Credentialing and Recredentialing for Pediatric Sedation

Given the complexity of the knowledge and skills required for the safe conduct of pediatric sedation, compounded by the diversity of sedation practitioners, a formal process for training and credentialing is recommended. Credentialing and recredentialing are the processes by which hospitals collect and review a practitioner’s qualifications as part of the initial step in granting clinical privileges. Regulatory boards mandate that each institution have a system in place that defines qualification requirements and approval of privileges for clinical practices such as procedural sedation. The credentialing process recurs at 2- to 3-year intervals along with renewal of privileges. Recredentialing of privileges may differ from the initial process.

Nursing Perspective

The nursing process can be used in the safe and effective delivery of pediatric sedation care. Nurses contribute to the direct care of sedated patients by developing competency and expanding knowledge and expertise within their specialty. While the provision of care to patients and families is of paramount importance, ensuring an environment conducive to delivery of safe, quality care by the healthcare team is another fundamental aspect of nursing. Management of sedation, analgesia, and anxiety in pediatric procedural sedation is an intrinsically multidisciplinary process that involves nursing, physicians, child life specialists, and other healthcare providers. In general, pediatric procedural sedation is a relatively new specialty with limited data on the role of the pediatric nurse in this multiprofessional team. It is an opportunity for nursing to collaborate with other healthcare professionals to establish guidelines and protocols to facilitate optimal patient care and efficiency as well as to share and expand their knowledge base and clinical skill set. Specialty certification and credentialing, team concept values, and the evolving role of the sedation nurse are all elements to consider within pediatric procedural sedation from the nursing perspective.

The NICE Guidelines and Pediatric Sedation in the United Kingdom

Pediatric procedural sedation is required for children across the globe in a wide variety of circumstances. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) is a government organization whose purpose is to provide guidelines to help ensure that patients receive effective, good-value healthcare across the whole of the National Health Service. In 2010 NICE published a guideline for the use of pediatric sedation. The overarching aims were to review the safety and efficacy of sedation for common procedures and to form a consensus view on the necessary resources to do this safely. This chapter summarizes the key recommendations and describes how pediatric sedation has since evolved in the UK.

Cutaneous

Lacerations, abscesses, and burns are common presenting complaints evaluated in outpatient settings, urgent care centers, and emergency departments. These conditions are often painful, and the treatment procedures may cause additional pain or anxiety. The location and severity of the wound and the chronologic and developmental age of the patient influence the need for local anesthesia or systemic medications to make procedures tolerable for the patient. This section discusses the safe administration of medications to facilitate laceration repair, incision and drainage of abscesses, and burn debridement. General principles of the types of analgesia or sedation that are useful for these procedures are discussed.

Cardiology

Congenital heart disease is the most common type of birth defect and is estimated to affect nearly 1% of all births per year in the United States. Echocardiograms are necessary to fully evaluate these defects, and depending on the age of the child, sedation may be required to ensure optimal imaging. This chapter discusses the sedation/anesthesia options for transthoracic echocardiography, transesophageal echocardiography, and cardioversion. For all of these procedures high-risk patients should be triaged to a pediatric anesthesia provider and in some cases, a pediatric cardiac anesthesiologist. Transthoracic echocardiograms can be completed with distraction and/or minimal sedation with oral or intranasal midazolam. If moderate sedation is required due to patient characteristics or previous history of failure with minimal sedation, intranasal dexmedetomidine is a good option. Transesophageal echocardiography is an invasive procedure; patients <2 years of age should be intubated and those >2 years of age can maintain a native airway with deep sedation with propofol. The need for cardioversion is infrequent in pediatrics but when needed, propofol is a good choice.

Pulmonary

Sedation is used for virtually all children undergoing fiberoptic airway endoscopy. Because the sedating and procedural physicians “share the airway,” overlapping responsibilities necessitate coordination between them. This section describes the components of a directed preprocedural assessment, emphasizes the need for communication with the bronchoscopist, gives an overview of sedation options, and outlines anticipated complications. Procedural considerations for common FAE indications are highlighted, along with how they influence the choice of setting and sedation agents and methods. Use of short-acting and ultrashort-acting agents will be stressed, as they are ideal sedatives to allow rapid return of normal respiratory drive. Adjuvant medications to facilitate the procedure will also be reviewed.

Solid Organ Biopsies

While solid organ biopsies are routinely done on adults with only local anesthesia or minimal sedation, children frequently require deep sedation or general anesthesia to achieve acceptable conditions (stillness, anxiolysis, analgesia) to facilitate these procedures. This is more frequently being done with pediatric sedation/anesthesia outside the operating room. Issues unique to sedation for these procedures are pain, the need for relative patient immobility (both during the procedure and following it), and the nonstandard positioning required during the procedure. Regardless of the medications chosen, adequate monitoring should occur during the procedure as well as during the recovery period. With a good sedation plan for both sedation and analgesia, adequate monitoring, and contingency planning for adverse events, this can safely be performed in institutions with highly motivated and organized sedation services.

Radiation Therapy

Radiation therapy is a therapeutic option in the treatment of many childhood cancers. It involves the use of high-energy waves and/or matter that injure and kill cancer cells. Radiation therapy may be delivered to a patient via external, internal, and systemic methods. Procedural sedation is most frequently requested for external radiation therapy. Regardless of the method of external radiation used, patient immobility contributes greatly to successful therapy. The goal of the sedationist in the management of a child undergoing radiation therapy is to maintain the optimal environment in terms of patient safety and immobility so that the radiation oncology team can provide the most effective treatment.

Moderate Adverse Events

The incidence of sedation-related adverse events depends on (1) the medications used; (2) the type, duration, invasiveness, and location of the procedure; and (3) patient factors (e.g., age, medical condition, psychological factors). For the purposes of this chapter, moderate adverse sedation-related events represent physiologic change that is extremely likely to lead to significant patient harm if unnoticed or responded to ineffectively by the sedationist. Apnea, airway obstruction, and laryngospasm are examples. The relative likelihood of events of this type (1 of every 400 sedation episodes) provides significant impetus for effective preparation and training so that sedationists can effectively respond to these adverse events or preempt them. Even though they are categorized as “moderate” and may not be associated with harm in and of themselves, these events may certainly progress to produce significant harm.

Definition and Incidence of Adverse Events

To perform effective and safe procedural sedation, one must be knowledgeable about the adverse events that can occur with the administration of various sedatives and analgesics. Adverse events (sometimes thought of as complications of care) are often predictable if the sedationist properly assesses the patient’s physiologic and psychological conditions and understands the side effects of the medications administered and the procedural conditions that may exacerbate risk. With such preparation, the sedationist can monitor for the event and can either prevent it or provide supportive care in a timely manner. The American Academy of Pediatrics and other national organizations have developed guidelines for caring for patients requiring procedural sedation with the intent of informing sedationists of the risks involved in sedation care and the skills and equipment needed to ameliorate or prevent patient harm. Adverse events can be classified as minor, moderate, and major.