e1 References 1 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, ed 5 Arlington, VA American Psychiatric Association; 2013 2 Peterson JF, Pun BT, Dittus RS, et a[.]
e1 References American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, ed Arlington, VA: American Psychiatric Association; 2013 Peterson JF, Pun BT, Dittus RS, et al Delirium and its motoric subtypes: a study of 614 critically ill patients: delirium subtypes in the critically ill J Am Geriatr Soc 2006;54(3):479-484 Ely EW, Siegel MD, Inouye M D SK Delirium in the Intensive Care Unit: an under-recognized syndrome of organ dysfunction Semin Respir Crit Care Med 2002;22(02):115-126 Barr J, Fraser GL, Puntillo K, et al Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit Crit Care Med 2013;41(1):278-280 Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y Incidence, risk factors and consequences of ICU delirium Intensive Care Med 2006; 33(1):66-73 Ely EW, Shintani A, Truman B, et al Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit JAMA 2004;291(14):1753-1762 Ely EW, Gautam S, Margolin R, et al The impact of delirium in the intensive care unit on hospital length of stay Intensive Care Med 2001;27(12):1892-1900 Girard TD, Jackson JC, Pandharipande PP, et al Delirium as a predictor of long-term cognitive impairment in survivors of critical illness Crit Care Med 2010;38(7):1513-1520 Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients Crit Care Med 2010; 38(12):2311-2318 10 Pisani MA, Kong SYJ, Kasl SV, Murphy TE, Araujo KLB, Van Ness PH Days of delirium are associated with 1-year mortality in an older intensive care unit population Am J Respir Crit Care Med 2009; 180(11):1092-1097 11 Milbrandt EB, Deppen S, Harrison PL, et al Costs associated with delirium in mechanically ventilated patients Crit Care Med 2004; 32(4):955-962 12 Traube C, Greenwald BM “The times they are a-changin”: universal delirium screening in pediatric critical care Pediatr Crit Care Med 2017;18(6):594-595 13 Maldonado JR Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidencebased approach to prevention and treatment Crit Care Clin 2008; 24(4):789-856 14 Maldonado JR Neuropathogenesis of delirium: review of current etiologic theories and common pathways Am J Geriatr Psychiatry 2013; 21(12):1190-1222 15 Trzepacz PT Update on the neuropathogenesis of delirium Dement Geriatr Cogn Disord 1999;10(5):330-334 16 Trzepacz PT Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine Semin Clin Neuropsychiatry 2000;5(2):132-148 17 Sarter M, Bruno JP Cortical cholinergic inputs mediating arousal, attentional processing and dreaming: differential afferent regulation of the basal forebrain by telencephalic and brainstem afferents Neuroscience 1999;95(4):933-952 18 Flacker JM, Cummings V, Mach JR, Bettin K, Kiely DK, Wei J The association of serum anticholinergic activity with delirium in elderly medical patients Am J Geriatr Psychiatry 1999;6(1):31-41 19 Tune LE Serum anticholinergic activity levels and delirium in the elderly Semin Clin Neuropsychiatry 2000;5(2):149-153 20 Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB The neuroinflammatory hypothesis of delirium Acta Neuropathol 2010;119(6):737-754 21 van Munster BC, Korevaar JC, Korse CM, Bonfrer JM, Zwinderman AH, de Rooij SE Serum S100B in elderly patients with and without delirium Int J Geriatr Psychiatry 2010;25(3):234-239 22 de Rooij SE, van Munster BC, Korevaar JC, Levi M Cytokines and acute phase response in delirium J Psychosom Res 2007;62(5):521-525 23 McGrane S, Girard TD, Thompson JL, et al Procalcitonin and Creactive protein levels at admission as predictors of duration of acute brain dysfunction in critically ill patients Crit Care 2011;15(2):R78 24 Elie M, Cole MG, Primeau FJ, Bellavance F Delirium risk factors in elderly hospitalized patients J Gen Intern Med 1998;13(3):204-212 25 Franco J, Valencia C, Bernal C, et al Relationship between cognitive status at admission and incident delirium in older medical inpatients J Neuropsychiatry Clin Neurosci 2010;22(3):329-337 26 Murray C, Sanderson DJ, Barkus C, et al Systemic inflammation induces acute working memory deficits in the primed brain: relevance for delirium Neurobiol Aging 2012;33(3):603-616.e3 