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Pediatric Sedation: The European Experience and Approach

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Pediatric Sedation Outside of the Operating Room

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Abstract

With more than 50 countries and as many national histories, Europe can hardly be considered as a solid set of common elements. Despite the increasing political, financial, economic, and administrative integration of a growing number of countries within the European Union (EU), European healthcare systems remain highly diverse. In the last few years, European experts on pediatric sedation have increasingly exchanged insights and experiences, and a growing number of local, national, and European initiatives intended to improve procedural sedation and analgesia (PSA) practice have been created.

This chapter avoids reiteration of what is commonly known in the United States and instead describes and contrasts what is different or new in Europe. In doing so, we have drawn upon our personal knowledge and experience in the Netherlands and the United Kingdom, researched the European literature, and gathered some of our own data to describe what we believe to be the important and interesting European problems and perspectives with pediatric sedation.

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Notes

  1. 1.

    http://www.ich.ucl.ac.uk/cypph/cnsf_audit_tool.pdf

  2. 2.

    http://www.each-for-sick-children.org

  3. 3.

    http://www.rcoa.ac.uk/nap4

  4. 4.

    http://www.collemergencymed.ac.uk/CEC/cec_ketamine.pdf

  5. 5.

    For most patients the following formula is used: 5 mg/kg of propofol is prepared in a 20 mL syringe and diluted to a total volume of 20 mL. The first bolus will always, therefore, be 12 mL (=3 mg/kg). If the procedure lasts longer than the anesthesia time given by this bolus, second or third boluses (each of 1 mg/kg = 4 mL) can be given. If the procedure lasts longer than the anesthesia by these doses, the technique is converted to inhalation of sevoflurane.

  6. 6.

    For most patients the following formula can be used: 2 μg/kg of remifentanil is prepared in a 20 mL syringe and diluted to a total volume of 20 mL. The first bolus will always, therefore, be 10 mL (=1 μg/kg). If the procedure lasts longer than the analgesia time given by this bolus, second or third boluses (each of 0.5 μg/kg = 5 mL) can be given. If the procedure outlasts these doses, the technique is converted to inhalation of sevoflurane.

  7. 7.

    Apnea is intended with this technique. Apnea is evidence of opioid effect and means that movement in response to lumbar puncture is extremely unlikely. The lumbar puncture has to be performed promptly for this technique to be advantageous. Longer procedures should be managed by an infusion or inhalation technique.

  8. 8.

    The half-life of remifentanil is approximately 5–10 min and is not context dependent. If postoperative pain is expected, another analgesic is necessary. Almost no patients complain of backache or headache within the first hour after lumbar puncture under this technique. Postoperative nausea is rare.

  9. 9.

    Bowel preparation should achieve a clean colon, and evidence of its effect will be the passing of watery stools. Dehydration is a common problem, and therefore intravenous fluid replacement will be necessary in some children.

  10. 10.

    The team brief should involve all members of the team. Communication of the details of the procedures and the expected problems can be discussed in order to minimize problems and delays. Essential safety and quality checks can be carried out at this stage.

  11. 11.

    This method will not be appropriate for all children. Small children and those with cardiorespiratory problems may be more safely managed by tracheal intubation. Propofol infusion provides a recovery profile that has minimal side effects. Occasionally this method is not successful because of airway obstruction—prompt airway rescue/support including tracheal intubation will be necessary in some children.

  12. 12.

    The lidocaine injection is for two reasons: to test the patency of the cannula and to help reduce any pain from the propofol.

  13. 13.

    The suction catheter stimulates the gag reflex and tests the “depth” of anesthesia to help predict whether or not the endoscope will be tolerated. If the patient does not tolerate the endoscope, the anesthetist needs to decide if the target propofol blood level should be increased or not. Often the patient will settle if extra time is allowed, and this may be because the mechanism of action of propofol (i.e., its pharmacodynamics) takes more time than expected.

  14. 14.

    Insertion of the colonoscope is not very stimulating. The first part of the colonoscopy is not stimulating until the colon is stretched by looping of the colonoscope. Some patients show signs of discomfort. A background infusion of remifentanil (0.1–0.5 μg/kg/min) is effective, and, provided it is adjusted to the respiratory rate, appreciable respiratory depression is unlikely.

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Authors and Affiliations

  1. Division of Pediatric Critical Care, Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands

    Piet L. J. M. Leroy

  2. Department of Anaesthestics, Great Ormond Street Hospital NHS Trust, London, UK

    Grant M. Stuart

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Correspondence to Piet L. J. M. Leroy .

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  1. Department of Anesthesiology, Harvard Medical School, Boston, MA, USA

    Keira P. Mason, MD

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Leroy, P.L.J.M., Stuart, G.M. (2021). Pediatric Sedation: The European Experience and Approach. In: Mason, MD, K.P. (eds) Pediatric Sedation Outside of the Operating Room. Springer, Cham. https://doi.org/10.1007/978-3-030-58406-1_27

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