Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures Charles J. Coté, MD, FAAP, Stephen Wilson, DMD, MA, PhD, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY The safe sedation of children for procedures requires a systematic approach abstract that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed for underlying medical or surgical conditions that would place the child at conflict of interest statements with the American Academy of increased risk from sedating medications, appropriate fasting for elective Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of procedures and a balance between the depth of sedation and risk for those Pediatrics has neither solicited nor accepted any commercial who are unable to fast because of the urgent nature of the procedure, involvement in the development of the content of this publication. a focused airway examination for large (kissing) tonsils or anatomic airway Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external abnormalities that might increase the potential for airway obstruction, a clear reviewers. However, clinical reports from the American Academy of understanding of the medication’s pharmacokinetic and pharmacodynamic Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. effects and drug interactions, appropriate training and skills in airway The guidance in this report does not indicate an exclusive course of management to allow rescue of the patient, age- and size-appropriate treatment or serve as a standard of medical/dental care. Variations, equipment for airway management and venous access, appropriate taking into account individual circumstances, may be appropriate. medications and reversal agents, sufficient numbers of appropriately trained All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, staff to both carry out the procedure and monitor the patient, appropriate revised, or retired at or before that time. physiologic monitoring during and after the procedure, a properly equipped DOI: https://doi.org/10.1542/peds.2019-1000 and staffed recovery area, recovery to the presedation level of consciousness PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). before discharge from medical/dental supervision, and appropriate discharge Copyright © 2019 by the American Academy of Pediatric Dentistry and instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics. This report is also being published in American Academy of Pediatrics and the American Academy of Pediatric Pediatr Dent 2019;41(4): in press. The articles are identical. Either citation can be used when citing this report. Dentistry to offer pediatric providers updated information and guidance in FINANCIAL DISCLOSURE: The authors have indicated they do not have delivering safe sedation to children. a financial relationship relevant to this article to disclose. FUNDING: No external funding. To cite: Coté CJ, Wilson S. AMERICAN ACADEMY OF INTRODUCTION PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. The number of diagnostic and minor surgical procedures performed on Guidelines for Monitoring and Management of Pediatric pediatric patients outside of the traditional operating room setting has Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019;143(6):e20191000 increased in the past several decades. As a consequence of this change and Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 143, number 6, June 2019:e20191000 FROM THE AMERICAN ACADEMY OF PEDIATRICS the increased awareness of the these safety principles have been Pediatric Sedation Research importance of providing analgesia and widely implemented and shown to Consortium has improved the anxiolysis, the need for sedation for reduce morbidity.† These practice sedation knowledge base, procedures in physicians’ offices, recommendations are proffered with demonstrating the marked safety dental offices, subspecialty procedure the awareness that, regardless of the of sedation by highly motivated suites, imaging facilities, emergency intended level of sedation or route of and skilled practitioners from departments, other inpatient hospital drug administration, the sedation of a variety of specialties practicing settings, and ambulatory surgery a pediatric patient represents the above modalities and skills – centers also has increased markedly.1 52 a continuum and may result in that focus on a culture of sedation In recognition of this need for both respiratory depression, laryngospasm, safety.45,83,95,128–138 However, these elective and emergency use of impaired airway patency, apnea, loss of groundbreaking studies also show sedation in nontraditional settings, the patient’sprotectiveairwayreflexes, a low but persistent rate of potential the American Academy of Pediatrics and cardiovascular instability.‡ sedation-induced life-threatening (AAP) and the American Academy of events, such as apnea, airway Pediatric Dentistry (AAPD) have Procedural sedation of pediatric obstruction, laryngospasm, x published a series of guidelines for patients has serious associated risks. pulmonary aspiration, desaturation, the monitoring and management of These adverse responses during and and others, even when the sedation pediatric patients during and after after sedation for a diagnostic or is provided under the direction of – sedation for a procedure.53 58 The therapeutic procedure may be a motivated team of specialists.129 purpose of this updated report is to minimized, but not completely These studies have helped define the unify the guidelines for sedation used eliminated, by a careful preprocedure skills needed to rescue children by medical and dental practitioners; review of the patient’s underlying experiencing adverse sedation to add clarifications regarding medical conditions and consideration events. monitoring modalities, particularly of how the sedation process might regarding continuous expired carbon affect or be affected by these The sedation of children is different dioxide measurement; to provide conditions: for example, children with from the sedation of adults. Sedation updated information from the developmental disabilities have been in children is often administered to medical and dental literature; and to shown to have a threefold increased relieve pain and anxiety as well as to suggest methods for further incidence of desaturation compared modify behavior (eg, immobility) so improvement in safety and outcomes. with children without developmental as to allow the safe completion of 74,78,103 This document uses the same disabilities. Appropriate drug a procedure. A child’s ability to language to define sedation selection for the intended procedure, control his or her own behavior to categories and expected physiologic a clear understanding of the sedating cooperate for a procedure depends responses as The Joint Commission, medication’s pharmacokinetics and both on his or her chronologic age the American Society of pharmacodynamics and drug and cognitive/emotional Anesthesiologists (ASA), and the interactions, as well as the presence development. Many brief procedures, – AAPD.56,57,59 61 of an individual with the skills needed such as suture of a minor laceration, to rescue a patient from an adverse may be accomplished with This revised statement reflects the response are critical.# Appropriate distraction and guided imagery current understanding of appropriate physiologic monitoring and techniques, along with the use of monitoring needs of pediatric patients continuous observation by personnel topical/local anesthetics and both during and after sedation for not directly involved with the minimal sedation, if needed.175–181 a procedure.* The monitoring and care procedure allow for the accurate and However, longer procedures that outlined may be exceeded at any time rapid diagnosis of complications and require immobility involving on the basis of the judgment of the initiation of appropriate rescue children younger than 6 years or responsible practitioner. Although interventions.** The work of the those with developmental delay intended to encourage high-quality oftenrequireanincreaseddepthof † patient care, adherence to the Refs 11, 23, 24, 27, 30–33, 35, 39, 41, 44, 47, 51, sedation to gain control of their – recommendationsinthisdocument and 74 84 behavior.86,87,103 Children younger ‡ – cannot guarantee a specificpatient Refs 38, 43, 45, 47, 48, 59, 62, 63, and 85 112 than 6 years (particularly those x Refs 2, 5, 38, 43, 45, 47, 48, 62, 63, 71, 83, 85, outcome. However, structured sedation younger than 6 months) may be at 88–105, and 107–138 protocols designed to incorporate 129 # Refs 42, 48, 62, 63, 92, 97, 99, 125–127, 132, 133, greatest risk of an adverse event. and 139–158 Childreninthisagegroupare * Refs 3, 4, 11, 18, 20, 21, 23, 24, 33, 39, 41, 44, 47, ** Refs 44, 63, 64, 67, 68, 74, 90, 96, 110,