27 Silver G, Traube C, Gerber LM, et al Pediatric delirium and associated risk factors: a single-center prospective observational study Pediatr Crit Care Med 2015;16(4):303-309 28 Engel GL, Romano J Delirium, A Syndrome of Cerebral Insufficiency 2014 [cited 2015 May 18] Available at: http://neuro.psychiatryonline.org/doi/10.1176/jnp.16.4.526 29 Seaman JS, Schillerstrom J, Carroll D, Brown TM Impaired oxidative metabolism precipitates delirium: a study of 101 ICU patients Psychosomatics 2006;47(1):56-61 30 Schoen J, Meyerrose J, Paarmann H, Heringlake M, Hueppe M, Berger KU Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial Crit Care 2011;15(5):R218 31 Dinges D The state of sleep deprivation: From functional biology to functional consequences Sleep Med Rev 2006;10(5):303-305 32 Mistraletti G, Carloni E, Cigada M, et al Sleep and delirium in the intensive care unit Minerva Anestesiol 2008;74(6):329-333 33 Smith HAB, Brink E, Fuchs DC, Ely EW, Pandharipande PP Pediatric delirium: monitoring and management in the Pediatric Intensive Care Unit Pediatr Clin North Am 2013;60(3):741-760 34 Traube C, Silver G, Reeder RW, et al Delirium in critically ill children: an international point prevalence study Crit Care Med 2017;45(4):584-590 35 Smith HAB, Boyd J, Fuchs DC, et al Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit Crit Care Med 2011;39(1):150-157 36 Traube C, Ariagno S, Thau F, et al Delirium in hospitalized children with cancer: incidence and associated risk factors J Pediatr 2017; 191:212-217 37 Patel AK, Biagas KV, Clarke EC, et al Delirium in children after cardiac bypass surgery Pediatr Crit Care Med 2017;18(2):165-171 38 Alvarez RV, Palmer C, Czaja AS, et al Delirium is a common and early finding in patients in the Pediatric Cardiac Intensive Care Unit J Pediatr 2018;195:206-212 39 Meyburg J, Dill ML, Traube C, Silver G, von Haken R Patterns of postoperative delirium in children Pediatr Crit Care Med 2017;18(2):128-133 40 Smith HAB, Gangopadhyay M, Goben CM, et al The preschool confusion assessment method for the ICU: valid and reliable delirium monitoring for critically ill infants and children Crit Care Med 2016;44(3):592-600 41 Traube C, Silver G, Kearney J, et al Cornell assessment of pediatric delirium: a valid, rapid, observational tool for screening delirium in the PICU Crit Care Med 2014;42(3):656-663 42 Traube C, Silver G, Gerber LM, et al Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium Crit Care Med 2017;45(5):891-898 43 Simone S, Edwards S, Lardieri A, et al Implementation of an ICU bundle: an interprofessional quality improvement project to enhance delirium management and monitor delirium prevalence in a single PICU Pediatr Crit Care Med 2017;18(6):531-540 44 Inouye SK, Westendorp RG, Saczynski JS Delirium in elderly people Lancet 2014;383(9920):911-922 45 Meyburg J, Dill ML, von Haken R, et al Risk factors for the development of postoperative delirium in pediatric intensive care patients Pediatr Crit Care Med 2018;19(10):e514-e521 e2 46 Deeter KH, King MA, Ridling D, Irby GL, Lynn AM, Zimmerman JJ Successful implementation of a pediatric sedation protocol for mechanically ventilated patients Crit Care Med 2011;39(4):683-688 47 Penk JS, Lefaiver CA, Brady CM, Steffensen CM, Wittmayer K Intermittent versus continuous and intermittent medications for pain and sedation after pediatric cardiothoracic surgery; a randomized controlled trial Crit Care Med 2018;46(1):123-129 48 Smith HAB, Gangopadhyay M, Goben CM, et al Delirium and benzodiazepines associated with prolonged ICU stay in critically ill infants and young children Crit Care Med 2017;45(9):1427-1435 49 Mody K, Kaur S, Mauer EA, et al Benzodiazepines and development of delirium in critically ill children: estimating the causal effect Crit Care Med 2018;46(9):1486-1491 50 Robins JM, Hernan MA, Brumback B Marginal structural models and causal inference in epidemiology Epidemiology 2000;11(5): 550-560 51 Aydogan MS, Korkmaz MF, Ozgül U, et al Pain, fentanyl consumption, and delirium in adolescents after scoliosis surgery: dexmedetomidine vs midazolam Paediatr Anaesth 2013;23(5):446-452 52 Nellis ME, Goel R, Feinstein S, Shahbaz S, Kaur S, Traube C Association between