This policy applies to:

Lucile Packard Childrens Hospital

Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 1 of 24
Departments Affected:
All Departments


Contents:
I. Purpose
II. Policy:
III. Definitions:
A. Minimal Sedation
B. Moderate Sedation
C. Deep Sedation
D. Anesthesia
IV. Equipment
V. Medication
VI. Process/Procedures
Moderate vs Deep Sedation:
A. Locations
B. Process
1. Pre-procedure Physician Responsibility
2. Pre-procedure Nursing Responsibility
3. Intra-procedure Monitoring and Care Requirements
4. Post-procedure Monitoring and Care Requirements
5. Management of Emergency Situations
VI. Requirements:
A. Credentialing
B. Personnel
C. Ongoing Performance Improvement and Outcomes Measurement
VII. Related Documents
VIII. Appendices


I. PURPOSE

The administration of drugs to produce sedation can have the unintended effect of
compromising a patient's protective reflexes, therefore this policy and procedure
are intended create the framework and outline the operational requirements to
facilitate a standardized approach to provide patients at Packard with the benefits
of sedation/analgesia while minimizing the associated risks. For the purposes of
this document, a clear distinction has been made between minimal, moderate,
and deep sedation, but moving from a state of consciousness to deep sedation
and further to general anesthesia is a continuum. This continuum depends on
individual response, age, health status, and drug combinations used.


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 2 of 24
Departments Affected:
All Departments






II. POLICY STATEMENT

Administration of any drug or drugs to sedate a patient in association with a
procedure requires implementation of the sedation policy.

III. DEFINITIONS

A. Minimal sedation/analgesia:
A drug-induced state during which patients remain conscious and
respond to verbal commands. Although cognitive function and
coordination may be impaired, consciousness, ventilatory and
cardiovascular functions are unaffected. Gag reflex and other protective
airway reflexes are maintained. This state may be referred to as
anxiolysis.

B. Moderate sedation/analgesia:
A drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or accompanied
by light tactile stimulation. No interventions are required to maintain a
patent airway, and spontaneous ventilation is adequate. Gag reflex and
other protective airway reflexes are maintained. Cardiovascular function is
usually maintained. Reflex withdrawal from a painful stimulus is not
considered a purposeful response.

C. Deep sedation/analgesia:
A drug-induced depression of consciousness during which patients
cannot be easily aroused but respond purposefully following repeated or
painful stimulation. The ability to independently maintain ventilatory
function may be impaired, and gag reflex and other protective airway
reflexes may be impaired or absent. Patients may require assistance in
maintaining a patent airway and spontaneous ventilation may be
inadequate. Gag reflex and other protective airway reflexes may be
impaired. Cardiovascular function is usually maintained. Reflex
withdrawal from a painful stimulus is not considered a purposeful
response.


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 3 of 24
Departments Affected:
All Departments


D. Anesthesia:
A drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients often require
assistance in maintaining a patent airway, and positive pressure ventilation
may be required because of depressed spontaneous ventilation or drug-
induced depression of neuromuscular function. Gag reflex and other
protective airway reflexes are absent. Cardiovascular function may be
impaired.

IV. EQUIPMENT

A. Use equipment that monitors and measures the following
1. Respiratory rate
2. Heart rate
3. EKG
4. Blood Pressure
5. Blood Oxygen saturation
6. ET CO2 levels (for patients receiving moderate or deep sedation)
B. Emergency equipment immediately available:
1. Code cart
2. Suction equipment (wall suction or portable suction generator,
suction canister, suction tubing, tonsil-tip or Yankauer suction, red
rubber catheters, or the equivalent, sterile tracheal suction catheters)
3. Self-inflating manual resuscitation bag and mask
4. Oral and Nasopharyngeal Airways, endotracheal tubes,
laryngoscopes of appropriate sizes, and a qualitative or quantitative
CO
2
detection device.
V. Medication
A. Moderate Sedation: Includes medications as ordered for sedation
(Refer to LPCH Housestaff Manual)
B. Deep Sedation: includes medications as listed in LPCH housestaff
manual
C. For the purpose of procedural sedation, drugs that are anesthetic
agents, such as propofol (Diprivan), and ketamine (Ketalar),
etc., must be administered by an appropriately credentialed
anesthesiologist, or by a credentialed physician using a written
protocol that has been approved by the Sedation Committee (see
Appendix E).

