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

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

Important Definitions

Minimal sedation: (anxiolysis) pt responds normally to verbal commands; ventilatory and cardiovascular fxn unaffected.

This can be done by the practitioner alone.

Moderate sedation: (conscious sedation) pt responds purposefully to verbal commands either alone or accompanied with light tactile stimulation. Interactive state for older patients, and age appropriate behaviors for younger patients (expect crying). No intervention needed to control airway. CV function is usually maintained. Practitioners must protect pt airways and if the pt’s reflexes don’t protect the airway, consider it a deep sedation.

additional support personal must be present.

recovery must be monitored in a facility until discharge criteria has been met. young children should be able to stay awake for at least 20min in a quiet environment.

Deep sedation: pt is not easily aroused, but respond purposefully after repeated verbal or painful stimulation. Ability to maintain ventilatory function may be impaired. CV function is usually maintained. Complete or partial loss of protective airway reflexes may be lost.

the state and risks may be indistinguishable from general anesthesia.

trained person is required to administer and monitor. must have electrocardiograph and defibrillator. vascular access is required.

recovery is same as for moderate sedation

Goals:

guard pt safety and welfare

minimize physical discomfort and pain

control anxiety, minimize psychological trauma, amnesia

control behavior/movement

return patient to safe state

Always use the lowest dose of drug with the highest therapeutic index for the procedure.

Combining drugs is ok, but the use of 3 or more is associated with increase in adverse reactions

Candidates:

ASA class 1 or 2 for minimal, moderate or deep sedation.

ASA classes 3 or 4 require special consideration and consultation with anesthesiologist is recommended

Prescription medications intended to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.

Responsible person:

Obviously sedated patients must be accompanied, but it’s best to have 2 adults present.

Facilities

must have immediate personnel and equipment to manage emergency and rescue situations

most adverse rxns are compromised airway, depressed respirations, even hypotension and cardiopulmonary arrest: must be able to treat these complication in a sedation facility.

Back-up

protocol for back-up emergency services must be identified. ready EMS notification will work, but availability of EMS services doesn’t replace the practitioner’s responsibility to provide initial rescue in managing life-threatening complicaions.

On-site monitoring and rescue equipment

emergency cart must be accessible. use appendix C and D for drugs and equipment lists.

Documentation before sedation

Informed consent

Instructions: written and verbal

Considerations for post-op observation

24-hour telephone access for patients

Dietary Precautions

for elective sedation use general anesthesia fasting guidelines as listed in Table 1.

for emergency sedation: must balance benefit vs. risks of aspiration

Use of Immobilization Devices

papoose must not obstruct airway or restrict chest. a hand or foot should always be exposed.

Documentation at time of sedation

Health evaluation must be done: there is a list of all items that should be included. Very similar to our current H&P (minus Does the patient have lice?)

herbal medicines and strongly affect cytochrome P450 systems and result in prolonged drug effect and altered blood drug concentrations

Documentation during treatment

time based record

time-out to start

include durgs and dosages as well as inspired oxygen and vitals

Documentation after treatment

use generally recognized scales to determine when patient is ready for release.

use recognized discharge criteria

be careful when using anecdotes that resedation does not occur.

Preparation: SOAPME

Suction

Oxygen

Airway

Pharmacy

Monitors

equiment or drugs

If you are going to aim for a particular level of sedation you must be prepared to handle the next deeper level or sedation.

Special considerations:

LA: must not overdose. Also max dosages can affect sedation levels. aspirate frequently to avoid intravascular injections.

New pulse oximeters are better than old ones

Capnography can be very helpful to monitor respiratory activity

LMA (laryngeal mask airway) is an new airway device that you should seek training in.

Intraosseous injection: another adjunct that may be useful

N2O

considered minimal sedation at levels under 50% when used alone.

when used in higher concentration than 50% moderate sedation can be achieved

some guidelines for usage are outlined.