Pediatric Sedation Outside of the Operating Room: A Multispecialty International Collaboration

Preface
Acknowledgments
Contents
Contributors
Part I: Pediatric Sedation Outside the Operating Room
	1: The History of Sedation
		Introduction
		Inebriation, Intoxication, Hallucination, and Anesthesia
			A Forme Fruste of the Sedation Continuum
		Ancient History
			Chinese Drug Lore
			Hindu Drugs
			Sumerian Drugs
			Jewish Medicine
			Egyptian Medicine
		Classical History
			Greek Medicine
			Roman Medicine
			Islamic Medicine
			Medieval Medicine
		Ether
		Varied Preparations of Varying Potencies
		The Scientific or Modern Epoch
		The Modern Story of Anesthesia
		“Modern” Sedation and Analgesia Services
		The Future of Sedation
		References
	2: Sedation Policies, Recommendations, and Guidelines Across the Specialties and Continents
		Introduction
		American Academy of Pediatrics (AAP) Guidelines
		American Society of Anesthesiologists (ASA) Policies and Recommendations
		Center for Medicare and Medicaid Services (CMS)
		The Joint Commission
		American College of Emergency Physicians (ACEP) Guidelines
			International Committee for the Advancement of Procedural Sedation Consensus Statement on Fasting for Procedural Sedation
		American Dental Association Sedation Guidelines
			British National Health Service Dental Sedation Standards
		Intercollegiate Advisory Committee for Sedation in Dentistry
		American Society of Gastroenterologists
		International Guidelines
		Summary
		References
	3: Procedural Sedation: Let’s Review the Basics
		Introduction
		Questions to Be Asked
		Definitions and Concepts
		Rescue
		Setting
		Personnel
		Equipment
		Monitoring
		Protocols
		Patients
		Procedures
		Other Considerations
		Future Directions
		Conclusion
		Case Studies
		References
	4: Pre-sedation Assessment
		Introduction
		Pre-sedation Screening
		History
		Physical Examination
		When Not to Proceed
		When Referral to General Anesthesia Is Required
		Fasting Guidelines and Sedation
		Preparation for and Considerations in Special Populations
			Asthma and Reactive Airway Disease
			Autism, Developmental Delay, and Intellectual Disability
			Bronchopulmonary Dysplasia
			Cannabis Use
			Cerebral Palsy
			Congenital Heart Disease
			Cystic Fibrosis
			Diabetes Mellitus
			Endocrinopathies
			Mitochondrial Disease
			Mucopolysaccharidosis
			Multiple Allergies
			Muscular Dystrophies
			Musculoskeletal Disorders
			Obesity
			Obstructive Sleep Apnea
			Pregnancy
			Premature Infant
			Psychiatric and Behavioral Disorders
			Sickle Cell Disease
			Syndromes
			Trauma
			Tuberous Sclerosis
			Upper Respiratory Tract Infection
		Summary
		Case Studies in Pre-sedation Assessment
		References
	5: Sedation Scales and Discharge Criteria: How Do They Differ? Which One to Choose? Do They Really Apply to Sedation?
		Introduction
		Sedation Scales
			The Ramsay Scale
			The Observer’s Assessment of Alertness/Sedation Scale and Modified Observer’s Assessment of Alertness/Sedation Scale
			The COMFORT Scale
			The University of Michigan Sedation Scale
			Dartmouth Operative Conditions Scale
			The Sedation-Agitation Scale
			Modified Aldrete Score as a Sedation Scale
		Processed EEG Monitors: The Bispectral Index and Amplitude-Integrated EEG
		Auditory Evoked Potentials
		Other Sedation Scales
		Objective, Physiologically Based Sedation Scales
		Recovery and Discharge Scales
		A Practical Approach to Sedation Scales and Discharge Scores
		Conclusion
		References
	6: Physiological Monitoring for Procedural Sedation
		Introduction
		Current Guidelines and Standards
		Observational Monitoring
		Electronic Monitoring
		Oxygenation Monitoring
		Ventilation Monitoring
		Hemodynamic Monitoring
		Cortical Activity Monitoring
			Bispectral Index Monitoring
			Cerebral Oximetry
		Future Directions
			Bioacoustic Methods
		Noninvasive Cardiovascular Monitoring
		Conclusion
		References
	7: Neuromonitoring and Sedation; Is There a Role?
		Introduction: The History
		Awareness Under Anesthesia and Neuromonitors
		A Global Review of Published Guidelines on Depth of Anesthesia Monitoring
		The Range of Neuromonitors: The Science, Practice, and Function
			BIS
			Validity of BIS Scores with Sedation Scales and Depth of Sedation in Infants and Children
			Validation of BIS with Inhalational Agents and Sedatives
				Nitrous Oxide
				Chloral Hydrate (CHO)
				Ketamine
				Propofol
				Dexmedetomidine
				Midazolam
			Narcotrend
			M-Entropy
			Auditory Evoked Potential (AEP)
		Limitations of EEG-Based Monitors
		Recent Advances and Future Considerations
		Conclusion
		Case 1
			Considerations
		Case 2
			Considerations
		Case 3
			Considerations
		References
	8: The Pediatric Airway: Anatomy, Challenges, and Solutions
		Anatomy of the Pediatric Airway
		Assessment of the Pediatric Airway for Sedation
		Risk Factors for Airway Compromise or Depression
		Sleep-Disordered Breathing
		Identification and Treatment of Airway-Related Adverse Events
		Conclusion
		Case Studies
			Case 1: Obstructive Sleep Apnea
			Case 2: Anterior Mediastinal Mass
			Case 3: The Child with a “Cold”
		References
	9: Pediatric Physiology: How Does It Differ from Adults?
