Are you performing pediatric conscious sedation safely? Careful monitoring, assessment is key
When a child comes to your ED and needs to undergo a lengthy or painful procedure, such as a closed reduction of fracture or lumbar puncture, conscious sedation can reduce pain and anxiety. "A two-year old won't be able to lay still while you're sewing up a complicated laceration for over an hour," says Steven Weber, RN, CEN, CFRN, MICN, manager of the children's ED at WakeMed in Raleigh, NC. "Conscious sedation also helps to minimize pain."
Under conscious sedation, children have a depressed level of consciousness but retain the ability to maintain an airway, protective reflexes, and respond to physical stimulation or verbal commands. Emergency nurses are being asked to manage the care of conscious sedation patients more often, because of the increase in diagnostic and surgical procedures performed in the ED, notes Weber.
Conscious sedation is one way to ensure that children's pain is not overlooked. "Pain relief and management, including procedural sedation and analgesia, should be at the core of both the nursing and medical professions and must be considered in every child we treat," says Alfred Sacchetti, MD, FACEP, an emergency physician at Our Lady of Lourdes Medical Center in Camden, NJ.
Medications used in the procedure have an amnesiac effect. "When they pop the bone back in place, the child may yell, but they never remember it. That advantage alone makes the extra time you spend well worth it," says Lynn Daum, RN, an emergency nurse at Children's Hospital Medical Center in Cincinnati, OH. "If you talk to any older person who had a broken bone as a child, they remember how horrible it was when they set it. With conscious sedation, the last thing they remember is their mom giving them a kiss."
If conscious sedation is used, children will be less likely to associate trauma with health care personnel, says Scott DeBoer, RN, MSN, CCRN, a flight nurse at University of Chicago (IL) Hospitals. "When children are sedated and pain-free for procedures, it helps with repeat visits as the child does not become fearful at the sight of anything or anyone associated with an ED," he explains.
Nurses can ensure parents that everything possible was done to alleviate their child's discomfort. "If a nurse can take a parent aside and tell them, `I gave your child some medicine so that she will be asleep, pain free, and shouldn't remember anything,' it makes a difficult situation easier," says DeBoer. Still, the procedure carries some risks that must be considered.
Here are some ways to reduce the risks of conscious sedation:
Record vital signs pre-procedure. At WakeMed's ED, nurses take children's vital signs every five minutes and record them on a presedation worksheet. (See form on page 116.) A score from 1-5 is given, depending on the child's level of alertness. This helps to identify patients at risk for complications, says Weber.
Never exceed the maximum dose allowed. At Children's Hospital, the conscious sedation protocol stipulates maximum safe dosages within an hour's time frame. "It has to be an hour after that last dose before we can give them more," notes Daum. "When we go in to do the sedations, we only take the maximum dose, so in case the physician says, `Just go ahead and give them 10 mg more,' we can say, 'Sorry, we didn't bring it in.'"
Make sure reversal agents are on hand. If complications arise, the procedure may need to be reversed immediately, so necessary equipment and reversal agents should be assembled in advance. "It is not necessary to have the medications physically drawn up into syringes, nor is it cost-effective to do so," notes DeBoer. "However, it makes life much less stressful to have calculated the dose for both mg and ccs that should be given in an emergency."
Cincinnati Children's hangs 8 ´ 10 laminated cards in the medication rooms that list correct dosages for reversal drugs. "The math is already done for us, so we won't have to calculate dosages if there is a problem," says Daum. Nurses should also be aware of the possible side effects of reversal agents, she stresses.
Be prepared for agitated children. Children who start out extremely upset will probably still be agitated after the sedation wears off, Daum explains. "Many times, if a child is very upset and out of control going into sedation, after you sedate them, it doesn't really change things," she says. (See related story on distraction techniques, page 117.)
After the sedation wore off, one six-year-old patient began flailing her fractured arm around, trying to remove the bandaging. "She was totally out of control and was that way before we gave the medication," says Daum. "When you're in that situation, all you can do is protect the patient from themselves. It eventually will wear off, but you have to weather the storm." If the child is up on a stretcher, consider doing seizure precautions, she recommends.
If a child is extremely agitated, the parents may become alarmed. "It can be very scary for the family if they've never seen their child out of control like this before, so they may need psychosocial support," says Daum. (See story on giving discharge instructions, above.)
Do careful checking, even if you don't observe the entire procedure. Boston Children's protocol calls for two people to be in the room at all times-one to perform the procedure and another strictly for observation. If the ED is very busy, the observer may not always be a nurse. "It's not always possible for a nurse to provide one-to-one monitoring throughout an entire procedure," says Francis Damian, MS, RN, the ED's director of nursing and patient services. "But, if you have a clinical assistant who is properly trained, and the equipment is all set up in the event the child has a problem, that is acceptable as long as the nurse makes frequent checks every five minutes."
Make monitoring a priority. At Children's Hospital in Cincinnati, the nurse's role is strictly to monitor the patient, without assisting in any way. "If the orthopedic surgeon needs somebody to hold an extremity, they need to get an ED tech to help. Nursing function is strictly to monitor the patient, because it's so vital," Daum explains. Nursing notes are carefully recorded throughout the procedure.
After the procedure, careful monitoring is still vital. "The recovery begins right after the procedure," notes Damian. "The main things you need to look for are stable vital signs, adequate hydration, and that the patient responds to his or her name."
Develop a policy. Specific guidelines for the procedure can help reduce risks. Wake Med's policy includes general guidelines, instructions for before, during, and after the procedure, and discharge criteria. (See a copy of the hospital's policy, page 118-119.) "The written policy allows the staff to ensure consistent practice," says Weber.
Make sure policy is consistent. Conscious sedation is a hot topic with Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) surveyors, who want to see consistency hospital-wide. "What you do in the ED should be the same level of care given elsewhere in the hospital," says Mary Anderson, RN, BSN, nurse manager of emergency services at the Medical University of South Carolina in Charleston. "So, if they have an anesthesiologist present in the ICU, you should have one present in the ED."
Be familiar with side effects. "Know the response to different medications and what their side effects are," advises Sacchetti. "There is a story of a nurse who called a code when a child was given ketamine because she was not expecting the normal dissociative reaction that kids get with this drug."
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