REVIEW ARTICLES
Review of Pediatric Sedation
Joseph P. Cravero, MD, and George T. Blike,
Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
Sedating children for diagnostic and therapeutic proce-
dures remains an area of rapid change and considerable
controversy. Exploration of this topic is made difficult by
the fact that the reports of techniques and outcomes for
pediatric sedation appear in a wide range of subspecialty
publications and rarely undergo comprehensive exami-
nation. In this review article, we will touch on many as-
pects of the topic of pediatric sedation from the perspec-
tive of the anesthesiologist. We begin with a review of the
historical role of anesthesiologists in the development of
S
edating children for diagnostic and therapeutic
procedures has engendered debate both within
and between the myriad of pediatric specialists
who provide this service. In hospitals across the
United States, there is little agreement as to which
medications, techniques, practice settings, or even per-
sonnel should be involved in its delivery. Confound-
ing any discussion of solutions to this quandary is the
fact that there has been scant discussion as to what
defines success (or best practice) in sedating children.
Furthermore, few aspects of anesthesia practice lead to
as much confusion over the exact role of the pediatric
anesthesiologist. (It is interesting to note that when the
New England Journal of Medicine published a review
article on pediatric sedation, it was written by two
emergency medicine physicians (1).) Perhaps now
more than ever, reflection is required on the state of
the art of pediatric sedation and the key areas where
anesthesiologists can function to help optimize its
safety and efficacy. In this review, we will seek to
examine the past role of anesthesiologists in shaping
the field of pediatric sedation, the current status of
pediatric sedation as reflected by the literature, and
goals for improving future practice.
Accepted for publication May 20, 2004.
Address correspondence and reprint requests to Joseph P.
Cravero, MD, Department of Anesthesiology, Dartmouth Hitchcock
Medical Center, One Medical Center Dr., Lebanon, NH 03756. Ad-
dress e-mail to Joseph.Cravero@Hitchcock.org.
DOI: 10.1213/01.ANE.0000134810.60270.E8
©2004 by the International Anesthesia Research Society
0003-2999/04
MD
the current standards for pediatric sedation. We also ex-
amine the current status of pediatric sedation as reflected
in published studies and reports. A specific review of the
issues surrounding safety of sedation services is included.
Current trends in sedation practice, including the expand-
ing role of potent sedative hypnotic drugs outside the
field of anesthesiology, are noted. Finally, we suggest fu-
ture areas for research and clinical improvement for seda-
tion providers.
(Anesth Analg 2004;99:1355–64)
The Historical Role of Anesthesiologists
Reports relating to specific involvement by anesthesi-
ologists in pediatric sedation are rare before the early
1980s. Arguably, the most significant contribution of
our specialty has been in the development of sedation
guidelines, which subsequently became international
standards. The first monitoring guideline for sedation
was written by Dr. Charles Coté and Dr. Theodore
Striker in 1983 (published in 1985) while working on
behalf of the American Academy of Pediatrics (AAP)
Section on Anesthesiology. This guideline was written
in response to reports of three deaths in a single dental
office and other concerns primarily involving dental
sedation (2). Written with the cooperation of the
American Academy of Pediatric Dentistry and the
American Society of Anesthesiologists (ASA), the pur-
pose of the guidelines was to develop a framework
from which improved safety could be developed for
children requiring sedation to perform a required pro-
cedure (3,4). The guideline emphasized systems is-
sues, such as the need for informed consent, appro-
priate fasting before sedation, frequent measurement
and charting of vital signs, the availability of age and
size appropriate equipment, the use of physiologic
monitoring, the need for basic life support skills, and
proper recovery and discharge procedures. The con-
cept of an independent observer whose only respon-
sibility was to monitor the patient was introduced for
deeply sedated pediatric patients. Advanced airway
and resuscitation skills were encouraged but not re-
quired. Finally, these original guidelines defined three
terms for depth of sedation: conscious sedation, deep
sedation, and general anesthesia. The descriptive term
Anesth Analg 2004;99:1355–64 1355
1356 REVIEW ARTICLES CRAVERO AND BLIKE
REVIEW OF PEDIATRIC SEDATION
conscious sedation was defined as, “A medically con-
trolled state of depressed consciousness that allows
the protective reflexes to be maintained; retains the
patient’s ability to maintain a patent airway indepen-
dently and continuously; and permits an appropriate
response by the patient to physical stimulation or
verbal command, e.g., ‘open your eyes’.” In retrospect,
the choice of this terminology was unfortunate, be-
cause this condition is rarely attained in sedated chil-
dren, and its use led to confusion and promoted prac-
tices that were not intended by the original guideline.
