Safe paediatric procedural sedation — formative SAQs

SAQ 1 (10 marks)

A 5-year-old, ASA I, presents to the emergency department with a displaced forearm fracture requiring urgent reduction. He last ate a light meal three hours ago. The team plans procedural sedation. ^{[1] [2]}

1. Define procedural sedation and analgesia, and outline the four levels of the sedation depth continuum with the responsiveness, airway and ventilation criterion for each. (4) ^[2]
2. Describe the structured pre-sedation assessment you will perform at the bedside before any drug is given. (3) ^[2]
3. State how you will use the fasting history, and defend your decision to proceed or delay. (3) ^[6]

Model answer — SAQ 1

(1) Definition and the sedation continuum (4). Procedural sedation and analgesia is a monitored, titrated, drug-induced depression of consciousness that allows an unpleasant or painful procedure to be performed while protective airway reflexes, spontaneous ventilation and cardiovascular function are preserved. The ASA continuum has four levels. In minimal sedation (anxiolysis) the child responds normally to verbal command and airway, ventilation and cardiovascular function are unaffected. In moderate or conscious sedation the child shows purposeful response to verbal command or light tactile stimulation, the airway is maintained independently and spontaneous ventilation is adequate. In deep sedation the child responds only purposefully to repeated or painful stimulation, the airway may require active intervention and spontaneous ventilation may be inadequate. In general anaesthesia the child is unarousable even to painful stimulus, the airway usually cannot be maintained without intervention and ventilation is frequently inadequate. The practical boundary is that deep sedation and general anaesthesia carry the risk of airway loss and require anaesthetic-level training. ^[2]

(2) Structured pre-sedation assessment (3). I perform a fixed pre-sedation check. First, I assign the ASA physical status class (ASA I or II is suitable for sedation by a trained team; ASA III or above needs anaesthetic input). Second, I take the history: age and weight in kilograms for dosing, the procedure to be performed and its anticipated pain and duration, the fasting history, recent upper airway infection or wheeze, snoring or sleep-disordered breathing, reflux or vomiting, previous sedation or anaesthetic problems, allergies and the past medical history. Third, I perform a focused airway assessment looking for mouth opening, neck movement, mandibular recession, visible tonsils and any stridor, and a cardiorespiratory examination recording baseline observations. Before the drug I confirm a two-person team, rescue airway equipment (suction, bag-valve-mask, age-appropriate airway adjuncts, oxygen) at the bedside, continuous monitoring with a baseline, and vascular access where the agent requires it, and I document consent. ^[2]

(3) Fasting history and the decision to proceed (3). I take the fasting history and use it to inform the risk and the depth of sedation, but I would proceed with sedation now. The evidence on pulmonary aspiration risk during emergency procedural sedation shows it is negligible and is not predicted by fasting status; aspiration is prevented by sedation depth and airway care rather than by the time since the last meal. The ASA elective fasting intervals (2 hours clear fluid, 6 hours light meal) were designed for elective anaesthesia and should not delay a child in pain needing a time-critical reduction. The current position, reflected in the guidelines, is that fasting is not a substitute for monitoring. I would choose an agent and depth matched to the child's risk, ensure rescue equipment and a dedicated observer are present, use capnography, and proceed. ^[6]