sedation of paediatric patients and young people clinical ... · summary no 30 1-16 years and bmi

Sedation of Paediatric Patients and Young People Clinical Guideline

V2.0

April 2019

Sedation of Paediatric Patients and Young People Clinical Guideline V2.0 of 29

Table of Contents

Sedation of Paediatric Patients and Young People Clinical Guideline ................. 1

V2.0 ............................................................................................................................. 1

Summary .................................................................................................................... 3

1. Introduction ........................................................................................................... 4

2. Purpose of this Policy/Procedure ........................................................................ 4

Aims of sedation .......................................................................................... 4 2.1.

3. Scope ..................................................................................................................... 5

4. Definitions / Glossary ........................................................................................... 5

5. Ownership and Responsibilities .......................................................................... 6

Role of Consultants ...................................................................................... 6 5.1.

Groups and Committees ............................................................................ 6

Role of Managers ......................................................................................... 7 5.3.

Role of Individual Staff ................................................................................. 7 5.4.

6. Standards and Practice ........................................................................................ 8

Assessment of Suitability for Sedation ......................................................... 8 6.1.

Contra-indications to sedation ...................................................................... 9 6.2.

Fasting ......................................................................................................... 9 6.3.

Analgesia and Psychological Preparation .................................................. 10 6.4.

Consent...................................................................................................... 10 6.5.

Personnel, equipment and monitoring ........................................................ 11 6.6.

Framework for the Conduct of Sedation ................................................. 13 6.7.

Drug Information ........................................................................................ 14 6.8.

Discharge criteria ....................................................................................... 15 6.9.

Advice Sheet following Paediatric Sedation ............................................... 16 6.10.

7. Dissemination and Implementation ................................................................... 17

8. Monitoring compliance and effectiveness ........................................................ 19

9. Updating and Review .......................................................................................... 20

10. Equality and Diversity .................................................................................. 20

Appendix 1. Governance Information .................................................................... 21

Appendix 2. Initial Equality Impact Assessment Form ........................................ 24

Appendix 3. Advice Sheet following Paediatric Sedation .................................... 27

Appendix 4. AAGBI Anaesthetic Machine Check ................................................. 28


Summary

<1 year or <10 kg or BMI >30

1-16 years and BMI <30 >16 years

Contraindications to sedation? See section 7.2

Is analgesia optimized?

See RCHT Paediatric Analgesia Guideline

Depth of sedation required?

See section 7.1

MILD sedation MODERATE sedation

DEEP Sedation MANDATES anaesthetic

involvement

Painful Painless Painful Painless

Inhaled N20/O2

(50:50)

Chloral

hydrate PO

Midazolam PO and analgesia

or

N2O (70:30)

Midazolam PO or

Chloral hydrate PO

Involve anaesthetist

or

paediatrician

Treat as adult. See RCHT Adult

Sedation Guideline

NO

YES

Are you trained? Undergo appropriate

training prior to sedating paediatric

patients YES

NO

YES

https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Paediatrics/AnalgesiaGuidelinesPaediatric.pdf

https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Anaesthetics/SafeSedationPracticeAdultPatients.pdf



1. Introduction

This version supersedes any previous versions of this document. 1.1.

Sedation is frequently required for children or young people needing 1.2.procedures that are painful or frightening. In February 2010 The National Institute for Clinical Excellence (NICE) published its first national guideline aiming to improve NHS care and safety standards within England and Wales for sedating infants, children and teenagers. The NICE guideline has since been supplemented with an Evidence Update in May 2012. This guideline, based on the NICE guidance, provides a framework for the sedation of children and young people within the Royal Cornwall Hospital Trust (RCHT) in the emergency department, paediatric wards and radiology.

This document is to be used in conjunction with: 1.3.

RCHT Paediatric Analgesia Guidelines

RCHT Entonox with Children – Clinical Guidelines for Use

Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in. DPA18 is applicable to all staff; this includes those working as contractors and providers of services. For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team [email protected]

2. Purpose of this Policy/Procedure

Aims of sedation 2.1.

