By Edward Fernandez, MD, Marshfield Clinic pediatric intensivist on staff at Ministry Saint Joseph’s Children’s Hospital
Children who need medical tests and procedures present unique problems compared to adults. A child who needs a MRI test might not voluntarily stay still for the 45 to 60 minutes needed to complete a test while an adult knows that it is in their best interests and will cooperate.
In most institutions the only reliable way to get these procedures done in children has been to put them under anesthesia. This is prohibitively expensive and also carries a significant risk. Alternatively physicians in many areas have used drugs like benzodiazepines and narcotics to sedate children for these procedures. Success rates have been variable and risks abound.
Marshfield Clinic/Ministry Saint Joseph’s Children’s Hospital, have, since 1997, offered the Pediatric Sedation Service at the Marshfield Campus. This service is run by the Pediatric Intensive Care Service and sedates about 1,200 cases every year. Both hospital inpatients as well as children who are outpatients are covered by this service.
These patients fall into one of two categories. One type is a painful procedure such as a bone marrow, spinal tap or reduction of a fracture. The other type is a procedure which demands that the child lie still and calm for a limited period of time which may vary from 2-3 minutes all the way up to 1-2 hours. An example of this latter type would be a MRI scan.
When a referral is made, the sedation service will typically evaluate the patient and the procedure needed. The patients medical history is reviewed, their cognitive ability and developmental level evaluated. Typically the patient will be offered one of three levels of sedation.
Level 1 sedation or Anxiolysis is typically offered to a patient who is undergoing a non painful but stressful procedure and needs some help to get him or her through that procedure. Usually distraction techniques or on a few occasions a very mild sedative may be used. An 8-year-old who is nervous about having a MRI scan of his brain would be a common example. This child will usually be met by a Child Life Specialist who will explain the procedure to the child. They might be taken to the MRI Scanner to familiarize themselves with the area. During the procedure itself the Child Life Specialist will stay with the child. All the MRI scanners at the Marshfield Clinic Marshfield Center have devices which allow the child to watch a movie while the scan is being performed via an ingenious goggle which the child wears which gives the appearance of watching a big screen movie. These techniques usually work well with non painful procedures in older children and adolescents.
Level 2 Sedation (Moderate Sedation) This type is usually offered to younger patient who are undergoing procedures which may have some mild pain and discomfort or require the patient to lie still for a period or time. These children do not have the mental maturity to know that the procedure is in their best interests and is being performed to help treat or diagnose a disease. Hence they usually will need to be asleep while the procedure is being carried out. The child will be evaluated by one of our pediatricians to see if he is healthy enough to tolerate the sedation regimen for the procedure. The child is then met by a child life specialist and a pediatric sedation nurse who then sedates the child for the procedure. The drugs used for sedation offer anxiolysis, sedation and amnesia. A peripheral IV may need to be placed in order for intravenous drugs to be used. The child is monitored by the sedation team which is trained to effectively and safely sedate the child for the procedure. The sedation nurse will stay with the child throughout the procedure and recovery till the child is ready to go home after complete recovery. Typical procedures carried out under moderate sedation are CT Scans, MRI’s and VCUG’s in a child who is not too sick.
Level 3 Sedation (Deep Sedation) This modality is offered to children who will have painful procedures where the child will need a more robust level of sedation in order to maintain comfort during the procedure.
Typical examples of this service are:
- The child may need to lie absolutely still for a procedure where any movement during the procedure could be hazardous like a CT guided needle biopsy or make the procedure technically difficult like placement of a PICC catheter.
- Alternatively, the child may need a procedure urgently and may be quite sick such that they may need an added level of expertise to safely carry out the procedure. An example of this indication would be a child who has been involved in an automobile accident and urgently needs imaging.
- Pediatric patients in the PICU who are critically ill and need some life saving procedure or diagnostic test avail of this service.
- Older children who are developmentally delayed and need diagnostic procedures like a MRI Scan are too big for conventional Type 2 Moderate Sedation drug protocols and will need Type 3 Deep Sedation
- Children with diseases which are a constant threat to life like a child with heart disease and heart failure typically need the monitoring and expertise offered by Type 3 Deep sedation staff to safely undergo otherwise relatively benign procedures.
- Patients undergoing very painful procedures such as Bone Marrow biopsies or reductions of fractures typically use Type 3 Deep Sedation.
A pediatric Intensive care doctor is the physician entrusted with carrying out these procedures safely and effectively. They will examine the child, and pick the drug regimen which will be used. These drugs are usually potent short acting intravenous anesthetics. The type of sedation offered, the risks, advantages, disadvantage and alternatives will be discussed with the parents and an informed consent obtained. The child will be monitored during the procedure by the pediatric Intensivist and the sedation nurse while the procedure is being carried out. These children are cared for using guidelines and protocols set up by the American Society of Anesthesiologists.
As in all treatments, parents and families are involved in any decision as to which sedation best services the child. The sedation nurse will in elective procedures call the parents and they will discuss the sedation options with the parents. The referring physician may also be called to help in these decisions. Once the type of sedation offered is decided upon; instructions about diet, medications, when to stop food and water are given to the parents. They are told where to come and the time of arrival. The parents are usually called the day before the visit and all the details are confirmed.
In case there are any questions about this service or the suitability of patients for this service please call 1 800 782 8581 Ext 17447 to talk to the Pediatric Sedation Nurses or Ext 75031 to talk to the Pediatric Sedation Service Appointment Coordinator Monday through Friday time between the hours of 8:00am and 5:00pm. Alternatively, the Pediatric Intensivist on call can be paged at any time at 800 782 8581.