Pediatric Sedation

Question 1

Define sedation as per International Committee for the Advancement of Procedural Sedation (ICAPS)

Answer 1

The International Committee for the Advancement of Procedural Sedation (ICAPS) defines procedural sedation as follows: “The practice of procedural sedation is the administration of one or more pharmacological agents to facilitate a diagnostic or therapeutic procedure while targeting a state during which airway patency, spontaneous respiration, protective airway reflexes, and hemodynamic stability are preserved, while alleviating anxiety and pain”.

Question 2

What does “Continuum of sedation” mean?

Answer 2

○ It implies that with an increase in drug administration (i.e. by increasing dosage or combining different drugs), the likelihood of advancing to the next level of sedation is increased. Patients may reach a deeper-than-intended level of sedation with accompanying adverse effects.
○ The level of sedation is also affected by drug interactions and the individual’s pharmacogenetic profile.

Question 3

What are the different levels of sedation?

Answer 3

1. minimal sedation or anxiolysis
2. moderate sedation/analgesia
3. deep sedation/analgesia, and
4. general anaesthesia.

Question 4

What is minimal sedation/anxiolysis?
What are the physiologic end points?

Answer 4

○ Minimal sedation/anxiolysis is a drug-induced state during which the patient responds normally to verbal commands.
○ This level is sometimes referred to as “changing the mood” of the patient.
○ Cognitive function and physical coordination may be impaired, but airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Question 5

What is moderate sedation?
What are its physiologic endpoints?

Answer 5

○ Moderate sedation/analgesia is also termed “conscious sedation”. This is a drug-induced depression of consciousness during which purposeful response to verbal commands (either alone or accompanied by light tactile stimulation) is maintained.
○ Interventions are not usually required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
○ There are societies that believe that dissociative sedation (i.e. using ketamine) should also be part of the sedation continuum and falls between moderate and deep sedation/analgesia.

Question 6

What is deep sedation?
Whatare the physiologic responses?

Answer 6

○ Deep sedation is a drug-induced depression of consciousness during which patients cannot easily be roused, but may respond purposefully following repeated or painful stimulation.
○ Reflex withdrawal from a painful stimulus is not considered to be a purposeful response.
○ Deep sedation may be accompanied by clinically significant ventilatory depression.
- Assistance with maintaining a patent airway and positive pressure ventilation may be necessary.
- Cardiovascular function is usually maintained.
○ This level of sedation is termed “monitored anaesthesia care (MAC)” in certain international sedation guidelines

Question 7

Who should administer deep sedation

Answer 7

In South Africa, deep sedation and analgesia should only be performed by trained doctors with experience in the field of anaesthesia, in accordance with the SASA Practice Guidelines 2018 (available from http://www.sasaweb.com). This is especially true for sedation in children.

Question 8

What is general anaesthesia?

Answer 8

○ This is a drug-induced loss of consciousness during which patients cannot be roused, even by painful stimulation.
○ The ability to maintain independent ventilatory function is impaired.
○ Patients require assistance in maintaining a patent airway, and positive pressure ventilation may be required due to the depression of spontaneous ventilation or a drug-induced depression of neuromuscular function.
○ Cardiovascular function may also be impaired.

Question 9

Define Non-dissociative sedation

Answer 9

○ Non-dissociative sedative drugs (including opioids, benzodiazepines, barbiturates, etomidate and propofol) operate on the sedation dose–response continuum.
○ Higher doses provide progressively deeper levels of sedation with possible respiratory and cardiovascular compromise, central nervous system depression and unconsciousness.
○ With the use of non-dissociative drugs, the key to minimising adverse events is the careful titration of drugs until the desired effect is reached.

Question 10

Define Dissociative sedation

Answer 10

○ Dissociative sedation (as seen with ketamine sedation/analgesia) causes a trance-like cataleptic state characterised by intense analgesia, amnesia, sedation, retention of protective reflexes, spontaneous breathing and cardiovascular stability.
○ When ketamine is administered in doses appropriate for PSA, loss of consciousness is unlikely.
○ As stated earlier, some practitioners believe that dissociative sedation should be part of the PSA continuum, and would fit in between moderate and deep sedation.