Aims of sedation during diagnostic or therapeutic procedures include reducing fear and anxiety, augmenting pain control and minimising movement

2.1.1. Intended benefits of sedation

Tolerance of an otherwise distressing or painful procedure without the potential complications and logistical difficulties of organising the same procedure under general anaesthetic.

Provide a framework to be used by non-anaesthetists for the conduct of 2.2.sedation in paediatric patients and young people that can be applied in the emergency department and paediatric wards.


https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Paediatrics/EntonoxInAClinicalSettingGuidelinesForUseOf.pdf

mailto:[email protected]


Standardises aspects of sedation practice such as staffing, sedative 2.3.agents, fasting, monitoring, training and record keeping with the primary aim of ensuring the safety of children requiring sedation.

Supports medical and nursing staff in ensuring the safety of children 2.4.requiring sedation.

3. Scope

This policy applies to all non-anaesthetist healthcare practitioners who are 3.1.responsible for prescribing and administering sedation to children or young people within the emergency department, paediatric wards and radiology i.e. doctors, nurses and practitioners.

This policy excludes trained anaesthetists who are competency assessed 3.2.in paediatric sedation, including deep sedation.

This policy does not cover sedation of neonates

3.3.1. In addition any child under the age of one year should only be sedated with the involvement of a consultant paediatrician or anaesthetist

This policy does not cover the conduct of deep sedation. Patients requiring deep sedation should be referred to the anaesthetic department.

4. Definitions / Glossary

Infant: children from birth to one year of age 4.1.

Neonate: infants aged up to one month 4.2.

Depth Of Sedation 4.3.

The definitions of minimal, moderate, conscious and deep sedation used in this guideline are based on those of the American Society of Anesthesiologists (ASA):

Minimal sedation: A drug-induced state during which patients are awake and calm, and respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation: Drug-induced depression of consciousness during which patients are sleepy but respond purposefully to verbal commands (also known as conscious sedation) or light tactile stimulation (reflex withdrawal from a painful stimulus is not a purposeful response). No interventions are required to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.


Deep sedation: Drug-induced depression of consciousness during which patients are asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function independently may be impaired. Patients may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anaesthesia: is a drug-induced loss of consciousness during which patients are not rousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Abbreviations

AAGBI Association of Anaesthetists of Great Britain and Ireland ASA American Society of Anaesthesiologists CO2 Carbon dioxide ESR Electronic Staff Record N20 Nitrous oxide NICE National Institute for Health and Care Excellence RCHT Royal Cornwall Hospital Trust SpO2 Oxygen saturations as measured by a pulse oximeter

5. Ownership and Responsibilities

Role of Consultants 5.1.

The Consultants and Ward Managers responsible for each of the areas that this guideline applies to (Paediatrics, Emergency Department and Radiology) retain overall accountability to ensure that the medical and nursing staff working within these areas are aware of the presence of this guideline and are using it appropriately:

Sian Ireland (Consultant, Emergency Department) Chris Williams (Consultant, Paediatrics) Katie Giles (Consultant, Radiology)

Groups and Committees

5.2.1. Sedation Working Party

o Presentation of audit findings and untoward incidents at the annual Paediatric Intensive Care Roadshow

o Triennial document review to ensure compliance with national guidelines and best practice

o Investigation of any untoward incident occurring during the sedation of paediatric patients or young people at RCHT

5.2.2. Pharmacy

5.2.3. Paediatric Critical Care Group


5.2.4. Anaesthesia Paediatric Interest Group

To facilitate, when required, the provision of airway training for non-anaesthetists during surgical lists when not teaching trainee anaesthetists

5.2.5. Paediatric Acute Pain Team

5.2.6. Paediatric Group

Role of Managers 5.3.

Line managers are responsible for ensuring that medical and nursing staff working within the areas listed above have access to the correct training, equipment and facilities to enable appropriate use of this guideline.

Role of Individual Staff 5.4.

