Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Abstract

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase thepotential for airway obstruction, a clear understanding of the medication’s pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children. 

Introduction

The number of diagnostic and minor surgical procedures performed on pediatric patients outside of the traditional operating room setting has increased in the past several decades. As a consequence of this change and the increased awareness of the importance of providing analgesia and anxiolysis, the need for sedation for procedures in physicians’ offices, dental offices, subspecialty procedure suites, imaging facilities, emergency departments, other inpatient hospital settings, and ambulatory surgery centers also has increased markedly.1–52  In recognition of this need for both elective and emergency use of sedation in nontraditional settings, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) have published a series of guidelines for the monitoring and management of pediatric patients during and after sedation for a procedure.53–58  The purpose of this updated report is to unify the guidelines for sedation used by medical and dental practitioners; to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurement; to provide updated information from the medical and dental literature; and to suggest methods for further improvement in safety and outcomes. This document uses the same language to define sedation categories and expected physiologic responses as The Joint Commission, the American Society of Anesthesiologists (ASA), and the AAPD.56,57,59–61

This revised statement reflects the current understanding of appropriate monitoring needs of pediatric patients both during and after sedation for a procedure.3,4,11,18,20,21,23,24,33,39,41,44,47,51,62–73  The monitoring and care outlined may be exceeded at any time on the basis of the judgment of the responsible practitioner. Although intended to encourage high-quality patient care, adherence to the recommendations in this document cannot guarantee a specific patient outcome. However, structured sedation protocols designed to incorporate these safety principles have been widely implemented and shown to reduce morbidity.11,23,24,27,30–33,35,39,41,44,47,51,74–84  These practice recommendations are proffered with the awareness that, regardless of the intended level of sedation or route of drug administration, the sedation of a pediatric patient represents a continuum and may result in respiratory depression, laryngospasm, impaired airway patency, apnea, loss of the patient’s protective airway reflexes, and cardiovascular instability.38,43,45,47,48,59,62,63,85–112

Procedural sedation of pediatric patients has serious associated risks.2,5,38,43,45,47,48,62,63,71,83,85,88–105,107–138  These adverse responses during and after sedation for a diagnostic or therapeutic procedure may be minimized, but not completely eliminated, by a careful preprocedure review of the patient’s underlying medical conditions and consideration of how the sedation process might affect or be affected by these conditions: for example, children with developmental disabilities have been shown to have a threefold increased incidence of desaturation compared with children without developmental disabilities.74,78,103  Appropriate drug selection for the intended procedure, a clear understanding of the sedating medication’s pharmacokinetics and pharmacodynamics and drug interactions, as well as the presence of an individual with the skills needed to rescue a patient from an adverse response are critical.42, 48,62,63,92,97,99,125–127,132,133,139–158  Appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure allow for the accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions.44,63,64,67,68,74,90,96,110,159–174  The work of the Pediatric Sedation Research Consortium has improved the sedation knowledge base, demonstrating the marked safety of sedation by highly motivated and skilled practitioners from a variety of specialties practicing the above modalities and skills that focus on a culture of sedation safety.45,83,95,128–138  However, these groundbreaking studies also show a low but persistent rate of potential sedation-induced life-threatening events, such as apnea, airway obstruction, laryngospasm, pulmonary aspiration, desaturation, and others, even when the sedation is provided under the direction of a motivated team of specialists.129  These studies have helped define the skills needed to rescue children experiencing adverse sedation events.

The sedation of children is different from the sedation of adults. Sedation in children is often administered to relieve pain and anxiety as well as to modify behavior (e.g., immobility) so as to allow the safe completion of a procedure. A child’s ability to control his or her own behavior to cooperate for a procedure depends both on his or her chronologic age and cognitive/ emotional development. Many brief procedures, such as suture of a minor laceration, may be accomplished with distraction and guided imagery techniques, along with the use of topical/local anesthetics and minimal sedation, if needed.175–181  However, longer procedures that require immobility involving children younger than 6 years or those with developmental delay often require an increased depth of sedation to gain control of their behavior.86,87,103  Children younger than 6 years (particularly those younger than 6 months) may be at greatest risk of an adverse event.129  Children in this age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, airway patency, and protective airway reflexes.62,63  Other modalities, such as careful preparation, parental presence, hypnosis, distraction, topical local anesthetics, electronic devices with age-appropriate games or videos, guided imagery, and the techniques advised by child life specialists, may reduce the need for or the needed depth of pharmacologic sedation.29,46,49,182–211 

Studies have shown that it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation,85,88,212,213 making the concept of rescue essential to safe sedation. Practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure. For example, if the intended level of sedation is “minimal,” practitioners must be able to rescue from “moderate sedation”; if the intended level of sedation is “moderate,” practitioners must have the skills to rescue from “deep sedation”; if the intended level of sedation is “deep,” practitioners must have the skills to rescue from a state of “general anesthesia.” The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size-appropriate equipment necessary to provide appropriate cardiopulmonary support if needed.

These guidelines are intended for all venues in which sedation for a procedure might be performed (hospital, surgical center, freestanding imaging facility, dental facility, or private office). Sedation and anesthesia in a nonhospital environment (e.g., private physician’s or dental office, freestanding imaging facility) historically have been associated with an increased incidence of “failure to rescue” from adverse events, because these settings may lack immediately available backup. Immediate activation of emergency medical services (EMS) may be required in such settings, but the practitioner is responsible for life-support measures while awaiting EMS arrival.63,214  Rescue techniques require specific training and skills.63,74,215,216  The maintenance of the skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction include the ability to open the airway, suction secretions, provide continuous positive airway pressure (CPAP), perform successful bag-valve-mask ventilation, insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA), and, rarely, perform tracheal intubation. These skills are likely best maintained with frequent simulation and team training for the management of rare events.128,130,217–220  Competency with emergency airway management procedure algorithms is fundamental for safe sedation practice and successful patient rescue (see Figs. 1, 2, and 3).215,216,221–223

Practitioners should have an in-depth knowledge of the agents they intend to use and their potential complications. A number of reviews and handbooks for sedating pediatric patients are available.30,39,65,75,171,172,201,224–233  There are specific situations that are beyond the scope of this document. Specifically, guidelines for the delivery of general anesthesia and monitored anesthesia care (sedation or analgesia), outside or within the operating room by anesthesiologists or other practitioners functioning within a department of anesthesiology, are addressed by policies developed by the ASA and by individual departments of anesthesiology.234  In addition, guidelines for the sedation of patients undergoing mechanical ventilation in a critical care environment or for providing analgesia for patients postoperatively, patients with chronic painful conditions, and patients in hospice care are beyond the scope of this document.

Goals of sedation

The goals of sedation in the pediatric patient for diagnostic and therapeutic procedures are as follows: (1) to guard the patient’s safety and welfare; (2) to minimize physical discomfort and pain; (3) to control anxiety, minimize psychological trauma, and maximize the potential for amnesia; (4) to modify behavior and/or movement so as to allow the safe completion of the procedure; and (5) to return the patient to a state in which discharge from medical/dental supervision is safe, as determined by recognized criteria (Supplemental Appendix 1).

These goals can best be achieved by selecting the lowest dose of drug with the highest therapeutic index for the procedure. It is beyond the scope of this document to specify which drugs are appropriate for which procedures; however, the selection of the fewest number of drugs and matching drug selection to the type and goals of the procedure are essential for safe practice. For example, analgesic medications, such as opioids or ketamine, are indicated for painful procedures. For nonpainful procedures, such as computed tomography or MRI, sedatives/hypnotics are preferred. When both sedation and analgesia are desirable (e.g., fracture reduction), either single agents with analgesic/sedative properties or combination regimens are commonly used. Anxiolysis and amnesia are additional goals that should be considered in the selection of agents for particular patients. However, the potential for an adverse outcome may be increased when 2 or more sedating medications are administered.62,127,136,173,235  Recently, there has been renewed interest in noninvasive routes of medication administration, including intranasal and inhaled routes (e.g., nitrous oxide; see below).236

Knowledge of each drug’s time of onset, peak response, and duration of action is important (e.g., the peak EEG effect of intravenous midazolam occurs at ~ 4.8 minutes, compared with that of diazepam at ~ 1.6 minutes237–239).  Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drugs.237  Drugs that have a long duration of action (e.g., intramuscular pentobarbital, phenothiazines) have fallen out of favor because of unpredictable responses and prolonged recovery. The use of these drugs requires a longer period of observation even after the child achieves currently used recovery and discharge criteria.62,238–241  This concept is particularly important for infants and toddlers transported in car safety seats; re-sedation after discharge attributable to residual prolonged drug effects may lead to airway obstruction.62,63,242  In particular, promethazine (Phenergan; Wyeth Pharmaceuticals, Philadelphia, Pa.) has a “black box warning” regarding fatal respiratory depression in children younger than 2 years.243  Although the liquid formulation of chloral hydrate is no longer commercially available, some hospital pharmacies now are compounding their own formulations. Low-dose chloral hydrate (10–25 mg/kg), in combination with other sedating medications, is used commonly in pediatric dental practice.

General guidelines

Candidates
Patients who are in ASA classes I and II are frequently considered appropriate candidates for minimal, moderate, or deep sedation (Supplemental Appendix 2). Children in ASA classes III and IV, children with special needs, and those with anatomic airway abnormalities or moderate to severe tonsillar hypertrophy present issues that require additional and individual consideration, particularly for moderate and deep sedation.68,244–249  Practitioners are encouraged to consult with appropriate subspecialists and/ or an anesthesiologist for patients at increased risk of experiencing adverse sedation events because of their underlying medical/surgical conditions.

Responsible person
The pediatric patient shall be accompanied to and from the treatment facility by a parent, legal guardian, or other responsible person. It is preferable to have 2 adults accompany children who are still in car safety seats if transportation to and from a treatment facility is provided by 1 of the adults.250

Facilities
The practitioner who uses sedation must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations. The most common serious complications of sedation involve compromise of the airway or depressed respirations resulting in airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea. Hypotension and cardiopulmonary arrest may occur, usually from the inadequate recognition and treatment of respiratory compromise.42,48,92,97,99,125,132,139–155  Other rare complications also may include seizures, vomiting, and allergic reactions. Facilities providing pediatric sedation should monitor for, and be prepared to treat, such complications.

Back-up emergency services
A protocol for immediate access to back-up emergency services shall be clearly outlined. For nonhospital facilities, a protocol for the immediate activation of the EMS system for lifethreatening complications must be established and maintained.44  It should be understood that the availability of EMS does not replace the practitioner’s responsibility to provide initial rescue for life-threatening complications.

On-site monitoring, rescue drugs, and equipment
An emergency cart or kit must be immediately accessible. This cart or kit must contain the necessary age-and sizeappropriate equipment (oral and nasal airways, bag-valve-mask device, LMAs or other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters, etc) to resuscitate a nonbreathing and unconscious child. The contents of the kit must allow for the provision of continuous life support while the patient is being transported to a medical/dental facility or to another area within the facility. All equipment and drugs must be checked and maintained on a scheduled basis (see Supplemental Appendices 3 and 4 for suggested drugs and emergency life support equipment to consider before the need for rescue occurs). Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters with size-appropriate probes, end-tidal carbon dioxide monitors, and defibrillators with size-appropriate patches/ paddles, must have a safety and function check on a regular basis as required by local or state regulation. The use of emergency checklists is recommended, and these should be immediately available at all sedation locations; they can be obtained from http://www.pedsanesthesia.org/.

Documentation
Documentation prior to sedation shall include, but not be limited to, the following recommendations:

  1. Informed consent: The patient record shall document that appropriate informed consent was obtained according to local, state, and institutional requirements.251,252
  2.  Instructions and information provided to the responsible person: The practitioner shall provide verbal and/or written instructions to the responsible person. Information shall include objectives of the sedation and anticipated changes in behavior during and after sedation.163,253–255 Special instructions shall be given to the adult responsible for infants and toddlers who will be transported home in a car safety seat regarding the need to carefully observe the child’s head position to avoid airway obstruction. Transportation in a car safety seat poses a particular risk for infants who have received medications known to have a long half-life, such as chloral hydrate, intramuscular pentobarbital, or phenothiazine because deaths after procedural sedation have been reported.62,63,238,242,256,257 Consideration for a longer period of observation shall be given if the responsible person’s ability to observe the child is limited (e.g., only 1 adult who also has to drive). Another indication for prolonged observation would be a child with an anatomic airway problem, an underlying medical condition such as significant obstructive sleep apnea (OSA), or a former preterm infant younger than 60 weeks’ post-conceptional age. A 24-hour telephone number for thepractitioner or his or her associates shall be provided to all patients and their families. Instructions shall include limitations of activities and appropriate dietary precautions.

Dietary precautions
Agents used for sedation have the potential to impair protective airway reflexes, particularly during deep sedation. Although a rare occurrence, pulmonary aspiration may occur if the child regurgitates and cannot protect his or her airway.95,127,258  Therefore, the practitioner should evaluate preceding food and fluid intake before administering sedation. It is likely that the risk of aspiration during procedural sedation differs from that during general anesthesia involving tracheal intubation or other airway manipulations.259,260  However, the absolute risk of aspiration during elective procedural sedation is not yet known; the reported incidence varies from ~1 in 825 to ~1 in 30037.95, 127,129,173,244,261  Therefore, standard practice for fasting before elective sedation generally follows the same guidelines as for elective general anesthesia; this requirement is particularly important for solids, because aspiration of clear gastric contents causes less pulmonary injury than aspiration of particulate gastric contents.262,263

For emergency procedures in children undergoing general anesthesia, the reported incidence of pulmonary aspiration of gastric contents from 1 institution is ~ 1 in 373 compared with ~ 1 in 4544 for elective anesthetics.262  Because there are few published studies with adequate statistical power to provide guidance to the practitioner regarding the safety or risk of pulmonary aspiration of gastric contents during procedural sedation,95,127,129,173,244,259-261,264-268 it is unknown whether the risk of aspiration is reduced when airway manipulation is not performed/ anticipated (e.g., moderate sedation). However, if a deeply sedated child requires intervention for airway obstruction, apnea, or laryngospasm, there is concern that these rescue maneuvers could increase the risk of pulmonary aspiration of gastric contents. For children requiring urgent/emergent sedation who do not meet elective fasting guidelines, the risks of sedation and possible aspiration are as-yet unknown and must be balanced against the benefits of performing the procedure promptly. For example, a prudent practitioner would be unlikely to administer deep sedation to a child with a minor condition who just ate a large meal; conversely, it is not justifiable to withhold sedation/analgesia from the child in significant pain from a displaced fracture who had a small snack a few hours earlier. Several emergency department studies have reported a low to zero incidence of pulmonary aspiration despite variable fasting periods260,264,268; however, each of these reports have, for the most part, clearly balanced the urgency of the procedure with the need for and depth of sedation.268,269  Although emergency medicine studies and practice guidelines generally support a less restrictive approach to fasting for brief urgent/ emergent procedures, such as care of wounds, joint dislocation, chest tube placement, etc, in healthy children, further research in many thousands of patients would be desirable to better define the relationships between various fasting intervals and sedation complications.262–270

Before elective sedation
Children undergoing sedation for elective procedures generally should follow the same fasting guidelines as those for general anesthesia (Table 1).271  It is permissible for routine necessary medications (e.g., antiseizure medications) to be taken with a sip of clear liquid or water on the day of the procedure.

For the emergency patient
The practitioner must always balance the possible risks of sedating nonfasted patients with the benefits of and necessity for completing the procedure. In particular, patients with a history of recent oral intake or with other known risk factors, such as trauma, decreased level of consciousness, extreme obesity (BMI ≥95% for age and sex), pregnancy, or bowel motility dysfunction, require careful evaluation before the administration of sedatives. When proper fasting has not been ensured, the increased risks of sedation must be carefully weighed against its benefits, and the lightest effective sedation should be used. In this circumstance, additional techniques for achieving analgesia and patient cooperation, such as distraction, guided imagery, video games, topical and local anesthetics, hematoma block or nerve blocks, and other techniques advised by child life specialists, are particularly helpful and should be considered.29,49, 182–201,274,275  The use of agents with less risk of depressing protective airway reflexes, such as ketamine, or moderate sedation, which would also maintain protective reflexes, may be preferred.276  Some emergency patients requiring deep sedation (e.g., a trauma patient who just ate a full meal or a child with a bowel obstruction) may need to be intubated to protect their airway before they can be sedated.