		Introduction
		Respiratory Physiology
		Cardiovascular Physiology
			Development from Neonate to Older Infant and Child
			Innervation of the Heart
			Development from Child to Adult
			Normal Heart Rate and Blood Pressure Ranges at Different Ages
		CNS Physiology
		Hematologic System Development
		Renal Physiology and Fluid and Electrolytes
		Hepatic/Gastrointestinal Physiology
		Temperature Regulation
		Drug Pharmacokinetics and Pharmacodynamics
		Conclusion
		References
	10: Capnography: The Science, Logistics, Applications, and Limitations for Procedural Sedation
		Why Should Capnography Be Used in Pediatric Patients
		Measurement of Exhaled Carbon Dioxide
		Side Stream Capnography
		Mainstream Capnography
		Colorimetric Devices
		Physiology of Capnography
			Time Capnogram
			Volume Capnogram
			Arterial to End-Tidal PCO2 Difference
		Abnormal Capnograms and Clinical Considerations
		Capnograms During Sedation
		Sampling Devices
		Algorithm for Monitoring Ventilation Via Capnography
		Capnography in Dental Practice
		Capnography and Cardiopulmonary Resuscitation (CPR)
		Conclusion
		Case Studies
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	11: Clinical Pharmacology of Sedatives, Reversal Agents, and Adjuncts
		Drug Selection and Administration
		Use of Multiple Drugs for Sedation
		Additional Pharmacologic Effects
		Off-Label Use
		Alternate Sites of Administration
		Reversal Agents
		The Effects of Psychotropic Drugs on the Developing Brain
		Formulary
			Sedatives and Analgesics
			Alfentanil (Alfenta, Rapifen)
			Chloral Hydrate
			Codeine
			Dexmedetomidine (Precedex, Dexdor)
			Diazepam (Valium, Antenex)
			Etomidate (Amidate)
			Etomidate Analogs
			Fentanyl (Fentanil, Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Onsolis, Instanyl, Abstral)
			Fospropofol (Lusedra)
			Ketamine (Ketanest, Ketaset, Ketalar)
			Ketofol (Ketamine + Propofol)
			Lorazepam (Ativan, Temesta)
			Meperidine (Demerol, Isonipecaine, Lidol, Pethanol, Piridosal, Algil, Alodan, Centralgin, Dispadol, Dolantin, Mialgin, Petidin Dolargan, Dolestine, Dolosal, Dolsin, Mefedina)
			Methohexital (Methohexitone, Brevital)
			Midazolam (Versed, Dormicum, Hypnovel)
			Morphine (MS Contin, MSIR, Avinza, Kadian, Oramorph, Roxanol, Kapanol)
			Nitrous Oxide
			Pentobarbital (Nembutal)
			Propofol (Diprivan)
			Remifentanil (Ultiva)
			Remimazolam (Byfavo)
			S-Ketamine (Ketanest, Ketaset, Ketalar)
			Sufentanil (Sufenta)
		Reversal Agents
			Flumazenil (Flumazepil, Anexate, Lanexat, Mazicon, Romazicon, Anexate)
			Naloxone (Narcan, Nalone, Narcanti)
		Local Anesthetics
			Lidocaine (Lignocaine)
		Anti-emetics
			Ondansetron (Zofran)
			Metoclopramide (Maxolon, Reglan, Degan, Maxeran, Primperan, Pylomid, Cerucal, Pramin)
			Scopolamine (Levo-Duboisine, Hyoscine)
			Diphenhydramine (Benadryl, DPH, DHM, Dimedrol, Daedalon)
			Dexamethasone
		References
			Alfentanil
			Pharmacokinetics
			Chloral hydrate
			Pharmacokinetics
			Clinical Application
			Codeine
			Dexmedetomidine
			Buccal
			Intranasal
			Intramuscular
			Pharmacokinetics and Pharmacodynamics
			Diazepam
			Etomidate
			Clinical Application
			Fentanyl
			Transdermal
			Intranasal
			Transmucosal
			Pharmacokinetics
			Fospropofol
			Ketamine
			Pharmacokinetics
			Clinical Application
			Ketofol
			Lorazepam
			Pharmacokinetics
			Meperidine
			Pharmacokinetics
			Methohexital
			Midazolam
			Pharmacokinetics
			Morphine
			Pharmacokinetics
			Nitrous Oxide
			Pharmacokinetics
			Clinical Application
			Pentobarbital
			Pharmacokinetics
			Propofol
			Pharmacokinetics
			Clinical Application
			Remifentanil
			Pharmacokinetics
			Clinical Application
			Remimazolam
			S-Ketamine
			Intranasal
			Caudal Block
			Rectal
			Pharmacodynamics and Pharmacokinetics
			Sufentanil
			Pharmacokinetics
			Flumazenil
			Intranasal
			Rectal
			Pharmacokinetics
			Naloxone
			Pharmacokinetics
			Lidocaine
			Pharmacokinetics
			Ondansetron
			Pharmacokinetics
			Metoclopramide
			Pharmacokinetics
			Scopolamine
			Diphenhydramine
			Pharmacokinetics
			Dexamethasone
			Pharmacokinetics
	12: The Pharmacology, Physiology and Clinical Application in Dentistry of Nitrous Oxide
		Introduction
		Administration Technique in Dentistry
		Monitoring
		Contraindications
		Adverse Effects
		Mechanisms of Action for Nitrous Oxide
		Personnel Safety
		References
	13: Sedation of the Obese Child: Essential Considerations
		Introduction and Background
		Definition of Obesity
		Obesity and Comorbidities
		The Pathophysiology of Obesity
		Assessment of Obese Children Before Procedural Sedation
		Adverse Respiratory Events
		Airway Management
		Pharmacological Considerations on Obese Children
		Pharmacokinetics
			Absorption
			Distribution
		Elimination
			Hepatic Metabolism
			Renal Elimination
		Pharmacodynamics
		Drugs and Doses for Sedation of the Obese Child
			Sedative/Hypnotics
			Thiopental
			Propofol
		Opioids
			Morphine
			Fentanyl and Fentanyl Derivatives (Alfentanil, Sufentanil, and Remifentanil)
			Dexmedetomidine
		Benzodiazepines
			Midazolam
			Newer Sedatives/Hypnotic Drugs
		Conclusion
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	14: Sedation; Is it Sleep, Is it Amnesia, What’s the Difference?
