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Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Pediatric Procedural Sedation (2.3.30)

Pediatric Procedural Sedation (2.3.30) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.30


UW HEALTH CLINICAL POLICY 1
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017

I. PURPOSE

To assure a consistent standard of care that promotes safe and effective moderate and deep sedation for
non-intubated pediatric patients receiving procedural sedation conducted within UW Health including UW
Health – American Family Children’s Hospital (AFCH), UW Health at the American Center (TAC), and the
University Hospital (UH). Provider privilege lists will indicate the age of patient that is covered under
Pediatric Sedation.

Note: This policy does not address children receiving minimal sedation for procedures. Pediatric procedural
sedation will not be administered in locations outside of UH, TAC and AFCH. The Department of
Anesthesiology will be consulted to provide sedation/anesthesia services in these off-site locations.

II. DEFINITIONS

A. SEDATIVE DRUGS are medications which when used in commonly employed dose ranges are intended to
result in central nervous system depression (see Appendix A). The use of these drugs may result in loss of
protective reflexes with subsequent airway, respiratory and/or cardiac compromise. The vast majority of
serious sedation related adverse events in children are secondary to respiratory depression with pharyngeal
upper airway obstruction and severe hypoventilation/apnea being the most common. The effects of
medications administered to achieve sedation are dose related and must be assessed individually for each
child. The combination of sedative drugs may result in synergistic central nervous system and
cardiorespiratory depression. Sedative drugs may be administered orally, intranasally, rectally, parenterally,
or by inhalation. Sedative drugs decrease activity, moderate excitement and calm the patient and can be
further categorized based on their particular clinical effects. Below is a classification of the different types of
sedative drugs:
i. Hypnotic: produces drowsiness and facilitates the onset and maintenance of sleep.
ii. Analgesic: relieves pain by altering perception of nociceptive stimuli.
iii. Anxiolytic: relieves apprehension and fear due to an anticipated event.
iv. Amnesic (antegrade): affects memory incorporation such that the child is unable to recall events
following drug delivery.
B. LEVELS OF SEDATION (Appendix B). The transition from moderate sedation to deep sedation and from
deep sedation to general anesthesia is a continuum. This transition can be difficult to predict and must be
anticipated whenever sedation is administered. If this transition is not appreciated and appropriate
interventions not taken, the child’s condition can rapidly deteriorate resulting in hypoxia, hypotension,
respiratory arrest, cardiac arrest and even death. The transition along this continuum can be especially
difficult to assess in many patients especially in infants and the cognitively impaired.
i. MINIMAL SEDATION is a drug –induced state during which patients respond normally to verbal
and physical stimulation (commands in older children). Airway control, and ventilatory and
cardiovascular functions are unaffected. Mild alteration in gross motor function may occur in which
coordination can be impaired. Minimal sedation correlates with a score of 1 on the pediatric
sedation scale (see Appendix B).
ii. MODERATE SEDATION is a drug-induced depression of consciousness during which patients
respond purposefully to repeated verbal commands or light to moderate tactile stimulation. The
patient has minimal loss of airway protection, is able to handle secretions without aspiration, and
can maintain a patent airway independently. Minimal to mild alteration in ventilatory
responsiveness may occur however spontaneous ventilation is adequate. Cardiovascular function
is usually maintained. The patient may be drowsy with mild to moderate impairment of gross motor
function. Complete loss of consciousness (sleep) may occur but unlikely. Moderate sedation
correlates with a score of 2-3 on the pediatric sedation scale (see Appendix B).
iii. DEEP SEDATION is a drug-induced depression of consciousness during which patients cannot be
easily aroused but respond to painful stimulation. Partial or complete loss of protective airway
reflexes may occur and patients may require assistance to maintain a patent airway ventilatory
function may be moderately impaired. Spontaneous ventilation may be inadequate and ability to
independently maintain ventilatory function may be impaired. Cardiovascular function is usually