Question 11

Whare are the main categories of Sedation techniques

Answer 11

Basic or standard sedation
Advanced sedation

Question 12

What is the “Basic techniques of sedation”?
Provide examples.

Answer 12

It is defined as sedation induced by a single agent and not a combination of several agents, for example:
• oral, transmucosal or rectal drugs (e.g. a small dose of an oral benzodiazepine, usually midazolam)
• inhalation of nitrous oxide (N2O) in oxygen, where the concentration of N2O must not exceed 50% in oxygen, or
• titrated intravenous doses of midazolam to a maximum dose of 0.1 mg/kg.

Question 13

Define “Advanced sedation” technique
Provide examples

Answer 13

Advanced sedation can be defined as sedation induced by one of the following techniques:
• any combination of drugs, administered by any route,
• any sedation administered by the intravenous route (e.g. propofol, etomidate, dexmedetomidine – with the exception of titrated doses of midazolam to a maximum of 0.1 mg/kg),
• any inhalational sedation (e.g. sevoflurane), with the exception of N2O used as the sole agent in a concentration not exceeding 50% in oxygen, or
• any infusion techniques (i.e. target-controlled infusions [TCIs]).
Advanced sedation techniques:
• can include both dissociative and non-dissociative techniques,
• should only be performed by SPs who have had supervised clinical training and life support training in paediatric sedation, and
• require the attendance of a dedicated SP and should not be performed by operator-SP

Question 14

Define “Failed sedation” and give reasons for it?

Answer 14

○ It is defined as the failure to achieve the desired level of sedation for the
procedure to be completed safely, such that the procedure has to be abandoned or the need arises to convert to GA.
○ Possible reasons for failed sedation include inadequate presedation assessment of the child, patient factors (i.e. children with special needs), drug factors or procedure-related and operator factors.
○ A previous episode of failed sedation may necessitate consideration for future procedures to be performed under GA instead of sedation.

Question 15

Define “Prolonged sedation”

Answer 15

○ It is recommended that in children, any sedation for procedures performed outside of a hospital and lasting more than 1.5 hours
is considered prolonged sedation.
○ Even though this approach may not be practical, these procedures should probably best be staged into two or more separate procedures.
○ Alternatively, the recommendation for procedures expected to last more than 1.5 hours, is to perform the procedure under GA in-hospital.

Question 16

Practice appraisal protocol for paediatric sedation: General requirements

Answer 16

1. Does the practice provide basic intravenous sedation, e.g. midazolam only?
2. Does the practice provide advanced intravenous sedation techniques (combination of drugs)?
3. Does the practice provide inhalation sedation (IS)?
4. Do children aged 12 years and younger receive intravenous sedation at the practice? If yes, which drugs are used?
5. Are sedation patients only ASA I or II? Do you do any fragile ASA II patients under sedation? Do you do any ASA III patients?
6. Does the practice only use operator-sedation practitioners? Which drugs are they using for sedation?
7. Does the practice normally operate with a separate sedation practitioner (dedicated)?
8. Is the practice in good standing with the HPCSA?

Question 17

What are Basic question to ask about the establishment providing sedation to ensure patient safely?

Answer 17

1 Do the premises appear to be well maintained?
2 Are the recovery and waiting areas separate, or the procedure room used as the recovery room?
3 Is there good lighting and ventilation in all clinical areas?
4 Is there access for emergency services to the building?
5 Is there access for emergency services to the surgery?
Do you have a wheelchair available to transport patients?
6 Is there space within the surgery to deal with an emergency?
7 Is there space within the surgery for the sedation practitioner to work effectively and do resuscitation if necessary?
8 Does the practice layout provide privacy for sedation of patients?
9 Can the dental or equivalent chair be placed in the head-down tilt position where applicable?
10 Are there facilities for a parent/caregiver to accompany their child while sedation is commenced?

