or another practitioner dedicated to monitoring the patient, whose sole responsibility is to continually observe and respond to the patient’s vital signs, physiologic status, and level of sedation. The practitioner should be skilled in assessment of cardiopulmonary function: respiratory rate and depth, early recognition of cyanosis, perfusion, and pulse assessment. Optimally, this individual would have a dedicated sedation nurse but this may not be possible at some institutions. Whether the sedation practitioner is a physician, physician assistant or nurse practitioner, they should be PALS certified and have adequate specialized training in pediatric procedural sedation and rescue techniques. Regular maintenance of these skills is recommended.
The majority of procedures are performed in endoscopy suites, which must be appropriately equipped to perform sedations safely. A crash cart or kit should include age‐ and size‐appropriate equipment and medications necessary to resuscitate a child. Airway equipment must include size‐appropriate BVM, airway delivery devices, and intubating equipment with age‐appropriate endotracheal tube sizes and laryngoscope blades. Cardiorespiratory monitoring should include electrocardiography, respiratory tracing, pulse oximetry, capnography, and noninvasive blood pressure monitoring with size‐appropriate cuffs. An oxygen source and suction with catheters must be available. A defibrillator, with pediatric paddles and adhesive pads, should be accessible. There should be a protocol for accessing a higher level of care such as a pediatric intensive care or step‐down unit, and in nonhospital environments, a system for accessing ambulance services.
Anesthesia apparatus is essential for procedures in general anesthesia. It may be situated in the endoscopy suite or the endoscopy team may perform procedures in the operating theatre with a mobile endoscopic device.
During sedation and monitoring
Before the administration of medications, a baseline set of vital signs should be documented. The name, route, site, time, and dosage of all drugs administered should be recorded. Once medication administration has begun, level of consciousness and vital signs should be documented on a time‐based flow sheet every five minutes. The vital signs documented should include heart and respiratory rate, oxygen saturation, and blood pressure. Once the procedure is complete and no more medications are to be administered, vital signs should be documented every 15 minutes until the child awakens.
Whether administration of medications is performed by the gastroenterologist or the sedation practitioner, good communication is crucial in order to provide optimal procedural sedation. It is important in order to anticipate physiologic changes or the conclusion of the procedure, which could affect a decision to administer a dose of medication or not. Timing of medication administration should be predicated on anticipating patient responses, which is best performed by maintaining an awareness of the procedure through observation and communication. It is the responsibility of the individual monitoring the patient to alert the gastroenterologist to physiologic deterioration, and to temporarily stop the procedure if rescue measures are required.
The nature of gastrointestinal endoscopy mandates a discussion of the specific physiological considerations inherent to the procedure. For example, esophageal intubation can induce apnea and bradycardia due to stimulation of the laryngeal branch of the vagus nerve. Infants or children with spastic neuromuscular disorders are especially prone to this, due to their small size and high cricopharyngeal tone, respectively. When air is insufflated into the gastrointestinal tract, it has the potential to cause respiratory insufficiency. Excess air in the stomach can elevate the left hemidiaphragm, impeding respiratory excursion and subsequently tidal volumes, which can be deleterious for ventilation and oxygenation. The loss of functional residual capacity can subsequently cause hypoxemia from loss of alveolar recruitment, and positive pressure ventilation, along with gastric decompression, may be necessary to recover adequate oxygen saturation.
Mesenteric stretch can cause various degrees of abdominal discomfort in some individuals, and adequate analgesia is needed to blunt this response. Intense pain during a colonoscopy, for example, is a sign of excessive mesenteric stretching and requires not only adequate analgesia but immediate adjustment of endoscopic technique. This situation highlights the need for constant communication between the gastroenterologist and monitor, as adjustments must be made by both individuals for the best procedural conditions.
The issue of standard supplemental oxygen use is controversial. Due to the nature of the procedure, supplemental oxygen is often needed to maintain adequate oxygen saturations. It must be kept in mind that failure in ventilation may be masked by supplemental oxygen, due to the law of partial pressures in the alveoli.
End‐tidal capnography
Oxygen desaturation (i.e., oxygen saturation <90% in USA or <92% in Europe) in the setting of procedural sedation is a sign of suboptimal ventilation. Patients receiving supplemental oxygen can be 100% saturated with significantly elevated carbon dioxide levels, and be at risk for respiratory deterioration. Over the last 10 years, improved microstream capnographs have arrived which allow accurate, real‐time measurement and continuous display of end‐tidal carbon dioxide. This does not, however, obviate the need for continued close observation of respiratory function at all times.
In a prospective, randomized, controlled trial, integrating capnography into monitoring of nonintubated children receiving moderate sedation for pediatric endoscopy and colonoscopy was shown to reduce hypoxemia. Many hospitals have instituted mandatory use of end‐tidal monitors for all procedural sedations.
Postsedation care
The child who has received moderate or deep sedation must be monitored in an appropriate environment which includes vital signs and pulse oximetry until they are awake. The period of wakefulness should be sustainable, as children emerging from sedation often drift between states of sleep and consciousness as the drugs are metabolized. The recovery area should include qualified staff to continuously record vital signs every 15 minutes, suction apparatus, and oxygen delivery devices including BVM. Patients who have received medications with a long half‐life, or reversal agents such as naloxone or flumazenil, should be monitored for a longer period of time due to the risk of resedation.
The following are recommended discharge criteria.
Cardiovascular function and airway patency are adequate and stable.
The patient is easily arousable and protective reflexes are intact.
The patient can talk (if age appropriate).
The patient can sit up without assistance (if age appropriate).
For patients who are very young or developmentally delayed, the presedation level of responsiveness or a level as close as possible for that child should be achieved.
The state of hydration is adequate.
Conclusion
Procedural sedation in children carries a significant number of considerations which depend on the developmental and chronological age of the patient, history of previous experiences, and individualized response to medication. In order to avoid complications, the setting for the procedure must be well equipped, and the staff performing procedural sedation must be adequately trained in pediatric pharmacology and resuscitation. Good communication between all practitioners during the procedure contributes to a safe and efficient environment, and the likelihood of procedural success.
Societal guidelines must be adapted to specific national legislation and institutional protocols. Once established, sedation and general anesthesia protocols must