UW HEALTH CLINICAL POLICY 2
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

maintained. There is moderate impairment in gross motor function with diminished muscle tone.
Deep sedation correlates with a score of 4 – 5 on the pediatric sedation scale (see Appendix B).
iv. GENERAL ANESTHESIA is a drug-induced loss of consciousness in which patients are not
arousable even with painful stimulation. Ability to independently maintain ventilatory function is
often impaired. Patients require assistance in maintaining an adequate airway, and positive
pressure ventilation may be required because of depressed ventilatory drive or drug-induced
depression of neuromuscular function. General anesthesia correlates with a score of 6 on the
pediatric sedation scale (see Appendix B).
C. QUALIFIED PERSONNAL includes physicians, nurse practitioners, physician assistants, and registered
nurses responsible for directing and/or administering sedative drugs for moderate and deep sedation.
Qualifications are as follows:
i. ALL STAFF will be:
a. Knowledgeable of the pharmacodynamics and pharmacokinetic properties of the sedative
drugs given.
b. Skilled and knowledgeable in the assessment and management of adverse effects of the
sedative, which include, but are not limited to, airway obstruction, respiratory insufficiency,
cardiovascular compromise, and neuropsychiatric complications.
c. Knowledgeable of and capable of assembling additional assistance.
d. Certified in, or demonstrate skills required for Healthcare Provider CPR as part of the
initial privilege request.
e. Able to demonstrate skills in oxygen delivery, use of suction equipment, and use of
manual resuscitation equipment.
ii. REGISTERED NURSES will:
a. Have successfully completed hospital approved core competency education to monitor
and administer sedation.
b. Be competent to administer and monitor sedation under the direction of a provider who is
privileged in moderate or deep sedation.
iii. ATTENDING PHYSICIANS, ADVANCED PRACTICE PROVIDERS (APP), (nurse practitioners,
physician assistants) – The attending physician/ APP who is privileged for directing and
administering sedation is ultimately responsible for ensuring that appropriate care is provided to the
patient during all phases of the sedation.
a. MODERATE SEDATION
1. Attending physician or APP privileged to provide pediatric moderate sedation in a
specific pediatric patient population.
2. Able to rescue from deep sedation
3. Certified in Pediatric Advanced Life Support (for non-Critical Care/Emergency
based faculty).
b. DEEP SEDATION
1. A physician member of the Division of Pediatric Critical Care Medicine, Pediatric
Emergency Medicine or specially trained pediatric subspecialist privileged in
deep sedation.
2. Able to rescue from general anesthesia

III. POLICY ELEMENTS

UW Health-AFCH Children’s Hospital Pediatric Sedation Program provides direction, leadership and clinical
expertise in the management and care of non-intubated pediatric patients receiving procedural sedation.

In order to provide a consistent standard of patient care, the following procedures will apply to all pediatric
patients who receive in any setting, by any route a sedative drug for moderate or deep procedural sedation.
The specific management of this patient population will be defined by the type of sedative administered, the
sedative dose, the patients underlying medical condition (e.g., diagnosis, illness severity), the intended level
of sedation, and the procedure conducted.

Note: This policy is intended to address sedation management for procedures only. Patients may receive
drugs with sedative properties with the primary intent to specifically treat an existing medical condition or
state (e.g., anxiety, pain, agitation, muscle spasticity, insomnia, etc.). Sedative drugs used in these
circumstances are to be used in a manner and dose not intended to result in moderate or deep sedation;
therefore, the following guidelines do not apply in these situations.