In 1992, the Committee on Drugs of the AAP (pri-
mary author Dr. Coté) revised the 1985 guideline (5).
This new iteration clearly stated that a patient could
readily progress from one level of sedation to another
and that the practitioner should be prepared to in-
crease vigilance and monitoring as indicated. Pulse
oximetry was recommended for all patients undergo-
ing sedation. This new guideline also discouraged the
practice of administering sedation at home by par-
ents—a practice that was not infrequent in dental and
radiologic sedation at that time. An amendment to this
guideline was produced by the same Committee on
Drugs of the AAP 2002 (6). It eliminated the use of the
term “conscious sedation” and clarified the fact that
these guidelines apply to any location where children
are sedated, including in or out of the hospital. The
current guidelines use the terminology of minimal
sedation, moderate sedation, deep sedation, and anes-
thesia. This language is consistent with that used by
the ASA and the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) (7).
Contemporaneous with the guideline development
described above, other organizations including the
American Academy of Pediatric Dentistry and the
American College of Emergency Physicians wrote
their own guidelines for sedation (8,9). These guide-
lines were at odds with the AAP/ASA guidelines in
some respects, perhaps most importantly in their def-
inition of sedation levels themselves. The result has
been considerable confusion when practitioners or
regulatory requirements overlap. Whereas the situa-
tion will not be resolved quickly, the AAP guidelines
are once again being revised, and dialogue with these
organizations has been initiated toward the goal of a
unified nomenclature and consistent recommenda-
tions for pediatric sedation.
Current Status Evaluation
It is difficult to fully comprehend the current status of
pediatric sedation because the reports concerning this
practice are published in such a wide range of journals,
and the outcome measures used vary so greatly. What
we do know is that each year, millions of infants and
children require sedation and pain control for medical
ANESTH ANALG
2004;99:1355–64
procedures. Hospitals and offices struggle with the lo-
gistical and medical difficulties associated with provid-
ing this service. There is often heavy demand for pedi-
atric sedation services throughout the usual work day as
well as off hours, and these cases must be performed in
a wide variety of locations involving many different
services, including radiology, dentistry, pediatric inpa-
tient service, emergency department, and nuclear med-
icine. The difficulty in meeting these demands was
pointed out in a study that found centers in the United
States were much less likely to offer sedation for painful
procedures than similar centers in Europe (10). Thirty
percent of US respondents to this mail survey reported
performing bone marrow biopsies in children without
significant sedation more than 50% of the time as com-
pared with 0% of European centers.
Attempts to accommodate the need for pediatric se-
dation have led to the formulation of a wide variety of
possible solutions. Some sedation services have opted
for direct physician involvement, whereas others are
directed by trained nursing personnel (11–13). Still, oth-
ers have developed the concept of a sedation room or a
sedation team combining provider types (14 –18).
