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PM Pediatrics
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Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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I Wanna Be Sedated

“Will she be asleep for this?”

I get this question a lot when I’m talking with parents about office medical procedures for their children.  No one likes to be or see a child uncomfortable or in pain, and expecting very young children to hold still for something like a spinal tap or stitches or abscess drainage while they’re scared and hurting can be both difficult and unrealistic.  As pediatric specialists, our primary goal is to make kids well and as pain-FREE as possible (and anxiety-free, for that matter).  But deciding whether or not to give sedation medicine for certain procedures isn’t as straightforward as it may seem.  Let’s look at a few of the issues.

First, there are different levels of sedation.

Many folks think that you are either “out cold” or fully awake, and procedural sedation, as it’s called (25 cent word) is really better thought of as a spectrum of inducing a decreased level of responsiveness.

There are some sedation medicines that may impair a patient’s coordination or thinking, but they’ll still respond normally to verbal commands.

Some other medicines depress the level of consciousness so deeply that a patient may not be easily aroused. This level of “arousability” may also apply to maintaining a clear airway and effective breathing, which can be risky business if not managed correctly.

And of course, there’s middle of the road sedation where patients require some light touch to be aroused but are otherwise quite sleepy.  Keep in mind that I’m not talking about general anesthesia in the operating rooms, where there is a complete loss of consciousness and clinicians are able to take over the patient’s breathing and all the body functions.

In this blog, I’m going to talk about sedation meant for simple office procedures (not taking away from the fact that the procedure can still be painful and a major drag) which require a patient to stay still. This kind of sedation is often used for a child who cannot be calmed down with distraction techniques alone during procedures like suturing, removal of a foreign object, reducing (setting) a fracture,  or draining an abscess.

Next, there are different ways to administer the sedation medicines.intranasal iv

Giving oral medicines for this purpose has fallen out of favor due to the variability and length of time it takes for the medicine to have an effect. Many Doctors, Physician Assistants, and Nurse Practitioners now choose  a quicker, more efficient way is to give it intranasally, like a nose spray. The medicine is absorbed rapidly into the lining of the nose where it gets into the body system and does the intended trick. The benefit here is that there’s no needle involved, which is great. The downside is that, in some children, there’s not as much of the sedative effect that’s desired.

 

Giving IV sedation is both rapid and effective, but it is a much bigger deal and involves a needle stick to establish the IV, plus very close heart and lung monitoring while the medicine is active.  IV sedation should be performed only by a specialist trained in pediatric sedation.

I bring this up because if your child needs to have procedural sedation for a procedure in an urgent care office or emergency department, it’s important to know that he/she will likely not be “knocked out.”  (S)He’ll be “loopy” (technical term here). The charm of these medicines is that they do have what we call an “amnestic effect,” so even if your child says some words or seems somewhat awake during the procedure, they most often won’t remember any of it.

I’m stressing all this because many parents seem concerned that the sedation might not be working unless their child is totally unarousable, and I want to assure everyone that, when performed correctly, this is not the case.  Everyone responds differently to these medicines of course, and they can be titrated (measured) very carefully to achieve the desired and appropriate effect with minimal risk of bad side effects, like depressing the respiratory drive if too much medicine is given.  We all want to avoid that kind of thing while practicing pain-LESS medicine!

It doesn’t make sense to give sedation medicine for every procedure.

Sometimes it really is better and quicker to just “get it over with.”  The risk/benefit balance must be considered. I try to use the rule of thumb that if the sedation component alone hurts just as much or takes as much time as the actual procedure, or if the procedure is very minor, then it might not be worth it to expose the child to these strong medicines.  It’s an individual decision for each child that should be made as a team between the parents, the child (when old enough), and the care team.

So if you are ever in the situation where your child is potentially facing a procedure with sedation, keep this in mind & ask:

  • Who will be performing/administering the sedation?
  • What kind of medicine is it and how is it given?
  • How long will it last?
  • What level of depressed consciousness is expected, if any?

I think if we all had more appropriate expectations of what will happen with any given set of sedation medicines, we’d do a better job helping our kids relax more, and we as parents can then do a better job focusing on other comfort and distraction measures (like calm music or quiet singing) that really can have a wonderful additive effect to every medicine out there.

Have a nice little snooze, I say.

Keep reading! Treating Children in the Urgent Care Setting

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