Sedation, Procedural
CLINICAL GUIDELINES
Sedation is ordered by a healthcare prescriber. Medications to achieve sedation are selected on the basis of type of procedure, length of the procedure, medical condition of the child, age and weight or body surface area of the child, expected painfulness, and the need for amnesia.
The healthcare prescriber, registered nurse (RN), or licensed practical nurse may administer sedation medications, as within their scope of practice. Practitioners who care for children receiving moderate sedation have received competency-based education regarding medication administration and assessment of the child before, during, and after sedation. Practitioners possess the skills to manage a compromised airway and provide adequate oxygenation and ventilation, should these become necessary.
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination might be impaired, ventilatory and cardiovascular functions are unaffected. Note anxiolysis is not considered moderate sedation and is excluded from this procedure.
Moderate sedation is used for diagnostic and therapeutic procedures that are painful or for which the child must remain immobile. Moderate sedation is a drug-induced depression of consciousness; the child can still respond purposefully, maintaining a patent airway and adequate spontaneous ventilation. A key consideration is that sedation to anesthesia is a continuum. Individuals react differently to medications, and healthcare practitioners must be competent to manage a child who enters a deeper than intended level of sedation.
At least one individual capable of establishing a patent airway and positive-pressure ventilation, other than the practitioner performing the procedure, is present to monitor the child during sedation procedures. This individual’s primary responsibility is to monitor the child, but the person may perform interruptible tasks in the room (e.g., charting) after the child’s vital signs and level of sedation-analgesia have stabilized, when adequate monitoring of the child’s level of sedation and response is maintained.
The person monitoring the child possesses the requisite knowledge and skills to assess, diagnose, and intervene in the event of complications or undesired outcomes and to institute nursing interventions in compliance with orders (including standing orders) or institutional protocols or guidelines. This individual meets institutional requirements for clinical competency related to monitoring the child receiving sedation. Competencies include pediatric basic life support and knowledge of the following:
Anatomy, physiology, pharmacology, and ability to recognize cardiac arrhythmia and complications related to IV sedation and medications
Total patient care requirements during IV sedation and recovery. Physiological measurements should include respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patient’s level of consciousness.
Role of reversal agents for narcotics and benzodiazepines
Signs, treatment, and interventions associated with clinical complications
Principles of oxygen delivery, respiratory physiology, transport and uptake, and the ability to use oxygen delivery equipment
Use of emergency equipment, including airway management resuscitation
Personnel who are expert in airway management, emergency intubation, and pediatric advanced life support (PALS) are immediately available (within 5 minutes) if complications arise.
Emergency equipment is present and ready to use in case the child experiences complications. Airway management and breathing equipment are checked for appropriate function before each sedation.
Oral intake before scheduled procedures is limited as follows (or as otherwise ordered):
All children are nothing by mouth (NPO) for 2 hours before the procedure.
Clear liquids may be consumed up to 2 hours before the procedure.
Breast milk may be consumed up to 4 hours before the procedure.
Infant formula, nonhuman milk, and light foods (no fried or fatty foods or meat) may be consumed up to 6 hours before the procedure.
Children at risk for pulmonary aspiration of gastric contents (e.g., history of gastroesophageal reflux, esophageal dysfunction, and extreme obesity) are evaluated for necessity of pharmacologic treatment to reduce gastric volume and increase gastric pH.
In an emergency when the child has had recent oral intake, the increased risks of sedation are evaluated against its potential benefit, and the need to protect the airway is evaluated before sedation.
Level of consciousness, and response to verbal commands, heart rate, blood pressure, respiratory rate, and oxygen saturations are monitored continuously during the procedure and documented at regular intervals in accordance with institutional policy. If available, continuous capnography assessment of ETCO2 is recommended. In the rare event that monitoring equipment causes undue stress to the patient or interferes with the procedure, vital signs may need to be postponed. A notation is made in the medical record describing such reasons. In children with a history of cardiovascular disease or anticipated arrhythmia problems, a cardiac monitor is recommended.
Monitoring continues after the procedure until the child is in a state in which safe discharge or transfer to a less acute unit is possible in accordance with institutional policies. If the child is transported from the procedure area to a recovery area, the practitioner or RN must remain with the child and continuously monitor by direct observation and pulse oximetry during transport.
When a reversal agent has been given, the child is monitored for at least 1 hour after the last dose.
Verbal and written discharge instructions are given to the family before discharge. Instruct the family that children are at risk for airway obstruction should the head fall forward while the child is secured in the cart seat for transport home. It is recommended that an adult sit in the backseat with the child while in the car seat.
EQUIPMENT
Sedation documentation record
Monitoring equipment:
Stethoscope
Cardiopulmonary monitor (heart rate, respiratory rate, pulse oximetry, capnography)
Blood pressure machine (automatic/manual)
Oxygen delivery system and supplies:
Positive-pressure oxygen delivery system, capable of administering greater than 90% oxygen for at least 60 minutes
Supplemental oxygen
Functional suction apparatus with appropriate suction catheters
Emergency cart or kit with age-appropriate drugs and appropriately sized equipment to establish and maintain an airway, and supplies for vascular access
Prescribed medications: sedation-analgesia and appropriate reversal agents (e.g., naloxone, flumazenil)
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Determine whether the patient’s status fits the criteria for American Society of Anesthesiologists class I (normal healthy patient) or class II (patient with mild systemic disease) candidate, frequently considered appropriate candidates for moderate or deep sedation. Children who are class III or IV require additional consideration.
Assess the child’s and family’s understanding of sedation and the subsequent procedure. Preparatory interventions such as careful explanation of the procedure and the effects of sedatives before the procedure are helpful in alleviating the child’s distress and family’s concerns.
Ensure that informed consent has been obtained (see Chapter 51).
If appropriate, invite the family to stay with the child and instruct them on their role to soothe and comfort the child (see Chapter 92).
Complete the pain assessment with the child and the family. As needed, review age-appropriate pain assessment scale with the child and family to assist in postprocedural pain evaluations.
PROCEDUREPreprocedure Evaluation
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