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Sedation/Analgesia Outside the Operating Room for Diagnostic and Therapeutic Procedures in Infants and Children
Richard F. Kaplan, M.D. Washington, District of Columbia

SCOPE: Sedation and analgesia in pediatric patients for procedures outside the operating room including offices and free standing medical facilities continues to increase as healthcare is being pushed to be more cost effective and efficient. It is the fastest growing part of pediatric anesthesiology services. Sedation for procedures at the Childrens National Medical Center (CNMC) in Washington, DC continues to grow at a rate of 10% per year and occurs in the Emergency Department (fractures, lacerations - 1500/yr); diagnostic imaging area (CT scan, MRI, barium studies - 4000/yr); GI (endoscopy - 1200/yr); Pulmonary (bronchoscopy - 100/yr); Cardiology (echocardiography, catheterization 750/yr); Burn Unit (dressing change); and in other areas (chest tube removal, bone marrow aspirations, etc.).(1) These procedures require various depths of sedation in multiple locations. Some procedures by their very nature (i.e. upper esophagoscopy, bronchoscopy) are associated with loss of airway reflexes and are at increased risk for complications. The upsurge in demand as well as apparent safety of drugs such as Propofol, Ketamine and Dexmedetomidine has propelled non-anesthesiologists (emergency room physicians, intensivists, pediatricians, gastroenterologists, RNs) to provide anesthesia services. Recent CMS standards(2,3) require ALL anesthesia services (i.e. general, regional, MAC, deep sedation, analgesia, moderate and minimal sedation) to fall under the direction and responsibility of the same physician who directs and is responsible for operating room anesthesia. Thus it is clear and appropriate that anesthesiology with its expertise in safety, monitoring and use of anesthetic drugs continue to take the lead in sedation/anesthesia outside of the operating room. THE CONTINUUM OF SEDATION/ANESTHESIA: The Joint Commission regulations(2,3) contain recommendations made by the ASA.(4) The ASA's efforts in developing guidelines for sedation led to updated CMS language in 2009. The amended standards include language pertaining to the definition of the continuum of sedation/anesthesia. The definition of the four levels of sedation and anesthesia are:

