behavior in pediatric dentalpatients. Pediatr Dent. 2002;24:114–11882. Domino KB. Office-based anesthesia: lessons learned from theclosed claims project. ASA Newsletter. 2001;65:9–11, 1583. American Heart Association. Pediatric Advanced Life SupportProvider Manual. Dallas, TX: American Heart Association; 200284. American Academy of Pediatrics and American College ofEmergency Physicians. APLS: The Pediatric Emergency MedicineResource. Rev 4th ed. Boston, MA: Jones and BartlettPublishers; 200485. Wheeler M. Management strategies for the difficult pediatricairway. In: Riazi J, ed. Anesthesiology Clinics of North America.Philadelphia, PA: WB Saunders Co; 1998:743–76186. Sullivan KJ, Kissoon N. Securing the child’s airway in theemergency department. Pediatr Emerg Care. 2002;18:108–12187. Levy RJ, Helfaer MA. Pediatric airway issues. Crit Care Clin.2000;16:489–50488. Krauss B, Green SM. Procedural sedation and analgesia inchildren. Lancet. 2006;367:766–78089. Krauss B, Green SM. Sedation and analgesia for procedures inchildren. N Engl J Med. 2000;342:938–94590. Ferrari LR. Anesthesia and Pain Management for the Pediatrician.Baltimore, MD: John Hopkins University Press; 199991. Malviya S, Naughton NN, Tremper KT, eds. Sedation Analgesiafor Diagnostic and Therapeutic Procedures. Totowa, NJ: HumanaPress; 200192. Yaster M, Krane EJ, Kaplan RF, Coté CJ, Lappe DG, eds.Pediatric Pain Management and Sedation Handbook. St Louis,MO: CV Mosby; 199793. Cravero JP, Blike GT. Review of pediatric sedation. AnesthAnalg. 2004;99:1355–136494. American Society of Anesthesiologists. Standards for Basic Intra-operativeMonitoring. Chicago, IL: American Society ofAnesthesiologists; 2005. Available at: www.asahq.org/publicationsAndServices/standards/02.pdf. Accessed October20, 200695. Mace SE, Barata IA, Cravero JP et al. Clinical policy: evidence-basedapproach to pharmacologic agents used in pediatricsedation and analgesia in the emergency department.Ann Emerg Med. 2004;44:342–37796. Deshpande JK, Tobias JD, eds. The Pediatric Pain Handbook. StLouis, MO: Mosby; 199697. Alcaino EA. Conscious sedation in paediatric dentistry: currentphilosophies and techniques. Ann R Australas Coll DentSurg. 2000;15:206–21098. Mitchell AA, Louik C, Lacouture P, Slone D, Goldman P,Shapiro S. Risks to children from computed tomographic scanpremedication. JAMA. 1982;247:2385–238899. Pershad J, Palmisano P, Nichols M. Chloral hydrate: the goodand the bad. Pediatr Emerg Care. 1999;15:432–435100. Malviya S, Voepel-Lewis T, Ludomirsky A, Marshall J, TaitAR. Can we improve the assessment of discharge readiness? Acomparative study of observational and objective measures ofdepth of sedation in children. Anesthesiology. 2004;100:218–224101. American Academy of Pediatrics, Committee on Injury andPoison Prevention. Transporting children with special healthcare needs. Pediatrics. 1999;104:988–992102. American Academy of Pediatrics, Committee on Bioethics.Informed consent, parental permission, and assent in pediatricpractice. Pediatrics. 1995;95:314–317103. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolongedrecovery and delayed side effects of sedation for diagnosticimaging studies in children. Pediatrics. 2000;105(3). Availableat: www.pediatrics.org/cgi/content/full/105/3/e42104. Babl FE, Puspitadewi A, Barnett P, Oakley E, Spicer M. Preproceduralfasting state and adverse events in children receivingnitrous oxide for procedural sedation and analgesia. PediatrEmerg Care. 2005;21:736–743105. Roback MG, Bajaj L, Wathen JE, Bothner J. Preproceduralfasting and adverse events in procedural sedation and anal-2598 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

