We searched the Cochrane Library, MEDLINE, and relevant specialty journals (all from 1980 to June, 2005). We used the search terms “procedural sedation and analgesia” or “conscious sedation” or “sedation and analgesia for procedures”. We largely selected publications in the past 15 years with an emphasis on the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We only searched articles in the English language or those translated into English. We
ReviewProcedural sedation and analgesia in children
Section snippets
Underlying principles
The principles of the procedure, including presedation assessment, continuous monitoring during the procedure, and recovery scoring systems, mirror longstanding anaesthesia practices.
Presedation assessment
The practice of procedural sedation and analgesia has three components done in sequence: presedation assessment, sedation for the procedure, and post-procedure recovery and discharge. A directed history and physical examination should precede the process, and if additional risk is discovered, the advisability of sedation should be reconsidered. High-risk cases might be better postponed or managed in theatre.
Presedation assessments are a JCAHO requirement in the USA, and hospitals have developed
Personnel and interactive monitoring
Continuous observation of patients by a health-care provider capable of recognising adverse sedation events is essential. This person must be able to continuously observe the patient's face, mouth, and chest-wall motion, allowing rapid detection of respiratory depression, apnoea, partial or complete airway obstruction, laryngospasm, emesis, and hypersalivation. Procedural sedation and analgesia personnel should be proficient at maintaining airway patency and assisting ventilation if needed.
Equipment and mechanical monitoring
The use of mechanical monitoring has greatly enhanced the safety of procedural sedation and analgesia. Continuous oxygenation (pulse oximetry with an audible signal), ventilation (capnography), and haemodynamics—blood pressure and ECG—can all be monitored non-invasively in spontaneously breathing patients. Pulse oximetry is not a substitute for monitoring ventilation, as there is a variable lag time (depending on age, physical status, and use of supplemental oxygen) between the onset of
Post-procedure assessment
Children should be monitored until they are no longer at risk for cardiorespiratory depression, their vital signs are stable, they are alert and at age-appropriate baseline level of consciousness, and they can talk and sit unaided, according to age. It is not a requirement that young children be able to walk unaided.21 Many hospitals use standardised recovery-scoring systems similar to those used in surgical post-anaesthesia recovery.53 A reliable adult should be given discharge instructions
Indications
Indications for procedural sedation and analgesia can be divided into three categories: minor trauma, instrumentation, and diagnostic imaging (panel 3). Many such procedures do not require procedural sedation and analgesia and can be accomplished with psychological techniques that can also reduce adverse responses to painful or frightening procedures.54, 55, 56, 57 A multifactorial decision-making process is used to determine the appropriate drugs, dosing, and sedation endpoint.53, 58 Selection
Classes of drugs
The five classes of procedural sedation and analgesia drugs are sedative-hypnotics, analgesics, dissociative sedatives, inhalational agents, and antagonists (table 2). The most widely used are sedative-hypnotics, including benzodiazepines (eg, midazolam, diazepam), barbiturates (eg, pentobarbital, methohexital, thiopental), and several drugs in their own pharmacological class (eg, chloral hydrate, etomidate, propofol). Propofol, etomidate, methohexital, and thiopental are referred to as
International differences in practice
The practice of procedural sedation and analgesia internationally can be divided into three categories: (1) anaesthetists are the sole practitioners, with most procedures happening in the operating theatre or day surgery units (eg, most of Europe, Africa, Latin America, and Asia); (2) a few trained practitioners outside of anaesthesia undertake procedural sedation and analgesia in well-defined circumstances and locations (eg, UK, Singapore, Hong Kong, South Korea, Taiwan, Philippines); (3)
Areas of controversy
There are two general areas of controversy in the practice of procedural sedation and analgesia: practitioner skills (who is qualified to undertake the procedure) and practise standards (what are they qualified to practise).
The future
The future of procedural sedation and analgesia will focus on enhancing training, safety, and effectiveness. Training issues include establishment of uniform minimum skill requirements, investigation of the effectiveness of simulation-based training in teaching and improving procedural sedation and analgesia skills, and development of curricula for training in countries where the practice is not well established. Safety issues involve defining the most appropriate monitoring for the different
Search strategy and selection criteria
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