Round and round we go: sedation -- what is it, who does it, and have we made things safer for children?

In this issue of Pediatric Anesthesia several papers and commentaries authored by anesthesiologists and nonanesthesiologists describe different perspectives regarding sedation ⁄ analgesia for children in the UK and the USA. I will provide historical perspectives from the USA and then examine these reports to see how they compare with current USA practice. I had the good fortune of being the co-author of the first Sedation Guideline (pediatric or adult) supported by any organization. This initial attempt at providing guidance for a systematic and safe approach to procedural sedation was a result of a number of sedation accidents in children undergoing dental procedures. We worked closely with our pediatric dental colleagues and developed joint guidelines (1,2). Unfortunately we adopted terminology that had been approved by the National Institutes of Health, i.e., the phrase conscious sedation (3). This resulted in much confusion particularly since the intended appropriate (purposeful) response to physical stimulus or verbal command was often miss-interpreted to mean any movement at all in response to any stimulus including painful stimuli! As time passed the American Academy of Pediatrics (AAP) recognized that sedation was provided by many specialists besides dental practitioners so the original guideline was revised in 1992 (4). A special emphasis was placed on a systems approach modeled after our specialty (anesthesiology). Points of interest included: (i) informed consent (parents needed to know that sedative ⁄ analgesics can cause harm); (ii) a presedation history was required (how would the child s underlying medical conditions affect the safety of sedation?); (iii) a focused airway examination (was there an airway abnormality or large tonsils that might affect airway patency or complicate airway management?); (iv) proper fasting prior to elective procedures and the need to balance the risk of sedation in children who required urgent or emergent procedures was described; (v) appropriate monitoring especially continuous pulse oximetry during the procedure and into the recovery period was required for the first time; (vi) appropriate monitoring by an independent observer whose only responsibility was to watch the patient was required during deep sedation; (vii) appropriate staffing and monitoring were required during recovery; and (viii) the children had to be returned to their presedation level of consciousness prior to discharge. With this 1992 revision, the dental community separated from the AAP and published their own specialty specific guideline which deviated significantly from that of the AAP (5–7). In 2002, the AAP published an addendum so that the AAP, the American Society of Anesthesiologists (ASA) and the Joint Commission of Accreditation of Healthcare Organizations all used the same terminology. The phrase conscious sedation was changed to sedation ⁄ analgesia and then changed again to moderate sedation (8,9). Children sedated in all venues including private offices were considered to fall under these guidelines. In particular, the updated guideline states that children aged <6 years usually require a state of pharmacologic coma, i.e., deep sedation to successfully complete most procedures without major psychologic trauma to both provider or child. A clear emphasis was made that sedative medications were only to be administered under the safety net of medical supervision (no home Pediatric Anesthesia 2008 18: 3–8 doi:10.1111/j.1460-9592.2007.02403.x