UW HEALTH CLINICAL POLICY 3
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30


The goal of pediatric procedural sedation/analgesia is to promote patient safety, minimize physical and
psychological discomfort and pain, enhance successful completion of the procedure and return the patient to
baseline medical status. Procedures utilizing sedation are done in both inpatient and outpatient settings.
Procedures requiring sedation include, but are not limited to invasive procedures including minor surgery,
endoscopy, hematology-oncology procedures, radiologic procedures, and non-invasive procedures including
diagnostic imaging studies, electroencephalograms, and echocardiograms. Certain procedural
characteristics (e.g., physical pain, psychological distress) will help guide the practitioner in choosing the
most appropriate sedative agent. Consequently, anticipating the procedural characteristics and
requirements and administering the appropriate sedative drug prior to and during the procedure promote the
delivery of high quality procedural sedation. Similarly, characteristics of individual children (e.g.,
temperament, psychological state, previous sedation experience, American Society of Anesthesiologists
(ASA) classification, etc.) are important in considering the level of sedation intended and the sedative to be
used (e.g., deep sedation may be required in some children undergoing a procedure generally associated
with minimal sedation). Finally, it is important to consider the context and setting in which the sedation is
conducted. Certain environments (e.g., intensive care units) may be uniquely qualified and suited to
conduct a specific type of procedural sedation when that procedure is a routine part of their patient care
practice.

This policy is intended to promote high quality patient care during procedural sedation, but does not
guarantee specific patient outcomes. The policy is not intended as a standard order or to replace clinical
judgment, but shall be considered minimum requirements when sedative medications are used

IV. PROCEDURE

A. RISK CATEGORIZATION. Every pediatric patient is considered at risk for losing their protective reflexes
whenever moderate or deep sedation is given. An otherwise previously healthy pediatric patient undergoing
moderate to deep sedation is at lower risk for losing protective reflexes than a child with comorbid conditions
or other underlying health conditions that predispose them to cardio respiratory compromise or interfere with
the metabolism of sedative agents.
i. HIGH RISK CASES are patient populations at greater risk of sedation related complications due to
an underlying comorbidity that predisposes the patient to cardiorespiratory compromise and/or a
deeper than planned level of sedation. A patient at high risk includes any patient meeting one or
more of the following criteria:
a. The child has received opioids, benzodiazepines, or initiated therapy with any CNS
depressant with the past six hours.
b. The child started extended release opioids or received methadone or intraspinal/ epidural
narcotics in the past 24 hours.
c. The child started opioids via an implantable pump within the past 72 hours.
d. The child has a medical/surgical condition in which an emergent diagnostic or therapeutic
procedural sedation is judged necessary to optimize patient outcome (Note: patient may
not meet NPO requirements under these circumstances).
e. The child is allergic to products that may be used during the procedure (e.g. latex products
or iodine).
f. The child will receive two or more sedative drugs concomitantly such that there is an
overlap in the duration of action or single agent drugs that are associated with a greater
chance of deep sedation.
ii. VERY HIGH RISK CASES include patient populations extremely vulnerable to the negative effects
of sedative drugs and those patients in which deep sedation is intended. These cases should be
managed by a member of the Pediatric Critical Care Medicine division or pediatric subspecialist
privileged in deep sedation and may require consultation with or support from the Anesthesiology
Department. Characteristics that may indicate a child is at very high risk with sedation include:
a. The child is less than three months old.
b. The child is unable to handle secretions without aspiration at baseline.
c. The child is unable to maintain a patent airway independently at baseline (excludes
mechanically ventilated children).
d. The child has significant systematic disturbance or disease (ASA3 or greater).
e. The child has cardiac and/or respiratory status that makes risk of cardiac or pulmonary
compromise likely.



UW HEALTH CLINICAL POLICY 4
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

