The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) have updated their guidelines for safely sedating pediatric patients, as published in Pediatrics.
The AAP and AAPD define the goals of pediatric sedation as follows:
- To guard the patient’s safety and welfare
- To minimize physical discomfort and pain
- To control anxiety, minimize psychological trauma, and maximize the potential for amnesia
- To modify behavior and/or movement so as to allow the safe completion of the procedure
- To return the patient to a state in which discharge from medical/dental supervision is safe, as determined by recognized criteria
The guidelines recommend that clinicians use the lowest dose of drug with the highest therapeutic index for the procedure.
Pediatric patients who are in the American Society of Anesthesiologists (ASA) class I or II are considered candidates for minimal, moderate, or deep sedation. Children in ASA class III or IV, children with special needs, and children with anatomic airway abnormalities or moderate to severe tonsillar hypertrophy should be considered on an individual basis.
If pediatric patients are going to be sedated, they must be accompanied to and from the treatment facility by a parent, legal guardian, or other responsible party.
If a practitioner is going to use sedation, he or she must have immediately available facilities, personnel, and equipment to manage emergency situations that may arise, including airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea. There should also be a protocol for immediate access to back-up emergency services. An emergency cart should also be immediately available; it should contain the equipment necessary to resuscitate a nonbreathing and unconscious child, including oral and nasal airways, bag-valve-mask device, laryngeal mask airways/other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters, etc.
Before sedation, informed consent should be obtained, and the patient’s parent/guardian should be provided with instructions and information regarding the procedure.
Patients undergoing elective sedation should generally follow the same fasting guidelines as those for general anesthesia. If a patient is undergoing emergency sedation, the practitioner should weigh the risks of sedating a nonfasted patient with the benefits (and necessity) for the procedure.
At the time of sedation, the patient should undergo a health evaluation that includes age, weight, gestational age at birth, food/medication allergies, medication history, conditions that may increase the potential for airway obstruction, pregnancy status, history of prematurity, history of seizure disorder, summary of previous relevant hospitalizations, history of sedation/general anesthesia, relevant family history, vital signs, physical examination, and physical status evaluation. Additionally, if prescriptions are used for sedation, a copy or description of the prescription should be in the patient’s chart.
During sedation, the patient’s chart should have a time-based record of the name, route, site, time, dosage/kilogram, and patient effect of administered drugs. It should include the patient’s level of consciousness and responsiveness, heart rate, blood pressure, respiratory rate, expired carbon dioxide values, and oxygen saturation. Adverse events and their treatments should also be documented.
After sedation, the patient should be taken to a dedicated recovery area. At discharge, the clinician should record the time and condition of the child, including documentation that the patient’s level of consciousness and oxygen saturation in room air are at safe levels for discharge.
- Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatrics. 2016 Jun 27. doi:10.1542/peds.2016-1212 [Epub ahead of print]