Pediatric Sedation Service Research Articles

Pediatric Sedation Assessment and Management System (PSAMS) for Pediatric Sedation in China: Development and Implementation Report.

Recently, the growing demand for pediatric sedation services outside the operating room has imposed a heavy burden on pediatric centers in China. There is an urgent need to develop a novel system for improved sedation services. This study aimed to develop and implement a computerized system, the Pediatric Sedation Assessment and Management System (PSAMS), to streamline pediatric sedation services at a major children's hospital in Southwest China. PSAMS was designed to reflect the actual workflow of pediatric sedation. It consists of 3 main components: server-hosted software; client applications on tablets and computers; and specialized devices like gun-type scanners, desktop label printers, and pulse oximeters. With the participation of a multidisciplinary team, PSAMS was developed and refined during its application in the sedation process. This study analyzed data from the first 2 years after the system's deployment. From January 2020 to December 2021, a total of 127,325 sedations were performed on 85,281 patients using the PSAMS database. Besides basic variables imported from Hospital Information Systems (HIS), the PSAMS database currently contains 33 additional variables that capture comprehensive information from presedation assessment to postprocedural recovery. The recorded data from PSAMS indicates a one-time sedation success rate of 97.1% (50,752/52,282) in 2020 and 97.5% (73,184/75,043) in 2021. The observed adverse events rate was 3.5% (95% CI 3.4%-3.7%) in 2020 and 2.8% (95% CI 2.7%-2.9%) in 2021. PSAMS streamlined the entire sedation workflow, reduced the burden of data collection, and laid a foundation for future cooperation of multiple pediatric health care centers.

The safety and efficacy of a nurse-led sedation service using Chloral Hydrate for auditory brainstem response testing

BackgroundThere is a growing number of pediatric procedures requiring sedation outside the operating room. Among these are auditory brainstem response (ABR) tests, the gold standard for objective hearing evaluation in infants and toddlers. Recently, a nurse-led pediatric sedation service based on a structured protocol has been developed for ABR testing. ObjectivesTo retrospectively analyze the safety and efficacy of the pediatric nurse-led sedation protocol (PNLSP) in a tertiary medical center using Chloral Hydrate (CH) in children undergoing ABR testing. MethodsData from medical charts of children who underwent sedation for ABR testing between January 2014 and December 2017, were retrieved. Analysis of sedation success/failure rates, sleep induction time (SIT), sleep duration time (SDT), and adverse events (AE), was performed. Findings1348 children with a mean age of 13.4 months (range 3–42 months), classified by the American Society of Anesthesiologists Physical Status Classification System (ASA score) 1–3, were included in the analysis. All children received a fixed dose of 75 mg / kg CH orally or rectally. Sedation success rate was 98.7% and enabled completion of ABR testing. Failure to sedate was evident in 17 children (1.3%), all classified as ASA score 1–2. Median SIT and SDT were 25 and 100 min, respectively. Mild AE occurred in 9 children (0.67%), none of which required further intervention. ConclusionsFindings support the use of a structured PNLSP using CH as safe and efficient. The suggested protocol is an effective alternative for general anesthesia (GA) for ABR testing in healthy young children.

Pediatric Deep Sedation for Ophthalmology Procedures in an Outpatient Setting, Risk Evaluation.