Question 18

Practice appraisal protocol for paediatric sedation: Sedation practices

Answer 18

1. Does the practice follow a recognised sedation protocol?
2. Are patients normally assessed for suitability for sedation at a preceding
   appointment or during day of surgery?
3. Are there possible options for anxiety and pain control explained to the patient prior to obtaining consent for sedation?
4. Do parents/caregivers have the opportunity to ask questions?
5. Are blood pressure and pulse oximetry assessed as part of the patient assessment and documented?
   -Is capnography used in the practice?
6. Is the patient monitored by a trained and experienced member of staff, during sedation and recovery?
7. Does the practice prohibit parents/caregivers from remaining in the surgery during the procedure?
8. Are recognised discharge criteria followed?
9. Where are patients normally recovered?
10. Does the sedation practitioner or trained staff discharge the patient?
11. Are patients given a telephone or cell phone number to call in case of problems or complications?
12. Does the practice ensure that all children have a responsible adult accompanying them home and to take responsibility for after-care at home?
    -Which mode of transport will the child and accompanying adult use?
13. Is there an agreed protocol with the local hospital and paramedics in case of an emergency?

Question 19

Practice appraisal protocol for pediatric sedation: DOCUMENTATION

Answer 19

1. Are parents/caregivers given written preoperative instructions?
2. Are parents/caregivers given written postoperative instructions?
3. Are the following noted and checked prior to sedation?
   -Medical, dental and social histories: medical history questionnaire
   -Previous sedations/general anaesthesia
   -ASA category
   -Fasting
   -Preoperative vital signs (including BP)
   -Treatment required
   -Information to the patient regarding the procedure
   -History of allergies
4. Is written informed, valid consent for sedation and the procedure obtained prior to sedation?
   -Is this sometimes changed during sedation?
5. Is a contemporaneous record (sedation flow chart) kept of the administration of sedation?
6. Do sedation practitioners keep a logbook or records of sedation cases?

Question 20

Practice appraisal protocol for paediatric sedation : Equipment

Answer 20

1. Is there equipment for measurement of blood pressures and oxygen saturation values?
2. Is there a dedicated Inhalation Sedation (IS) machine? Does this have the
   following?
   - Minimum delivery of 30% O2
   - Emergency N2O cut-off
3. Is the IS machine checked by a suitably trained and qualified member of staff prior to each session?
4. Is there scavenging of waste gases?
5. Is the equipment serviced according to the manufacturers’ guidelines?
6. Are the gases stored according to current safety requirements?
7. Date of last service?
8. Is a pulse oximeter available?
   -Is an ECG monitor available?
   -Is a capnograph available?
   -Are they all being used to monitor the patient?
9. Does the pulse oximeter have audible alarms?
10. Is the equipment serviced according to the manufacturers’ guidelines?
11. Date of last service?
12. Is emergency oxygen available? What is the size of the cylinder? Is there a back-up supply/cylinder?
13. Is there a self-inflating bag valve mask with reservoir bag for children (e.g. Ambu-bag)?
    -Is there a 40% oxygen mask?
    -Is there a rebreathing bag?
14. Is there a pocket face mask (e.g. Laerdal pocket mask) to provide assistance with ventilation?
15. Is there a set of nasal cannulae available?
16. Is suction available and in working order? How often is suction cleaned and checked?
17. Is back-up suction available?
18. Is a laryngeal mask available?
19. Are Yankauer suckers available?
20. Is a defibrillator available?
21. Is an AED available?
22. Date of last service?
23. Is the emergency equipment readily available? (SASA guidelines)

Question 21

Practice appraisal protocol for paediatric sedation: DRUGS

Answer 21

1. Are emergency drugs immediately available? (see SASA guidelines)
   -Which ones do you have?
2. Are all drugs, sedation and emergency, in date?
3. Is there a designated person responsible for stock control?
4. Are all emergency drugs readily available?

