Sedation in under 19s: using sedation for diagnostic and therapeutic procedures - NICE guideline

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Sedation in under 19s: using sedation for diagnostic and therapeutic procedures offers evidence-based advice on the care and treatment of children and young people under the age of 19 having sedation for therapeutic or diagnostic procedures. This guideline was previously called Sedation in children and young people: Sedation for diagnostic and therapeutic procedures in children and young people.

Key recommendations

Pre‑sedation assessment

For children and young people under the age of 19 having diagnostic and therapeutic procedures under sedation, what factors should be assessed to establish the need for sedation and reduce the risk of adverse events?

Why this is important

Some children need sedation, some need anaesthesia, and some need behavioural management alone. There is wide variation in how this choice is made. A recommended standard method of assessment could reduce variation and improve both success and safety when sedation is chosen. Furthermore, an assessment tool could help prevent unsuitable choices and improve the overall management of procedures in children.

The Guideline Development Group suggests an observational study to determine the important factors, followed by a consensus study to develop a tool. The assessment tool should be tested by a randomised comparison of children and young people who have been assessed routinely with those who have been assessed using the tool. The aim is for the assessment tool to improve sedation success and quality, and reduce any complications.

Training for personnel involved in sedation

For personnel involved in delivering sedation to children and young people under the age of 19 having diagnostic and therapeutic procedures, what training is required to achieve and maintain essential skills?

Why this is important

Potent drugs can cause unintended airway obstruction. Anaesthetists are skilled at managing airway obstruction because they practise the skills regularly. However, anaesthetists are a scarce resource so non‑anaesthetists need to learn how to manage airway obstruction. The skills that are needed have been identified but can these skills be attained and maintained by professionals who need them only occasionally? The Guideline Development Group suggests that a standard teaching method and assessment tool are developed. This would involve an observational study of a cohort of trainees, who can be assessed, trained and then reassessed at intervals to determine whether the training is successful and how often it is necessary.

Drugs combination

For children and young people under the age of 19 having minor painful procedures, what potent analgesic drugs can be combined with midazolam to provide safe moderate sedation?

Why this is important

Midazolam has a strong safety profile in inducing either minimal or moderate sedation. For painful procedures midazolam should be combined with analgesia. Ideally, analgesia is achieved by local anaesthesia. Sometimes local analgesia is insufficient and potent opioid analgesia is necessary. The combination of potent opioid and midazolam can cause deep sedation and airway obstruction. These effects can be managed safely but involve extra resources. If would be safer if a technique could be developed that was both reliable and had a wide margin of safety. Prospective and retrospective audit data are available to help guide the choice of opioid and the doses. A randomised controlled trial is needed to test the efficacy and safety of these combinations.

Development of a national registry of sedation

What are the safety and efficacy profiles of sedation techniques in current practice?

Why this is important

There are no data on the safety of sedation in the UK. A large prospective database of sedation cases, that includes data on drugs, procedures, the depth of sedation and complications, would help to define the safety of sedation and actively promote safe practice. The Guideline Development Group suggests that a national registry for paediatric sedation is established to help create a database with sufficient data.

Aim of sedation

The aims of sedation during diagnostic or therapeutic procedures include reducing fear and anxiety, augmenting pain control and minimising movement. The importance of each of these aims will vary depending on the nature of the procedure and the characteristics of the patient.

There are many sedation techniques available but there is insufficient guidance on which techniques are effective and what resources, including staff training, are required to deliver them safely.

You can read the guideline on NICE's website.