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 4 of 24
Departments Affected:
All Departments


VI. PROCESS/PROCEDURE

LOCATIONS: Sedation for procedures will be completed whenever possible
in locations as specified in the Location Matrix for Sedation at LPCH (See
appendix F)

These standards apply to all LPCH patients in all locations where invasive and/or
diagnostic procedures are performed under sedation, with the following
clarifications:
A. Locations staffed by Anesthesiologists:
When general anesthesia, regional anesthesia, or sedation is
administered by an anesthesiologist at LPCH or SHC, at a
minimum the sedation policy will apply, but may be augmented by
the policies of the Department of Anesthesia, pertinent to specific
locations.
B. Pediatric, Cardiovascular, and Neonatal Intensive Care Units:
1. When patients who are not intubated or mechanically ventilated
receive sedation for any procedure, the provisions of the Sedation
Policy will apply.
2. When patients who are intubated and currently receiving sedation
require a deeper level of sedation in order to have a procedure
performed, the documentation requirements of the Sedation Policy
will apply, including the need for obtaining consent.
3. The provisions of the Sedation Policy do not apply to patients who
are administered sedatives either by continuous infusion or by
intermittent boluses for the purpose of maintaining a continuously
sedated state to facilitate mechanical ventilation or other routine
ICU therapy that does not itself require an informed consent.

PROCESS

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 5 of 24
Departments Affected:
All Departments


The standards below apply to the administration of moderate sedation and deep
sedation. Note that the standards for practitioner presence and practitioner
completion of preparation and evaluation differ for moderate and deep sedation.
These standards do not apply to the administration of minimal sedation (e.g.
anxiolysis).

Moderate Sedation: requires either a physician credentialed in moderate sedation,
or a moderate sedation credentialed physician assistant or nurse practitioner,
working under a protocol with the supervision of a responsible physician.

Deep Sedation: requires an intensive care physician credentialed for deep sedation
or an anesthesiologist


A. Pre-Procedure Practitioner Responsibility:
1. Ensure there is a complete History and Physical Examination
documented as specified in the hospital bylaws. Complete and
document a pre-procedure assessment, with a focus on the
following elements of the H&P, within 48 hours of the planned
sedation:
a. History:
(1) Acute and chronic medical problems
(2) History of adverse reactions to anesthesia or
sedative medication, potential risks or problems
(3) Allergies
(4) History of airway anomalies (see Appendix A)
(5) Any history of apnea
(6) Current medications
(6) Recent dosing of sedative and/or opioid
medications
(7) Last food and fluid intake
b. Physical Examination:
(1) Airway evaluation
(2) Cardiovascular evaluation
(3) Pulmonary evaluation
(4) the patient's general condition/neurologic status
c. Assign American Society of Anesthesiologists Physical
Status (see Appendix B)


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 6 of 24
Departments Affected:
All Departments


2. For a patient with unstable or poorly controlled systemic disease or
organ dysfunction (ASA 3), obtain a consultation with a member of
one of the following departments or divisions as appropriate to the
childs underlying disease state and condition:
a. Department of Anesthesia
b. Division of Critical Care
c. Division of Pediatric Cardiology
d. Division of Neonatology
3. Referral to, or consultation by, the Department of Anesthesia is
required for ASA Physical Status 4 or 5 patients (see Appendix B)
and all patients with congenital or acquired airway abnormalities
(see Appendix A), unless under the care of an intensivist or a
neonatologist in an intensive care environment.
4. Practitioner responsible for and ordering sedation must obtain and
document informed consent for sedation.
5. Establish and document a plan for sedation, and write or enter
orders in the Electronic Health Record for 1. NPO status, (See
Appendix C), 2. sedative medications, and 3. intravenous access if
required.
6. Immediately prior, within 1 hour, of administering the sedation,
review and reassess the following:
a. the pre-sedation assessment
b. sedation plans
c. current patient condition including recent dosing of sedative and
opioid medications and last food and fluid intake
d. Document this reassessment