Question 22

STAFF

Answer 22

1. Names and qualifications of all dentists, doctors and nursing staff involved in sedation practice at this address. Do they all have airway certification?
   Please supply details.
2. Can all staff demonstrate in-house training in sedation, as well as a commitment to continuing professional education? Give details.
3. Can all nurses assisting demonstrate in-house training in sedation?
4. Can all recovery staff (if applicable) demonstrate training appropriate to their duties?
5. Is all staff trained in at least BLS (airway certification)?
6. How often is emergency training provided? Give dates.
7. When was the last emergency training session?
8. Is the facility suitable to provide moderate sedation and analgesia?
   If no, the following observations would need to be addressed for successful
   practice appraisal:

Question 23

Valid informed consent to sedation and analgesia for medical or dental procedures : Information that should be discussed with caregiver

Answer 23

1. information about the sedation and procedure must be provided in a clear and understandable way.
   - This should happen at an appropriate time in order for the patient/parent/caregiver to be able to digest the information and formulate questions.
   - The discussion should, therefore, if possible, not occur immediately before the procedure or even on the day of the procedure
2. Patients/parents/caregivers must understand the risks of sedation before consenting.
   -There-fore, an explanation of the procedure, the proposed sedation technique and the risks and benefits of the proposed technique should be given.
   - Patients/parents/caregivers must be aware of the possibility that the sedation may fail and that the procedure may have to be abandoned
   or performed under GA at a later date.
3. Alternatives to sedation (e.g. GA or local/regional anaesthesia) should also be discussed.
4. Behavioural management techniques as an alternative to sedation, if relevant, should be discussed to ensure that the most suitable form of treatment is selected.

Question 24

When can a minor consent

Answer 24

○ As cited in the Southern African Journal of Anaesthesia and Analgesia,7 children can give consent in the following situations:
(i) for medical treatment, if they are older than 12 years of age, and if they have the maturity and capacity “to understand the benefits, risks, social and other implications of the treatment” – this is independent of parents’ consent; or
(ii) for surgical procedures, if they are 12 years of age and assisted by their parent or legal guardian (Form 34, or Form 35 if the child’s parents themselves are aged 18 years and younger).
○ The planned usage of suppositories or rectal medication must also be explained carefully to the parents and consent be obtained ahead of time.

Question 25

Patient selection for day case

Answer 25

○ Only children in ASA Class I, II and fragile ASA II well-controlled, should be considered for sedation outside of a hospital operating theatre.
- It is possible for the ASA status to deteriorate from the time the child was initially evaluated to the time of the sedation (e.g. ASA II patients
may become ASA III patients by the time of the procedure). Therefore, the recommendation is that children should be evaluated again immediately prior to the procedure.

Question 26

Which Children are considered to be at an increased risk for complications for sedation?

Answer 26

• Children younger than 3 years of age.
• Children with a history of prematurity with residual pulmonary, cardiovascular, gastrointestinal or neurological problems, or significant anaemia.
• Children with congenital syndromes.
• Children with obesity (> 95th percentile body mass index (BMI) for their age).
*The association between obesity and obstructive sleep apnoea (OSA) limits the use of sedatives and opioids and increases risk in light of early discharge requirements. Children with restrictive lung disease are prone to desaturation – they must be evaluated on a case-by-case basis.
• Children with previous failed sedation.
• Children with any known adverse reactions (hyperactive or paradoxical response) or allergy to any of the sedation drugs.
• Children who display severe behavioural problems or hyperactivity, or who are mentally challenged.
• Children whose parents are reluctant.

Question 27

Guidelines for fasting prior to sedation

Answer 27

• Clear fluids, apple juice: two hours. Some clinicians allow clear fluids even one hour before the procedure. A “clear fluid” is defined as fluid without particles.
• Breast milk: four hours.
• Formula feeds and solid food: six hours.

