The guideline makes reference to the use of propofol, ketamine, opioid combinations and sevoflurane for sedation. There
NICE Guidelines for Sedation in Children and Young People RCoA/AAGBI response: July 2011 The Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) strongly support the principle of developing national evidence-based recommendations on sedation practice in children, and we welcome the NICE Guideline ‘Sedation in children and young people’ (1). NICE are to be congratulated for publishing such a comprehensive document, in particular for emphasising the need for appropriate standards of training and monitoring, the avoidance of ‘operator-sedationists’, and the need for appropriate preparation, post procedure care and use of suitable discharge criteria after sedation in children. The guideline includes a comprehensive discussion and literature review on the pharmacology and indications and uses of the various candidate sedative agents. After correspondence with NICE we would like to highlight some of the recommendations in the Guidelines that need more clarification. In particular: 1. The use of anaesthetic agents. The guideline makes reference to the use of propofol, ketamine, opioid combinations and sevoflurane for sedation. There is a narrow margin of safety when such drugs are used for moderate or deep sedation in children and, in addition, sevoflurane requires the use of specialised anaesthetic equipment. The RCoA and AAGBI believe that such drugs can only be administered safely by doctors with the relevant training in the delivery of anaesthetic agents, such as those detailed in the CCT in Anaesthetics 2010 to the intermediate level (attached as an appendix), in conjunction with training and acquisition of competence in ‘Airway rescue skills’ (see 2 below). If, as a result of the NICE guideline, these tasks are to be performed by ‘other healthcare workers’, full details of the training and competencies required should be identified by NICE and they should be to the standard we have outlined. 2. Airway rescue skills The effect of sedative drugs on conscious level is a continuum ranging from the awake state, through progressively deeper levels of sedation, to anaesthesia. Deeper levels of sedation require more advanced management because the child’s protective reflexes are affected and the child has the potential to progress to anaesthesia. There may be serious adverse effects if the level of sedation is greater than intended. The RCoA and AAGBI view is that rescue skills for deep sedation cannot be gained by simply undertaking basic, intermediate or advanced life support courses as they do not train personnel in airway management in the context of anaesthesia or sedation, only in the situation of cardiac arrest where there is likely to be complete loss of airway reflexes. For those undertaking moderate or deep sedation in children, formal and on-going training in airway management in anaesthetised children is essential to ensure acquisition and retention of airway management skills, particularly for those who do not use these skills as part of their regular clinical practice. There is a need to develop ‘accredited’ training programmes for the whole range of sedation practices in the UK. Additional competencies are required for deep sedation in children, such as those defined in the RCoA Intermediate Level curriculum for sedation practice (appendix 1). Training and assessment in the recognition and management of airway complications in children is essential. Regular refresher training and assessment should be mandated as part of continuing professional development for those administering sedation to children. 3. Guidance on the venue for sedation The venue where sedation is undertaken is an important safety consideration. Sedation for children in the context of a specialist children’s hospital is different from a district hospital where there may be a lower age limit defined for anaesthetic practice. Deep sedation outside a hospital environment is potentially hazardous even for experienced sedationists. In the event of a critical incident it may take some time for additional anaesthetic support to be mobilised to a remote location, particularly an isolated dental practice.
4. Sedation Committees The RCoA and AAGBI support the multi disciplinary approach to developing sedation practice (2). To this end we would strongly recommend the development of multidisciplinary sedation committees in all hospitals. Such committees would be expected to define the sedation practices and age limits for sedation in the hospital, review practice and learning from audit cycles, and would be expected to report critical incidents in sedation to the National Reporting and Learning Service (or equivalent in the new NHS Commissioning Board). The RCoA and AAGBI would wish to see that such reviews of practice are expected wherever sedation is administered, including venues outside of NHS hospital practice. References 1.
NHS National Institute for Health and Clinical Excellence. Sedation in children and young people http://guidance.nice.org.uk/CG112 (accessed 19th June 2011)
2.
Sury M, Bullock I, Rabar S, Demott K; Guideline Development Group. Sedation for diagnostic and therapeutic procedures in children and young people: summary of NICE guidance. BMJ. 2010 Dec 16;341:c6819. doi: 10.1136/bmj.c6819.
APPENDIX: Basic and Intermediate Training Guidance in Sedation Practice from the: CCT in Anaesthetics 2010. FOR NON-ANAESTHETISTS, ADVANCED AIRWAY RESCUE SKILLS TRAINING WILL BE REQUIRED IN ADDITION TO THE SEDATION COMPETENCIES OUTLINED BELOW.