All staff, including temporary staff, working in the Trust must adhere to the following principles before assisting or undertaking sedation of a paediatric patient or young person:

To work within their sphere of competency/scope of practice

Identify their training requirements with their line manager at the time of appraisal

Remain vigilant to discrepancies in practice and challenge appropriately

All non-anaesthetic staff involved in sedating children within the emergency department, paediatric wards and radiology must ensure they comply with the following:

Ensure valid consent has been obtained. See section 7.5

Use appropriate personnel, equipment and monitoring as detailed in section 7.6

Complete trust sedation record

Follow the Framework for Practice of Sedation flow chart detailed in section 7.7

All drugs must be prescribed on EPMA (or a drug chart if EPMA not available)

Ensure discharge criteria are met and supply parents/ guardians/ carers with post sedation advice sheet. See section 7.9

On completion of the sedation, ensure the trust sedation record is photocopied and sent to the paediatric sedation lead

Ensure that all untoward incidents are reported via the RCHT Incident Report Form (Datix)

http://datixrcht.cornwall.nhs.uk/Live/


6. Standards and Practice

Assessment of Suitability for Sedation 6.1.

Sedation documentation including the pre assessment, safety checks and observation chart can be found later in this in section of the document

Confirm age and weight: If age < 1 year or weight < 10kg or BMI >30

Involve an anaesthetist or senior paediatrician

Take past medical history/ drug history/ previous anaesthesia and perform appropriate physical examination of the patient. Determine American Society of Anaesthesiologists (ASA) grade and consider contra-indications to sedation.

If ASA grade 3 or above or any contra-indications present ensure anaesthetic involvement

Confirm fasting status (see section 7.3 for further advice)

Assess the patient’s airway If there are any concerning airway features involve an anaesthetist

Assess type of sedation required:

Minimal sedation: A drug-induced state during which patients are awake and calm,

and respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation: Drug-induced depression of consciousness during which

patients are sleepy but respond purposefully to verbal commands (also known as conscious sedation) or light tactile stimulation (reflex withdrawal from a painful stimulus is not a purposeful response). No interventions are required to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep sedation: Drug-induced depression of consciousness during which patients are

asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function independently may be impaired. Patients may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

If deep sedation required involve an anaesthetist

Following confirmation and documentation of the above follow guidance in ‘Framework for Conduct of Paediatric Sedation” found in section 7.7

ASA Grading System 1. A normal healthy patient 2. A patient with mild systemic disease 3. A patient with severe systemic disease. 4. A patient with severe systemic disease that is a constant threat to life 5. A moribund patient who is not expected to survive without the operation

http://en.wikipedia.org/wiki/Disease


Contra-indications to sedation 6.2.

MRI and other longer radiological procedures The unique challenges faced when caring for patients in MRI and the training required to deliver this mean that that sedation in this environment at RCHT is discouraged. Children at RCHT should either be completely awake or have a general anaesthetic as sedation for these long studies may pose a risk to the child. The radiology department have agreed to give a “trial without GA” appointments first to see what the child can manage. If sedation in MRI or for another longer radiological procedure is being contemplated it should be discussed with the trust Sedation Lead or the trust Paediatric Anaesthetic lead before proceeding. The following comorbidities mandate discussion with an anaesthetist or senior paediatrician prior to sedation:

Abnormal airway – craniofacial anomalies

Raised intra cranial pressure or depressed conscious level

History of sleep apnoea

Major organ dysfunction including congenital cardiac anomalies

Gastro oesophageal reflux disease

Neuromuscular disorders

Bowel obstruction

Ongoing upper or lower respiratory tract infection

Polytrauma patients

Refusal by parent/ guardian/ child

Corrected age < 1 year because of severe prematurity Specific contra-indications to nitrous oxide sedation:

Pneumocephalus

Pneumothorax

Pneumopericardium

Pulmonary bullae

Lobar emphysema

Severe pulmonary hypertension

Bowel obstruction

Pneumoperitoneum

Pregnancy

Fasting 6.3.

Prior to 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 (N20) in oxygen Apply the below fasting rules for elective procedures using moderate sedation:


For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.

Analgesia and Psychological Preparation 6.4.