Background:Pediatric deep sedation (PDS) performed by a dedicated pediatric sedation service has been found to be safe, convenient, and efficient for minor procedures. Major complications such as cardiopulmonary resuscitation, intubation, and death are rare. However, minor complications such as desaturation, apnea, suctioning, or laryngospasm can occur infrequently. To date, little data exist evaluating PDS use for minor ophthalmology procedures.Aims:The aim of this study was to evaluate the incidence of complications for subjects receiving PDS for minor ophthalmology procedures.Setting:Pediatric children's hospital sedation service.Materials and Methods:This was a review of a prospectively collected database between 2018 and 2020. A hundred and thirty-four subjects aged 0–18 years, who underwent PDS for minor ophthalmology procedures, were compared to 1119 subjects who received PDS for other procedures (e.g., lumbar puncture, bone marrow aspirate/biopsy, and Botox).Statistical Analysis:SAS software, version 9.4, was used to determine variables associated with deep sedation that were predictive of complications. A multiple logistic regression procedure was conducted. Statistical significance was set at the 0.05 level.Results:Subjects receiving PDS for ophthalmology procedures had a higher rate of minor complications than the control group (n = 18, 13.4%, vs. n = 58, 5.7%; P < 0001). No major complications occurred in any of the studied subjects. The ophthalmology group had a higher rate of bag-mask ventilation, airway positioning, and suctioning.Conclusions:Ophthalmology procedures using PDS have a greater occurrence of minor complications compared to other painful procedures. No major complications were noted in either group, providing evidence that PDS can be performed safely for ophthalmology procedures using the sedation team model.

Evolution of the Pediatric Intensivist Sedation Service

Discuss significant changes in provision of pediatric procedural sedation care in the last 2 decades. Organized pediatric sedation services have enabled statistically significant compilations of risk involved in providing sedation care to children. Sedation care outside of the operating room setting involves a wide variety of providers, novel medication administration techniques, and differentiation of scheduled and unscheduled sedation care. Pediatric intensivists have been and are critical to providing procedural sedation for children particularly those with severe illness.

Development of a Pediatric PICC Team Under an Existing Sedation Service: A 5-Year Experience.

Objective:To examine our institutional experiences with ultrasound-guided peripherally inserted central catheter (US-PICC) placement by a dedicated US-PICC team under the umbrella of an existing pediatric sedation service.Methods:Retrospective review of quality data examining 968 US-PICC encounters over a 5-year period from 2012 to 2016. Data for each encounter included line indications, success rate, dwelling time, need for sedation, and incidence of complications including venous thrombosis, infection, and accidental removal.Results:US-PICC lines were successfully placed in 89% of patients with an average age of 5.4 years. Extended antibiotic treatment was the most common indication for US-PICC placement and the mean dwell time was 23 days. Long-term complications were noted in 6.1% of cases, with venous thrombosis and line infection complicating 1.7% and 0.9% of encounters, respectively.Conclusion:Results suggest that our endeavor of creating a dedicated US-PICC team under an existing pediatric sedation service is successful with regard to the number of lines placed, success rates, and incidence of complications. This approach may be beneficial to other institutions seeing to maximize resource utilization and streamline patient care.

Factors affecting same-day cancelation of outpatient pediatric oncologic procedural sedation

Background: Children with cancer undergo serial invasive, painful procedures as a part of their diagnosis, treatment, and surveillance regimens that require procedural sedation (PS). Some may have a delay in their treatment plan due to same-day cancelation (SDC) of the procedure due to issues related to sedation or other factors. The objective of this report was to evaluate the factors resulting in the SDC of hematology and oncology patients in an outpatient pediatric sedation service.Methods: Retrospective review of children with cancer or other hematologic disorders undergoing outpatient procedures using a dedicated pediatric sedation team from January 2012 to December 2017. The children with SDC were compared to controls (ie, patients not canceled) during the above study period.Results: A total of 100 patients had SDC during the study. The median age was 10 years (25th percentile to 75th percentile: 7–10 years). The overall SDC rate was 3% and 78/100 (78%) had acute lymphoblastic leukemia. Most common procedure was lumbar puncture with intrathecal chemotherapy in 82/100 (82%) patients. Inadequate blood counts, acute illness, and not nil per os (NPO) accounted for 83% of the reasons for SDC. Type of health insurance, estimated household income, or distance traveled to the clinic did not impact SDC.Conclusions: The most common factors for SDC included inadequate blood counts, acute illness, and not meeting NPO guidelines. Understanding factors affecting SDC may help improve the efficiency of time-sensitive care delivered to children with cancer and other hematologic concerns by a pediatric sedation service.

Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service

BackgroundPropofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. ObjectiveDescribe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. MethodsRetrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. ResultsMethohexital was used in 240 patient encounters. Median age was 4years (IQR 2–7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9–2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0–6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28–57). ConclusionMethohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies.

Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.

High-dose dexmedetomidine for noninvasive pediatric procedural sedation and discharge readiness.

The University of North Carolina's (UNC) Pediatric Sedation Service adopted a noninvasive procedural sedation protocol that uses dexmedetomidine in children based on review of literature that reported fast recovery times and low morbidity. This study aimed to compare dexmedetomidine discharge readiness times observed at UNC with those previously published with a hypothesis that the discharge times at UNC are longer than those previously published. A secondary aim was to evaluate the safety profile of the protocol. Pediatric outpatients (6 months-18 years) who received dexmedetomidine per protocol for a noninvasive procedure or study from January 2011 through April 2012 were included in this retrospective chart review. A total of 615 patient encounters were evaluated. Patients received bolus doses of 2 μg·kg(-1) over 10 min for up to three doses followed by a 1 μg·kg(-1) ·h(-1) infusion (group 1) or a 1.5 μg·kg(-1) ·h(-1) infusion (group 2). Primary outcomes included time to sedation, time to arousal, and time to discharge. No significant differences between the dosing groups were noted. Time to discharge was significantly shorter for group 1 (79 min) than for group 2 (101 min). The range of discharge times at UNC was 78.7-100.9 min compared to previous studies that report recovery times of 24.8-35.2 min. Dexmedetomidine arousal and discharge times observed at UNC were longer than anticipated when compared to literature. The safety profile of the drug was comparable to prior studies.

Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center

Freestanding imaging centers are popular options for health care systems to offer services accessible to local communities. The provision of deep sedation at these centers could allow for flexibility in scheduling imaging for pediatric patients. Our Children's Sedation Services group, comprised of pediatric critical care medicine and pediatric emergency medicine physicians, has supplied such a service for 5 years. However, limited description of such off-site services exists. The site has resuscitation equipment and medications, yet limited staffing and no proximity to hospital support. To describe the experience of a cohort of pediatric patients undergoing sedation at a freestanding imaging center. A retrospective chart review of all sedations from January 2012 to December 2012. Study variables include general demographics, length of sedation, type of imaging, medications used, completion of imaging, adverse events based on those defined by the Pediatric Sedation Research Consortium database and need for transfer to a hospital for additional care. Six hundred fifty-four consecutive sedations were analyzed. Most patients were low acuity American Society of Anesthesiologists physical class ≤ 2 (91.8%). Mean sedation time was 55 min (SD ± 24). The overwhelming majority of patients (95.7%) were sedated for MRI, 3.8% for CT and <1% (three patients) for both modalities. Propofol was used in 98% of cases. Overall, 267 events requiring intervention occurred in 164 patient encounters (25.1%). However, after adjustment for changes from expected physiological response to the sedative, the rate of events was 10.2%. Seventy-five (11.5%) patients had desaturation requiring supplemental oxygen, nasopharyngeal tube or oral airway placement, continuous positive airway pressure or brief bag valve mask ventilation. Eleven (1.7%) had apnea requiring continuous positive airway pressure or bag valve mask ventilation briefly. One patient had bradycardia that resolved with nasopharyngeal tube placement and continuous positive airway pressure. Fifteen (2.3%) patients had hypotension requiring adjustment of the sedation drip but no fluid bolus. Overall, there were six failed sedations (0.9%), defined by the inability to complete the imaging study. There were no serious adverse events. There were no episodes of cardiac arrest or need for intubation. No patient required transfer to a hospital. Sedation provided at this freestanding imaging center resulted in no serious adverse events and few failed sedations. While this represents a limited cohort with sedations performed by predominately pediatric critical care medicine and pediatric emergency medicine physicians, these findings have implications for the design and potential scope of practice of outpatient pediatric sedation services to support community-based pediatric imaging.