f. The child has altered mental status making assessment of level of awareness, pain, and
response to administered medications difficult.
g. The child has had a previous adverse experience with sedation.
h. The child is allergic or sensitive to sedative or analgesic drugs.
i. The child has severe sleep disordered breathing or Obstructive Sleep Apnea.
j. The child will receive intravenous sedative drugs that are commonly used as anesthetic
agents.
B. PRE-PROCEDURE PHASE
i. PROVIDER OVERSIGHT AND DIRECTION. A qualified staff physician or advanced practice
provider (APP) privileged in sedation is ultimately responsible for ensuring that appropriate care is
provided to the child during all phases of sedation. When the physician or APP ordering sedation is
not on site at the time of sedation, a qualified privileged provider will be designated to be
responsible for the sedation including assessment and monitoring during the pre, intra, and post
sedation phases. Additionally, in the event that the physician or APP privileged for sedation who is
responsible for the sedation is not available for any part of the sedation and procedural period, s/he
shall delegate the care to another clearly identified privileged provider who has accepted the
responsibility and is knowledgeable about the child’s condition. In cases where deep sedation is
intended or likely, one privileged provider must be present other than the provider performing the
procedure, whose only responsibilities are to consistently monitor the patient’s vital signs, airway
patency, oxygen saturation, ventilation and sedation score. Qualified personnel (registered nurses)
will record and administer drugs under the direct supervision of the privileged provider. In addition,
another person must be readily available to assist in any supportive or resuscitative measures, as
required.
ii. PRIVILEGED PROVIDER RESPONSIBILITIES
a. Assess and document a child’s appropriateness to receive sedation prior to receiving any
sedative drugs as evidenced by his/her signature on the appropriate sedation form.
b. Re-evaluate the patient immediately prior to sedation administration.
c. Order and direct the administration of sedative medication based on findings of the pre-
procedure assessment.
d. For moderate sedation, be on site and able to respond to changing patient status and treat
complications of sedation that may occur.
e. For deep sedation be present in the sedation room and able to respond to changing
patient status and treat complications of sedation that may occur.
f. Have immediate access to support from Anesthesiology, or the Resuscitation Team (refer
to UW Health clinical policy #5.1.2, Cardiopulmonary Resuscitation Response Team).
iii. REGISTERED NURSES trained in sedation will be present from the time of administration of
sedative drugs until the child returns to baseline status. Registered nurses responsible for
monitoring the child:
a. Shall continuously assess and respond to the child’s condition.
b. Shall document assessments and findings as outlined by policy.
iv. GRADUATE MEDICAL EDUCATION (GME) TRAINEES (Residents and Fellows):
a. GME trainees must be supervised during all phases of the sedation encounter by an
attending physician/ APP who is privileged in sedation
b. GME trainees may perform tasks/skills during the sedation encounter under the direction
of a privileged provider.
v. RESUSCITATIVE AND MONITORING EQUIPMENT: Must be readily available on site and during
transfer and include the following:
a. Suction apparatus with appropriately sized suction catheters (i.e., Yankaeur).
b. Oxygen delivery system capable of 15 L/min flows for greater than 44 minutes.
c. Appropriately sized masks, and oral and nasal airways.
d. Pediatric intubation tray with laryngoscope, blades, and endotracheal tubes.
e. Self-inflating resuscitation bag.
f. Pulse oximeter
g. Blood pressure monitoring equipment.
h. ECG equipment and defibrillator.
i. Carbon dioxide monitoring device.
j. Stethoscope
k. Emergency medications including reversal and resuscitative agents.
vi. PARENT (CAREGIVER) AND CHILD EDUCATION: Prior to the administration of sedative



UW HEALTH CLINICAL POLICY 5
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

