Issue date: December 2010
Sedation in children and young people
Sedation for diagnostic and therapeutic procedures in children and young people
NICE clinical guideline 112 Sedation for diagnostic and therapeutic procedures in children and young people
Ordering information
You can download the following documents from
www.nice.org.uk/guidance/CG112
； The NICE guideline (this document) – all the recommendations.
； A quick reference guide – a summary of the recommendations for
healthcare professionals.
； ‘Understanding NICE guidance’ – a summary for patients and carers.
； The full guideline – all the recommendations, details of how they were
developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email
publications@nice.org.uk and quote:
； N2380 (quick reference guide)
； N2381 (‘Understanding NICE guidance’).
NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales. This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
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NICE clinical guideline 112 – Sedation in children and young people
Contents
Introduction ...................................................................................................... 4 Patient-centred care ......................................................................................... 7 Key priorities for implementation ...................................................................... 8 1 Guidance ................................................................................................. 11 1.1 Pre-sedation assessment, communication, patient information and
consent ............................................................................................. 11 1.2 Fasting .............................................................................................. 12 1.3 Psychological preparation ................................................................. 13 1.4 Personnel and training ...................................................................... 14 1.5 Clinical environment and monitoring ................................................. 15 1.6 Discharge criteria .............................................................................. 17 1.7 Painless imaging ............................................................................... 17 1.8 Painful procedures ............................................................................ 18 1.9 Dental procedures............................................................................. 18 1.10 Endoscopy ........................................................................................ 19 2 Notes on the scope of the guidance ........................................................ 19 3 Implementation ........................................................................................ 19 4 Research recommendations .................................................................... 20 5 Other versions of this guideline ............................................................... 22 6 Related NICE guidance ........................................................................... 22 7 Updating the guideline ............................................................................. 22 Appendix A: The Guideline Development Group, National Clinical Guideline
Centre and NICE project team ....................................................................... 24 Appendix B: The Guideline Review Panel...................................................... 27 Appendix C: The algorithms ........................................................................... 28 Appendix D: Licensing indications ................................................................. 29
NHS Evidence has accredited the process used by the Centre for Clinical Practice at NICE to produce guidelines. Accreditation is valid for 3 years from April 2010 and is applicable to guidance produced using the processes described in NICE’s ‘The guidelines manual’ (2009). More information on accreditation can be viewed at www.evidence.nhs.uk
NICE clinical guideline 112 – Sedation in children and young people
Introduction
Advances in the treatment of paediatric diseases has led to an increase in the number of painful or distressing diagnostic or therapeutic procedures for which many children will need effective sedation or anaesthesia. The choice between sedation and anaesthesia will depend on the type of procedure. Some procedures are very common and healthcare providers and
practitioners need to understand under which circumstances either sedation or anaesthesia is most cost effective.
In adults, many procedures can be undertaken with local anaesthesia and reassurance. In children and young people this is often not possible because the procedures are too frightening, too painful or need to be carried out in children who may be ill, in pain or have behavioural problems. The aims of sedation during diagnostic or therapeutic procedures include reducing fear and anxiety, augmenting pain control and minimising movement. The importance of each of these aims will vary depending on the nature of the procedure and the characteristics of the patient.
There are many sedation techniques available but there is insufficient guidance on which techniques are effective and what resources, including staff training, are required to deliver them safely.
Sedation is not always effective enough and so occasionally the procedure has to be delayed until the child or young person can be anaesthetised. This may need to take place in a different healthcare setting or on another day. Consequently, sedation failure is distressing for the child or young person and also has major NHS cost implications.
Excessive sedation can cause unintended loss of consciousness and dangerous hypoxia. Planned anaesthesia, in comparison, is effective but might have resource implications.
NICE clinical guideline 112 – Sedation in children and young people 4
Definitions
Age ranges
This guideline covers infants, children and young people under 19 years. ； Infants: children from birth to 1 year.
； Neonates: infants aged up to 1 month.
Levels of sedation
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 (known as conscious sedation in dentistry, see below) 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.
； Conscious sedation: Drug-induced depression of consciousness, similar to moderate sedation, except that verbal contact is always maintained with the patient. This term is used commonly in dentistry.
； 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. NICE clinical guideline 112 – Sedation in children and young people 5
Specialist sedation techniques
Sedation techniques that have a reduced margin of safety and increased risk of unintended deep sedation or anaesthesia, accompanied by airway obstruction and/or inadequate spontaneous ventilation. Healthcare professionals using specialist sedation techniques need to be trained to administer sedation drugs safely, to monitor the effects of the drug and to use equipment to maintain a patent airway and adequate respiration. Prescribing drugs
The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients.
This guideline recommends some drugs for indications, for ages or at doses for which they do not have a UK marketing authorisation at the date of publication (‘off-label use’), if there is good evidence to support that use. A brief explanation is given in a footnote in each case, with further details in appendix D. Informed consent should be obtained and documented for any use outside the UK marketing authorisation.
NICE clinical guideline 112 – Sedation in children and young people 6
Patient-centred care
This guideline offers best practice advice on the care of children and young people under the age of 19 undergoing sedation for diagnostic or therapeutic procedures.
Treatment and care should take into account patients’ needs and preferences. Children and young people undergoing sedation and their parents and carers should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health’s advice on consent (available from
www.dh.gov.uk/consent) and the code of practice that accompanies the
Mental Capacity Act (summary available from www.publicguardian.gov.uk). In
Wales, healthcare professionals should follow advice on consent from the
www.wales.nhs.uk/consent). Welsh Assembly Government (available from
If the patient is under 16, healthcare professionals should follow the guidelines in ‘Seeking consent: working with children’ (available from
www.dh.gov.uk/consent).
Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Families and carers should be given the information and support they need. Care of young people in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in ‘Transition: getting it right for young people’ (available from www.dh.gov.uk).
NICE clinical guideline 112 – Sedation in children and young people 7
Key priorities for implementation
Pre-sedation assessment, communication, patient information and consent
； 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
1Anesthesio or greater
; 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
1 The ASA physical status classification system (grades 1–6) is a system to classify and grade
a patient’s physical status before anaesthesia.
NICE clinical guideline 112 – Sedation in children and young people 8
; target level of sedation
; contraindications
; side effects
; patient (or parent or carer) preference.
Personnel and training
； 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 members of the sedation team have the following life support skills:
Minimal Moderate Deep asedation sedation sedation
All members Basic Basic Basic
At least one Intermediate Advanced
member
a including sedation with nitrous oxide alone (in oxygen) and conscious
sedation in dentistry.
NICE clinical guideline 112 – Sedation in children and young people 9
； 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.
Clinical environment and monitoring
2； For deep sedation continuously monitor, interpret and respond to all of the
following:
; depth of sedation
; respiration
; oxygen saturation
; heart rate
; three-lead electrocardiogram
3; end tidal CO (capnography) 2
3; blood pressure (monitor every 5 minutes)
; pain
; coping
; distress.
2 For deep sedation, the healthcare professional administering sedation should be involved only in continuously monitoring, interpreting and responding to all of the above. 3 End tidal CO and blood pressure should be monitored, if possible, provided that monitoring 2does not cause the patient to awaken and so prevent completion of the procedure. NICE clinical guideline 112 – Sedation in children and young people 10