Question 28

Standards of monitoring

Answer 28

7.1 Anxiety levels and behaviour, such as confusion, restlessness and
agitation : exclude hypoxaemia, hypoglycaemia, under-sedation or even over-sedation) and a full bladder which can also cause restlessness, especially during longer cases.
7.2 Level of consciousness and depth of sedation: Wilson score or Michigan sedation score
7.3 Pain and degree of discomfort: observe behavior, face and movements of extremities
7.4 Airway patency:
7.5 Oxygenation and mucosal colour: capnograph
7.7 Heart rate and rhythm
7.8 Non-invasive blood pressure
7.9 Operator-dependent factors
7.10 Minimum monitoring standards
• ASA I and ASA II patients: pulse oximetry and NIBP
• Fragile ASA II patients, prolonged sedation and patients under deep sedation: pulse oximetry,
NIBP, ECG and capnography

Question 29

7.1 Anxiety levels and behaviour, such as confusion, restlessness and
agitation

Question 30

evel of consciousness and depth of sedation

Answer 30

University of Michigan Sedation Scale [UMSS])
Wilson
sedation scale

Question 31

Pain and degree of discomfort

Answer 31

Close and continuous observation of the child’s face and possible movement of extremities
may aid as clues that the child is experiencing discomfort or pain.
signalling system for pain or discomfort should
be established prior to the initiation of sedation.

Question 32

Airway patency

Answer 32

Relaxation of the mandible and involuntary opening of the mouth are early signs that the level
of sedation is deepening. Noisy inspiration and/or expiration and snoring are indications of an
obstructed upper airway and should be corrected by either repositioning the head and neck or
lessening the sedation. A patient who stops snoring should be evaluated for complete airway
obstruction

Question 33

Oxygenation and mucosal colour

Answer 33

These should be observed continuously at all levels of sedation.

Question 34

Breathing, respiratory rate and ventilation

Answer 34

breathing pattern and movement of the chest and abdomen should be observed for the
duration of the procedure. Breathing should be rhythmic. Signs to watch out for are paradoxical
breathing, rib retraction, use of accessory muscles and tracheal tug, which all may indicate
airway obstruction. Stridor or coughing and bucking might be the earliest indication of
laryngospasm and requires immediate action.
The respiratory rate should be recorded intermittently. When a capnograph is used, the
respiratory rate will be displayed continuously. The use of a precordial stethoscope may be
useful if capnography is unavailable

Question 35

Heart rate and rhythm

Answer 35

moderate sedation,
in ASA I and II patients, where continuous verbal contact with the patient is maintained, an
electrocardiogram (ECG) is not essential and pulse rate, as recorded by pulse oximetry, should
be sufficient.
prolonged sedation or in fragile ASA II patients, ECG monitoring is indicated when
standard or advanced techniques are used. Any patient with underlying cardiovascular disease
should be monitored with an ECG.

Question 36

.8 Non-invasive blood pressure

Answer 36

NIBP must be monitored at all levels of sedation, except maybe for minimal sedation or
anxiolysis of short duration. It is important to ensure that the size of the NIBP cuff is appropriate
for the age and weight of the child, to ensure accurate measurements.

Question 37

0 Minimum monitoring standards

Answer 37

• ASA I and ASA II patients: pulse oximetry and NIBP
• Fragile ASA II patients, prolonged sedation and patients under deep sedation: pulse oximetry,
NIBP, ECG and capnography

Question 38

The sedation practitioner

Answer 38

• have a primary, registered medical qualification,
• have full registration with the HPCSA as appropriate,
have formal training in standard and advanced sedation techniques specifically for children,
or be able to demonstrate equivalent experience and training (provision of audit records of
safe administration of sedation drugs is also required),
• provide evidence of regular and recent paediatric sedation-related continuing professional
development (CPD) activity appropriate to the sedation techniques provided,
• have a logbook, or equivalent, reflecting cases where sedation was done, as well as the
technique used,
• comply with SASA recommendations for safe sedation practice in children, and
• have evidence available of up-to-date qualifications in BLS and APLS.