		Introduction: Sedation, Sleep, Memory, and Amnesia
			Sedation vs. Anesthesia
			To Sleep, Perchance To….To Sedate
			To Sedate … Perchance … Not to Remember!
			Memory: What Is It, Really?
			The Last Building Block of a Conscious Memory: Consolidation
			The First Building Block of Amnesia: Forgetting
			Mechanistic Implications of Drug-Induced Amnesia
			Memories We Don’t Know We Have: The Unconscious Mind
			Clinical Practice
		Sedative Agents: Brief Considerations
			Propofol
			Benzodiazepines
			Dexmedetomidine
			Ketamine
			Etomidate
			Inhalational and Miscellaneous Agents
		Case Studies
			Case 1
			Case 2
			Case 3
		References
	15: Pharmacokinetics and Pharmacodynamics in the Pediatric Population
		Introduction
		PK Differences in the First Year of Life
			Input
				Absorption
					Enteral
					Intramuscular
					Nasal
					Cutaneous
					Alveolar
				Bioavailability
			Distribution
				Body Composition
				Plasma Proteins
				Regional Blood Flows
					Blood–Brain Barrier
			Drug Metabolism
				Descriptors for Metabolism Maturation
			Hepatic Elimination
				Phase 1
				Phase 2
			Renal Elimination
			Pulmonary Elimination
		Metabolites
		Pharmacogenomics
		Pharmacodynamic Differences in the First Year of Life
		Measurement of PD Endpoints
		Population Modeling
		The Target Concentration Approach
		Pharmacokinetic Models
		Pharmacodynamic Models
		The Sigmoid Emax Model
		Quantal Effect Model
		Logistic Regression Model
		Linking PK with PD
		Adverse Effects
		Drug Interactions
		Defining Target Concentration
		Conclusion
		References
	16: Billing and Reimbursement for Sedation Services in the United States
		Introduction
		Minimal Sedation
		Moderate Sedation
		Key Components of Evaluation and Management Services Documentation
		Deep Sedation (MAC)
		General, Regional, and Monitored Anesthesia Care
		Fee for Services
		Physician Quality Measure Reporting
		Legal Consequences of Incorrect Coding/Documentation
		Conclusion
		Case Scenarios
		References
Part II: Sedation Models Delivered by Different Specialties: A Global Voyage
	17: The Pediatric Hospital Medicine Service: Models, Protocols, and Challenges
		Introduction
		Training Hospitalists to Provide Moderate and Deep Sedation
			On-the-Job Training
			Residency and Fellowship Training
			Training Under Direct Supervision
			Operating Room Time
			Simulation Time
			Pediatric Advanced Life Support Training
			Ongoing Competency
		Credentialing Hospitalists to Provide Moderate and Deep Sedation in the United States
		Logistics of Setting Up a Hospitalist-Run Sedation Service
			Staffing
			Staffing Example
		Triaging Patients to Sedation by Pediatric Hospitalists
		How and When Medical Evaluations Are Performed for Triage
		Funding Pediatric Hospitalist Sedation Programs
		The Future of Hospitalist Sedation Services
		Developing National Standards for Training and Credentialing Pediatric Hospitalists in Sedation
		Planning, Monitoring, and Recovering from a Sedation
			Pre-sedation Evaluation
			Personnel
			Monitoring
			Medications
			Final Checklist Prior to Sedation
			Recovery
			Discharge/Transfer Criteria
		Commonly Administered Sedation Drugs
			Ketamine
			Dosing
			Fentanyl and Midazolam
			Dosing
			Nitrous Oxide
			Dosing
			Pentobarbital
			Dosing
			Propofol
			Dosing
			Chloral Hydrate
			Dosing
			Dexmedetomidine
			Dosing
		Case Scenarios
			Case 1
				Considerations for Case 1
				Sedative Options and Considerations for Case 1
			Case 2
				Considerations for Case 2
				Sedative Options and Considerations for Case 2
				For This Case
			Case 3
				Considerations for Case 3
				Sedative Options and Considerations for Case 3
			Case 4
				Considerations for Case 4
				Sedative Options and Considerations for Case 4
			Case 5
				Considerations for Case 5
				Sedation Options and Considerations for Case 5
		References
	18: Sedation in the Neonatal Intensive Care Unit: International Practice
		Introduction
			Why Do Neonates Need Procedural Analgo-sedation?
				Take-Home Messages: Why a Focused Chapter on Neonatal Analgo-sedation?