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 7 of 24
Departments Affected:
All Departments


B. Pre-Procedure Nurse Responsibility
1. Initiate the pre-procedure checklist and Universal Protocol, located
in the Ad Hoc charting section of the Electronic Health Record.
Satellite units will document on the paper Pre-Procedure Checklist
form. Outpatients also require the short form nursing assessment
and nursing history.
2. Notify the manager if the appropriately trained staff is not available
or if additional medical evaluation is required.
3. If an outpatient, ensure that the patient has transportation home and
will be accompanied by a responsible adult.
4. Verify that a completed history, physical, pre-sedation assessment,
and sedation informed consent are documented. Also if needed,
consultation from an anesthesiologist or appropriate intensive care
or cardiology specialist. (See A. 2. and 3 above)
5. Confirm and document NPO status. If not in compliance with
guidelines, notify the responsible physician, physicians assistant,
or nurse practitioner.
6. Assess and document the pre-sedation condition of the patient using
the Recovery Scoring Tool on the paper or Interactive Flowsheet.
This includes:
a. Baseline Level of consciousness
b. Baseline Level of pain
c. Baseline Sp02
d. Baseline capillary refill
e. Baseline level of nausea or vomiting
7. Document baseline vital signs in the Interactive Flowsheet
8. Ensure that patients have patent IV access; mandatory for those
undergoing deep sedation, suggested for all patients undergoing
sedation but at the discretion of the attending physician or
practitioner ordering the sedation
9. Ensure that the "Pediatric WHO Checklist" is completed prior to
initiation of the procedure and documented on the Universal
Protocol (See appendix G).

C. Intra-Procedure Monitoring and Care Requirements (also see
Appendix D)
1. Continuous observation and monitoring of the patient during
administration of sedation for:
a. Airway patency and respiratory rate
(including ETCO2 value for moderate and deep sedation)

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 8 of 24
Departments Affected:
All Departments


b. Hemoglobin oxygen saturation and pulse rate using pulse
oximetry
c. Electrocardiogram
d. Level of consciousness
e. Occurrence of adverse reactions
2. Intermittent blood pressure monitoring as follows:
a. For moderate sedation: measurement and documentation
on the interactive flowsheet of blood pressure after
administering the sedative drugs, and intermittent
monitoring of blood pressure as follows:
(1) Blood pressure will be recorded every 15 minutes
except for the following patients, for whom blood
pressure will be recorded every 5 minutes:
(a) Patients with a history of hypertension,
whether treated or not at the time of the
procedure
(b) Patients who have had a renal transplant
(c) Patients with acquired or congenital heart
disease
(d) Patients with a history of cardiac arrhythmias
(e) Patients who have or are at risk for
dehydration.
(f) Patients less than 52 weeks Post-conceptional
age
(g) Patients with a history of sleep apnea

b. For deep sedation: measurement and documentation on
the paper or interactive flowsheet of blood pressure after
administering the sedative drugs, and intermittent
monitoring of blood pressure every 5 min.
3. Documentation will be made of observations and monitoring, the
names, dosage, route, and time of all drugs administered and
patients response to medication on the paper or interactive
flowsheet and MAR
4. If the MD administers a medication during the procedure, the nurse
must document the medication administration on the paper or
electronic MAR noting the name of the MD who administered the
medication in the Performed By field.


