Since the 1985 release of the first guidelines standardizing sedation care for young children, the number of pediatric cases requiring sedation has increased - as has the number of cases of preventable morbidity and mortality. As a result, the guidelines were revised in December. Here's an update.

Proper precautions
Before and during the administration of sedation agents, the guidelines recommend the following:

• Calculate the maximum allowable safe dosage of local anesthetics before administration.
• Intermittently aspirate the local anesthetic syringe during administration to avoid intravascular injection.
• Recognize the improvements in pulse oximetry monitoring and proper positioning.
• Encourage capnography as an adjunct to sedation, especially when patients are positioned in less-accessible locations.
• Pay attention to special locations where the magnetic field may require the use of special monitors, such as the MRI.
• Be aware of additional risks from these locations, such as thermal injuries and the attraction of metal objects into the scanner.

The correct techniques of sedating children are much different from adult sedation due to physical, psychological and developmental differences. Perhaps the most important factor is the provider's ability to rescue a child should the unexpected occur. This means recognizing the various levels of sedation and the need for cardiopulmonary support, which may involve using specialized equipment to provide assisted or controlled ventilation and to relieve airway obstruction.

• ASA I or ASA II. Candidates for sedation should be ASA I or ASA II (healthy or with a mild systemic disease). Patients with higher ASA classes, airway abnormalities or other special needs may need consultation with an appropriate sub-specialist or anesthesiologist. A responsible person, or preferably two people, should accompany all the patients regardless of ASA class. For sedations considered non-elective, carefully weigh the benefit of using emergency sedation against the risk of aspiration if the patient had a recent gastric intake.
• Lowest doses possible. Administer the agents for sedation in the lowest doses possible with the highest therapeutic index for the procedure. Match drug effects to the procedure - consider such factors as titration to effect, duration of action and side effects. Even with these precautions, it's common for pediatric patients to pass from the intended level of sedation to a deeper, unintended level, which means a patient who is under moderate sedation may slip into deep sedation. This continuum could lead to respiratory depression and loss of the patient's protective reflexes. If you use immobilization devices, avoid any airway obstruction or chest restriction.
• Ready to rescue. Since sedation can often go deeper than the targeted level, you must have the appropriate personnel and equipment for rescue and emergency management immediately available. Non-hospital facilities must have a protocol in place to access the emergency medical system. Have life support equipment and monitoring available to resuscitate an apneic or unconscious child. All of this equipment should be age-appropriate and allow for continuous life support.
• Be familiar with alternative devices. Occasionally patients may need endotracheal intubation as part of a pediatric sedation. Other airway devices, such as the laryngeal mask airway, cuffed oropharyngeal airway or emergency cricothyroidotomy kits, are available for airway management. And you can use intraosseous needles to provide fluids and medications.
• If you administer nitrous oxide...Equipment to provide 100 percent oxygen must be available, and the FiO2 should never be less than 25 percent. Use an oxygen analyzer if the delivery system covers the nose and mouth. Sedation providers should also keep in mind that combining nitrous oxide with other sedative medications or administering it in concentrations above 50 percent increases the likelihood of progression to moderate or deep sedation.

Child-proofing the OR
Besides having advanced airway assessment and management training and being skilled in resuscitating infants and children, all healthcare providers who sedate children should follow uniform, specialty-independent guidelines for monitoring children during and after sedation.

REFERENCES
1. Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000 Oct;106(4):633-44.
2. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000 Apr;105(4 Pt 1):805-14.
3. Cote CJ, Wilson S. Work Group on Sedation, Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update, Pediatrics. 2006;118:2587-2602.
4. Cravero JP, Blike GT. Review of Pediatric Sedation. Anesthesia and Analgesia. 2004;99:1355?64.
5. Lalwani K, Michel M. Pediatric Sedation in North American Children's Hospitals: A Survey of Anesthesia Providers. Pediatric Anesthesia. 2005;15:209-213.