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Aims and Objectives: This paper aims to critically review and analyse available literature to inform and advance patient care., Background: Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990 s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness., Search Strategies: A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were 'Paediatric', 'Sedation', 'Withdrawal' and 'Intensive care'., Inclusion and Exclusion Criteria: Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included., Results: A total of 2,232,586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies., Conclusions: Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty-one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place., Relevance to Clinical Practice: Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.

Children undergoing urethral catheterization for urologic imaging under existing sedation practices were identified as an underserved patient population. Using a multidisciplinary approach, a registered nurse (RN)-administered nitrous oxide sedation program was developed to meet the needs of these children. Program development required delineation of RN scope of practice, evaluation of equipment, formulation of an educational program, and compliance with occupational safety standards. The program was implemented in 2004 using standard "dental" nitrous oxide equipment coupled with distraction and imagery to enhance the efficacy of the sedation experience. Initial assessment via telephone questionnaire indicated fewer adverse effects and more rapid return to baseline than oral midazolam, the sedative previously used for these procedures. Ongoing evaluation continues to confirm patient and environmental safety. The nitrous oxide program has expanded to provide sedation for additional tests in radiology as well as in other hospital departments. By implementing an RN-administered nitrous oxide program, children's access to this sedative/analgesic agent is increased.

Central venous catheters have been established as a reliable source of vascular access since the 1970s. Peripherally inserted central catheters became a popular central catheter in the early 1990s for adults and children. The management of vascular access in children is an essential part of inpatient and outpatient care. Assessing and inserting the appropriate catheter for the pediatric patient is just a part of the component for central catheter care. Care providers also need to assess these children for sedation or distraction for the procedure. This article discusses factors for catheter choice and points for assessing children for sedation or distraction for vascular access insertion.

As professionals who care for the sickest children, we want to provide the best evidence-based care available. While there are questions still to be answered, it is clear that when propofol is administered to children, it should be done in a manner that is intentional, well planned, and consistent with national guidelines and regulatory groups. Haphazard administration of propofol will place children at risk.

Aim: This article describes the current magnetic resonance imaging (MRI) sedation service, the role of the nurse sedationist, results of clinical audits, and future issues within MRI., Method: Data from 2004 until 2006 were analysed to describe the percentage of children who were successfully sedated, and any complications. The recovery profile was investigated by a questionnaire of 100 consecutive cases., Findings: Sedation was attempted in 455 cases with chloral hydrate, and 325 with temazepam and droperidol. The success rate was 97.4 and 92.6 per cent respectively. Top-up sedation was used in 10 and 29 per cent respectively. There were seven minor incidents but none required admission. Approximately 20 per cent of children were drowsy the following day., Conclusion: We believe that the success of the service depends upon three main factors: the deselection of children in whom sedation is unsafe or likely to be unsuccessful, the use of appropriate drugs in limited doses, and the training of experienced nurses.

Advanced practice nurses (APNs) prescribe sedation, analgesia, and neuromuscular blocking agents in the management of critically ill children. Although most children are unscathed from the use of the medications, some suffer adverse responses. This article elucidates adverse responses to these medications for the APN, including withdrawal syndrome, muscle weakness, decreased gastric motility, corneal abrasions, and costs associated with these morbidities.

Optimal management of the postoperative pediatric cardiac surgical patient requires a thorough understanding of patient anatomy, physiology, surgical repair or palliation, and clinical condition. This necessitates a dedicated team of clinicians including skilled nurses, physicians, and respiratory therapists specialized in the care of patients who have complex congenital heart disease. This article provides an overview of the multisystemic risk factors and consequences associated with cadiopulmonary bypass and cardiac surgery. An evaluation of cardiac hemodynamics and a review of major organ systems are included. Essential assessment information and interventional strategies for managing the pediatric postoperative cardiac surgery patient are detailed.

Introduction: A retrospective analysis of sedation management for children receiving prolonged ventilation in one Australian paediatric intensive care unit (PICU) revealed no identifiable pattern in sedation management and an inadequacy in the sedation scoring system. Therefore, the investigators sought to explore the current practice of sedation in critically ill children in PICUs across Australia and New Zealand., Method: This study used a mail-out survey to audit sedation management within the eight dedicated Australian and New Zealand PICUs., Results: 100% of the units surveyed replied (n=8). There were a total of 6,133 admissions to 8 Australian and New Zealand PICUs, where 3036 (49.5%) required ventilation. Of these children, 888 (29.2%) required ventilation > or =72 hours. Only 4 units had written guidelines for sedation management. A combined sedation regime of benzodiazepines and opioids was employed in six units. Administration and titration of sedation agents was managed by nursing staff alone in six units. All units indicated that they aimed to achieve a 'moderate level' of sedation. Two units used designated assessment tools for sedation and withdrawal assessment. One unit utilised Bispectral Index (BIS) monitoring., Conclusion: There were similarities observed in the methods and types of sedation agents used within Australian and New Zealand PICUs. However, only half of the units had guidelines for sedation management, and most units did not use validated paediatric scales to assist staff in assessing patient sedation and pain levels. Therefore it is recommended that a standardised approach to sedation assessment and management of critically ill children requiring prolonged ventilation be developed and tested.