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 9 of 24
Departments Affected:
All Departments


5. Documentation for patients receiving sedation or anesthesia by an
anesthesiologist will comply with Anesthesia Department processes

6. The practitioner responsible for the sedation must be
immediately available during the administration of the sedative
medication, or designate another qualified practitioner who will be
so available. The identity and beeper number and/or direct phone
link for the responsible practitioner must be communicated to the
nurse administering the sedation.
7. If deep sedation is planned, a responsible physician must be
present, with no other conflicting immediate responsibilities.
D. Post-Procedure Monitoring and Care Requirements
1. A practitioner, credentialed in sedation,
a. Must remain immediately available throughout the recovery period
b. If the patient requires reversal medications and/or does not meet
discharge criteria within 1 hour of admission to recovery, the practitioner
must evaluate the patient and order their discharge to the next appropriate
level of care.
c. If no recovery (PACU) or sedation-level-2 competent nursing staff is
available, a practitioner credentialed in sedation will remain with the
patient until he/she is recovered.
2. A nurse, recovery (PACU) or sedation-level-2 competent, will remain
with the patient through the recovery period and complete the following:
a. Using the same protocol as during the procedure, continually assess
and monitor the patient for a minimum of 30 minutes post-
procedure, and continue until the patient meets the following post-
procedure discharge criteria. (see appendix D for frequency of
monitoring required during recovery from sedation) .
b. The following criteria indicate that the patient has recovered
sufficiently to safely return home if an outpatient, or if an inpatient,
to return to pre-procedure level of care.
i. Able independently to maintain an airway
ii. SpO
2
at the patients baseline level
iii. Stable cardiovascular status. An adequate post-procedure
blood pressure must be recorded.
iv. Easily aroused, able to talk (if age appropriate), or is at
pre-procedure baseline level of consciousness
v. If reversal agent given, monitor for 1 hour before
discharge.
vi. For outpatients:

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 10 of 24
Departments Affected:
All Departments


(1) The patients discharge from the hospital must be
ordered by a physician, or meet established
discharge criteria.
(2) A responsible adult must be present to escort the
patient home.
(3) The patient or parent/guardian must be given
written post-procedure instructions.
c. Document the post-procedure assessment using the Recovery
Scoring Tool located on the paper or Interactive Flowsheet. If the
patient does not return to the documented baseline assessment
within one hour, continue to monitor frequently and notify the MD.
d. For infants receiving sedation, please see the LPCH Policy on
Admission of Infants after Anesthesia or Sedation

E. Management of Emergency Situations
1. Any practitioner ordering, responsible for, or supervising a trainee
ordering or responsible for sedation, and any practitioner
monitoring the patient must be competent to institute appropriate
emergency care if the patients airway, breathing, or circulation
becomes compromised.
2. Immediately report all untoward effects (e.g. respiratory or
hemodynamic instability, adverse reaction to drugs, altered level of
consciousness, prolonged drug effect, etc.) to the responsible
practitioner and intervene as ordered by the responsible practitioner.
3. If a patients condition deteriorates, STAT page or call the direct
contact phone line for the responsible practitioner; consider calling
the rapid response or code team if appropriate.

4. For urgent or emergent assistance for patients receiving sedation or
anesthesia by an anesthesiologist, emergency protocols delineated
in the perioperative policies and procedures will apply.

VII. Staffing Requirements

Individuals ordering, administering, and/or supervising moderate and/or deep
sedation must be qualified and have the appropriate credentials to manage patients
at whatever level of sedation is achieved, either intentionally or unintentionally.
Residents ordering sedation must be supervised by an attending physician
who is also credentialed to manage that planned level of sedation.


This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 11 of 24
Departments Affected:
All Departments




A. Physician, Physicians Assistant, and Nurse Practitioner Competency
Requirements
Privileges for Minimal Sedation:
1. Completion of a sedation teaching module.
2. Successful completion of a written examination to test the
knowledge of medications being given, and principles of
physiologic monitoring including the interpretation of ECG and
arrhythmia recognition.
Privileges for Moderate Sedation
1.

Must meet all Criteria for Minimal Privileges

2. Demonstration of sedation and airway skills supervised by
anesthesiologist or intensive care physician credentialed for deep
sedation: may take place in simulated environment with infant sized
simulation equipment or in operating/sedation environment with a
patient.


