Standards of Care

UWHC Pediatric Sedation Policy # 8.56 defines the minimum standard of care for all pediatric patients receiving sedation for procedures throughout University of Wisconsin Hospital and Clinics.

Patient Risk Categories

Sedated Pediatrics Patient

Every pediatric patient is considered at risk for losing his or her protective airway reflexes whenever sedation is administered. An otherwise previously healthy pediatric patient (ASA I) undergoing mild to moderate sedation is at lower risk of an adverse sedation event than a child with an underlying medical condition that could compromise cardiorespiratory status or interfere with metabolism of sedative agents.

High-Risk

High-risk cases require advanced training and expertise for delivery and management of sedation. These cases should be managed by a pediatric intensivist or other pediatric specialist specifically credentialed for moderate sedation within his or her area of expertise. Characteristics that may indicate high risk in a child who is a candidate for sedation include the following:

The child has:
- received opioids or benzodiazepines, or initiated therapy with any CNS depressant, within the past 6 hours; or
- started extended-release opioids or received methadone; or
- received intraspinal/epidural narcotics within the past 24 hours; or
- started opioids via an implantable pump within the past 72 hours.
The child will receive two or more sedative drugs concomitantly or sequentially such that there is an overlap in the duration of action.
The child will receive single-agent drugs that are associated with a high likelihood of deep sedation. This includes pentobarbital and ketamine by any route.
The child is allergic to products that may be used during the procedure (e.g., latex products or iodine).

Very High-Risk

Very high-risk cases require advanced training and expertise for delivery and management of sedation. These cases should be managed by a pediatric intensivist credentialed in deep sedation and may require consultation with or support from the anesthesiology department. Characteristics that may indicate very high risk for sedation in a child include that the child:

is younger than two months old.
is unable to handle secretions without aspiration at baseline.
is unable to maintain a patent airway independently at baseline (excluding mechanically ventilated children).
is known to have a history of airway obstruction (e.g., obstructive sleep apnea).
has a significant systemic disturbance or disease (ASA III or greater).
has a cardiac and/or respiratory status that makes cardiac or pulmonary compromise likely.
has altered mental status, making assessment of level of awareness, pain and response to administered medications difficult.
has had a previous adverse experience with sedation.
will receive intravenous anesthetic agents such as propofol, etomidate, methohexital or thiopental. These agents easily and commonly produce general anesthesia.
is allergic or sensitive to sedative or analgesic drugs.

Qualified Personnel

Personnel (Physicians and RNs) responsible for directing and/or administering sedative drugs will be:

Nurses who have successfully completed hospital-approved core competency education to monitor and administer sedation under the direction of a qualified physician (additional educational qualification or experience is recommended for deep sedation);
Staff physicians credentialed for directing and administering moderate sedation;
Knowledgeable of the pharmacodynamic and pharmacokinetic properties of the sedative drugs given;
Skilled and knowledgeable in assessment and management of adverse effects of the sedative, including but not limited to airway obstruction, respiratory insufficiency, cardiovascular compromise and neuropsychiatric complications;
Knowledgeable of and capable of assembling additional assistance;
Certified in or able to demonstrate skills required for health care provider CPR;
Able to demonstrate skills in oxygen delivery, use of suction equipment and use of manual resuscitation equipment.

Physicians conducting sedation in high-risk cases and when using ketamine, pentobarbital or other sedative drug (e.g., fentanyl) associated with moderate sedation shall be:

in compliance with the above criteria;
credentialed to provide pediatric moderate sedation for particular procedures in a specific pediatric patient population; and
able to rescue from deep sedation.

Monitoring Requirements

The essential resuscitation and monitoring equipment is based on the level of sedation anticipated. Below are the monitoring requirements for each sedation level. Note that these are minimum requirements for monitoring and management. Monitoring may be elevated to a higher level at any time based on the discretion of the sedating personnel.

Monitoring According to Level of Sedation
	Mild Sedation	Moderate Sedation	Deep Sedation
Characteristics	Normal airway control Normal respiratory responsiveness Mild to minimal change in gross motor function Normal level of awareness Appropriate response to all stimuli	Minimal to no loss of airway control Minimal to mild alteration in ventilatory responsiveness (≤5% decrease in O₂ sat) Mild to moderate impairment of gross motor function Significant loss of orientation and impaired interaction with environment Blunted response to light tactile and/or verbal stimulation	Potential for partial or complete loss of airway control Moderate alteration in ventilatory responsiveness (>5% decrease in O₂ sat) Moderate impairment in gross motor function Loss of orientation to and interaction with environment Blunted response to painful stimuli
Resuscitation Equipment/Drug Box	Available in area	Present in sedation area, including suction	Immediately available within arm’s length, including suction
NPO Status**	No NPO requirement	≤6 mo: 4 hours milk/solids >6 mo: 6 hours milk/solids 4 hours breast milk all ages 2 hours clear liquids all ages	≤6 mo: 4 hours milk/solids >6 mo: 6 hours milk/solids <4 hours breast milk all ages 2 hours clear liquids all ages
IV Access	Available	Immediately available	Must be present/ immediately available
Respiratory Effort	Baseline and at 20 min	Baseline and continuous Document every 5 min	Baseline and continuous Document every 3–5 min
Heart Rate	Baseline and at 20 min	Baseline and continuous Document every 5 min	Baseline and continuous Document every 3–5 min
EKG	Not required	Not required	Required*
Blood Pressure	Baseline	Baseline	Baseline and continuous Document every 3–5 min
Pulse Oximerty	Not required	Baseline and continuous Document every 5 min	Baseline and continuous Document every 5 min
Mental Status	Baseline and at 20 min	Baseline and every 5 min	Baseline and every 5 min
RN Attendance	Immediately available	Continuous	Continuous
MD Attendance	Readily available (on site)	Immediately available	Continuous

*Exception: May not be able to be used during MRI

**NPO status for patients receiving oral contrast: Patients who receive oral contrast for diagnostic studies are not considered to have an empty stomach. Thus, the risk of vomiting and aspiration in a sedated patient with oral contrast is higher than for patients with an empty stomach. All attempts must be made to perform these procedures under the “lightest” sedation possible. All children must be accompanied by a physician and a nurse throughout the entire procedure. Oral contrast should be administered at the earliest time possible before the procedure (preferably >1 hour). Timing of oral contrast administration must be arranged with the radiologist.