transfusion of RBCs and subsequent development of delirium in critically ill children Pediatr Crit Care Med 2018;19(10):925-929 53 Traube C, Mauer EA, Gerber LM, et al Cost associated with pediatric delirium in the ICU Crit Care Med 2016;44(12):e1175-e1179 54 Shann F, Pearson G, Slater A, Wilkinson K Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care Intensive Care Med 1997;23(2):201-207 55 Silver G, Kearney J, Traube C, Atkinson TM, Wyka KE, Walkup J Pediatric delirium: Evaluating the gold standard Palliat Support Care 2015;13(3):513-516 56 Silver G, Kearney J, Traube C, Hertzig M Delirium screening anchored in child development: The Cornell Assessment for Pediatric Delirium Palliat Support Care 2015;13(4):1005-1011 57 Schieveld JNM, Leroy PLJM, Os J, Nicolai J, Vos GD, Leentjens AFG Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit Intensive Care Med 2007;33(6):1033-1040 58 Silver G, Traube C, Kearney J, et al Detecting pediatric delirium: development of a rapid observational assessment tool Intensive Care Med 2012;38(6):1025-1031 59 Inouye SK, Schlesinger MJ, Lydon TJ Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care Am J Med 1999;106(5):565-573 60 Schieveld JN, Janssen NJ Delirium in the pediatric patient: on the growing awareness of its clinical interdisciplinary importance JAMA Pediatr 2014;168(7):595-596 61 Harris J, Ramelet AS, van Dijk M, et al Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals Intensive Care Med 2016;42(6):972-986 62 Patel AK, Bell MJ, Traube C Delirium in pediatric critical care Pediatr Clin North Am 2017;64(5):1117-1132 63 Tobias JD Acute pain management in infants and children—Part 2: intravenous opioids, intravenous nonsteroidal anti-inflammatory drugs, and managing adverse effects Pediatr Ann 2014;43(7): e169-e175 64 Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP Rapidly reversible, sedation-related delirium versus persistent delirium in the Intensive Care Unit Am J Respir Crit Care Med 2014;189(6):658-665 65 Colville G, Kerry S, Pierce C Children’s factual and delusional memories of intensive care Am J Respir Crit Care Med 2008; 177(9):976-982 66 Clukey L, Weyant RA, Roberts M, Henderson A Discovery of unexpected pain in intubated and sedated patients Am J Crit Care 2014;23(3):216-220 67 Silver G, Traube C A systematic approach to family engagement: feasibility pilot of a pediatric delirium management and prevention toolkit Palliat Support Care 2019;17(1):42-45 68 Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MA The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients Pediatr Crit Care Med 2008;9(6):573-580 69 Ista E, de Hoog M, Tibboel D, Duivenvoorden HJ, van Dijk M Psychometric evaluation of the sophia observation withdrawal symptoms scale in critically ill children Pediatr Crit Care Med 2013;14(8):761-769 70 Traube C, Silver G Iatrogenic withdrawal syndrome or undiagnosed delirium? Crit Care Med 2017;45(6):e622-e623 71 Madden K, Hussain K, Tasker RC Anticholinergic medication burden in pediatric prolonged critical illness: a potentially modifiable risk factor for delirium Pediatr Crit Care Med 2018;19(10):917-924 72 Hipp DM, Ely EW Pharmacological and nonpharmacological management of delirium in critically ill patients Neurotherapeutics 2012;9(1):158-175 73 Inouye SK, Bogardus Jr ST, Charpentier PA, et al A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med 1999;340(9):669-676 74 Schweickert WM, Pohlman MC, Nigos C, et al Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial Lancet 2009;373(9678): 1874-1882 75 Needham DR, Zanni J, Pradhan P, et al Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project Arch Phys Med Rehabil 2010;91(4):536-542 76 Wieczorek B, Ascenzi J, Kim Y, et al PICU Up!: impact of a quality improvement intervention to promote early mobilization in critically ill children Pediatr Crit Care Med 2016;17(12):e559-e566 77 Kudchadkar SR, Yaster M, Punjabi NM Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community Crit Care Med 2014;42(7):1592-1600 78 Kawai Y, Weatherhead JR, Traube C, et al Quality improvement initiative to reduce pediatric intensive care unit noise pollution with the use of a pediatric delirium bundle J Intensive Care Med 2019; 34(5):383-390 