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The good news is that there is increasing recognition that children need to be treated in a humane fashion when having diagnostic and therapeutic procedures outside the operating room environment. The bad news is that some of the practitioners who use sedation and analgesia for these circumstances do not do so in a safe manner. Other good news is that there is increasing recognition by nonsurgeons that anesthesiologists provide an increased measure of safety and convenience for procedures on children in nonstandard settings. The bad news is that the proposed conditions may not be convenient or timely for us. Lastly, the good news is that hospitals, families, and regulatory agencies are also gaining recognition of the important advantages we can bring to diagnostic and therapeutic procedures in new settings. The bad news is that there is a growing discordance between recognition of need for our services and commitment to physical and fiscal support. This talk will focus on some of the trends in providing sedation and analgesia for diagnostic and therapeutic procedures in children, along with suggestions about strategies to ensure the best care. Do we, as anesthesiologists, really need to become involved in sedation outside our normal environment, the operating rooms? Recent articles have identified some of the problems encountered when sedation or analgesia are provided by practitioners who are also providing the diagnostic or therapeutic procedure. Malviya et al. (1) and Cote et al. (2) have recently published studies attempting to identify important issues related to sedation-related problems. Some of the important issues from their work include the importance of the use of pulse oximetry for detection of hypoxemia, the higher incidence of hypoxemia in children who were classified as ASA class III or IV (3), and the importance of drug overdose as an important cause of permanent patient damage (4). Of interest, Cote et al. found that although drug overdose was identified as a cause of death or permanent disability, there was no clear evidence that any particular drug or method of administration (PO versus IM versus IV) could be implicated as associated with a higher incidence of injury (4). Lastly, the potential for adverse events after the child had been discharged from the facility was identified (4). Although there is no absolute requirement that anesthesiologists either provide direct patient care or assist in the development of appropriate systems, we as a specialty are best trained to be important resources for these issues. Anesthesiologists are uniquely trained to provide sedative and anesthetic services outside the operating room because of our tradition of focused evaluation of patients, appropriate monitoring, sophisticated understanding of drug choice and administration, and continued care of the patient until the patient is safe for discharge. Because of this systematic and complete approach, anesthesiologists are able to provide safe and superior conditions for a variety of painful or uncomfortable procedures. Our approach can increase throughput for procedures by decreasing lost time secondary to lack of patient cooperation. These advantages have led to increased requests for our routine participation for procedures such as cardiac catheterization, magnetic resonance imaging examinations, invasive radiography, and trauma and emergency room care. However, for an anesthesia department to respond to these requests in a timely and appropriate fashion, the department must have a clear plan for providing services in nontraditional environments.

Sedation and Analgesia for Diagnostic and Therapeutic Procedures in Children