When a child needs a procedure, there is often a need to provide some degree of sedation and, if the procedure is a painful one, analgesia. Additional goals of sedation are to relieve anxiety, to control patient behavior, to return them to their baseline state of alertness, and to conduct this entire process in a safe fashion.
Within 1 year's time in the early 1980s, three children in the United States suffered adverse outcomes while being sedated for dental procedures. This was the impetus for the first sedation guidelines published by any organization, coming from the American Academy of Pediatrics (AAP).1 Every AAP policy statement is reviewed on a 3 -year basis to determine if the statement should be reaffirmed or revised. Six years after the initial 1985 sedation guideline, it became clear that many physicians misunderstood the original document because of its title and thought that it applied only to children receiving general anesthesia.2,3 Therefore, the AAP Committee on Drugs changed the guideline's title to reflect more closely what was intended: "Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures."4
The specialty of anesthesiology has long been a proponent for the development of safety nets for patients undergoing a variety of anesthetic processes. In 1984, the American Society of Anesthesiologists (ASA) began a project called the Closed Claims Analysis. This consists of a task force of anesthesiologists who examine the medical records of patients who have had an adverse event that has resulted in an insurance claim or a lawsuit that was dropped or settled. Retrospectively analyzing these reports - which now number well more than 5,000 - allows the organization to examine rare events and, therefore, to focus anesthesiologists on methods to avoid adverse outcomes that occur uncommonly.5
Since the beginning of this process, and with the institution of ASA guidelines and standards for patient monitoring, patient evaluation, recovery room procedures, and discharge criteria for patients undergoing anesthesia, there has been dramatic improvement in anesthetic outcomes. Anesthesia-related mortality has been reduced from 1 in 20,000 in the 1950s to 1 in 200,000 today. Thus, the systematic approach to the entire anesthesia process has improved safety dramatically. The 1992 AAP sedation guideline revision took a similar direction, presenting a systematic approach to children requiring sedation so that they could undergo a procedure (Sidebar 1).
ADVERSE EVENTS SURVEY
In the mid-1990s, through the Freedom of Information Act, I was able to obtain adverse drug reports related to a variety of medications used to sedate children. In addition, I contacted the United States Pharmacopoeia and conducted a survey of pediatric anesthesiologists, pediatric intensivists, and pediatric emergency medicine physicians who were members of the AAP In total, 629 reports were received from the Food and Drug Administration, and the survey was sent to approximately 1,300 physicians. Critical incident analysis was used - that is, what went wrong, why did it go wrong, and how this adverse event could be prevented from happening again. Using the ASA's closed claims approach, each of these reports was examined independently by four physicians; each case later was debated by two pediatric anesthesiologists, a pediatric intensivist, and a pediatric emergency medicine physician.7,8 The only reports that were accepted were those that were in English, from the United States, and for which there was sufficient information such that all four reviewers agreed upon the causes, or the likely contributory factors, relating to the adverse event. We only accepted reports in which the patient was sedated for a procedure by a nonanesthesiologist. Outcome measures examined were death, neurologic injury, prolonged hospitalization, or no harm. In the end, 95 cases fulfilled study criteria: 57 from the FDA, three from the United States Pharmacopoeia, 27 from the physician survey, and three that had been sent to the reviewers anonymously. Some reports were received from all four sources. The categories of contributory factors are outlined in Table 1.
Contributory Causes to Sedation Adverse Events
A review of these reports prompted astonishment at some of the information related. In fact, there was a visceral sense of indignation among the reviewers that children had been injured because of careless breakdowns in the "systems process" for providing sedation safely. Some examples of egregious violations of how to sedate children safely:
* A patient was sedated without any monitoring at all (inadequate monitoring).
* A patient received tablespoons instead of teaspoons of drug (dispensing error).
* A physician administering sedating medications left the patient with a technician (abandonment of the patient).
* A patient was given a greater than tenfold overdose of intravenous fentanyl, then developed chest wall or glottic rigidity; the physician did not know how to manage chest wall rigidity (lack of understanding of the drug's pharmacodynamics).
* A 6-week-old given meperidine, promethazine, and chlorpromazine for circumcision was found dead in bed, an example of inappropriate drug selection (drugs with an extremely long half-life administered to a neonate).
ASA Physical Status Classification
* A drug was administered at home by a parent (medically unsupervised drug administration).
