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FIGURE 129.2 A: The Wong–Baker FACES Pain Rating Scale (From Wong DL, Hockenberry-Eaton M, Wilson D, et al Wong’s Essentials Of Pediatric Nursing 6th ed St Louis, MO: Mosby; 2001:1301 Copyright Mosby, Inc Reprinted by permission.) B: The front and back of a visual analog scale TABLE 129.2 DEFINITIONS OF FOUR LEVELS OF SEDATION AND ANESTHESIA Level Minimal sedation Respond purposefully (not reflexively) to Verbal commands Moderate Light tactile sedation/analgesia stimulation Deep Painful sedation/analgesia stimulation Anesthesia None Airway and breathing maintained Cardiovascular function maintained Yes Yes Yes Yes Potentially not Yes No Potentially not Adapted from American Academy of Pediatrics, American Academy of Pediatric Dentistry, Coté CJ, et al Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update Pediatrics 2006;118:2587–2602 PROCEDURAL SEDATION AND ANALGESIA Definitions When discussing PSA, it is useful to review terminology, which is most accurately categorized by the intended effects, rather than by the specific medications used Analgesia refers to an agent that reduces or eliminates pain in response to a normally painful stimulus Sedation refers to a state of drug-induced depressed level of consciousness Certain medications may have one or both of these properties and are used to that effect For example, topical lidocaine for a laceration repair is an analgesic, but will not affect consciousness Midazolam causes an alteration in level of consciousness, but does not take away pain Ketamine is an example of a medication that has both analgesic and sedative properties PSA has replaced conscious sedation in the lexicon of emergency medical treatment of ill or injured patients The American College of Emergency Physicians (ACEP) defines PSA as “techniques of administering sedatives or dissociative agents with or without analgesia to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.” The now outdated term conscious sedation is no longer acceptable as it does not allow for describing the depth of sedation desired or achieved The Joint Commission accepts the continuum of depth of sedation proposed by the American Society of Anesthesiologists (ASA) in 1999 It is important to focus on the word continuum as it highlights the essential point that a patient can easily move from one depth of sedation to another There are four defined depths of PSA: minimal sedation (or anxiolysis), moderate sedation, deep sedation, and general anesthesia ( Table 129.2 ) It is important to note that ketamine, a commonly used dissociative agent, does not fit neatly on this continuum In the ED, the depth of PSA desired depends on the child and the situation For example, a clinician may choose to administer mild sedation to an anxious child with a nail bed injury in addition to digit nerve block For a child with a forearm fracture requiring closed reduction, a clinician will likely aim for moderate to deep sedation or dissociative sedation with ketamine Progression from mild sedation or analgesia to general anesthesia cannot be divided simply into discrete stages In general, as the dose of analgesic and sedative agents increases, consciousness decreases and in most cases the risk of cardiorespiratory depression increases A child may continue to advance along the sedation continuum until protective airway reflexes are lost and he or she is effectively under general anesthesia Again, ketamine is unique because airway reflexes and ventilatory drive may be preserved despite attainment of the dissociated (sedated) state It is not always possible to predict how a child will respond to medications Although the ED physician may intend to achieve mild sedation, moderate or deep sedation may result Thus, individuals administering moderate or deep sedation and anesthesia should be qualified (and have appropriate credentials) to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally Decision to Perform PSA One of the most important decisions a clinician will make regarding PSA is whether a child is an appropriate candidate Children encountered in the ED will have a variety of conditions potentially requiring sedation and analgesia PSA carries risks within itself, most frequently respiratory depression and cardiovascular instability, but potentially others depending on the regimen chosen, and the risks of sedation must be carefully weighed against the anticipated benefits Factors that must be taken into account when deciding to proceed with PSA include a child’s past medical history and comorbid conditions, prior difficulty with PSA medications, type of procedure, anticipated pain or anxiety, need for immobility, and duration and urgency of the procedure In order to assess a patient’s degree of current illness, the ASA Classification System ( Table 129.3 ) is used Assignment of an ASA physical status (PS) level is not associated with outcome, but rather with a patient’s current condition It is useful to assign an ASA PS level to children as part of the presedation evaluation In general, children who are rated ASA PS I and II are appropriate for PSA in the ED ASA PS III and IV should have consultation with an anesthesiologist except in extremely urgent situations Evaluation and Preparation of Patient Prior to Sedation The ASA recommends that clinicians administering sedation/analgesia should be familiar with aspects of the patient’s medical history that may relate to the medication about to be given This includes abnormalities of any major organ system; previous personal or family history of adverse experience with sedation analgesia; drug allergies; current medications; time of last oral intake of solids and liquids; and use of alcohol, tobacco, or drugs of abuse Patients should have a focused physical examination before sedation is administered This should include at a minimum vital signs, auscultation of the heart and lungs, and evaluation of the pharynx and airway Conditions that may make endotracheal intubation more difficult (such as short neck, limited cervical spine mobility, small mandible, large tongue, or trismus) should be noted TABLE 129.3 AMERICAN SOCIETY OF ANESTHESIOLOGISTS CLASSIFICATION FOR PHYSICAL STATUS LEVEL I II III IV V Normal healthy patient Patient with mild systemic disease Patient with severe systemic disease Patient with severe systemic disease that is a constant threat to life Moribund patient who is not expected to survive without the operation Adapted from Dripps RD, Lamont A, Eckenhoff JE The role of anesthesia in surgical mortality JAMA 1961;178:261–266 For moderate and deep sedation, the ASA recommends providing patients and parents with information on the risks, benefits, and alternatives to sedation and analgesia before a procedure Informed consent should be obtained Preprocedure Fasting The importance of preprocedure fasting remains controversial, and it is not known whether a certain nil per os (NPO) time results in decreased incidence of adverse outcomes Studies with large numbers of patients receiving PSA from the Pediatric Sedation Research Consortium (139,142 children) and the Pediatric Emergency Research Canada (6,183 children) have demonstrated no association between NPO time and incidence of adverse events The American Academy of Pediatrics (AAP) acknowledges that for emergency procedures, “the risks of sedation and possible aspiration are as yet unknown and must be balanced against the benefits of performing the procedure promptly” and also recommends further research into this topic with many thousands of patients The AAP continues to recommend several dietary precautions before elective sedation: children should not have milk or solids for several hours before elective sedation (not within hours for human milk, hours for nonhuman milk, infant formula, or a light meal, and hours for a fatty meal) Intake of clear liquids may continue, but should cease within hours of the scheduled sedation Routine oral ... Studies with large numbers of patients receiving PSA from the Pediatric Sedation Research Consortium (139,142 children) and the Pediatric Emergency Research Canada (6,183 children) have demonstrated... properties PSA has replaced conscious sedation in the lexicon of emergency medical treatment of ill or injured patients The American College of Emergency Physicians (ACEP) defines PSA as “techniques of... association between NPO time and incidence of adverse events The American Academy of Pediatrics (AAP) acknowledges that for emergency procedures, “the risks of sedation and possible aspiration are as