Use of immobilization devices (protective stabilization)
Immobilization devices, such as papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction.277–281  The child’s head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended. If sedating medications are administered in conjunction with an immobilization device, monitoring must be used at a level consistent with the level of sedation achieved.

Documentation at the time of sedation

  1. Health evaluation: Before sedation, a health evaluation shall be performed by an appropriately licensed practitioner and reviewed by the sedation team at the time of treatment for possible interval changes.282 The purpose of this evaluation is not only to document baseline status but also to determine whether the patient has specific risk factors that may warrant additional consultation before sedation. This evaluation also facilitates the identification of patients who will require more advanced airway or cardiovascular management skills or alterations in the doses or types of medications used for procedural sedation. An important concern for the practitioner is the widespread use of medications that may interfere with drug absorption or metabolism and therefore enhance or shorten the effect time of sedating medications. Herbal medicines (e.g., St. John’s wort, ginkgo, ginger, ginseng, garlic) may alter drug pharmacokinetics through inhibition of the cytochrome P450 system, resulting in prolonged drug effect and altered (increased or decreased) blood drug concentrations (midazolam, cyclosporine, tacrolimus).283–292 Kava may increase the effects of sedatives by potentiating γ-aminobutyric acid inhibitory neurotransmission and may increase acetaminophen-induced liver toxicity.293–295 Valerian may itself produce sedation that apparently is mediated through the modulation of γ-aminobutyric acid neurotransmission and receptor function.291,296–299 Drugs such as erythromycin, cimetidine, and others may also inhibit the cytochrome P450 system, resulting in prolonged sedation with midazolam as well as other medications competing for the same enzyme systems.300–304 Medications used to treat HIV infection, some anticonvulsants, immunosuppressive drugs, and some psychotropic medications (often used to treat children with autism spectrum disorder) may also produce clinically important drug-drug interactions.305–314 Therefore, a careful drug history is a vital part of the safe sedation of children. The practitioner should consult various sources (a pharmacist, textbooks, online services, or handheld databases) for specific information on drug interactions.315–319 The U.S. Food and Drug Administration issued a warning in February 2013 regarding the use of codeine for postoperative pain management in children undergoing tonsillectomy, particularly those with OSA. The safety issue is that some children have duplicated cytochromes that allow greater than expected conversion of the prodrug codeine to morphine, thus resulting in potential overdose; codeine should be avoided for postprocedure analgesia.320–324
  2. Prescriptions. When prescriptions are used for sedation, a copy of the prescription or a note describing the content of the prescription should be in the patient’s chart along with a description of the instructions that were given to the responsible person. Prescription medications intended to accomplish procedural sedation must not be administered without the safety net of direct supervision by trained medical/dental personnel. The administration of sedating medications at home poses an unacceptable risk, particularly for infants and preschool-aged children traveling in car safety seats because deaths as a result of this practice have been reported.63,257

The health evaluation should include the following:

  • age and weight (in kg) and gestational age at birth (preterm infants may have associated sequelae such as apnea of prematurity); and
  • health history, including (1) food and medication allergies and previous allergic or adverse drug reactions; (2) medication/drug history, including dosage, time, route, and site of administration for prescription, overthe-counter, herbal, or illicit drugs; (3) relevant diseases, physical abnormalities (including genetic syndromes), neurologic impairments that might increase the potential for airway obstruction, obesity, a history of snoring or OSA,325–328 or cervical spine instability in Down syndrome, Marfan syndrome, skeletal dysplasia, and other conditions; (4) pregnancy status (as many as 1% of menarchal females presenting for general anesthesia at children’s hospitals are pregnant)329–331 because of concerns for the potential adverse effects of most sedating and anesthetic drugs on the fetus329,332–338; (5) history of prematurity (may be associated with subglottic stenosis or propensity to apnea after sedation); (6) history of any seizure disorder; (7) summary of previous relevant hospitalizations; (8) history of sedation or general anesthesia and any complications or unexpected responses; and (9) relevant family history, particularly related to anesthesia (e.g., muscular dystrophy, malignant hyperthermia, pseudocholinesterase deficiency).

The review of systems should focus on abnormalities of cardiac, pulmonary, renal, or hepatic function that might alter the child’s expected responses to sedating/analgesic medications. A specific query regarding signs and symptoms of sleepdisordered breathing and OSA may be helpful. Children with severe OSA who have experienced repeated episodes of desaturation will likely have altered mu receptors and be analgesic at opioid levels one-third to one-half those of a child without OSA325–328,339,340; lower titrated doses of opioids should be used in this population. Such a detailed history will help to determine which patients may benefit from a higher level of care by an appropriately skilled health care provider, such as an anesthesiologist. The health evaluation should also include: 

  • vital signs, including heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature (for some children who are very upset or noncooperative, this may not be possible and a note should be written to document this circumstance);
  • physical examination, including a focused evaluation of the airway (tonsillar hypertrophy, abnormal anatomy [e.g., mandibular hypoplasia], high Mallampati score [i.e., ability to visualize only the hard palate or tip of the uvula]) to determine whether there is an increased risk of airway obstruction74,341–344;
  • physical status evaluation (ASA classification [see Appendix 2]); and
  • name, address, and telephone number of the child’s home or parent’s, or caregiver’s cell phone; additional information such as the patient’s personal care provider or medical home is also encouraged.

For hospitalized patients, the current hospital record may suffice for adequate documentation of presedation health; however, a note shall be written documenting that the chart was reviewed, positive findings were noted, and a management plan was formulated. If the clinical or emergency condition of the patient precludes acquiring complete information before sedation, this health evaluation should be obtained as soon as feasible.

  • 2. Prescriptions. When prescriptions are used for sedation, a copy of the prescription or a note describing the content of the prescription should be in the patient’s chart along with a description of the instructions that were given to the responsible person. Prescription medications intended to accomplish procedural sedation must not be administered without the safety net of direct supervision by trained medical/dental personnel. The administration of sedating medications at home poses an unacceptable risk, particularly for infants and preschool-aged children traveling in car safety seats because deaths as a result of this practice have been reported.63,257

Documentation during treatment
The patient’s chart shall contain a time-based record that includes the name, route, site, time, dosage/ kilogram, and patient effect of administered drugs. Before sedation, a “time out” should be performed to confirm the patient’s name, procedure to be performed, and laterality and site of the procedure.59 During administration, the inspired concentrations of oxygen and inhalation sedation agents and the duration of their administration shall be documented. Before drug administration, special attention must be paid to the calculation of dosage (i.e., mg/kg); for obese patients, most drug doses should likely be adjusted lower to ideal body weight rather than actual weight.345 When a programmable pump is used for the infusion of sedating medications, the dose/kilogram per minute or hour and the child’s weight in kilograms should be doublechecked and confirmed by a separate individual. The patient’s chart shall contain documentation at the time of treatment that the patient’s level of consciousness and responsiveness, heart rate, blood pressure, respiratory rate, expired carbon dioxide values, and oxygen saturation were monitored. Standard vital signs should be further documented at appropriate intervals during recovery until the patient attains predetermined discharge criteria (Appendix 1). A variety of sedation scoring systems are available that may aid this process.212,238 346–348 Adverse events and their treatment shall be documented.

Documentation after treatment
A dedicated and properly equipped recovery area is recommended (see Appendices 3 and 4). The time and condition of the child at discharge from the treatment area or facility shall be documented, which should include documentation that the child’s level of consciousness and oxygen saturation in room air have returned to a state that is safe for discharge by recognized criteria (see Appendix 1). Patients receiving supplemental oxygen before the procedure should have a similar oxygen need after the procedure. Because some sedation medications are known to have a long half-life and may delay a patient’s complete return to baseline or pose the risk of re-sedation62,104,256, 349,350 and because some patients will have complex multiorgan medical conditions, a longer period of observation in a less intense observation area (e.g., a step-down observation area) before discharge from medical/dental supervision may be indicated.239 Several scales to evaluate recovery have been devised and validated.212, 346–348, 351, 352 A simple evaluation tool may be the ability of the infant or child to remain awake for at least 20 minutes when placed in a quiet environment.238

 

Continuous quality improvement

The essence of medical error reduction is a careful examination of index events and root-cause analysis of how the event could be avoided in the future.353–359 Therefore, each facility should maintain records that track all adverse events and significant interventions, such as desaturation; apnea; laryngospasm; need for airway interventions, including the need for placement of supraglottic devices such as an oral airway, nasal trumpet, or LMA; positive-pressure ventilation; prolonged sedation; unanticipated use of reversal agents; unplanned or prolonged hospital admission; sedation failures; inability to complete the procedure; and unsatisfactory sedation, analgesia, or anxiolysis.360 Such events can then be examined for the assessment of risk reduction and improvement in patient/family satisfaction.

Preparation for sedation procedures

Part of the safety net of sedation is using a systematic approach so as to not overlook having an important drug, piece of equipment, or monitor immediately available at the time of a developing emergency. To avoid this problem, it is helpful to use an acronym that allows the same setup and checklist for every procedure. A commonly used acronym useful in planning and preparation for a procedure is SOAPME, which represents the following:

S = Size-appropriate suction catheters and a functioning suction apparatus (e.g., Yankauer-type suction). 
O= an adequate Oxygen supply and functioning flow meters or other devices to allow its delivery.
A = size-appropriate Airway equipment (e.g., bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, LMA, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask.
P = Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated.
M = Monitors: functioning pulse oximeter with size-appropriate oximeter probes,361,362 end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (e.g., noninvasive blood pressure, ECG, stethoscope).
E = special Equipment or drugs for a particular case (e.g., defibrillator).

Specific guidelines for intended level of sedation

Minimal sedation
Minimal sedation (old terminology, “anxiolysis”) is a druginduced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Children who have received minimal sedation generally will not require more than observation and intermittent assessment of their level of sedation. Some children will become moderately sedated despite the intended level of minimal sedation; should this occur, then the guidelines for moderate sedation apply.85,363

Moderate sedation
Moderate sedation (old terminology, “conscious sedation” or “sedation/analgesia”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands or after light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. The caveat that loss of consciousness should be unlikely is a particularly important aspect of the definition of moderate sedation; drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Because the patient who receives moderate sedation may progress into a state of deep sedation and obtundation, the practitioner should be prepared to increase the level of vigilance corresponding to what is necessary for deep sedation.85 

Personnel
The practitioner.  The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, to provide the level of monitoring described in these guidelines, and to manage complications of these techniques (i.e., to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to rescue a child with apnea, laryngospasm, and/or airway obstruction, including the ability to open the airway, suction secretions, provide CPAP, and perform successful bag-valvemask ventilation should the child progress to a level of deep sedation. Training in, and maintenance of, advanced pediatric airway skills is required (e.g., pediatric advanced life support [PALS]); regular skills reinforcement with simulation is strongly encouraged.79,80,128,130,217–220,364

Support personnel.  The use of moderate sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures, if required. This individual may also be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment.60  This individual should be trained in and capable of providing advanced airway skills (e.g., PALS). The support person shall have specific assignments in the event of an emergency and current knowledge of the emergency cart inventory. The practitioner and all ancillary personnel should participate in periodic reviews, simulation of rare emergencies, and practice drills of the facility’s emergency protocol to ensure proper function of the equipment and coordination of staff roles in such emergencies.133,365–367  It is recommended that at least 1 practitioner be skilled in obtaining vascular access in children.

Monitoring and documentation
Baseline.
Before the administration of sedative medications, a baseline determination of vital signs shall be documented. For some children who are very upset or uncooperative, this may not be possible, and a note should be written to document this circumstance.

During the procedure. The physician/dentist or his or her designee shall document the name, route, site, time of administration, and dosage of all drugs administered. If sedation is being directed by a physician who is not personally administering the medications, then recommended practice is for the qualified health care provider administering the medication to confirm the dose verbally before administration. There shall be continuous monitoring of oxygen saturation and heart rate; when bidirectional verbal communication between the provider and patient is appropriate and possible (i.e., patient is developmentally able and purposefully communicates), monitoring of ventilation by (1) capnography (preferred) or (2) amplified, audible pretracheal stethoscope (e.g., BluetoothTM technology)368-371 or precordial stethoscope is strongly recommended. If bi-directional verbal communication is not appropriate or not possible, monitoring of ventilation by capnography (preferred), amplified, audible pretracheal stethoscope, or precordial stethoscope is required. Heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values should be recorded, at minimum, every 10 minutes in a time-based record. Note that the exact value of expired carbon dioxide is less important than simple assessment of continuous respiratory gas exchange. In some situations in which there is excessive patient agitation or lack of cooperation or during certain procedures such as bronchoscopy, dentistry, or repair of facial lacerations capnography may not be feasible, and this situation should be documented. For uncooperative children, it is often helpful to defer the initiation of capnography until the child becomes sedated. Similarly, the stimulation of blood pressure cuff inflation may cause arousal or agitation; in such cases, blood pressure monitoring may be counterproductive and may be documented at less frequent intervals (e.g., 10-15 minutes, assuming the patient remains stable, well oxygenated, and well perfused). Immobilization devices (protective stabilization) should be checked to prevent airway obstruction or chest restriction. If a restraint device is used, a hand or foot should be kept exposed. The child’s head position should be continuously assessed to ensure airway patency.

After the procedure.  The child who has received moderate sedation must be observed in a suitably equipped recovery area, which must have a functioning suction apparatus as well as the capacity to deliver >90% oxygen and positive-pressure ventilation (bag-valve mask) with an adequate oxygen capacity as well as age- and size-appropriate rescue equipment and devices. The patient’s vital signs should be recorded at specific intervals (e.g., every 10–15 minutes). If the patient is not fully alert, oxygen saturation and heart rate monitoring shall be used continuously until appropriate discharge criteria are met (see Appendix 1). Because sedation medications with a long half-life may delay the patient’s complete return to baseline or pose the risk of re-sedation, some patients might benefit from a longer period of less intense observation (e.g., a step-down observation area where multiple patients can be observed simultaneously) before discharge from medical/ dental supervision (see section entitled “Documentation Before Sedation” above).62,256,349,350  A simple evaluation tool may be the ability of the infant or child to remain awake for at least 20 minutes when placed in a quiet environment.238  Patients who have received reversal agents, such as flumazenil or naloxone, will require a longer period of observation, because the duration of the drugs administered may exceed the duration of the antagonist, resulting in re-sedation.

Deep sedation/General anesthesia
“Deep sedation” (“deep sedation/ analgesia”) is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation (e.g., purposefully pushing away the noxious stimuli). Reflex withdrawal from a painful stimulus is not considered a purposeful response and is more consistent with a state of general anesthesia. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes. Patients may pass from a state of deep sedation to the state of general anesthesia. In some situations, such as during MRI, one is not usually able to assess responses to stimulation, because this would defeat the purpose of sedation, and one should assume that such patients are deeply sedated.

“General anesthesia” is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Personnel
During deep sedation, there must be 1 person whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration. This individual must, at a minimum, be trained in PALS and capable of assisting with any emergency event. At least 1 individual must be present who is trained in and capable of providing advanced pediatric life support and who is skilled to rescue a child with apnea, laryngospasm, and or airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, LMA), and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation.

Equipment
In addition to the equipment needed for moderate sedation, an ECG monitor and a defibrillator for use in pediatric patients should be readily available.

Vascular access
Patients receiving deep sedation should have an intravenous line placed at the start of the procedure or have a person skilled in establishing vascular access in pediatric patients immediately available.