* Sedation given by a gynecologist in an abortion clinic (a physician trying to do two things at the same time, that is, being the anesthesiologist as well as the physician performing the procedure).
* Enormous overdoses, such as a child who received a 6,000 mg dose of chloral hydrate.
The age distribution in the survey also was of interest. Two-thirds of the children (70 of 95) were 6 or younger. This certainly fits the demographics of how difficult it is to control the behavior of a child below the age of reasoning. Sixty-eight of the 95 patients were healthy or had only a mild systemic illness, that is, ASA Class I or II (Table 2). However, the outcomes of these 95 cases were very disturbing; 60 resulted in death or neurologic injury, and the remainder resulted in prolonged hospitalization or no harm.
Drug interaction issues were the most common associated factor, followed by drug overdose, inadequate monitoring, inadequate cardiopulmonary resuscitation skills, inadequate evaluation prior to the patient undergoing sedation, premature discharge from medical supervision, and others. Some children had more than one contributory cause, and one child had received overdoses of five sedating medications, indicating gross incompetenceby the person administering sedation.
When we examined the practitioners whose patients had experienced an adverse outcome, we were surprised to find that nearly half (29 of 60) of those who suffered death or neurologic injury were undergoing dental procedures. Had this been known a priori, a pediodontist would have been enlisted to help with the analysis. The training of the dentists involved was unknown; however, 11 were described as oral surgeons and three as pediodontists.
Other specialties included 11 patients in radiology, three in cardiology, one in gastroenterology, two in unknown pediatric medical specialties, two in gynecology, two in general pediatrics, and one in surgery; one case was an audiology clinic patient. Of note, 80% of the patients presented with some compromise of respiration, but a high fraction then progressed to cardiac arrest, indicating a lack of rescue skills of the practitioners involved.7
Additionally, all drug categories were associated with the identified adverse outcomes, with equal representation among opioids, benzodiazepines, barbiturates, and sedatives. There were 13 cases associated with chloral hydrate and one with ketamine, drugs generally considered to have a very good safety profile. One half of the patients received one sedating medication and the remainder received two to five sedating medications. There was a highly significant relationship with adverse outcomes when three or more sedating medications were used. The adverse outcomes of death and neurologic injury were observed with intravenous, oral, rectal, nasal, intramuscular, or inhalation administration, suggesting that there may be little difference in safety among the various routes of drug administration.8
Another observation was that 41 of the sedation events occurred in a hospital environment, 22 in a nonhospital medical environment (eg, a private physician's office or a freestanding imaging facility), eight at home, and four in an automobile.7 Two of these latter events occurred when children received a sedating medication at home prior to a procedure. The apparent mechanism of death in these cases was the child falling asleep in the car seat and the head falling forward, obstructing the airway. Both of these children received drug doses that are normally considered very safe (eg, 0.5 mg/kg of midazolam or 40 mg/kg of chloral hydrate). Because of the sedating medication, the children were unable to unobstruct their airway. The remaining children developed problems after the procedure, indicating that they had been sent home prior to adequate recovery. Of note is that all of these children had received medications with a long half-life, such as chloral hydrate, promezine, promethazine, chlorpromazine, or intramuscular pentobarbital.9,10 The take-home message here is that medications with a long half-life may require a longer period of observation following apparent recovery from the sedation process.
There was also a difference in outcomes between those children sedated in a nonhospital venue and in a hospital venue. The nonhospital patients were significantly older (mean age of 7.0 versus 3.8) and healthier (lower ASA status), but the outcomes were also dramatically different. There was the same rate of respiratory depression but there was a threefold greater incidence of cardiac arrest as the second event, and a successful outcome occurred in only 9%.7 We asked why circumstances would be different in an office environment compared with the hospital environment, and the answer appears to be relatively simple. In a hospital, a code button can be pressed, and staff with advanced airway management skills come from the operating room, the emergency room, and the intensive care unit to help with the rescue of the patient. However, in the office setting the only backup is an emergency service such as 911, which takes a period of time to arrive to help rescue a patient with compromised respiration (eg, apnea, obstruction). In addition, there likely is some reluctance to call 911 until the event has progressed to a serious endpoint, so as not to alarm families in the waiting area.