ASA & Joint Commission Continuum of Sedation

Minimal Sedation Anxiolysis Deep Sedation/ Analgesia

Moderate Sed/Analg

General Anesthesia

Responds normally to verbal commands

Responds purposefully to verbal commands/ light touch airway maintained

Responds purposefully to repeated or painful stimuli ? airway maintained

No response/ Reflex withdrawal

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Minimal sedation (anxiolysis). A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. In the author's opinion this level of sedation is rarely adequate for completion of diagnostic/therapeutic procedures in children. Moderate sedation/analgesia. A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate. CV function is usually maintained. This level of sedation was referred to as conscious sedation in the past. Deep sedation/analgesia. A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Reflex withdrawal is not considered a purposeful response. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway. Ventilation may be inadequate. CV function is usually maintained. General Anesthesia. A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. CV function may be impaired. MAC. Monitored anesthesia care is anesthesia care that includes monitoring by a qualified anesthesia provider. Deep sedation/analgesia is included under MAC.(3) The line between sedation and analgesia as well as provider qualifications can be easily blurred. CMS(2) specifies that hospitals must establish policies and procedures that address whether specific clinical situations involve anesthesia versus analgesia. In addition, hospitals must also specify the qualifications for each category of practitioner who administers analgesia and their supervision requirements. The above terms were not specifically designed for children. Many pediatric patients are developmentally delayed or too young to understand verbal commands. Procedures performed in children younger than 6 yrs often require deep levels of sedation to gain control of their behavior. There is also a tendency to misinterpret any response to stimulation as a purposeful one. Thus the patient may be misclassified as moderately sedated when they are truly deeply sedated or misclassified as deeply sedated when they are truly under anesthesia depending on the interpretation of a purposeful response. Clear examples of the stages of sedation for different age groups are very helpful in clarifying any misconceptions. There is also the assumption in these definitions that there is a consistent correlation between different levels of sedation and the ability to maintain a patent airway. This correlation has not been carefully studied in children especially when different drugs are used for sedation (e.g. propofol, fentanyl, dexmedetomidine). Other organizations use other classifications of sedation. The term procedural sedation is a term used by the American College of Emergency Physicians. Procedural sedation is defined as the use of agents that allows the patient to tolerate procedures while maintaining cardio-respiratory function (5). This term has been misunderstood and therefore misused to include any form of sedation/anesthesia when used for any procedure whether or not cardio-respiratory function is preserved. It is not clear where procedural sedation lies in the ASA continuum of anesthesia/sedation. Some patients who are given general anesthesia with potent inhalational anesthetics may also maintain cardio-respiratory function. The line between deep sedation, procedural sedation and general anesthesia becomes dangerously blurred by various nonuniform definitions of sedation.
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GUIDELINES / JOINT COMMISSION STANDARDS / CONTROVERSY / WORK TO BE DONE: Recent changes in CMS interpretive guidelines (IGs)(2,3) has stirred fierce debate among anesthesia and nonanesthesia providers of deep sedation. The CMS guidelines reaffirm anesthesia to include general anesthesia, regional anesthesia, deep sedation/analgesia and MAC. CMS limits the ability to administer anesthesia to: qualified anesthesiologists, non-anesthesiologists MD/DOs, certified registered nurse anesthetists, anesthesiologist assistants, dentists, oral surgeons and podiatrists who are qualified to administer anesthesia under state law. In an effort to guarantee hospital wide uniform standard of care CMS states(2,3): anesthesia services throughout the hospital (including all departments in all campuses) must be organized into one anesthesia service. Anesthesia services must be under the direction of one individual Thus it is clear that the Division of Anesthesiology has oversight responsibility for defining privileges and quality performance of ALL practitioners involved in sedation (i.e. emergency room, intensive care, gastroenterologists and nurses). In an effort to help anesthesiology departments create consistent guidelines the ASA in 2010 has created recommendations on deep sedation guidelines for non-anesthesiologists.