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Procedural sedation

Copyright © 2010 Society of Hospital Medicine

Introduction

Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Knowledge

Pediatric hospitalists should be able to:

  • Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.

  • List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.

  • Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.

  • Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).

  • Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.

  • Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.

  • Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.

  • Describe how age, disease process, and anatomy may increase the risk of sedation complications.

  • Discuss the proper level of monitoring personnel necessary to maximize safety.

  • Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.

Skills

Pediatric hospitalists should be able to:

  • Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.

  • Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.

  • Correctly obtain informed consent from the family/caregiver.

  • Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.

  • Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.

  • Identify complications and respond with appropriate actions.

  • Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.

  • Order appropriate monitoring and correctly interpret monitor data.

  • Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.

Attitudes

Pediatric hospitalists should be able to:

  • Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.

  • Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.

  • Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.

  • Work with hospital staff and subspecialists to develop and implement management strategies for sedation.

  • Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.

  • Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.

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