		Assessment of Distress and Pain in Neonates
			Limitations of Assessment of Distress and Pain in Neonates
			Implementation of Assessment
				Take-Home Messages on Pain Assessment
		Preventive Strategies
			Take-Home Messages
		Complementary Interventions
			Non-nutritive Sucking, Sucrose, Glucose, and Human Milk
			Swaddling and Containment Procedures
			Multisensorial Stimulation and Sensorial Saturation
			From Evidence to Practice: The Implementation Issue
				Take-Home Messages
		Pharmacological Interventions
			Topical and Local Anesthesia
				Take-Home Messages
			Propofol
				Take-Home Messages
			Ketamine
		Pharmacokinetics
		Pharmacodynamics
			Take-Home Messages
			Remifentanil
				Take-Home Messages
			Chloral Hydrate
				Take-Home Messages
			Morphine and Fentanyl
				Take-Home Messages
			Benzodiazepines
				Take-Home Messages
			Dexmedetomidine
				Take-Home Messages
			Inhalational Agents
				Take-Home Messages
			Acetaminophen (Paracetamol)
			Efficacy
			Safety
				Take-Home Messages
		Neonatal Analgo-sedation: Balancing Between Scylla and Charybdis
		Case studies
			Case 1
				Issues
			Case 2
				Potential Options, To Consider
			Case 3
			Case 4
		References
	19: Sedation in the Pediatric Intensive Care Unit: Challenges, Outcomes, and Future Strategies in the United States
		Introduction
		Pre-procedure Preparation
		Assessing the Depth of Sedation
		Basic Principles
		Choice of Agent and Route of Delivery
			Inhalational Anesthetic Agents
			Benzodiazepines
			Etomidate
			Ketamine
			Propofol
			Barbiturates
			Opioids
			Phenothiazines and Butyrophenones
			Alpha2-Adrenergic Agonists
			Chloral Hydrate
		Tolerance, Physical Dependency, and Withdrawal
		Clinical Signs and Symptoms of Withdrawal
		Treatment of Withdrawal and Clinical Scoring Systems
		Delirium
			Classification of Delirium
			Diagnosis of Delirium
			Pathophysiology of Delirium
			Prevention and Treatment of Delirium
		Palliative Sedation Therapy
			Ketamine
			Propofol
			Dexmedetomidine
		Conclusion
		Case Scenarios
			Case 1
				Considerations
				Drugs
			Case 2
				Considerations
				Drugs
			Case 3
				Considerations
				Drugs
		References
	20: Sedation in the Pediatric Intensive Care Unit: Current Practice in Europe
		Introduction
		Pharmacologic Aspects
			General Aspects
		Specific Aspects
			Opioids
			Benzodiazepines
			Ketamine
		Inhalational Agents
		Alpha-2 Receptor Agonists
		Propofol
		Immunity
		Neuropathologic Effects
		Measuring Sedation
		Delirium
		Tolerance and Withdrawal
		Staff
		Conclusion
		Clinical Case Samples
			Case 1
				Consideration
					Withdrawal
			Case 2
				Considerations
					Delirium
					Sleep Cycle
					Neuromyopathy
			Case 3
				Consideration
					Context-Sensitive Half-Life
		References
	21: Sedation for Pediatric Gastrointestinal Procedures
		Introduction
		Goals and Optimal Levels of Sedation to Minimize Complications for Pediatric GI Procedures
		Pre-procedure Preparation and Patient Assessment
		Patient Positioning
		Common IV Sedation Regimens for Pediatric Gastrointestinal Procedures
			Fentanyl
			Midazolam
			Reversal Agents for Narcotics and Benzodiazepines
			Ketamine
			Nitrous Oxide
			Diprivan (Propofol)
		Non-anesthesiologist-Administered Propofol Sedation (NAAPS)
			Dexmedetomidine
		Training in Sedation Administration
		Monitoring of Children Undergoing Endoscopic Procedures with Sedation
			Pulse Oximetry
			Capnography
			Electroencephalography Monitoring
		Future Sedation Strategies for Endoscopy in Children
		Conclusion
		Case Studies
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	22: Sedation in the Emergency Department: A Complex and Multifactorial Challenge
		Introduction
			Why Procedural Sedation and Analgesia (PSA)?
			Long-Term Negative Impact of Painful Procedures
			When May PSA Not Be Needed?
		Nearly Painless Local Anesthesia
			Topical Anesthetics
			Buffering Injected Lidocaine
			Psychological Interventions Reduce Distress and Need for PSA
			What Makes PSA in the Emergency Department Different?
			Deciding Whether to Perform PSA
		Systematic Approach to Safe ED PSA
			Knowledge of Clinical Policies Specific to Emergency Department
			Goals of PSA
			Pre-sedation Patient Evaluation and Risk Assessment
			Informed Consent
			Plan for Sedation
			Equipment
		Preparation for and Management of Adverse Events
			Anticipation
			Management of Respiratory Depression and Apnea
			Airway and Ventilation Maintenance
		Treatment: Respiratory Depression and Apnea
			First Line (in Rapid Succession, If Needed)
			Second Line: Reversal Medications for Opioids and Benzodiazepines
			Naloxone (Narcan®)
			Flumazenil (Romazicon®)
			Upper Airway Obstruction
			Treatment
			Laryngospasm
			Emesis
		Treatment: Emesis During Procedural Sedation
			Ondansetron (Zofran®)
			Pulmonary Aspiration
		Medications
			Basic Pharmacokinetics: Simplified
		Dosing Details
			Titration to Desired Effect
			Intravenous Administration at the Hub
			Intramuscular Administration
			Sedative–Hypnotic Agents
				Chloral Hydrate [76]
				Pregnancy Category C
				Barbiturates
				Methohexital (Brevital®)
				Pregnancy Category B
				Pentobarbital (Nembutal®)
				Pregnancy Category D
			Anxiolytic–Amnestic–Sedative Agents
				Benzodiazepines
				Paradoxical Reactions
				Midazolam (Versed®)
				Pregnancy Category D
				Diazepam (Valium®)
				Pregnancy Category D
			Other Non-analgesic Sedative Agents
				Propofol (Diprivan®)
				Pharmacology
				Pharmacokinetics
				Pregnancy Category B
				Etomidate
				Pregnancy Category D
				Sedative–Analgesic Agents
				Opiates (Narcotics) (Table 22.7): Fentanyl (Sublimaze®)
				Pregnancy Category C
				Morphine
				Pregnancy Category C
				Meperidine (Demerol®)
				Pregnancy Category C
				Codeine
				Oxycodone
				Pregnancy Category B (D for Prolonged Use)
				Hydrocodone
			NMDA Antagonists
				Ketamine (Ketalar®)