Privileges for Deep Sedation
1. Must meet all criteria for Moderate Sedation
2. Must be board certified or in active participation in pediatric critical
care, or adult critical care, or board certified or board eligible in
anesthesiology
Physician Trainees
1.


must meet all criteria for minimal sedation

2. must be immediately supervised by physician credentialed in the
level of sedation/anesthesia planned for the procedure

B. Nursing Competency Requirements:
Only RNs who complete Sedation Level II competency may administer
minimal or moderate sedation at LPCH. To achieve Sedation Level II,
the RN must complete:
1. The Sedation Level I Health Stream training module and post-test
on an annual basis

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 12 of 24
Departments Affected:
All Departments


2. The Sedation Level II validation of sedation skills through
supervised demonstration. Validation of skill will be completed
through a simulation-based training and testing curricula or by
observation of skill by a Sedation Level II competent RN.
C. Personnel
1. Responsible practitioner: Each patient undergoing sedation must
have a credentialed practitioner immediately available to respond to
adverse events occurring during the sedation or during recovery
from sedation. The responsible practitioner must have at a
minimum competency-based education, training, and experience in
evaluating patients before moderate or deep sedation and
anesthesia, and in performing moderate or deep sedation, including
rescuing patients who slip into a deeper than desired level of
sedation or analgesia. This includes the following:
a. Moderate sedation: qualification to rescue patients from
deep sedation, and competence to manage a compromised
airway and provide adequate oxygenation and ventilation.
b. Deep sedation: qualification to rescue patients from
general anesthesia and are competent to manage an
unstable cardiovascular system as well as a compromised
airway and inadequate oxygenation and ventilation.
2. Designated sedation monitor: A designated physician, physicians
assistant, nurse practitioner, RN, or licensed practitioner other than
the person performing the procedure must be present to administer
sedative drugs, observe the patient, measure and document the
required physiologic parameters throughout the procedure, and
assist in any supportive or resuscitative measures as required.

3.
Medication administration:
a. A physician, physician's assistant, nurse practitioner, or RN
may administer the medications used for minimal or
moderate sedation.
b. A physician, or CRNA must either administer medications
for deep sedation, or be present to give directed order for
specific doses of medications to be given.




This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 13 of 24
Departments Affected:
All Departments


VIII. Performance Improvement:
. There will be periodic quality management evaluations of policy
compliance, performance and outcome.
B. Related to sedation, all reported adverse events or adverse drug reactions
will be reviewed; in addition, items to be reviewed, tracked, or audited will
include cases in which the following occur:
1. Administration of naloxone, flumazenil,
epinephrine, or atropine.
2. Manual intervention to support airway or breathing
3. Unplanned admission to a higher level of care,
including unplanned admission of an outpatient
4. Cancellation of a procedure due to unsuccessful
sedation.
5. Cardiopulmonary resuscitation
6. Death.




IX. RELATED DOCUMENTS

LPCH Policies and Bylaws that May Apply to Sedation Cases
A. Universal Protocol: Verification of Patient Identity, Correct Surgical Site
and Time Out

B. Discharge by Criteria, Outpatients and PACU Transfers Only

C. Code Blue Management

D. Anesthesia; Intra-Operative Care and Monitoring

E. Informed Consent Policy

F. Protocol for use of intravenous anesthetic agents by Critical Care Medicine
physicians to facilitate procedures in non-intubated patients.

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 14 of 24
Departments Affected:
All Departments


G. Housestaff Manual: Medications
H. Policy : Admission of Infants after Anesthesia and Sedation


IX. APPENDICES

A. Example of Airway Assessment for Sedation and Analgesia
B. American Society of Anesthesiologists Physical Status (PS) Classifications
C. NPO Policy
D. Intra-procedure Monitoring Requirements
E. Request for Sedation Strategy That Differs from Sedation Policy
F. Matrix for Sedation Locations at LPCH
G. Pediatric WHO Checklist


