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Patient Safety Issues in Sedation: Pitfalls and Best Practices
September 28, 2006

                                                                      

                      Timothy Corden, MD, FAAP                      Gregg Hollman, MD, FAAP

 

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SEDATION   

The following questions and answers deal with the issue of pediatric sedation.

The following exchange is provided for informational purposes only.  The actions suggested will not apply to every institution; individual circumstances may vary.  The expert responses reflect the individuals’ opinions and do not necessarily represent official AAP positions or policy.  For specific guidance on AAP Policy, visit http://aappolicy.org.

HELP!  I am a Sedation Nurse with only Adult ICU experience.  My employer now wants us to sedate pediatrics even though I have no pediatric experience outside of school. They are willing to train us although I still don't feel competent nor confident sedating pediatrics with chloral hydrate or versed.  Please contact me with advice.

This is a bit difficult to fully answer without understanding the practitioner’s institution and local sedation environment. No doubt further training will be required which for starters could begin with a sedation conference and sedation provider course. The Society for Pediatric Sedation will be giving the first ever Sedation Provider course in Philadelphia next year. I am the course director for the conference and for many it will be a good place to start for training. That is the easy part. The more difficult part will be the hands on training that will be required to become fully competent for providing pediatric sedation. This also depends on the infrastructure of the institution and who will be the nurse/physician leaders driving the program.

Greg Hollman, MD
Medical Director, Pediatric Sedation Program
American Family Children’s Hospital, Madison, WI

Sedation guidelines for non-anesthesiologists sedating children can be found on the American Society of Anesthesiologist (ASA) website, this publication must be bought, but if you google ASA, a link to this publication comes up and can be copied from the internet. Also, the American Academy of Pediatrics has guidelines for sedating children and can be found on their website (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/2/512) or linked to the Society for Pediatric Anesthesiologists website. These are very thorough, strict and safe guidelines, also a lot of educational information on assessing sedation levels in children. Proper pre-sedation evaluation, understanding of the drugs being used, monitoring equipment, suction, oxygen, airway devices, someone competent in managing the airways of children and providing CPR for children, a recovery area with a designated person to monitor the patient are all necessary. The bottom line, if this person does not feel comfortable, then they should not participate in this care.

Deborah Vermaire, MD
Dept. of Anesthesia
Division of Pain Management
Cincinnati Children's Hospital, Cincinnati, OH

Online tutorials and pediatric courses may be of help.  A nice first start would be the CHEX modules (perhaps accessed via the closest children's hospital's education dept) and of course the sedation section in PALS.  As most would agree, the best is to have a subset of individuals trained to sedate children, keeping within appropriate limits for age, development, and underlying disease state as well as simple ASA class.

Erin R. Stucky, MD
Member, Project Advisory Committee, AAP Safer Health Care for Kids
Pediatric Hospitalist, Rady Children’s Hospital San Diego, CA

My organization is looking at conscious and moderate sedation in the emergency department and how long of a fasting period is required or is one required?   Any information would be most helpful.  Thanks so much.

The emergency department environment is recognized as unique in that the ability to control for NPO status is limited. While recent reports from the emergency medicine literature question the inherent risk of not being NPO prior to sedation, it is still recommended that the NPO guidelines established by the ASA and AAP be followed. Yet in the emergency medicine environment that may simply not be possible. The risks of postponing or not performing sedation must always be weighed against the benefits of conducting a sedation procedure earlier than what NPO guidelines would recommend. Sometimes it is simply in the patient’s best interest to conduct the sedation sooner, understanding that some risk exists, albeit not fully known, related to not being NPO. Bottom line I recommend following the NPO guidelines established by the ASA/AAP, however not so rigidly that it may interfere with best patient care.

Greg Hollman, MD
Medical Director, Pediatric Sedation Program
American Family Children’s Hospital, Madison, WI

Fasting (NPO) guidelines are thus: 2 hours for clears, 4 hours for breast milk, 6 hours for solids. This information can be found on the American Society of Anesthesiologists web site. Some institutions still use 8 hours for solids to be more conservative.

Deborah Vermaire, MD
Dept. of Anesthesia
Division of Pain Management
Cincinnati Children's Hospital, Cincinnati, OH

The NPO guidelines have been a topic of discussion in the ED where propofol is being used more often. While sedation time and recovery are shortened, some would also like to shorten the total ED visit time by re-visiting the NPO guidelines for some patients. At present in the hospital setting, it is usually straightforward, with typically only planned or emergent sedation events.

Erin R. Stucky, MD
Member, Project Advisory Committee, AAP Safer Health Care for Kids
Pediatric Hospitalist, Rady Children’s Hospital San Diego, CA

Related Articles

Karian VE, Burrows PE, Zurakowski D, Connor L, Mason KP.  Sedation for pediatric radiological procedures: analysis of potential causes of sedation failure and paradoxical reactions.  Pediatr Radiol. 1999 Nov;29(11):869-73.

Keidan I, Gozal D, Minuskin T, Weinberg M, Barkaly H, Augarten A.  The effect of fasting practice on sedation with chloral hydrate.  Pediatr Emerg Care. 2004 Dec;20(12):805-7.

Lane RD, Schunk JD.  Atomized intranasal midazolam use for minor procedures in the pediatric emergency department.  Pediatr Emerg Care. 2008 May;24(5):300-3.

Sharieff GQ, Trocinski DR, Kanegaye JT, Fisher B, Harley JR.  Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department.  Pediatr Emerg Care. 2007 Dec;23(12):881-4.