Outcomes
When sedation is attempted for pediatric procedures,
the reported efficacy of the various sedation system
options differs considerably. The major goals of pedi-
atric procedural sedation may vary with the specific
procedure, but generally encompass anxiety relief,
pain control, and control of excessive movement. The
rate of failure to achieve these goals has been reported
by various investigators to be as infrequent as 1%–3%
(19 –22) and by others to be as frequent as 10%–20%
(23–28). Success rates not only depend on the setting
(including the provider) and the type of procedure
that is being performed, but also on the definition
used for adequate or successful sedation. In most pub-
lished studies, any sedation regimen that allows a
procedure to be completed is counted as successful
(29). We are rarely informed of the condition of the
patient during the procedure or during the recovery
period. In this way, a child who is given a dose of oral
midazolam and cries or screams during a lumbar
puncture and then sleeps for 2 h is considered an
equal success as the patient who lies perfectly still
under brief propofol sedation, although objective ob-
servers would clearly count one strategy a success and
the other a failure.
When sedation fails, procedures are performed on
children who are crying, struggling, and requiring
significant restraint. This situation leads to unwanted
stress in the child and family, adverse procedure out-
comes, and care that is generally less effective (30).
ANESTH ANALG
2004;99:1355–64
Theroux et al. (27) described the common practice of
suturing children who have lacerations without seda-
tion using only local anesthesia and papoose boards to
restrain noncompliant patients. As expected, adding
sedation dramatically reduced crying and struggling
and increased parental satisfaction. Similarly, Stok-
land et al. (31) documented decreased stress (and in-
creased satisfaction) in a cohort of patients undergo-
ing voiding cystourethrogram studies. Kain et al. (32)
found inadequate preoperative sedation was clearly
linked to anxiety in children and their families sur-
rounding surgical procedures. Even more concerning,
these investigators documented that 54% of children
undergoing stressful anesthesia induction have post-
operative maladaptive behaviors. Furthermore, they
found that the incidence of these behaviors could be
decreased through the use of appropriate sedation.
Similar findings of post-traumatic stress syndrome
have been documented in a population of children after
hospitalization with repeated invasive procedures (33).
Diagnostic procedure quality suffers when subopti-
mal sedation leaves movement uncontrolled, particu-
larly in radiology practice. Malviya et al. (34) have re-
ported clear improvement in the quality of magnetic
resonance imaging (MRI) scans performed using anes-
thesia as compared with moderate sedation. In addition,
when movement is grossly excessive, procedures must
often be rescheduled with an expert sedation service
providing the sedation. This logically leads to significant
increases in cost of the procedure because of lost time in
the scanner and lost work time for care providers. Mul-
tiple centers report cancellation rates as much as 15% for
radiological procedures (MRIs, CT scans, etc.) in children
because of excessive movement (23,24,35). Rates of fail-
ure in this setting decrease dramatically when sedation is
provided by a dedicated team, by implementing clear
protocols (28,36), or when anesthesiologists provide se-
dation (37).
The manner in which length of duration of sedation
matches the requirements for a procedure must also be
considered in evaluating the success of a sedation tech-
nique. A case in point is the (still very) common use of
chloral hydrate for CT scans or other brief procedures
(26,38 – 40). Whereas many reports catalog successful
completion of studies without injury to patients, one
must ask whether 60 –150 min of sedation is appropriate
for a 5-min study. Perhaps even more important are the
delayed side effects described by Malviya et al (41).
These investigators found restlessness and agitation last-
ing more than 6 h in one-third of children undergoing
neuroimaging with chloral hydrate sedation, 5% of
whom did not return to their baseline activity for 2 days
after their procedure. The financial implications of lost
workdays for parents and return visits to emergency
departments have never been fully considered in studies
of long-acting sedatives used for brief procedures.