Ensure analgesia is adequate for the procedure to be undertaken by using:

o RCHT Paediatric Analgesia Guidelines

o Topical/local anaesthesia

Ensure that the child or young person is prepared psychologically for sedation by offering information about what the procedure involves, the role of the health care professionals and any expected sensations associated with the procedure

Ensure that the information uses language appropriate for the developmental stage of the child or young person and check they have understood

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

Consider contacting Play Specialist for expert help

Consent 6.5.

Offer child/ parents/ carers verbal and written information on the proposed sedation technique, alternatives to sedation and risks and benefits. Informed verbal consent for sedation should be obtained from the parents/carer/child and once delivered the box should be ticked on the pre procedure form to confirm that the procedure has been discussed and verbal consent obtained.

Recommendation is that the following is discussed with the child/ parents/ guardian:

Intended benefits of sedation:

Tolerance of an otherwise distressing or painful procedure without the potential complications and logistical difficulties of organising the same procedure under general anaesthetic.

1 hour for clear fluids

4 hours for breast milk

6 hours for solids and formula milk



Frequently occurring risks:

Failure of procedure due to inadequate sedation and need to progress to general anaesthesia.

Disinhibition or paradoxical excitement.

Post procedure nausea, drowsiness and unsteadiness.

Rare but serious risks:

Respiratory depression requiring intervention (e.g. bag mask valve ventilation)

Vomiting whilst sedated which may lead to aspiration pneumonitis/pneumonia

Personnel, equipment and monitoring 6.6.

Minimal Sedation Moderate Sedation

Deep Sedation

Example procedures

Application of POP to fracture; IV access; Venepuncture;

Cleaning, steri-stripping, gluing lacerations

Suturing under local anaesthetic;

Relocation dislocated phalanx;

Burn dressing change

Fracture manipulation

Personnel required

1. Healthcare professional to perform procedure.

2. Trained healthcare professional to deliver sedation and monitor patient.

1. Healthcare professional to perform procedure

2. Trained doctor to deliver sedation and monitor patient

3. Additional trained nurse or ODP

Refer to anaesthetic department

Paediatric Life Support Qualifications required

All team members must have basic paediatric life support skills

All team members must have basic plus one must have intermediate paediatric life support skills

All must have basic life support skills plus one member must have advanced paediatric life support skills

Monitoring required

Depth of sedation including pain, coping and distress.

Respiratory rate Pulse oximetry

Depth of sedation including pain, coping and distress.

Respiratory rate Pulse oximetry Heart rate



Equipment required

Full paediatric resuscitation equipment must be available.

Full paediatric resuscitation equipment must be available.


It is important to note that the NICE guidance mandates end tidal CO2 monitoring only in patients undergoing Deep Sedation, however thought should be given on how to achieve this quickly when providing Moderate Sedation in the event that over sedation occurs

Resuscitation equipment that must be available for sedation:

Oxygen: reliable source for face mask oxygen and a size appropriate self-inflating positive pressure oxygen delivery system

Head down tipping trolley and suction equipment Appropriately sized oral airways, nasopharyngeal airways, laryngeal mask

airways and sized endotracheal tubes Pulse oximeter/ ECG machine/ NIBP monitor Defibrillator with appropriate paediatric pads Cardiac arrest resuscitation drugs Reversal agents –flumazenil (and naloxone if patient receiving opiates) must

be readily available


Framework for the Conduct of Sedation 6.7.

<1 year or <10 kg or BMI >30

1-16 years and BMI <30 >16 years

Contraindications to sedation? See section 7.2

Is analgesia optimized?

See RCHT Paediatric Analgesia Guideline

Depth of sedation required? See section 7.1

MILD sedation MODERATE sedation

DEEP Sedation MANDATES anaesthetic

involvement

Painful Painless Painful Painless

Inhaled N20/O2

(50:50)

Chloral

hydrate PO

Midazolam PO and analgesia

or

N2O (70:30)

Midazolam PO or

Chloral hydrate PO

Involve anaesthetist

or

paediatrician

Treat as adult. See RCHT Adult

Sedation Guideline

NO

YES

Are you trained? Undergo appropriate

training prior to sedating paediatric

patients YES

NO

YES





Drug Information 6.8.

