Guidelines for Monitoring and Management of Pediatric Patients During and After

Title: Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures
Authors: AAPD Clinical Guidelines 09-10
Summary: Sedation of any kind should not be pursued by any provider who is not properly trained and experienced. The concept of rescue is essential to safe sedation and providers should have the skills to rescue a patient from a deeper level than that intended for the procedure. Minimal sedation (formerly known as ‘anxiolysis’): a drug induced state in which patients respond normally to verbal commands. Cardiopulmonary function is unhindered. Moderate Sedation (‘conscious sedation’ or ‘sedation/analgesia’): patient responds purposefully to verbal commands but perhaps requiring light tactile stimulus. No intervention is required to maintain a patent airway and spontaneous ventilation is adequate. If the patient is not making spontaneous efforts to open their airway, consider them deeply sedated. Deep Sedation (‘deep sedation/analgesia’): patients cannot be easily aroused but respond purposefully with repeated or painful stimuli (including sternal rub. These patients may require assistance in maintaining a patent airway.
Goals of Sedation: guard patients safety and welfare, minimize physical discomfort and pain, control anxiety, minimize psychological trauma, control behavior and movement so as to complete a procedure and to return the patient to a state in which safe discharge from medical supervision.
Potential for adverse outcome greatly increases when 3 or more agents are used (not including LA). You must be familiar with half-lives and titration, particularly knowing whether a dose of drug has taken effect before administering another. Common drugs with long half lives include: chloral hydrate, intramuscular pentobarbital and phenothiazines)è these require longer post op observation times, especially with infants and toddlers who are at risk for resedation due to lingering effects and potential for airway obstruction.
Candidates: ASA I and II patients are allowed for minimal, moderate or deep sedation. III and IV and those with additional airway complications should be considered for GA. A responsible person must be present whenever performing sedation, ideally a guardian and ideally 2 adults if it is a child, particularly those who are still in car seats. Facilities must have immediate access to and maintain equipment to deal with an obstructed airway. Back up emergency services must also be available for life threatening situations. On site monitoring and rescue equipment must also be present including a crash kit: airways, intubation materials, reversal agents, epipen etc. ECG, pulse oximeters, end tidal CO2 monitors and defibrillators must have a safety and function check on a regular basis.
Documentation: Informed consent. Instructions for the responsible person, especially concerning car seats. A 24 hour number should be available for all patients receiving sedation. Dietary precautions: ideally the same precautions for GA should be taken for sedation (see table). For emergency patients, the risk of sedation should be balanced against the value of the procedure and whether it can be postponed to when the proper dietary precautions have been taken. Immobilization devices should be used so that they do not obstruct the airway or restrict the chest. A foot or hand should always be exposed in case of need for venous access or O2 sat.
A thorough health history should be taken in order to determine eligibility for sedation as well as elucidate any additional risks a patient may present with. Be sure to inquire about herbal supplements which may have side effects such as inhibition of CYP450 (St Johns Wort, Echinacea) which may result in increased or decreased drug effectiveness. A health history should include all the basic information including a review of systems, vital signs and info concerning their medical home.
Prescription medications to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.
A “time out” must be performed immediately prior to treatment to confirm correct patient and procedure. After treatment, time and condition of child at discharge should be recorded including confirmation that the patient maintained proper O2 sats and consciousness in room air. A recent and popular technique for assuring recovery is that the patient can stay awake for 20 minutes in a quiet environment.
Setting Up:
· Suction of appropriate size
· Oxygen supply
· Airway management materials
· Pharmacy: rescue drugs including reversal agents
· Monitors: pulse ox, ECG, CO2 end tidal monitor, BP cuff, stethoscope as needed
· Equipment – special requirements
Minimal sedation require observation and intermittent assessment of their level of sedation. Practitioners must be trained in and capable of providing at the minimum, bag valve-mask ventilation so as to be able to oxygenate a child who develops an airway obstruction. Training and maintenance of pediatric airway skills is required.
Supportive personnel should be BLS certified and be able to support in any resuscitative attempts. Baseline vitals should be taken if possible. Practitioner must document the name, route, site, time and dosage of all drugs administered. Moderate sedation: O2 sat and heart rate should be monitored at all times. After moderate or deeper sedation, the patient must be monitored in a facility with proper suction and the ability to deliver 90%+ oxygen. Vitals should be taken intermittently and for the unconscious patient, O2 sat and heart should be continually monitored. Deep sedation: ECG and defibrillator should be present, vascular access should be achieved or at least the equipment and personnel to do so.
When administering LA, be sure to aspirate regularly as it can act as a depressant on the cardiopulmonary system. Capnography is valuable to diagnose the presence of breathing, airway obstruction or respiratory depression. The vast majority of sedation complications can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning and bag-valve mask ventilation.
Assessment: Dense but important stuff. Know your limits.