REVIEW ARTICLES CRAVERO AND BLIKE 1357
REVIEW OF PEDIATRIC SEDATION
Trends
Pediatric sedation practice extends over a diverse group
of medical specialties (anesthesiology, intensive care
medicine, emergency medicine, and radiology) and pro-
vider types (registered nurse [RN], advanced registered
nurse practitioner, certified registered nurse practitioner,
physician assistant, and MD). Whereas this makes defin-
itive statements about the direction of current practice
difficult, we believe several trends are evident:
1. Propofol sedation delivered by nonanesthesiolo-
gists is a growing practice across the country. This is
particularly true in the intensive care environment
and the emergency department. Most of the literature
regarding this practice is found in the intensive care
literature, where the virtues of propofol’s rapid onset
and recovery are extolled. A common model that is
being promoted is that of the intensive care unit (ICU)
sedation team headed by an intensivist using some
portion of the pediatric ICU to run a pediatric sedation
service (17,42– 44). This practice is made more attrac-
tive by the fact that many of these practitioners can be
credentialed in the hospital to deliver this care and
will bill under anesthesia codes (45). Other models,
such as the initiation of propofol sedation in the ICU
and sending patients with RN monitors to other loca-
tions in the hospital have also been reported (14). Use
in dentistry, oral surgery, endoscopy, and radiology
has also been advocated by nonanesthesiologists
(25,35,46 –51). Two new studies describe the use of
propofol for procedural sedation by emergency phy-
sicians (52,53). All of these reports are notable for the
fact that they represent nonanesthesiologists inform-
ing other nonanesthesiologists on the proper tech-
nique for administering propofol. Their recommenda-
tions for use and treatment of minor side effects are
not always in line with those of anesthesiologists (54).
2. Although it is certainly not a new drug, ketamine
sedation has experienced a resurgence in popularity,
particularly in the emergency department—if pub-
lished studies and reports are any indication of prac-
tice. IM and IV ketamine (with and without midazo-
lam) are favorite strategies for accomplishing closed
fracture reductions and other painful minor proce-
dures in this setting (19,55– 63). Authors site the lack of
respiratory depression and the maintenance of airway
reflexes as great advantages for ketamine over other
sedation options. Its effectiveness in producing ade-
quate sedation for painful procedures is excellent.
However, postsedation nausea and vomiting, emer-
gence reactions, and infrequent episodes of laryn-
gospasm continue to be cited (64 – 66) with its use.
Leading proponents of the use of ketamine suggest
that it should be considered in its own separate
category of sedation— dissociative sedation—and
1358 REVIEW ARTICLES CRAVERO AND BLIKE
REVIEW OF PEDIATRIC SEDATION
that guidelines concerning its use should reflect this
unique nature (67).
3. Led by emergency physicians, the applicability of
nil per os (NPO) guidelines, which have been propa-
gated for pediatric sedation as an extension of anes-
thesia practice, have been called into question (68 –70).
Although the largest prospective or retrospective
studies involving this practice are still relatively small
(1500 patients), the authors point out that there seems
to be little evidence for patient harm. In addition,
these investigators point out that there are no case
reports of aspiration during pediatric sedation in the
emergency department, regardless of NPO status.
These studies drive home the fact that sedation of
nonfasted children is commonplace in the emergency
department setting, and publication of prospective
data on the outcomes of this practice may ultimately
impact thinking on this issue for elective sedation.
4. Finally, a review of the current literature reveals
that specialists outside of anesthesiology continue to ex-
pand their repertoire of medications used for pediatric
sedation to include those normally associated with gen-
eral anesthesia, attaining depths of sedation that un-
doubtedly reach this level. The published literature out-
side of anesthesiology is replete with descriptive or
randomized studies of small numbers of patients under-
going procedures with one deep sedation regimen or
another (17,43,46,52,71,72). At the same time, reports of
sedation experience and innovation are relatively rare in
the anesthesia literature, probably because this work is
considered so routine as to not be worthy of reporting.
The result is the perception by other medical specialists
that pediatric sedation is evolving into the domain of
intensivists and emergency medicine specialists, where
anesthesiologists are experts in the operating room
domain.
Current Sedation Strategies
Pediatric sedation technique should ideally be custom-
ized for the patient and the procedure to be performed.
For example, a distinction should be made as to whether
the procedure will involve significant discomfort. Non-
painful procedures, such as MRI scans or nuclear scans,
are best accomplished with a rapid acting pure sedative
such as propofol. The effectiveness and smooth recovery
characteristics of this drug are familiar to anesthesiolo-
gists and without peer for this application. Indeed it is
the clear advantages of propofol that have caused non-
anesthesiologists to gravitate toward its use, despite con-
cerns about monitoring and airway management skills.