Just as the ASA Closed Claims Analysis provided and continues to provide guidance for anesthesiologists, analysis of adverse sedation outcomes provides important information regarding prevention of an accident during the sedation process. It is not the drugs, the route of administration, or the patient population that is the problem. Monitoring can and does make a difference. There needs to be a systematic approach to all children who are sedated, and those who administer sedation must have adequate cardiopulmonary resuscitation skills so they can rescue the patient who develops a problem. Complex cases should be referred to those specialists with the required rescue skills (eg, an anesthesiologist, an emergency medicine physician, or a critical care specialist).
Figure 1. Time to peak electroencephalographic effect (EEG) of diazepam versus midazolam in adults. Note that it takes nearly three times longer to achieve a peak EEG effect following intravenous midazolam compared with diazepam. This is most likely due to differences in fat solubility. Because midazolam is less fat soluble, it does not cross biologic membranes as readily. The clinical importance of this observation is the need to wait a sufficient time between midazolam doses so as to avoid stacking and excessive drug effect.16
A number of years ago, I conducted a series of pulse oximetry studies in pediatric patients undergoing anesthesia.11,12 Anesthesiologists pride themselves on being able to recognize desaturation and to intervene rapidly to rescue their patients. In these studies, however, we blinded the anesthesiology team to having pulse oximetry available or having it unavailable.
Interestingly, in a combined total of about 550 pediatric patients, there was nearly a threefold higher incidence of major desaturation events when the anesthesia team did not have the pulse oximetry data available to them (an event was defined as a saturation of less than or equal to 85% for 30 seconds or longer). Also, when queried, half the time when a patient was desaturated (ie, more than 5 grams of desaturated hemoglobin) the anesthesiologist stated that the patient was not desaturated (ie, was not cyanotic), and half the time, when the patient could not have been cyanotic (ie, less than 5 grams of desaturated hemoglobin), the anesthesiologist stated that the patient was cyanotic.
These results clearly indicate that physicians, even those who deal with sedation every day, are not very good at diagnosing desaturation. That is why pulse oximetry is essential in providing an early warning for a developing adverse event related to oxygenation and why it is such an important part of the safety net for children who are sedated for a procedure.4
Another monitoring modality that is gaining increasing use in sedated children is expired carbon dioxide monitoring.13"15 The accuracy of this device depends in part on where the sensor is placed. Nasal cannulae allow the simultaneous administration of oxygen and the measurement of expired carbon dioxide. If, however, the patient is a mouth breather, the cannula may need to be adjusted so that it is over the mouth. Several manufacturers have made modification to allow simultaneous measurement from both the mouth and the nose. In the past, transcutaneous measurement of arterialized skin (achieved by heating) provided a reasonable estimate of arterial carbon dioxide, but this monitoring did not provide breath-to-breath analysis and in some patients caused minor skin irritation from the heating element. Monitoring end-tidal carbon dioxide enables the individual observing the patient to know immediately if the patient is not breathing or has developed airway obstruction. Trending allows the diagnosis of developing hypoventilation and hypercarbia. In reality, the actual number on the monitor is less important than simply knowing that the child is breathing, because most sedation regimens produce some degree of hypercarbia. Expired carbon dioxide monitoring is especially useful for the patient undergoing magnetic resonance imaging or computed tomography scan because they must be positioned a long distance from the trained observer.
Figure 2. The elimination half-life of the active metabolite of chloral hydrate trichloroethanol in term infants (L = left bar) versus toddlers (R = right bar). Note the extremely long half-lives in all age groups and the large standard deviations, particularly in the newborns. It is clear that chloral hydrate is not a short-acting sedative and can have profound effects that are long lasting. This may be a reason to observe children sedated with chloral hydrate for an extended period of time and to be certain that a responsible adult can observe the child in the car seat (ie, the mom or dad are not driving with the child unattended in the back seat).18
It is vital that the person administering the sedating medications understand the drugs' pharmacokinetics and pharmacodynamics. For example, drugs that are highly lipid-soluble are able to enter the central nervous system (CNS) much more rapidly. This explains in part the near-immediate analgesia provided by fentanyl compared with the longer onset for morphine. Practitioners also should understand that, in part because of this rapid ability to cross into the CNS, fentanyl and other highly lipid-soluble opioids can result in chest wall or glottic rigidity that can be relieved only with an opioid antagonist or a muscle relaxant such as succinylcholine.