Question 39

single operator-sedation practitioner

Answer 39

healthcare practitioner who provides the sedation and at the same
time performs the required procedur

Question 40

Contraindications to single operator-sedation practitioner

Answer 40

○ It is recommended that the operator-SP should undertake the dual role of SP and operator only when basic or standard sedation techniques are employed and the level of sedation does not progress beyond minimal sedation or anxiolysis.
○ It is recommended that combination of drugs not be administered.
○ Since minimal or moderate sedation may not be sufficient to complete most procedures safely in young children, taking on the role of single operator-SP in young children is not recommended.
○ Older children, who will cooperate and follow instructions, can safely be
managed in this way if the operator and assistant are appropriately trained. ○ The trained second person must be present throughout the procedure and must be capable of monitoring the clinical condition of the child and assisting the operator-SP in the event of complications.
- The second person may have received only in-house training, including competency in airway rescue, provided that this training is fully documented.

Question 41

8.1.3 The dedicated sedation practitioner indication

Answer 41

• The operator has no training in the administration of sedation in children.
• Fragile ASA II children.
• Children with comorbidities.
• The procedure is expected to be prolonged.
• The surgical procedures are complex.
• Advanced sedation techniques are to be used.
• Complex sedation techniques involving intravenous infusions (i.e. TCIs).

Question 42

Role of the assistant of the operator-SP

Answer 42

According to the Academy of Medical Royal
Colleges,13 the assistant of the operator-SP can fulfil this role for procedures less than 30 minutes.

Question 43

SPs (either single operator-SPs or dedicated SPs) training requirements

Answer 43

• have a good understanding of the pharmacokinetics and pharmacodynamics of the agents
that they administer and specifically their use in children; this includes the pharmacology of
the appropriate antagonists (which should be reserved for emergency use).
• understand the synergistic effects when combining drugs.
• be able to recognise and manage complications associated with the drugs in use,.
• be able to apply APLS techniques and manage, rescue and recover a child who unexpectedly
enters a deeper-than-intended level of sedation.
• regularly audit their practice.

Question 44

Observer and ancillary personnel requirements

Answer 44

○ monitoring the child patient when a single operator-SP provides sedation, even for brief or simple procedure should have at least the equivalent of nursing training and must be proficient at maintaining airway patency and
monitoring of vital signs.
○ Such a person must be able to assist with ventilation if necessary.

Question 45

The following tasks must be completed with every sedation:

Answer 45

• Preprocedural screening, including patient evaluation, providing pre- and postsedation
instructions and obtaining written informed consent (Appendices 3, 4, 8 and 9)
• Completing the preprocedural checklist (Appendix 11)
• Prescribing and administering sedation
• Patient monitoring (and rescue, where necessary) (Appendix 7)
• Performing the procedure
• Recovery and discharge after the procedure (Appendix 12)

Question 46

Minimal sedation or anxiolysis monitoring

Answer 46

This level of sedation is suitable for the operator-SP, but in accordance
with all international guidelines, there must be a second person, apart from the operator, who
is responsible for monitoring the patient and helping with rescue, if needed. This is usually
a level of sedation suitable for brief, simple procedures lasting less than 30 minutes. Clinical
monitoring is extremely important. This level of sedation is often referred to as “changing the
mood of the patient”.

Question 47

Moderate sedation/analgesia (conscious sedation)

Answer 47

◦ trained in the selection, assessment and evaluation of the child for PSA, and specifically in
airway assessment;
◦ trained in specific paediatric sedation techniques;
◦ trained in resuscitation and airway management in children and experienced in APLS;
◦ with an understanding of the pharmacokinetics and pharmacodynamics of sedative,
analgesic drugs and dissociative agents, their possible synergistic effects and specific
reversal antagonists, as related to children – the SP must demonstrate competency when
using combinations of drugs;
◦ trained and experienced in the use of the drugs for moderate sedation and analgesia
techniques in children;
◦ with an understanding of the procedure to be undertaken: painful or non-painful, duration,
requirements for immobilisation; and
◦ with an understanding of the value of monitoring the patient, and to never leave the
patient unattended.
• A trained and dedicated observer, usually a nursing assistant, experienced in airway
management and monitoring, to ensure that:
◦ the child remains conscious;
◦ respiratory function is adequate;
◦ vital signs are within normal limits; and
◦ the child is rescued from deeper-than-intended levels of sedation.
• An assistant to the SP is recommended for procedures longer than 30 minutes.
The observer must also be trained in BLS.
For more complex procedures, where combinations of drugs are used, prolonged sedation is
required, or in children with comorbidities, a dedicated SP must be present.

