In the photo, left to right: Jennifer Knapton, MSN, RN; Christina Bryndzia, DO; Sushant Srinivasan, MD, MHPE; Kristin Tiedt, MD; Megan Peters, MD; Tricia Smith, NP; Sarah Webber, MD; and Juan Boriosi, MD. Photo by Kate Feldt/Department of Pediatrics
Established in 1991, the Pediatric Sedation Clinic is one of the longest-operating procedural pediatric sedation units in the country. Now located in the American Family Children’s Hospital (AFCH) in the Diagnostic and Therapy Center, the clinic has grown from small beginnings of one clinician and two nurse practitioners (NPs) to a staff of six physicians and two NPs offering a range of sedation and related services.
Megan Peters, MD, associate professor in the Division of Critical Care, now serves as the medical director of the Diagnostic and Therapy Center. Other staff members from the Division of Critical Care include Christina Bryndzia, DO, assistant professor; Juan Boriosi, MD, professor; Sushant Srinivasan, MD, MHPE, associate professor; Tricia Smith, NP; and Ashton Nell, NP. Kristin Tiedt, MD, assistant professor, and Sarah Webber, MD, associate professor and director of well-being, are both in the Division of Hospital Medicine and Complex Care.
Greg Hollman, MD, who retired in 2021, initially established the clinic next to the pediatric ICU in the old University Hospital to improve the procedure for pediatric patients undergoing MRI. It quickly expanded its mission to support children undergoing painful and invasive procedures during treatment for oncological disorders. The clinic moved to AFCH when it opened in 2007.
Peters explained that there are two methods to support children through painful or anxiety-inducing procedures: general anesthesia, in which the patient is usually unconscious with a protected airway, and natural airway sedation, in which a patient may be in any of various states of consciousness, depending upon the medications used.
Peters described the three levels of sedation as minimal (slightly sedated but still aware), moderate (sleepy but not necessarily sleeping), and deep (fully asleep and not responsive to painful stimulus). The principal difference from general anesthesia is that in the Pediatric Sedation Clinic, patients are expected to be able to breath on their own throughout.
Procedures that take up to two and half hours can be facilitated with various methods of sedation. Child life specialists may also use psychological/non-pharmacologic methods to ease a patient’s fears.
“Our goal is to help facilitate natural airway sedation in a way that’s safe and efficient and effective,” Peters said. She has been involved with the sedation clinic since 2015 and is enthusiastic about her work. “The clinic’s primary mission spoke to me: it is making procedures that would otherwise be scary or painful a bit less scary and painful for pediatric patients,” Peters said. “It’s fulfilling to take care of these patients who come in scared, their parents come in uncertain, and we can provide a pain-free and successful experience.”
Every patient appointment includes preliminary time for discussion with the child and the parents to determine the how nervous the child is, what the parents’ concerns are, what kinds of medicines would be most helpful.
“Sometimes we determine that a patient would do well with a lesser level of sedation,” Peters said. “Maybe we can coach them through the procedure with a drug that won’t necessarily make them fall asleep.”
Some drugs, for example, can reduce the child’s anxiety and also block memory of the procedure. Others will induce a light sleep that allows the patient to fully recover in much less time than anesthesia would require.
The group applied for and received the Society for Pediatric Sedation designation of Center of Excellence in 2024. That designation proclaims that the staff is proficient and the program exemplary. Full time with the clinic since April 2021, Christina Bryndzia applied her extensive knowledge of the clinic to complete the application for the clinic to qualify as a Pediatric Sedation Center of Excellence.
Bryndzia noted that patients arrive through referral, and the initial intake meeting is designed to learn the patient’s nature and needs, as well as to counsel the family about the most appropriate levels of sedation for their child to undergo their procedure.
“A lot of families come in with the idea that their child is going to be asleep,” Bryndzia explained. “And that is not the case.” She noted that she is working on a pamphlet that that will provide information about levels of sedation to families who are scheduled with the clinic.
“Our goal is to help patients get through these procedures with the least amount of sedation possible,” Bryndzia said, “but in a successful and non-traumatic way.”
The clinic oversees sedation for many procedures, from simple lab draws and vaccines — some people have severe needle phobia — to more complex procedures, such as MRIs, lumbar punctures, and biopsies.
Every sedation plan is customized to the patient and to the procedure to be performed, matching sedation to what that patient needs. For example, a patient may get numbing cream for the placement of an IV.
“Sometimes we use a medication to help IV placement that affects memory, so the child won’t remember,” Bryndzia said. “Some kids won’t get that because they are able to cope. It depends on the child. We work with the families.”
She said the most effective way to reassure families is to make them feel as though their concerns are being heard. “I love that I get to work with families,” she said, “helping them through these difficult times so they are able to think, Hey, it wasn’t so bad.”
Hospitalist Sarah Webber joined the clinic in 2016. “What I like most about the clinic is working with one patient at a time, right in front of me,” Webber explained. “Even though we do many procedures, we have a subset of patients who come to us repeatedly. We get to have longitudinal relationships. That’s really important to me.”
Webber noted that clinicians need to know that the clinic offers solutions they may not be aware of. “I think we are really skilled at getting kids through hard medical experiences,” she said. “Sometimes that requires medication, but we have a lot of other tools as well.”
Webber noted that the clinic gives kids good early medical experiences, preventing medical trauma.
As the clinic grew from Greg Hollman’s initial small group, he developed a six-month intensive course and on-the-job training for all new clinicians and nurses who joined the group. Tricia Smith, NP, has been with the clinic since 2009. She went through that training when she joined and described it as comprehensive and rigorous. With the help of sedation nursing staff, Smith conducts thorough patient screening to ensure that patients are likely to be successful undergoing their procedures in sedation clinic. They typically work with two to three physicians in the clinic, serving 1,600 to 1,700 patients annually in the clinic’s six rooms.
“I was made for this job,” Smith said. “I love taking care of the child and the family and it’s often a stressful situation. We may need to get information to make a diagnosis or to check brain tumor management or seizures.”
Smith regards part of her role to be turning down the stress level. “Especially for the kids with cancer who come here frequently,” she said. “I don’t want them dreading their MRI.”
Smith appreciates the fact that they allow enough time to closely tailor procedures to every patient. “I love that time has been designed into what this clinic does,” Smith explained.
The entire process also requires constant engaged attention. Not only to the nature of the patient before the procedure — fidgeting? calm? — but also to the state of the patient during: listening second to second for possible changes in breathing, a cough. “You are engaging all your senses to get them through the process safely,” Smith explained.
The clinic is part of the Pediatric Sedation Research Consortium (PSRC), which tracks adverse events and provides benchmarks for the clinic’s performance relative to similar centers. The Pediatric Sedation Clinic at AFCH has extremely low adverse event numbers. As the Center of Excellence designation proclaims: this Pediatric Sedation Clinic is incredibly good at what it does.
Physicians who would like to send their patients to the Pediatric Sedation Clinic can request sedation by entering an order into Healthlink. The name of the order is “Pediatric Sedation Request.” Providers are prompted to answer a list of related questions to identify patients for whom natural airway sedation may be optimal. Questions can be directed to Megan Peters at mpeters@pediatrics.wisc.edu.