medication, education the parent (and the child, when appropriate) regarding the risks and potential
adverse effects of sedation, anticipated sedative effects, reason for sedation and potential options
other than sedation. Include information about what the patient can anticipate before, during and
after sedation including symptoms and side effects to report. When possible, work out a pre-
established signaling system for pain. Where applicable, pre-sedation instruction will be given to
the patient i.e., medication adjustments, NPO requirements, designated driver post procedure, etc.
vii. OBTAIN CONSENT and document if given verbally, or if emergency exception applies. See
UWHC policy #4.17, “Informed Consent.” The consent statement is included on the appropriate
sedation forms as part of the physician attestation statement.
viii. PERFORM AND RECORD A HEALTH ASSESSMENT of the patient to determine baseline status
of the patient and identify factors that may increase the patient’s risk during the period of sedation.
No child shall receive sedation until:
a. A pre-sedation assessment has been completed.
b. The privileged physician (or supervised resident/fellow) or privileged APP has attested to
the patient’s appropriateness to receive sedation as evidenced by his/her signature on an
appropriate documentation form.
c. The plan of care has been communicated between the physician and the nurse assigned
to the patient for the sedation.
d. The person administering the sedative agent has verified that the required documentation
is completed prior to any sedation being given.
e. All non-emergent procedures will be delayed or cancelled until all pre-procedure
documentation is completed.
f. Minimal assessment required before sedation includes, but is not limited to, the
determination and documentation of medical history and physical exam:
1. Age and weight in kilograms
2. Drug and food allergies
3. Recent or current illness
4. Major illnesses or congenital defects
5. History of prematurity
6. History of airway problems (e.g. snoring, Obstructive Sleep Apnea)
7. Previous hospitalizations, surgeries, sedations and anesthesia
8. Previous problems with anesthesia/sedation or adverse drug reactions
9. Current medication use (including opioid and sedative use within the past 24
hours)
10. Time of last oral intake (see Appendix E)
11. Heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature
where appropriate
12. Focused airway examination for risk of airway compromise (e.g., Mallampati
Classification, Tonsillar grade when appropriate, facial anatomy)
13. Respiratory and cardiovascular status which may include findings from heart and
lung auscultation and other physical findings as appropriate.
14. A brief neurological examination and determination of developmental status
including level of awareness.
15. ASA physical status classification score (see Appendix D)
16. Baseline assessment of pain, where appropriate
17. Baseline sedation score (see Appendix B)
18. Marking of surgical site involving right/left distinction, multiple structures (such as
fingers or toes) or levels (such as spine); teeth do not require marking (See
UWHC policy #8.48, Operative, Invasive and Other Procedures)
ix. ESTABLISH VENOUS ACCESS for the administration of intravenous sedation and ready access
should additional medications or IV fluids be required during or after the procedure. The
responsible physician determines the need for venous access on a case-by-case basis, and when
ordered, IV catheters will be inserted by protocol. Refer to Nursing Patient Care departmental
policy #1.23AP, Continuous Peripheral Intravenous Therapy (Adult and Pediatric).
x. WHEN TRANSFERRING A CHILD RECEIVING SEDATION to another location, two qualified
personnel, with appropriate equipment and supplies, shall accompany the child. Strollers, wagons
and wheelchairs are not acceptable modes of transportation for children who are sedated to the
point of sleep. Children should be transported on a cart with a flat surface that provides easy
access to the child in addition to being large enough for equipment.



UW HEALTH CLINICAL POLICY 6
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