This aims to provide a brief review of the commonly used sedative drugs (dosing current at time of guideline publication).

Please confirm all drug doses from current edition of BNFc before prescribing

Drug Route Dose Advice for use

Chloral hydrate

Oral/NG 1-11 years 50mg/kg minimal sedation (Max 1g)

100mg/kg moderate sedation (Max 2g)

12-17 years 1-2g

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

Give 45-60 minutes prior to procedure.

Unpleasant taste and can be mixed with blackcurrant etc.

There is NO reversal agent available

Midazolam Buccal product

“Epistatus”

10 mg in 1 mL

Oral or buccal route

Or

Dilute IV preparation of midazolam 1mg in 1mL. For oral administration only

Oral (i.e. swallowed)/NG

0.5mg/kg (Max 20mg) Beware respiratory depression/ hypotension/loss of airway reflexes at high doses.

Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

Can lead to a distressing paradoxical excitement in children

ORALLY give 30-60 minutes before procedure. BUCCALLY give 15 minutes pre-procedure.

No easily available oral preparation. Please use either buccal preparation orally or the IV preparation orally (diluted in apple or orange juice, squash etc.).

Reversal agent is Flumazenil (10 mcg/kg [Max 200 mcg], repeat at 1-minute intervals up to 5 times).

Buccal (Half the dose into each side of the mouth)

1-9 years 200-300mcg/kg (max 5mg) 10-17 years (<70kg) 6-7mg 10-17 years (>70kg) 6-7mg (max.8mg)

Nitrous oxide (up to 70% with oxygen).

Inhalational Self-administration via demand valve OR via anaesthetic machine if trained.

Beware diffusion hypoxia post procedure. Additional oxygen should be given for 5-10 minutes to prevent this.

Colourless, odourless gas with analgesic and anxiolytic effects with rapid onset and offset.

Useful for short painful procedures and very effective in cooperative school aged children.

Delivered as Entonox – 50:50 mix with oxygen (minimal sedation)

Delivered as a 70:30 mix with oxygen (moderate sedation)

During non-anaesthetist led sedation all sedative drugs must be prescribed on EPMA (or a drug chart if EPMA not available)

Nitrous oxide 70:30 mix available in ED via the anaesthetic machine in procedure room. Only to be given if trained and machine check performed by user before use, see AAGBI machine check in Appendix 1

https://bnfc.nice.org.uk/


Discharge criteria 6.9.

Monitoring must continue until the child or young person:

• Maintains their own airway.

• Has full restoration of protective airway and breathing reflexes

• Is haemodynamically stable

• Is easily roused

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

• Return to baseline vital signs

• Return to baseline level of consciousness

• Nausea/vomiting/pain adequately managed

• Responsible parent or guardian available to remain with child for 24 hours

Refer to anaesthetist if child or young person could not tolerate the procedure under sedation.

Provide parents with an advice sheet prior to discharge (see following page, section 7.11)


Advice Sheet following Paediatric Sedation 6.10.

Your child attended the Emergency Department/ Paediatric Ward/ Endoscopy/ Oral Surgery Unit

On __________________ for ________________________________

and was sedated with ___________________________________

at ____am/pm.

You may find that your child is a little quiet when you get home, but this will gradually improve. You should be extra vigilant and not leave your child unsupervised for the next 24 hours, due to risk of injury during this time we suggest not allowing your child to engage in play that require significant co-ordination (e.g. cycling, swings, monkey bars, swimming). Allow your child to sleep if they wish and to eat and drink as tolerated. If you have any worries or concerns, please contact the appropriate department on the telephone number below and ask to speak to the nurse in charge. They will be pleased to help and advise you.

9am – 5pm Endoscopy

01872 252805

Oral Surgery 01872 253980

24 hours Emergency Department

01872 253111

Paediatric Observation Unit 01872 253468

RCHT switchboard 01872 250000


7. Dissemination and Implementation

This guideline will be passed through the following RCHT committees to 7.1.gain approval and improve awareness of implementation:

Paediatric guidelines group Paediatric critical care group Medicines practice committee Resuscitation Committee

Once the guideline has been approved it will be accessible via the RCHT 7.2.Document Library. Medical and nursing staff working in the relevant areas will be informed how to access it by email.

