What is the appropriate monitored anesthesia care (MAC) plan for a healthy 4‑year‑old boy (American Society of Anesthesiologists (ASA) physical status I) with a small superficial laceration of the hard palate?

Monitored Anesthesia Care for Pediatric Hard Palate Laceration Repair

For a healthy 4-year-old boy with a small superficial hard palate laceration, intravenous ketamine at 1.5 mg/kg is the preferred agent for monitored anesthesia care, providing effective procedural sedation while maintaining respiratory drive and cardiovascular stability. 1, 2

Sedation Approach and Drug Selection

Primary Agent: Ketamine

• IV ketamine 1.5-2 mg/kg is the optimal choice for this intraoral procedure, with onset of sedation averaging 96 seconds and providing adequate depth for laceration repair 1, 2
• Ketamine maintains systemic vascular resistance and preserves respiratory drive, making it particularly safe for pediatric airway procedures 2, 3
• The average recovery time is approximately 84 minutes for IV ketamine, which is acceptable for outpatient procedures 1

Alternative Considerations

• Intranasal midazolam (0.3-0.5 mg/kg) combined with local anesthesia may be considered for very brief repairs, though onset is slower (17 minutes) and efficacy may be suboptimal for adequate immobility 4, 5
• Oral midazolam alone is generally insufficient for intraoral procedures requiring complete immobility in a 4-year-old 4

Critical Safety Requirements

Personnel and Monitoring

• A dedicated provider separate from the proceduralist must continuously monitor the patient throughout the procedure 1, 2
• Continuous pulse oximetry, ECG, and blood pressure monitoring are mandatory 1, 2
• End-tidal CO2 monitoring is strongly recommended to detect early respiratory depression, particularly important given the intraoral nature of this procedure 1, 2

Rescue Capability

• You must be prepared to rescue the patient from deep sedation or general anesthesia, as children commonly progress beyond the intended sedation level 1, 2
• This requires skills in advanced airway management including bag-mask ventilation, supraglottic device insertion, and potentially endotracheal intubation 1
• Age-appropriate resuscitation equipment and medications must be immediately available 1, 2

Pre-Procedure Preparation

Fasting Guidelines

• Clear liquids: 2 hours minimum 1, 2
• Breast milk: 4 hours minimum 1, 2
• Formula/solid foods: 6 hours minimum 1, 2

Assessment Priorities

• Verify ASA physical status (this patient is ASA I) 1
• Screen for upper respiratory infection, as children under 6 years with URI have increased risk of respiratory adverse events 3
• Confirm no developmental disabilities, which triple the risk of desaturation 1

Intraoperative Management

Airway Considerations

• For intraoral procedures, general anesthesia with a secure airway (endotracheal tube) is preferable to deep sedation without airway protection when the surgical field may mechanically compromise the airway 1
• However, for a small superficial laceration, MAC with ketamine and meticulous airway monitoring may be appropriate if the surgeon can work around spontaneous ventilation 1
• Position the patient to optimize airway patency and prevent aspiration of blood 1

Adjunctive Measures

• Apply topical anesthesia (lidocaine gel) to the laceration site before infiltration 5
• Use buffered lidocaine for local infiltration to minimize injection pain 5
• Consider anticholinergic premedication (glycopyrrolate 5 mcg/kg IV) to reduce secretions, though this is optional with ketamine 1

Common Pitfalls to Avoid

Critical Errors

• Never underestimate the risk of airway obstruction during intraoral procedures - blood, secretions, and surgical manipulation can rapidly compromise the airway 1
• Do not add midazolam to ketamine for children under 10 years, as it increases recovery agitation without improving sedation quality 1
• Avoid using opioids as primary agents due to respiratory depression risk in this age group 2

Monitoring Failures

• Do not rely solely on pulse oximetry - capnography detects hypoventilation earlier than oxygen desaturation 1
• Never allow the proceduralist to simultaneously monitor sedation - this significantly increases adverse event risk 1

Recovery and Discharge

Post-Procedure Monitoring

• Continue monitoring until the child returns to baseline mental status and vital signs 1, 2
• Expect recovery agitation in approximately 7% of patients receiving ketamine alone 1
• Nausea/vomiting occurs in approximately 19% of patients with ketamine 1

Discharge Criteria

• Patient must be awake, alert, and able to maintain airway patency 1
• Vital signs stable and at baseline 1, 2
• No active bleeding from the surgical site 1
• Responsible adult present to accompany child home with clear discharge instructions 1, 2