Sedation for diagnostic and therapeutic procedures on children

Pre sedation assessment, communication and patient information and consent

Health care professionals delivering sedation should have knowledge and understanding of and competency in:

• Sedation pharmacology and applied physiology
• Assessment of children and young people
• Monitoring
• Recovery care
• Complications and immediate management, including paediatric life support

Health care professionals delivering sedation should have practical experience of:

• Effectively delivering the chosen sedation technique and managing complications
• Observing clinical signs (for example, airway patency breathing rate and depth, pulse, pallor and cyanosis and depth of sedation)
• Using monitoring equipment
• All members of the sedation team should have basic life support skills and at least one member with intermediate life support when delivering minimal and moderate sedation.

Patient-centred care and consent

Children and young people undergoing sedation and their parents and carers should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Informed consent should be obtained for sedation as well as the procedure and documented in the patient’s notes.

Fasting

Before starting sedation, confirm and record the time of last food and fluid intake in the healthcare record.

Fasting is not mandatory for:

• Minimal sedation or
• Moderate sedation during which the child or young person will maintain verbal contact with the healthcare professional.

Apply the 1-4-6 fasting rule for: (1hr for clear fluids, 4hrs for breast milk, 6hrs for solids)

• Deep sedation and moderate sedation during which the child or young person may not maintain verbal contact with the healthcare professional.

Monitoring

For moderate sedation: continuously monitor and interpret and respond to changes in all of the following:

• Depth of sedation
• Respiration Rate
• Oxygen Saturation
• Heart rate
• Pain and distress

The patient should have a patent airway throughout the procedure, be able to protect their airway, be haemodynamically stable and be easily aroused if they are sedated to a minimal/ moderate level. If they have any signs of the above then the person giving the sedation needs to be aware that the patient is over sedated and a senior person needs to be contacted and PICU informed if required.

The following age appropriate equipment should be available:

• Suction apparatus with Yankeur sucker attached
• Oxygen with age appropriate mask and tubing
• Self inflating resuscitation bag
• Audible pulse oximeter and blood pressure monitoring
• An emergency call system to summon additional help

Facilities for observation until the child has recovered from sedation to a point where it is safe to be discharged

• Choice of sedative agent depends on child factors, the experience of the clinical team and the rationale for sedation.
• No drugs have a UK marketing authorisation specifically for sedation in all of infants, children and young people under 19 years.
• Refer to BNFc for up to date dosage instructions of conscious sedation for procedure.

As per the NICE guideline Midazolam and Chloral Hydrate will be used for the following patient group. Midazolam has a strong safety profile in inducing either minimal or moderate sedation. It is contraindicated in anticipated difficult airway, increased aspiration risk, obstructive sleep apnoea, severe renal or hepatic impairment, reduced Glasgow Coma Scale, previous allergic or behavioural reaction to midazolam, raised intracranial pressure, acute systemic illness e.g. severe sepsis and reduced oxygen saturation in room air.

For children and young people undergoing a practical procedure where sedation is required, the target level of sedation is classed as minimal to moderate: Consider one of the following drugs EITHER:

• Midazolam (first line) 30-60 minutes pre-procedure:
  Oral Route: 0.5mg/kg as per BNFc (max dose of 20mg)
  Please note that this is a different dose from the buccal route used for status epilepticus
• Chloral Hydrate (if midazolam not suitable) 45-60 minutes pre-procedure:
  Oral Route : 50mg/kg as per BNFc
• Ensure the patient only receives one of these drugs. They should NOT be prescribed both at the same time. Ensure adequate analgesia, monitor for combined effect of sedation and opiate analgesia (Administer oral analgesia at least 30 minutes prior to procedure)

Alternatives if sedation is not successful

Trial of alternative sedation choice may be considered if safe and appropriate to do so.

Psychological Preparation

Ensure the child or young person is prepared psychologically for sedation by offering information about:

• The procedure
• Sensations associated with the procedure
• Offer parent and carers to be present during sedation if appropriate
• Obtain informed consent

After the procedure, continue monitoring until the child or young person:

• Has a patent airway with return of airway reflexes 
• Has return of ventilatory function-normal Spo2 & RR for age
• Shows protective and breathing reflexes 
• Is haemodynamically stable
• Is easily roused
• Ensure vital signs have returned to normal
• The young person is awake

Ensure the following criteria are met before the child or young person is discharged:

• Vital signs have returned to normal
• The child or young person is awake and there is no risk of further reduced level of consciousness
• Patient can be discharged from 2-4 hours post dose of sedation
• Nausea, vomiting and pain have been adequately managed.