Monitoring
A competent individual shall observe the patient continuously. Monitoring shall include all parameters described for moderate sedation. Vital signs, including heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide, must bedocumented at least every 5 minutes in a time-based record. Capnography should be used for almost all deeply sedated children because of the increased risk of airway/ ventilation compromise. Capnography may not be feasible if the patient is agitated or uncooperative during the initial phases of sedation or during certain procedures, such as bronchoscopy or repair of facial lacerations, and this circumstance should be documented. For uncooperative children, the capnography monitor may be placed once the child becomes sedated. Note that if supplemental oxygen is administered, the capnograph may underestimate the true expired carbon dioxide value; of more importance than the numeric reading of exhaled carbon dioxide is the assurance of continuous respiratory gas exchange (i.e., continuous waveform). Capnography is particularly useful for patients who are difficult to observe (e.g., during MRI or in a darkened room).64,67,72,90,96,110,159–162,164–166,167–170,372–375

The physician/dentist or his or her designee shall document the name, route, site, time of administration, and dosage of all drugs administered. If sedation is being directed by a physician who is not personally administering the medications, then recommended practice is for the nurse administering the medication to confirm the dose verbally before administration. 

The inspired concentrations of inhalation sedation agents and oxygen and the duration of administration shall be documented.

Postsedation care
The facility and procedures followed for postsedation care shall conform to those described under“moderate sedation.” The initial recording of vital signs should be documented at least every 5 minutes. Once the child begins to awaken, the recording intervals may be increased to 10 to 15 minutes. Table 2 summarizes the equipment, personnel, and monitoring requirements for moderate and deep sedation. 

Special considerations

Neonates and former preterm infants
Neonates and former preterm infants require specific management, because immaturity of hepatic and renal function may alter the ability to metabolize and excrete sedating medications,376 resulting in prolonged sedation and the need for extended post-sedation monitoring. Former preterm infants have an increased risk of postanesthesia apnea,377 but it is unclear whether a similar risk is associated with sedation, because this possibility has not been systematically investigated.378

Other concerns regarding the effects of anesthetic drugs and sedating medications on the developing brain are beyond the scope of this document. At this point, the research in this area is preliminary and inconclusive at best, but it would seem prudent to avoid unnecessary exposure to sedation if the procedure is unlikely to change medical/dental management (e.g., a sedated MRI purely for screening purposes in preterm infants).379–382

Local anesthetic agents
All local anesthetic agents are cardiac depressants and may cause central nervous system excitation or depression. Particular weight-based attention should be paid to cumulative dosage in all children.118,120,125,383–386  To ensure that the patient will not receive an excessive dose, the maximum allowable safe dosage (e.g., mg/kg) should be calculated before administration. There may be enhanced sedative effects when the highest recommended doses of local anesthetic drugs are used in combination with other sedatives or opioids (see Tables 3 and 4 for limits and conversion tables of commonly used local anesthetics).118,125,387–400  In general, when administering local anesthetic drugs, the practitioner should aspirate frequently to minimize the likelihood that the needle is in a blood vessel; lower doses should be used when injecting into vascular tissues.401 If high doses or injection of amide local anesthetics (bupivacaine and ropivacaine) into vascular tissues is anticipated, then the immediate availability of a 20% lipid emulsion for the treatment of local anesthetic toxicity is recommended (Tables 3 and 5).402–409  Topical local anesthetics are commonly used and encouraged, but the practitioner should avoid applying excessive doses to mucosal surfaces where systemic uptake and possible toxicity (seizures, methemoglobinemia) could result and to remain within the manufacturer’srecommendations regarding allowable surface area application.410–415

Pulse oximetry
Newer pulse oximeters are less susceptible to motion artifacts and may be more useful than older oximeters that do not contain updated software.416–420  Oximeters that change tone with changes in hemoglobin saturation provide immediate aural warning to everyone within hearing distance. The oximeter probe must be properly positioned; clip-on devices are easy to displace, which may produce artifactual data (under-or overestimation of oxygen saturation).361,362

Capnography
Expired carbon dioxide monitoring is valuable to diagnose the simple presence or absence of respirations, airway obstruction, or respiratory depression, particularly in patients sedated in less-accessible locations, such as in MRI machines or darkened rooms.64,66,67,72,90,96,110,159–162,164–170,372–375,421–427  In patients receiving supplemental oxygen, capnography facilitates the recognition of apnea or airway obstruction several minutes before the situa-tion would be detected just by pulse oximetry. In this situation, desaturation would be delayed due to increased oxygen reserves; capnography would enable earlier intervention.161  One study in children sedated in the emergency department found that the use of capnography reduced the incidence of hypoventilation and desaturation (7% to 1%).174  The use of expired carbon dioxide monitoring devices is now required for almost all deeply sedated children (with rare exceptions), particularly in situations in which other means of assessing the adequacy of ventilation are limited. Several manufacturers have produced nasal cannulae that allow simultaneous delivery of oxygen and measurement of expired carbon dioxide values.421,422,427  Although these devices can have a high degree of false-positive alarms, they are also very accurate for the detection of complete airway obstruction or apnea.164,168,169  Taping the sampling line under the nares under an oxygen face mask or nasal hood will provide similar information. The exact measured value is less important than the simple answer to the question: Is the child exchanging air with each breath?

Processed EEG (Bispectral Index)
Although not new to the anesthesia community, the processed EEG (bispectral index [BIS]) monitor is slowly finding its way into the sedation literature.428  Several studies have attempted to use BIS monitoring as a means of noninvasively assessing the depth of sedation. This technology was designed to examine EEG signals and, through a variety of algorithms, correlate a number with depth of unconsciousness: that is, the lower the number, the deeper the sedation. Unfortunately, these algorithms are based on adult patients and have not been validated in children of varying ages and varying brain development. Although the readings correspond quite well with the depth of propofol sedation, the numbers may paradoxically go up rather than down with sevoflurane and ketamine because of central excitation despite a state of general anesthesia or deep sedation.429,430

Opioids and benzodiazepines have minimal and variable effects on the BIS. Dexmedetomidine has minimal effect with EEG patterns, consistent with stage 2 sleep.431 Several sedation studies have examined the utility of this device and degree of correlation with standard sedation scales.347,363,432–435  It appears that there is some correlation with BIS values in moderate sedation, but there is not a reliable ability to distinguish between deep sedation and moderate sedation or deep sedation from general anesthesia.432  Presently, it would appear that BIS monitoring might provide useful information only when used for sedation with propofol363; in general, it is still considered a research tool and not recommended for routine use.

Adjuncts to airway management and resuscitation
The vast majority of sedation complications can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning, placement of an oral or nasopharyngeal airway, and bag-mask-valve ventilation. Rarely, tracheal intubation is required for more prolonged ventilatory support. In addition to standard tracheal intubation techniques, a number of supraglottic devices are available for the management of patients with abnormal airway anatomy or airway obstruction. Examples include the LMA, the cuffed oropharyngeal airway, and a variety of kits to perform an emergency cricothyrotomy.436,437

The largest clinical experience in pediatrics is with the LMA, which is available in multiple sizes, including those for late preterm and term neonates. The use of the LMA is now an essential addition to advanced airway training courses, and familiarity with insertion techniques can be life-saving.438–442  The LMA can also serve as a bridge to secure airway management in children with anatomic airway abnormalities.443,444  Practitioners are encouraged to gain experience with these techniques as they become incorporated into PALS courses.

Another valuable emergency technique is intraosseous needle placement for vascular access. Intraosseous needles are available in several sizes; insertion can be life-saving when rapid intravenous access is difficult. A relatively new intraosseous device (EZ-IO Vidacare, now part of Teleflex, Research Triangle Park, N.C.) is similar to a hand-held batterypowered drill. It allows rapid placement with minimal chance of misplacement; it also has a low-profile intravenous adapter.445–450 Familiarity with the use of these emergency techniques can be gained by keeping current with resuscitation courses, such as PALS and advanced pediatric life support.

Patient simulators
High-fidelity patient simulators are now available that allow physicians, dentists, and other health care providers to practice managing a variety of programmed adverse events, such as apnea, bronchospasm, and laryngospasm.133,220,450–452  The use of such devices is encouraged to better train medical professionals and teams to respond more effectively to rare events.128, 131,451,453–455  One study that simulated the quality of cardiopulmonary resuscitation compared standard management of ventricular fibrillation versus rescue with the EZ-IO for the rapid establishment of intravenous access and placement of an LMA for establishing a patent airway in adults; the use of these devices resulted in more rapid establishment of vascular access and securing of the airway.456

Monitoring during MRI
The powerful magnetic field and the generation of radiofrequency emissions necessitate the use of special equipment to provide continuous patient monitoring throughout the MRI scanning procedure.457–459  MRI-compatible pulse oximeters and capnographs capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Thermal injuries can result if appropriate precautions are not taken; the practitioner is cautioned to avoid coiling of all wires (oximeter, ECG) and to place the oximeter probe as far from the magnetic coil as possible to diminish the possibility of injury. ECG monitoring during MRI has been associated with thermal injury; special MRI-compatible ECG pads are essential to allow safe monitoring.460–463  If sedation is achieved by using an infusion pump, then either an MRI-compatible pump is required or the pump must be situated outside of the room with long infusion tubing so as to maintain infusion accuracy. All equipment must be MRI compatible, including laryngoscope blades and handles, oxygen tanks, and any ancillary equipment. All individuals, including parents, must be screened for ferromagnetic materials, phones, pagers, pens, credit cards, watches, surgical implants, pacemakers, etc, before entry into the MRI suite.

Nitrous oxide
Inhalation sedation/analgesia equipment that delivers nitrous oxide must have the capacity of delivering 100% and never less than 25% oxygen concentration at a flow rate appropriate to the size of the patient. Equipment that delivers variable ratios of nitrous oxide >50% to oxygen that covers the mouth and nose must be used in conjunction with a calibrated and functional oxygen analyzer. All nitrous oxide-to-oxygen inhalation devices should be calibrated in accordance with appropriate state and local requirements. Consideration should be given to the National Institute of Occupational Safety and Health Standards for the scavenging of waste gases.464  Newly constructed or reconstructed treatment facilities, especially those with piped-in nitrous oxide and oxygen, must have appropriate state or local inspections to certify proper function of inhalation sedation/analgesia systems before any delivery of patient care.

Nitrous oxide in oxygen, with varying concentrations, has been successfully used for many years to provide analgesia for a variety of painful procedures in children.14,36,49,98,465–493  The use of nitrous oxide for minimal sedation is defined as the administration of nitrous oxide of ≤50% with the balance as oxygen, without any other sedative, opioid, or other depressant drug before or concurrent with the nitrous oxide to an otherwise healthy patient in ASA class I or II. The patient is able to maintain verbal communication throughout the procedure. It should be noted that although local anesthetics have sedative properties, for purposes of this guideline they are not considered sedatives in this circumstance. If nitrous oxide in oxygen is combined with other sedating medications, such as chloral hydrate, midazolam, or an opioid, or if nitrous oxide is used in concentrations >50%, the likelihood for moderate or deep sedation increases.107,197,492,494,495  In this situation, the practitioner is advised to institute the guidelines for moderate or deep sedation, as indicated by the patient’s response.496