Question 48

Deep sedation/analgesia

Answer 48

Deep sedation/analgesia is part of the sedation continuum and the standard of care must be
identical to that for an unconscious patient.
It is advised that a dedicated SP who is trained in paediatric sedation and preferably with
experience in paediatric anaesthesia, as well as a trained assistant be present. The SP must have
a valid APLS certification.
During deep sedation, intervention may be required to maintain the airway. Ventilatory efforts
must be closely monitored as they may be inadequate, or even ineffective, against a closed
glottis.
It is highly recommended that capnography is used to monitor ventilation.

Question 49

Personnel requirements for PSA in children who need special care

Answer 49

Sedation for these children must only be undertaken by SPs with experience in sedating
children with special needs. It is often necessary to use deeper levels of sedation. It may be
extremely difficult to judge the level of sedation, so adjustments in treatment protocols may be
necessary. Careful monitoring of the airway is mandatory. These cases should therefore not be
attempted by the single-operator SP and a dedicated SP should be employed.

Question 50

Before sedation

Answer 50

Valid informed consent to sedation and analgesia for medical or dental procedures (Section 4
and Appendix 3)
• Medical history questionnaire
Pre- and postsedation instructions (Appendices 8 and 9)
Cover letter to the parent/caregiver (Appendix 10)
Preprocedural checklist (

Question 51

Sedation preoperative checklist

Answer 51

◦ Details of the child, including ASA classification
◦ Details of the procedure (elective or emergency)
◦ The medical history questionnaire, which must be checked by the SP
◦ Confirmation that the child is fasted appropriately
◦ Confirmation that an adult will be responsible for aftercare at home
◦ History of previous sedation (i.e. failed sedation, previous airway problems and con-
traindications to sedation)
◦ Physical examination and evaluation of the child, including a focused assessment of the
airway
◦ Details of chronic medication and whether the child took any medication on the day of
the procedure (e.g. anti-epileptics, methylphenidate)
◦ Details of any prescribed presedation medication at the facility, with details of the
prescribing practitioner, the person administering the medication and the time of
administration.
◦ Confirmation that the facility, equipment, monitoring devices and drugs were checked
for safe sedation practice (Appendix 2).

Question 52

During recovery
9.3.1 Postsedation monitoring chart

Question 53

.
9.3.2 Postsedation instructions

Question 54

9.3.3 Discharge scoring systems

Answer 54

modified Aldrete scoring system to evaluate the child, the score must be
≥ 9 before discharge from the recovery room can be considered. In addition, there must be no
complications related to the procedure (e.g. bleeding or vomiting).
When using the MPADSS, patients are
judged as fit for discharge when the score is ≥ 9 out of a maximum

Question 55

9.3.4 Documentation after discharge

Answer 55

A responsible adult, who is capable of taking care of the child unaided, must accompany the
child home after treatment under sedation. A dedicated and responsible adult should remain
with the child for the rest of the day and the responsibility of this caregiver at home extends
to ensuring that the child takes the normal prescribed medication and to contact the SP in
the case of adverse events. Both the accompanying adult and caregiver should receive the
telephone number of a medical practitioner, hospital and ambulance service in the event of
any procedure- or sedation-related adverse events. Sedation must not be administered if an
accompanying adult or caregiver is not available.
The parent/caregiver must be supplied with written and verbal information with regard to
postdischarge activities. This is extremely important as it has medico-legal implications.
Patients residing in rural areas must spend the first 24 hours post-procedure within a reasonable
distance of medical assistance, or must guarantee that they have access to a telephone in case
of complications.