				Circulatory Effects
				Ventilatory Effects
				Protective Airway Reflexes
				Sedative–Analgesic Effects
				Dissociative Effects
				Prolonged Analgesic Effects
				Neurotoxicity
				Psychotomimetic Effects
				Beneficial Psychiatric Effects
				Other Adverse Effects
				Pharmacokinetics
				Pregnancy Category B
				Adjuncts
				Glycopyrrolate (Robinul®)
				Atropine
				Ketamine with Sedatives or Analgesics
				Ketamine Plus Propofol (Ketofol)
				Ketamine Plus Dexmedetomidine (Ketadex)
				Nitrous Oxide (N2O)
				Pregnancy Category C
				Dexmedetomidine
			Techniques
				Pregnancy Category C
				Ketamine + Midazolam or Fentanyl + Midazolam Techniques for Deep Sedation
				Pre-sedation Assessment and Preparation
				During Sedation
				Fentanyl Technique
				Ketamine Technique
		Conclusion: Final Thoughts
		Case Studies
			Case 1
			Case 2
			Case 3
			Case 4
			Case 5
			Case 6
			Case 7
		References
	23: Sedation for Radiological Procedures
		Introduction
		Radiology Sedation: Common Themes
		Magnetic Resonance Imaging (MRI)
			Medications
				Dexmedetomidine
				Propofol
				Barbiturates
				Chloral Hydrate
			Special Populations: Autistic Patients
		Nuclear Medicine (NM) Procedures
		Magnetoencephalography (MEG)
		Interventional Radiology (IR)
		Computed Tomography (CT)
		Fluoroscopic Voiding Cystourethrogram (VCUG) and Nuclear Medicine Cystogram
		Transthoracic Echocardiogram (TTE)
		Conclusion
		Case Scenarios
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	24: Sedation of Pediatric Patients for Dental Procedures: The USA, European, and South American Experience
		Introduction
		Section 1
			Extent and Treatment of Dental Caries
		Children’s Behavior
		Measuring Anxiety in Children Undergoing Dental Treatment
		Pediatric Dental Sedation Appointment Protocols
		Sedatives Used in Pediatric Dentistry
		Propofol for Adolescents
		The Evidence for Conscious Sedation in Pediatric Dentistry: Cochrane
		Morbidity and Mortality: Dental Sedation
		Alternatives to Sedation
		Section 2
			Guidelines and Training in the USA
		Sedation Guidelines in the USA
		Reimbursement for Dental Sedation and Anesthesia
		Future of Sedation for Dental Procedures in the USA
		Section 3
			Sedation for Pediatric Dental Patients in the UK and Europe
		UK Pediatric Dentistry
			Background
		UK: Local Anesthesia
		The UK Definition of Conscious Sedation
		National Institute for Health and Care Excellence
		NICE Levels of Sedation Definitions
		UK Pediatric Dental Sedation Training
		Pediatric Dental Sedation and General Anesthesia in the UK
		The Link Between “Conscious Sedation” and General Anesthesia
		Premedication (Sedation) Prior to General Anesthesia
		Titrated Nitrous Oxide Inhalation Sedation
		Intravenous Sedation
		Oral Sedation
		Sedation and Dental-Specific Guidelines of the UK and European Union
			British Society of Paediatric Dentistry
			European Association of Pediatric Dentistry
		Section 4
			Pediatric Dental Sedation in South America
				What Is the Regulatory Language Related to Performing Dental Sedation in the Pediatric Dental Office?
				What Sedation Guidelines Do Pediatric Dentists Follow in South America?
				What Sedation Regimens Have Been Used and/or Investigated in South America?
		Closing Thoughts on Sedation in South America
		Conclusion
			The Future
		Section 5
			Case Studies
				Case 1 (from Brazil)
				Case 2 (from Brazil)
				Case 3
				Case 4
				Case 5
				Case 6
				Case 7
				Case 8
		References
	25: Sedation Strategies and Techniques for Painful Dental Procedures
		Intraoral Local Anesthetic Techniques
			Maxillary Local Anesthesia
			Mandibular Local Anesthesia
		Specific Dental Equipment and Safety Considerations
		Procedural Sedation Techniques and Considerations
			Monitoring with Special Considerations to Dental Procedural Sedation
		Type of Procedures and Considerations
			Dental Extractions
			Cleft Lip and Palate Surgeries
			Oral Trauma
		Postoperative Analgesia
		Conclusion
		References
	26: Special Considerations During Sedation of the Child with Autism Spectrum Disorder
		Introduction
		Background and Diagnosis
		Medical and Psychiatric Comorbidities
		Behavioral Challenges
		Communication Challenges
		Pre-procedural Planning
		Patient Selection
		Premedication
		Intraprocedure Considerations
		Conclusion
		Case 1
			Considerations
			The MTHFR Mutation Debate
				Our Patient Has a MTHFR Mutation
				Our Patient Was Never Tested for a MTHFR Mutation
		Case 2
			Considerations
			Sedation
			Debrief
		References
	27: Pediatric Sedation: The European Experience and Approach
		Introduction
		General Problems and Challenges
			Growing Demand for Optimal Procedural Sedation and Analgesia
		Expanding the Horizon: PSA as a Component of Family-Centered Procedural Comfort Care
		Defining High-Quality Procedural Sedation
		Cultural Aspects, Diversities, and Inconsistencies Within Europe
		Anesthesia Services Are Limited in Europe
		Non-anesthesiology Sedation Providers in Europe
		Challenges and Solutions in Europe
		Monitoring Practices in Europe Are Inconsistent
			Capnography
			Processed EEG
		Recommendations, Policy Statements, and Guidelines in Europe
		Ethical and Legal Aspects and the Debate on Neurotoxicity
		Definitions Particular to Europe
		Training and Credentialing in Europe
		Implementation of Practice Standards in Europe
		Financial Aspects of Sedation Delivery in Europe
		Common European Sedation Practice for Selected Procedures
			Painless Imaging
			Interventional Radiology and Cardiology
			Gastroenterology
			Oncology
			Emergency Medical Care
			Dentistry
		Conclusion
			New and Future Developments
		Case Studies
			Case 1 (the Netherlands)
				The Sedation
				Summary Points
			Case 2 (the Netherlands)
				The Sedation
				Summary Points
			Case 3 (the Netherlands)
				The Sedation
				Summary Points
