Sedation in under 19s: using sedation for diagnostic and therapeutic procedures

Ensure that trained healthcare professionals (see section 1.4) carry out pre‑sedation assessments and document the results in the healthcare record.

Establish suitability for sedation by assessing all of the following:

• current medical condition and any surgical problems

• weight (growth assessment)

• past medical problems (including any associated with previous sedation or anaesthesia)

• current and previous medication (including any allergies)

• physical status (including the airway)

• psychological and developmental status.

Seek advice from a specialist before delivering sedation:

• if there is concern about a potential airway or breathing problem

• if the child or young person is assessed as American Society of Anesthesiologists (ASA) grade 3 or greater (the ASA physical status classification system [grades 1 to 6] is a system to classify and grade a patient's physical status before anaesthesia).

• for infants, including neonates.

Ensure that both the following will be available during sedation:

• a healthcare professional and assistant trained (see section 1.4) in delivering and monitoring sedation in children and young people

• immediate access to resuscitation and monitoring equipment (see section 1.5).

Choose the most suitable sedation technique based on all the following factors:

• what the procedure involves

• target level of sedation

• contraindications

• side effects

• patient (or parent or carer) preference.

To enable the child or young person and their parents or carers to make an informed decision, offer them verbal and written information on all of the following:

• proposed sedation technique

• the alternatives to sedation

• associated risks and benefits.

Obtain and document informed consent for sedation.

Before starting sedation, confirm and record the time of last food and fluid intake in the healthcare record.

Fasting is not needed for:

• minimal sedation

• sedation with nitrous oxide (in oxygen)

• moderate sedation during which the child or young person will maintain verbal contact with the healthcare professional.

Refer to professional guidance for fasting for elective procedures using any sedation technique other than those in recommendation 1.2.2 (that is, for deep sedation and moderate sedation during which the child or young person might not maintain verbal contact with the healthcare professional).

Note that in 2018 a change to the 2-4-6 fasting rule (fasting times should be as for general anaesthesia: 2 hours for clear fluids; 4 hours for breast milk; 6 hours for solids) was endorsed by the relevant professional bodies, supporting a reduction in the fasting period for clear fluids to 1 hour (see for example the Association of Paediatric Anaesthetists of Great Britain and Ireland consensus statement on clear fluids fasting for elective pediatric general anesthesia).

For an emergency procedure in a child or young person who has not fasted, base the decision to proceed with sedation on the urgency of the procedure and the target depth of sedation.

Ensure that the child or young person is prepared psychologically for sedation by offering information about:

• the procedure

• what the child or young person should do and what the healthcare professional will do

• the sensations associated with the procedure (for example, a sharp scratch or numbness)

• how to cope with the procedure.

Ensure that the information is appropriate for the developmental stage of the child or young person and check that the child or young person has understood the information.

Offer parents and carers the opportunity to be present during sedation if appropriate. If a parent or carer decides to be present, offer them advice about their role during the procedure.

For an elective procedure, consider referring to a mental health specialist children or young people who are severely anxious or who have a learning disability.

Healthcare professionals delivering sedation should have knowledge and understanding of and competency in:

• sedation drug pharmacology and applied physiology

• assessment of children and young people

• monitoring

• recovery care

• complications and their immediate management, including paediatric life support.

Healthcare professionals delivering sedation should have practical experience of:

• effectively delivering the chosen sedation technique and managing complications

• observing clinical signs (for example, airway patency, breathing rate and depth, pulse, pallor and cyanosis, and depth of sedation)

• using monitoring equipment.

Ensure that all members of the sedation team have basic life support skills for minimal, moderate and deep sedation. At least 1 team member should have intermediate life support skills for moderate sedation and advanced life support skills for deep sedation. Minimal sedation includes sedation with nitrous oxide alone (in oxygen) and conscious sedation in dentistry.

