Use of sedation and local anesthesia to prepare children for procedures

Author: Theodore Sectish
Date: Feb 15, 1997

Analgesic and sedative needs depend on the type of procedure, the child's age and the degree of cooperation from the child and parents. Local anesthesia, which may be administered subcutaneously or in topical gel form, generally is sufficient for common procedures such as lumbar puncture and laceration repair. Frequently used local anesthetics in children include buffered lidocaine, the eutectic mixture of lidocaine and prilocaine and the combination of tetracaine, adrenaline and cocaine. To reduce the potential for systemic absorption and toxicity, anesthetics should not be applied on or near mucosal areas. To minimize drug interactions, only a single sedating drug should be used, with dosage limits defined and never exceeded. If sedation is necessary, continuous pulse oximetry, a resuscitation cart and personnel trained in sedative drug use and advanced airway management must be available. Because of its therapeutic index and low toxicity, chloral hydrate has long been a popular sedative-hypnotic drug. Midazolam may be considered when amnesia is desired.

Although children require local anesthesia and/or sedation for many procedures (Table 1), the office-based physician typically performs only a small number of these procedures, including lumbar puncture, laceration repair and various types of imaging procedures. This article focuses on the assessment of pediatric patients for sedation, the care of the sedated child and the options for sedation and local anesthesia in children undergoing common office procedures.

TABLE 1 Procedures That May Require Local Anesthesia or Sedation in Children

Bone marrow aspirationBrainstem auditory evoked potentialCardiac catheterizationComputed tomographyDental procedureEchocardiographyElectroencephalographyEndoscopyInterventional radiologyLaceration repairLaser therapyLiver biopsyLumbar punctureMagnetic resonance imagingNuclear medicine studyOrthopedic manipulationRadiation therapySexual abuse examinationWound debridementVoiding cystourethrogram

When an infant or a child is to undergo an imaging procedure, the primary care physician may be asked to consult with the radiologist or to facilitate the imaging study by administering sedation to immobilize the patient. However, many imaging procedures may be performed successfully without sedation. Infants less than three months of age may sleep adequately during a procedure after an interval of sleep deprivation if appropriate feeding guidelines are followed to minimize hunger and ensure a calm infant. According to these guidelines, an infant should be given no milk or formula for six hours before a procedure, but the infant may receive clear liquids for up to three hours before the procedure. With supportive personnel and preprocedure educational efforts to minimize anxiety or apprehension, children six years of age or older may not require sedation for many procedures.

After the assessment is complete, risk is considered and the decision to administer analgesia and/or sedation is made. The procedure and analgesic and sedative needs are discussed with the parents, and informed consent is obtained. By explaining the rationale for the therapeutic choice and the logistics of the procedure, the physician engages the child's parents as partners in the process and reinforces the parents' supportive role throughout the procedure.

CARE OF THE SEDATED PATIENT

Guidelines for monitoring patients under the influence of sedating drugs have been developed by national organizations, including the American Academy of Pediatrics (AAP).[9] The Joint Commission for Accreditation of Hospital Organizations expects medical institutions and individual physicians to follow these guidelines, which provide a safety net to ensure an optimal outcome. Basic elements of care include the following:

1. Trained personnel should be present during the procedure. These individuals must be able to monitor and respond to the patient during sedation, and they must have expertise in the use of the drugs and advanced airway management techniques. These skilled professionals must be available to the patient and should not be assisting in the procedure.

2. Special equipment, including continuous pulse oximetry and a resuscitation cart, must be immediately available facilitate intervention if the patient has minor airway problem or requires cardiopulmonary resuscitation. The mo common intervention entails repositioning the airway when respiratory depression induced by the sedating drug relaxes the tone of the upper airway muscles, compromising the airway.

3. The physician who will be responsible for the child's sedation needs and who is to manage any adverse side effects of drugs needs to be identified. Depending on the type of procedure, it may be necessary to assign this responsibility to physician who is not involved in the procedure and who can give full attention to the sedation needs of the child.

4. Vigilance on the part of all personnel is the key element in ensuring patient safety, since oversedation can occur even within safe dosage ranges.

5. Time-based recordings of assessment and monitoring must be done by trained personnel until the patient has fully recovered from the effects of the sedating drug.

6. Explicit discharge criteria must include stable vital signs, a responsive patient with intact protective reflexes and the presence of a responsible adult who may assist the patient with transportation needs.

