A new NICE guideline offers advice on when infants, children and young people need sedation and how to carry this out safely
McArthur L (2011) Nursing Times; 107: 18, early online publication.
Every year, around two million children and young people who visit hospital emergency departments due to accidental injuries may undergo procedures where sedation is required (Audit Commission/Healthcare Commission, 2007). Children may also need sedation for radiological or dental procedures, during inpatient investigations and interventions, or when they present at GP surgeries and walk-in centres.
While sedating children is part of health professionals’ practice, there has been little guidance on which techniques are most effective and what resources, including staff training, are needed to administer sedatives safely. Evidence and research increasingly highlights the impact on children of procedures that are poorly planned and managed. These effects, which can be long-lasting, include anxiety, pain and avoidance behaviours.
The National Institute for Health and Clinical Excellence developed a guideline to improve care and safety standards in England and Wales for sedating infants, children and young people by providing clear recommendations for health professionals. It classifies sedation based on the American Society of Anesthesiologists (ASA) definitions. They are:
Minimal sedation Where patients are awake and calm and respond normally to verbal commands;
Moderate sedation Where patients are sleepy, but respond purposefully to verbal commands or light tactile stimulation;
Conscious sedation Similar to moderate sedation, except verbal contact is always maintained with the patient. This is commonly used in dentistry;
Deep sedation Patients are asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. They may need assistance to maintain a patent airway.
Health professionals preparing for the procedure and assessment of a sedative agent must consider young patients’ medical condition, problems with sedatives, physical status including the condition of the airway and psychological and developmental status. It is also important to consider whether the procedure is defined as painless or painful. This enables health professionals to include suitable analgesics to avoid unnecessary pain.
There is also guidance on fasting before sedatives are administered.
The guidance advocates routine monitoring for moderate to deep sedation. Parameters include behavioural and psychological criteria, such as depth of sedation, oxygen saturation, pain and anxiety. Electrocardiography, capnography and blood pressure monitoring should also be used if deep sedation is administered.
NICE makes recommendations for education and training to ensure health professionals keep their knowledge up to date. The guideline outlines areas where education and training should be targeted. These include:
- Knowledge, understanding and competency in sedation drug pharmacology and applied physiology;
- Assessment of children, monitoring and managing complications;
- Practical experience of effective delivery of sedation techniques and managing complications, which include observing, interpreting and managing clinical signs, and how to use equipment;
- Documented up-to-date evidence of competency, including satisfactory completion of theoretical training covering the principles, and a comprehensive record of practical experience of sedations carried out.
The guideline recommends that trained health professionals should carry out the assessment of technique which is suitable before a young patient is given sedation. If this assessment identifies problems, specialist advice must be sought before proceeding.
Two trained members of staff should be available during the period of sedation to monitor the child or young person. Immediate access to resuscitation and monitoring should be at hand during sedation.
The guideline includes evidence for the use of chloral hydrate, fentanyl, ketamine, midazolam, nitrous oxide, opioids, propofol and sevoflurane in sedation. Recommendations on using these drugs to achieve a desired level of sedation should ensure they are delivered by safe, competent health professionals.
In producing the guideline NICE aims to ensure that the assessment of children before a procedure – taking into account their history, levels of anxiety and coping mechanisms – will be planned and managed in a structured way and result in a positive and safe outcome.
Offering children and young people (and their parents or carers) verbal and written information about proposed sedation techniques, alternatives to sedation and associated risks and benefits may encourage them to become more engaged in the process, resulting in better outcomes.
The guideline Sedation in Children and Young People is available for download atwww.nice.org.uk/guidance/CG112
Author Liz McArthur is clinical nurse specialist, pain and sedation service, Alder Hey Children’s Foundation Trust, Liverpool and a member of the NICE guideline development group
Audit Commission/Healthcare Commission (2007) Better Safe than Sorry: Preventing Unintentional Injury to Children. London: Audit Commission.