Sedation for Scans and Painless Procedures

Paediatric Clinical Guideline Emergency 1.2 Sedation for scans

Short Title: Sedation for scans and painless procedures

Full Title: Guideline for sedation for scans and painful procedures in children and young people

Date of production/Last revision: June 2008

Explicit definition of patient group This guideline applies to all children and young people under the age of 19 to which it applies: years.

Name of contact author Drusilla Ferdinand, Paediatric SpR Dr Damian Wood, Consultant Paediatrician Ext: 64041

Revision Date June 2011

This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Sedation for scans and painless procedures

Scope of guideline

This guideline is for the sedation of paediatric patients undergoing painless diagnostic or therapeutic procedures. For these procedures sedation is aimed to reduce fear, anxiety or stress and induce drowsiness.

This guideline will outline the four steps used to sedate a child for a painless procedure.

Contra-indications to sedation

 Abnormal airway  Severe respiratory disease  Respiratory failure  Raised intracranial pressure  Depressed conscious level  Cardiac failure  Neuromuscular disease  Impaired bulbar reflexes  Bowel obstruction  Allergy to sedative drug / previous adverse reaction  Behavioural problems  Refusal by parent / guardian / child  Significant risk of aspiration including significant cerebral palsy and gastro- oesophageal reflux

Situation where caution may be required

Drusilla Ferdinand Page 1 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans  Neonates, especially premature or ex-premature

o Those born prematurely or less than 3 months of age should be observed for 4-6 hours post sedation and have tolerated at least one good feed

 Renal impairment

o There will be reduced clearance of drugs so a lower dose may need to be considered

 Hepatic impairment

o There may be a prolonged duration of action due to impaired metabolism so a lower dose may need to be considered

 Anticonvulsant therapy

o Sedative drugs may act synergistically to produce profound sedation o Some children will be resistant to conventional doses due to hepatic enzyme induction

 Gastro-oesophageal reflux

 Children receiving opioids, other sedatives or drugs which potentiate the action of sedatives e.g. macrolide antibiotics

 Distressed child

Preparation

Consent

Written, informed consent is required prior to the procedure. This should be obtained by a person who is able to prescribe and give the sedation.

Parents should be informed of the possible side effects of sedation, including respiratory depression and the need for ventilatory support.

They should be informed that;

 sedation may fail and the procedure may need to be abandoned  the child may require a general anaesthetic at a future date  the effects of the sedating agents may continue for several hours and sometime to the next day

The nurse must ensure that the patient is compatible with the MRI scanner before giving the sedation.

The parent / carer must accompany the child to MRI to fill in the safety questionnaire with the radiographer.

Drusilla Ferdinand Page 2 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans Equipment

The following equipment should be available with the patient and through transfers:

 Oxygen with appropriate tubing and mask  Suction with appropriate tubing, Yankaur suction and suction catheters  Pulse oximeter  Bag and mask and oral airways

The following equipment should be available in the department:

 Emergency trolley including airway support and resuscitation drugs

Other equipment to consider:

 ECG monitor  Non-invasive blood pressure monitor  Thermometer  Reversal agents for benzodiazepines (Flumazenil) if appropriate

Fasting

Sedation of children can lead to vomiting which increases the risk of aspiration. The procedure may also lead to the requirement of general anaesthesia. Therefore patients should be starved as for a general anaesthetic. A longer time is required for food due to the unpredictable clearance from the stomach. Unlimited clear fluids can be given up to 2 hours prior to sedation. These are reliably cleared from the stomach in a short time. Examples of clear fluids are water and dilute squash. Orange juice is NOT a clear liquid.

The decision to override the fasting guidelines should be undertaken by a doctor and be documented in the notes.

Food – including cow’s milk and formula milk 6 hours Breast milk 4 hours Clear fluids 2 hours

Personnel

Two nurses or one nurse plus another professional who is competent and up to date with Basic Life Support should be present throughout transfers between departments and one nurse should remain present throughout the procedure.

Drusilla Ferdinand Page 3 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans

2. Sedation

Many painless procedures can be accomplished without pharmacological intervention if there are child-friendly facilities, good preparation of the child and family and a cooperative child. Babies under 3 months should ideally not require pharmacological sedation. They should be given a feed and wrapped well in a warm, quiet environment to promote sleep. This is an exception to the fasting guidelines.

Babies, however, usually require sedation for MRI scans. The MRI scanners are very loud and the examinations frequently lengthy (30 minutes or more). “Feed and swaddle “is therefore rarely successful. This should be discussed with the radiologist and the consultant responsible for the child.

