Procedural Sedation: Anesthesia and Sedation of Children Away from the OR

Abstract

Children need anesthesia and sedation for many procedures an adult would tolerate awake. These procedures are often performed away from the operating theatre. Although the terms conscious, moderate and deep are still used to define sedation levels, they are subjective and poorly defined. Minimal and moderate sedation are rarely effective in children, as small doses of sedation do not change a hungry toddler into an awake yet cooperative patient. Non-anesthetists often believe sedation is safer than anesthesia, not appreciating the risks of the deeper levels of sedation often required for children, especially those having painful procedures. Oral sedation has a slow onset, a long duration and is difficult to titrate to a desired effect. Upper endoscopy (gastroscopy) causes airway and ventilation problems in children. The endoscope partly occupies the upper airway and may compress the trachea. There is gastric distension from air insufflation, and there may be a risk of regurgitation and pulmonary aspiration. General anesthesia with endotracheal intubation is common in infants and children younger than 2 or 3 years. Either a laryngeal mask or facemask with intravenous anesthesia is used for older children. MRI scans are difficult for awake, young children to tolerate and require sedation or anesthesia in an environment with a high magnetic field. Techniques to facilitate the scan balance safety, scanner efficiency and staffing requirements, affecting the technique chosen by different institutions. Positron emission tomography (PET) is the most recent type of scan now needing sedation of children.

Review Questions

• 1. A 3 year old girl is being managed in ICU after an intracerebral hemorrhage. She is intubated and ventilated and you are going to take her to MRI for scanning. Describe the precautions you would take to prevent burns to the child in the scanner. Describe the other precautions you would take while the patient is having the scan.

• 2. A 2 year old child is going to have a gastroscopy to investigate possible reflux. What are the advantages and disadvantages of the different ways to manage the airway in this child for this procedure?