Alternatively, for painful procedures such as a bone
marrow biopsy, procedural conditions are improved by
the addition of an analgesic component such as a small
dose of fentanyl, infusion of remifentanil, or the use of
ANESTH ANALG
2004;99:1355–64
ketamine as a sedation adjunct. Additionally, patient
factors, such as hemodynamic instability because of car-
diomyopathy, make the choice of a drug such as etomi-
date preferable to propofol in some instances.
Finally, the personnel involved in monitoring and
delivering pediatric sedation will influence the choice
of sedation drug. When anesthesiologists are deliver-
ing sedation, any of the currently available sedative
hypnotics and analgesics can be brought to bear on a
given case. When a sedation system is configured with
nurse providers, drugs with a very wide safety mar-
gin, such as chloral hydrate and pentobarbital, are
usually selected. As mentioned above, the willingness
and ability of nonanesthesiologist MDs to use potent
sedative hypnotics is an area of evolution at this time,
but the published trend is clearly toward expansion of
the use of these drugs outside of anesthesiology
(17,43,46,52,71,72).
With these caveats in mind, we have constructed
Table 1(73– 88) to represent some of the most common
current strategies for sedation of children. This is not
meant to be an all-inclusive listing, but rather it is a
catalog of the most common medications for sedation
based on literature review, discussion with colleagues,
and personal experience.
Of course, any of the painful procedures mentioned
could be accomplished through the use of potent in-
haled anesthetics. There is one recent study (30) that
showed improved satisfaction and procedural condi-
tions when general anesthesia was used instead of
midazolam for moderate sedation for painful oncol-
ogy procedures. Whereas this is always an option,
inhaled anesthesia, which requires the use of an anes-
thesia machine and appropriate scavenging equip-
ment, can lead to undesired emergence phenomena
(89). For the purposes of this review, we will focus on
sedation delivered by other routes and include only
nitrous oxide for inhalation.
Note: We have not included a discussion of local
anesthetics; their use is very important for any proce-
dural sedation provider. Appropriate application of
local anesthesia may allow pure sedative use for an
otherwise painful procedure because it may constitute
the analgesic component of the sedation plan. Large
doses of local anesthetics may have their own sedating
effects and add to the sedation that is produced by
other drugs and deepen the sedation level achieved.
Safety Issues in Pediatric Sedation
Statistics
The safety of pediatric sedation practice has proven
difficult, if not impossible, to assess with prospective
ANESTH ANALG REVIEW ARTICLES CRAVERO AND BLIKE 1359
2004;99:1355–64 REVIEW OF PEDIATRIC SEDATION

Table 1. Sedation Regimens for Children

Drug regimen Dose/route of administration
⫺1 ⫺1
Propofol 100–200 ␮g 䡠 kg 䡠 min
Pentobarbital 4–6 mg/kg IV or PO
Midazolam 0.5–0.75 mg/kg PO
0.025–0.5 mg/kg IV
0.2 mg/kg intranasal
Chloral hydrate 50–100 mg/kg PO
Etomidate 0.1–0.4 mg/kg IV
Methohexital (not readily 0.25–0.50 mg/kg IV
available at this time) 20–25 mg/kg rectal
Propofol with fentanyl Fentanyl 1–2 ␮g/kg IV with
Propofol 50–150 ␮g/kg IV
Midazolam with fentanyl Midazolam 0.020 mg/kg IV
Fentanyl 1–2 ␮g/kg IV
Ketamine 3–4 mg/kg IM
1–2 mg/kg IV
Remifentanil 0.1 ␮g 䡠 kg⫺1min⫺1
Nitrous oxide 50% in 50% oxygen, up to
70% used by some.
Comments (general citations at end of text)
IV Ideal agent for nonpainful diagnostic procedures. Only for
use by expert airway managers with good back-up
systems. (25,46,73)
Long history of effective use in radiology imaging.