gesia in a pediatric emergency department: are they related?Ann Emerg Med. 2004;44:454–459106. Agrawal D, Manzi SF, Gupta R, Krauss B. Preproceduralfasting state and adverse events in children undergoing proceduralsedation and analgesia in a pediatric emergency department.Ann Emerg Med. 2003;42:636–646107. Green SM. Fasting is a consideration—not a necessity—foremergency department procedural sedation and analgesia.Ann Emerg Med. 2003;42:647–650108. Green SM, Krauss B. Pulmonary aspiration risk during emergencydepartment procedural sedation: an examination of therole of fasting and sedation depth. Acad Emerg Med. 2002;9:35–42109. Treston G. Prolonged pre-procedure fasting time is unnecessarywhen using titrated intravenous ketamine for paediatricprocedural sedation. Emerg Med Australas. 2004;16:145–150110. Green SM, Krauss B. Ketamine is a safe, effective, and appropriatetechnique for emergency department paediatric proceduralsedation. Emerg Med J. 2004;21:271–272111. Gorski JC, Huang SM, Pinto A, et al. The effect of echinacea(Echinacea purpurea root) on cytochrome P450 activity in vivo.Clin Pharmacol Ther. 2004;75:89–100112. Hall SD, Wang Z, Huang SM, et al. The interaction between StJohn’s wort and an oral contraceptive. Clin Pharmacol Ther.2003;74:525–535113. Markowitz JS, Donovan JL, DeVane CL, et al. Effect of StJohn’s wort on drug metabolism by induction of cytochromeP450 3A4 enzyme. JAMA. 2003;290:1500–1504114. Spinella M. Herbal medicines and epilepsy: the potential forbenefit and adverse effects. Epilepsy Behav. 2001;2:524–532115. Wang Z, Gorski JC, Hamman MA, Huang SM, Lesko LJ, HallSD. The effects of St John’s wort (Hypericum perforatum) onhuman cytochrome P450 activity. Clin Pharmacol Ther. 2001;70:317–326116. Xie HG, Kim RB. St John’s wort-associated drug interactions:short-term inhibition and long-term induction [publishedcorrection appears in Clin Pharmacol Ther. 2005;78:550]? ClinPharmacol Ther. 2005;78:19–24117. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperativecare. JAMA. 2001;286:208–216118. Abebe W. Herbal medication: potential for adverse interactionswith analgesic drugs. J Clin Pharm Ther. 2002;27:391–401119. von Rosensteil NA, Adam D. Macrolide antibacterials: druginteractions of clinical significance. Drug Saf. 1995;13:105–122120. Hiller A, Olkkola KT, Isohanni P, Saarnivaara L. Unconsciousnessassociated with midazolam and erythromycin. Br J Anaesth.1990;65:826–828121. Mattila MJ, Idanpaan-Heikkila JJ, Tornwall M, VanakoskiJ. Oral single doses of erythromycin and roxithromycin mayincrease the effects of midazolam on human performance.Pharmacol Toxicol. 1993;73:180–185122. Olkkola KT, Aranko K, Luurila H, et al. A potentially hazardousinteraction between erythromycin and midazolam. ClinPharmacol Ther. 1993;53:298–305123. Flockhart DA, Oesterheld JR. Cytochrome P450-mediateddrug interactions. Child Adolesc Psychiatr Clin N Am. 2000;9:43–76124. Yuan R, Flockhart DA, Balian JD. Pharmacokinetic and pharmacodynamicconsequences of metabolism-based drug interactionswith alprazolam, midazolam, and triazolam. J ClinPharmacol. 1999;39:1109–1125125. Young B. Review: mixing new cocktails—drug interactions inantiretroviral regimens. AIDS Patient Care STDS. 2005;19:286–297126. Wilkinson GR. Drug metabolism and variability among patientsin drug response. N Engl J Med. 2005;352:2211–2221127. American Academy of Pediatrics, Section on Pediatric Pulmonology,Subcommittee on Obstructive Sleep Apnea Syndrome.Clinical practice guideline: diagnosis and managementof childhood obstructive sleep apnea syndrome.Pediatrics. 2002;109:704–712128. Schechter MS. Technical report: diagnosis and managementof childhood obstructive sleep apnea syndrome. Pediatrics.2002;109(4). Available at: www.pediatrics.org/cgi/content/full/109/4/e69129. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Upper airwayobstruction during midazolam/nitrous oxide sedation in childrenwith enlarged tonsils. Pediatr Dent. 1998;20:318–320130. Fishbaugh DF, Wilson S, Preisch JW, Weaver JM II. Relationshipof tonsil size on an airway blockage maneuver in childrenduring sedation. Pediatr Dent. 1997;19:277–281131. Mayers DJ, Hindmarsh KW, Sankaran K, Gorecki DK, KasianGF. Chloral hydrate disposition following single-dose administrationto critically ill neonates and children. Dev PharmacolTher. 1991;16:71–77132. Terndrup TE, Dire DJ, Madden CM, Davis H, Cantor RM,Gavula DP. A prospective analysis of intramuscular meperidine,promethazine, and chlorpromazine in pediatric emergencydepartment patients. Ann Emerg Med. 1991;20:31–35133. Coté CJ. Discharge criteria for children sedated bynonanesthesiologists: is “safe” really safe enough? Anesthesiology.2004;100:207–209134. Macnab AJ, Levine M, Glick N, Susak L, Baker-Brown G. Aresearch tool for measurement of recovery from sedation: theVancouver Sedative Recovery Scale. J Pediatr Surg. 1991;26:1263–1267135. Chernik DA, Gillings D, Laine H, et al. Validity and reliabilityof the Observer’s Assessment of Alertness/Sedation Scale:study with intravenous midazolam. J Clin Psychopharmacol.1990;10:244–251136. Bagian JP, Lee C, Gosbee J, et al. Developing and deploying apatient safety program in a large health care delivery system:you can’t fix what you don’t know about. Jt Comm J QualImprov. 2001;27:522–532137. May T, Aulisio MP. Medical malpractice, mistake prevention,and compensation. Kennedy Inst Ethics J. 2001;11:135–146138. Kazandjian VA. When you hear hoofs, think horses, notzebras: an evidence-based model of health care accountability.J Eval Clin Pract. 2002;8:205–213139. Connor M, Ponte PR, Conway J. Multidisciplinary approachesto reducing error and risk in a patient care setting. Crit CareNurs Clin North Am. 2002;14:359–367140. Gosbee J. Human factors engineering and patient safety. QualSaf Health Care. 2002;11:352–354141. Barker SJ, Hyatt J, Shah NK, Kao YJ. The effect of sensormalpositioning on pulse oximeter accuracy during hypoxemia.Anesthesiology. 1993;79:248–254142. Kelleher JF, Ruff RH. The penumbra effect: vasomotiondependentpulse oximeter artifact due to probe malposition.Anesthesiology. 1989;71:787–791143. Hart LS, Berns SD, Houck CS, Boenning DA. The value ofend-tidal CO 2 monitoring when comparing three methods ofconscious sedation for children undergoing painful proceduresin the emergency department. Pediatr Emerg Care. 1997;13:189–193144. Aubuchon RW. Sedation liabilities in pedodontics [abstract].Pediatr Dent. 1982;4:171–180145. Fitzmaurice LS, Wasserman GS, Knapp JF, Roberts DK, WaeckerleJF, Fox M. TAC use and absorption of cocaine in apediatric emergency department. Ann Emerg Med. 1990;19:515–518PEDIATRICS Volume 118, Number 6, December 2006 2599Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

146. Tipton GA, DeWitt GW, Eisenstein SJ. Topical TAC (tetracaine,adrenaline, cocaine) solution for local anesthesia inchildren: prescribing inconsistency and acute toxicity. SouthMed J. 1989;82:1344–1346147. Gunter JB. Benefit and risks of local anesthetics in infants andchildren. Paediatr Drugs. 2002;4:649–672148. Resar LM, Helfaer MA. Recurrent seizures in a neonate afterlidocaine administration. J Perinatol. 1998;18:193–195149. Yagiela JA. Local anesthetics. In: Yagiela JA, Dowd FJ, NeidleEA, eds. Pharmacology and Therapeutics for Dentistry. St Louis,MO: Mosby; 2004:251–270150. Haas DA. An update on local anesthetics in dentistry. J CanDent Assoc. 2002;68:546–551151. Malamed SF. Local anesthetic considerations in dental specialties.In: Malamed SF, ed. Handbook of Local Anesthesia. 5thed. St Louis, MO: Mosby; 2004:269, 274–275152. Malamed SF. The needle. In: Malamed SF, ed. Handbook ofLocal Anesthesia. 