References

  1. Milnes AR. Intravenous procedural sedation: an alternative to general anesthesia in the treatment of early childhood caries. J Can Dent Assoc 2003;69(5):298–302.
  2. Law AK, Ng DK, Chan KK. Use of intramuscular ketamine for endoscopy sedation in children. Pediatr Int 2003;45(2):180–5.
  3. Flood RG, Krauss B. Procedural sedation and analgesia for children in the emergency department. Emerg Med Clin North Am 2003;21(1):121–39.
  4. Jaggar SI, Haxby E. Sedation, anaesthesia and monitoring for bronchoscopy. Paediatr Respir Rev 2002;3(4):321–7.
  5. de Blic J, Marchac V, Scheinmann P. Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures. Eur Respir J 2002;20(5):1271–6. 
  6. Mason KP, Michna E, DiNardo JA, et al. Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients. Radiology 2002;225(2):457–65.
  7. Houpt M. Project USAP 2000—use of sedative agents by pediatric dentists: a15-year follow-up survey. Pediatr Dent 2002;24(4):289–94. 
  8. Vinson DR, Bradbury DR. Etomidate for procedural sedation in emergency medicine. Ann Emerg Med 2002;39(6):592–8.
  9. Everitt IJ, Barnett P. Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department. Pediatr Emerg Care 2002;18(2):72-4. 
  10. Karian VE, Burrows PE, Zurakowski D, Connor L, Poznauskis L, Mason KP. The development of a pediatric radiology sedation program. Pediatr Radiol 2002;32(5):348-53.
  11. Kaplan RF, Yang CI. Sedation and analgesia in pediatric patients for procedures outside the operating room. Anesthesiol Clin North America 2002;20(1):181-94, vii. 
  12. Wheeler DS, Jensen RA, Poss WB. A randomized, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography. Clin Pediatr (Phila) 2001;40(7):381-7.
  13. Hain RD, Campbell C. Invasive procedures carried out in conscious children: contrast between North American and European paediatric oncology centres. Arch Dis Child 2001;85(1):12-5. 
  14. Kennedy RM, Luhmann JD. Pharmacological management of pain and anxiety during emergency procedures in children. Paediatr Drugs 2001;3(5):337-54. 
  15. Kanagasundaram SA, Lane LJ, Cavalletto BP, Keneally JP, Cooper MG. Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures. Arch Dis Child 2001;84(6):492-5.
  16. Younge PA, Kendall JM. Sedation for children requiring wound repair: a randomised controlled double blind comparison of oral midazolam and oral ketamine. Emerg Med J 2001;18(1):30-3.
  17. Ljungman G, Gordh T, Sörensen S, Kreuger A. Lumbar puncture in pediatric oncology: conscious sedation vs. general anesthesia. Med Pediatr Oncol 2001;36(3):372-9. 
  18. Poe SS, Nolan MT, Dang D, et al. Ensuring safety of patients receiving sedation for procedures: evaluation of clinical practice guidelines. Jt Comm J Qual Improv 2001;27(1):28-41. 
  19. D’Agostino J, Terndrup TE. Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care 2000;16(1):1-4. 
  20. Green SM, Kuppermann N, Rothrock SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35(1):35-42.
  21. Hopkins KL, Davis PC, Sanders CL, Churchill LH. Sedation for pediatric imaging studies. Neuroimaging Clin N Am 1999;9(1):1-10.
  22. Bauman LA, Kish I, Baumann RC, Politis GD. Pediatric sedation with analgesia. Am J Emerg Med 1999;17(1):1-3.
  23. Bhatt-Mehta V, Rosen DA. Sedation in children: current concepts. Pharmacotherapy 1998;18(4):790-807.
  24. Morton NS, Oomen GJ. Development of a selection and monitoring protocol for safe sedation of children. Paediatr Anaesth 1998;8(1):65-8.
  25. Murphy MS. Sedation for invasive procedures in paediatrics. Arch Dis Child 1997;77(4):281-4. 
  26. Webb MD, Moore PA. Sedation for pediatric dental patients. Dent Clin North Am 2002;46(4):803-14, xi. 
  27. Malviya S, Voepel-Lewis T, Tait AR, Merkel S. Sedation/ analgesia for diagnostic and therapeutic procedures in children. J Perianesth Nurs 2000;15(6):415-22.
  28. Zempsky WT, Schechter NL. Office based pain management: the 15-minute consultation. Pediatr Clin North Am 2000;47(3):601-15.
  29. Kennedy RM, Luhmann JD. The “ouchless emergency department”: getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999;46(6):1215-47, vii-viii.
  30. Rodriguez E, Jordan R. Contemporary trends in pediatric sedation and analgesia. Emerg Med Clin North Am 2002;20(1):199-222.
  31. Ruess L, O’Connor SC, Mikita CP, Creamer KM. Sedation for pediatric diagnostic imaging: use of pediatric and nursing resources as an alternative to a radiology department sedation team. Pediatr Radiol 2002;32(7):505-10.
  32. Weiss S. Sedation of pediatric patients for nuclear medicine procedures. Semin Nucl Med 1993;23(3):190-8. 
  33. Wilson S. Pharmacologic behavior management for pediatric dental treatment. Pediatr Clin North Am 2000;47(5):1159-75.
  34. McCarty EC, Mencio GA, Green NE. Anesthesia and analgesia for the ambulatory management of fractures in children. J Am Acad Orthop Surg 1999;7(2):81-91.
  35. Egelhoff JC, Ball WS Jr, Koch BL, Parks TD. Safety and efficacy of sedation in children using a structured sedation program. AJR Am J Roentgenol 1997;168(5):1259-62.
  36. Heinrich M, Menzel C, Hoffmann F, Berger M, Schweinitz DV. Selfadministered procedural analgesia using nitrous oxide/oxygen (50:50) in the pediatric surgery emergency room: effectiveness and limitations. Eur J Pediatr Surg 2015;25(3):250-6.
  37. Hoyle JD Jr, Callahan JM, Badawy M, et al; Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma. Pediatr Emerg Care 2014;30(1):1-7.
  38. Chiaretti A, Benini F, Pierri F, et al. Safety and efficacy of propofol administered by paediatricians during procedural sedation in children. Acta Paediatr 2014;103(2):182-7.
  39. Pacheco GS, Ferayorni A. Pediatric procedural sedation and analgesia. Emerg Med Clin North Am 2013;31(3):831-52.
  40. Griffiths MA, Kamat PP, McCracken CE, Simon HK. Is procedural sedation with propofol acceptable for complex imaging? A comparison of short vs. prolonged sedations in children. Pediatr Radiol 2013;43(10):1273-8.
  41. Doctor K, Roback MG, Teach SJ. An update on pediatric hospitalbased sedation. Curr Opin Pediatr 2013;25(3):310-6. 
  42. Alletag MJ, Auerbach MA, Baum CR. Ketamine, propofol, and ketofol use for pediatric sedation. Pediatr Emerg Care 2012;28(12):1391-5; quiz: 1396-8. 
  43. Jain R, Petrillo-Albarano T, Parks WJ, Linzer JF Sr, Stockwell JA. Efficacy and safety of deep sedation by non-anesthesiologists for cardiac MRI in children. Pediatr Radiol 2013;43(5):605-11.
  44. Nelson T, Nelson G. The role of sedation in contemporary pediatric dentistry. Dent Clin North Am 2013;57(1):145-61.
  45. Monroe KK, Beach M, Reindel R, et al. Analysis of procedural sedation provided by pediatricians. Pediatr Int 2013;55(1):17-23.
  46. Alexander M. Managing patient stress in pediatric radiology. Radiol Technol 2012;83(6):549-60.
  47. Macias CG, Chumpitazi CE. Sedation and anesthesia for CT: emerging issues for providing high-quality care. Pediatr Radiol 2011;41(suppl 2):517-22.
  48. Andolfatto G, Willman E. A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol). Acad Emerg Med 2010;17(2):194-201.
  49. Brown SC, Hart G, Chastain DP, Schneeweiss S, McGrath PA. Reducing distress for children during invasive procedures: randomized clinical trial of effectiveness of the PediSedate. Paediatr Anaesth 2009;19(8):725-31.
  50. Yamamoto LG. Initiating a hospital-wide pediatric sedation service provided by emergency physicians. Clin Pediatr (Phila) 2008;47(1):37-48.
  51. Doyle L, Colletti JE. Pediatric procedural sedation and analgesia. Pediatr Clin North Am 2006;53(2):279-92.
  52. Todd DW. Pediatric sedation and anesthesia for the oral surgeon. Oral Maxillofac Surg Clin North Am 2013;25(3):467-78, vi-vii.
  53. Committee on Drugs, Section on Anesthesiology, American Academy of Pediatrics. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 1985;76(2):317-21.
  54. American Academy of Pediatric Dentistry. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. ASDC J Dent Child 1986;53(1):21-2.
  55. Committee on Drugs, American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89(6 pt 1):1110-5.
  56. Committee on Drugs, American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics 2002;110(4):836-8.
  57. American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines on the elective use of minimal, moderate, and deep sedation and general anesthesia for pediatric dental patients. 2011. Available at: "http://www.aapd.org/media/policies_guidelines/g_sedation.pdf". Accessed May 27, 2016.
  58. Coté CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006;118(6):
    2587-602.
  59. The Joint Commission. Comprehensive Accreditation Manual for Hospitals (CAMH): the official handbook. Oakbrook Terrace, Ill.: The Joint Commission; 2014. 
  60. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 2002;96(4):1004-17.
  61. Committee of Origin: Ad Hoc on Non-Anesthesiologist Privileging. Statement on granting privileges for deep sedation to non-anesthesiologist sedation practitioners. 2010. Available at: “http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/advisory-
    on-granting-privileges-for-deep-sedation-tonon-anesthesiologist.pdf”. Accessed May 27, 2016.
  62. Coté CJ, Karl HW, Notterman DA, Weinberg JA, Mc Closkey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics 2000;106(4):633-44.
  63. Coté CJ, Notterman DA, Karl HW, Weinberg JA, Mc Closkey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000;105(4 pt 1):805-14. 
  64. Kim G, Green SM, Denmark TK, Krauss B. Ventilatory response during dissociative sedation in children–a pilot study. Acad Emerg Med 2003;10(2):140-5.
  65. Coté CJ. Sedation for the pediatric patient: a review. Pediatr Clin North Am 1994;41(1):31-58.
  66. Mason KP, Burrows PE, Dorsey MM, Zurakowski D, Krauss B. Accuracy of capnography with a 30 foot nasal cannula for monitoring respiratory rate and end-tidal CO2 in children. J Clin Monit Comput 2000;16(4):259-62.
  67. McQuillen KK, Steele DW. Capnography during sedation/ analgesia in the pediatric emergency department. Pediatr Emerg Care 2000;16(6):401-4.
  68. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by non-anesthesiologists. Anesth Analg 1997;85(6):1207-13.
  69. Coté CJ, Rolf N, Liu LM, et al. A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology 1991;74(6):980-7.
  70. Guideline SIGN; Scottish Intercollegiate Guidelines Network. SIGN Guideline 58: safe sedation of children undergoing diagnostic and therapeutic procedures. Paediatr Anaesth 2008;18(1):11-2.
  71. Peña BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 1999;34(4 pt 1):483-91.
  72. Smally AJ, Nowicki TA. Sedation in the emergency department. Curr Opin Anaesthesiol 2007;20(4):379-83. 
  73. Ratnapalan S, Schneeweiss S. Guidelines to practice: the process of planning and implementing a pediatric sedation program. Pediatr Emerg Care 2007;23(4):262-6.
  74. Hoffman GM, Nowakowski R, Troshynski TJ, Berens RJ, Weisman SJ. Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/ American Society of Anesthesiologists process model. Pediatrics 2002;109(2):236-43.
  75. Krauss B. Management of acute pain and anxiety in children undergoing procedures in the emergency department. Pediatr Emerg Care 2001;17(2):115-122; quiz: 123-5.
  76. Slovis TL. Sedation and anesthesia issues in pediatric imaging. Pediatr Radiol 2011;41(suppl 2):514-6.
  77. Babl FE, Krieser D, Belousoff J, Theophilos T. Evaluation of a paediatric procedural sedation training and credentialing programme: sustainability of change. Emerg Med J 2010;27(8):57781.
  78. Meredith JR, O’Keefe KP, Galwankar S. Pediatric procedural sedation and analgesia. J Emerg Trauma Shock 2008;1(2):88-96. 
  79. Priestley S, Babl FE, Krieser D, et al. Evaluation of the impact of a paediatric procedural sedation credentialing programme on quality of care. Emerg Med Australas 2006;18(5-6):498-504.
  80. Babl F, Priestley S, Krieser D, et al. Development and implementation of an education and credentialing programme to provide safe paediatric procedural sedation in emergency departments. Emerg Med Australas 2006;18(5-6):489-97.
  81. Cravero JP, Blike GT. Pediatric sedation. Curr Opin Anaesthesiol 2004;17(3):247–51.
  82. Shavit I, Keidan I, Augarten A. The practice of pediatric procedural sedation and analgesia in the emergency department. Eur J Emerg Med 2006;13(5):270-5.
  83. Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J; Pediatric Sedation Research Consortium. Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med 2012;166(11):990-8.
  84. Primosch RE. Lidocaine toxicity in children—prevention and intervention. Todays FDA 1992;4:4C-5C.
  85. Dial S, Silver P, Bock K, Sagy M. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care 2001;17(6):414-20.
  86. Maxwell LG, Yaster M. The myth of conscious sedation. Arch Pediatr Adolesc Med 1996;150(7):665-7.
  87. Coté CJ. “Conscious sedation”: time for this oxymoron to go away! J Pediatr 2001;139(1):15-7; discussion: 18-9.
  88. Motas D, McDermott NB, VanSickle T, Friesen RH. Depth of consciousness and deep sedation attained in children as administered by nonanaesthesiologists in a children’s hospital. Paediatr Anaesth 2004;14(3):256-60. 
  89. Cudny ME, Wang NE, Bardas SL, Nguyen CN. Adverse events associated with procedural sedation in pediatric patients in the emergency department. Hosp Pharm 2013;48(2):134-42. 
  90. Mora Capín A, Míguez Navarro C, López López R, Marañón Pardillo R. Usefulness of capnography for monitoring sedoanalgesia: infl uence of oxygen on the parameters monitored [in Spanish]. An Pediatr (Barc) 2014;80(1): 41-6.
  91. Frieling T, Heise J, Kreysel C, Kuhlen R, Schepke M. Sedation-associated complications in endoscopy— prospective multicentre survey of 191142 patients. Z Gastroenterol 2013;51(6):568-72.
  92. Khutia SK, Mandal MC, Das S, Basu SR. Intravenous infusion of ketaminepropofol can be an alternative to intravenous infusion of fentanylpropofol for deep sedation and analgesia in paediatric patients undergoing emergency short surgical procedures. Indian J Anaesth 2012;56(2):145-50.
  93. Kannikeswaran N, Chen X, Sethuraman U. Utility of end-tidal carbon dioxide monitoring in detection of hypoxia during sedation for brain magnetic resonance imaging in children with developmental disabilities. Paediatr Anaesth 2011;21(12):1241-6. 
  94. McGrane O, Hopkins G, Nielson A, Kang C. Procedural sedation with propofol: a retrospective review of the experiences of an emergency medicine residency program 2005 to 2010. Am J Emerg Med 2012;30(5):706-11. 
  95. Mallory MD, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physicianadministered propofol sedation: a report on 25, 433 sedations from the Pediatric Sedation Research Consortium. Ann Emerg Med 2011;57(5):462-468.e1.
  96. Langhan ML, Chen L, Marshall C, Santucci KA. Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine. Pediatr Emerg Care 2011;27(5):394-7.
  97. David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 2011;57(5):435-41.
  98. Babl FE, Belousoff J, Deasy C, Hopper S, Theophilos T. Paediatric procedural sedation based on nitrous oxide and ketamine: sedation registry data from Australia. Emerg Med J 2010;27(8):607-12.
  99. Lee-Jayaram JJ, Green A, Siembieda J, et al. Ketamine/ midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions. Pediatr Emerg Care 2010;26(6):408-12.
  100. Melendez E, Bachur R. Serious adverse events during procedural sedation with ketamine. Pediatr Emerg Care 2009;25(5):325-8.
  101. Misra S, Mahajan PV, Chen X, Kannikeswaran N. Safety of procedural sedation and analgesia in children less than 2 years of age in a pediatric emergency department. Int J Emerg Med 2008;1(3):173-7.
  102. Green SM, Roback MG, Krauss B, et al.; Emergency Department Ketamine Meta-Analysis Study Group. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009;54(2):158-68.e1-e4.
  103. Kannikeswaran N, Mahajan PV, Sethuraman U, Groebe A, Chen X. Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities. Paediatr Anaesth 2009;19(3):250-6. 
  104. Ramaswamy P, Babl FE, Deasy C, Sharwood LN. Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration. Acad Emerg Med 2009;16(2):101-7.
  105. Vardy JM, Dignon N, Mukherjee N, Sami DM, Balachandran G, Taylor S. Audit of the safety and effectiveness of ketamine for procedural sedation in the emergency department. Emerg Med J 2008;25(9):579-82.
  106. Capapé S, Mora E, Mintegui S, García S, Santiago M, Benito J. Prolonged sedation and airway complications after administration of an inadvertent ketamine overdose in emergency department. Eur J Emerg Med 2008;15(2):92-4.
  107. Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation. Pediatrics 2008;121(3):e528-32. Available at: “www.pediatrics.org/cgi/content/full/121/3/e528”. 
  108. Mahar PJ, Rana JA, Kennedy CS, Christopher NC. A randomized clinical trial of oral transmucosal fentanyl citrate versus intravenous morphine sulfate for initial control of pain in children with extremity injuries. Pediatr Emerg Care 2007;23(8):544-8.
  109. Sacchetti A, Stander E, Ferguson N, Maniar G, Valko P. Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry. Pediatr Emerg Care 2007;23(4):218-22.
  110. Anderson JL, Junkins E, Pribble C, Guenther E. Capnography and depth of sedation during propofol sedation in children. Ann Emerg Med 2007;49(1):9-13.
  111. Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics 2006;118(4):e1078-86. Available at: “www.pediatrics.org/cgi/content/full/118/4/e1078”.
  112. Waterman GD Jr, Leder MS, Cohen DM. Adverse events in pediatric ketamine sedations with or without morphine pretreatment. Pediatr Emerg Care 2006;22(6):408-11.
  113. Moore PA, Goodson JM. Risk appraisal of narcotic sedation for children. Anesth Prog 1985;32(4):129-39.
  114. Nahata MC, Clotz MA, Krogg EA. Adverse effects of meperidine, promethazine, and chlorpromazine for sedation in pediatric patients. Clin Pediatr (Phila) 1985;24(10):558-60.
  115. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine. Pediatr Emerg Care 2001;17(5):351-3.
  116. Benusis KP, Kapaun D, Furnam LJ. Respiratory depression in a child following meperidine, promethazine, and chlorpromazine premedication: report of case. ASDC J Dent Child 1979;46(1):50-3.
  117. Garriott JC, Di Maio VJ. Death in the dental chair: three drug fatalities in dental patients. J Toxicol Clin Toxicol 1982;19(9):987-95.
  118. Goodson JM, Moore PA. Lifethreatening reactions after pedodontic sedation: an assessment of narcotic, local anesthetic, and antiemetic drug interaction. J Am Dent Assoc 1983;107(2):239-45.
  119. Jastak JT, Pallasch T. Death after chloral hydrate sedation: report of case. J Am Dent Assoc 1988;116(3):345-8.
  120. Jastak JT, Peskin RM. Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases. Anesth Prog 1991;38(2):39-44.
  121. Kaufman E, Jastak JT. Sedation for outpatient dental procedures. Compend Contin Educ Dent 1995;16(5):462-6; quiz: 480. 
  122. Wilson S. Pharmacological management of the pediatric dental patient. Pediatr Dent 2004;26(2):131-6.
  123. Sams DR, Thornton JB, Wright JT. The assessment of two oral sedation drug regimens in pediatric dental patients. ASDC J Dent Child 1992;59(4):306-12.
  124. Geelhoed GC, Landau LI, Le Souëf PN. Evaluation of SaO2 as a predictor of outcome in 280 children presenting with acute asthma. Ann Emerg Med 1994;23(6):1236-41. 