X. DOCUMENT INFORMATION

A. Legal Authority/References
1. American Academy of Pediatric Dentistry (1997). Guidelines for
the elective use of pharmacologic conscious sedation and deep
sedation in pediatric dental patients. Pediatric Dental Journal.
19:48-52.
2. American Academy of Pediatric Dentistry (1985). Guidelines for
the elective use of conscious sedation, deep sedation, and general
anesthesia in pediatric patients. Committee on Drugs Section on
Anesthesiology. Pediatrics, 76(5) 317-321
3. American Academy of Pediatrics Committee on Drugs (1992).
Guidelines for monitoring and management of pediatric patients
during and after sedation for diagnostic and therapeutic procedures.
Pediatrics 89:1110-1115.
4. American College of Emergency Physicians. (1998)Clinical policy
for procedural sedation and analgesia in the emergency department
Annals of Emergency Medicine 31 663-677.
5. American Dental Society of Anesthesiologists (1998). A. D. S. A.
guidelines of intra-operative monitoring of patients undergoing
conscious sedation, deep sedation and general anesthesia. J ournal of
Connecticut State Dental Association 62:210-211.

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 15 of 24
Departments Affected:
All Departments


6. American Medical Association Council on Scientific Affairs: The
use of pulse oximetry during conscious sedation (1993). J AMA
270:1463-1458.
7. American Society of Anesthesiologists (1996). Practice guidelines
for sedation and analgesia by non-anesthesiologists. Anesthesiology
84:459-471.
8. American Society of Anesthesiologists.(2009) Standards:
Continuum of Depth of Sedation/Definition of General Anesthesia
and Levels of Sedation/analgesia. Accessed at:
http://www.asahq.org/publicationsAndServices/standards/20.pdf
9. Chudnofsky CR (1997). Safety and efficacy of flumazenil in
reversing conscious sedation in the emergency department;
Emergency medicine conscious sedation study group. Academic
Emergency Medicine. 4:944-50.
10. Cot CJ , et al. (2000). Adverse Sedation Events in Pediatrics: A
critical Incident analysis of contributing factors. Pediatrics 105:805-
14.
11. Cot CJ : Sedation for the pediatric patient (1994). Pediatric Clinics
of North America 41: 31-58.
12. Holzman RS, et al. (1994). Guidelines for the sedation by non-
anesthesiologists during diagnostic and therapeutic procedures.
Journal of Clinical Anesthesia 6; 265-76.
13. Kao et al. (1999). A survey of post-discharge side effects of
conscious sedation using chloral hydrate in pediatric CT and MR
imaging. Pediatric Radiology. 29:287-90.
14. Macpherson CF, Lundblad LA (1997). Conscious sedation of
pediatric oncology patients for painful procedures: development and
implementation of a clinical practice protocol. Journal of Pediatric
Oncology Nursing. 14:33-42.
15. Malviya S et al. (1997). Adverse events and risk factors associated
with the sedation of children by nonanesthesiologists. Anesthesia &
Analgesia 85:1207-13.
16. Mayers, DJ , et al. (1991). Chloral hydrate disposition following
single-dose administration to critically ill neonates and children.
Developmental Pharmacology and Therapeutics 16: 71-7.
17. Morton NS, et al. (1998). Development of a selection and
monitoring protocol for safe sedation of children. Pediatric
Anesthesia 8:65-8.

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 16 of 24
Departments Affected:
All Departments


18. National Institutes of Health (1985). Consensus conference
anesthesia and sedation in the dental office Journal of American
Medical Association 254:1073-1076.
19. Nelson, J r. MD (1994). Commentary: Guidelines for the monitoring
and care of children during and after sedation for imaging studies.
American Journal of Radiology 160: 581-582.
20. Pediatric Committee of the American College of Emergency
Physicians.(1994) Pediatric analgesia and sedation. Annals
Emergency Medicine February 23: 237-250.
21. Somerson SJ , et al. (1995). Insights into conscious sedation.
American of Journal of Nursing 95(6) 26-33,
22. Strain, et al. (1986). Administration of intravenous pentobarbital
sodium for sedation in pediatric CT. Radiology 161:105-108.
23. Yaster M, et al. (1997). The Pediatric Pain and Sedation Handbook.
St. Louis, MO: Mosby-Yearbook, Inc.