If using sedation agents give these when the nurse caring for the patient is directly instructed to do so by the radiographer in charge of the scanner, the superintendant radiographer or the MRI sedation nurse (usually 20 minutes prior to the procedure) and monitor the child in a quiet environment.

3 months – 1 year Choral hydrate 50 -100mg/kg orally

Choral hydrate 75 -100mg/kg orally 1-3 years Maximum dose = 2 grams

Quinalbarbitone 7.5 - 10mg/kg 4-5 years Maximum dose = 200mg

Please prescribe maximum doses unless medical reason to give lower dose.

If this is unsuccessful after 30 minutes assess the patient. If the child is wide awake and there are no signs of drowsiness or agitation, give rectal Paraldehyde 0.3ml/kg with equal volume of olive oil (0.6ml/kg of the ready mixed solution). Maximum dose is 10ml (20ml). This should be prescribed before the child is transferred. If the child is agitated or restless at 30 minutes, withhold the paraldehyde for a further 10-20 minutes. If after this the child is not sedated, give rectal paraldehyde.

If an older child requires sedation their case should be discussed with ambulatory care and the consultant responsible for the child.

Children over 5 years old do not remain sedated well during MRI scans. They should be considered for an MRI under general anaesthesia.

If the above has failed on previous occasions then sedation using Midazolam can be considered. This should be discussed with and ideally supervised by and appropriate paediatric anaesthetist. However, general anaesthesia is preferable and safer. If Midazolam is used then appropriate reversal agents (such as Flumazenil) should be to hand.

Drusilla Ferdinand Page 4 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans Chloral Hydrate

Contra-indications:

 severe cardiac disease  marked hepatic or renal impairment  gastritis

Cautions:

 Respiratory insufficiency  Avoid contact with skin and mucous membranes

Side effects:  gastric irritation  abdominal distension  flatulence  drowsiness  headache  ataxia  confusion  excitement

Administration:

 It is corrosive to mucous membranes unless well diluted with water. It has an unpleasant taste which can be disguised with sweet juice. Using a syringe may aid administration.

Quinalbarbitone

Cautions:

 respiratory disease  renal disease  hepatic impairment

Side effects:

 Hangover with drowsiness  Dizziness  Ataxia  respiratory depression  hypersensitivity reactions

Administration:

 Mix with water. Capsules can be opened.

Paraldehyde

Contra-indications:

Drusilla Ferdinand Page 5 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans

 gastric disorders

Cautions:

 bronchopulmonary disease  hepatic impairment

Side effects:

 drowsiness (increased if barbiturates or other sedatives have been given)  rectal irritation can occur

Administration:

 Mix with an equal volume of olive oil. Give immediately if using a plastic syringe as it destroys plastic with prolonged contact.

 Paraldehyde decomposes easily. Do not use if it has a brownish colour or odour of acetic acid.

 Some children become disinhibited by sedative agents and become restless and unmanageable. It is important to recognise this and avoid additional sedative doses as this can worsen restlessness or result in deep sedation. If the child becomes disinhibited consider re-scheduling the procedure with alternative sedation or general anaesthesia.

 The effects of sedation can last several hours and sometimes until the next day.

 These agents have a sedative effect. They are not analgesics.

3. Monitoring

 Continuous monitoring of the child by a trained member of staff should commence when the sedation is administrated until the recovery criteria are met (see below).  A pulse oximeter should be attached when sedation is commenced.  Regular measurement of heart rate, respiratory rate, oxygen saturations and temperature should be noted.

4. Procedure

The child should be transferred between departments with the relevant personnel. The portering department must not be involved.

5. Post-procedure care

Drusilla Ferdinand Page 6 June 2008 Paediatric Clinical Guideline Emergency 1.2 Sedation for scans The child should be transferred to a recovery area post procedure until the following criteria are met:

 Airway patent and stable without support  Easily rousable with normal responsiveness for age and mental status  Oxygen saturation 95% or above in air  Haemodynamically stable  Adequate hydration and urine output  No nausea or vomiting (has eaten / drunk)  No pain

If these criteria are not met then the child may need continued observation overnight on a ward. On discharge the family should be given contact information to use if there are concerns in the 24 hours following sedation.

Contact information

Department Name Extension Number

CT1 Sr Jean Crofts 61020 / 61021 Alison Fenwick 66750 / 64927 CT2 +3 Superintendant Radiographer SN Sue Nowak 62219 MRI Annie Martin Andrew Cooper – Superintendant 62230 MRI Radiographer 63067

Ambulatory Care Sr Louise Richardson 66147 / 66936 Unit

Drusilla Ferdinand Page 7 June 2008