Training Requirements 7.3.

7.3.1. It is vital that all staff involved in paediatric sedation are aware that because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue* those patients whose level of sedation becomes deeper than initially intended.

This is especially pertinent for individuals administering Moderate Sedation (“Conscious Sedation”) who should be able to rescue* patients who enter a state of Deep Sedation. If these appropriate measures are not performed this can lead to hypoxia and cardiac arrest.

(*Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than- intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.)

7.3.2. Therefore in order to maintain patient safety, all staff that treat and care for patients receiving sedation are required to possess a defined level of clinical competence. The tables below describe the training that staff must undertake in order to demonstrate clinical competence. There are 3 levels of training, appropriate for different staff for the role that they will perform for sedated patients.

7.3.3. There is overlap with the training required for adult sedation as per the Clinical Guideline for RCHT Safe Sedation Practice: Adult Patients which allows some of these training sessions to be run concurrently, to avoid repetition.

7.3.4. Departmental leads are responsible for ensuring that staff prescribing and administering paediatric sedation have completed the following levels of training. The Trust Lead for Paediatric Sedation will help with training as required.

7.3.5. A copy of certificates issued to demonstrate the completion of modules should be sent to Learning and Development and uploaded to



the individuals Electronic Staff Record (ESR)

7.3.6. Equivalent training in paediatric sedation at another hospital must be confirmed in writing with the Paediatric Sedation Lead.

7.4.

Module 1 Prescribing and/ or administering minimal

sedation

Required training

Paediatric Life Support (ALSG) or Paediatric Immediate Life Support (Resuscitation Council UK) as a minimum

Chloral hydrate

Have signed that they have read and understood the

indications and cautions for chloral hydrate

Entonox- nitrous oxide: oxygen 50:50 (not 70:30)

As per the RCHT Clinical Guideline for Use of Entonox with Children staff should complete the

on line training at Entonox - Discover Pain Management

For moderate sedation there is a pre-requisite of peripheral cannulation 7.5.skills

7.6.

Module 2 Prescribing and/ or administering moderate sedation

Required

training

Completion of Advanced Paediatric Life Support (ALSG) or EPALS (Resuscitation Council UK)

Completion of face to face theoretical knowledge spanning pre-assessment, consent, team working, human factors, physiology and pharmacology of sedation and contraindications to sedation

Learning/ demonstration of clinical airway skills in paediatric theatre under supervision of senior anaesthetist

There will be requirement for observation of 5 cases of moderate sedation 7.7.and completion of a logbook.

There may be need for on-going supervision. 7.8.




http://www.boctraining.co.uk/local/coursecatalogue/index.php?parent=22

http://www.boctraining.co.uk/local/coursecatalogue/index.php?parent=22


7.9.

Module 3 Monitoring moderately sedated patients

Required training

Paediatric Life Support (ALSG) - minimum

Completion of face to face theory module for assistants

Optional training

Learning/ demonstration of clinical airway skills in paediatric theatre under supervision of senior anaesthetist

Equivalent training in sedation at another hospital must be confirmed in 7.10.writing with the Line manager/ appropriate person. Directly observed assessment of at least one patient, by Consultant level clinician, at each module level must be undertaken at RCHT to confirm practical competency

8. Monitoring compliance and effectiveness

Element to be monitored

Critical incidents: adverse respiratory and cardiovascular events, unplanned admission to high dependency/ ITU, prescription or dosing errors, requirement for reversal.

Failure of technique: abandonment rate, conversion rate to general anaesthesia.

Efficiency: total procedure time, recovery time, unplanned admission rate.

Quality: patient /parent satisfaction, pain scores.

Lead Each clinical area is responsible for completing and forwarding a copy of the trust sedation record to the Paediatric Sedation Lead. The results will be collated by the paediatric sedation lead and presented at the annual September PICU roadshow

Audit A copy of the sedation record should be forwarded to the paediatric sedation lead after the sedation is complete

Frequency Six monthly audit for each clinical area Yearly collation of results for PICU roadshow

Reporting arrangements

The paediatric sedation lead is responsible for ensuring production of a yearly report. The completed report will be presented and discussed at the PICU roadshow.