5th ed. St Louis, MO: Mosby; 2004:99–107153. Malamed SF. Clinical action of specific agents. In: MalamedSF, ed. Handbook of Local Anesthesia. 5th ed. St Louis, MO:Mosby; 2004:55–81154. Ram D, Amir E. Comparison of articaine 4% and lidocaine2% in paediatric dental patients. Int J Paediatr Dent. 2006;16:252–256155. Jakobs W, Ladwig B, Cichon P, Ortel R, Kirch W. Serum levelsof articaine 2% and 4% in children. Anesth Prog. 1995;42:113–115156. Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. Use ofarticaine local anesthesia in children under 4 years of age: aretrospective report. Anesth Prog. 1989;36:268–271157. Malamed SF, Gagnon S, Leblanc D. A comparison betweenarticaine HCl and lidocaine HCl in pediatric dental patients.Pediatr Dent. 2000;22:307–311158. American Academy of Pediatric Dentistry. Guideline on appropriateuse of local anesthesia for pediatric dental patients.Available at: www.aapd.org/media/PoliciesGuidelines/GLocalAnesthesia.pdf. Accessed September 14, 2006159. Next-generation pulse oximetry. Health Devices. 2003;32:49–103160. Barker SJ. “Motion-resistant” pulse oximetry: a comparisonof new and old models. Anesth Analg. 2002;95:967–972161. Malviya S, Reynolds PI, Voepel-Lewis T, et al. False alarmsand sensitivity of conventional pulse oximetry versus theMasimo SET technology in the pediatric postanesthesia careunit. Anesth Analg. 2000;90:1336–1340162. Barker SJ, Shah NK. Effects of motion on the performance ofpulse oximeters in volunteers. Anesthesiology. 1996;85:774–781163. Barker SJ, Shah NK. The effects of motion on the performanceof pulse oximeters in volunteers (revised publication).Anesthesiology. 1997;86:101–108164. Colman Y, Krauss B. Microstream capnography technology: anew approach to an old problem. J Clin Monit Comput. 1999;15:403–409165. Wright SW. Conscious sedation in the emergency department:the value of capnography and pulse oximetry. Ann Emerg Med.1992;21:551–555166. Croswell RJ, Dilley DC, Lucas WJ, Vann WF Jr. A comparisonof conventional versus electronic monitoring of sedated pediatricdental patients. Pediatr Dent. 1995;17:332–339167. Tobias JD. End-tidal carbon dioxide monitoring during sedationwith a combination of midazolam and ketamine forchildren undergoing painful, invasive procedures. PediatrEmerg Care. 1999;15:173–175168. Primosch RE, Buzzi IM, Jerrell G. Monitoring pediatric dentalpatients with nasal mask capnography. Pediatr Dent. 2000;22:120–124169. Roelofse J. Conscious sedation: making our treatment optionssafe and sound. SADJ. 2000;55:273–276170. Wilson S, Creedon RL, George M, Troutman K. A history ofsedation guidelines: where we are headed in the future. PediatrDent. 1996;18:194–199171. Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxidemonitoring during procedural sedation. Acad Emerg Med.2002;9:275–280172. Vascello LA, Bowe EA. A case for capnographic monitoring asa standard of care. J Oral Maxillofac Surg. 1999;57:1342–1347173. Iwasaki J, Vann WF Jr, Dilley DC, Anderson JA. An investigationof capnography and pulse oximetry as monitors ofpediatric patients sedated for dental treatment. Pediatr Dent.1989;11:111–117174. Berry AM, Brimacombe JR, Verghese C. The laryngeal maskairway in emergency medicine, neonatal resuscitation, andintensive care medicine. Int Anesthesiol Clin. 1998;36:91–109175. Patterson MD. Resuscitation update for the pediatrician. PediatrClin North Am. 1999;46:1285–1303176. Selim M, Mowafi H, Al Ghamdi A, Adu-Gyamfi Y. Intubationvia LMA in pediatric patients with difficult airways. Can JAnaesth. 1999;46:891–893177. Munro HM, Butler PJ, Washington EJ. Freeman-Sheldon(whistling face) syndrome: anaesthetic and airway management.Paediatr Anaesth. 1997;7:345–348178. Rowe R, Cohen RA. An evaluation of a virtual reality airwaysimulator. Anesth Analg. 