(6) This is a change from the previous position(7) of 2006 which stated privileges to administer deep sedation should be granted only to practitioners who are qualified to administer general anesthesia or to appropriately supervised anesthesia professionals. The 2010 statement is not meant to be an ASA endorsement of non-anesthesiologists providing deep sedation but rather a guide to members who will be called upon by hospital administrators to provide input into the privileging process. The new statement details: licensure, education and training, performance evaluations and performance improvement. Highlights of formal training include: specific formal training in deep sedation (part of an ACGME residency/fellowship or separate ACGME CME program), knowledge based test, methods to obtain informed consent, skills in history taking and physical exam, assessment of risk of aspiration, knowledge of pharmacology of sedative/analgesia and reversal agents, adequacy of oxygenation and ventilation function, airway rescue and physiologic monitoring, documentation as well as ACLS (or PALS). Clinical experience with at lease 35 patients or simulations is required. A quality assurance system must have oversight by the director of anesthesia services. In addition, special education and training is required for pediatric deep sedation. The details are not defined. Specific educational opportunities within the ASA are being actively reviewed.
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ETCO2 monitoring. ETCO2 monitoring is a mainstay of general anesthesia practices. In October 2010 the Standards and Practice Committee amended its guidelines for ETCO2 to be effective July 1, 2011.(8) Under ventilation it states: during moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment. Since the Joint Commission frequently follows ASA recommendations all divisions supplying moderate and deep sedation should prepare for compliance. An informal pool of pediatric institutions shows that not all places are prepared for this requirement. The CMS deep sedation regulations and ASA guidelines for granting privileges have met stiff opposition. This is particularly true from emergency medicine physicians.(9) They take umbrage with anesthesiologists unilaterally regulate the deep sedation practice of all specialties, dictate the scope of practice and exclusively regulatedeep sedation practice. They point to studies and clinical practice guidelines for the safe E.D. use of Ketamine(10) and Propofol(11) as proof of safety. The question of E.D. physician qualifications are partially answered in the frequently asked questions (FAQs) of the 2011 CMS manual system.(3) It states that these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general). The ASAs response(12) notes that FAQs are not CMS policy and emphasizes that the skill set of the clinical staff must be taken into consideration in developing the policies. Letters from the ASA for ACEP(13) have clarified some of the issues of anesthesiology oversight of E.D. sedation. Clearly, much discussion is needed to further clarify and resolve these new guidelines and resolutions. Our Children's Hospital anesthesiology division leads oversight and compliance with ALL sedation requirements. Our department's credentialing process includes: 1) An on-line intranet course on sedation. The course is mandatory for sedation practitioners and is given to all faculty, residents and RN's. It is required every 2 years. The course describes personnel, regulations, drugs (including reversal drugs) and techniques. A post-course quiz is required (> 80% correct). The intranet course is being updated to include training on our new sedation electronic record as well as simulation training using computerized game therapy (AVITARS). 2) BLS certification is required for practitioners of moderate sedation. BLS training should provide basic airway support and thus allow RESCUE from deep sedation. 3) PALS certification is required for practitioners of deep sedation. PALS training should provide airway and cardiovascular support training and thus allow RESCUE from general anesthesia. 4) Intranet course attendance, post-course quiz score and BLS/PALS certification are tracked by the medical staff office and is a requirement for hospital privileges in sedation. 5) Each direct supervisor must attest to the competence of individuals providing sedation. RISKS OF SEDATION: There are numerous case reports and clinical studies attempting to document and quantitate the risks of sedation. The Food and Drug Administration has collected over 150(14) severe adverse drug reactions using a self-reporting system.