  125. Chicka MC, Dembo JB, Mathu-Muju KR, Nash DA, BushHM. Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent 2012;34(3):231-8.
  126. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth 2013;23(8):741-6.
  127. Sanborn PA, Michna E, Zurakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 2005;237(1):288-94. 
  128. Shavit I, Keidan I, Hoffmann Y, et al. Enhancing patient safety during pediatric sedation: the impact of simulationbased training of nonanesthesiologists. Arch Pediatr Adolesc Med 2007;161(8):740-3.
  129. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium. The incidence and nature of adverse events during pediatric sedation/ anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009;108(3):795-804. 
  130. Blike GT, Christoffersen K, Cravero JP, Andeweg SK, Jensen J. A method for measuring system safety and latent errors associated with pediatric procedural sedation. Anesth Analg 2005;101(1):48-58.
  131. Cravero JP, Havidich JE. Pediatric sedation—evolution and revolution. Paediatr Anaesth 2011;21(7):800-9. 
  132. Havidich JE, Cravero JP. The current status of procedural sedation for pediatric patients in out-ofoperating room locations. Curr Opin Anaesthesiol 2012;25(4):453-60.
  133. Hollman GA, Banks DM, Berkenbosch JW, et al. Development, implementation, and initial participant feedback of a pediatric sedation provider course. Teach Learn Med 2013;25(3):249-57.
  134. Scherrer PD, Mallory MD, Cravero JP, Lowrie L, Hertzog JH, Berkenbosch JW; Pediatric Sedation Research Consortium. The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth 2015;25(7):689-97.
  135. Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol 2014;44(8):1020-5.
  136. Kamat PP, McCracken CE, Gillespie SE, et al. Pediatric critical care physician-administered procedural sedation using propofol: a report from the Pediatric Sedation Research Consortium Database. Pediatr Crit Care Med 2015;16(1):11-20.
  137. Couloures KG, Beach M, Cravero JP, Monroe KK, Hertzog JH. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics 2011;127(5):e1154-60. Available at: “www.pediatrics.org/cgi/content/full/127/5/e1154”.
  138. Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol 2010;23(4):523-31.
  139. Patel KN, Simon HK, Stockwell CA, et al. Pediatric procedural sedation by a dedicated nonanesthesiology pediatric sedation service using propofol. Pediatr Emerg Care 2009;25(3):133-8.
  140. Koo SH, Lee DG, Shin H. Optimal initial dose of chloral hydrate in management of pediatric facial laceration. Arch Plast Surg 2014;41(1):40-4.
  141. Ivaturi V, Kriel R, Brundage R, Loewen G, Mansbach H, Cloyd J. Bioavailability of intranasal vs. rectal diazepam. Epilepsy Res 2013;103(2–3):254-61. 
  142. Mandt MJ, Roback MG, Bajaj L, Galinkin JL, Gao D, Wathen JE. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care 2012;28(9):898-904. 
  143. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care 2012;28(8):767-70.
  144. Jasiak KD, Phan H, Christich AC, Edwards CJ, Skrepnek GH, Patanwala AE. Induction dose of propofol for pediatric patients undergoing procedural sedation in the emergency department. Pediatr Emerg Care 2012;28(5):440-2.
  145. McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care 2012;28(3):292-6.
  146. Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012;24(2):225-32. 
  147. Sacchetti A, Jachowski J, Heisler J, Cortese T. Remifentanil use in emergency department patients: initial experience. Emerg Med J 2012;29(11):928-9.
  148. Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med 2011;57(5):425-433.e2.
  149. Herd DW, Anderson BJ, Keene NA, Holford NH. Investigating the pharmacodynamics of ketamine in children. Paediatr Anaesth 2008;18(1):36-42.
  150. Sharieff GQ, Trocinski DR, Kanegaye JT, Fisher B, Harley JR. Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department. Pediatr Emerg Care 2007;23(12):881-4.
  151. Herd DW, Anderson BJ, Holford NH. Modeling the norketamine metabolite in children and the implications for analgesia. Paediatr Anaesth 2007;17(9):831-40.
  152. Herd D, Anderson BJ. Ketamine disposition in children presenting for procedural sedation and analgesia in a children’s emergency department. Paediatr Anaesth 2007;17(7):622-9. 
  153. Heard CM, Joshi P, Johnson K. Dexmedetomidine for pediatric MRI sedation: a review of a series of cases. Paediatr Anaesth 2007;17(9):888-92.
  154. Heard C, Burrows F, Johnson K, Joshi P, Houck J, Lerman J. A comparison of dexmedetomidine-midazolam with propofol for maintenance of anesthesia in children undergoing magnetic resonance imaging. Anesth Analg 2008;107(6):1832-9. 
  155. Hertzog JH, Havidich JE. Nonanesthesiologist-provided pediatric procedural sedation: an update. Curr Opin Anaesthesiol 2007;20(4):365-72.
  156. Petroz GC, Sikich N, James M, et al. A phase I, two-center study of the pharmacokinetics and pharmacodynamics of dexmedetomidine in children. Anesthesiology 2006;105(6):1098-110.
  157.  Potts AL, Anderson BJ, Warman GR, Lerman J, Diaz SM, Vilo S. Dexmedetomidine pharmacokinetics in pediatric intensive care—a pooled analysis. Paediatr Anaesth 2009;19(11):1119-29. 
  158. Mason KP, Lerman J. Dexmedetomidine in children: current knowledge and future applications [review]. Anesth Analg 2011;113(5):112942.
  159. Sammartino M, Volpe B, Sbaraglia F, Garra R, D’Addessi A. Capnography and the bispectral index—their role in pediatric sedation: a brief review. Int J Pediatr 2010;2010:828347.
  160. Yarchi D, Cohen A, Umansky T, Sukhotnik I, Shaoul R. Assessment of end-tidal carbon dioxide during pediatric and adult sedation for endoscopic procedures. Gastrointest Endosc 2009;69(4):87782.
  161. Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006;117(6):e1170-8. Available at: “www.pediatrics.org/cgi/content/full/117/6/e1170”.
  162. YldzdaƟ D, Yapcoglu H, Ylmaz HL. The value of capnography during sedation or sedation/analgesia in pediatric minor procedures. Pediatr Emerg Care 2004;20(3):1625.
  163. Connor L, Burrows PE, Zurakowski D, Bucci K, Gagnon DA, Mason KP. Effects of IV pentobarbital with and without fentanyl on end-tidal carbon dioxide levels during deep sedation of pediatric patients undergoing MRI. AJR Am J Roentgenol 2003;181(6):1691-4. 
  164. Primosch RE, Buzzi IM, Jerrell G. Monitoring pediatric dental patients with nasal mask capnography. Pediatr Dent 2000;22(2):120-4.
  165. Tobias JD. End-tidal carbon dioxide monitoring during sedation with a combination of midazolam and ketamine for children undergoing painful, invasive procedures. Pediatr Emerg Care 1999;15(3):173-5.
  166. Hart LS, Berns SD, Houck CS, Boenning DA. The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department. Pediatr Emerg Care 1997;13(3):189-93.
  167. Marx CM, Stein J, Tyler MK, Nieder ML, Shurin SB, Blumer JL. Ketaminemidazolam versus meperidinemidazolam for painful procedures in pediatric oncology patients. J Clin Oncol 1997;15(1):94-102.
  168. Croswell RJ, Dilley DC, Lucas WJ, Vann WF Jr. A comparison of conventional versus electronic monitoring of sedated pediatric dental patients. Pediatr Dent 1995;17(5):332-9. 
  169. Iwasaki J, Vann WF Jr, Dilley DC, Anderson JA. An investigation of capnography and pulse oximetry as monitors of pediatric patients sedated for dental treatment. Pediatr Dent 1989;11(2):111-7.
  170. Anderson JA, Vann WF Jr. Respiratory monitoring during pediatric sedation: pulse oximetry and capnography. Pediatr Dent 1988;10(2):94-101.
  171. Rothman DL. Sedation of the pediatric patient. J Calif Dent Assoc 2013;41(8):603-11. 
  172. Scherrer PD. Safe and sound: pediatric procedural sedation and analgesia. Minn Med 2011;94(3):43-7.
  173. Srinivasan M, Turmelle M, Depalma LM, Mao J, Carlson DW. Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr 2012;160(5):801-6.e1. 
  174. Langhan ML, Shabanova V, Li FY, Bernstein SL, Shapiro ED. A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Am J Emerg Med 2015;33(1):25-30.
  175. Vetri Buratti C, Angelino F, Sansoni J, Fabriani L, Mauro L, Latina R. Distraction as a technique to control pain in pediatric patients during venipuncture: a narrative review of literature. Prof Inferm 2015;68(1):52-62. 
  176. Robinson PS, Green J. Ambient versus traditional environment in pediatric emergency department. HERD 2015;8(2):71-80.
  177. Singh D, Samadi F, Jaiswal J, Tripathi AM. Stress reduction through audio distraction in anxious pediatric dental patients: an adjunctive clinical study. Int J Clin Pediatr Dent 2014;7(3):149-52.
  178. Attar RH, Baghdadi ZD. Comparative efficacy of active and passive distraction during restorative treatment in children using an iPad versus audiovisual eyeglasses: a randomised controlled trial. Eur Arch Paediatr Dent 2015;16(1):1-8.
  179. McCarthy AM, Kleiber C, Hanrahan K, et al. Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial. Nurs Res 2014;63(6):397-407.
  180. Guinot Jimeno F, Mercadé Bellido M, Cuadros Fernández C, Lorente Rodríguez AI, Llopis Pérez J, Boj Quesada JR. Effect of audiovisual distraction on children’s behaviour, anxiety and pain in the dental setting. Eur J Paediatr Dent 2014;15(3):297-302.
  181. Gupta HV, Gupta VV, Kaur A, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: a quasiexperimental study. J Clin Diagn Res 2014;8(8):PC01-PC04. 
  182. Newton JT, Shah S, Patel H, Sturmey P. Nonpharmacological approaches to behaviour management in children. Dent Update 2003;30(4):194-9.
  183. Peretz B, Bimstein E. The use of imagery suggestions during administration of local anesthetic in pediatric dental patients. ASDC J Dent Child 2000;67(4):263-7, 231. 
  184. Iserson KV. Hypnosis for pediatric fracture reduction. J Emerg Med 1999;17(1):53-6. 
  185. Rusy LM, Weisman SJ. Complementary therapies for acute pediatric pain management. Pediatr Clin North Am 2000;47(3):589-99. 
  186. Langley P. Guided imagery: a review of effectiveness in the care of children. Paediatr Nurs 1999;11(3):18-21.
  187. Ott MJ. Imagine the possibilities! Guided imagery with toddlers and pre-schoolers. Pediatr Nurs 1996;22(1):34-8.
  188. Singer AJ, Stark MJ. LET versus EMLA for pretreating lacerations: a randomized trial. Acad Emerg Med 2001;8(3):223-30.
  189. Taddio A, Gurguis MG, Koren G. Lidocaine-prilocaine cream versus tetracaine gel for procedural pain in children. Ann Pharmacother 2002;36(4):687-92.
  190. Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics 2002;109(6):1093-9.
  191. Shaw AJ, Welbury RR. The use of hypnosis in a sedation clinic for dental extractions in children: report of 20 cases. ASDC J Dent Child 1996;63(6):418-20.
  192. Stock A, Hill A, Babl FE. Practical communication guide for paediatric procedures. Emerg Med Australas 2012;24(6):641-6.
  193. Barnea-Goraly N, Weinzimer SA, Ruedy KJ, et al; Diabetes Research in Children Network (DirecNet). High success rates of sedation-free brain MRI scanning in young children using simple subject preparation protocols with and without a commercial mock scanner—the Diabetes Research in Children Network (DirecNet) experience. Pediatr Radiol 2014;44(2):181-6.
  194. Ram D, Shapira J, Holan G, Magora F, Cohen S, Davidovich E. Audiovisual video eyeglass distraction during dental treatment in children. Quintessence Int 2010;41(8):673-9. 
  195. Lemaire C, Moran GR, Swan H. Impact of audio/visual systems on pediatric sedation in magnetic resonance imaging. J Magn Reson Imaging 2009;30(3):649-55.
  196. Nordahl CW, Simon TJ, Zierhut C, Solomon M, Rogers SJ, Amaral DG. Brief report: methods for acquiring structural MRI data in very young children with autism without the use of sedation. J Autism Dev Disord 2008;38(8):1581-90.
  197. Denman WT, Tuason PM, Ahmed MI, Brennen LM, Cepeda MS, Carr DB. The PediSedate device, a novel approach to pediatric sedation that provides distraction and inhaled nitrous oxide: clinical evaluation in a large case series. Paediatr Anaesth 2007;17(2):162-6. 
  198. Harned RK II, Strain JD. MRI-compatible audio/visual system: impact on pediatric sedation. Pediatr Radiol 2001;31(4):247-50. 
  199. Slifer KJ. A video system to help children cooperate with motion control for radiation treatment without sedation. J Pediatr Oncol Nurs 1996;13(2):91-7.
  200. Krauss BS, Krauss BA, Green SM. Videos in clinical medicine: procedural sedation and analgesia in children. N Engl J Med 2014;370(15):e23.
  201. Wilson S. Management of child patient behavior: quality of care, fear and anxiety, and the child patient. Pediatr Dent 2013;35(2):170-4.
  202. Kamath PS. A novel distraction technique for pain management during local anesthesia administration in pediatric patients. J Clin Pediatr Dent 2013;38(1):45-7.
  203. Asl Aminabadi N, Erfanparast L, Sohrabi A, Ghertasi Oskouei S, Naghili A. The impact of virtual reality distraction on pain and anxiety during dental treatment in 4-6 year-old children: a randomized controlled clinical trial. J Dent Res Dent Clin Dent Prospect 2012;6(4):117-24.
  204. El-Sharkawi HF, El-Housseiny AA, Aly AM. Effectiveness of new distraction technique on pain associated with injection of local anesthesia for children. Pediatr Dent 2012;34(2):e35-e38.
  205. Adinolfi B, Gava N. Controlled outcome studies of child clinical hypnosis. Acta Biomed 2013;84(2):94-7.
  206. Peretz B, Bercovich R, Blumer S. Using elements of hypnosis prior to or during pediatric dental treatment. Pediatr Dent 2013;35(1):33-6.
  207. Huet A, Lucas-Polomeni MM, Robert JC, Sixou JL, Wodey E. Hypnosis and dental anesthesia in children: a prospective controlled study. Int J Clin Exp Hypn 2011;59(4):424-40. 
  208. Al-Harasi S, Ashley PF, Moles DR, Parekh S, Walters V. Hypnosis for children undergoing dental treatment. Cochrane Database Syst Rev 2010;8:CD007154.
  209. McQueen A, Cress C, Tothy A. Using a tablet computer during pediatric procedures: a case series and review of the “apps”. Pediatr Emerg Care 2012;28(7):712-4.
  210. Heilbrunn BR, Wittern RE, Lee JB, Pham PK, Hamilton AH, Nager AL. Reducing anxiety in the pediatric emergency department: a comparative trial. J Emerg Med 2014;47(6):623-31.
  211. Tyson ME, Bohl DD, Blickman JG. A randomized controlled trial: child life services in pediatric imaging. Pediatr Radiol 2014;44(11):1426-32.
  212. Malviya S, Voepel-Lewis T, Tait AR, Merkel S, Tremper K, Naughton N. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). Br J Anaesth 2002;88(2):241-5.
  213. amble C, Gamble J, Seal R, Wright RB, Ali S. Bispectral analysis during procedural sedation in the pediatric emergency department. Pediatr Emerg Care 2012;28(10):1003-8. 
  214. Domino KB. Office-based anesthesia: lessons learned from the closed claims project. ASA Newsl 2001;65:9-15. 
  215. American Heart Association. Pediatric Advance Life Support Provider Manual. Dallas, Texas: American Heart Association; 2011.
  216. American Academy of Pediatrics, American College of Emergency Physicians. Advanced Pediatric Life Support, 5th ed. Boston, Ma.: Jones and Bartlett Publishers; 2012.
  217. Cheng A, Brown LL, Duff JP, et al; International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE) CPR Investigators. Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial. JAMA Pediatr 2015;169(2):137-44.
  218. Nishisaki A, Nguyen J, Colborn S, et al. Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit. Pediatr Crit Care Med 2011;12(4):406-14. 
  219. Howard-Quijano KJ, Stiegler MA, Huang YM, Canales C, Steadman RH. Anesthesiology residents’ performance of pediatric resuscitation during a simulated hyperkalemic cardiac arrest. Anesthesiology 2010;112(4):9937.
  220. Chen MI, Edler A, Wald S, DuBois J, Huang YM. Scenario and checklist for airway rescue during pediatric sedation. Simul Healthc 2007;2(3):194-8.
  221. Wheeler M. Management strategies for the difficult pediatric airway. In: Riazi J, ed. The Difficult Pediatric Airway. 16th ed. Philadelphia, Pa.: W.B. Saunders Company; 1998:743-61.
  222. Sullivan KJ, Kissoon N. Securing the child’s airway in the emergency department. Pediatr Emerg Care 2002;18(2):108-21; quiz: 122-4. 
  223. Levy RJ, Helfaer MA. Pediatric airway issues. Crit Care Clin 2000;16(3):489-504. 
  224. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367(9512):766–80. 
  225. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med 2000;342(13):938-45.
  226. Ferrari L, ed. Anesthesia and Pain Management for the Pediatrician, 1st ed. Baltimore, MD: John Hopkins University Press; 1999.
  227. Malvyia S. Sedation Analgesia for Diagnostic and Therapeutic Procedures, 1st ed. Totowa, NJ: Humana Press; 2001.
  228. Yaster M, Krane EJ, Kaplan RF, Coté CJ, Lappe DG. Pediatric Pain Management and Sedation Handbook. 1st ed. St. Louis, Mo.: Mosby-Year Book, Inc.; 1997.
  229. Cravero JP, Blike GT. Review of pediatric sedation. Anesth Analg 2004;99(5):1355-64. 
  230. Deshpande JK, Tobias JD. The Pediatric Pain Handbook. 1st ed. St. Louis, Mo.: Mosby; 1996.
  231. Mace SE, Barata IA, Cravero JP, et al.; American College of Emergency Physicians. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 2004;44(4):342-77.
  232. Alcaino EA. Conscious sedation in paediatric dentistry: current philosophies and techniques. Ann R Australas Coll Dent Surg 2000;15:206-10.
  233. Tobias JD, Cravero JP. Procedural Sedation for Infants, Children, and Adolescents. Elk Grove Village, Ill.: American Academy of Pediatrics; 2015.
  234. Committee on Standards and Practice Parameters. Standards for Basic Anesthetic Monitoring. Chicago, Ill.: American Society of Anesthesiologists; 2011. 
  235. Mitchell AA, Louik C, Lacouture P, Slone D, Goldman P, Shapiro S. Risks to children from computed tomographic scan premedication. JAMA 1982;247(17):2385-8.
  236. Wolfe TR, Braude DA. Intranasal medication delivery for children: a brief review and update. Pediatrics 2010;126(3):532-7.
  237. Bührer M, Maitre PO, Crevoisier C, Stanski DR. Electroencephalographic effects of benzodiazepines. II. Pharmacodynamic modeling of the electroencephalographic effects of midazolam and diazepam. Clin Pharmacol Ther 1990;48(5):555-67. 
  238. Malviya S, Voepel-Lewis T, Ludomirsky A, Marshall J, Tait AR. Can we improve the assessment of discharge readiness? A comparative study of observational and objective measures of depth of sedation in children. Anesthesiology 2004;100(2):218-24.
  239. Coté CJ. Discharge criteria for children sedated by nonanesthesiologists: is “safe” really safe enough? Anesthesiology 2004;100(2):207-9.
  240. Pershad J, Palmisano P, Nichols M. Chloral hydrate: the good and the bad. Pediatr Emerg Care 1999;15(6):432-5.
  241. McCormack L, Chen JW, Trapp L, Job A. A comparison of sedation related events for two multiagent oral sedation regimens in pediatric dental patients. Pediatr Dent 2014;36(4):302-8.
  242. Kinane TB, Murphy J, Bass JL, Corwin MJ. Comparison of respiratory physiologic features when infants are placed in car safety seats or car beds. Pediatrics 2006;118(2):522-7.
  243. Wyeth Pharmaceuticals. Wyeth Phenergan (Promethazine HCL) Tablets and Suppositories [package insert]. Philadelphia, Pa.: Wyeth Pharmaceuticals; 2012. 
  244. Caperell K, Pitetti R. Is higher ASA class associated with an increased incidence of adverse events during procedural sedation in a pediatric emergency department? Pediatr Emerg Care 2009;25(10):661–4. 
  245. Dar AQ, Shah ZA. Anesthesia and sedation in pediatric gastrointestinal endoscopic procedures: a review. World J Gastrointest Endosc 2010;2(7):257-62. 
