From the Guidelines
Procedural sedation is recommended for chest tube insertion in children to minimize pain and distress. The most recent and highest quality study 1 supports the use of sedation to guard the patient's safety and welfare, minimize physical discomfort and pain, control anxiety, and provide appropriate cardiopulmonary support if needed. A combination of midazolam (0.05-0.1 mg/kg IV) for anxiolysis and fentanyl (1-2 mcg/kg IV) for analgesia is commonly used, administered 5-10 minutes before the procedure. Alternatively, ketamine (1-2 mg/kg IV or 4-5 mg/kg IM) provides both sedation and analgesia with preserved respiratory drive. For longer procedures, propofol (1-2 mg/kg IV initial dose, followed by 0.5-1 mg/kg as needed) may be appropriate under close monitoring.
Key Considerations
- Local anesthesia with lidocaine 1% (maximum 5 mg/kg) should be infiltrated at the insertion site regardless of sedation choice.
- Continuous monitoring of vital signs including oxygen saturation, heart rate, blood pressure, and respiratory rate is essential throughout the procedure and recovery period.
- A provider skilled in pediatric airway management should be present, with resuscitation equipment immediately available.
- NPO (nothing by mouth) guidelines should be followed: clear liquids up to 2 hours before, breast milk up to 4 hours before, and solids/formula up to 6 hours before the procedure.
Sedation Goals
The goals of sedation in pediatric patients for diagnostic and therapeutic procedures include:
- Guarding the patient's safety and welfare
- Minimizing physical discomfort and pain
- Controlling anxiety and minimizing psychological trauma
- Providing appropriate cardiopulmonary support if needed These goals can be achieved by selecting the lowest dose of drug with the highest therapeutic index for the procedure, as recommended by 1.
Monitoring and Management
The patient should be observed in a suitably equipped recovery area with a functioning suction apparatus, oxygen delivery, and positive-pressure ventilation, as recommended by 1. The patient's vital signs should be recorded at specific intervals, and oxygen saturation and heart rate monitoring should be used continuously until appropriate discharge criteria are met.
Medication Selection
The selection of sedating medications should be based on the type and goal of the procedure, with consideration of the potential for adverse outcomes when multiple sedating medications are administered, as noted in 1. Knowledge of each drug's time of onset, peak response, and duration of action is essential for safe practice.
Training and Equipment
Appropriate training and skills in airway management are necessary to allow rescue of the patient, and age- and size-appropriate equipment for airway management and venous access should be available, as recommended by 1.
From the FDA Drug Label
Monitoring Patient response to sedative agents, and resultant respiratory status, is variable. Regardless of the intended level of sedation or route of administration, sedation is a continuum; a patient may move easily from light to deep sedation, with potential loss of protective reflexes. This is especially true in pediatric patients Sedative doses should be individually titrated, taking into account patient age, clinical status and concomitant use of other CNS depressants. Pediatrics For deeply sedated pediatric patients, a dedicated individual, other than the practitioner performing the procedure, should monitor the patient throughout the procedure
For procedural sedation in kids, such as chest tube insertion, the following key points should be considered:
- Sedative doses should be individually titrated, taking into account patient age, clinical status, and concomitant use of other CNS depressants.
- Continuous monitoring of respiratory and cardiac function is required.
- A dedicated individual should monitor the patient throughout the procedure.
- Titration to effect with multiple small doses is essential for safe administration 2.
From the Research
Procedural Sedation for Chest Tube Insertion in Kids
- The provided studies do not directly address procedural sedation for chest tube insertion in kids. However, they do discuss procedural sedation in pediatric patients for various procedures.
- A study from 3 measured changes in end-tidal carbon dioxide levels with different sedation/analgesia during pediatric minor surgical procedures, but it did not specifically focus on chest tube insertion.
- Another study from 4 compared midazolam/fentanyl with midazolam/ketamine for procedural sedation for insertion of central venous catheters in children, which may have some relevance to chest tube insertion.
- A review of pediatric procedural sedation from 5 discussed the use of sedation outside the operating room for various procedures, including those performed by pediatric hospital medicine teams, but did not specifically address chest tube insertion.
- Studies from 6 and 7 discussed the use of intranasal sedation for procedural sedation and analgesia in children, but these were for different procedures such as myringotomy and ventilation tube insertion, and in the neonatal intensive care unit, respectively.
Sedation Options
- Midazolam, ketamine, fentanyl, and propofol are some of the sedation options discussed in the provided studies 3, 4.
- The combination of intranasal dexmedetomidine, fentanyl, and inhaled nitrous oxide was considered as a possible option for procedural sedation in children undergoing tympanostomy tube placement 6.
- Intranasal midazolam and fentanyl were used for procedural sedation and analgesia in infants in the neonatal intensive care unit 7.
Safety and Efficacy
- The studies highlighted the importance of monitoring and evaluating the safety and efficacy of procedural sedation in pediatric patients 3, 4, 6, 7.
- The use of capnography as a monitoring tool was discussed in one study 3.
- The need for larger, prospective studies to evaluate the safety and efficacy of certain sedation regimens was noted in some studies 4, 7.