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Patient Care for Pediatric Patients Before, During, and After Minimal Sedation with Enteral Medications (2.3.24)

Patient Care for Pediatric Patients Before, During, and After Minimal Sedation with Enteral Medications (2.3.24) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.24


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Care for Pediatric Patients Before, During, and After Minimal
Sedation with Enteral Medications
Policy Number: 2.3.24
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: May 26, 2017

I. PURPOSE

To ensure a consistent, safe approach to monitoring and managing children (for the purposes of this policy
children are defined as less than 13 years of age) receiving enteral pain and anxiolytic medications intended
to result in a state of minimal sedation for inpatient or outpatient procedures or examinations. This policy is
intended to address sedation management for procedures or examinations only. This does not apply to the
treatment of pre-existing pain or anxiety.

II. DEFINITIONS

Minimal sedation is a drug-induced state during which patients respond normally to verbal commands.
Although cognitive function and physical coordination may be mildly impaired, airway reflexes, ventilatory
and cardiovascular functions are unaffected.
ξ Normal Airway Control
ξ Normal respiratory responsiveness
ξ Mild to minimal change in gross motor function
ξ Normal to minimally depressed level of awareness
ξ Appropriate response to stimuli

III. POLICY ELEMENTS

A. This policy addresses the monitoring and management of minimal sedation in children who meet the
following criteria:
i. American Society of Anesthesiologists (ASA) level less than or equal to 2 (refer to UWHC policy
#8.56, Pediatric Sedation, Appendix D)
ii. Age 6 months and older
iii. Baseline Pediatric Sedation Score of 0 to 2 (refer to UWHC policy #8.56, Pediatric Sedation,
Appendix B)
B. If a patient is ASA level 3 or greater, has a history of sleep disordered breathing including obstructive sleep
apnea, under 6 months of age, or is likely to require a higher level of sedation during a procedure, refer to
UWHC policy #8.56, Pediatric Sedation.
C. Children receiving minimal sedation for procedures that are cared for on the inpatient/outpatient unit, in the
emergency department, or travel “off unit” must be accompanied and monitored by an appropriate member
of the health care team.
D. Patients receiving only local anesthesia, or therapeutic pain and or anxiolytic medications are not covered by
this policy
E. No special privileges are required for prescribing medications for minimal sedation.

IV. PROCEDURE

A. Procedures and examinations
i. An evaluation of the patient will be completed and documented in the patient’s clinical record by a
health care provider before prescribing pain and anxiolytic medications for minimal sedation.
Minimal standards include reviewing the patient’s medications and allergies and response to past
sedations and anesthesia. Further assessment may be necessary depending on the patient,
procedure being performed, and/or procedure location.
ii. Sedation/procedure rooms will have ready access to an emergency response cart and must have
resuscitation, monitoring and intravenous access equipment in the area.
iii. Monitoring - minimal monitoring requirements include:
a. Baseline: Sedation score, respiratory rate, and heart rate.
b. At 20-30 minutes post administration: Sedation score, respiratory rate and heart rate.
iv. No NPO status is required.
v. The effects and side effects of the minimal sedation medication will be discussed with the patient’s



UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Care for Pediatric Patients Before, During, and After Minimal Sedation with Enteral Medications
Policy Number: 2.3.24

parent/caregiver and the patient (if appropriate) prior to administration of the medication.
vi. Patient will receive enteral medications as ordered. If these are administered within the institution
the RN will:
a. Review patient’s allergies and medication administration record prior to administration of
pain and anxiolytic medications.
b. Document all medications administered including dosage, time, route, and site.
vii. If enteral sedation medication is prescribed for the procedure and self-administered outside of the
hospital, the RN will document the reported medication, dose, route, and time of administration.
viii. RN Attendance: Immediately available on unit; does not need to stay in the patient’s room if patient
can be safely left in room; no noticeable increase in fall risk. A responsible adult should remain with
the patient for at least an hour after the administration of the medication that could alert the RN to
any concerning changes in sedation. Additionally, the patient should stay in bed for one hour after
the administration. If the child needs to be out of bed such as transferring to a wheelchair or
ambulating to the restroom, they need to be assisted by health care professional (NA, RN, or
Tech).
ix. Physician or Advanced Practice Provider Attendance: Must be readily available in the hospital.
(does not need to be resident or attending of record).
x. Regardless of where the sedation is administered:
a. The RN will monitor sedation using the pediatric sedation scale. Additional monitoring
may be appropriate depending on the patient and the procedure.
b. The RN will immediately treat and document any unexpected or adverse events, the
management of those events and the patient's response
c. If enteral midazolam is the single agent used and effective minimal sedation is not
achieved within 30 minutes of the first dose, a second dose of midazolam can be given
not to exceed a cumulative dose of 0.75mg/kg or 20 mg (note: maximum single dose of
midazolam for minimal sedation is 0.75mg/kg, not to exceed 20 mg). If the initial sedative
dose of another agent is insufficient to perform the needed procedure and a second dose
is administered or if the use of midazolam results in unintended moderate sedation the
patient will be managed and monitored in accordance with moderate sedations (see
UWHC policy #8.56, Pediatric Sedation). Patients receiving multiple medications must
be managed as moderate sedation in accordance with UWHC policy #8.56.
xi. Activation of a higher level of care to assist with unexpected complications will be readily available.
xii. Patient will be monitored in the post procedure phase until return to baseline sedation score and for
at least one hour after the administration of enteral sedation.
a. Document patient status at the completion of the procedure including at a minimum
sedation score, respiratory rate and heart rate
b. RN will immediately treat and document any post procedure complications, the
management of those events and the patient's response
B. Audit data will not be submitted for minimal sedation unless the patient experiences a sedation related
adverse event beyond that anticipated for minimal sedation or the patient progresses to moderate sedation.

V. COORDINATION

Author: Co-Chairs, Sedation Steering Committee
Senior Management Sponsor: SVP/Chief Nurse Executive
Approval committees: Sedation Steering Committee; UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: April 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer



UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Care for Pediatric Patients Before, During, and After Minimal Sedation with Enteral Medications
Policy Number: 2.3.24


J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC policy #8.16, Patient Care Orders
UWHC policy #8.17, Administration of Medications
UWHC policy #8.56, Pediatric Sedation
ASA Classification: UWHC policy #8.56, Pediatric Sedation, Appendix D
Sedation Score: UWHC policy #8.56, Pediatric Sedation, Appendix B

VIII. REVIEW DETAILS

Version: Original
Last Full Review: May 26, 2017
Next Revision Due: May 2020