Acting on recommendations and Lead(s)

Identified problems will be discussed and resolved at the paediatric critical care group meeting. Implementation of change will be guided by the paediatric sedation lead.

Change in practice and lessons to be Shared

Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward where appropriate. Serious incidents will be shared with all the relevant stakeholders


9. Updating and Review

This document will be reviewed every three years

Revisions will be made ahead of the review date if new national guidelines are published that conflict with this RCHT document

Where the revisions are significant and the overall policy is changed, the author will ensure the revised document is taken through the standard consultation, approval and dissemination processes

Where the revisions are minor, e.g. amended job titles or changes in the organisational structure, approval will be sought from the Executive Director responsible for signatory approval, and can be re-published accordingly without having gone through the full consultation and ratification process

Any revision activity will be recorded in the Version Control Table as part of the document control process

10. Equality and Diversity

This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

Equality Impact Assessment 10.2.

The Initial Equality Impact Assessment Screening Form found in Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


Appendix 1. Governance Information

Document Title Sedation of Paediatric Patients and Young People Clinical Guideline V2.0

Date Issued/Approved: April 2019

Date Valid From: April 2019

Date Valid To: April 2022

Directorate / Department responsible (author/owner):

Anaesthesia: Dr Thomas Bevir

Contact details: Via Switchboard

Brief summary of contents GUIDELINES FOR SEDATION OF PAEDIATRIC PATIENTS AND YOUNG PEOPLE

Suggested Keywords: Sedation; Paediatric; Midazolam; Nitrous Oxide; Chloral Hydrate

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: April 2019

This document replaces (exact title of previous version):

GUIDELINES FOR SEDATION OF PAEDIATRIC PATIENTS AND YOUNG PEOPLE (V1.6) – Time Expired

Approval route (names of committees)/consultation:

Paediatric Guidelines group Paediatric Critical Care group Resuscitation Committee Medicines Practice committee Documentation Sub Group

Divisional Manager confirming approval processes

Roberta Fuller

Name and Post Title of additional signatories

Not Required

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Alison Moore

Signature of Executive Director giving approval

{Original Copy Signed}


Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

RCHT; Clinical; Paediatric

Links to key external standards

NICE Guideline (CG112): Sedation in under 19s: using sedation for diagnostic and therapeutic procedures (2010)

Related Documents:

NICE Quick Reference Guide for Sedation in Children and Young People (2010)

NHS Evidence Update 19 – Sedation in children and young people (2012)

NICE Guidelines for Sedation in Children and Young People RCOA/AAGBI response (2011)

Academy of Medical Royal Colleges. Safe Sedation Practice for Healthcare Procedures. Standards and Guidance. (2013)

Royal College of Anaesthetists. Guidelines for the Provision of Anaesthesia Services (GPAS). Guidance on the Provision of Sedation Services (2016)

RCHT Analgesia Guidelines - Paediatric

RCHT Entonox with Children – Clinical Guideline For Use

Clinical Guideline for RCHT Safe Sedation Practice: Adult Patients

Training Need Identified? Yes

Version Control Table

Date Version No Summary of Changes Changes Made by

03/2012 V1.0

Dr.Rebecca Mawer Anaesthetic Consultant

Dr.Sian Ireland Emergency Medicine Consultant

Dr.John Ellis Paediatric Consultant

03/2012 V1.0 Minor changes Medicines practice committee

04/2012 V1.1 Doses of chloral hydrate,

training Paediatric Consultant meeting

05/2012 V1.2 Training package Resuscitation

Committee Meeting

05/2012 V1.3 Changes to minimal sedation criteria and training specification

Paediatric Critical Care Meeting

06/2012 V1.4 Minor changes to 2.2 CSIG 10/2012 V1.5 Changes to wording L&D

https://www.nice.org.uk/guidance/cg112



https://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Clinical%20Effectiveness/Endorsed%20guidelines/Sedation%20in%20Children%20and%20Young%20People/Quick%20Reference%20GuideA.pdf

