Immediate Questions

A. Is patient a candidate for procedural sedation? Sedation is considered for procedures that are painful and when child must lie immobile. Patients who undergo procedural sedation must undergo presedation assessment focusing on potential complications. Screening should include review of patient's medical history, allergies, medications, prior sedation history, and last food intake. Physical exam should assess for potential airway obstruction and respiratory compromise.

B. Does patient have risk factors for adverse events during sedation? Risk factors include positive history for snoring or sleep apnea, reactive airways disease, or other chronic pulmonary disease; congenital or acquired heart disease; hypertension; gastroesophageal reflux or vomiting; and neurologic disease, such as muscle weakness or poorly controlled seizures.

C. Any underlying medical conditions? Hepatic or renal disease may affect metabolism of sedative agents. Patients with active upper or lower tract respiratory infections, vomiting, dehydration, and recent head or multisystem trauma are at increased risk for sedation complications.

D. Has patient had any previous experience or problems with sedation or analgesics? True allergies to agents of sedation and analgesia are rare; avoid using agent or class of agents that patient has not tolerated well in the past. Some patients react paradoxically to midazolam with increased agitation rather than relaxation. Patients receiving procedural sedation multiple times over several days may develop tolerance to medications, requiring increased dosing or change of agent for effective results.

E. What medications does patient currently take? Certain medications, most commonly antiepileptic and behavioral modification medications, may affect sedation. In general, it is best to have patient continue on his or her usual medication regimen, and to titrate sedatives accordingly.

F. When did patient last eat? Although fasting for procedural sedation is still considered desirable, a nonfasting state is not an absolute contraindication to procedure. Mounting evidence suggests that risk of vomiting is not related to time of last enteral intake.

G. Is setting appropriate for procedural sedation? Safe procedural sedation requires personnel who are skilled in airway management and resuscitation. Staffing should allow for a dedicated patient observer who is not responsible for performing procedure.

III. Indications. Choice of sedative agent or combination of agents is dependent on several key questions. Is procedure painful? How long will procedure take? Does patient need to be completely immobile, or is some movement acceptable? Figure I-7 lists indications for specific sedation agents.

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