Intubated infants and children require optimal sedation and comfort measures. Key elements that ensure the provision of quality care for these patients include the use of pain, comfort, and sedation assessment tools; pharmacologic and nonpharmacologic strategies; and the inclusion of the patient and parents as part of the team. This article describes approaches for using sedation and ensuring comfort in these patients. Application of research and the education of team members and the patient and family are crucial aspects of care and are also discussed.

Young children may be unwilling or unable to cooperate if they are required to remain motionless for a prolonged period of time. In the hospitalized child, investigative procedures perceived as painful or threatening may need the administration of a sedative. Clinical guidelines, within a large teaching hospital NHS trust in the North of England, were implemented in an attempt to reduce the diversity of the practices of healthcare professionals caring for the child requiring sedation. The guidelines were formulated by a multidisciplinary team and, in conjunction with active dissemination strategies, resulted in a change in practice that included: (1) improved communication and cooperation between departments, (2) implementation of starvation times before the administration of a sedative, and (3) the appropriate referrals to a senior paediatrician to seek advice if contraindications to sedation were identified. Audit was integral to the process, facilitating the comparison of actual practice with the standards developed from the guidelines and ensuring a continuous monitoring programme.

Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.

Sedation of pediatric patients is a current practice issue; however, little has been published on performance measurement or evidence-based practice. The development of educational initiatives, the design of performance-improvement activities, and the validation of practice standards are described. Performance measures specific to the process of sedating pediatric patients are examined to show how to turn data into useful information to guide decision-making and nursing-practice changes.

Successful completion of diagnostic and therapeutic orthopaedic procedures in children requires a high level of cooperation and pain control. This article provides a framework for safe and effective sedation of children undergoing such procedures. Following the definition of levels of sedation, the dynamics of the three phases of sedation (pre, intra, and post) are described. Specific sedative-analgesic agents, monitoring, and transport are discussed. Finally, the art of working with children who require sedation is outlined.

The role of the paediatric cardiothoracic nurse specialist is explored in relation to the sedation of critically ill children. Assessment assists the nurse in selecting the most suitable drug, dose and method of administration. Issues surrounding the administration of Midazolam and morphine are considered. Further research on sedation scoring methods for use with children is recommended.

Nurses play a vital role in ensuring the safety of children who receive sedative medications for diagnostic and therapeutic procedures. Established guidelines for providing care for this special population can be helpful in understanding how to fulfill this role. Nursing involvement in all phases of the sedation process not only promotes patient safety, but increases patient and family satisfaction.

In the last 5 years, the number of nonoperating room procedures performed on the pediatric population requiring sedation has skyrocketed. Some of these procedures, such as bone marrow aspiration or dental restorations, may be painful, whereas others, such as magnetic resonance imaging, are not painful but require a motionless patient. Anesthesia departments are being tasked more and more frequently to provide the sedation and monitoring for these procedures. The pediatric patient offers unique challenges in attaining the desired level of sedation for the optimal duration of time, without compromising protective reflexes, a patent airway, or cardiopulmonary stability. Currently, there are several medications or combinations of medications that offer advantages over the commonly used chloral hydrate and "lytic" cocktail. Selection of medication(s) should be based on the type of procedure (painful v painless), the length of the procedure, the medical condition of the patient (current medications, fasting status, and disease processes or metabolic disorders), and the need for anxiolysis or amnesia. This article briefly reviews: (1) developmental changes and metabolic capacity in the pediatric patient; (2) the American Academy of Pediatrics guidelines for care of the pediatric patient undergoing sedation; (3) basic pharmacology of sedative-hypnotics and opioids; and (4) patient monitoring and discharge.

The child requiring sedation has unique needs. The nurse caring for pediatric patients must have adequate knowledge to incorporate the physical, emotional, and psychological differences between children and adults into the child's overall plan of care. Because of these differences, sedation of the child presents a challenge. The nurse must continue to assess his or her knowledge of all facets of sedative agents and monitoring principles in the pediatric population to provide safe, effective quality care to children and their families.

The case study illustrates safe use of conscious sedation and careful attention to prevention of complications as outlined in the AAP and ASA practice guidelines. Before implementation of a conscious sedation program, care providers need to have a clear idea of the goals of conscious sedation. These goals, as described by the American Academy of Pediatrics (1992) are: "1) to guard the patient's safety and welfare; 2) to minimize physical discomfort or pain; 3) to minimize negative psychologic responses to treatment by providing analgesia and to maximize the potential for amnesia; 4) to control behavior; and 5) to return the patient to a state in which safe discharge, as determined by recognized criteria, is possible" (p. 1,110). With careful attention to these goals, conscious sedation can be a valuable adjunct to pediatric care.

Sedation of children undergoing surgical procedures is one of many issues facing perioperative nurses today. This article reviews relevant professional guidelines for the practice of sedation in children and describes the implications for perioperative nurses. Topics covered include preparation of the patient, monitoring guidelines, and the use of pharmacological agents.