Similar to the opioids, the peak electroencephalographic effect of midazolam is 4.8 minutes in adults, compared with 1.6 minutes for diazepam (Figure 1, see page 629). This is, again, related to differences in fat solubility between the two formulations. 16Thus, depending on the drug, it is important to wait an appropriate period of time between doses so as to avoid "stacking of doses" and overshooting the desired effect.
PROLONGED RECOVERY OBSERVATION
The sedation study referred to previously revealed that at least nine deaths or neurologic injury following sedation and discharge from medical supervision were associated with long-acting drugs.7,8 A study of emergency department patients sedated with the longacting (and no longer recommended) Demerol-Phenergan-Thorazine (DPT) lytic cocktail took, on average, 19 ±15 hours to return to normal behavior.10 Another prospective study of children sedated for echocardiograms found what the study discussed here showed retrospectively: children who have been sedated with chloral hydrate have prolonged drug effect.17 Therefore, another important direction to improve safety is prolonged observation of children who have received drugs with a long half-life (eg, chloral hydrate has a half-life of 9 hours in a toddler and nearly 30 hours in a newborn; Figure 2).18,19
A number of recovery scoring systems have been used commonly, but a new system that evaluates the child's ability to stay awake while in a quiet environment for more than 20 minutes shows great promise.17 It would seem reasonable to keep children who have received medications with a long halflife in a step-down observation unit for an extended period of time, even if the child has failed sedation. In one case, a patient received two doses of chloral hydrate and did not become sedated; the mother left the hospital and noted that her child fell deeply asleep in the car seat, so she returned and the child had a successful CT scan. This anecdote points out another safety issue - the need to have someone in the back seat of the car who can observe the child to make certain that the child's head does not fall forward, resulting in airway obstruction. Such an admonition should be a part of the discharge process for all children who have received sedating medications, especially those under age 5.
Over time, there has been much discussion about definitions to describe the sedation process. The most confusing is the oxymoron "conscious sedation."20 In recent years, there has been an attempt to bring together the language used to describe the sedation process by those organizations that have been active in accident prevention. These include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the ASA, the AAP, and the American Academy of Pediatric Dentistry (AAPD).4,21-24 A recent joint task force was formed by the AAP and the AAPD to develop an updated sedation document, now under review by both academies at the executive level. If it is approved, all four organizations will use the same terminology to describe the sedation process, making it much easier for everyone to be on the same wavelength in terms of knowing what has to be done and the training skills required when sedating children for a procedure.
The new terminology being reviewed is "minimal," "moderate," and "deep" sedation. Minimal is equivalent to what used to be called "anxiolysis," moderate is equivalent to what used to be called "conscious sedation" or "sedation analgesia." Deep sedation remains the same. The caveat that a patient may readily progress from one level of sedation to the next is still present. JCAHO and ASA further refined this by stating that if one's intended level of sedation is minimal, the practitioner must have the skills to rescue the patient who slips into a moderate level of sedation. If the intended level of sedation is moderate sedation, then the practitioner must have the skills to rescue the patient who has become deeply sedated. If the intended level of sedation is deep sedation, then the practitioner must have the skills to rescue the patient who has progressed into a state of general anesthesia.
It is recognized that with minimal and moderate sedation, the patient responds purposefully to a verbal or tactile stimulation, no airway interventions are required, the patient breathes spontaneously, and the cardiovascular system is generally stable. With deep sedation, however, the patient responds purposefully only following a repeated or painful stimulus. Interventions may be required to maintain a patent airway, generally, spontaneous ventilations are adequate, and cardiovascular function is maintained. When the patient progresses to a state of general anesthesia, the patient is unarousable even with repeated painfill stimulus. Interventions regarding the airway (ie, maintaining a patent airway) often are required, and spontaneous respirations may be compromised.
These JCAHO recommendations are supported by several studies that found many children who received sedation for a procedure exceeded the intended level of sedation; that is, many children whose intended level of sedation was "moderate" in fact became deeply sedated.17,19,25,26 It is also of interest that there continue to be sedation studies describing "safety and efficacy" yet reporting a 20% complication rate.27 These studies often are underpowered to make any legitimate statement regarding safety. Certainly, there is a great need to collect further outcomes data to improve safety, but large-scale studies are required.28
When one examines the published sedation guidelines, it is clear that the JCAHO guidelines only apply to hospital settings and the ASA do not specify a venue. The earlier iterations of the AAP document also did not specify venues until an addendum was published in 2002.21 That document is the only sedation guideline that specifically states the guidelines apply to any child who is sedated for a procedure, even in a private practitioner's office.