Sedation [Basic] The use of sedation in clinical practice, particularly in non-theatre areas, is increasing and anaesthetists are frequently asked to provide/oversee its administration. It is essential that CT 1/2 anaesthetic trainees understand what is meant by conscious sedation [“A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation”] and how it is administered safely. Learning outcomes: To gain a fundamental understanding of what is meant by conscious sedation and the risks associated with deeper levels of sedation To be able to describe the differences between conscious sedation and deeper levels of sedation, with its attendant risks to patient safety Understands the particular dangers associated with the use of multiple sedative drugs especially in the elderly To be able to manage the side effects in a timely manner, ensuring patient safety is of paramount consideration at all times To be able to safely deliver pharmacological sedation to appropriate patients and recognise their own limitations Minimum clinical learning outcome: Provision of safe and effective sedation to ASA 1 and 2 adult patients, aged less than 80 years of age using a maximum of two short acting agents
Knowledge Competence
CS_BK_01
CS_BK_02 CS_BK_03 CS_BK_04
CS_BK_05
CS_BK_06
Assessment Methods
GMP
Can explain: • What is meant by conscious sedation and why understanding the definition is crucial to patient safety • The differences between conscious sedation, deep sedation and general anaesthesia • The fundamental differences in techniques /drugs used /patient safety • That the significant risks to patient safety associated with sedation technique requires meticulous attention to detail, the continuous presence of a suitably trained individual with responsibility for patient safety, safe monitoring and contemporaneous record keeping
A,D,E
1,2,3
Describes the pharmacology of drugs commonly used to produce sedation
A,C,E
1
A,C,E
1,2
A,C,E
1,2
A,C,E
1,2,3
A,C,E
1,2,3,4
Description
Explains the need for and means of monitoring the sedated patient including the use of commonly used sedation scoring systems Describes how drugs should be titrated to effect and how the use of multiple drugs with synergistic actions can reduce the therapeutic index and hence the margin of safety Describes the importance of recognising the following when multiple drug techniques are employed: • Increased potential for adverse outcomes when two or more sedating/analgesic drugs are administered and the importance of titrating to effect • Knowledge of each drugs time of onset, peak effect, duration of action and potential for synergism leading to unpredictable responses Can list which sedative drugs should not be given to the elderly [over 80 years of age], with reasons
CS_BK_07
Can explain the minimal monitoring required during pharmacological sedation
A,C,E
1
CS_BK_08
Describes the indications for the use of conscious sedation
A,C,E
1,2
CS_BK_09
Describes the risks associated with conscious sedation including [but not exclusively] those affecting the respiratory and cardiovascular systems
A,C,E
1,2
CS_BK_10
Can explain the use of single drug, multiple drug and inhalation techniques
A,C,E
1,2
CS_BK_11
Describes the particular risks of multiple drug sedation techniques
A,C,E
1,2,3
CS_BK_12 CS_BK_13
Outlines the unpredictable nature of sedation techniques in children [Cross ref paediatrics] Explains the need for robust recovery and discharge criteria when conscious sedation is used for out-patient procedures and the importance of ensuring appropriate escort arrangements are in place [cross ref day surgery]
A,C,E
1,2,3
A,C,E
1,2,3
Skills Competence
Description
Assessment Method
GMP
CS_BS_01
Demonstrates the ability to select patients for whom sedation is an appropriate part of clinical management
A,C,D
1,2,3
CS_BS_02
Demonstrates the ability to explain sedation to patients and to obtain consent
A,D
1,2,3
A,D
1,2,3
A,D
1,2,3
A,D
1,2,3
CS_BS_03 CS_BS_04 CS_BS_05
Demonstrates the ability to administer and monitor inhalational sedation to patients for clinical procedures [cross ref obstetrics] Demonstrates the ability to administer and monitor intravenous sedation to patients for clinical procedures Demonstrates the ability to recognise and manage the complications of sedation techniques appropriately, including recognition and correct management of loss of verbal responsiveness
Sedation [Intermediate] Learning outcomes: Builds on the knowledge, understanding and clinical skills in sedation developed in basic level training To be able to discuss where and when deeper levels of sedation may be indicated To be able to deliver pharmacological sedation to patients of all ages, safely and effectively, whilst recognising their own limitations Minimum clinical learning outcome: To recognise the important principal of minimum intervention, where the simplest and safest technique which is likely to be effective is used to achieve the clinical goal Provision of safe and effective sedation to any adult patient using multiple drugs if required
Knowledge Competence CS_IK_01 CS_IK_02 CS_IK_03 CS_IK_04 CS_IK_05 CS_IK_06 CK_IK_07
Description Explains what is meant by ‘deep sedation’ and when its use may be justifiable, identifies the associated risks and how these may be minimised to ensure patient safety is not compromised [see also CK_IK_07] Discusses how multiple drug use may enhance sedation techniques, whilst detailing how this increases risks Explains why it is essential to titrate multiple drugs [sedatives, analgesics and anaesthetic agents] to effect whilst recognising that the possibility of differing times of onset, peak effect and duration, can result in unpredictable responses Discusses the place of infusions compared to bolus doses as well as target-controlled infusions [TCI], and the pharmacological models and pump technology relevant to their use Discusses options for ‘alternative’ route of delivery of drugs used for conscious sedation including intra-nasal and rectal Discusses the unpredictable nature of sedation techniques in the ‘extremes of life’ and strategies for safe delivery [cross ref paeds] Discusses the use of sedation in the high risk patient and the advantages/disadvantages of using general anaesthesia as opposed to sedation to cover necessary investigations/procedures in such patients
Assessment Methods
GMP
A,C,E
1,2
A,C,E
1,2,3
A,C,E
1,2,3
A,C,E
1,2
A,C,E
1,2
A,C,E
1,2,3
A,C,D
1,2,3,4
Skills Competence CS_IS_01 CS_IS_02
CS_IS_03
Description Demonstrates the ability to select sedation techniques appropriate to management in patients of all ages [above 5 years [cross ref paeds] to the elderly] Demonstrates the ability to administer and monitor sedation techniques to all patients [identified in CB_IS_01 above] for appropriate clinical procedures, safely and effectively Demonstrate the ability to consider the following when considering the choice of sedation technique: • That no one technique is suitable for all patients and that the most appropriate technique is that based on minimum intervention, using the simplest and safest effective technique based on patient assessment and clinical need • That techniques using multiple drugs/anaesthetic drugs should only be considered where there is a clear clinical justification, having excluded simpler techniques
Assessment Method
GMP
A,C,D
1,2,3
A,D
1,2,3
A,D
1,2,3