Emergence can be prolonged. (11,74)
Track record of safe use both PO and IV. Paradoxical
reactions are not infrequent. Intranasal route is so irritating
we do not recommend it. (38,51,75)
Still the most popular drug for radiologic sedation in
community hospitals. Prolonged sedation and paradoxical
reactions are reported. Monitoring required. (25,39,74)
Emerging use in emergency medicine for brief painful
procedures, although no intrinsic analgesic effect. (72,76,77)
Post sedation nausea reported. Little effect on heart rate
and blood pressure in most cases.
Effective sedation in IV form. Rectal route is not
recommended because of high frequency of apnea/
desaturation events. (78–80)
Best for deep sedation/anesthesia. Risk of requiring
advanced airway management is high. (13,81)
Most common combination for painful procedures in the
emergency department. Risk of apnea and hypoxia is
significant (61,82)
Effective sedation and analgesia for painful procedures.
Relatively common nausea and vomiting after procedure.
Layngospasm reported. (55,63,71) Best if combined with an
anticholinergic for control of secretions. Combination with
midazolam is common, although effectiveness in treating
emergence dysphoria is debated.
Emerging use in pediatric sedation, exclusively by
anesthesiologists at this point—apnea a significant risk.
(13,83–85)
Long history of safe use providing moderate sedation for
minimally moderately painful procedures. Care must be
taken when used in addition to other sedatives (?local
anesthetics) where deep sedation can easily result. (86–88)

studies. There are simply no large, sufficiently pow-
ered, multicentered trials to evaluate safety in this
context. Instead, the literature is replete with descrip-
tions of how sedative medications can be used in a
variety of settings on a series of patients (usually less
that 200 in a cohort) without a fatality (38,51,55,76,79,90).
Given that the expected incidence of a sedation-induced
crisis should be on the order of 1 in tens of thousands, it
is not surprising that these studies rarely uncover a
critical event. In fact, if a study were designed to detect
a difference between one sedation method with a fatality
rate of one in 5000 compared to another method with a
fatality rate of one in 20,000, the study would require
more than 50,000 patients in each group.
Efforts to detect safe or unsafe practice from epide-
miological studies will require large cooperative data-
bases that have the power to detect (what should be)
rare events. Alternatively, techniques are required
that will reveal much more detail of our current prac-
tice and investigate the potential impact (or lack of
importance) of desaturation events or other minor
complications.
Defining Safety in the Context of Pediatric
Sedation
In addition to these statistical difficulties, we must
define the nature of safety and what constitutes com-
plications. Science has taught us that error and failure
in complex systems can be thought of in terms of
accomplishing the work goal and avoiding or manag-
ing side effects. The focus on sedation safety tends to
be directed towards how often a sedative drug pro-
duces an unwanted side effect or toxicity. In this con-
text, the most serious complication of pediatric proce-
dural sedation, death, is most often caused by the
unmanaged respiratory depressant side effect of sed-
ative medications. Although an incidence of death or
permanent neurological injury during pediatric seda-
tion is impossible to calculate because of a lack of data,
1360 REVIEW ARTICLES CRAVERO AND BLIKE
REVIEW OF PEDIATRIC SEDATION
evaluation of the published literature on pediatric se-
dation indicates that these events are rare (29). How-
ever, sedation is a prevalent situation (millions of
children receive sedation annually) (91). In their often-
cited retrospective studies, Dr. Charles Coté et al. re-
viewed 95 cases of sedation-related deaths and critical
incidents derived from the Food and Drug Adminis-
tration’s adverse drug event reporting system from
the US Pharmacopeia and from a survey of pediatric
specialists (92,93). Their analysis revealed that (rather
than being related to a specific medication) the over-
whelming majority of critical events were preventable
and caused by operator error or lack of robust rescue
systems when incidents occurred. Whereas many of
the incidents cited in this study occurred over 20 years
ago, and therefore predated the implementation of
AAP sedation guidelines, the findings in this study
were similar to those in all high-risk fields and are
likely applicable today. In fact, even when clinicians
adhere to current practice guidelines for pediatric pro-
cedural sedation, there is risk of iatrogenic injury. One
study prospectively followed 1140 children (age, 2.96
⫾ 3.7 yr) sedated for procedures by nonanesthesiolo-
gists following AAP guidelines and using a quality
assurance tool. Approximately 13% of the children
received inadequate sedation. They also reported a
5.3% incidence of respiratory events, including one in
which a child stopped breathing (23).