B. Author/Original Date
LPCH Sedation Committee; 5/04

C. Distribution and Training Requirements
1. This policy resides in the Patient Care Manual of Lucile Packard
Childrens Hospital. Web URL:
https://intranet.lpch.org/formsPoliciesReferences/policies/hospitalW
ide/ patientCare/sedationPolicy.html
2. New documents or any revised documents will be distributed to
Patient Care Manual holders. The department/unit/clinic manager
will be responsible for communicating this information to the
applicable staff.

D. Review and Renewal Requirements
This policy will be reviewed and/or revised every three years or as required
by change of law or practice.

E. Review and Revision History
1/05; 11/06,
Stephanie Martian, RN, Clinical Transformation, 09/07
E. Krane, 05/10
A. Honkanen, 6-2010, 6/2011
F. Approvals
Sedation Committee; 11/06

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 17 of 24
Departments Affected:
All Departments


Medical Executive Committee: 01/07; 10/11
Clinical Practice Committee; 1/07, 05/10



This document is intended for use by staff of Stanford Hospital & Clinics and/or Lucile Packard
Childrens Hospital.
No representations or warranties are made for outside use.
Not for outside reproduction or publication without permission.

Appendix A:

Example of Airway Assessment for Sedation and Analgesia

A. History
1. Previous problems with anesthesia or sedation
2. Stridor, snoring, or sleep apnea
3. Dysmorphic facial features (e.g. Pierre-Robin syndrome, Trisomy
21)
4. Advanced rheumatoid arthritis

B. Physical examination
1. Habitus
- Obesity (especially involving the neck and facial
structures)
2. Head and neck
- Short neck
- Limited neck extension
- Decreased hyoid-mental distance (<3cm in an adult)
- Neck mass
- Cervical spine disease or trauma
- Tracheal deviation
3. Mouth
- Small opening (<3cm in an adult)
- Protruding incisors
- Loose or capped teeth
- High arched palate
- Macroglossia
- Tonsillar hypertrophy
- Uvula obscured by base of tongue or tonsils

This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 18 of 24
Departments Affected:
All Departments


4. J aw
- Micrognathia
- Retrognathia
- Trismus
- Significant malocclusion

Appendix B:

American Society of Anesthesiologists Physical Status (PS) Classifications

PS-1: A healthy patient without illness or disease

PS-2: A patient with localized disease or a systemic disease in good control

(examples: VSD without CHF, juvenile onset diabetes mellitus in good
control, asymptomatic reactive airway disease, localized or systemic
infection under treatment)

PS-3: A patient with systemic disease that is not controlled

(examples: VSD with CHF, cystic fibrosis, cyanotic congenital heart
disease, uncontrolled hypertension, infection with fever or sepsis)

PS-4: A patient with a localized or systemic disease that represents an
immediate threat to life; a patient who is not expected to survive
without the planned procedure

(examples: acute or end-stage organ failure, hypotension or shock,
DKA, coma of any cause)

PS-5: A moribund patient who is not expected to survive with or without the
planned procedure.

E: Added to above classifications to designate an unplanned emergency
procedure (example: PS-2E)



This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 19 of 24
Departments Affected:
All Departments


Appendix C:

NPO Policy

All patients should be NPO prior to moderate and/or deep sedation, and should
not have any risk factors for aspiration. The use of sedation must be preceded by
an evaluation of food and fluid intake.