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CONCLUSIONS FROM THE FDA AND OTHER STUDIES: ALL sedatives and narcotics have caused problems even in recommended doses. ALL areas using sedation have reported adverse events. Children 1-5 yr of age are at most risk. Most had no severe underlying disease. Respiratory depression and obstruction are the most frequent causes of adverse events. Adverse events involved - multiple drugs, drug errors or overdose, inadequate evaluation, inadequate monitoring, inadequate practitioner skills, and premature discharge.

A now classic article(15) emphasizes the above results and brings to light complications both inside and outside of the hospital setting. It emphasizes the need for uniform, specialty-independent guidelines for monitoring children during sedation both inside and outside of the hospital setting. A group of over 26 institutions has been created to carefully review pediatric sedation techniques and complications. This Pediatric Sedation Research Consortium has now received data on over 150,000 sedation encounters. The initial data (16) showed differences in complication rates based on types of providers and location with sedation provided by an anesthesiologist having the lowest complication rate. Recent data(17) reviews over 130,000 pediatric procedural sedation cases. Comparisons are made between different providers and major adverse events (death, cardiac arrest, emergency anesthesia consult, aspiration, unplanned admission, and increase in care). Major complication rates were: anesthesiologists (7.6/10,000), emergency medicine (7.8/10,000), intensivists (9.6/10,000), pediatricians (12.4/10,000) and other (pediatric resident, fellow, radiologist, surgeon, dentist, advanced practice nurse, CRNA or registered nurse) (10.2/10,000). There was no difference in severe complications in any group. This study is a major step in carefully analyzing data. Limitations of interpretation and conclusions are recognized by the authors and include lack of comparison of the different levels of sedation used, painful vs. non-painful procedures, selection bias of patients with anticipated complicated patients referred to anesthesiologists rather then the sedation service (i.e. data not collected). The use of propofol was adjusted (without giving details) and found not to influence speciality complication rate. Although other investigators have found an increase in complications due to age < 1 yr and ASA physical status > 2 the present study found no increased risk due to age, physical status, NPO status or emergent procedures. The limitations noted above and conflicting results compared to other studies require careful review. SEDATION/ANESTHESIA DRUGS AND NEURODEVELOPMENT: Additional issues which have recently surfaced also need resolution and national guidelines. The recent information regarding the effects of anesthesia on apoptosis in animals and learning disabilities in young children(18) need to be addressed. In March 2011, the FDA convened its second meeting on neurotoxicity of anesthetic agents and brain maturation in humans.(19) NMDA antagonists and GABA agonists were both associated with neuroapoptosis. NMDA antagonists and GABA agonists include most anesthetic/sedation agents (ketamine, isoflurane, sevoflurane, propofol, benzodiazepines, chloral hydrate, barbiturates, and nitrous oxide). Multiple studies in animals and humans have implicated a potential for learning deficits from these agents when used in children < 3 yrs of age.(19) Future studies to determine age risk, drugs, doses and duration in humans are underway to resolve these questions. In particular, the FDA and IARS have forged a partnership (Smart Tots Strategies for Mitigating Anesthesia Related Neurotoxicity in Tots) to encourage studies. No changes in practice in the use of these drugs are required at this time. The 3rd PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) symposium recently reviewed available animal and human studies on neuroapoptosis and learning disabilities. No new clinical recommendations were advised with the exception of possibly delaying elective procedures until they are past the most critical age of neurodevelopment (3 years) and grouping essential procedures using one anesthetic. Of all sedatives drugs presently available dexmedetomidine appears to have unusual properties. Dexmedetomidine prevents cortical apoptosis in vitro and in vivo in the developing rat brain.(20) Dexmedetomidine is a selective high affinity alpha2
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agonist which has recently been used for various sedation procedures (0.5-1 microgram/kg over 10 minutes followed by 1 microgram/kg/hr). It provides sedation and some analgesia with minimal respiratory depression.( 21,22) Low heart rate may be associated with this technique. It should be used with caution in patients taking digoxin.(23) Studies have shown the drug to be effective for sedation with minimal respiratory effects and acceptable cardiovascular parameters.(24) Anesthetic Drug Shortages. There has been a recent surge in anesthetic drug shortages. The list of drug shortages can be found on the American Society of Health System Pharmacists (www.asahq.org/shortages). The list includes etomidate, fentanyl, ketamine and sufentanil. Chloral hydrate is no longer available as of April 2012. Chloral hydrate is frequently used for BAER studies and is a mainstay for many nonpainful procedures in children < 3 yrs. Oral alternatives (oral midazolam) may interfere with certain EEG studies and are not ideal. Chloral hydrate may be bought in crystallin form and compounded by individual hospital pharmacies. Propofol and Mitochondrial Diseases: Propofol has gained widespread acceptance and is regarded in some circles as the automatic sedative of choice for all procedures in children. Mitochondrial diseases raise concern regarding the use of propofol. Mitochondrial disorders have an incidence of one in 4000. Mitochondrial diseases affect ATP production and present as clinical disorders of skeletal muscle, brain and heart. The clinician is frequently presented with patients (i.e. developmental delay, muscle weakness, epilepsy) for procedures such as MRI, CT and muscle biopsy who may be at risk for mitochondrial disease.