Procedure Sedation Phases
The following will apply during procedures for pediatric patients receiving moderate sedation:
Preprocedure Phase
Provice Physician Oversight & Direction
A qualified staff physician is ultimately responsible for ensuring that appropriate care is provided to the child during all phases of sedation. When the physician ordering sedation is not on site at the time of sedation, a qualified physician will be designated to be responsible, including assessment and monitoring during the pre-, intra-, and postsedation phases. Additionally, in the event that the physician responsible is not available for any part of the sedation and procedural period, he or she shall delegate care to another clearly identified credentialed physician who has accepted the responsibility and is knowledgeable about the child’s condition.
A qualified physician shall:
- assess and document a child’s appropriateness to receive sedation prior to receiving any sedative drugs, as evidenced by his or her signature on the appropriate sedation form;
- re-evaluate the patient immediately prior to sedation administration, as evidenced by his or her signature on the appropriate sedation form;
- order and direct the administration of sedation based on findings of the preprocedure assessment;
- be on site and able to respond to changing patient status and treat complications of sedation that may occur;
- be continuously present while the patient is moderately to deeply sedated; and
- have immediate access to support from anesthesiology or the blue cart team.
Perform & Record Patient Assessment
A collaborative patient assessment for sedation is essential for safe and effective care. Both the physician and the nurse have a role in patient selection and preparation for procedural sedation. It is mandatory that certain key elements of the physical assessment and patient interaction be documented before sedation is given, even if a full dictated note is to follow. These include:
- Evidence of informed verbal consent,
- Assessment and documentation of patient appropriateness to receive the planned sedation based on the preprocedure history and physical, and
- Re-evaluation of the patient immediately prior to sedation administration.
Ready Resuscitative & Monitoring Equipment
Determine that resuscitative and monitoring equipment is readily available on site and during transport, including:
- suction apparatus with appropriately sized suction catheters (i.e. Yankeur);
- oxygen-delivery system capable of 15 L/min flows for greater than 60 minutes;
- appropriately sized masks, with oral and nasal airways;
- pediatric intubation tray with laryngoscope, blades and endotracheal tubes;
- self-inflating resuscitation bag;
- pulse oximeter and blood pressure monitoring equipment;
- ECG equipment and defibrillator; and
- emergency medications, including reversal and resuscitative agents.
Educate Parent (or Caregiver) & Child
Educate parent (or caregiver) and child, if appropriate, prior to administration of sedative medication regarding the risks and potential adverse effects of sedation, anticipated sedative effects, reason for sedation, and potential options other than sedation. Include information about what the patient can anticipate before, during and after sedation, including symptoms and side effects to report. When possible, work out a pre-established signaling system for pain. Where applicable, presedation instructions will be given to the patient (e.g., medication adjustments, NPO requirements, designated driver postprocedure, etc.).
Obtain Verbal Informed Consent
Discuss the risks, benefits and alternatives to the procedure, with and without sedation, with the patient and/or family members as appropriate. Include postprocedural expectations, such as management of any pain and anticipated short- and long-term changes in activities of daily living.
By providing preprocedure patient education, the physician can allay patient and family fears and anxiety regarding the planned procedure. These measures can lead to decreased dosages of medications needed for sedation.
Documented consent includes a note in the patient’s chart outlining risks and benefits and alternatives to the plan of care. It should be signed by the responsible physician and note that the patient or representative understands and agrees to proceed with the plan as discussed. Patient or caretaker written consent is not required.
In emergency situations, when the patient or parent is unable to give consent and delaying medical care has the potential to cause harm, medical care may be given to the extent needed to respond to the emergency needs of the patient, provided there is no known advance directive to the contrary. In case of doubt concerning the validity or applicability of an advance directive that directs withholding of treatment, emergency medical care will be given. When possible, attempts to obtain consent from the patient or the patient's authorized representative should continue while care is given. The responsible physician will determine the existence of an emergency. It is advisable to document in the medical record the nature of the emergency and the efforts made to obtain consent.
Perform & Record a Health Assessment
Perform and record a health ssessment of the patient to determine baseline status and identify factors that may increase the patient's risk during the period of sedation. No child shall receive sedation until:
- A presedation assessment has been completed and documented;
- The physician (attending physician or supervised resident) has attested to the patient’s appropriateness to receive sedation, as evidenced by his or her signature on an appropriate documentation form;
- The plan of care has been communicated by the physician to the nurse assigned to the patient; and
- The person administering the sedative agent has verified that the required documentation is completed prior to any sedation being given.