Ensure that a healthcare professional trained in delivering anaesthetic agents is available to administer:

• sevoflurane

• propofol

• opioids combined with ketamine.

Healthcare professionals delivering sedation should have documented up‑to‑date evidence of competency including:

• satisfactory completion of a theoretical training course covering the principles of sedation practice

• a comprehensive record of practical experience of sedation techniques, including details of:

  • sedation in children and young people performed under supervision

  • successful completion of work‑based assessments.

Each healthcare professional and their team delivering sedation should ensure they update their knowledge and skills through programmes designed for continuing professional development.

Consider referring to an anaesthesia specialist a child or young person who is not able to tolerate the procedure under sedation.

Ensure that all of the following criteria are met before the child or young person is discharged:

• vital signs (usually body temperature, heart rate, blood pressure and respiratory rate) have returned to normal levels

• the child or young person is awake (or returned to baseline level of consciousness) and there is no risk of further reduced level of consciousness

• nausea, vomiting and pain have been adequately managed.

Do not routinely use ketamine or opioids for painless imaging procedures.

For children and young people who are unable to tolerate a painless procedure (for example, during diagnostic imaging) consider one of the following drugs, which have a wide margin of safety:

• chloral hydrate for children under 15 kg

• midazolam.

For children and young people who are unable to tolerate painless imaging with the above drugs, consider one of the following, used in specialist techniques, which have a narrow margin of safety (see section 1.4):

• propofol

• sevoflurane.

For moderate sedation excluding with nitrous oxide alone (in oxygen) continuously monitor, interpret and respond to changes in all of the following:

• depth of sedation

• respiration

• oxygen saturation

• heart rate

• pain

• coping

• distress.

For deep sedation continuously monitor, interpret and respond to changes in all of the following:

• depth of sedation

• respiration

• oxygen saturation

• heart rate

• three‑lead electrocardiogram

• pain

• coping

• distress.
  
  Also continuously monitor, interpret and respond to the following, provided that monitoring does not cause the patient to awaken and so prevent completion of the procedure:
  

• end tidal CO₂ (capnography)

• blood pressure (monitor every 5 minutes).
  
  The healthcare professional administering sedation should be involved only in continuously monitoring, interpreting and responding to all of the above.

Ensure that data from continuous monitoring during sedation are clearly documented in the healthcare record.

After the procedure, continue monitoring until the child or young person:

• has a patent airway

• shows protective airway and breathing reflexes

• is haemodynamically stable

• is easily roused.

For children and young people undergoing a painful procedure (for example suture laceration or orthopaedic manipulation), when the target level of sedation is minimal or moderate, consider:

• nitrous oxide (in oxygen) and/or

• midazolam (oral or intranasal).

For all children and young people undergoing a painful procedure, consider using a local anaesthetic, as well as a sedative.

For children and young people undergoing a painful procedure (for example, suture laceration or orthopaedic manipulation) in whom nitrous oxide (in oxygen) and/or midazolam (oral or intranasal) are unsuitable consider:

• ketamine (intravenous or intramuscular), or

• intravenous midazolam with or without fentanyl (to achieve moderate sedation).

For children and young people undergoing a painful procedure (for example suture laceration or orthopaedic manipulation) in whom ketamine (intravenous or intramuscular) or intravenous midazolam with or without fentanyl (to achieve moderate sedation) are unsuitable, consider a specialist sedation technique such as propofol with or without fentanyl.

For a child or young person who cannot tolerate a dental procedure with local anaesthesia alone, to achieve conscious sedation consider:

• nitrous oxide (in oxygen) or

• midazolam.
  
  If these sedation techniques are not suitable or sufficient, refer to a specialist team for an alternative sedation technique.

Consider intravenous midazolam to achieve minimal or moderate sedation for upper gastrointestinal endoscopy.

Consider fentanyl (or equivalent opioid) in combination with intravenous midazolam to achieve moderate sedation for lower gastrointestinal endoscopy.