( 25,26,27) Some children with these disorders have developed progression of their disease after sedation and anesthesia. Propofol has several negative effects on mitochondrial ATP production which include: 1) inhibition of enzyme activity of electron transport complex 1; 2) inhibition of carnitine palmitoyl transferase; and 3) inhibition of !-oxidation. These depressant mitochondrial effects may account for propofol infusion syndrome occurring in these susceptible patients. Propofol infusion syndrome is characterized by severe lactic acidosis, rhabdomyolysis and lipidemia which can lead to cardiovascular collapse(28) The suggested dose and duration to avoid propofol infusion syndrome in healthy patients is > 4 mg/kg/h over 48 hours. The syndrome may occur with smaller doses and duration in children with underlying mitochondrial disorders (200 mcg/k/min over 150 min in a 7 y.o.).(29) The best management of these children is still under discussion with no proven clinical advantage of inhalation anesthesia vs. propofol TIVA(30) Propofol and the Non-Anesthesiologist: There is presently a desire for clinicians other than anesthesiologists (i.e. intensivists, pulmonologists, emergency medicine, gastroenterologists, RNs etc.) to use propofol for sedation in pediatric patients.(31) An ASA statement on sedation with propofol(32) states that propofol is a anesthetic drug, and the ASA believes that the involvement of a anesthesiologist in the care of every patient undergoing anesthesia is optimal. Other providers, however, do administer this drug. Anesthesiologists, as leaders of sedation need to take all these factors into consideration so that policies are created to assure that all patients receive safe care." Our Children's Hospital has strict regulations on the use of propofol by non-anesthesiologists. The reasons include: 1) propofol causes significant decreases(33) and changes(34) in airway dimensions in children in sedation doses; 2) propofol can unpredictably cause loss of airway reflexes even in sedative doses in children; and 3) the most recent PDR does not recommend the use of propofol for sedation of pediatric patients in the ICU. It must be appreciated, however that many drugs presently used in children are not recommended for such use in the PDR and that propofol (although not approved for pediatric sedation) may be the drug of choice for sedation in some circumstances. Therefore, until further studies on safety are published our Children's Hospital recommends that propofol sedation be considered deep sedation/general anesthesia. Its use by non-anesthesiologists should be restricted to short procedures in intubated patients in intensive care unit patients and administered by qualified and credentialed intensive care faculty. Monitors, equipment and personnel skilled in airway resuscitation and deep sedation must be immediately available.
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MRI Anesthesiology Supervised Deep Sedation Service: There is a growing need to provide deep sedation for children needing MRIs. An anesthesiology supervised deep sedation service is efficient, provides deep sedation with agents that allow smooth and rapid induction and emergence and is uniquely qualified to rescue from general anesthesia. Further, if general anesthesia is required then rescheduling is not necessary. RNs involved in deep sedation receive extensive training in identifying the difficult airway, identifying airway obstruction, resolving airway obstruction, PALS, starting IVs and receive additional training in the pharmacology and use of agents used for deep sedation. Anesthesia is induced immediately outside of the MRI room using propofol (1-2 mg/kg) or sevoflurane (if an IV is not initially placed). The child is then stabilized, nasal cannulae (with CO2 sampling) applied and a propofol infusion is started and titrated to a level of deep sedation (100 250 mcg/kg/min). Deep sedation is verified when the child moves appropriately to a painful stimulus (lifts arms towards a painful stimulus at the shoulder in an attempt to remove the stimulus). Once stable and deeply sedated, the child is transported to the MRI room where the RN stays with the child. Vital signs, SaO2, ETCO2 and level of sedation are monitored and recorded q 5 min. Adjustments in propofol administration if necessary are made by the anesthesiologist. The anesthesiologist is immediately outside the magnet preparing another child for sedation in the second MRI scanner. After the scan is complete the child is recovered in the MRI recovery area and is discharged within 1 hour after completion of the study. This technique is efficient, quick, safe, easy and allows one anesthesiologist to supervise the care of over 4000 deeply sedated children for MRIs per year using 3 MRI scanning machines. REFERENCES: 1. Kaplan RF, Cravero JP, Yaster M, Cot C. Sedation for diagnostic and therapeutic procedures outside the operating room. In A Practice of Anesthesia for Infants and Children. Cot Lerman, Todres, 2009, pp102349. 2. CMS manual system. Pub 100-07 state operational provide certification. Subject: Revised Appendix A, Interpretive Guideline for Hospitals, January 2011. 3. CMS manual system. Pub 100-07 state operational provide certification. Transmittal 59. Clarification of Anesthesia Services. May 21, 2010. 4. Practice Guidelines for Sedation and Analgesia by non-Anesthesiologists (Amended October 17, 2001) Anesthesiology 96, 1004-7,2002 5. Mace SE, et al. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Journal of Pediatric Surgery. 39(10):1472-84, 2004 Oct. 6. Granting privileges for deep sedation to non-anesthesiologist sedation practitioners (ASA House of Delegates, Oct 2010) 7. Statement on granting privileges to non-anesthesiologist practitioners for personally administering deep sedation or supervising deep sedation by individuals who are not anesthesia providers. (ASA House of Delegates, Oct 18, 2006) 8. Standards for Basic Anesthetic Monitoring (Approved by the ASA House of Delegates, amended October 20, 2010, effective July 1, 2011). 9. Green S, Kraus B. Who owns deep sedation? Annals of Emerg Med 2001; 57(5):105, pp470-474.