https://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Clinical%20Effectiveness/Endorsed%20guidelines/Sedation%20in%20Children%20and%20Young%20People/Quick%20Reference%20GuideA.pdf

http://arms.evidence.nhs.uk/resources/hub/731166/attachment

http://arms.evidence.nhs.uk/resources/hub/731166/attachment

https://www.rcoa.ac.uk/system/files/CSQ-NICE-Sedation-response.pdf

https://www.rcoa.ac.uk/system/files/CSQ-NICE-Sedation-response.pdf

https://www.rcoa.ac.uk/system/files/PUB-SafeSedPrac2013.pdf



https://www.rcoa.ac.uk/system/files/GPAS-2016-19-SEDATION.pdf









12/2012 V1.6 Minor changes to

wording Paediatric Guidelines group

Dr R Mawer

04/2018 V2.0

Revision of document as previous version expired including spelling changes, and rearrangement of wording. AAGBI Machine Check added to Appendix And note added to 7.9 Drug Information: “Nitrous oxide 70:30 mix available in ED via the anaesthetic machine in procedure room. Only to be given if trained and machine check performed by user before use, see AAGBI machine check in Appendix 1” Paediatric Sedation Record Removed from Guideline as not previously agreed by the Form Review Group

Dr Thomas Bevir Consultant Anaesthetist

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way

without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Sedation of Paediatric Patients and Young People Clinical Guideline V2.0

Directorate and service area:

Is this a new or existing Policy? Existing

Name of individual completing assessment: Thomas Bevir

Telephone: Via Switchboard

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

To provide a framework for the conduct of sedation in paediatric patients and young people.

2. Policy Objectives*

To standardise aspects of sedation practice such as staffing, sedative agents, fasting, monitoring and record keeping across the RCHT.

3. Policy – intended Outcomes*

Appropriate use of sedative agents

Standardise practice with quality of care

Improve patient safety

4. *How will you measure the outcome?

Audit of sedation practice

5. Who is intended to benefit from the policy?

RCHT staff and patients

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

Please record specific names of groups Anaesthesia Paediatric Interest Group Paediatric Acute Pain Team Paediatric Guideline Committee Pharmacy Play Specialists


Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age Document provides a guideline for sedation practice in children and young people and aims to standardise and improve quality of practice

Sex (male,

female, trans-gender / gender reassignment)

Document does not impact upon this group.

Race / Ethnic communities /groups


Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.


Religion / other beliefs


Marriage and Civil partnership


Pregnancy and Maternity


Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

been identified as not requiring consultation. or

What was the outcome of the consultation?

See version control table in Appendix 1

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

Not applicable, as this guideline will not have a differential impact on any group.

Signature of policy developer / lead manager / director

Dr Thomas Bevir

Date of completion and submission January 2018

Names and signatures of members carrying out the Screening Assessment

1. Dr Thomas Bevir 2. HREI Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site.

Signed __ Dr Thomas Bevir _____________

Date ____April 2019____________


Appendix 3. Advice Sheet following Paediatric Sedation

Your child attended the Emergency Department/ Paediatric Ward/ Endoscopy/ Oral Surgery Unit

On __________________ for ________________________________

and was sedated with ___________________________________

at ____am/pm.

You may find that your child is a little quiet when you get home, but this will gradually improve. You should be extra vigilant and not leave your child unsupervised for the next 24 hours, due to risk of injury during this time we suggest not allowing your child to engage in play that require significant co-ordination (e.g. cycling, swings, monkey bars, swimming). Allow your child to sleep if they wish and to eat and drink as tolerated. If you have any worries or concerns, please contact the appropriate department on the telephone number below and ask to speak to the nurse in charge. They will be pleased to help and advise you.

9am – 5pm Endoscopy

01872 252805

Oral Surgery 01872 253980

24 hours Emergency Department

01872 253111

Paediatric Observation Unit 01872 253468

RCHT switchboard 01872 250000


Appendix 4. AAGBI Anaesthetic Machine Check


Reproduced with the kind permission of the Association of Anaesthetists of Great Britain and Ireland