xi. TIME-OUT. As per UWHC policy# 8.48, Operative, Invasive & Other Procedures, final
verification/time-out will be performed prior to the start of the procedure.
a. No patient shall receive sedation until a pre-sedation assessment has been completed
and documented by the physician responsible for the sedation. Documentation includes
the patients’ appropriateness to receive sedation.
b. The person administering the sedation medication (generally the RN) is responsible for
assuring the requirements are completed before administering the medication. A
procedure will be delayed or cancelled until all pre-procedure documentation is complete
This includes:
1. Verbal informed consent
2. History and Physical exam
3. Physician signature on the Attestation Statement of appropriateness
C. INTRA-PROCEDURE PHASE
i. DOCUMENT MEDICATIONS USED, including:
a. Dosage of all medications administered.
b. Time, route and site of administration of all medications.
c. Responsible party administering the medication.
d. Type and amount of any fluids infused including blood and blood products. See UWHC
policy #8.17, Administration of Medications.
ii. MONITOR AND DOCUMENT PATIENT STATUS. Continuously monitor throughout the sedation
period and document the child’s status in accordance with the level of sedation as outlined in
Appendix E, including:
a. Moderate Sedation
1. Direct observation, pulse oximetry and blood pressure monitor required
2. ECG, Capnography and Pre-tracheal stethoscopy when indicated.
3. Heart rate, respiratory rate and oxygen saturation monitored continuously*.
4. Blood pressure monitored every 5 minutes*
5. Heart rate, respiratory rate, oxygen saturation and blood pressure recorded at
baseline and every 5 minutes*
A. Some children in which moderate sedation is planned will not achieve a
depth of sedation consistent with moderate sedation (e.g., Pediatric
Sedation Score 0 – 1). Under these circumstances attempting to
monitor the patient as described above may be unsuccessful if not
counterproductive. Consequently, reasonable attempts to apply
monitoring as described above should occur and adapted to the
patient’s state.
b. Deep Sedation
1. Direct observation, pulse oximetry, ECG* and monitoring of ventilation** via
capnography are required with or without pre-tracheal stethoscopy.
* Procedural exceptions to the use of ECG may include compatibility problems
(e.g. MRI) and very brief procedures in which procedures may be completed prior
to ECG lead placement (e.g. invasive oncology procedures).
** Some form of ventilatory monitoring is required for deep sedation. Ideally
monitoring of ventilation is best achieved with both capnography and pre-tracheal
stethoscopy. Realistically however each of these tools has their advantages and
disadvantages. Capnography is the ventilation monitor of choice in patients
difficult to observe and in patients in a steady state. However capnography may
not be feasible in the early phases of sedation if the child is agitated.
Consequently the pre-tracheal stethoscope may be preferable to capnography
for the initial phases of sedation and for very brief procedures (e.g. LP)
2. Heart rate, respiratory rate, oxygen saturation, blood pressure and carbon
dioxide and upper airway airflow (when applicable) monitored continuously and
with the exception of upper airway airflow, recorded every 3 minutes.
iii. DIAGNOSE AND IMMEDIATELY TREAT ANY ADVERSE OR UNEXPECTED EVENTS during the
sedative period such as bradycardia, apnea, oxygen desaturation, hypotension, emesis, vasovagal
reaction, seizure, anaphylaxis or anaphylactoid reactions, neuropsychiatric disturbances, and any
other cardiopulmonary impairment. A Pediatric Code Blue shall be called when necessary (e.g.,
the child experiences apnea/bradycardia that is not responsive to immediate medical intervention).
Refer to UW Health clinical policy #5.1.2, Cardiopulmonary Resuscitation Response Team.



UW HEALTH CLINICAL POLICY 7
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