79 Lonergan E, Britton AM, Luxenberg J Antipsychotics for delirium In: The Cochrane Collaboration, Lonergan E, eds Cochrane Database of Systematic Reviews [Internet] Chichester, UK: John Wiley & Sons, Ltd; 2007 80 Devlin JW, Roberts RJ, Fong JJ, et al Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Crit Care Med 2010;38(2):419-427 81 Traube C, Witcher R, Mendez-Rico E, Silver G Quetiapine as treatment for delirium in critically ill children: a case series J Pediatr Intensive Care 2013;2(3):121-126 82 Karnik NS, Joshi SV, Paterno C, Shaw R Subtypes of pediatric delirium: a treatment algorithm Psychosomatics 2007;48(3):253-257 83 Turkel SB, Hanft A The pharmacologic management of delirium in children and adolescents Paediatr Drugs 2014;16(4):267-274 84 Silver GH, Kearney JA, Kutko MC, Bartell AS Infant delirium in pediatric critical care settings Am J Psychiatry 2010;167(10):1172-1177 85 Traube C, Augenstein J, Greenwald B, LaQuaglia M, Silver G Neuroblastoma and pediatric delirium: a case series: Neuroblastoma and Delirium Pediatr Blood Cancer 2014;61(6):1121-1123 86 Joyce C, Witcher R, Herrup E, et al Evaluation of the safety of quetiapine in treating delirium in critically ill children: a retrospective review J Child Adolesc Psychopharmacol 2015;25(9):666-670 e3 Abstract: Delirium is a frequent and serious complication of pediatric critical illness It is independently associated with delayed time to extubation, increased hospital length of stay, and higher medical costs After controlling for severity of illness, children with delirium have been shown to have excess mortality rates Modifiable risk factors for delirium have been identified, including benzodiazepine-based sedation With implementation of routine screening for all children in the pediatric intensive care unit (PICU), delirium can be detected early, when it is most amenable to treatment A change in PICU culture can decrease the burden of delirium in critically ill children Key words: Delirium, pediatric, critical care, epidemiology, risk factor, outcome, prevention, treatment, screening, diagnosis, CAPD 135 Procedural Sedation for the Pediatric Intensivist NIR ATLAS, RAHUL C DAMANIA, AND PRADIP P KAMAT In the last decades, there has been a robust demand for outpatient pediatric procedural sedation, now provided by myriad pediatric subspecialists, including pediatric intensivists.1,2 The intensivist who is trained in the early recognition and management of airway and cardiopulmonary issues is a perfect fit to provide procedural sedation outside the pediatric intensive care unit (PICU).3 A 2015 survey by Kamat et al reported that intensivists staffed 78% of all sedation programs within the Society for Pediatric Sedation (SPS).4 Pediatric intensivists no longer solely sedate within the PICU; they also provide procedural sedation in sedation suites, radiology suites, oncology clinics, and endoscopy suites.1,5 Conventional procedures for which the pediatric intensivist provides procedural sedation are shown in Box 135.1 Differences Between Outpatient and Inpatient Sedation Within the PICU, intensivists have the luxury of assistance from multiple team members, including nurses, respiratory therapists, an intravenous catheter placement team, and back-up emergency services (such as rapid response or the resource nurse) In addition, the PICU is equipped with advanced airway equipment, capnography, and extensive hemodynamic monitoring capabilities In contrast, in the outpatient setting, the sedationist is usually partnered with a single nurse who is exclusively dedicated to the sedation.6 An additional nurse may be assisting the proceduralist and not directly involved with the process of sedation A goal of outpatient sedation is maintenance of the natural airway during sedation Thus, the need for intubation may be deemed as a failure Monitoring of exhaled end-tidal carbon dioxide with capnography may not be readily available, though highly recommended.7 Physical access to the patient may be particularly challenging in certain locations, such as magnetic resonance imaging (MRI) suites Given the distinctive challenges that arise from outpatient procedural sedation, the intensivist must be trained to perform