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Introduction: Procedural sedation (PS) on pediatric patients outside the OR setting have increased in the past 20 years, and as a consequence of this change, institutions have adopted sedation polices that create pediatric sedation units, exclusively for children, to enhance patient safety and satisfaction.The importance of sedation during endoscopy is well established, but there is no consensus about the best techniques for sedation, which specialist should perform it, and in which location. To address all the issues mentioned above, we at the Children’s Hospital at Saint Peter’s University Hospital established a pediatric sedation unit (PSU) in 2004 with a dedicated sedation nurse and pediatric intensivist to provide PS safely and efficiently. The Saint Peters pediatric sedation service provides 100% of all sedations outside the operating room including deep sedation for GI endoscopic procedures. Hypothesis: Based on our experience, we hypothesize that deep sedation for pediatric GI endoscopic procedures can be provided safely using intravenously administered agents, such as Propofol, by non-anesthesiologists (NA) outside the OR. Methods: In our retrospective chart study with consecutive data, children admitted between 2004 and 20102 to the Children’s Hospital at Saint Peter’s University Hospital who underwent upper and lower GI endoscopic procedures for various reasons were extracted. Patients were identified by using the CPT Codes for EGD and colonoscopy. Clinical and patient data, such as sex, age, duration, and sedative used, along with any complications were logged and used for the study.Complications were defined as occurrences that warranted intervention and were classified as hypotension, desaturation, bradycardia, hypertension, arrhythmia, aspiration, respiratory depression, hypoglycemia,cardiac arrest, and/or respiratory arrest. Results: A total1491 patients were identified, of whom 989 (188 for esophageal foreign body (EFB) removal) underwent upper endoscopic procedures and the other 485 underwent colonoscopies. A flexible endoscope was used in all but one patient who had esophageal mucosal erosion due to a button battery which necessitated a rigid endoscopy under general anesthesia. Propofol was the most used drug. Complications were rare (2.6%).Transient hypotension and desaturation were the main adverse events noted during the review. A total of six patients had AI, of whom five had EFB and one known seizure patient had an episode of epilepsy during the procedure. Conclusions: Deep sedation for pediatric GI endoscopic procedures can be provided safely using intravenously administered agents by NA outside the traditional OR.

The current status of procedural sedation for pediatric patients in out-of-operating room locations

To illustrate the changes that are occurring in the rapidly growing field of pediatric sedation. In the USA and throughout the world, children receive sedation from a multitude of specialists with varying levels of training. The current pediatric sedation literature reflects a growing body of sedation literature by medical specialists other than anesthesiologists. This article will review the controversial use of propofol by nonanesthesiologists and the manner in which this varied group of providers along with government entities, regulatory agencies, and national organizations contribute to the continuing evolution of sedation practices. The number of diagnostic and therapeutic procedures performed on children outside of the operating room continues to increase. The growing body of pediatric sedation literature suggests anesthesiologists are no longer at the forefront of pediatric sedation training, education, and research. Articles published by nonanesthesiologists describe pediatric sedation services, safety, and quality initiatives, drugs, and original sedation research. Medications that were considered under the realm of anesthesiologists are utilized by nonanesthesiologists to provide sedation to children. Regulating and government agencies, including the Joint Commission and the Center for Medicaid and Medicare Services have recently issued statements on the oversight and practice of sedation. The direction of pediatric sedation is no longer solely under the leadership of anesthesiologists. The use of anesthetic agents, including propofol, have been administered by nonanesthesiologists and reported as safe and effective agents. Nonanesthesiologists and governmental and regulatory agencies influence the delivery of sedation services. The future direction of pediatric sedation will ultimately depend upon the ability of anesthesiologists to collaborate with specialists, hospital administrators, credentialing committees, and oversight agencies in order to provide high-quality efficient sedation services to children.

