Is monitored anesthesia care an absolute contraindication for a pediatric patient undergoing operative repair of an oral cavity injury?

Monitored Anesthesia Care is NOT an Absolute Contraindication in Pediatric Patients

Pediatric age is not an absolute contraindication to monitored anesthesia care (MAC) for oral cavity injury repair, but it requires careful patient selection, appropriate monitoring, and rescue capabilities equivalent to the next deeper level of sedation. 1

Key Considerations for MAC in Pediatric Oral Cavity Procedures

Patient Selection Factors

The decision to use MAC depends on several critical factors rather than age alone:

• Developmental and chronologic age: Children younger than 6 years and those with developmental delays often require deep sedation to control behavior and may not be suitable candidates for MAC 1
• Ability to cooperate: The child must be able to control their behavior sufficiently to cooperate with the procedure, which depends on both chronologic and cognitive age 1
• Nature of the injury: Complex oral cavity repairs requiring prolonged immobility may necessitate deeper sedation or general anesthesia rather than MAC 1

Critical Safety Requirements

If MAC is chosen for a pediatric patient, the following must be in place:

• Rescue capability: Practitioners must have the skills to rescue the patient from one level deeper than intended—if planning moderate sedation, you must be able to rescue from deep sedation 1
• Continuous monitoring: Pulse oximetry, capnography (once child is sedated to avoid agitation), heart rate, and blood pressure at appropriate intervals 1
• Personnel requirements: At least one individual present whose sole responsibility is monitoring the patient, not performing the procedure 1
• Emergency equipment: Functioning suction, capacity to deliver >90% oxygen, positive-pressure ventilation capability, and age-appropriate rescue equipment 1
• PALS certification: Personnel must be trained in Pediatric Advanced Life Support and capable of managing airway obstruction, respiratory depression, and cardiovascular complications 1

Common Pitfalls to Avoid

The sedation continuum is unpredictable in children: Even with intended moderate sedation, children frequently pass to deeper levels unintentionally, particularly in younger age groups 1. This is not a contraindication but rather a reason to prepare for deeper sedation from the outset.

Behavioral control requirements: If the procedure absolutely requires immobility and the child cannot cooperate, attempting MAC may be unsafe and general anesthesia with secured airway should be considered instead 1

Alternative Approaches for Difficult Cases

For uncooperative or very young children requiring oral cavity repair, consider:

• General anesthesia with secured airway: This is often safer than attempting inadequate MAC in a struggling child 1
• Adjunctive techniques: Topical local anesthetics, nerve blocks, distraction techniques, and child life specialist involvement can reduce sedation requirements 1
• Ketamine-based sedation: This maintains protective airway reflexes better than other agents and may be preferred for emergency procedures 1

Documentation Requirements

When using MAC in pediatric patients, document:

• ASA physical status classification 1
• Fasting status and risk-benefit analysis if not fasted (common in trauma) 1
• Informed consent including risks of deeper sedation 1
• Continuous monitoring parameters and any deviations 1

The bottom line: MAC can be safely performed in appropriately selected pediatric patients with oral cavity injuries when proper monitoring, personnel, equipment, and rescue capabilities are available. Age alone does not constitute an absolute contraindication. 1