  246. Kiringoda R, Thurm AE, Hirschtritt ME, et al. Risks of propofol sedation/anesthesia for imaging studies in pediatric research: eight years of experience in a clinical research center. Arch Pediatr Adolesc Med 2010;164(6):554-60.
  247. Thakkar K, El-Serag HB, Mattek N, Gilger MA. Complications of pediatric EGD: a 4-year experience in PEDSCORI. Gastrointest Endosc 2007;65(2):213-21.
  248. Jackson DL, Johnson BS. Conscious sedation for dentistry: risk management and patient selection. Dent Clin North Am 2002;46(4):767-80.
  249. Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth 2000;84(6):743-8.
  250. O’Neil J, Yonkman J, Talty J, Bull MJ. Transporting children with special health care needs: comparing recommendations and practice. Pediatrics 2009;124(2):596-603.
  251. Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice Pediatrics 1995;95(2):314-7.
  252. Committee on Pediatric Emergency Medicine; Committee on Bioethics. Consent for emergency medical services for children and adolescents. Pediatrics 2011;128(2):427-33. 
  253. Martinez D, Wilson S. Children sedated for dental care: a pilot study of the 24-hour postsedation period. Pediatr Dent 2006;28(3):260-4.
  254. Kaila R, Chen X, Kannikeswaran N. Postdischarge adverse events related to sedation for diagnostic imaging in children. Pediatr Emerg Care 2012;28(8):796-801.
  255. Treston G, Bell A, Cardwell R, Fincher G, Chand D, Cashion G. What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation? Emerg Med Australas 2009;21(4):315-22.
  256. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics 2000;105(3):E42.
  257. Nordt SP, Rangan C, Hardmaslani M, Clark RF, Wendler C, Valente M. Pediatric chloral hydrate poisonings and death following outpatient procedural sedation. J Med Toxicol 2014;10(2):219-22.
  258. Walker RW. Pulmonary aspiration in pediatric anesthetic practice in the UK: a prospective survey of specialist pediatric centers over a one-year period. Paediatr Anaesth 2013;23(8):702-11.
  259. Babl FE, Puspitadewi A, Barnett P, Oakley E, Spicer M. Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia. Pediatr Emerg Care 2005;21(11):736-43. 
  260. Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related? Ann Emerg Med 2004;44(5):454-9.
  261. Vespasiano M, Finkelstein M, Kurachek S. Propofol sedation: intensivists’ experience with 7304 cases in a children’s hospital. Pediatrics 2007;120(6): e1411-7. Available at: “www.pediatrics.org/cgi/content/full/120/6/e1411”. 
  262. Warner MA, Warner ME, Warner DO, Warner LO, Warner EJ. Perioperative pulmonary aspiration in infants and children. Anesthesiology 1999;90(1):66-71.
  263. Borland LM, Sereika SM, Woelfel SK, et al. Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth 1998;10(2):95-102. 
  264. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003;42(5):636-46. 
  265. Green SM. Fasting is a consideration—not a necessity—for emergency department procedural sedation and analgesia. Ann Emerg Med 2003;42(5):647-50. 
  266. Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation—an examination of the role of fasting and sedation depth. Acad Emerg Med 2002;9(1):35-42.
  267. Treston G. Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation. Emerg Med Australas 2004;16(2):145-50.
  268. Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med 2003;157(11):1090-6.
  269. Thorpe RJ, Benger J. Pre-procedural fasting in emergency sedation. Emerg Med J 2010;27(4):254-61.
  270. Paris PM, Yealy DM. A procedural sedation and analgesia fasting consensus advisory: one small step for emergency medicine, one giant challenge remaining. Ann Emerg Med 2007;49(4):465-7.
  271. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011;114(3):495-511. 
  272. Mace SE, Brown LA, Francis L, et al. Clinical policy: Critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med 2008;51(4):378-99, 399.e1-57.
  273. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus based clinical practice advisory. Ann Emerg Med 2007;49(4):454-61.
  274. Duchicela S, Lim A. Pediatric nerve blocks: an evidencebased approach. Pediatr Emerg Med Pract 2013;10(10):1-19; quiz: 19-20.
  275. Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: a report of the Pediatric Sedation Research Consortium. Anesthesiology 2016;124(1):80-8. 
  276. Green SM, Krauss B. Ketamine is a safe, effective, and appropriate technique for emergency department paediatric procedural sedation. Emerg Med J 2004;21(3):271-2.
  277. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. The use of physical restraint interventions for children and adolescents in the acute care setting. Pediatrics 1997;99(3):497-8.
  278. American Academy of Pediatrics Committee on Child Abuse and Neglect. Behavior management of pediatric dental patients. Pediatrics 1992;90(4):651-2.
  279. American Academy of Pediatric Dentistry. Guideline on protective stabilization for pediatric dental patients. Pediatr Dent 2013;35(5):E169-E173.
  280. Loo CY, Graham RM, Hughes CV. Behaviour guidance in dental treatment of patients with autism spectrum disorder. Int J Paediatr Dent 2009;19(6):390-8. 
  281. McWhorter AG, Townsend JA; American Academy of Pediatric Dentistry. Behavior symposium workshop A report—current guidelines/revision. Pediatr Dent 2014; 36(2):152-3.
  282. American Society of Anesthesiologists CoSaPP. Practice advisory for preanesthesia evaluation an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116: 1-17.
  283. Gorski JC, Huang SM, Pinto A, et al. The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo. Clin Pharmacol Ther 2004;75(1):89-100. 
  284. Hall SD, Wang Z, Huang SM, et al. The interaction between St John’s wort and an oral contraceptive. Clin Pharmacol Ther 2003;74(6):525-35. 
  285. Markowitz JS, Donovan JL, DeVane CL, et al. Effect of St John’s wort on drug metabolism by induction of cytochrome P450 3A4 enzyme. JAMA 2003;290(11):1500-4.
  286. Spinella M. Herbal medicines and epilepsy: the potential for benefit and adverse effects. Epilepsy Behav 2001;2(6):524-32.
  287. Wang Z, Gorski JC, Hamman MA, Huang SM, Lesko LJ, Hall SD. The effects of St John’s wort (Hypericum perforatum) on human cytochrome P450 activity. Clin Pharmacol Ther 2001;70(4):317-26.
  288. Xie HG, Kim RB. St John’s wortassociated drug interactions: short-term inhibition and long-term induction? Clin Pharmacol Ther 2005;78(1):19-24.
  289. Chen XW, Sneed KB, Pan SY, et al. Herbdrug interactions and mechanistic and clinical considerations. Curr Drug Metab 2012;13(5):640-51. 
  290. Chen XW, Serag ES, Sneed KB, et al. Clinical herbal interactions with conventional drugs: from molecules to maladies. Curr Med Chem 2011;18(31):4836-50.
  291. Shi S, Klotz U. Drug interactions with herbal medicines. Clin Pharmacokinet 2012;51(2):77-104.
  292. Saxena A, Tripathi KP, Roy S, Khan F, Sharma A. Pharmacovigilance: effects of herbal components on human drugs interactions involving cytochrome P450. Bioinformation 2008;3(5):198-204.
  293. Yang X, Salminen WF. Kava extract, an herbal alternative for anxiety relief, potentiates acetaminophen-induced cyto-toxicity in rat hepatic cells. Phytomedicine 2011;18(7):592-600.
  294. Teschke R. Kava hepatotoxicity: pathogenetic aspects and prospective considerations. Liver Int 2010;30(9):1270-9.
  295. Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: an updated systematic review. Drugs 2009;69(13):1777-98.
  296. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001;286(2):208-16.
  297. Abebe W. Herbal medication: potential for adverse interactions with analgesic drugs. J Clin Pharm Ther 2002;27 (6):391-401.
  298. Mooiman KD, Maas-Bakker RF, Hendrikx JJ, et al. The effect of complementary and alternative medicines on CYP3A4-mediated metabolism of three different substrates: 7-benzyloxy-4-trifluoromethyl-coumarin, midazolam and docetaxel. J Pharm Pharmacol 2014;66(6):865-74. 
  299. Carrasco MC, Vallejo JR, Pardo-de-Santayana M, Peral D, Martín MA, Altimiras J. Interactions of Valeriana officinalis L. and Passifl ora incarnata L. in a patient treated with lorazepam. Phytother Res 2009;23(12):1795-6.
  300. von Rosensteil NA, Adam D. Macrolide antibacterials: drug interactions of clinical significance. Drug Saf 1995;13(2):105-22.
  301. Hiller A, Olkkola KT, Isohanni P, Saarnivaara L. Unconsciousness associated with midazolam and erythromycin. Br J Anaesth 1990;65(6):826-8.
  302. Mattila MJ, Idänpään-Heikkilä JJ, Törnwall M, Vanakoski J. Oral single doses of erythromycin and roxithromycin may increase the effects of midazolam on human performance. Pharmacol Toxicol 1993;73(3):180-5.
  303. Olkkola KT, Aranko K, Luurila H, et al. A potentially hazardous interaction between erythromycin and midazolam. Clin Pharmacol Ther 1993;53(3):298-305.
  304. Senthilkumaran S, Subramanian PT. Prolonged sedation related to erythromycin and midazolam interaction: a word of caution. Indian Pediatr 2011;48(11):909.
  305. Flockhart DA, Oesterheld JR. Cytochrome P450-mediated drug interactions. Child Adolesc Psychiatr Clin N Am 2000;9(1):43-76.
  306. Yuan R, Flockhart DA, Balian JD. Pharmacokinetic and pharmacodynamic consequences of metabolism-based drug interactions with alprazolam, midazolam, and triazolam. J Clin Pharmacol 1999;39(11):1109-25.
  307. Young B. Review: mixing new cocktails: drug interactions in antiretroviral regimens. AIDS Patient Care STDS 2005;19(5):286-97.
  308. Gonçalves LS, Gonçalves BM, de Andrade MA, Alves FR, Junior AS. Drug interactions during periodontal therapy in HIV-infected subjects. Mini Rev Med Chem 2010;10(8):766-72.
  309. Brown KC, Paul S, Kashuba AD. Drug interactions with new and investigational antiretrovirals. Clin Pharmacokinet 2009;48(4):211-41.
  310. Pau AK. Clinical management of drug interaction with antiretroviral agents. Curr Opin HIV AIDS 2008;3(3):319-24.
  311. Moyal WN, Lord C, Walkup JT. Quality of life in children and adolescents with autism spectrum disorders: what is known about the effects of pharmacotherapy? Paediatr Drugs 2014;16(2):123-8.
  312. van den Anker JN. Developmental pharmacology. Dev Disabil Res Rev 2010;16(3):233-8.
  313. Pichini S, Papaseit E, Joya X, et al. Pharmacokinetics and therapeutic drug monitoring of psychotropic drugs in pediatrics. Ther Drug Monit 2009;31(3):283–318.
  314. Tibussek D, Distelmaier F, Schönberger S, Göbel U, Mayatepek E. Antiepileptic treatment in paediatric oncology—an interdisciplinary challenge. Klin Padiatr 2006;218(6):340-9.
  315. Wilkinson GR. Drug metabolism and variability among patients in drug response. N Engl J Med 2005;352(21):2211-21.
  316. Salem F, Rostami-Hodjegan A, Johnson TN. Do children have the same vulnerability to metabolic drug–drug interactions as adults? A critical analysis of the literature. J Clin Pharmacol 2013;53(5):559-66.
  317. Funk RS, Brown JT, Abdel-Rahman SM. Pediatric pharmacokinetics: human development and drug disposition. Pediatr Clin North Am 2012;59(5):1001-16.
  318. Anderson BJ. My child is unique: the pharmacokinetics are universal. Paediatr Anaesth 2012;22(6):530-8. 
  319. Elie V, de Beaumais T, Fakhoury M, Jacqz-Aigrain E. Pharmacogenetics and individualized therapy in children: immunosuppressants, antidepressants, anticancer and anti-inflammatory drugs. Pharmacogenomics 2011;12(6):827-43. 
  320. Chen ZR, Somogyi AA, Reynolds G, Bochner F. Disposition and metabolism of codeine after single and chronic doses in one poor and seven extensive metabolisers. Br J Clin Pharmacol 1991;31(4):381-90.
  321. Gasche Y, Daali Y, Fathi M, et al. Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med 2004;351(27):2827-31.
  322. Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultrarapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J 2007;7(4):257-65.
  323. Voronov P, Przybylo HJ, Jagannathan N. Apnea in a child after oral codeine: a genetic variant—an ultra-rapid metabolizer. Paediatr Anaesth 2007;17(7):684-7. 
  324. Kelly LE, Rieder M, van den Anker J, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012;129(5):e1343-7. Available at: “www.pediatrics.org/cgi/content/full/129/5/e1343”. 
  325. Farber JM. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;110(6):1255–7; author reply: 1255-7. 
  326. Schechter MS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69. Available at: “www.pediatrics.org/cgi/content/full/109/4/e69”.
  327. Marcus CL, Brooks LJ, Draper KA, et al.; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130(3):576-84. 
  328. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg 2014;118(6):1276-83. 
  329. Wheeler M, Coté CJ. Preoperative pregnancy testing in a tertiary care children’s hospital: a medicolegal conundrum. J Clin Anesth 1999;11(1):56-63. 
  330. Neuman G, Koren G. Safety of procedural sedation in pregnancy. J Obstet Gynaecol Can 2013;35(2):168-73.
  331. Larcher V. Developing guidance for checking pregnancy status in adolescent girls before surgical, radiological or other procedures. Arch Dis Child 2012;97(10):857-60.
  332. August DA, Everett LL. Pediatric ambulatory anesthesia. Anesthesiol Clin 2014;32(2):411-29. 
  333. Maxwell LG. Age-associated issues in preoperative evaluation, testing, and planning: pediatrics. Anesthesiol Clin North America 2004;22(1):27-43.
  334. Davidson AJ. Anesthesia and neurotoxicity to the developing brain: the clinical relevance. Paediatr Anaesth 2011;21(7):716-21.
  335. Reddy SV. Effect of general anesthetics on the developing brain. J Anaesthesiol Clin Pharmacol 2012;28(1):6-10. 
  336. Nemergut ME, Aganga D, Flick RP. Anesthetic neurotoxicity: what to tell the parents? Paediatr Anaesth 2014; 24(1):120-6. 
  337. Olsen EA, Brambrink AM. Anesthesia for the young child undergoing ambulatory procedures: current concerns regarding harm to the developing brain. Curr Opin Anaesthesiol 2013;26(6):677-84.
  338. Green SM, Coté CJ. Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine. Ann Emerg Med 2009;54(2):181-90.
  339. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology 2004;100(4):806-10; discussion: 5A. 
  340. Moss IR, Brown KA, Laferrière A. Recurrent hypoxia in rats during development increases subsequent respiratory sensitivity to fentanyl. Anesthesiology 2006;105(4):715-8.
  341. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Upper airway obstruction during midazolam/nitrous oxide sedation in children with enlarged tonsils. Pediatr Dent 1998;20(5):318-20. 
  342. Fishbaugh DF, Wilson S, Preisch JW, Weaver JM II. Relationship of tonsil size on an airway blockage maneuver in children during sedation. Pediatr Dent 1997;19(4):277-81.
  343. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth 2012;22(8):729-36.
  344. Kumar HV, Schroeder JW, Gang Z, Sheldon SH. Mallampati score and pediatric obstructive sleep apnea. J Clin Sleep Med 2014;10(9):985-90. 
  345. Anderson BJ, Meakin GH. Scaling for size: some implications for paediatric anaesthesia dosing. Paediatr Anaesth 2002;12(3):205-19.
  346. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. BMJ 1974;2(5920):656-9.
  347. Agrawal D, Feldman HA, Krauss B, Waltzman ML. Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children. Ann Emerg Med 2004;43(2):247-55.
  348. Cravero JP, Blike GT, Surgenor SD, Jensen J. Development and validation of the Dartmouth Operative Conditions Scale. Anesth Analg 2005;100(6):1614-21.
  349. Mayers DJ, Hindmarsh KW, Sankaran K, Gorecki DK, Kasian GF. Chloral hydrate disposition following singledose administration to critically ill neonates and children. Dev Pharmacol Ther 1991;16(2):71-7.
  350. Terndrup TE, Dire DJ, Madden CM, Davis H, Cantor RM, Gavula DP. A prospective analysis of intramuscular meperidine, promethazine, and chlorpromazine in pediatric emergency department patients. Ann Emerg Med 1991;20(1):31-5.
  351. Macnab AJ, Levine M, Glick N, Susak L, Baker-Brown G. A research tool for measurement of recovery from sedation: the Vancouver Sedative Recovery Scale. J Pediatr Surg 1991;26(11):1263-7.
  352. Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the Observer’s Assessment of Alertness/ Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol 1990;10(4):244-51.
  353. Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can’t fix what you don’t know about. Jt Comm J Qual Improv 2001;27(10):522-32. 
  354. May T, Aulisio MP. Medical malpractice, mistake prevention, and compensation. Kennedy Inst Ethics J 2001;11(2):135-46.
  355. Kazandjian VA. When you hear hoofs, think horses, not zebras: an evidence-based model of health care accountability. J Eval Clin Pract 2002;8(2):205-13.
  356. Connor M, Ponte PR, Conway J. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am 2002;14(4):359-67, viii.
  357. Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care 2002;11(4):352-4.
  358. Tuong B, Shnitzer Z, Pehora C, et al. The experience of conducting Mortality and Morbidity reviews in a pediatric interventional radiology service: a retrospective study. J Vasc Interv Radiol 2009;20(1):77-86. 
  359. Tjia I, Rampersad S, Varughese A, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg 2014;119(1):122-36.
  360. Bhatt M, Kennedy RM, Osmond MH, et al. Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC); Pediatric Emergency Care Applied Research Network (PECARN). Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med 2009;53(4):426-35.e4.
  361. Barker SJ, Hyatt J, Shah NK, Kao YJ. The effect of sensor malpositioning on pulse oximeter accuracy during hypoxemia. Anesthesiology 1993;79(2):248-54.
  362. Kelleher JF, Ruff RH. The penumbra effect: vasomotiondependent pulse oximeter artifact due to probe malposition. Anesthesiology 1989;71(5):787-91.
  363. Reeves ST, Havidich JE, Tobin DP. Conscious sedation of children with propofol is anything but conscious. Pediatrics 2004;114(1):e74-6. Available at: “www.pediatrics.org/cgi/content/full/114/1/e74”.
  364. Maher EN, Hansen SF, Heine M, Meers H, Yaster M, Hunt EA. Knowledge of procedural sedation and analgesia of emergency medicine physicians. Pediatr Emerg Care 2007;23(12):869-76.
  365. Fehr JJ, Boulet JR, Waldrop WB, Snider R, Brockel M, Murray DJ. Simulation-based assessment of pediatric anesthesia skills. Anesthesiology 2011;115(6):1308-15.
  366. McBride ME, Waldrop WB, Fehr JJ, Boulet JR, Murray DJ. Simulation in pediatrics: the reliability and validity of a multiscenario assessment. Pediatrics 2011;128(2):335-43.
  367. Fehr JJ, Honkanen A, Murray DJ. Simulation in pediatric anesthesiology. Paediatr Anaesth 2012;22(10):988-94.
  368. Martinez MJ, Siegelman L. The new era of pretracheal/ precordial stethoscopes. Pediatr Dent 1999;21(7):455-7.
  369. Biro P. Electrically amplified precordial stethoscope. J Clin Monit 1994;10(6):410-2. 
  370. Philip JH, Raemer DB. An electronic stethoscope is judged better than conventional stethoscopes for anesthesia monitoring. J Clin Monit 1986;2(3):151-4. 
  371. Hochberg MG, Mahoney WK. Monitoring of respiration using an amplified pretracheal stethoscope. J Oral Maxillofac Surg 1999;57(7):875-6.
  372. Fredette ME, Lightdale JR. Endoscopic sedation in pediatric practice. Gastrointest Endosc Clin N Am 2008; 18(4):739-51, ix.
  373. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with midazolam and fentanyl: a randomized, controlled trial. Ann Emerg Med 2007;49(1):1-8.