sedation safely in a variety of clinical settings Outpatient Procedural Sedation Training During Pediatric Critical Care Fellowship As the demand for procedural sedation outside the PICU increases, so does the need for the intensivist to demonstrate 1624 proficiency in outpatient procedural sedation management and monitoring A recent article describing trends in outpatient procedural sedation reports a consistent intensivist presence in the provision of procedural sedation over the last 10 years.2 Despite the important role of the intensivist in procedural sedation, a recent survey of pediatric critical care medicine (PCCM) fellowship directors reported that only one-third of PCCM fellowship trainees received formal procedural sedation training during their fellowship.8 Additionally, only 61% of fellows felt adequately prepared to provide procedural sedation on their own after finishing fellowship.8 Current training for procedural sedation in most PCCM fellowship programs appears to be inconsistent and optional, highlighting a training gap that must be addressed.9 Given that most PCCM fellows likely will be required to perform procedural sedation outside the PICU, it is imperative that fellowship programs incorporate outpatient procedural sedation training in their academic and training curricula The SPS (www.pedsedation.org) provides simulationbased training in procedural sedation during its annual conference Simulation has been shown to be effective in teaching sedation competencies and enhancing team dynamics; it should be routinely employed to train providers of procedural sedation.10 Sedation Team Structure Considering the increasing role of the intensivist in procedural sedation outside the PICU, the newly graduated PCCM fellow will likely be required to incorporate this practice into clinical service Some institutions allow intensivists to “moonlight” in the sedation service for compensation in addition to their PICU responsibilities Transition to being a sedationist (part time or even full time) may also appeal to senior intensivists trying to decrease PICU clinical service or on-call duties before retirement or those experiencing burnout or moral distress while working in the PICU Some programs use a hybrid of full-time sedationists (usually senior physicians from PCCM or Pediatric Emergency Medicine) and other intensivist and emergency medicine specialists who cover sedation shifts when not working in their primary clinical sites.4 In addition to the intensivist, most sedation programs allow a dedicated trained sedation nurse to assist mostly with sedation monitoring An observer (usually another nurse) may be involved in monitoring but may also help with interruptible tasks All personnel providing procedural sedation must have training in pediatric advanced life support.6 CHAPTER 135 Procedural Sedation for the Pediatric Intensivist • BOX 135.1 Examples of Common Procedures Requiring Pediatric Procedural Sedation Radiology Imaging Magnetic resonance imaging Computed tomography scan Positron emission tomography scan Nuclear medicine scans Hematology-Oncology Bone marrow biopsy/aspiration Lumbar puncture intrathecal administration of medications Gastroenterology Colonoscopy Upper endoscopy Percutaneous endoscopic gastrostomy/gastrostomy tube placement/change Surgical Abscess drainage Biopsies (renal, liver, thyroid) Fracture reduction and cast placement Wound dressing/vacuum-assisted closure Central venous line or peripherally inserted central catheter placement Chest tube placement Suture removal Laceration repair Neurology Brainstem auditory response test Electroencephalography Electromyography Epidural blood patching Lumbar puncture (diagnostic) Magnetoencephalography Somatosensory evoked potentials Other Eye examination Sexual assault examination Painful procedures not otherwise defined Classification of Sedation The American Society of Anesthesiology (ASA) classifies sedation as mild, moderate, deep, and general anesthesia.11 The classification is based on responsiveness to voice, touch, painful stimulus, and the ability to maintain airway reflexes and cardiovascular function The type of medication used does not define the level of sedation Mild