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Sedation for Procedural Pain
Skilled supervision is necessary whenever systemic pharmacologic agents are used for conscious sedation (i.e., the patient maintains a response to verbal and physical stimuli). At any site where painful procedures may be performed, patient-size-appropriate resuscitative equipment and resuscitative drugs should be immediately available to treat promptly any untoward effects. When conscious sedation is used, at least one health care professional who is well trained in airway management and advanced life support should be available. Patients should not eat or drink before procedures that use conscious sedation.
During such procedures, a health care professional not involved in performing the procedure or restraining the patient should monitor the patient. Monitoring includes frequent assessment of heart rate, respiratory rate and effort, blood pressure, and level of consciousness. Continuous pulse oximetry to measure arterial oxygen saturation is strongly encouraged because visual observation of cyanosis is not sensitive to level of oxygen saturation. Guidelines from the American Academy of Pediatrics (1992) emphasize the importance of vigilant monitoring during conscious sedation:
The caveat that loss of consciousness should be unlikely is a particularly important aspect of the definition of conscious sedation, and the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely. Since the patient who receives conscious sedation may progress into a state of deep sedation and obtundation, the practitioner should be prepared to increase the level of vigilance corresponding to that necessary for deep sedation. After the procedure, monitoring should continue until the patient is fully awake and has resumed the former level of function. Discharged patients should be accompanied by an adult for a time at least as long as two half-lives of the agents used (e.g., at least 6 hours for morphine). These patients should be advised not to drive an automobile or operate dangerous machinery until it is likely that all medication effects are resolved (usually 24 to 48 hours). Documentation of the monitoring during the procedure, observation before discharge, and discharge instructions should be part of the patient's permanent record. In contrast to conscious sedation, deep sedation (i.e., when the patient is not responsive to verbal or physical stimuli) is equivalent to general anesthesia and should be performed only under controlled circumstances by a professional trained in its use and skilled in airway management and advanced life support. Reference to specific published guidelines is recommended (e.g., in particular, American Academy of Pediatrics, 1985, 1992. American Nurses Association, 1991). Despite careful titration of sedative doses, individual responses are variable, and patients may occasionally have respiratory compromise or loss of airway reflexes. Because respiratory depression is strongly related to the degree of sedation, stimulation of the patient, -and administration of small doses of naloxone (e.g., 0.04-mg doses for patients weighing 40 kg or more, or 0.5 to 2 pg/kg for patients weighing less than 40 kg), may be adequate to reverse mild degrees of hypoventilation.409 Assisted ventilation by bag and mask or (ultimately) by endotracheal incubation and repetitive naloxone dosing may be required to reverse severe degrees of respiratory depression. If such depression does occur, the patient should be observed until well after the naloxone effect has worn off (usually after 1 hour).
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