Community Paediatric Policy for minimal sedation

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Jeremy May
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Community Paediatric Policy for minimal sedation Classification: Policy Lead Author: Amy Wilson Consultant Community Paediatrician Additional author(s): Trust Sedation Comittee Authors Division:

1 Community Paediatric Policy for minimal sedation Classification: Policy Lead Author: Amy Wilson Consultant Community Paediatrician Additional author(s): Trust Sedation Comittee Authors Division: Salford Health Care Unique ID: TWCG35(15) Issue number: 2 Expiry Date: March 2019 Contents Section Page Who should read this document 2 Key points 2 Background/ Scope 2 Policy 3-5 Standards 5 Explanation of terms and Definitons 5 References and supporting Documents 5 Roles and Responsibilites 5 Appendices 1 American Society of Anaesthetists guidelines for risk classification 6 2 Drug doses and information 7 3 Consent for sedation 8 Document control information (published as a separate document) Policy implementation plan Monitoring and review Endorsement Equality analysis Page 1 of 8

2 Who should read this document? Community Paediatricians General Paediatricians Specialist School Nurses PANDA nursing staff Learning Disabilities Nursing Team Staff trained in Clinical Holding techniques Community Paediatric nursing staff Key Messages The need for sedation in children and young people in the community is extremely rare This policy covers community use of sedative medication in school aged children (5-18) This policy covers the administration of sedation once behavioural and desensitisation programs have been implemented. See the clinical holding policy to be used in conjunction with this policy Only the use of oral sedatives to produce an anxiolytic/minimal sedative action are appropriate in a community setting If deeper sedation is required it must be in a hospital setting and this would currently be done at Royal Manchester Children s Hospital. This policy does not refer to sedation used for dental procedures. Background & Scope Children and young people with complex neurodisability require routine procedures in the community such as immunisation, blood taking or nail cutting. Due to the individual s needs these routine procedures can be anxiety provoking and be actively resisted. This is usually successfully managed by careful behavioural management and desensitisation programs. On very rare occasions these measures fail to sufficiently reduce anxiety. It may then be in the young persons best interests to implement a combination of mild sedative and clinical holding plan to facilitate a necessary procedure. The clinical holding aspect of these cases is covered in a separate clinical holding policy. This sedation policy covers the safe use of oral sedation medication in these circumstances and is based on the NICE guidance for sedation of children and young people Where there is deviation from this guidance, this is highlighted in the policy. What is new in this version? Clarification of the drugs and their doses used for paediatric sedation in appendix 2. Page 2 of 8

3 Policy The definitions of minimal, moderate, conscious and deep sedation from the American Society of Anesthesiologists (ASA) are: 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. In this group of patients in order to facilitate procedures, only minimal sedation is appropriate to minimize active resistance for painless procedures. If a deeper level of sedation is required then this should be done within a hospital setting. See Trust Sedation policy. Prior to undertaking any sedation, the child s consultant paediatrician should establish suitability for sedation by assessing all of the following and document in the child s healthcare record: 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. The following are contraindications to sedation in the community: if there is concern about a potential airway or breathing problem if the child or young person is assessed using the American Society of Anaesthesiologists (ASA) guidelines for risk classification as ASA grade 3 or greater (appendix 1) Page 3 of 8

4 Consider if minimal sedation is the most suitable option based on the following factors: what the procedure involves contraindications side effects method of administration of medication patient (or parent/carer) preference. Preparation for sedation: Fasting is not necessary for minimal sedation All members of the health care team must have up to date training in basic life support A paediatric registrar or Consultant must be present during the period of sedation Although monitoring and resuscitation equipment are not mandatory for minimal sedation, it is good practice to have such equipment available. Consent form to be discussed and signed (appendix 3) Psychological preparation for the procedure includes desensitization to the environment and equipment and explanations of what will happen which are appropriate for the child/young person s level of functioning. Sedation will only be undertaken when these behavioural techniques have already been undertaken. Environment: The aim of the sedative medication is to reduce anxiety in the child or young person. Care should be given to environmental factors which could also affect anxiety levels: A location which is familiar to the young person should ideally be chosen Staff who are familiar to the young person should be present along with a parent or carer The use of play therapy or distraction techniques should be considered Discharge criteria: Young person is alert and has returned to pre sedation state, including vital signs if being monitored. Choice of medication (see table in appendix 2): For painless procedures midazolam is recommended by NICE due to its wide margin of safety. For this cohort of patients alternative medications which are available in different forms for easier administration may need to be considered, for example: Temazepam and Lorazepam. These do not from part of the NICE guidance but are recommended in the BNFc. The choice of drug needs to be tailored to the individual case Page 4 of 8