All nonemergent procedures will be delayed or cancelled until all preprocedure documentation is completed.
Minimal assessment required before sedation includes, but is not limited to, determination and documentation of:
Medical history:
- age;
- drug allergies;
- recent or current illness;
- major illnesses or congenital defects;
- previous hospitalizations, surgeries, sedations and anesthesia;
- previous problems with anesthesia or sedation;
- current medication use (including opioid and sedative use within the past 24 hours); and
- time of last oral intake:
- <6 months of age: 4 hours milk or solids
- >6 months of age: 6 hours milk or solids
- 4 hours breast milk for all ages
- 2 hours clear liquids for all ages.
Gastric emptying is influenced by many factors, including anxiety, pain, pregnancy and mechanical obstruction. Therefore, following a fasting protocol does not guarantee that complete gastric emptying has occurred.
Physical exam:
- weight in kilograms;
- respiratory and cardiovascular status, which may include findings from heart and lung auscultation and other physical findings as appropriate;
- ASA physical status classification score;
- brief neurological examination and determination of developmental status, including level of awareness;
- heart rate, blood pressure, respiratory rate, oxygen saturation and temperature, where appropriate;
- baseline assessment of pain, where appropriate;
- baseline pediatric sedation score;
- final verification to confirm the correct patient, procedure, and site using a “time out”; and
- airway assessment (assessment for risk of airway compromise).
Preprocedure airway assessment aids in management of the airway if respiratory depression occurs, including identification of the need for increased expertise in airway management for patients at higher risk. Complete a visual airway inspection to identify potential risk factors in management of the patient's airway. This includes identifying the presence of loose teeth and/or excess oral secretions, and assessment of the neck (chin to chest flexion and hyperextension) and jaw mobility (ability to open his or her mouth). Review the patient's history for factors that may make airway maintenance difficult, such as head or neck surgery, obesity, cervical stenosis, arthritis, injury, craniofacial anomalies, etc.
Establish Venous Access
Establish venous access, if appropriate, for administration of intravenous sedation should additional medications or IV fluids be required during or after the procedure. The responsible physician determines the need for venous access on a case-by-case basis and, when ordered, IV catheters will be inserted by protocol. See UWHC Policy #8.18, “Vascular Catheters”.
Provide Qualified Personnel
Provide qualified personnel who will be present from the time of administration of sedative drugs until the child returns to baseline status. Qualified personnel responsible for monitoring the child:
- require additional training and proof of competency in the assessment, monitoring, and management of pediatric patients;
- may administer sedative drugs under the direction and supervision of the credentialed physician;
- shall continuously assess and respond to the child’s condition; and
- shall document assessments and findings as outlined by policy.
During procedures with mild sedation, monitoring personnel may assist with minor interruptible tasks but shall not leave the child unattended.
During moderate and deep sedation, monitoring personnel shall not perform tasks other than those related to sedation and airway management and shall remain with the child continuously during the sedative period.
Transferring a Child
When transferring a child, at least one qualified person, with appropriate equipment and supplies shall accompany the child during any part of the sedative period. Strollers, wagons and wheelchairs are not acceptable modes of transportation for children who are sedated to the point of sleep. Children should be transported on a cart with a flat surface that provides easy patient access in addition to being large enough for equipment.
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No patient shall receive sedation until a presedation assessment has been completed and documented by the physician responsible for the sedation. Documentation includes the patient's appropriateness to receive sedation. The person administering the sedation medication (generally the RN) is responsible for assuring that requirements are completed before administration. A procedure will be delayed or cancelled until all preprocedure documentation is complete. These include:
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Intrasedation Care
Drug Documentation
Drug documentation, to include:
- dosage of all medications administered;
- time, route and site of administration of all medications;
- responsible party administering the medication; and
- type and amount of any fluids infused, including blood and blood products. See UWHC Policy #8.17, “Administration of Medications”.
Patient Status
Patient status is to be monitored continuously throughout the sedation period and the child’s status documented in accordance with the level of sedation:
- heart rate and respiratory rate;
- oxygen saturation; and
- blood pressure, ECG, EtCO2 and other findings where applicable.
Adverse or Unexpected Events
Adverse or unexpected events are to be diagnosed and treated immediatelyduring the sedative period. These include bradycardia, apnea, oxygen desaturation, hypotension, emesis, vasovagal reaction, seizure, anaphylaxis or anaphylactoid reactions, neuropsychiatric disturbances, or any other cardiopulmonary impairment. A pediatric blue cart must be called when necessary (e.g., if the child experiences apnea or bradycardia that is not responsive to immediate medical intervention).Document any events, interventions, and subsequent patient response related to an event and interventions.