Pediatric Sedation Outside of the Operating Room: A Multispecialty International Collaboration

Table of Contents Preface Acknowledgments Part I: Pediatric Sedation outside the Operating Room 1. The History of Sedation 2. Procedural Sedation - Let's Review the Basics: The Pediatrician's Perspective 3. Sedation Policies, Recommendations and Guidelines Across the Specialties and Continents 4. Sedation Scales and Discharge Criteria: How Do They Differ? Which One to Choose? Do They Really Apply to Sedation? 5. Physiological Monitoring for Procedural Sedation: The Routine and Beyond 6. The Pediatric Airway: Anatomy, Challenges, and Solutions 7. Pediatric Physiology: How Does it Differ from Adults? 8. Pharmacology and Clinical Application of Sedatives, Analgesics and Adjuncts 9. Pharmacokinetics and Pharmacodynamics in the Pediatric Population 10. Billing and Reimbursement for Sedation Services Part II: Sedation Models Delivered by Different Specialties: A Global Voyage 11. The Pediatric Hospital Medicine Service: Models, Protocols, and Challenges 12. The Anesthesia Directed Sedation Service: Models, Protocols, and Challenges 13. Sedation in the Intensive Care Unit: Challenges, Outcomes and Future Strategies 14. Sedation for Pediatric Gastrointestinal Procedures 15. Sedation in the Emergency Department: A Complex and Multifactorial Challenge 16. Sedation of Pediatric Patients for Dental Procedures 17. Pediatric Sedation: The European Experience and Approach 18. Pediatric Sedation in the Underdeveloped Third World - An African Perspective: Models, Protocols, and Challenges Part III: Safety in Sedation 19. Pediatric Sedatives and the Food and Drug Administration (FDA): Challenges, Limitations, and Drugs in Development 20. Incidence and Stratification of Adverse Events Associated with Sedation: Is there a Benchmark? 21. Medicolegal Risks and Outcomes of Sedation 22. Designing a Safe Pediatric Sedation Service: Adopting a New Culture Part IV: Sedation into the 22nd Century 23. Intravenous Infusions for Sedation: Rationale, State of the Art and Future Trends 24. Usage of Complementary and Alternative Medicine in Pediatric Sedation 25. Future of Pediatric Sedation Index

Office-Based Deep Sedation for Pediatric Ophthalmologic Procedures Using a Sedation Service Model

Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62–100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.

Development of a pediatric hospitalist sedation service: Training and implementation

There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital. In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC. This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers. A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists.

Factors affecting parental satisfaction following pediatric procedural sedation

Study Objective To investigate factors affecting parental satisfaction with a pediatric sedation service in a university hospital setting. Design Prospective, observational study with interviews using a survey instrument. Setting Academic university hospital. Subjects Parents (or legal guardians; hereafter “parents") of 220 children scheduled for sedation with the hospital's pediatric sedation service. Interventions and Measurements Caregivers of children scheduled for sedation were interviewed using a validated survey instrument. The instrument was designed to investigate the quality of communication, environment, care provided, and the overall experience. We followed patients by telephone the day after discharge. Chi-square or linear-by-linear association tests were used to evaluate associations between satisfaction scores and demographic variables; the Mann-Whitney test was used for mean levels of satisfaction in anxious versus non-anxious children. Main Results Of 222 parents approached, 220 agreed to participate (response rate = 99.1%). Significant associations between each area of satisfaction and parents' overall satisfaction existed ( P < 0.001). Previous sedations, types of sedation, age of child, or any individual provider were not significantly associated with overall satisfaction. Caregivers of anxious children reported less satisfaction than caregivers of non-anxious children. Parents of children who underwent magnetic resonance imaging reported the lowest mean satisfaction scores. Conclusions Overall satisfaction was high, and care provided by anesthesiologists was significantly associated with overall satisfaction. A site in our institution was associated with significantly lower satisfaction as a result of inadequate space and privacy.