5 In case of a reaction to medication please follow the anaphylaxis protocol (APLS) Any adverse events associated with sedation must be reported throught the Trusts reporting system (DATIX). Standards Behavioural and desensitisation management techniques must be tried before considering sedation Only minimal sedation using oral medication to be used in the community setting Consent form to be signed All staff must be BLS trained A paediatric doctor is to be present during the sedation (registrar or above) All episodes of sedation+/- clinical holding to be formally recorded and reported to the children s board on a quarterly basis Explanation of terms & Definitions PANDA- Paediatric assessment and decision area NICE- National Institute for Clinical Excellence BLS- basic life support APLS- Advance Paediatric Life Support References and Supporting Documents NICE guidance on Sedation in Children and Young People (2010) SRFT Trust Sedation Policy British National Formulary for Children 2016 SRFT Clinical Holding Policy Anaphylaxis Protocol APLS Roles and responsibilities It is the role of the Community Paediatrician to: discuss the procedure and consent form with the parent/carer record the pre-sedation assessment prescribe the medication record and report the episode of sedation The decision to use sedative medication should be a multidisciplinary one, once other behaviour management and desensitisation strategies have been exhausted. Page 5 of 8

6 Appendices Appendix 1 American Society of Anaesthesiologists (ASA) guidelines for risk classification ASA Grade please circle Grade I II III IV V Definition Healthy individual with no systemic disease Mild systemic disease not limiting activity Severe systemic disease that limits activity but is not incapacitating Incapacitating systemic disease which is constantly lifethreatening Moribund, not expected to survive 24 hours or without surgery Page 6 of 8

7 Appendix 2 1 st line due to NICE recommendations 2 rd line Not part of NICE guidance. Advantages are route of administration and short duration of action 3 th line Not part of NICE guidance. Can be considered as an alternative to Temazepam Drug Dose (BNFc) Route/product Comments Midazolam By mouth : Buccolam (Product licensed Child 1 month 18 years for use in epilepsy) 500 micrograms/kg (max. Available as prefilled 20 mg) syringes containing 2.5mg, Buccal: 5mg.7.5mg and 10mg Child 6 months 10 years midazolam micrograms/kg Approx Weight Buccolam (max. 5 mg) age of (kg) dose Child years 6 child (buccal) 7 mg (max. 8 mg if 70 kg mg or over) yrs Temazepam Child years 10-20mg Lorazepam Child 1 month 12 years micrograms/kg (max. 4 mg) at least 1 hour before procedure Child years 10+ yrs mg Oral- suspension 10mg/5ml or tablet 10mg or 20mg Oral- 1mg or 2.5mg tablet Recommended by NICE Can be given orally but has a very bitter taste Give minutes before procedure Please note: The use of midazolam in sedation for procedures is unlicensed Midazolam needs to be stored as a controlled drug Not part of NICE guidance. Recommended in BNFc for premedication in older children. Give 1 hour before procedure. Has a short duration of action- approximately 90 minutes. Please note: Temazepam needs to be prescribed as a controlled drug Not part of NICE guidance. Recommended in BNFc for premedication in older children. Give at least 1 hour before procedure. Longer duration of action than Temazepam 1 4 mg NB: Diazepam, Opiates and Ketamine are not recommended to be used in minimal sedation for painless procedures in children by NICE or in BNFc Page 7 of 8

8 Appendix 3 Consent for sedation Name NHS No.. DOB Allergies. I. consent for the above named person to have.(state drug, dose and formulation). This is a sedative medication to facilitate. (state procedure). I have parental responsibility. I understand that there are the following risks to giving this medication: The medication might not work well enough for the procedure to go ahead. The medication might make the person agitated and active rather than sleepy. The medication might make the person too sleepy. If this is the case the young person may need transfer to hospital. Signature Parent/carer. Date. Signature of interpreter if applicable.. Signature. Date.. Consultant Paediatrician Cc parent/carer Page 8 of 8

Sedation in Children

CHILDREN S SERVICES Sedation in Children See text for full explanation and drug doses Patient for Sedation Appropriate staffing Resuscitation equipment available Monitoring equipment Patient suitability