2002;95:62–66179. Medina LS, Racadio JM, Schwid HA. Computers in radiology.The sedation, analgesia, and contrast media computerizedsimulator: a new approach to train and evaluate radiologists’responses to critical incidents. Pediatr Radiol. 2000;30:299–305180. Blike G, Cravero J, Nelson E. Same patients, same criticalevents—different systems of care, different outcomes: descriptionof a human factors approach aimed at improving theefficacy and safety of sedation/analgesia care. Qual ManagHealth Care. 2001;10:17–36181. Kanal E, Shellock FG, Talagala L. Safety considerations in MRimaging. Radiology. 1990;176:593–606182. Shellock FG, Kanal E. Burns associated with the use of monitoringequipment during MR procedures. J Magn Reson Imaging.1996;6:271–272183. Shellock FG. Magnetic resonance safety update 2002: implantsand devices. J Magn Reson Imaging. 2002;16:485–496184. Dempsey MF, Condon B, Hadley DM. MRI safety review.Semin Ultrasound CT MR. 2002;23:392–401185. National Institute for Occupational Safety and Health. Criteriafor a recommended standard: occupational exposure to wasteanesthetic gases and vapors. Publication 77–140. 1977. Availableat: www.cdc.gov/niosh/77–140.html. Accessed October4, 2006186. O’Sullivan I, Benger J. Nitrous oxide in emergency medicine.Emerg Med J. 2003;20:214–217187. Kennedy RM, Luhmann JD, Luhmann SJ. Emergency departmentmanagement of pain and anxiety related to orthopedicfracture care: a guide to analgesic techniques and proceduralsedation in children. Paediatr Drugs. 2004;6:11–31188. Frampton A, Browne GJ, Lam LT, Cooper MG, Lane LG.Nurse administered relative analgesia using high concentrationnitrous oxide to facilitate minor procedures in children inan emergency department. Emerg Med J. 2003;20:410–413189. Everitt I, Younge P, Barnett P. Paediatric sedation in emergencydepartment: what is our practice? Emerg Med(Fremantle). 2002;14:62–66190. Krauss B. Continuous-flow nitrous oxide: searching for theideal procedural anxiolytic for toddlers. Ann Emerg Med. 2001;37:61–622600 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

191. Otley CC, Nguyen TH. Conscious sedation of pediatric patientswith combination oral benzodiazepines and inhalednitrous oxide. Dermatol Surg. 2000;26:1041–1044192. Luhmann JD, Kennedy RM, Jaffe DM, McAllister JD. Continuous-flowdelivery of nitrous oxide and oxygen: a safe andcost-effective technique for inhalation analgesia and sedationof pediatric patients. Pediatr Emerg Care. 1999;15:388–392193. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50% nitrousoxide/50% oxygen during laceration repair in children. AcadEmerg Med. 1998;5:112–117194. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenousregional anesthesia in pediatric forearm fracture manipulation.J Pediatr Orthop. 1996;16:187–191195. Hennrikus WL, Shin AY, Klingelberger CE. Self-administerednitrous oxide and a hematoma block for analgesia in theoutpatient reduction of fractures in children. J Bone Joint SurgAm. 1995;77:335–339196. Hennrikus WL, Simpson RB, Klingelberger CE, Reis MT. Selfadministerednitrous oxide analgesia for pediatric fracturereductions. J Pediatr Orthop. 1994;14:538–542197. Wattenmaker I, Kasser JR, McGravey A. Self-administerednitrous oxide for fracture reduction in children in an emergencyroom setting. J Orthop Trauma. 1990;4:35–38198. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in apediatric emergency department. Ann Emerg Med. 1989;18:177–181199. Kalach N, Barbier C, el Kohen R, et al. Tolerance of nitrousoxide-oxygen sedation for painful procedures in emergencypediatrics: report of 600 cases [in French]. Arch Pediatr. 