The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) have issued updated clinical guidelines on the monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. “The original sedation guideline was written after three children died in a dental office in California [in 1983]…it’s been a long history, but it’s a real victory for children because now everything — monitoring requirements and presedation evaluation, all that — is now unified,” lead author Charles J. Coté, MD, told Medscape Medical News.
Dr Coté, professor of anesthesiology, Harvard Medical School, Boston, Massachusetts, who is also recently retired from MassGeneral Hospital for Children, also in Boston, and Stephen Wilson, DMD, PhD, medical director, Division of Pediatric Dentistry, Cincinnati Children’s Hospital Medical Center, and professor, University of Cincinnati Department of Pediatrics, Ohio, published the updated guideline online June 27 and in the July issue of Pediatrics. “The purpose of this updated report is to unify the guidelines for sedation used by medical and dental practitioners; to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurement; to provide updated information from the medical and dental literature; and to suggest methods for further improvement in safety and outcomes,” the authors write.
“Two Major Changes”
The guidelines include two major changes, Dr Coté said. The first has been to add capnography monitoring of children who are deeply sedated and to encourage capnography for children who are moderately sedated. Capnography measures expired carbon dioxide to ensure airway patency and gas exchange. “That’s a huge advance, because now the AAP guideline is basically the same as what the [American Society of Anesthesiologists] has had for several years now, in terms of monitoring patients that are sedated. Now it applies to children, which is great,” Dr Coté said. “What’s interesting is that the AAPD originally approached the American Academy of Pediatrics to write a second statement on the use of capnography…and I said it makes much more sense to just incorporate it into the previous guideline,” Dr Coté said. “[Dr Wilson] worked very hard with the dental community to convince them of the wording that was in this document.” “The second [change] is that the assistant to the person who is doing the sedating had to have [pediatric advanced life support] training. That’s an increased in level of training that wasn’t there previously,” Dr Coté added.
Rescue Skills Needed
Pediatric sedation is different from sedation of adults. Pediatric sedation is used to relieve pain and anxiety, but it is also used to modify behavior; for example, to help immobilize a child who might not be able to hold still for a test or procedure. “[It] is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation, making the concept of rescue essential to safe sedation,” the authors write. Practitioners who use sedation must have the facilities, personnel, and equipment to manage emergencies and rescue the child. They must have ready access to emergency medical services but also must be able to manage emergencies until those services arrive. Clinicians should use a systematic approach to prevent them from overlooking an important medication, piece of equipment, or monitor they might need in an emergency.
The authors recommend using an acronym and checklist for each procedure. “The real issue is that we still have children that are dying related to sedation, and it’s because people aren’t following recommended guidelines and lack the skills to rescue the child when they get into trouble, and that’s always the problem,” Dr Coté told Medscape Medical News. “Whoever’s going to give a drug that can sedate them deeply needs to have the skills [to rescue the child]. We added specific wording that they had to be able to provide bag-mask ventilation to unobstruct an obstructed airway, to perform [cardiopulmonary resuscitation], and for deep sedation, they had to have the skills to also intubate.”
Pediatric Sedation Research Consortium
Dr Coté said there are many different sedation services: some that are run by emergency physicians, some that are run by pediatric intensivists, and some that are run by anesthesiologists. The Pediatric Sedation Research Consortium is a group of 48 different hospitals that has collected more than 300,000 pediatric procedural sedation encounters. The group “tracks all the different ways where the system might have broken down to cause an event to occur. They’re highly motivated people and they’ve done a spectacular job,” Dr Coté explained.
Family Education Needed
The other thing that does not get talked about adequately is that parents are not necessarily informed about what risks to which their child might be exposed and that they need to be educated to ask the right questions of the person who will be sedating their child: What are your skills? What is your training? What are you going to do to take good care of my baby today? “That’s a very important message that needs to get out there, and that applies to every child that’s being sedated for anything,” Dr Coté said.