Document any events, interventions, and subsequent patient response related to an event and
interventions (See Section V.).
iv. PERSONNEL
a. Registered Nurse
1. Moderate Sedation: Registered nurse will be in constant attendance and may
assist in minor interruptible tasks of short duration but will not leave the patient
unattended
2. Deep Sedation: Registered nurse will be in constant attendance whose sole
responsibility will be monitoring and administering sedation under the direction
and supervision of the privileged sedation provider and not perform tasks other
than that related to sedation and airway management and shall remain with the
child continuously during the sedation period.
b. Privileged Provider
1. Moderate Sedation: Privileged provider must be on site and immediately
available.
2. Deep Sedation: Provider (or supervised designee) must be in constant
attendance
v. DOCUMENT PATIENT STATUS UPON COMPLETION OF THE PROCEDURE, including: heart
rate, blood pressure, respiratory rate, oxygen saturation, level of awareness, and level of pain
where appropriate.
D. POST-PROCEDURE PHASE. This phase is characterized by two recovery phases. Phase I and II are
minimal requirements for patient discharge; additional monitoring and recovery time is at the discretion of
the privileged provider.
i. PHASE I – Continuously observe and monitor the child, documenting according to level of sedation
(see Appendix E). Using the pediatric discharge scoring system, proceed to phase II monitoring
once a minimum score of 8 is achieved, when all individual category scores greater than 0 (see
Appendix F). Exceptions to this score are per privileged provider order only. There is no minimum
monitoring time requirement for this phase and this can occur in the procedure room, designated
recovery area, or impatient room. Patients who meet phase I criteria immediately upon completion
of the procedure may proceed to phase II.
ii. PHASE II – monitoring and documentation of vital signs continues every 15 minutes until the
patient meets Phase II criteria (see Appendix F). Use of pulse oximetry monitoring during Phase II
recovery is indicted in children who are not at baseline oxygen saturation status upon completion of
the procedure or phase I; otherwise, continued use of pulse oximetry monitoring is at the discretion
of health care personnel monitoring the child. Monitor and document findings as outlined in
Appendix E.
iii. IDENTIFY CHILDREN WHO REQUIRE PROLONGED PHASE II MONITORING (including those
receiving reversal agents) due to complications and/or slow recovery. Where indicated, the
responsible physician will determine further plan of care and when needed will direct patient
transfer to an appropriate care area until baseline condition returns. Any child who receives
naloxone or flumazenil following sedation/analgesia shall have continued monitoring with
documentation of assessments and vital signs. Minimal monitoring shall include heart rate, blood
pressure, respiratory rate, and pulse oximetry, following administration of the reversal agent for a
minimum of 2 hours AND until Phase II criteria are met.
iv. ASSESS THE CHILD’S READINESS FOR DISCHARGE/CESSATION OF SEDATION
MONITORING based on the Phase II discharge criteria (see Appendix F).
v. PROVIDE INSTRUCTIONS, verbal and written, to the parent (caregiver) and/or discharged child
regarding diet, medications, activities, potential complications and course of action if a complication
develops (see UWHC Form #9143 Pediatric Post Sedation Instructions Appendix G).
vi. COMMUNICATE INFORMATION to the qualified staff member assuming the child’s care, if the
child is transferred to another care area.
vii. EXCEPTION. The privileged provider may authorize variations from these procedures in individual
cases based on the specific clinical situation.

V. QUALITY REVIEW

The AFCH Diagnostic and Therapy Center Pediatric Sedation Program will assist in quality review pediatric
sedation. Key aspects of care required by this policy shall be monitored and reported bi annually to the
Sedation Steering Committee.



UW HEALTH CLINICAL POLICY 8
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30


A quality review process for complications shall be completed according to UWHC policy #8.48, Operative,
Invasive and Other Procedures.

Allergic and adverse reactions (i.e., noxious and unintended) to any sedation medication will be reported to
the Pharmacy & Therapeutics Committee. See UWHC policy #8.20, Adverse Drug Event Documentation

VI. COORDINATION

Author: Sedation Steering Committee Co-Chairs in collaboration with the Pediatric Critical Care Medicine
Division; Chair
Senior Management Sponsor: Sr. VP Medical Affairs
Reviewers: Sedation Steering Committee
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: July 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.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

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

VIII. REFERENCES

UWHC policy #7.44, American Family Children’s Hospital (AFCH) Admissions
UW Health clinical policy #5.1.2, Cardiopulmonary Resuscitation Response Team
UWHC policy #4.17, Informed Consent
UWHC policy #8.48, Operative, Invasive and other Procedures
Nursing Patient Care departmental policy #1.23AP, Continuous Peripheral Intravenous Therapy (Adult and
Pediatric)
UWHC policy #8.17, Administration of Medication
UWHC policy #8.20, Adverse Drug Event Documentation

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analysis of medications used for sedation. Pediatrics 2000, 106(4):633-644.

Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002, 96(4):1004-
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Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett BE, Moore J: Clinical policy: procedural
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Cote CJ, Wilson S: Guidelines for monitoring and management of pediatric patients before, during and after
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The Joint Commission: 2017 Comprehensive Accreditation Manual for Hospitals

Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B: Incidence and nature of



UW HEALTH CLINICAL POLICY 9
Policy Title: Pediatric Procedural Sedation
Policy Number: 2.3.30

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Society for Pediatric Sedation, Sedation Provider Course Syllabus. In: 5th International Multidisciplinary
Society for Pediatric Sedation Conference. Louisville KY; 2010

IX. REVIEW DETAILS

Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #8.56