2002;9:1213–1215200. Michaud L, Gottrand F, Ganga-Zandzou PS, et al. Nitrousoxide sedation in pediatric patients undergoing gastrointestinalendoscopy. J Pediatr Gastroenterol Nutr. 1999;28:310–314201. Baskett PJ. Analgesia for the dressing of burns in children: amethod using neuroleptanalgesia and Entonox. Postgrad MedJ. 1972;48:138–142202. Veerkamp JS, van Amerongen WE, Hoogstraten J, Groen HJ.Dental treatment of fearful children, using nitrous oxide. Part1: treatment times. ASDC J Dent Child. 1991;58:453–457203. Veerkamp JS, Gruythuysen RJ, van Amerongen WE, HoogstratenJ. Dental treatment of fearful children using nitrousoxide. Part 2: the parent’s point of view. ASDC J Dent Child.1992;59:115–119204. Veerkamp JS, Gruythuysen RJ, van Amerongen WE, HoogstratenJ. Dental treatment of fearful children using nitrousoxide. Part 3: anxiety during sequential visits. ASDC J DentChild. 1993;60:175–182205. Veerkamp JS, Gruythuysen RJ, Hoogstraten J, van AmerongenWE. Dental treatment of fearful children using nitrousoxide. Part 4: anxiety after two years. ASDC J Dent Child.1993;60:372–376206. Houpt MI, Limb R, Livingston RL. Clinical effects of nitrousoxide conscious sedation in children. Pediatr Dent. 2004;26:29–36207. Shapira J, Holan G, Guelmann M, Cahan S. Evaluation of theeffect of nitrous oxide and hydroxyzine in controlling thebehavior of the pediatric dental patient. Pediatr Dent. 1992;14:167–170208. Primosch RE, Buzzi IM, Jerrell G. Effect of nitrous oxideoxygeninhalation with scavenging on behavioral and physiologicalparameters during routine pediatric dental treatment.Pediatr Dent. 1999;21:417–420209. McCann W, Wilson S, Larsen P, Stehle B. The effects ofnitrous oxide on behavior and physiological parameters duringconscious sedation with a moderate dose of chloral hydrateand hydroxyzine. Pediatr Dent. 1996;18:35–41210. Wilson S, Matusak A, Casamassimo PS, Larsen P. The effectsof nitrous oxide on pediatric dental patients sedated withchloral hydrate and hydroxyzine. Pediatr Dent. 1998;20:253–258211. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Breathingpatterns and levels of consciousness in children during administrationof nitrous oxide after oral midazolam premedication.J Oral Maxillofac Surg. 1997;55:1372–1377212. Litman RS, Kottra JA, Verga KA, Berkowitz RJ, Ward DS.Chloral hydrate sedation: the additive sedative and respiratorydepressant effects of nitrous oxide. Anesth Analg. 1998;86:724–728213. American Academy of Pediatric Dentistry. Guideline on appropriateuse of nitrous oxide for pediatric dental patients. Availableat: www.aapd.org/media/PoliciesGuidelines/GNitrous.pdf. AccessedSeptember 14, 2006PEDIATRICS Volume 118, Number 6, December 2006 2601Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

APPENDIX 1Class IClass IIClass IIIClass IVClass VASA Physical Status ClassificationA normally healthy patientA patient with mild systemic disease (eg, controlled reactiveairway disease)A patient with severe systemic disease (eg, a child who isactively wheezing)A patient with severe systemic disease that is a constantthreat to life (eg, a child with status asthmaticus)A moribund patient who is not expected to survive withoutthe operation (eg, a patient with severe cardiomyopathyrequiring heart transplantation)APPENDIX 2 Recommended Discharge Criteria1. Cardiovascular function and airway patency are satisfactory and stable.2. The patient is easily arousable, and protective reflexes are intact.3. The patient can talk (if age appropriate).4. The patient can sit up unaided (if age appropriate).5. For a very young or handicapped child incapable of the usually expectedresponses, the presedation level of responsiveness or a level as close aspossible to the normal level for that child should be achieved.6. The state of hydration is adequate.APPENDIX 3 Drugs That May Be Needed to Rescue a SedatedPatientAlbuterol for inhalationAmmonia spiritsAtropineDiphenhydramineDiazepamEpinephrine (1:1000, 1:10 000)FlumazenilGlucose (25% or 50%)Lidocaine (cardiac lidocaine, local infiltration)LorazepamMethylprednisoloneNaloxoneOxygenFosphenytoinRacemic epinephrineRocuroniumSodium bicarbonateSuccinylcholineThe choice of emergency drugs may vary according to individual or procedural needs.Source: American Society of Anesthesiologists, Task Force on Sedation and Analgesia by Nonanesthesiologists.Anesthesiology. 