Paediatric Sedation

• The role of sedation is to reduce the distress during a painful procedure
• It is not a replacement for adequate pain relief or local anaesthetic
• Local anaesthetic gel, analgesia and lots of distraction can often obviate the need for sedation and the risks it entails

If they definitely do need sedation, how much are we talking?

Is this to put in a cannula, get an xray, or pull a very painful elbow dislocation?

Sedation is a spectrum, and you need to know where you're aiming.

You need to treat this as you would any anaesthetic, and perform a thorough preoperative assessment.

History

• Previous anaesthesia with or without adverse reactions?
• Any medical problems or medications?
• Any significant surgical history?
• Any allergies?
• Last food and drink?
• Any active respiratory tract infections?

Examination

• Well child?
• Snotty and feverish?
• Any airway concerns?

Make sure you're happy that the child is safe to have an anaesthetic, no matter how brief the procedure is expected to be.

Remember contraindications are always broken down into absolute and relative.

Absolute

• Lack of trained staff
• Inability to manage airway safely
• Parent or competent child refusal

Relative

• Active asthma
• Less than 1 year of age
• Airway abnormality
• Substantial cardiac comorbidity
• Any procedure in the mouth or pharynx
• Recent head injury with drop in GCS
• Intracranial hypertension
• Intraocular disease
• Uncontrolled epilepsy
• Porphyria
• Thyroid disease
• Previous problem with sedation
• Procedure expected to last more than twenty minutes

• The short answer is no
• If you're a core trainee anaesthetist, it is very unlikely that your consultant would expect you to independently sedate a child in the emergency department
• If you are a registrar then you may be perfectly capable of safely and competently sedating this child, but you probably want a second set of hands available for good vibes

I have seen many consultants ask for a junior to accompany them to do a paediatric sedation, simply because a second set of airway trained hands is enormously reassuring to have.

Sedation should only be performed in a resuscitation bay or high dependency area with immediate access to resuscitation equipment and medication.

So essentially it's a choice between resus and theatres.

• Can you get this done safely in resus, avoiding all the hassle and delay of transferring to theatre?
• Is the orthopod going to decide halfway through that actually they need to put in some wires, and so could we just give a 'little bit' of muscle relaxant?
• Does this kid actually need a full GA so the surgeon has full remit to explore a wound and put some metalwork in?

If it's a simple pull-and-cast job, then resus is fine.

If there is any doubt about what the surgeon actually needs to do, then this should be a general anaesthetic in theatre.

• If yes, then fantastic
• If not, how do you plan to get some?
• Ask the nurses to slather on some ametop or equivalent
• Ask the parents how you think the kid will be with you putting a cannula in

If you're finding yourself thinking about how you're going to sedate a child before putting a cannula in, you should probably be thinking about doing a fasted gas induction in theatre instead.

You need to be treating this the same way you would a general anaesthetic.

• Heart rate
• Blood pressure
• Oxygen saturations
• Respiratory rate
• Capnography

An upset child might not let you get much monitoring on before you start, but you need at least a sats probe and capnography before you inject anything, and then immediately get the rest on once they've calmed down.

You have a variety of options available.

• Ketamine - you'll need IV access and prepare for drooling
• Propofol - you'll need IV access and prepare for apnoea
• Nitrous oxide - the kid will need to tolerate the mask
• Midazolam - you'll need IV access and prepare for apnoea and paradoxical agitation

We're professional catastrophisers, and we refuse to apologise for that.

Our job is to think 'what do I do if this all goes wrong?' and to be prepared for any eventuality.

• Airway obstruction - jaw thrust, adjuncts, Mapleson C circuit, Igel, tube, suxamethonium immediately available
• Hypoventilation - oxygen, Mapleson C, face mask, EtCO2 monitoring
• Bradycardia - atropine
• Hypotension - IV fluid, pressors
• Agitation - another form of sedation nearby
• Regurgitation - suction, airway equipment, RSI drugs

Calculate your doses of emergency and resuscitation drugs before you start.

• Atropine 20 mcg/kg for bradycardia
• Suxamethonium 1.5 mg/kg IV or 4 mg/kg IM
• Adrenaline 10 mcg/kg arrest dose (0.1 mL/kg of 1:10,000)

"Should I give atropine or glycopyrrolate to reduce secretions before ketamine sedation in kids?"

Nope. The evidence suggests this may even increase rates of laryngospasm and other adverse events, so just keep it simple.

Ketamine is a strange drug that is absolutely brilliant when used properly.

• NMDA receptor antagonist
• Produces a dissociative state of anaesthesia*
• Powerful analgesic and amnestic agent
• Maintains airway reflexes
• Sympathetic stimulation maintains blood pressure and usually causes tachycardia

*The patient's eyes may stay open as they stare into the K-hole abyss into which you have sent them.

The trend of giving a prophylactic benzodiazepine at the same time has gone out of fashion, due to increased adverse events when compared with ketamine on its own.

If the child experiences significant emergence delirium then 0.05-0.1 mg/kg midazolam is a sensible plan.

Your department almost certainly has a bespoke 'how to sedate kids in our hospital' protocol, which you should follow.

If not, then here are some sensible tips:

• The standard dose is 1-1.5 mg/kg
• Top up doses are usually 0.5 mg/kg
• Inject slowly over a minute to reduce laryngospasm and apnoea
• Be patient, allow at least 60-90 seconds before assessing whether the patient is adequately sedated
• You're looking for horizontal nystagmus and loss of response to voice as your cue to tell the orthopod to get started
• You can use IM (2-4 mg/kg) in certain emergency scenarios to allow you to get IV access, but you really don't want to be doing this as a junior on your own
• Tell the parents they can take up to two hours to fully recover from sedation

After ten minutes or so, the patient may give a deep sigh or yawn - this is an indication that they are starting to lighten, and you need to decide now whether further sedation is needed, or you're ready for them to return to planet Earth.

You need to make the following very clear:

• This is not a full general anaesthetic
• They may still make noises and respond, and that's okay - they won't remember it and they're not 'feeling' it in the way they normally would
• Their eyes may stay open if using ketamine - this is entirely normal
• The child may be woozy, confused or strange for a while afterwards, and that's okay

• Tell the orthopod to stop
• Call for help
• 100% oxygen
• Gentle suction of any visible secretions
• Jaw thrust and Larson's manoeuvre
• PEEP and manual ventilation with Mapleson C
• RSI

Here's our full post on laryngospasm.