American Academy of Pediatrics - Pediatric Sedation Guidelines
American Academy of Pediatrics
Management of Pediatric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures
Pediatrics 143(6) June 2019
"Procedural sedation for pediatric patients has serious associated risks...the presence of an individual with the skills needed to rescue a patient from an adverse response are critical...Children younger than 6 years (particularly those younger than 6 months) may be at greatest risk of an adverse event." (p.2)
"The most common serious complications of sedation involve compromise of the airway or depressed respirations resulting in airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea. Hypotension and cardiopulmonary arrest may occur, usually from the inadequate recognition and treatment of respiratory compromise." (p.4)
"The availability of EMS [Emergency Medical Services] does not replace the practitioner's responsibility to provide initial rescue for life-threatening complications. An emergency cart must be immediately accessible ...contain the necessary equipment (oral and nasal airways, bag-valve-mask devices, LMAs or other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters, ect.) to resuscitate a nonbreathing and unconscious child...Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters with size-appropriate probes, end-tidal carbon dioxide monitors, and defibrillators with size-appropriate patches/paddles..." (p.5)
"...fasting
before elective sedation generally follows the same guidelines as for elective general anesthesia..." (p.5)
"Children undergoing sedation for elective procedures generally should follow the same fasting guidelines as those for general anesthesia." (p.6)
"Prescription medications intended to accomplish procedural sedation must not be administered without the safety net of direct supervision by trained medical/dental personnel. The administration of sedating medications at home poses and unacceptable risk, particularly for infants and preschool-aged children traveling in car safety seats because of deaths as a result of this practice have been reported." (p.8)
"Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to rescue a child with apnea, laryngospasm, and/or airway obstruction, including the ability to open the airway, suction secretions, provide CPAP, and perform successful bag-valve-mask ventilation should the child progress to a level of deep sedation." (p.9)
"The use of moderate sedation shall include the provisions of a person, in addition to the practitioner, whose responsibility is to monitor...and assist in any supportive or resuscitation measures, if required...This individual should be trained in and capable of providing advanced airway skills (eg.
PALS)." (p.9)
Deep Sedation and General Anesthesia
[in Dental Office]
"During deep sedation and/or general anesthesia of a pediatric patient in a dental facility, there must be at least 2 individuals present with the patient throughout the procedure. These two individuals
must have appropriate training and up-to-date certification (including)...PALS
or Advanced Pediatric Life Support. One of these 2 must be an independent observer
who is independent of performing or assisting with the dental procedure. This individual's sole responsibility is to administer drugs and constantly observe the patient's vital signs, depth of sedation, airway patency and adequacy of ventilation. The independent observer must...be capable of managing any airway, ventilatory, or cardiovascular emergency event resulting from deep sedation and/or general anesthesia...trained and skilled to establish intravenous access and draw up and administer rescue medications...rescue a nonbreathing child; a child with airway obstruction; or a child with hypotension, anaphylaxis, or cardiopulmonary arrest, including the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, or laryngeal mask airway), and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation...must be one of the following: a physician anesthesiologist, a certified registered nurse anesthetist, a second oral surgeon, or a dentist anesthesiologist." (p.10-11)
"The second individual, who is the practitioner in the dental facility performing the procedure [operating dentist], must be trained in PALS (or APLS) and capable of providing skilled assistance to the independent observer with the rescue of a child experiencing any of the adverse events described above." (p.11)
"In a hospital or surgicenter setting, at least 2 individuals must be present with the patient throughout the procedure with skills in patient rescue and up-to-date PALS (or APLS) certification as delineated above." (p.11)
"In addition to the equipment needed for moderate sedation, an ECG monitor and a defibrillator
for use in pediatric patients should be readily available." (p.11)
Monitoring
(p.12)
Moderate Sedation
Pulse Oximetry
ECG Recommended
Heart Rate
Blood Pressure
Respiration
Capnography recommended
Deep Sedation
[In addition to Moderate Sedation Requirements]
ECG required
Capnography required (as feasible)
"The use of expired carbon dioxide monitoring devices is now required for almost all deeply sedated children (with rare exceptions)" (p.13)