2002;96:1004–1017APPENDIX 4 Emergency Equipment That May Be Needed to Rescuea Sedated PatientIntravenous equipmentAssorted intravenous catheters (eg, 24-, 22-, 20-, 18-, and 16-gauge)TourniquetsAlcohol wipesAdhesive tapeAssorted syringes (eg, 1, 3, 5, and 10 mL)Intravenous tubingPediatric drip (60 drops per mL)Pediatric buretteAdult drip (10 drops per mL)Extension tubing3-way stopcocksIntravenous fluidLactated Ringer solutionNormal saline solutionD 5 0.25 normal saline solutionPediatric intravenous boardsAssorted intravenous needles (eg, 25-, 22-, 20-, and 18-gauge)Intraosseous bone marrow needleSterile gauze padsAirway Management EquipmentFace masksInfant, child, small adult, medium adult, large adultBreathing bag and valve setOropharyngeal airwaysInfant, child, small adult, medium adult, large adultNasopharyngeal airwaysSmall, medium, largeLMAs (1, 1.5, 2, 2.5, 3, 4, and 5)Laryngoscope handles (with extra batteries)Laryngoscope blades (with extra light bulbs)Straight (Miller) No. 1, 2, and 3Curved (Macintosh) No. 2 and 3Endotracheal tubes2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, and 6.0 uncuffed and 6.0, 7.0, and 8.0 cuffedStylettes (appropriate sizes for endotracheal tubes)Surgical lubricantSuction catheters (appropriate sizes for endotracheal tubes)Yankauer-type suctionNasogastric tubesNebulizer with medication kitsGloves (sterile and nonsterile, latex-free)The choice of emergency equipment may vary according to individual or procedural needs. Thepractitioner is referred to the SOAPME acronym described in the text in preparation for sedatinga child for a procedure.2602 AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012

Guidelines for Monitoring and Management of Pediatric Patients During andAfter Sedation for Diagnostic and Therapeutic Procedures: An UpdateAmerican Academy of Pediatrics, American Academy of Pediatric Dentistry, CharlesJ. Coté and Stephen WilsonPediatrics 2006;118;2587DOI: 10.1542/peds.2006-2780Updated Information &Servicesincluding high resolution figures, can be found at:http://pediatrics.aappublications.org/content/118/6/2587.full.htmlReferencesCitationsPost-PublicationPeer Reviews (P 3 Rs)Subspecialty CollectionsPermissions & LicensingReprintsThis article cites 192 articles, 37 of which can be accessedfree at:http://pediatrics.aappublications.org/content/118/6/2587.full.html#ref-list-1This article has been cited by 30 HighWire-hosted articles:http://pediatrics.aappublications.org/content/118/6/2587.full.html#related-urlsOne P 3 R has been posted to this article:http://pediatrics.aappublications.org/cgi/eletters/118/6/2587This article, along with others on similar topics, appears inthe following collection(s):Committee on Drugshttp://pediatrics.aappublications.org/cgi/collection/committee_on_drugsTherapeutics & Toxicologyhttp://pediatrics.aappublications.org/cgi/collection/therapeutics_and_toxicologyInformation about reproducing this article in parts (figures,tables) or in its entirety can be found online at:http://pediatrics.aappublications.org/site/misc/Permissions.xhtmlInformation about ordering reprints can be found online:http://pediatrics.aappublications.org/site/misc/reprints.xhtmlPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Downloaded from pediatrics.aappublications.org at Medical Library on October 2, 2012