sedation is a drug-induced state in which the patient responds to verbal commands For example, mild sedation may be employed in a child to reduce anxiolysis before a nonpainful imaging study Moderate sedation is a state of depressed consciousness in which the patient may respond to verbal commands or tactile stimulation No airway interventions are required, and cardiovascular function is maintained For example, moderate sedation may be appropriate in a cooperative adolescent during suture repair of a laceration Deep sedation is defined as a depression of consciousness in which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation The patient may require assistance in maintaining a patent airway, but the cardiovascular system is usually maintained In outpatient procedural sedation, the intensivist commonly induces 1625 deep sedation, typically with propofol The sedation specialist must have in-depth knowledge of monitoring as well as rescue of pediatric patients undergoing deep sedation Last, general anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation The ability to maintain ventilatory function is commonly impaired and patients often require positive-pressure ventilation Neuromuscular and cardiovascular functions may also be impaired For these reasons, general anesthesia is reserved for operating rooms and not performed in the outpatient procedural sedation setting It is important to recognize that sedation is a continuum and that any child can slip from moderate sedation to deep sedation, making airway rescue skills paramount.6 Equipment, Monitoring, and Rescue Drugs Essential components that must be available in any outpatient sedation location include an emergency cart, hemodynamic monitoring devices, and rescue drugs Equipment in emergency carts must include bag-valve-mask devices, oral and nasopharyngeal airways, laryngeal mask airways (LMAs), endotracheal tubes, laryngoscopy blades, and intravenous lines In addition to these lifesaving devices, sedation specialists should have access to portable telemetry, pulse oximetry, capnography, blood pressure monitoring, and defibrillators.12 Last, common rescue medications—such as albuterol, atropine, diphenhydramine, dextrose, epinephrine, flumazenil, lidocaine, lorazepam, methylprednisolone, naloxone, oxygen, racemic epinephrine, and sodium bicarbonate—should be readily available.6 Pediatric intensivists are trained to rescue a child using these tools, making them uniquely suited to provide outpatient sedation for diagnostic and therapeutic procedures Sedation Prescreening Not all patients are candidates for procedural sedation Pediatric intensivists should be aware that certain conditions necessitate the services of a pediatric anesthesiologist Children with difficult airway (determined by history or physical examination), microcephaly, micrognathia, retrognathia, mandibular/midface hypoplasia, or genetic syndromes with known complex airway anatomy are best referred to the anesthesiologist In addition, patients with ASA physical status classification of IV or higher (Table 135.1), severe obstructive sleep apnea (apnea-hypopnea index 10), morbid obesity (body mass index 95th percentile), and complex TABLE American Society of Anesthesiology 135.1 Classification Class Description I Normal healthy patient II Patient with mild systemic disease III Patient with severe systemic disease IV Patient with severe systemic disease that is a constant threat to life V Moribund patient who is not expected to survive without an operation VI Declared brain-dead patient whose organs are being removed for donor purposes ... intensivists staffed 78% of all sedation programs within the Society for Pediatric Sedation (SPS).4 Pediatric intensivists no longer solely sedate within the PICU; they also provide procedural sedation... difficult airway (determined by history or physical examination), microcephaly, micrognathia, retrognathia, mandibular/midface hypoplasia, or genetic syndromes with known complex airway anatomy... recent survey of pediatric critical care medicine (PCCM) fellowship directors reported that only one-third of PCCM fellowship trainees received formal procedural sedation training during their fellowship.8