Conscious sedation for children​​

​In this article
  • How we help children needing painful procedures

  • Children with cancer

  • Babies having MRIs
  • Risks and possible side-effects

Children often have to undergo procedures, which can be extremely painful. Earlier on, they were given g​​eneral anaesthesia, but now with the advancement of sedation, all these procedures can be easily done without any complications and in a short span of time. This has been made possible by widely used, secure sedatives like Ketamine and Propofol that have a 10-15 minute maximum recovery duration.

​​​A newborn baby lies in an incubator at our Neonatal Intensive Care Unit at Aga Khan University Hospital, Karachi. His breathing is helped with a CPAP machine, which produces a steady flow of warm air for premature babies whose lungs are still developing. Image: AKU/Paediatrics​

In anaesthesia, the child is made completely unconscious. And it is necessary for that child to be put on a ventilator during that period of unconsciousness. However, during sedation, we gi​​ve medicines so the child is immune from the pain. Comparing sedation to general anaesthesia, which is a lengthy procedure and has higher hazards, we can see that sedation is rather risk-free.

Paediatric oncological patients​

​​​​​Our patients are mostly those with either a blood cancer or a tumour. Whenever we have to treat children with cancer, the first thing we do is perform a biopsy. A biopsy is an unpleasant procedure in which a small piece of the cancer or tumour is extracted through a needle. In children who have cancer, this tumour extraction is ​​called a lumbar puncture which can be safe if procedural sedation is provided to them. During this process, we take a tiny sample of the fluid around the brain or cerebrospinal fluid, and this is obtained by introducing a needle into the spine of the child. For this purpose, we require them to be consciously sedated, and this minimises the possible pain, discomfort and fear.

Conscious sedation makes the child unaware of the trauma and pain and also reduces the parents’ anxiety. The children usually wake up within a few minutes and come back to their original state within 10 to 15 minutes. Unfortunately, children with cancer require som​​e painful procedures multiple times. And because we have to do these repeatedly, we feel it is very important to ensure they don't remember experiencing that pain and trauma.

Sedation pr​​​ocedure with Chemotherapy

​​​Chemotherapy is like any other medication, which is generally either given through a cannula or through the PICC line. The peripherally inserted cannula is called intrathecal chemotherapy, which is given particularly to patients with leukaemia. Since this proc​edure involves putting a needle in the water of the back, the pain cannot be easy for the children or the parents. Sometimes people abandon treatments because they don't want to go through the pain.

For long-term medications like chemotherapy or when multiple cannulations make it difficult to find a vein, children may need a PICC line or peripherally inserted central catheter. Once a PICC line is placed, the patient does not need a cannula for months, since it delivers all kinds of medications. In order to put a PICC line, we have to puncture a small vessel. To accomplish this, we sedate the patient, because the window of the ​​vessel is very narrow and we can mis-puncture or miss the vein, especially if the patient is moving. Usually, there is no such complication in a PICC line, except where the PICC line is placed, a local hematoma may form or there may be blood clotting. This is a common complication that is spontaneously resolved within 24 hours.

We do vascular sedation as well, i.e. through the IV cannula. The benefit is that the children are sedated immediately, within a few minutes. In this way, one procedure may take 10-15 m​inutes, but the entire procedure may take an hour or more. When their children are getting treatment in sedation, particularly, as I said, intrathecal chemotherapy or lumbar puncture procedure, the child does not have any memory or emotional trauma and that increases the compliance of our treatment.

Hemangioma, AVM, and other abnormalities are only a few of the other blood vessel-related illnesses that affect children. Here, sedation is used to allow us to use a needle or punctur​e a body part, both of which are painful for the patient. Whether it is an emergency or elective surgery, we can very easily align it with our sedation procedure because our ICU has a very devoted team to administer sedation.

Sedation in MRI

MRI is basically a cross-sectional imaging, which can be a long procedure that can take up to 15 to 20 minutes, or sometimes 30 to 45 minutes. It is not possible for small children to get a procedure done without moving, especially for an MRI, where you have to stay still so sedation is crucial to complete that procedure. For babies, the sedation criterion is 6 months and above 6 kg and for children sedation can be provided to anyone between 6 a​​nd 18 years of age. In a situation where the child is 5 months old, or even 6 kg, we don't take the child and tell the parents that this is a high risk for us, and the following possibilities can occur with the child. However, if they are still willing to take this risk, we get a high risk consent signed and then give the procedure.

Sometimes children get hydronephrosis or their kidneys swell. The treatment for swelling in the kidn​​eys is that we puncture a needle in the kidney and through that needle we put a tube in the kidney which is called PCN. This is a reliable treatment for swelling in​ the kidneys or the hydronephrosis. However, this can be a very difficult procedure or failure can be very high, if the patient is not in sedation.

Risks and side effects of procedural sedation

Individuals with a history of c​​ardiac arrest or congenital heart disease are not advised to be sedated, instead, general anaesthesia is advised for these individuals. For instance, general anaesthesia is recommended for children with a higher risk who are younger than 6 months. General anaesthesia is also advised when children need to have their breathing stopped during procedures like some MRIs so that the anaesthesia can control their breathing. This can be an expensive procedure, and the cost of sedation is almost a third.

Vomiting is a frequent adverse effect of sedation. For this reason, we keep the child in recovery and make sure the​y don't vomit after being sedated. To ensure that they are digesting, we provide them with food and liquids. Infants are evaluated for 1-2 hours before being let out of recovery. The greatest side effect we care about is allergic reactions.

With almost 1,500 patients each year, the procedure's annual maximum success or failure rate is practically zero percent. We protect children, particularly their cognitive and learning abilities, by providing them with sedation. All procedures, including biopsies, drainage, PICC lines, and​ PCNs, have been carried out incredibly successfully over the past few years with the help of a highly competent sedation team.​