Updated guidelines focus on monitoring pediatrics
Recommendations address before, after sedation
Updated guidelines for all medical and dental practitioners regarding the monitoring and management of pediatric patients during and after sedation have been developed jointly by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.
"This document goes into greater detail about the responsibilities of the person administering the sedatives and monitoring the patient as well as the responsibilities of the physician/dentist overseeing that person," says Randall M. Clark, MD, chair of the American Society of Anesthesiologists' (ASA) Committee on Pediatric Anesthesia.
The significance of the document is that it specifically recognizes that pediatric patients frequently need a deeper level of sedation to accomplish a procedure than an adult would need for a similar procedure, he says. "The practitioner must recognize that this puts the pediatric patient at greater risk than an adult in a comparable situation," he says. This document also discusses the concept that a greater depth of sedation than intended can frequently occur "and therefore the practitioner must be prepared and qualified to 'rescue' the patient from that deeper level."
Speaking from his personal viewpoint, Clark sees a troubling trend developing in pediatric outpatient surgery. Traditionally, pediatric anesthesiologists were asked, "Do you think we can take care of this child at the outpatient surgery center [OSC]?" "That, I think, is the proper question," he says. "It puts the onus on the caregivers to say, 'Have we met all of the tests necessary to take this child out of a care setting with significant backup — like a hospital — and put them in a setting with fewer safeguards?'"
Clark says the question now seems to be, "Why can't we do this child in an OSC?" "While the change is subtle, in this second scenario some children that are not appropriate for care in an OSC will slip through because no one spoke up ahead of time," he says. "This puts some of these pediatric patients at greater risk, in my personal opinion."
Take these steps to avoid trouble
To avoid treating a patient beyond the capabilities of your program, the guidelines recommend the following1:
• Appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure.
Health care providers should find out what a child has eaten or drank in the past 24 hours and identify any medical conditions or treatments that could complicate sedation, the guidelines say.2 For instance, many children take herbal treatments such as St. John's wort or kava that can prolong the effects of anesthesia or deepen the level of sedation, according to anesthesia experts.2
• Age- and size-appropriate equipment for airway management and venous access, plus appropriate medications and reversal agents.
All programs administering pediatric sedation should have crash carts that are appropriate for the age of the patient, monitoring devices that are updated, and other equipment such as face masks that are sized for children, intravenous lines, and breathing tubes, according to the guidelines.2 Also, programs need policies that are well established for contacting backup emergency services, the guidelines say.2
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, says, "What I advocate is always predict the most extreme situation and make sure you can handle that situation. It will happen."
• Appropriate physiologic monitoring during and after the procedure. A properly equipped and staffed recovery area, recovery to pre-sedation level of consciousness before discharge from medical supervision, and appropriate discharge instructions.
When the pediatric patient has recovered from anesthesia, parents should receive an emergency contact number, information about potential side effects, and information about how long they should carefully monitor their children, the guidelines say.2 Parents also should be told that young children traveling home in car seats could stop breathing if they slump over while they are taking naps, the guidelines say.2
This danger is of special concern because car seats often lay infants somewhat on their backs and typically seat them backward, says Melissa Ehlers, MD, director of pediatric anesthesia at Albany (NY) Medical Center. "If you're alone in the car, you can't see what's happening," she says. Ehlers recommends that the parent has a second adult in the car to ride beside the infant.
Obviously, the issue of monitoring pediatric patients before and after sedation is a significant one for outpatient surgery providers, Kain says. "It is the biggest issue," he says. Always be prepared by considering the pharmacodynamics of medications such as chlorohydrate which can be long-lasting, and by ensuring that your discharge criteria are met. "If you've finished the procedure, that's nice, but you can't send them home until pharmacodynamically, this patient is ready to go," Kain says.
References
- New Guidelines Issued for Sedation of Children. Chicago Tribune. Dec. 4, 2006. Web: www.redorbit.com.
- American Academy of Pedatrics. New Guidelines for Sedation of Pediatric Patients Reinforce Safe and Proven Standards for All Medical Care Providers. Chicago; 2006. Web: www.aap.org/advocacy/releases/dec06sedation.htm.
Source/Resource
For more information on the guidelines for monitoring pediatric anesthesia patients, contact:
- Randall M. Clark, MD, 1601 E. 19th Ave., Suite 5300, Denver, CO 80218. Phone: (303) 278-4350. Chair of ASA's Committee on Pediatric Anesthesia.
The guidelines were published in the December 2006 issue of Pediatrics. They are available at pediatrics.aappublications.org. Click on "Past Issues" to access that issue, then click on "Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update."
Updated guidelines for all medical and dental practitioners regarding the monitoring and management of pediatric patients during and after sedation have been developed jointly by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content