			Case 4 (the United Kingdom)
				A 6-Year Old Boy for a Surveillance MRI Scan of His Brain
			Case 5 (the United Kingdom) [81]
				Magnetic Response Imaging (MRI) in a 10-Month-Old
				The Sedation
			Case 6 (the United Kingdom)
				A 13-Year-Old Boy with Down Syndrome and Leukemia
				The Sedation
			Case 7 (the United Kingdom)
				Gastrointestinal Endoscopy in an Anxious 15-Year-Old Girl
		References
	28: Pediatric Sedation in South America
		Introduction
		Pediatric Sedation in South America: A General Overview
		Argentina
		Brazil
		Chile
		Other Countries
		Common Sedation Techniques and Strategies in South America
		Review of Published Sedation Literature from South America
		Summary
		Case Studies
			Case 1
			Case 2
			Case 3
			Case 4
		References
	29: Paediatric Sedation: The Asian Approach—Current State of Sedation in China
		Introduction
		An Example of Sedation Services in Large-Scale Sedation Unit
			Chloral Hydrate
			Intranasal Dexmedetomidine
		Sedation Service at the Hong Kong Children’s Hospital
			Anaesthesiologist-Administered Sedation Services in Hong Kong
			Non-painful Procedures
				Case Scenario 1
					MRI of Brain and Whole Spine
			Sedation for Painful Interventional Radiological Procedures
				Pre-sedation Assessment
				Room Preparation
				Choices of Drugs
					Dexmedetomidine
					Propofol
					Ketamine
					Fentanyl
					Local Anaesthetics (LA)
					Other Analgesic Adjuncts
				Case Scenario 2
					Renal Biopsy
				Case Scenario 3
					Pleural Mass Biopsy
			Electronic Clinical Information System in Sedation Service
		References
	30: Pediatric Sedation: The Approach in Australia and New Zealand
		Introduction
		The Key Guiding Documents
			The Australian and New Zealand College of Anaesthetists Guideline
			Limitation of the ANZCA Guidelines
		The Royal Australasian College of Physicians Guideline Statements
		Development of a Sedation Program
		Specific Locations and Services
			Inpatient Wards
			Sedation in the Pediatric Intensive Care Units
			Neonatal Intensive Care Units
			Emergency Departments
			Dental Sedation
			Sedation for Medical Imaging
			Sedation of Children with Burns
			Sedation for Oncologic Procedures
		Non-pharmacological Management
		Case Studies
			Case 1
			Case 2
			Case 3
		References
	31: Pediatric Sedation in the Underdeveloped Third World: An African Perspective
		Introduction
		Provision of Safe Pediatric Sedation in the Third World
		Recovery and Discharge
		Discharge from the Facility to Home
		Sedation Models
			The Sedation Unit Model Within the Hospital
			The Mobile Sedation Model Within the Hospital
			A Combined Sedation Model Within the Hospital
			The Mobile Sedationist Model Outside the Hospital
			The Operator-Sedationist Model
			The Dedicated Mobile Sedationist Model
		Common Sedation Strategies in the Developing Nations
			Oral Route: Single Agent
			Nasal Route: Single Agent
			Rectal Route: Single Agent
			Intravenous Route: Single Agent
			Inhalational Route
		Sedative and Analgesic Combination
		Behavioral and Non-pharmacological Method
		Sedation Training Opportunities in Africa
		Accreditation of Providers and Clinics
		Clinical Governance in South Africa
		Patient Satisfaction in Children
		Conclusion
		Case Studies
			Case 1
			Case 2
			Case 3
		References
Part III: Safety in Sedation
	32: Pediatric Sedatives and the Food and Drug Administration (FDA): Challenges, Limitations, and Drugs in Development
		Introduction
		General Drug Development
		Pediatric Legislation
		Drug Development for Pediatrics
		Chemistry, Manufacturing, and Controls
		Nonclinical Studies
			Clinical Trials
			Ethics
		Pharmacokinetics and Pharmacodynamics
		Pediatric Extrapolation
		Phase 3 Safety and Efficacy Studies
		References
	33: Apoptosis and Neurocognitive Effects of Intravenous Anesthetics
		Introduction
		Characterization of Sedative-Induced Developmental Neurotoxicity
		Mechanisms of Aberrant Neuronal Development from Sedative Drugs
		Clinical Evidence for Sedative-Induced Neurological Sequelae
		Conclusions from Preclinical and Clinical Investigations
		References
	34: Adverse Events: Risk Factors, Predictors, and Outcomes
		Introduction
		Patient Characteristics
			Age/Prematurity
			Weight/Obesity/Underweight
			Genetic/Trisomy 21/Metabolic
			Autistic Spectrum Disorder
			Cerebral Palsy
			Congenital Heart Disease/Pulmonary Hypertension
			Cancer/Mediastinal Mass
			Nil Per Os (NPO) Status
			URI Status
			Current Fever
			Allergy
		Procedural Characteristics
			Airway Manipulation: Dental, Bronchoscopy, and Esophagogastroduodonescopy (EGD)
			Invasive vs Noninvasive
			Positioning: Supine vs Prone
			Duration
			Emergent vs Urgent vs Elective
		Environmental Characteristics
			Indirect Patient Access: CT, MRI, and Radiation
			Remote Locations within Hospital Locations
			Satellite Locations
			Free-Standing Sedation Locations
			Provider Characteristics
			Medications
		Predictive Tools
			ASA Physical Status Classification
			Outcome Studies
		Case Scenarios
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	35: Fasting Status, Aspiration Risk, and Sedation Outcomes
		Introduction
		Incidence and Severity of Clinically Apparent Pulmonary Aspiration
		Aspiration Risk in Procedural Sedation Compared to General Anesthesia
		Fasting Status as a Risk Factor for Aspiration
			Disadvantage of Fasting Guidelines
			Specialty Society Recommendations for Fasting Prior to Procedural Sedation
		Additional Risk Factors for Aspiration
		Strategies to Mitigate Aspiration Risk
			Gastric Ultrasound
			Selection of Sedation Medication
			Duration and Depth of Sedation
			Referral to Anesthesiology
			ICAPS Strategy
		Conclusions and Future Directions
		Case Studies
			Case 1
			Considerations
			Case 2
			Considerations
			Case 3
			Considerations
		References
	36: Outcomes of Procedural Sedation: What Are the Benchmarks?
