A Child Needs Sedation: When Is It OK?

Krista Preisberga, MD


January 25, 2013

What Are the Best Recommendations?

Several general recommendations can be made in light of the information presented:

  1. Preoperative assessment should include an evaluation for factors that would increase chances of aspiration, including gastroesophageal reflux disease, dysphagia, gastrointestinal motility disorders, and potential for difficult airway management. ASA class should be determined.

  2. For elective procedures, such as medical imaging, it is prudent to maintain the standard NPO times as recommended by ASA. Despite a significant deficiency in evidence supporting recommended fasting times, until more information and new guidelines are published, adherence to current standards of practice should continue.

  3. Children requiring semiurgent procedures, such as laceration repair, clean wound irrigation, imaging, or shoulder reduction, can receive any level of sedation if the child has received only clear liquids within the past 3 hours. Moderate or dissociative sedation may be used if the child has had nothing more than a light snack in the past 3 hours. Deep sedation should be avoided.

  4. The depth of sedation for urgent procedures, such as debridement and repair of animal bite wounds, acute burn management, arthrocentesis for suspected septic arthritis, lumbar puncture in suspected sepsis, eye irrigation for ocular trauma or chemical burns, and emergent cardioversion, can be tailored similarly to the recommendation for sedation for semiurgent procedures. The length of deep sedation, if needed, should be minimized.

  5. Proper patient monitoring and postsedation observation should always be maintained. A provider should be dedicated to sedating the patient and should not be assisting or performing the procedure. That clinician should always be trained to rescue a patient 1 level deeper than the intended sedation depth.

Case Conclusion

The patient described above had a light meal 3 hours ago. The emergency department staff should proceed with reduction with the goal of moderate sedation without further delay. He is considered a low-risk patient given his unremarkable medical history. While strict NPO guidelines would dictate waiting an additional 3 hours to perform the sedation, the goal for this scenario is moderate to brief deep sedation, and there is a low risk for adverse events expected in this patient. However, close observation and monitoring during the procedure by dedicated personnel should be ensured.