Most prospective studies of sedation practice avail-
able at this time do little to clarify what is meant by
safety in pediatric sedation. Authors will invariably
cite the incidences of hypotension, hypoxia, and air-
way obstruction (and interventions required to rees-
tablish normoxia or normotension). However, as long
as no child is critically injured (or dies) during the
study, the conclusions are that their technique is safe
and effective (42,51,65,78,94). Despite the lack of pa-
tient injury or death, a detailed examination of the
data from some of these studies calls these conclusions
into question. Is the requirement to bag-mask 10% of
patients and intubate 1% of patients consistent with a
safe technique, or does this indicate that rescue sys-
tems in that institution are particularly robust? (43)
Safety can only be implied for the setting in which
these studies have taken place. In most cases, these are
large teaching hospitals with copious and readily
available assistance. In different settings with less ro-
bust rescue systems, the outcomes from these events
could be much more concerning.
Sedation is not a primary therapy but rather a treat-
ment of procedural side effects, such as pain, anxiety,
and dangerous movement. Failure to treat these side
effects with adequate sedation may help the provider
avoid respiratory depression but results in accom-
plishing the procedure through physical restraint. As
reviewed in the Outcomes section of this paper,
whereas no child may die of their pain or stress during
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2004;99:1355–64
a procedure, the psychological injury that accompa-
nies this type of error remains an unwanted (unsafe)
outcome of the care provided. We remember the his-
torical record of when surgery was performed before
the invention of adequate anesthesia. In many in-
stances, the psychological trauma was severe, and in
many cases, patients refused required surgery.
Whereas the psychological trauma associated with
unsedated bone marrow aspiration, lumbar puncture,
and urinary catheter placement on children has not
been quantified, post-traumatic stress disorder has
been well documented in children experiencing
trauma in the hospital setting (95,96). In addition, it is
logical that the safety of a given procedure may be
compromised when the operative conditions are poor.
For example, a thrashing, crying child receiving intra-
thecal chemotherapy is at increased risk for extradural
injection. In this safety framework, we strongly advo-
cate that sedation providers define as inadequate or
failure any sedation that results in patients who are in
severe distress during a procedure.
Simulation
Human simulation offers an extremely promising
technology in the promotion of pediatric sedation
safety. As with other industries that face high-risk,
infrequent events, simulators can be extremely helpful
in recreating rare clinical situations and testing the
response of individuals and systems to rescue patients
who are in respiratory or cardiovascular arrest (97–
99). At Dartmouth Hitchcock Medical Center, we have
piloted the use of the pediatric simulator to test the
response of sedation care providers to sedation emer-
gencies in three different areas of our hospital. The
resulting data revealed significant differences in the
time it took for different care teams to recognize and
rescue patients from apnea and hypoxia, varying from
⬍2 min to more than 6 min (100).
In a more widespread application, human simula-
tion is rapidly gaining popularity as a training tool for
care providers in anesthesiology and other specialties
(98,101,102). The use of this technology to train seda-
tion providers to recognize critical airway emergen-
cies and initiate resuscitation is already in place in
several institutions (103). Future work will need to
establish the validity of this type of training for pedi-
atric sedation and refine realistic scenarios.