For infants and children over 3kg in weight, minimum NPO* intervals are:

A. >8 hours for heavy solids
B. >6 hours for milk, formula, barium contrast, light solids
C. >4 hours for breast milk
D. >2 hours for clear liquids
E. Pregnant and postpartum women require special consideration regarding
NPO* status; the minimum times above may be inadequate to assure
gastric emptying

F. Patients with various medical conditions may require longer NPO times to
ensure adequate gasric emptying; times will be adjusted at the discretion of
the anesthesiologist or physician administering sedation as required.
For infants under 3kg in weight, the minimum NPO* interval depends upon
routine feeding frequency:
A. >than the usual duration between feedings for formula, breast milk,
barium contrast, etc. For example, if a former premature weighing 2 kg is
fed formula or breast milk every 3 hours, then NPO time must be >3
hours.
B. Formula and breast milk and fluids may be administered to the jejunum
through a stoma, other than the nose or mouth continuously
* NPO here indicates nothing by mouth, nasogastric tube, or gastrostomy tube.
Please note that the above instructions are meant to guide the practitioner. Many
patients have special needs and these must be considered in regard to preparing
them for anesthesia and / or sedation. The anesthesia nurse practitioner or the
anesthesia resident (after 5pm ) should be consulted for questions related to NPO
instructions.





This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 20 of 24
Departments Affected:
All Departments


Appendix D:

Intraprocedure Sedation Level Recovery
Parameter Minimal Moderate Deep
Continuous
Observation

Continuous Pulse
Oximetry

Continuous ECG
ETCO2
Blood Pressure
q-15 min

Blood Pressure
q-5 min

Documentation
q5m

Documentation
q15m




This policy applies to:
Lucile Packard Childrens Hospital
Date Written or Last Revision:
J UNE 2011
Name of Policy:
Sedation Policy
Page 21 of 24
Departments Affected:
All Departments


Appendix E:

Request for Sedation Strategy That Differs from Sedation Policy

The introduction of a new sedation technique or procedure that differs from this
policy that improves the quality of care for patients, or the use of anesthetic agents
such as propofol, ketamine, sodium thiopental, or etomidate for sedation, requires
that a written request be formally submitted to the Sedation Committee. The
following information and criteria must be included in a department's or division's
request. Requests may be submitted to the Sedation Committee Chair via the
LPCH Medical Staff Office
1. Names of supervising physician(s).
2. Location of the practice change.
3. Procedures for which the new procedure will be used.
4. Desired level of sedation.
5. Patient inclusion/exclusion criteria.
6. Proposed regimen: drug(s), dosage(s), route, and frequency of
administration.
7. Education plan for staff responsible for drug administration.
8. Desired outcome and monitoring plan:
a. Purpose statement including pertinent background information.
b. How will you measure an improvement over current practice?

(1) Include a summary of baseline measures that will be used to
determine the effectiveness of the changes (i.e. chart review
of x patients).
(2) Specify the desired goal and outcome.
9. Results: Data must be presented to the Committee 6 months after
implementation.

All aspects of the current policy will apply unless a specific change in
practice is proposed within the request. The Sedation Committee will
review the request at its next quarterly meeting and notify the
department/division of the Committee's decision in writing. All requests
will be approved for a 6-month pilot period, after which pilot results must
be presented to the Committee for final review and approval.



This policy
Lucile
Name of Po
Sedation Po
Departmen
All Departm



Appe
Requ


applies to:
Packard C
olicy:
olicy
nts Affected:
ments
endix F: Mat
uirements
Childrens
:
trix for Seda
s Hospital
ation Require ements and L
D
Locations
Date Writte
Page 2
n or Last R
J UN
22 of 24
Revision:
NE 2011

This policy
Lucile
Name of Po
Sedation Po
Departmen
All Departm






Appe
Locat









applies to:
Packard C
olicy:
olicy
nts Affected:
ments
endix F. (con
tions
Childrens
:
nt.):
s Hospital
DDate Writte
Page 2
n or Last R
J UN
23 of 24
Revision:
NE 2011

This policy
Lucile
Name of Po
Sedation Po
Departmen
All Departm


Appe


WHO

applies to:
Packard C
olicy:
olicy
nts Affected:
ments
endix G:
O Surgical S
Childrens
:
afety Check
s Hospital
klist:
DDate Writte
Page 2
n or Last R
J UN
24 of 24
Revision:
NE 2011