Pediatric Procedural Sedation by a Dedicated Nonanesthesiology Pediatric Sedation Service Using Propofol

To evaluate the success and dosing requirements of propofol in children for prolonged procedural sedation by a nonanesthesiology-based sedation service. The pediatric sedation service at this institution uses propofol as its preferred sedative, and the local guideline suggests using 3 mg/kg for induction and 5 mg kg(-1) h(-1) for maintenance sedation. Doses can be adjusted as needed to individualize successful sedation. A retrospective analysis of patients sedated for 30 minutes or longer was conducted. Patients were stratified into 4 cohorts based on age (<1 year [n = 16], 1-2 years [n = 85], 3-7 years [n = 54], and >7 years [n = 55]) and dosing patterns, success, and adverse effects were investigated. Two hundred forty-nine patients met the inclusion criteria. Mean age was 4.8 years (SD, 4.1). The mean induction dose was 3.2 mg/kg (range, 0.9-9.7), and the mean maintenance infusion was 5.2 mg kg(-1) h(-1) (range, 0.14-21.3). No differences were seen in the induction doses in the different age cohorts, yet the SD was largest in the youngest cohort compared to any other. Although no differences were seen in maintenance rates by age, the greatest SD for dosing was seen in the oldest cohort. For all ages, all sedations were successful (100%) and unanticipated adverse effects rare (<1%). Although it seems that the mean dosing of propofol does not vary significantly with age, there is greater variability in induction dosage for those younger than 1 year and in maintenance dosing for those 7 years or older. The results and general dosing parameters may assist pediatric subspecialists in using propofol for prolonged procedural sedation.

Initiating a Hospital-Wide Pediatric Sedation Service Provided by Emergency Physicians: Yamamoto LG. Clin Pediatr (Phila) 2008;47:37–48

Initiating a Hospital-Wide Pediatric Sedation Service Provided by Emergency Physicians: Yamamoto LG. Clin Pediatr (Phila) 2008;47:37–48

The pediatric sedation service: who is appropriate to sedate, which medications should I use, who should prescribe the drugs, how do I bill?

The pediatric sedation service: who is appropriate to sedate, which medications should I use, who should prescribe the drugs, how do I bill?

Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective

Procedural sedation and analgesia (PSA) techniques for pediatrics are developing rapidly (1,2) but there are still tensions amongst specialties with regard to safe implementation, autonomy, and limits of practice, competences, training and credentialing. Practice varies around the world and even within countries, and an important factor is availability of pediatric anesthesiology services to undertake large numbers of cases under anesthesia. In the United Kingdom (UK), some regions have these services well organized and the demand for pediatric PSA is quite limited. Other regions or individual centers have a relative shortage of pediatric anesthesiology provision or hotspots of high demand, for example for diagnostic imaging, and this can only be met by introducing a pediatric PSA service. An example from the UK is the nurse-led pediatric sedation service at Great Ormond Street Hospital (3,4). Another clinical pressure point in the UK is in Emergency Medicine with 4-h waiting time targets and reduction in availability of primary care out-of-hours services. Drawing on experience from the USA (5) and Australia, a number of enthusiasts in the UK have introduced PSA with ketamine into their pediatric emergency medicine practices and have argued cogently for its more widespread use (5–10). Not all agree however that the UK is ready for this yet (11) and in the Scottish pediatric procedural sedation guidelines, ketamine is regarded as a general anesthetic agent for use by anesthesiologists (12). There are no universally agreed national guidelines in the UK for pediatric PSA and this has led to the proliferation of a number of specialty-specific guidelines, including in pediatric emergency medicine (13). This article reviews the problems of introducing ketamine for PSA in pediatric emergency medicine in the UK.