Another new direction in the 2002 document is the recognition that children 6 and younger generally require deep pharmacologic restraint to accomplish a procedure. Therefore, it is reasonable to assume that every child 6 or younger is likely to be deeply sedated from the beginning of a procedure; therefore, the skill set required to achieve this level of sedation is different from that needed for the teenager who receives a modest dose of midazolam for anxiolysis. Appropriate monitoring capability and adequate personnel need to be present from the beginning of the procedure.
It is also clearly stated that those who provide sedation must have advanced airway management skills to be able to deal with airway obstruction, provide bag/mask ventilation, and know how to perform cardiopulmonary resuscitation properly. These skills may be partially acquired through the typical pediatric advanced life support (PALS) or advanced pediatric life support (APLS) courses and textbooks. In reality, the incidence of these events is rare, and so it is very easy for practitioners to lose these skills. Published reports suggest that, increasingly, sedation is being provided by pediatric anesthesiologists, pediatric intensivists, and pediatric emergency medicine physicians because they have the needed skills as part and parcel of their daily workload.28-32
Pediatric hospitalists also are being trained to provide or supervise sedation by nurses. The concept of a sedation team that can be used throughout the hospital to provide sedation in a variety of venues is evolving. Many children's hospitals have constructed procedure suites to provide sedation in a standardized environment for a variety of procedures, such as upper and lower endoscopy, echocardiograms, bone marrow tests, spinal taps, and kidney and liver biopsy. These processes foster a systematic approach and therefore provide an improved safety net. One suggested eponym to help assure safe anesthesia care is shown in Sidebar 2.
In the future, patient simulators may be useful in helping physicians and nurses to maintain their skills in terms of both recognition and appropriate interventions when an airway-related or other emergency arises.33-35 This kind of training will be expensive to provide but will assure that those who provide this kind of sedation have the skill set to rescue their patients. It is also hoped that continuous quality improvement activities can be used to collect common events such as desaturation, airway obstruction, and apnea, which could be used for surrogates of potentially lifethreatening events.36
We have come a long way in sedation accident prevention, and we need to continue to improve. Although the systems approach has made flying very safe, accidents can and will continue to occur. Fortunately, when sedating a child, we can rescue the patient if we have the skills to do it. It is our obligation to provide the safety net needed to achieve the goal of accomplishing sedation safely, painlessly, and returning the child safely to a pre-sedation level of consciousness.
1. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Committee on Drugs. Section on Anesthesiology. Pediatrics. 1985; 76(2):317-321.
2. Keeter S, Benator RM, Weinberg SM, Harten - berg MA. Sedation in pediatric CT: national survey of current practice. Radiology. 1990; 175(3):745-752.
3. Hawk W, Crockett RK, Ochsenschlager DW, Klein BL. Conscious sedation of the pediatric patient for suturing: a survey. Pediatr Emerg Care. 1990;6(2):84-88.
4. American Academy of Pediatrics Committee on Drugs: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics. 1992;89(6 Pt 1): 1110-1115.
5. Lee LA, Domino KB. The Closed Claims Project. Has it influenced anesthetic practice and outcome? Anesthesiol Clin North America. 2002;20(3):247-263.
6. Litman RS, Kottra JA, Berkowitz RJ, Ward DS. Upper airway obstruction during midazolam/ nitrous oxide sedation in children with enlarged tonsils. Pediatr Dent. 1998;20(5):3 18-320.
7. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributory factors. Pediatrics. 2000; 105(4 Pt 1):805-814.
8. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000106(4):633-644.
9. Nahata MC. Sedation in pediatric patients undergoing diagnostic procedures. Drug Intell Clin Pharm. 1988;22(9):711-715.
10. Terndrup TE, Dire DJ, Madden CM, et al. A prospective analysis of intramuscular meperidine, promethazine, and chlorpromazine in pediatric emergency department patients. Ann Emerg Med. 1991;20(1):31-35.
11. Coté CJ, Goldstein EA, Coté MA, Hoaglin DC, Ryan JF. A single-blind study of pulse oximetry in children. Anesthesiology. 1988; 68(2): 184-188.
