Preventing or minimizing the pain and anxiety of procedures to diagnose or treat medical conditions is an essential aspect of pediatric care. In an effort to promote safe and effective strategies that involve sedation, several medical organizations have published sedation guidelines. Unfortunately, terms used to describe levels of sedation have been inconsistent, confusing, and misinterpreted.
To address this problem, the American Academy of Pediatrics (AAP) (2002) has published a statement intended to clarify the term conscious sedation. In the AAP's 1992 statement on sedation for procedures, conscious sedation was defined as a state of sedation that "permits appropriate response by the patient to physical stimulation or verbal command, e.g., 'open your eyes.'" The intent was to describe a very minimal state of sedation that allows the child to make appropriate responses to pain, such as crying, saying "ouch," or moving away from the stimulus. The AAP now recommends replacing the term conscious sedation with moderate sedation as used by the American Society of Anesthesiologists (1999) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2001).
In the AAP 1992 statement, deep sedation was defined as "a medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. Deep sedation may be accompanied by a partial or complete loss of protective reflexes, including the inability to maintain a patent airway independently and to respond purposefully to physical stimulation or verbal command." For the purpose of monitoring, deep sedation and general anesthesia are synonymous. Both require support personnel whose only responsibility is to monitor the patient - not assist with the procedure. Also, at least 1 individual must be present who is trained in and able to provide pediatric basic life support, airway management, and cardiopulmonary resuscitation (CPR). AAP strongly recommends that one person be trained in advanced life support.
The 2002 statement also clarifies that the guidelines apply to all settings and to all practitioners who care for children. Nurses can be instrumental in ensuring that these guidelines are appropriately and consistently implemented. With the current nursing shortage, nurses may be pressured to both monitor the child and assist with the procedure. Since children can develop respiratory depression/apnea in seconds, nurses must protect their practice by insisting that they can monitor or assist, but not do both.
November 17, 2002
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