Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Resident: Swan
Article Title: Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures
Major Topic: Sedation protocol
Main Purpose: To unify the guidelines for sedation used by medical and dental practitioners, add clarifications regarding monitoring modalities, provide new information from medical and dental literature, and suggest methods for further improvement in safety and outcomes.
Key points from this guideline:
Basic overview of a safe sedation: No administration of sedating meds without medical supervision, careful pre-sedation evaluation for underlying medical or surgical conditions that would increase risk, appropriate fasting for elective procedures, a focused airway examination for large tonsils or anatomic airway anomalies that might increase risk of airway obstruction, clear understanding of the effects of meds used for sedation, along with their drug interactions, hone and practice skills needed for airway management/rescue and for gaining IV access, appropriate medications and reversal agents on hand, sufficient staff to carry out procedure and monitor the patient, a properly equipped and staffed recovery area, recovery to pre-sedation level of consciousness before discharge from medical supervision, appropriate discharge instructions given.
In general: The need for in-office sedation is increasing. Parents are demanding it as it becomes more and more common. Adherence to this guideline won’t, however, guarantee a specific patient outcome. We need to be aware that regardless of the intended level of sedation, sedation always represents a continuum that could result in respiratory depression and loss of the patient’s protective reflexes. Serious risks associated with sedation include hypoventilation, apnea, airway obstruction, laryngospasm, and cardiopulmonary impairment.
The sedation of children is different than sedation for adults. Children in the under-6 age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, airway patency, and protective reflexes. The concept of rescue is essential to safe sedation. Practitioners must have the skills to rescue the patient from a deeper level than that intended for the procedure. Most sedation complication can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning, and BVM ventilation.
Levels of sedation: Minimal sedation=patients respond normally to verbal commands. Ventilatory and cardiovascular functions are unaffected, although cognition and coordination may be impaired. Moderate sedation=patients respond purposefully to verbal commands (open your eyes) and/or with light tactile stimulation. No intervention needed to maintain airway, spontaneous ventilation is adequate. Deep sedation=patients cannont be easily aroused but respond purposefully after repeated verbal/painful stimulation. Independent ventilation may be impaired and patients may need help maintaining a patent airway. Spontaneous ventilation may be inadequate. Protective reflexes may be partially or completely lost. General anesthesia=not arousable, even by painful stimulation.

--always select the lowest dose of drug with the highest therapeutic index.
--knowledge of each drug’s time of onset, peak response, and duration of action is essential.

Some basic guidelines:
Candidates: ASA class I/II for minimal, moderate, deep sedation. ASA III/IV, special needs kids, abnormal airway patients all require additional consideration. Consult with appropriate subspecialists or anesthesiologist as needed.
Responsible person: Patient needs to be accompanied to and from appt by one, preferably two responsible adults, especially if they’re still in a carseat.
Facilities and Back-up Emergency Services: Practitioners using sedation must have immediately available access to emergency facilities, personnel, and equipment. Protocol for access to back up emergency services must be clearly identified. An emergency cart must be immediately available.
Dietary Precautions: for elective procedures, follow the same fasting guidelines as before general anesthesia. In an emergency situation, balance the risks/benefits.
Documentation:
before sedation: 1. Informed consent 2. Instructions provided to the responsible person (objectives of the sedation and anticipated changes in behavior during and after sedation
at time of sedation: Health evaluation, careful drug history
during sedation: time-based record with name, route, site, time, dosage, and patient effect of administered drugs.
after sedation: time and condition of child at discharge (level of consciousness, O2 sat)
Setting up: SOAPME or SCOMLADI
Monitoring: for moderate sedation, continuous monitoring of O2 sat, HR, intermittent resp. rate/BP. For deep sedation, all the same equipment, plus a precordial stethoscope or capnograph is recommended
For various important tables regarding discharge criteria, ASA classifications, LA doses/duration, drugs and equipment needed for rescue, see actual guideline.
Assessment of Article: Of course it’s a shame we can’t try out the techniques described in this guideline. Without getting hands on experience with deeper levels of conscious sedation, many of the concepts described are foreign. I think it’s good for each of us to take a healthy fear of sedation with us wherever we end up practicing.