		Background
		Introduction
		Setting the Standards for Safety
		Safety: Disparities in Adverse Event Rate Reporting
		Safety: Recommendations for Defining and Reporting Adverse Events
		Efficacy of Sedation
		Tracking and Reporting Outcomes of Procedural Sedation
		Multicenter Investigations
		Future Directions
		Conclusions
		References
	37: Medicolegal Risks and Outcomes of Sedation
		Introduction and Background
		Preventing Litigation
		Practice “Good” Medicine
		The Sedation Process
		Pre-sedation Evaluation/Decisions
		Medication Errors
		Post-sedation/Discharge
		Policies and Protocols
		Clinical Guidelines
		Communicate Well with Patients/Families
		Informed Consent
		Communicate Well with Colleagues
		Document Carefully
		Never Alter Medical Records
		Managing Medical Errors in the Event of an Adverse Event
		When to Contact an Attorney
		Quality Improvement
		Family Member Presence for Procedures
		Case Studies
			Case 1
			Case 2
			Case 3
			Case 4
			Case 5
			Case 6
		Conclusion
		Glossary
		References
			Additional Reading
	38: Improving the Safety of Pediatric Sedation: Human Error, Technology, and Clinical Microsystems
		Introduction
		The Need for a Paradigm Shift
		Errors and Violations
		The Nature of Medication Error in Children
		Additional Causes of Errors in Children
		The Clinical Microsystem as a Unit of Analysis
		People Versus Systems
		Rules and Rule Following: The Boeing MAX Aircraft and the Thailand Cave Rescue
		Making Sense of Uncommon Adverse Events
		The Nature of Human Error
		Error Types
			Knowledge-Based Errors (or Errors of Deliberation)
			Rule-Based Errors
			Skill-Based Errors
			Technical Errors
		Exhortation and Protocols
			The Effects of Fatigue
			Human Factors and the Culture of Safety
			Simulation and Safety
			Teamwork and Communication
			The Nature of System Failures
		Characteristics of Safe and Unsafe Systems
			Barriers to System Failure
		Traversing the Incident Pyramid
			Root Cause Analysis
			Failure Mode and Effect Analysis
			Lessons from the Development of Safety in the Nuclear Power Industry
			The Three Mile Island Nuclear Power Plant Accident
			A State-Space Approach to Failure in Complex Systems
			The Role of Incident Reporting
			The Value of Incident-Based Recovery Pathways
			Closed Claims Settlements for Cases Outside the Operating Room
			The Value of Best Practice Guidelines in Procedural Sedation
			The Future of Safety in Pediatric Sedation
			New Approaches to Safety Monitoring and Improvement
		Conclusion
		References
Part IV: Sedation into the Twenty-Second Century
	39: Intravenous Infusions for Sedation: Rationale, State of the Art, and Future Trends
		Introduction
			Benefits of the Intravenous Route of Administration
			Choice of Agents
		Pharmacodynamics of Commonly Used Agents
			Propofol
			Dexmedetomidine
			Ketamine
			Remifentanil
		Basic Principles of Pharmacokinetics
			What Is a Pharmacokinetic Model and How Is It Derived?