Future Direction for Pediatric Sedation
Research
In considering the current status of pediatric sedation
and the safety issues involved, the future can either be
viewed as murky and disturbing or an opportunity to
provide clarity through collaborative research and
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clinical program development. To begin, there is a
need to better define the effectiveness and risks asso-
ciated with the various pediatric sedation protocols
that have been proposed in the last several years and
will be proposed in the future. As is the case with
anesthesia, large clinical trials or databases are re-
quired to sort out the frequency of critical events.
Information collected from the various institutions
and including providers from a multitude of pediatric
specialties and practice settings would allow meaning-
ful data analysis on which drugs are being used, how
they are delivered, by whom, and with what kinds of
outcomes.
Sedation vs. Anesthesia
The proliferation of the use of drug combinations in-
cluding propofol with potent opiates by nonanesthe-
siologists in the future will continue to force us to
examine the question as to where deep sedation ends
and general anesthesia begins. According to the ASA/
JCAHO/AAP criteria, the distinguishing characteris-
tic between these two entities is the presence or ab-
sence of a response to repeated painful stimuli.
Whereas most studies involving sedation do not de-
scribe the condition of sedated patients adequately
enough to determine the sedation level of the patient,
there is no doubt that many of the regimens used in
emergency departments and ICUs around the country
are evolving into recipes for brief general anesthesia
rather than sedation. In light of the fact that the dif-
ference between these two states can be subtle (pa-
tients can go in and out of a given state quite rapidly)
and that there is no practical way to police this prac-
tice, any effort to limit anesthesia by nonanesthesiolo-
gists for brief procedures in children is doomed to
failure.
In terms of promoting safety and generally good
sedation delivery, pediatric patients will be better
served by advocating for standards anesthesiologists
have successfully used to improve the safety of anes-
thesia care by 10-fold over the last 20 yr (104). Specif-
ically, all providers of deep sedation (that is, everyone
who sedates children for painful procedures) should
be able to rescue patients from side effects of general
anesthesia, as mandated by the JCAHO. To do this,
anesthesiologists need to demand that high standards
are met by these individuals. These should include,
but not be limited to, the following: (a) There should
be defined competencies in terms of airway manage-
ment (i.e., effective bag-mask ventilation), and these
skills should be demonstrated in clinical practice or
simulation setting; (b) Knowledge of disease entities
that impact sedation and anesthesia should be docu-
mented; (c) Familiarity with sedation drugs (doses,
side effects, and contraindications), reversal drugs,
and rescue medications should be documented; (d)
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REVIEW OF PEDIATRIC SEDATION
Intraprocedural monitoring should mirror those for
anesthesia, including optimal methods for monitoring
ventilation (capnography) as well as oxygenation; (e)
All equipment required for emergency interventions
such as masks, airways, suction, and ventilation bags
must be present for each sedation, and they must be
regularly checked and accounted for; and (f) Sedation
systems must have a quality improvement program
that examines its own outcomes on a continuing basis.
Reimbursement
The continued improvement of pediatric sedation
practice depends on the involvement of qualified pro-
fessionals. This involvement can only be guaranteed
through proper reimbursement. Unfortunately, reim-
bursement depends on payer mix, private insurer
commitment to sedation, and state medicaid reim-
bursement schedules. As such, there is no blanket
answer to the problem of making pediatric sedation an
attractive or practical pursuit. To assure reimburse-
ment is appropriate, anesthesiologists need to lobby
insurance companies and state agencies to assure that
payment is appropriate for this critical service.
Conclusion
Providing sedation to children is an area of rapid
change marked by evolving standards. Whereas anes-
thesiologists have played a critical role in establishing
guidelines for safe sedation, considerable work re-
mains in defining what represents effective and safe
practice. The overwhelming demographic demand for
pediatric sedation services has mandated that other
pediatric specialists and nurses deliver a wide range
of sedation outside the operating room. It is critical at
this time that anesthesiologists use their established
identity as the ultimate experts in this field with a
proven track record of practice improvement to assure
that clinical practice, training, and safety in this field is
optimized.
The authors would like to thank Charles Coté, MD, for his help in
compiling this review.
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