medications may be taken with a sip of water ASA noted insufficient evidence to assess the impact of timing of fasting on emesis, reflux, or pulmonary aspiration, however, they continue to recommend maintenance of current preprocedure fasting times ACEP publications have also noted that there is insufficient evidence to fully support these time intervals, and offer a “level B recommendation” (moderate clinical certainty) that “procedural sedation may be safely administered to pediatric patients who have had recent oral intake.” Clinicians should be aware of other factors besides stomach contents that can increase the risk of pulmonary aspiration The depth of sedation is an important consideration, as deep sedation may impair airway reflexes, making aspiration more likely Medication choice also plays a role The dissociative sedation caused by ketamine preserves airway reflexes, and aspiration is much less likely with this agent compared to others Conversely volatile agents frequently used by anesthesiologists not only impair airway reflexes, but can also cause vomiting, thereby increasing risk of aspiration Any positive pressure ventilation may increase risk of aspiration in a sedated patient Patient characteristics that increase the risk for pulmonary aspiration include known difficult airway, extremes of age, higher ASA PS, and any medical condition that increases risk of gastroesophageal reflux Patients with known gastroesophageal reflux or dysmotility disorders may benefit from appropriate pharmacologic treatment to reduce gastric volume and increase gastric pH, although routine use for all patients is not recommended Similarly, although presedation antiemetics may decrease the incidence of emesis, they have not been shown to reduce pulmonary aspiration because emesis most commonly occurs during the recovery stage of sedation For the emergency patient, sedation should still be preceded by an evaluation of food and fluid intake It is prudent to assume that patients in the ED have full stomachs when planning the use of sedatives or analgesics When determining preprocedure fasting time, it is important to individualize the decision Clinicians should consider depth of desired sedation, specific agents used, timing and urgency of procedure, and any conditions that may increase the chance of aspiration The risks of sedation must be weighed against the benefits; the lightest effective sedation should be used Some patients may benefit from delaying the procedure or administration of appropriate pharmacologic treatment to reduce gastric volume and increase gastric pH In the event that a patient requires emergent sedation, and is at high risk for aspiration with concerning NPO status, consider airway protection Personnel who are trained in basic life support and the recognition of complications of sedation should be available in the procedure room at all times once sedation has started One such person should be responsible for monitoring the patient and should not be involved in the procedure itself Personnel must understand the pharmacology of the sedatives they use The AAP recommends that an additional person trained in advanced pediatric resuscitation should be available to assist the patient if needed Equipment For children who are undergoing moderate sedation, emergency equipment should be available of the appropriate size This should include a suction device and a positive pressure oxygen delivery system capable of delivering at least 90% FiO2 In areas where moderate and deep sedations are being administered, advanced airway equipment should be available, including nasopharyngeal airways, oral airways, laryngeal mask airways, and endotracheal tubes and laryngoscope Reversal agents such as naloxone and flumazenil should be immediately available Additional equipment recommendations include a nearby defibrillator and medications that might be needed for resuscitation Monitoring A designated person must continuously observe the child’s face and chest wall motion Unless truly unavoidable, equipment and special drapes must not block this observation Patients should have continuous monitoring of oxygen saturation, respiration, and heart rate with (at least) intermittent monitoring of blood pressure during and after the procedure Monitoring with pulse oximetry is essential because of the proven difficulty in recognizing hypoxemia even by experienced personnel Measurement of exhaled carbon dioxide (EtCO2 ) is another modality that has been used extensively in anesthetized patients and has gained a foothold as a sensitive method for monitoring sedated patients in the ED Noninvasive capnography by nasal cannula is available for pediatric patients; some units combine this nasal cannula device with an oxygen delivery component as well The visualization of the “sidestream” EtCO2 waveform over time can offer the clinician insight into the ventilatory status of a nonintubated patient who has normal baseline lung function The specific waveforms elicited by capnography can assist the clinician in determining central apnea, laryngospasm or airway obstruction, bronchospasm, periodic breathing, hyperventilation, and hypoventilation Monitoring of EtCO2 provides earlier detection of respiratory depression than traditional monitoring techniques The ASA has long been recommending the use of EtCO2 for all general anesthesia cases, and the AAP recommends use for moderate and deep sedation If a patient requires deep sedation, an IV line should be established before sedation and maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression If a patient is receiving an intramuscular (IM) agent, the clinician should determine the need for an IV based on the risk for cardiovascular compromise or the potential need for rapid sequence intubation (RSI) Vital signs should be documented at baseline, after drug administration, and every 10 minutes for moderate sedation and every minutes for deep sedation until after the procedure is completed and during early recovery, after which the frequency of documented vital signs can be extended Patients are at highest risk for complications from sedation during the to 10 minutes after administration of the medication and during the period immediately after the procedure when painful stimuli are discontinued After the procedure, appropriate staff should continue to observe patients who received sedation; continuous monitoring of heart rate and oxygen saturation should continue until the patient has met discharge criteria Before discharge, any child who has received sedation should be awake enough to speak and sit without assistance and preferably able to ambulate with minimal assistance Younger children should be able to perform ageappropriate functions The child should also have adequate hydration status, documentation of stable cardiovascular function, and an adequate airway Sedation Protocols Because of the potential for respiratory depression with the sedative and analgesic agents discussed in this chapter, it is imperative that EDs develop protocols for their use Several organizations, such as the AAP, the ACEP, and the ASA, have prepared guidelines for sedation in children These protocols differ in certain fine points, but there is general agreement on major issues The specifics of the ED protocol should be modified at each individual institution Choice of Technique and Medications Selection of medication is informed by the specific procedure, the patient, and the desired depth of sedation ( Table 129.4 ) For example, the clinician can decide that a child needs some assistance in keeping still, an increased receptiveness to distraction techniques, or amnesia for the procedure This child requires anxiolysis rather than sedation, and will receive a relatively smaller dose of a medication that will not require cardiorespiratory monitoring However, a child who needs to be still during a delicate procedure may require a larger dose of the same medication with some risk of cardiorespiratory compromise and, therefore, more intensive monitoring For procedures, it is helpful to discuss the sedation plan with the proceduralist It is important to know the anticipated duration of the procedure, and the time that the child may need to remain immobile For example, one may decide to use morphine rather than fentanyl if a procedure is expected to last longer than 10 minutes It is equally important to know the duration and severity of pain usually involved in this procedure Some procedures, such as fracture reduction, are only brief but very painful and also require the child to remain immobile during the casting portion of the procedure The same is true for procedures in which the administration of regional anesthesia is painful, but the remainder of the procedure is not Patients who undergo nonpainful procedures, such as computed tomography (CT) or magnetic resonance imaging (MRI) scans, or those receiving regional analgesia, may be best served by receiving an agent that provides anxiolysis or sedation alone Finally, one must consider the level of distress that visualization of the procedure may cause for patient and family members Agents that provide an amnestic effect may be desirable in the case where a child could be frightened by the sight of blood or other body fluid The child’s likely reaction to the procedure can be estimated from his or her current pain rating, developmental level, and initial reaction to healthcare ... person trained in advanced pediatric resuscitation should be available to assist the patient if needed Equipment For children who are undergoing moderate sedation, emergency equipment should... monitoring sedated patients in the ED Noninvasive capnography by nasal cannula is available for pediatric patients; some units combine this nasal cannula device with an oxygen delivery component