SEDATION OPTIONS FOR COMMON OFFICE PROCEDURES

Physicians should adhere to the following guidelines for sedative selection and use:

1. The list of possible drug choices should be limited, and the physician should know the pharmacokinetics of each drug.

2. To minimize drug-drug interactions, only a single sedative agent should be used.

3. Dosage limits should be defined, and these limits should never be exceeded.

4. Some failures of sedation should be expected.

Because of individual variation in the response to sedating drugs, it is impossible to achieve success in every patient. For the patient's safety, caution must be exercised and predefined dosage limits should be used. Although it is tempting to give a small additional dose when the patient is not adequately sedated, it is prudent to reschedule the procedure with a new plan for sedation if the maximum dosage has been administered. Because conscious sedation and deeper levels of sedation exist on a continuum, patients may progress quickly to a state of general anesthesia and may then require airway management, oxygen administration and ventilatory assistance.

In one survey,[10] the sedative drugs most commonly used in children were, in descending frequency of use, as follows: chloral hydrate; the lytic cocktail consisting of meperidine (Demerol), promethazine (Phenergan) and chlorpromazine (Thorazine), referred to as DPT; pentobarbital (Nembutal); diazepam (Valium); midazolam (Versed); morphine sulfate, and fentanyl (Sublimaze). Note that the AAP recently asked for a reappraisal of the use of DPT, since this combination often produces prolonged sedation and has an unacceptable side effect profile.[11]

The two sedatives that are most useful during procedures in infants and children are chloral hydrate and midazolam. Dosage guidelines for these agents are presented in Table 4.

TABLE 4 Dosage Guidelines for Use of Chloral Hydrate and Midazolam in Infants and Children

Chloral hydrateDosage: 50 to 100 mg per kg, to a maximum of 2 gOnset of action: 30 to 60 minutes, but varies based on absorptionDuration of action: four to eight hours but varies, and prolonged sedation is possibleSide effects: vomiting, behavioral changeCautions: erratic absorption may delay effect or lead to prolonged sedationToxicity: respiratory depressionMidazolam (Versed)Dosage: 0.05 to 0.10 mg per kg administered intravenously, with a maximum intravenous dose of 5 ma; 0.5 mg per kg administered orally, with a maximum dose of 25 mg (the oral route is currently unapproved)Onset of action: five to 15 minutes with intravenous administration; 30 to 60 minutes with oral administrationDuration of action: two hours after onset of actionSide effects: amnesiaCautions: because of the potential for respiratory depression, caution should be exercised when midazolam is given with other sedative-hypnotics or with opiatesToxicity: respiratory depression

In children, midazolam is used for medical situations in which anxiety reduction or amnesia is desired. For painful procedures, this medication needs to be given in combination with a local or systemic analgesic. Because of the potential for respiratory depression, caution should be exercised when midazolam is given with other sedative hypnotics or with opiates.

Selecting an Appropriate Agent

The primary care physician who is considering analgesia and/or sedation for an office-based procedure in an infant or a child should begin the process with an assessment of the patient. The physician also needs to review the requirements of the procedure and the characteristics of the pharmacologic agents that may be used. In addition, planning for the procedure also includes plans for monitoring and for observation from the time the patient is under the influence of the sedating drug to the time the patient is fully recovered and has met explicit discharge criteria. Suggested sedative and analgesic options for common office procedures are as follows:

1. A local anesthetic such as EMLA or buffered lidocaine should be used for lumbar puncture. Sedation with midazolam or chloral hydrate should be considered only if the patient is extremely anxious or repeated lumbar punctures are anticipated.

2. TAC or buffered lidocaine (or, in the future, LAT) should be used for analgesia in laceration repair. Sedation should be considered only if the procedure is lengthy or the patient is expected to be unusually uncooperative.

3. For imaging studies, no analgesia is required unless invasive procedures are necessary. Sedation is preferred to minimize movement artifact. The choice of sedative drug depends on the time needed for the sequence of images.

With knowledge and good clinical judgment, the primary care physician can use analgesia and sedation to prepare an infant or child for a procedure, to relieve pain, to minimize anxiety and to optimize outcome.

REFERENCES

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The Author

THEODORE C. SECTISH, M.D. is director of the residency training program in the Department of Pediatrics at Stanford University School of Medicine, Palo Alto, Calif., where he also serves as inpatient medical director on the general medical wards at Lucile Salter Packard Children's Hospital. Dr. Sectish received his medical degree from the Johns Hopkins University School of Medicine, Baltimore, and completed a pediatric residency at Children's Hospital, Boston. Before assuming his present position, he was in private pediatric practice in Salinas, Calif.

Address correspondence to Theodore C. Sectish, M.D., Residency Training Program/ Department of Pediatrics, Lucile Salter Packard Children's Hospital, 725 Welch Rd. Palo Alto, CA 94304.

The author thanks his residency coordinator, Pamela Rowe, for helping in the preparation of this manuscript and Carrie Tsang, Pharm.D., for providing pharmacokinetic information.

Richard W. Sloan, M.D., RPM., coordinator of this series, is chairman and residency program director of the Department of Family Medicine at York (Pa.) Hospital and clinical associate professor in family and community medicine at the Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pa.

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