10. Green S, et al. Clinical practice guidelines for emergency department ketamine dissociative sedation: 2011
update. Annals of Emerg Med 2011; 57(5):449-61.

11. Mallory M, et al. Emergency Physician Administered propofol sedation: A report on 25,433 sedations from
the pediatric sedation consortium. Annals of Emerg Med 2011;57(5):462-468.
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12. Statement by American Society of Anesthesiologists on granting deep sedation to non-anesthesiologists

sedation practitioners. Letter to S. Schneider, MD from M. Warner, MD, President, ASA, January 2011.

13. www.asahq.org/for-members/advocacy/federal-legislative-and-regulatory-activities/interpretive-guidelines 14. Report of Anesthesia and Life Support Advisory Committee, 3/94 FDA, Rockville, Maryland. 15. Cot CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics:
analysis of medications used for sedation. Pediatrics 106:633-44, 2000.

16. Cravero JP, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.
for procedures outside the operating room: A report from the pediatric sedation research consortium. Anesth Analg 2009; 108(3):795-804. Couloures KG, Beach M, Cravero J, et al. Pediatrics 127(5):May 2011, pp1154-1160. Rappaport R, et al. Defining safe use of anesthesia in children. NEJM, March 9, 2011. Durieux M, Davis P. The safety of key inhaled and intravenous drugs in pediatrics (SafeKids): An Update. Anesth Analg 2010; 110(5):1265-6. Sanders RD, et al. Dexmedetomidine provides cortical neuroprotection: impact on anesthetic-induced neuro apoptosis in the rate developing brain. Acta Anaesthesiol Scand 2010; 54(6):710-6. Tobias, JD, Berkenbosch JW, Initial experience with dexmedetomidine in paediatric aged patients. Paediatric Anaesthesia, 2002. 12(2):p 171-5. Tobias, JD, Berkenbosch JW, Russo P, Additional experience with dexmedetomidine in pediatric patients (Review). Southern Medical Journal, 2003. 96(9): p. 871-5. Berkenbosch JW, Tobias, JD. Development of bradycardia during sedation with dexmedetomidine in an infant concurrently receiving digoxin. Pediatr Crit Care Med 2003 Apr;4(2):203-5. Mason KP, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth 2008;18(5):403-11. Morgan PG, Hoppel CL, Sedensky. Mitochondrial defects and anesthetic toxicity. Anesthesiology 2002;96(5):1268-70. Schwartz D, Ragunathan K. Anesthesia and mitochondrial disorders. Paediatr Anaesth 2009;19(1):60-1. Driesen JJ. Neuromuscular and mitochondrial disorders: What is relevant to the anesthesiologist? Current Opinion in Anesthesiology 2008;21:350-5. Faraq E, et al. Metabolic acidosis due to propofol infusion. Anesthesiology 2005;102:697-8. Kill C, et al. Lacticacidosis after short-term infusion of propofol for anaesthesia in a child with osteogenesis imperfecta. Paed Anaesth 2003;13:823-6. Driesen J, et al. Anesthesia-related morbidity and mortality after surgery for muscle biopsy in children with mitochondrial defects. Ped Anesth 2007;17:16-21. Green SM, Krauss B. Barriers to propofol use in emergency medicine. Ann Emerg Med, Feb 21, 2008. Phillip BK. Sedation with Propofol: A new ASA statement. ASA Newsletter. Feb 20:5, Vol 69, No 2, 2005, p29-30. Evans RG, Crawford MW, Noseworthy M, Shi-Joon Y: MRI examination of airway geometry during propofol anesthesia in children. Anesthesiology 2001;A1277. Litman RS, Weissend EE, Shrier DA, Denhams: Morphologic changes in the upper airway of children during awakening from propofol administrations". Anesthesiology 2002; 96(3):607-11.

DISCLOSURE This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a commercial product or provider of a commercial service that may be discussed in this presentation.

Refresher Course Lectures Anesthesiology 2012 American Society of Anesthesiologists. All rights reserved. Note: This publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.