12. Coté CJ, Rolf N, Liu LM, et al. A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology. 1991; 74(6):980-987.
13. Friesen RH, Alswang M. End-tidal PC02 monitoring via nasal cannulae in pediatric patients: accuracy and sources of error. J Clin Monit. 1996;12(2): 155-159.
14. Miner JR, Heegaard W, Plummer D. End-tidal carbon dioxide monitoring during procedural sedation. Acad Emerg Med. 2002;9(4):275-280.
15. Primosch RE, Buzzi LM, Jerrell G. Monitoring pediatric dental patients with nasal mask capnography. Pediatr Dent. 2000;22(2): 120-124.
16. Buhrer M, Maitre PO, Crevoisier C, Stanski DR. Electroencephalographic effects of benzodiazepines. II. Pharmacodynamic modeling of the electroencephalographic effects of midazolam and diazepam. Clin Pharmacol Ther. 1990;48(5): 555-567.
17. Malviya S, Voepel-Lewis T, Ludomirsky A, Marshall J, Tait AR. Can we improve the assessment of discharge readiness?: A comparative study of observational and objective measures of depth of sedation in children. Anesthesiology. 2004;100(2):218-224.
18. Mayers DJ, Hindmarsh KW, Sankaran K, Gorecki DK, Kasian GE Chloral hydrate disposition following single-dose administration to critically ill neonates and children. Dev Pharmacol Ther. 1991;16(2):71-77.
19. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics. 2000;105(3):E42.
20. Coté CJ. "Conscious sedation": time for this oxymoron to go away! J Pediatr. 2001;139(1): 15-17.
21. Committee on Drugs. American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics. 2002;110(4):836-838.
22. Policy on the Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office. 2004. American Acadmey of Pediatric Dentistry. Available at: http://www.aapd.org/ media/Policies_Guidelines/P_Sedation.pdf. Accessed July 21, 2005.
23. Practice guidelines for sedation and analgesia by non-anesthesiologists. A report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 1996;84(2):459-471.
24. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non- Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4): 1004-1017.
25. Dial S, Silver P, Bock K, Sagy M. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care. 2001;17(6):414-420.
26. Malviya S, Voepel-Lewis T, Tait AR, Merkel S, Tremper K Naughton N. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). Br J Anaesth. 2002;88(2): 24 1-245.
27. Austin T, Vüke GM, Nyheim E, Kelly D, Chan TC. Safety and effectiveness of methohexital for procedural sedation in the emergency department. J Emerg Med. 2003;24(3):315-318.
28. Cravero JP, Blike GT. Review of pediatric sedation. Anesth Analg. 2004 ;99(5): 1355- 1364.
29. Gozal D, Drenger B, Levin PD, Kadari A, Gozal Y. A pediatric sedation/anesthesia program with dedicated care by anesthesiologists and nurses for procedures outside the operating room. J Pediatr. 2004;145(1):47-52.
30. Lightdale JR. Sedation and analgesia in the pediatric patient. Gastrointest Endose Clin N Am. 2004;14(2):385-399.
31. Wheeler DS, Vaux KK, Ponaman ML, Poss BW. The safe and effective use of propofol sedation in children undergoing diagnostic and therapeutic procedures: experience in a pediatric ICU and a review of the literature. Pediatr Emerg Care. 2003; 19(6): 385-392.
32. Barbi E, Gerarduzzi T, Marchetti E et al. Deep sedation with propofol by nonanesthesiologists: a prospective pediatric experience. Arch Pediatr Adolesc Med. 2003;157(11):1097-1103.
33. Blike G, Cravero J, Nelson E. Same patients, same critical events - different systems of care, different outcomes: description of a human factors approach aimed at improving the efficacy and safety of sedation/analgesia care. Qual Manag Health Care. 2001;10(1):17-36.
34. Farnsworth ST, Egan TD, Johnson SE, Westenskow D. Teaching sedation and analgesia with simulation. J Clin Monit Comput. 2000; 16(4):273-285.
35. Rowe R, Cohen RA. An evaluation of a virtual reality airway simulator. Anesth Analg. 2002;95(1):62-66.
36. Mohr JJ, Barach P, Cravero JP, et al. Microsystems in health care: Part 6. Designing patient safety into the microsystem. Jt Comm J Qual Safi 2003;29(8):401-408.
Contributory Causes to Sedation Adverse Events
ASA Physical Status Classification