Patient Status Postprocedure
Patient status postprocedure to be documented, including: heart rate, blood pressure, respiratory rate, oxygen saturation, level of awareness and level of pain, where appropriate.
Post-Sedation Care Phase
This period is characterized by Phase I and Phase II recovery. Phases I and II are minimal requirements for patient discharge; additional monitoring and recovery time are at the discretion of the physician or mid-level provider. Refer to Pediatric Discharge Criteria below.
Phase I
Continuously observe and monitor the child, documenting according to the level of sedation. Using the pediatric discharge scoring system, proceed to Phase II monitoring once a minimum score of 8 is achieved and all individual category scores are greater than 0. Exceptions to this score are per MD order only. There is no minimum monitoring time requirement for this phase. Monitoring may take place in the procedure room, designated recovery area or inpatient room. Patients who meet Phase I criteria immediately upon completion of the procedure may proceed to Phase II.
Phase II
Monitoring and documentation of vital signs continues every 15 minutes using the pediatric discharge scoring system.
| Category | Observation | Score |
|---|---|---|
| Vital Signs (VS) | Stable | 1 |
| Unstable | 0 | |
| Respirations (Resp) | Normal/preprocedure level | 2 |
| Shallow/tachypnea | 1 | |
| Apnea/periodic respirations | 0 | |
| Level of Consciousness (LOC) | Alert, oriented/returned to preprocedure level | 2 |
| Arousable, giddy, agitated, disoriented | 1 | |
| Blunted response to verbal/physical stimuli | 0 | |
| Oxygen Saturation (O2 Sat) | 94–100% | 2 |
| 88–93% | 1 | |
| <88% | 0 | |
| Color | Pink/preprocedure color | 2 |
| Pale/dusky | 1 | |
| Cyanotic | 0 | |
| Activity | Normal gross motor function/moves on command/preprocedure level | 2 |
| Altered gross motor function/uncoordinated walking | 1 | |
| No or minimal spontaneous movement | 0 |
Phase I Criteria Score
≥8 When score is ≥8 and no category has a score of 0, continue to Phase II recovery (minimum of q.15 min vital signs for 30 min).
<8 continue with vital signs as per sedation P&P.
Phase II Criteria Score
May be discharged from Phase II after a minimum of 30 min (VS q. 15 min) and by meeting the following requirements:
- Stable respiratory status: equal breath sounds, unlabored resp effort, or resp status at baseline.
- Able to maintain patent airway independently: manage oral secretions and demonstrate ability to swallow.
- No nausea/vomiting; tolerates clear liquids without emesis.
- LOA: awake and alert (able to keep eyes open and converse with parents if developmentally appropriate).
- Activity: good head control, sits unaided, walks with assistance (if developmentally appropriate).
- Vital signs: remain stable and Phase I score maintained.
Use of pulse oximetry monitoring during Phase II recovery is indicated in children who are not at baseline oxygen saturation status upon completion of the procedure or Phase I; otherwise, continued use is at the discretion of health care personnel monitoring the child.
Identify Children Who Require Prolonged Phase II Monitoring
Identify children who require prolonged Phase II monitoring (including those receiving reversal agents) due to complications and/or slow recovery. Where indicated, the responsible physician will determine a further plan of care and when needed will direct patient transfer to an appropriate hospital care area until baseline condition returns.
Any child who receives naloxone or flumazenil following sedation/analgesia shall have continued monitoring with documentation of assessments and vital signs. Minimal monitoring shall include heart rate, blood pressure, respiratory rate and pulse oximetry following administration of the reversal agent for a minimum of two hours AND until Phase II criteria are met.
Assess the Child's Readiness for Discharge/Cessation of Sedation Monitoring
Assess the child's readiness for discharge/cessation of sedation monitoring based on the Phase II discharge criteria.
Provide Instructions
Provide instructions, verbal and written, to the parent (caregiver) and/or discharged child regarding diet, medications, activities, potential complications and course of action if a complication develops (see UWHC Form # 9143 Pediatric Postsedation Instructions Appendix G).
Communicate Information
Communicate information to the qualified staff member assuming the child’s care, if the child is transferred to another care area.
Exception
The credentialed attending physician may authorize variations from these procedures in individual cases based on the specific clinical situation.