		Important Mathematical Concepts for Understanding of Pharmacokinetic Models
			Half-Life, Time Constant, and Rate Constant
			Volume of Distribution
		Single Compartment Pharmacokinetic Models
		Three Compartment Models
			Context-Sensitive Half-Time
			Pharmacokinetic Models for Propofol
		Pediatric Propofol Infusion Regimens
			Disadvantages of Repeated Bolus Dose Administration
		Commonly Used Regimens
			PK Models for Dexmedetomidine
				Infusion Regimens for Dexmedetomidine
			PK Models for Ketamine
				Infusion Regimens for Ketamine
			PK Models for Remifentanil
				Infusion Regimens for Remifentanil
		Target-Controlled Infusions
			Definition
			Rationale for TCI
			Principles of TCI
		Choice of Propofol Target Concentration
		Predictive Performance of PK Models During TCI
		Choice of Dexmedetomidine and Remifentanil Target Concentrations
		Future Directions
			Model Development and the Open TCI Initiative
			Drug Interactions
			Effect-Site Targeted TCI Systems
		Closed-Loop Control
		References
	40: Usage of Nonpharmacological Complementary and Integrative Medicine in Pediatric Sedation
		Introduction
		Guided Imagery
		Acupuncture and Related Techniques
		Music
		Hypnotherapy
		Sucrose Sucking in Infants
		Conclusion
		Case Study
			Case 1
				Suggestions
		Case Study
			Case 2
				Suggestions
		Case Study
			Case 3
				Suggestions
		References
	41: Towards Integrated Procedural Comfort Care: Redefining and Expanding “Non-pharmacology”
		Introduction
		The “Non-sense” and “Complexity” of “Non-pharmacology”
			Non-pharmacology Versus Pharmacology
			“Non-pharmacology”: A Problematic Concept
			Non-pharmacology as a Specific Educational Challenge
		Deconstructing Non-pharmacology
			First of All: Do Not Harm
			Creating the Human Connection
				Relevance of Previous Experience and Information
				Procedural Disclosure May Do Harm Concept
				Right Words, Wrong Words
				Distraction Versus Reassurance
				Role of Parents
				Evaluation of the Child Level of Anxiety and Search for the Less Scary Approach
				Conclusion
			Physical Comfort Measures and Physical Analgesia
		Distraction Techniques
			Virtual Reality as a Possible New Frontier
				Burn Care
				Venipuncture
				Dental Treatment
				Limitations of the Technology
				Conclusion
		Final Conclusions
		References
	42: The Role of Simulation in Safety and Training
		History of Medical Simulation
		General Applications of Simulation for Sedation Safety and Training
		Simulation for Pediatric Sedation
		Examples of Simulation-Based Training in Pediatric Sedation
			Initial Training
			Advanced Training
		General Principles for the Development of a Pediatric Sedation Simulation Scenario and Course
		Pediatric Sedation Simulation Scenario Development
		Sample Pediatric Sedation Simulation Scenario
			Debriefing
		Evaluation of Pediatric Simulation Activities
		Future of Simulation for Pediatric Sedation Training
		References
	43: Criminal Homicide Versus Medical Malpractice: Lessons from the Michael Jackson Case and Others
		Legal Versus Professional Standards and Ethics
		The Death of Michael Jackson: A Legal Perspective
		The Death of Michael Jackson: Professionalism and Medical Ethics
		Was Dr. Murray Practicing Medicine?
		Did a Legitimate Physician-Patient Relationship Exist?
			Ethical Principles in Medical Care
			Respect for Autonomy
			Beneficence
			Nonmaleficence
			Outcome of the Case
		Another Sedation Case
			The Case
				Legal Analysis
				Professionalism and Ethics
		Summary
		Glossary
		References
	44: Considerations for the Intersection of Sedation and Marijuana
		Introduction
		Pharmacology of Cannabis
		Medical Cannabis
			Indications
			Formulations
		Acute Cannabinoid Effects and Withdrawal
			Cardiovascular Actions
			Pulmonary Actions
			Gastrointestinal Actions
			Cannabis and Procedural Sedation
		Summary
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	45: Proportionate Sedation in Pediatric Palliative Care
		Introduction
		The Principles of Proportionate Sedation
		The Practice of Proportionate Sedation
			Pain
				Dexmedetomidine (DEX)
				Ketamine
				Propofol
			Dyspnea
				Opioids
				Dexmedetomidine (DEX)
			Delirium
				Dexmedetomidine (DEX)
		Conclusions
		Case Studies
			Case #1
				Considerations
			Case #2
				Considerations
			Case #3
				Considerations
		References
	46: Ethical and Clinical Aspects of Palliative Sedation in the Terminally Ill Child
		Introduction
		Palliative Sedation: What Exactly Are We Talking About?
		Deep Continuous Sedation
			Epidemiology of DCS
			What Is Suffering?
			Existential Suffering and Transcendence
		DCS and Euthanasia: Is Permanent Loss of Consciousness a Form of Death?
			What Is Euthanasia?
			Defining Death
		DCS and Hastening Death
			The Principle of Double Effect and DCS
		DCS and Withdrawal of Hydration and Nutrition
		Legal Precedents and Physician Attitudes Regarding DCS
		Professional Societies and Opinions Regarding DCS
		Guidelines
		Initiating DCS: Goals, Monitoring, and Evaluation of Efficacy
		Recommendations for Initiating DCS in Pediatric Patients [77]
		Conclusion
		Case Studies
			Case 1
				Considerations
			Case 2
				Considerations
			Case 3
				Considerations
		References
	47: Future of Pediatric Sedation
		Introduction
		The Optimal Level of Sedation
			Outcome Assessment and Standardization of Adverse Event Identification and Documentation
			Defining the Depth of Sedation
			“Consciousness” Monitoring as an Indication of Sedation Depth
		Assessment of Oxygenation, Respiration, and Identification of Hypoxia
			Pulse Oximetry
			Capnography
		Risk Assessment in Balancing the Urgency for the Procedure with the Associated Risk of Sedation
		Analgesia, Prophylaxis, and Avoiding Conditioned Behaviors
		Training and Credentialing of Sedation Providers
		Educating the Public
		Developing the “Safety Culture” of Sedation: Implementing Safety Measures
		Collecting Outcome Data to Guide Safety and Practice Parameters: Adoption of Standardized Definitions of Sedation-Related Adverse Events
		Sedatives: Exploring New Agents and Alternative Methods and Modes of Delivery
			Propofol
			Etomidate
			Alpha 2 Agonists
			Synthetic Opioids
			Benzodiazepines
			Ketamine
			Chemical Restraint
			Drug Administration
		Conclusion
		References
Epilogue
Index