Is your staff prepared to monitor a sedated child?
The biggest challenge for outpatient centers is having the anesthesiologists, anesthetists, sedation nurses, circulating nurses, and post-anesthesia care nurses who have the knowledge and experience to care for sedated pediatric patients, says Randall M. Clark, MD, chair of the American Society of Anesthesiologists' (ASA's) Committee on Pediatric Anesthesia.
"Beyond just the knowledge base, there is also an art to caring for pediatric patients that only comes from frequent and regular exposure to this population," he says. "These staff must have a comfort level that is appropriate to the level of sedation that is needed to accomplish the procedure."
Concerns from Randall and other pediatric anesthesia experts have led to the development of updated guidelines for all medical and dental practitioners regarding the monitoring and management of pediatric patients during and after sedation from the American Academy of Pediatrics and the American Academy of Pediatric Dentistry. The guidelines advise careful pre-sedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications. Also, no sedating medications should be administered without the safety net of medical supervision, they say.
Providers should have a sufficient number of staff to carry out the procedure and monitor the patient during and after the procedure, the guidelines say. In many procedures, the same health care provider is doing the procedure and providing the sedation, says Zeev Kain, MD, chair of the ASA's Subcommittee on Pediatric Anesthesia and professor of anesthesiology, pediatrics, and child psychiatry at Yale University School of Medicine in New Haven, CT. "That should not be the same person, and you should make sure they're not the same person," he says. "If you're doing a colonoscopy, you can't be focused on managing the airway."
If anything more than mild sedation is used, the new guidelines advise that a second professional trained in pediatric life support be in the room to monitor the patient's vital signs and assist in "any supportive or resuscitation measures if required."
Also, providers must have a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation as well as an appreciation for drug interactions, the guidelines say. They must have appropriate training and skills in airway management to allow rescue of the patient should there be an adverse response, they say.
The guidelines say that "sedation and anesthesia in a nonhospital environment (private physician or dental office or freestanding imaging facility) may be associated with an increased incidence of 'failure to rescue' the patient. . . . Rescue therapies require specific training and skills."
When a medication such as propofol is used on a child who continues to scream and move around, a provider may push the medication to a level of moderate sedation, Kain says. If the child still is agitated to the point that the procedure can't be conducted, a provider may push the sedation even more to the point of general anesthesia, he says. "The drug is capable of providing all these various aspects of the sedation, so you really have to appreciate that when you use a drug such as propofol." .
With medications such as phenobarbital, you have to be sure you can resuscitate the patients, intubate them, perform mask ventilation, and provide general anesthesia, Kain says. "You don't know when the patient is going to convert from talking to you to going apnea," he says. "That's the message that needs to be sent out there."
The biggest challenge for outpatient centers is having the anesthesiologists, anesthetists, sedation nurses, circulating nurses, and post-anesthesia care nurses who have the knowledge and experience to care for sedated pediatric patients, says Randall M. Clark, MD, chair of the American Society of Anesthesiologists' (ASA's) Committee on Pediatric Anesthesia.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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