What are considerations prior to sedation of children?

Updated: Nov 06, 2018
  • Author: Arul M Lingappan, MD; Chief Editor: Erik D Schraga, MD  more...
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Essentially all the sedatives and analgesics listed above can be used in children. However, the clinician should recognize the differences between children and adults and how that relates to the type of sedation chosen. Differences exist in cognitive abilities and developmental status, respiratory mechanics, airway anatomy, drug metabolism, and toxic dosages. Presedation assessment of a child is very different than that of adults and must adapt to the limited speech and expressive capabilities of children. [44] A child's behavioral state must be assessed before picking an agent, as his or her state may affect the choice of drug and the dose. [44, 45, 46]

Small children have a higher oxygen consumption and lower alveolar volume relative to their weight, making them more susceptible to desaturation and apnea. [22] Moreover, their tongues are larger and they are at increased risk for airway obstruction during moderate or deep sedation. [22] Body composition changes as the child grows, thus altering the distribution of a given medication. Hepatic enzyme systems, plasma concentration of proteins, and renal dynamics all change as the child grows; thus, a guide should be handy to the clinician to accommodate those differences.

Initial dosing and incremental dosing are generally based on weight. Two important considerations are (1) prolonged administration of propofol, which is associated with lactic acidosis (see nonbarbiturate sedatives, propofol in Sedatives and Analgesics); and (2) opiate use in neonates. Opiate clearance is relatively slow in neonates; continuous pulse oximeter monitoring and easy access to airway equipment is strongly recommended, as apnea is a risk. [22] End tidal CO2 monitoring may be useful as well.

Pediatric procedural sedation is being used in a safe and effective manner outside of the academic setting. According to the recent Procedural Sedation in the Community Emergency Department (ProSCED) registry, emergency clinician-directed procedural sedation resulted in successful completion of procedures 99.4% of the time, with complications arising in only 0.6% of cases. [47] Those cases resulted in no significant adverse events and no significant delay in the ED length of stay. A small 2010 study compared the effects of etomidate/fentanyl vs ketamine/midazolam during orthopedic reductions in a pediatric ED. [48] The results indicated that the incidence of adverse reactions to ketamine, including emergence phenomenon, is lower than previously thought.

Fortunately, very severe adverse events are rare in pediatric sedation. However, less severe reactions do occur, and many feel they are underreported because definitions of most adverse events are not standardized. One example is the underreporting of retching in pediatric procedural sedation literature. [49] Prominent experts within the pediatric community recently released a consensus panel to standardize some terminology used in procedural sedation, particularly adverse events and rescue tactics or maneuvers.

The goals of such standardization are to create some established definitions that can fuel more uniform reporting in future publications and give more accurate statistics about adverse events of available medications; and to decrease the occurrence of adverse events by providing a standardized approach at remedying them. [44, 49] Hopefully, such consensus guidelines will translate into the adult literature as well.

For a complete discussion of sedation in the pediatric population, see Pediatrics, Sedation.

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