A presedation assessment is essential to identify high-risk patient populations and anticipate and reduce adverse sedation events. Presedation preparation begins prior to patient arrival. Studies have shown that background knowledge and skills in resuscitation (particularly airway management), education in sedative pharmacology, and presedation risk assessment reduce the frequency and severity of adverse events during sedation. All in all, the majority of preventable adverse sedation events tend to occur as a consequence of inadequate practitioner experience and skills (insufficient education) and violation of hospital policy and procedure (rule violation). Several general statements can be made regarding adverse events during sedation:
- The vast majority of adverse outcomes during sedation are preceded by a respiratory event.
- The greater the depth of sedation, the greater the risk of complications.
- The majority of poor outcomes related to adverse sedation events are due to a rule violation or insufficient education and skills of the practitioner.
- Adverse sedation events are not associated with either a specific sedative drug class or route of administration.
A relevant presedation history includes the following: allergies, medications, sedation/anesthesia history, history of upper airway obstruction, major medical illnesses, last oral intake, and recent acute illnesses (e.g., upper respiratory infection, fever, etc.).
- Upper respiratory infection – Laryngospasm may be more common in children with an ongoing or recent URI.
- Asthma – Due to an increased risk of bronchospasm in children with poorly controlled asthma, asthma medical therapy should be continued prior to undergoing elective sedation procedures. As a general rule, elective sedation should not be performed in children who are actively wheezing.
- Prematurity – Studies have demonstrated increased risk for apnea in former preterm infants. Ideally, delaying sedation until the child is older than 48 to 60 postconceptual weeks is recommended.
- Bronchopulmonary dysplasia – Children with bronchopulmonary dysplasia may have increased risk for bronchospasm and oxygen desaturations during sedation.
- Obstructive sleep apnea (OSA) – Children with OSA are at very high risk. In general, patients with OSA should not be sedated unless airway support is planned.
- Children younger than 1 year – Children younger than a year old are considered at higher risk than older children.
A physical examination should focus primarily on the upper airway, lungs, cardiovascular system, and baseline neurological status. In addition, baseline vital signs must include blood pressure, heart rate, respiratory rate, and oxygen saturation by pulse oximetry.
Patient health classification and anesthesia/sedation risk are defined by the American Society of Anesthesiologists (ASA). The table below defines the ASA levels with clinical examples. ASA 1 and 2 are considered low-risk patient populations. ASA 3 and 4 are high-risk patient populations.
|1||Normally healthy patient||Unremarkable medical history||Excellent|
|2||Patient with mild systemic disease (no functional limitation)||Mild asthma, controlled seizure disorder, anemia, controlled diabetes mellitus||Generally good|
|3||Patient with severe systemic disease (definite functional limitation)||Moderate to severe asthma, poorly controlled seizure, pneumonia, poorly controlled IDDM, moderate obesity||Intermediate to poor; consider benefits relative to risks|
|4||Patient with severe systemic disease that is a constant threat to life||Severe bronchopulmonary dysplasia, sepsis, advanced degrees of pulmonary, cardiac, hepatic, renal, or endocrine insufficiency||Poor; benefits rarely outweigh risks|
(from N Engl J Med 2000;342:913)
A common acronym to remember the necessary equipment for conducting pediatric sedation is SOAPME:
- S (suction) – size-appropriate suction catheters and a functioning suction apparatus (e.g., Yankauer-type suction)
- O (oxygen) – adequate oxygen supply and functioning flow meters or other devices to allow its delivery
- A (airway) – size-appropriate airway equipment: nasopharyngeal and oropharyngeal airways, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask, bag-valve-mask or equivalent device (functioning)
- P (pharmacy) – all the resuscitation drugs needed for an emergency, sedatives, and sedative antagonists
- M (monitors) – pulse oximeter with size-appropriate probes and other monitors as appropriate for the procedure (e.g., noninvasive blood pressure, end-tidal carbon dioxide, ECG, stethoscope)
- E (extra equipment) – special equipment or drugs for a particular case (e.g., defibrillator)