• Sedating children for outpatient procedures and tests

    December 2007

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    Every year, millions of children undergo diagnostic or therapeutic procedures outside the operating room that require sedation. The sedation occurs in a variety of settings, including physician and dental offices, imaging facilities, emergency departments and ambulatory surgery centers. The medications used vary and may be delivered by non-anesthesiologists as well as anesthesiologists.

    Guidelines for administering sedation and the medications used differ greatly from one institution to another. 

    Reasons for sedation

    Children need to be sedated more frequently than adults and for different reasons, such as controlling their behavior for safety's sake. A doctor can tell an adult to remain still during a 45-minute MRI scan or explain that a certain procedure isn't going to be painful. Reasoning with a 2-year-old isn't likely to work, however.

    Sedation also helps relieve anxiety and minimize a child's physical discomfort and pain. Additionally, children need to be more deeply sedated than adults. Because of their physiology, this puts them at greater risk for respiratory distress or hypoxia.

    Safety concerns

    In the interests of safety and standardization, several national organizations have released guidelines for the delivery of pediatric sedation, including the American Academy of Pediatrics and American Academy of Pediatric Dentistry. However, a study by the Pediatric Sedation Research Consortium, an international collaborative group of 35 institutions, more clearly delineates a need for organized sedation services.

    "Modern medicine is winning the battle against many diseases in children," the study authors wrote. "Unfortunately, the treatments that are used to obtain this progress often are invasive, stressful and a source of significant suffering in this patient population."

    These procedures are frequently performed in an urgent manner with the patient sedated, yet guidelines for administering sedation and the medications used differ greatly from one institution to another.

    To better understand the nature and frequency of the possible side-effects of sedation, the consortium analyzed data on more than 30,000 procedures at 26 institutions between 2004 and 2005. The sedation used in these cases was performed for a variety of diagnoses - ranging from burns and cardiac conditions to rheumatologic and hematology-oncology conditions. Patients were 6 months to 21 years of age. The study was published in the September 2006 issue of Pediatrics .

    “Serious adverse events were rare among the children sedated at the participating institutions. 

    Study findings

    The consortium found that serious adverse events were rare among the children sedated at the participating institutions. There were no deaths, and only one cardiac arrest was reported.

    However, there were more minor, potentially serious events such as vomiting or apnea. And one in every 200 sedations required airway and ventilation interventions. Events requiring timely rescue interventions occurred once per 89 sedation encounters. These findings underscore the need for providers with the skills to manage such events or "immediate and completely reliable access to such assistance," the researchers stated.

    Based on their findings, the researchers concluded that the safety of pediatric sedation depends on an institution's ability to manage less serious events. The study was limited by the fact that participants were all dedicated pediatric sedation programs. In addition, there was no control group.

    Sedation depth and satisfaction

    At the other end of the spectrum, some practitioners offer little or no sedation to children. An earlier study found that 30 percent of U.S. respondents to a mail survey performed painful bone marrow biopsies on children without significant sedation more than 50 percent of the time. In instances where sedation actually fails, struggling, crying children are sometimes restrained while the procedures are carried out.

    Addressing this issue, a review of pediatric sedation appearing in Current Opinion in Anaesthesiology states , "The simple act of completing a procedure may no longer be the milestone that defines 'successful' sedation."

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  • Related resources

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  • UK HealthCare Pediatric Services - Kentucky Children’s Hospital

    For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 800-333-8874. 

Page last updated: 8/7/2015 2:18:27 PM
  • What the news means for you

    Potent new sedatives more effective for children

    Cheri D. Landers, MD
    Pediatric Intensivist

    Wright, Heather, MDWhen a child goes into an operating room for surgery, parents understand that anesthesia will be used. However, they may not realize there are many procedures or tests done outside the operating room environment where sedation can be used. These include spinal taps, bone marrow biopsies, endoscopies, cardiac catheterizations, CT scans, MRIs, radiation medicine treatment or minor surgical treatments such as drainage of an abscess.

    “Pediatric sedation is growing in importance as people realize that children often need more than pain control for certain tests and procedures.” 

    Kentucky Children's Hospital Sedation Services has four pediatric intensivists, or critical care physicians, and two pediatric-trained nurses. In 2006, we did more than 1,500 sedations. We usually do deep sedation, in which the child is sedated to the degree that he or she will not respond to voice or touch. Anything deeper than that would be general anesthesia, which is typically done by an anesthesiologist.

    Finding the ideal medication

    Pediatric sedation is growing in importance as people realize that children often need more than pain control for certain tests and procedures. Children also need a medication to take care of the anxiety and, for some tests, control movement. Any test that involves a needle or an incision requires immobility.

    More evidence is showing that children who have had painful experiences in a health care setting are at risk for post-traumatic stress disorder. Quite frankly, many procedures just wouldn't get done without sedation, and brute force is not an option. It's not right to try to physically restrain a child when another safe option is available.

    The ideal medication is one that takes effect quickly, wears off quickly and provides reliable depth of sedation. In the past, drugs like Demerol or Thorazine were commonly used for procedural sedation. The problem with those medications was the difficulty in determining when they would start working. They lasted a long time and were unreliable in the depth of sedation achieved.

    For the past 10 years we have used the sedative propofol at UK. Propofol is a sedative/hypnotic/anesthetic with a very rapid onset. It produces a very nice, deep sleep with a feeling of well-being. You don't even realize you're falling asleep. It can be titrated very easily until you have the right level of sedation, so I've never had problems with it failing to sedate a child, which can happen with other medications.

    When the procedure is completed, the patient can be awake in sometimes less than 15 minutes. There is no nausea afterwards. Propofol has really been a godsend. We've used it for all ages, including newborns if necessary.

    Dedicated sedation team

    Now that we have medications more appropriate for pediatric sedation, it's not just anesthesiologists who are administering them. Pediatric intensivists like our group are providing sedation services.

    Obviously, with sedation comes risk. With deep sleep, there's the risk of breathing problems, airway obstruction, a drop in blood pressure and low oxygen levels. If the procedure is painful, an opiate must be used with propofol, so the risks are higher for apnea or airway obstruction. As pediatric intensivists, our team is trained in intensive care so we can recognize the early signs of complications and intervene with appropriate airway and blood pressure management when needed.

    Preparing children for sedation

    Oftentimes staff from UK's Child Life Program will start play therapy with a child to distract them while the IV is put in place. All of us on the team are parents, too, so it helps that we enjoy and play with the children. One of my colleagues even wears a red clown's nose to help the child feel less fearful.

    Older children often want to make sure they won't wake up in the middle of a painful procedure. I reassure them I'll be with them the whole time and make sure that they do not wake up during the procedure.  For the younger kids, we don't use the term "put to sleep." I tell them the drug will "make you sleepy."

    After the procedure when the child is fully awake, families get discharge instructions for taking care of the child. We ask that two adults be in the car going home with a child in a car seat so one can note any change in color. At home, they need to call us right away if the child can't keep food down or if he gets too sleepy.

    There are some cases where you really can't relieve a child's anxiety. Autistic children, for example, can be a real challenge to approach without producing excessive anxiety. In these cases, we try to just get the child to sleep as quickly as possible to minimize the time the child spends upset. In some instances, we may sedate the child with an injection initially before placing the IV. Each child's case is different and we try to individualize our approach to what the family and our group feels is best for the child in that particular situation.

    Dr. Landers is director of pediatric sedation services at Kentucky Children's Hospital and assistant professor of pediatrics at the UK College of Medicine.

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