  374. Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006;13(5):500-4.
  375. Wilson S, Farrell K, Griffen A, Coury D. Conscious sedation experiences in graduate pediatric dentistry programs. Pediatr Dent 2001;23(4):307-14.
  376. Allegaert K, van den Anker JN. Clinical pharmacology in neonates: small size, huge variability. Neonatology 2014;105(4):344-9.
  377. Coté CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy: a combined analysis. Anesthesiology 1995;82(4):809-22. 
  378. Havidich JE, Beach M, Dierdorf SF, Onega T, Suresh G, Cravero JP. Preterm versus term children: analysis of sedation/anesthesia adverse events and longitudinal risk. Pediatrics 2016;137(3):1-9.
  379. Nasr VG, Davis JM. Anesthetic use in newborn infants: the urgent need for rigorous evaluation. Pediatr Res 2015;78(1):2-6.
  380. Sinner B, Becke K, Engelhard K. General anaesthetics and the developing brain: an overview. Anaesthesia 2014;69(9):1009-22. 
  381. Yu CK, Yuen VM, Wong GT, Irwin MG. The effects of anaesthesia on the developing brain: a summary of the clinical evidence. F1000 Res 2013;2:166.
  382. Davidson A, Flick RP. Neurodevelopmental implications of the use of sedation and analgesia in neonates. Clin Perinatol 2013;40(3):559-73.
  383. Lönnqvist PA. Toxicity of local anesthetic drugs: a pediatric perspective. Paediatr Anaesth 2012;22(1):39-43.
  384. Wahl MJ, Brown RS. Dentistry’s wonder drugs: local anesthetics and vasoconstrictors. Gen Dent 2010;58(2):114-23; quiz: 124-5.
  385. Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med 2008;33(5):449-60. 
  386. Ecoffey C. Pediatric regional anesthesia—update. Curr Opin Anaesthesiol 2007;20(3):232-5.
  387. Aubuchon RW. Sedation liabilities in pedodontics. Pediatr Dent 1982;4:171-80.
  388. Fitzmaurice LS, Wasserman GS, Knapp JF, Roberts DK, Waeckerle JF, Fox M. TAC use and absorption of cocaine in a pediatric emergency department. Ann Emerg Med 1990;19(5):515-8.
  389. Tipton GA, DeWitt GW, Eisenstein SJ. Topical TAC (tetracaine, adrenaline, cocaine) solution for local anesthesia in children: prescribing inconsistency and acute toxicity. South Med J 1989;82(11):1344-6.
  390. Gunter JB. Benefit and risks of local anesthetics in infants and children. Paediatr Drugs 2002;4(10):649-72.
  391. Resar LM, Helfaer MA. Recurrent seizures in a neonate after lidocaine administration. J Perinatol 1998;18(3):193-5.
  392. Yagiela JA. Local anesthetics. In: Yagiela JA, Dowd FJ, Johnson BS, Mariotti AJ, Neidle EA, eds. Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo.: Mosby, Elsevier; 2011:246-65. 
  393. Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc 2002;68(9):546-51.
  394. Malamed SF. Anesthetic considerations in dental specialties. In: Malamed SF, ed. Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Elsevier; 2013:277-91. 
  395. Malamed SF. The needle. In: Malamed SF, ed. Handbook of Local Anesthetics. 6th ed. St Louis, Mo.: Elsevier; 2013:92-100.
  396. Malamed SF. Pharmacology of local anesthetics. In: Malamed SF, ed. Handbook of Local Anesthesia. 6th ed. St. Louis, Mo.: Elsevier; 2013:25-38.
  397. Ram D, Amir E. Comparison of articaine 4% and lidocaine 2% in paediatric dental patients. Int J Paediatr Dent 2006;16(4):252-6.
  398. Jakobs W, Ladwig B, Cichon P, Ortel R, Kirch W. Serum levels of articaine 2% and 4% in children. Anesth Prog 1995;42(3–4):113-5.
  399. Wright GZ, Weinberger SJ, Friedman CS, Plotzke OB. Use of articaine local anesthesia in children under 4 years of age—a retrospective report. Anesth Prog 1989;36(6):268-71.
  400. Malamed SF, Gagnon S, Leblanc D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22(4):307-11.
  401. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Guidelines on use of local anesthesia for pediatric dental patients. Chicago, Ill.: American Academy of Pediatric Dentistry; 2015. Available at: “http://www.aapd.org/media/policies_guidelines/g_localanesthesia.pdf”. Accessed May 27, 2016.
  402. Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg 2008;106(5):1572-4.
  403. Eren CS, Tasyurek T, Guneysel O. Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series. Am J Emerg Med 2014;32(9):1103-8. 
  404. Evans JA, Wallis SC, Dulhunty JM, Pang G. Binding of local anaesthetics to the lipid emulsion Clinoleic™ 20%. Anaesth Intensive Care 2013;41(5):618-22.
  405. Presley JD, Chyka PA. Intravenous lipid emulsion to reverse acute drug toxicity in pediatric patients. Ann Pharmacother 2013;47(5):735-43.
  406. Li Z, Xia Y, Dong X, et al. Lipid resuscitation of bupivacaine toxicity: long-chain triglyceride emulsion provides benefits over long- and medium-chain triglyceride emulsion. Anesthesiology 2011;115(6):1219-28.
  407. Maher AJ, Metcalfe SA, Parr S. Local anaesthetic toxicity. Foot 2008;18(4):192-7.
  408. Corman SL, Skledar SJ. Use of lipid emulsion to reverse local anesthetic-induced toxicity. Ann Pharmacother 2007;41(11):1873-7.
  409. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anaesthesia 2006;61(8):800-1.
  410. Raso SM, Fernandez JB, Beobide EA, Landaluce AF. Methemoglobinemia and CNS toxicity after topical application of EMLA to a 4-year-old girl with molluscum contagiosum. Pediatr Dermatol 2006;23(6):592-3.
  411. Larson A, Stidham T, Banerji S, Kaufman J. Seizures and methemoglobinemia in an infant after excessive EMLA application. Pediatr Emerg Care 2013;29(3):377-9.
  412. Tran AN, Koo JY. Risk of systemic toxicity with topical lidocaine/prilocaine: a review. J Drugs Dermatol 2014;13(9):1118-22.
  413. Young KD. Topical anaesthetics: what’s new? Arch Dis Child Educ Pract Ed 2015;100(2):105-10.
  414. Gaufberg SV, Walta MJ, Workman TP. Expanding the use of topical anesthesia in wound management: sequential layered application of topical lidocaine with epinephrine. Am J Emerg Med 2007;25(4):379-84.
  415. Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for repair of dermal laceration. Cochrane Database Syst Rev 2011;6:CD005364.
  416. Next-generation pulse oximetry. Health Devices 2003;32(2):49-103.
  417. Barker SJ. “Motion-resistant”pulse oximetry: a comparison of new and old models. Anesth Analg 2002;95(4):967-72.
  418. Malviya S, Reynolds PI, Voepel-Lewis T, et al. False alarms and sensitivity of conventional pulse oximetry versus the Masimo SET technology in the pediatric postanesthesia care unit. Anesth Analg 2000;90(6):1336-40.
  419. Barker SJ, Shah NK. Effects of motion on the performance of pulse oximeters in volunteers. Anesthesiology 1996;85(4):774-81.
  420. Barker SJ, Shah NK. The effects of motion on the performance of pulse oximeters in volunteers (revised publication). Anesthesiology 1997;86(1):101-8.
  421. Colman Y, Krauss B. Microstream capnograpy technology: a new approach to an old problem. J Clin Monit Comput 1999;15(6):403-9.
  422. Wright SW. Conscious sedation in the emergency department: the value of capnography and pulse oximetry. Ann Emerg Med 1992;21(5):551-5.
  423. Roelofse J. Conscious sedation: making our treatment options safe and sound. SADJ 2000;55(5):273-6.
  424. Wilson S, Creedon RL, George M, Troutman K. A history of sedation guidelines: where we are headed in the future. Pediatr Dent 1996;18(3):194-9.
  425. Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med 2002;9(4):275-80.
  426. Vascello LA, Bowe EA. A case for capnographic monitoring as a standard of care. J Oral Maxillofac Surg 1999;57(11):1342-7.
  427. Coté CJ, Wax DF, Jennings MA, Gorski CL, KurczakKlippstein K. Endtidal carbon dioxide monitoring in children with congenital heart disease during sedation for cardiac catheterization by nonanesthesiologists. Paediatr Anaesth 2007;17(7):661-6. 
  428. Bowdle TA. Depth of anesthesia monitoring. Anesthesiol Clin 2006;24(4):793-822.
  429. Rodriguez RA, Hall LE, Duggan S, Splinter WM. The bispectral index does not correlate with clinical signs of inhalational anesthesia during sevoflurane induction and arousal in children. Can J Anaesth 2004;51(5):472-80.
  430. Overly FL, Wright RO, Connor FA Jr, Fontaine B, Jay G, Linakis JG. Bispectral analysis during pediatric procedural sedation. Pediatr Emerg Care 2005;21(1):6-11.
  431. Mason KP, O’Mahony E, Zurakowski D, Libenson MH. Effects of dexmedetomidine sedation on the EEG in children. Paediatr Anaesth 2009;19(12):1175-83.
  432. Malviya S, Voepel-Lewis T, Tait AR, Watcha MF, Sadhasivam S, Friesen RH. Effect of age and sedative agent on the accuracy of bispectral index in detecting depth of sedation in children. Pediatrics 2007;120(3) e461-70. Available at: “www.pediatrics.org/cgi/content/full/120/3/e461”.
  433. Sadhasivam S, Ganesh A, Robison A, Kaye R, Watcha MF. Validation of the bispectral index monitor for measuring the depth of sedation in children. Anesth Analg 2006;102(2):383-8.
  434. Messieha ZS, Ananda RC, Hoffman WE, Punwani IC, Koenig HM. Bispectral Index System (BIS) monitoring reduces time to discharge in children requiring intramuscular sedation and general anesthesia for outpatient dental rehabilitation. Pediatr Dent 2004;26(3):256-60. 
  435. McDermott NB, VanSickle T, Motas D, Friesen RH. Validation of the bispectral index monitor during conscious and deep sedation in children. Anesth Analg 2003;97(1):39-43. 
  436. Schmidt AR, Weiss M, Engelhardt T. The paediatric airway: basic principles and current developments. Eur J Anaesthesiol 2014;31(6):293-9. 
  437. Nagler J, Bachur RG. Advanced airway management. Curr Opin Pediatr 2009;21(3):299-305.
  438. Berry AM, Brimacombe JR, Verghese C. The laryngeal mask airway in emergency medicine, neonatal resuscitation, and intensive care medicine. Int Anesthesiol Clin 1998;36(2):91-109.
  439. Patterson MD. Resuscitation update for the pediatrician. Pediatr Clin North Am 1999;46(6):1285-303.
  440. Diggs LA, Yusuf JE, De Leo G. An update on out-ofhospital airway management practices in the United States. Resuscitation 2014;85(7):885-92.
  441. Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM. Out-of-hospital airway management in the United States. Resuscitation 2011;82(4):378-85. 
  442. Ritter SC, Guyette FX. Prehospital pediatric King LT-D use: a pilot study. Prehosp Emerg Care 2011;15(3):401-4.
  443. Selim M, Mowafi H, Al-Ghamdi A, Adu-Gyamfi Y. Intubation via LMA in pediatric patients with difficult airways. Can J Anaesth 1999;46(9):891-3.
  444. Munro HM, Butler PJ, Washington EJ. Freeman-Sheldon (whistling face) syndrome: anaesthetic and airway management. Paediatr Anaesth 1997;7(4):345-8.
  445. Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care 2008;24(6):347-50.
  446. Gazin N, Auger H, Jabre P, et al. Efficacy and safety of the EZ-IO™ intraosseous device: out-of-hospital implementation of a management algorithm for difficult vascular access. Resuscitation 2011;82(1):126-9.
  447. Frascone RJ, Jensen J, Wewerka SS, Salzman JG. Use of the pediatric EZ-IO needle by emergency medical services providers. Pediatr Emerg Care 2009;25(5):329-32.
  448. Neuhaus D. Intraosseous infusion in elective and emergency pediatric anesthesia: when should we use it? Curr Opin Anaesthesiol 2014;27(3):282-7.
  449. Oksan D, Ayfer K. Powered intraosseous device (EZ-IO) for critically ill patients. Indian Pediatr 2013;50(7):689-91. 
  450. Santos D, Carron PN, Yersin B, Pasquier M. EZ-IO(®) intraosseous device implementation in a prehospital emergency service: a prospective study and review of the literature. Resuscitation 2013;84(4):440-5.
  451. Tan GM. A medical crisis management simulation activity for pediatric dental residents and assistants. J Dent Educ 2011;75(6):782-90.
  452. Schinasi DA, Nadel FM, Hales R, Boswinkel JP, Donoghue AJ. Assessing pediatric residents’ clinical performance in procedural sedation: a simulation-based needs assessment. Pediatr Emerg Care 2013;29(4):447-52.
  453. Rowe R, Cohen RA. An evaluation of a virtual reality airway simulator. Anesth Analg 2002;95(1):62-6.
  454. Medina LS, Racadio JM, Schwid HA. Computers in radiology—the sedation, analgesia, and contrast media computerized simulator: a new approach to train and evaluate radiologists’ responses to critical incidents. Pediatr Radiol 2000;30(5):299-305. 
  455. Blike G, Cravero J, Nelson E. Same patients, same critical events—different systems of care, different outcomes: description of a human factors approach aimed at improving the efficacy and safety of sedation/analgesia care. Qual Manag Health Care 2001;10(1):17-36.
  456. Reiter DA, Strother CG, Weingart SD. The quality of cardiopulmonary resuscitation using supraglottic airways and intraosseous devices: a simulation trial. Resuscitation 2013;84(1):93-7.
  457. Schulte-Uentrop L, Goepfert MS. Anaesthesia or sedation for MRI in children. Curr Opin Anaesthesiol 2010;23(4):513-7. 
  458. Schmidt MH, Downie J. Safety first:recognizing and managing the risks to child participants in magnetic resonance imaging research. Account Res 2009;16(3):153-73.
  459. Chavhan GB, Babyn PS, Singh M, Vidarsson L, Shroff M. MR imaging at 3.0 T in children: technical differences, safety issues, and initial experience. Radiographics 2009;29(5):1451-66. 
  460. Kanal E, Shellock FG, Talagala L. Safety considerations in MR imaging. Radiology 1990;176(3):593-606.
  461. Shellock FG, Kanal E. Burns associated with the use of monitoring equipment during MR procedures. J Magn Reson Imaging 1996;6(1):271-2.
  462. Shellock FG. Magnetic resonance safety update 2002: implants and devices. J Magn Reson Imaging 2002;16(5):485-96.
  463. Dempsey MF, Condon B, Hadley DM. MRI safety review. Semin Ultrasound CT MR 2002;23(5):392-401.
  464. Department of Health and Human Services, Centers for Disease Control and Prevention Criteria for a Recommended Standard: Waste Anesthetic Gases: Occupational Hazards in Hospitals. 2007. Publication 2007-151. Available at: “http://www.cdc.gov/niosh/docs/2007-151/pdfs/2007-151.pdf”. Accessed May 27, 2016.
  465. O’Sullivan I, Benger J. Nitrous oxide in emergency medicine. Emerg Med J 2003;20(3):214-7.
  466. Kennedy RM, Luhmann JD, Luhmann SJ. Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children. Paediatr Drugs 2004;6(1):11-31. 
  467. Frampton A, Browne GJ, Lam LT, Cooper MG, Lane LG. Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department. Emerg Med J 2003;20(5):410-3.
  468. Everitt I, Younge P, Barnett P. Paediatric sedation in emergency department: what is our practice? Emerg Med (Fremantle) 2002;14(1):62-6.
  469. Krauss B. Continuous-flow nitrous oxide: searching for the ideal procedural anxiolytic for toddlers. Ann Emerg Med 2001;37(1):61-2.
  470. Otley CC, Nguyen TH. Conscious sedation of pediatric patients with combination oral benzodiazepines and inhaled nitrous oxide. Dermatol Surg 2000;26(11):1041-4. 
  471. Luhmann JD, Kennedy RM, Jaffe DM, McAllister JD. Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients. Pediatr Emerg Care 1999;15(6):388-92.
  472. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children. Acad Emerg Med 1998;5(2):112-7.
  473. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop 1996;16(2):187-91.
  474. Hennrikus WL, Shin AY, Klingelberger CE. Selfadministered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children. J Bone Joint Surg Am 1995;77(3):335-9.
  475. Hennrikus WL, Simpson RB, Klingelberger CE, Reis MT. Self-administered nitrous oxide analgesia for pediatric fracture reductions. J Pediatr Orthop 1994;14(4):538-42. 
  476. Wattenmaker I, Kasser JR, McGravey A. Self-administered nitrous oxide for fracture reduction in children in an emergency room setting. J Orthop Trauma 1990;4(1):35-8.
  477. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med 1989;18(2):177-81. 
  478. Kalach N, Barbier C, el Kohen R, et al. Tolerance of nitrous oxide-oxygen sedation for painful procedures in emergency pediatrics: report of 600 cases [in French]. Arch Pediatr 2002;9(11):1213-5. 
  479. Michaud L, Gottrand F, Ganga-Zandzou PS, et al. Nitrous oxide sedation in pediatric patients undergoing gastrointestinal endoscopy. J Pediatr Gastroenterol Nutr 1999;28(3):310-4. 
  480. Baskett PJ. Analgesia for the dressing of burns in children: a method using neuroleptanalgesia and Entonox. Postgrad Med J 1972;48(557):138-42.
  481. Veerkamp JS, van Amerongen WE, Hoogstraten J, Groen HJ. Dental treatment of fearful children, using nitrous oxide. Part I: treatment times. ASDC J Dent Child 1991;58(6):453-7.
  482. Veerkamp JS, Gruythuysen RJ, van Amerongen WE, Hoogstraten J. Dental treatment of fearful children using nitrous oxide. Part 2: the parent’s point of view. ASDC J Dent Child 1992;59(2):115-9.
  483. Veerkamp JS, Gruythuysen RJ, van Amerongen WE, Hoogstraten J. Dental treatment of fearful children using nitrous oxide. Part 3: anxiety during sequential visits. ASDC J Dent Child 1993;60(3):175-82.
  484. Veerkamp JS, Gruythuysen RJ, Hoogstraten J, van Amerongen WE. Dental treatment of fearful children using nitrous oxide. Part 4: anxiety after two years. ASDC J Dent Child 1993;60(4):372-6.
  485. Houpt MI, Limb R, Livingston RL. Clinical effects of nitrous oxide conscious sedation in children. Pediatr Dent 2004;26(1):29-36.
  486. Shapira J, Holan G, Guelmann M, Cahan S. Evaluation of the effect of nitrous oxide and hydroxyzine in controlling the behavior of the pediatric dental patient. Pediatr Dent 1992;14(3):167-70.
  487. Primosch RE, Buzzi IM, Jerrell G. Effect of nitrous oxideoxygen inhalation with scavenging on behavioral and physiological parameters during routine pediatric dental treatment. Pediatr Dent 1999;21(7):417-20.
  488. McCann W, Wilson S, Larsen P, Stehle B. The effects of nitrous oxide on behavior and physiological parameters during conscious sedation with a moderate dose of chloral hydrate and hydroxyzine. Pediatr Dent 1996;18(1):35-41.
  489. Wilson S, Matusak A, Casamassimo PS, Larsen P. The effects of nitrous oxide on pediatric dental patients sedated with chloral hydrate and hydroxyzine. Pediatr Dent 1998;20(4):253-8.
  490. Pedersen RS, Bayat A, Steen NP, Jacobsson ML. Nitrous oxide provides safe and effective analgesia for minor paediatric procedures—a systematic review [abstract]. Dan Med J 2013;60(6):A4627.
  491. Lee JH, Kim K, Kim TY, et al. A randomized comparison of nitrous oxide versus intravenous ketamine for laceration repair in children. Pediatr Emerg Care 2012;28(12):1297-301.
  492. Seith RW, Theophilos T, Babl FE. Intranasal fentanyl and highconcentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation. Acad Emerg Med 2012;19(1):31-6.
  493. Klein U, Robinson TJ, Allshouse A. End expired nitrous oxide concentrations compared to flowmeter settings during operative dental treatment in children. Pediatr Dent 2011;33(1):56-62.
  494. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Breathing patterns and levels of consciousness in children during administration of nitrous oxide after oral midazolam pre-medication. J Oral Maxillofac Surg 1997;55(12):1372-7; discussion: 1378-9. 
  495. Litman RS, Kottra JA, Verga KA, Berkowitz RJ, Ward DS. Chloral hydrate sedation: the additive sedative and respiratory depressant effects of nitrous oxide. Anesth Analg 1998;86(4):724-8.
  496. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Guideline on use of nitrous oxide for pediatric dental patients. Chicago, IL: American Academy of Pediatric Dentistry; 2013. Available at: “http://www.aapd.org/media/policies_guidelines/g_nitrous.pdf”. Accessed May 27, 2016.

Supplemental information

Appendix 1.   Recommended Discharge Criteria 

  1. Cardiovascular function and airway patency are satisfactory and stable.
  2. The patient is easily arousable, and protective reflexes are intact.
  3. The patient can talk (if age appropriate).
  4. The patient can sit up unaided (if age appropriate).
  5. For a very young or handicapped child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved.
  6. The state of hydration is adequate.

Appendix 2.   ASA Physical Status Classification

Class I A normally healthy patient.
Class II A patient with mild systemic disease (e.g., controlled reactive airway disease).
Class III A patient with severe systemic disease (e.g., a child who is actively wheezing).
Class IV A patient with severe systemic disease that is a constant threat to life (e.g., a child with status asthmaticus).
Class V A moribund patient who is not expected to survive without the operation (e.g., a patient with severe cardiomyopathy requiring heart transplantation).

Appendix 3.   Drugs*  That May Be Needed to Rescue a Sedated Patient44

Albuterol for inhalation
Ammonia spirits
Atropine
Diphenhydramine
Diazepam
Epinephrine (1:1000, 1:10 000)
Flumazenil Glucose (25 percent or 50 percent)
Lidocaine (cardiac lidocaine, local infiltration)
Lorazepam
Methylprednisolone
Naloxone
Oxygen
Fosphenytoin
Racemic epinephrine
Rocuronium
Sodium bicarbonate
Succinylcholine

* The choice of emergency drugs may vary according to individual or procedural needs.

Appendix 4.   Emergency Equipment    That May Be Needed to Rescue a Sedated Patient ‡

Intravenous Equipment
Assorted IV catheters (e.g., 24-, 22-, 20-, 18-, 16-gauge)
Tourniquets
Alcohol wipes
Adhesive tape
Assorted syringes (e.g., 1-, 3-, 5-, 10-mL)
IV tubing
     Pediatric drip (60 drops/mL)
     Pediatric burette
     Adult drip (10 drops/mL)
     Extension tubing
     3-way stopcocks
IV fluid
     Lactated Ringer solution
     Normal saline solution
     D5 0.25 normal saline solution
Pediatric IV boards
Assorted IV needles (e.g., 25-, 22-, 20-, and 18-gauge)
Intraosseous bone marrow needle
Sterile gauze pads

Airway Management Equipment
Face masks (infant, child, small adult, medium adult, large adult)
Breathing bag and valve set
Oropharyngeal airways (infant, child, small adult, medium adult, large adult)
Nasopharyngeal airways (small, medium, large)
Laryngeal mask airways (1, 1.5, 2, 2.5, 3, 4, and 5)
Laryngoscope handles (with extra batteries)
Laryngoscope blades (with extra light bulbs)
     Straight (Miller) No. 1, 2, and 3
     Curved (Macintosh) No. 2 and 3

Endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, and 6.0 uncuffed and 6.0, 7.0, and 8.0 cuffed)
Stylettes (appropriate sizes for endotracheal tubes)
Surgical lubricant
Suction catheters (appropriate sizes for endotracheal tubes)
Yankauer-type suction
Nasogastric tubes
Nebulizer with medication kits
Gloves (sterile and nonsterile, latex free)

† The choice of emergency equipment may vary according to individual or procedural needs.
‡ The practitioner is referred to the SOAPME acronym described in the text in preparation for sedating a child for a procedure.