Discharge Criteria for Children Sedated by Nonanesthesiologists

ONE of the dilemmas faced by any caregiver providing sedation or anesthesia is the question, When is it safe to send the child home? Most sedation guidelines suggest that the patient should be returned to their baseline status before discharge. In this issue of the Journal, Malviya et al. describe a simple but elegant means for assessing the street readiness of infants sedated with chloral hydrate. One of the reasons that it has been so difficult to make sedation safe is the long-standing battle between specialties regarding definitions, drugs, monitoring, and qualifications. Organizations have modified definitions* or developed guidelines to fit the needs of their specialty. The first guideline for monitoring children sedated for diagnostic procedures was published by the American Academy of Pediatrics (AAP). Unfortunately, we adopted language from the National Institutes of Health regarding dental sedation, especially the misnomer “conscious sedation,” an oxymoron in the pediatric population. The AAP later revised the guideline. Pulse oximetry was required for all sedated children and a systematic approach similar to that used by anesthesiologists was developed, i.e., proper fasting, informed consent, focused airway examination, medical and/or surgical history, family history, previous sedation experiences, recommended equipment and medications, proper monitoring and documentation during and after the procedure, and strict discharge criteria. During the following years, the American Society of Anesthesiologists (ASA) became involved with sedation safety, in part because the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) modified their regulations in such a way that made departments of anesthesiology responsible for developing “within institution” sedation guidelines. In response to the JCAHO requirements, and with a strong emphasis on improving safety, the ASA established a task force that developed the guideline for sedation by nonanesthesiologists. The first ASA iteration succeeded in changing the terminology from the oxymoron “conscious sedation” to the more appropriate term “sedation/analgesia,” but it did not address deep sedation. In 2002, the ASA published revised sedation guidelines that address all depths of sedation. The ASA, working closely with JCAHO, also developed new language to describe the sedation process,† which was later incorporated by the JCAHO.‡ Now, three stages of sedation are described: minimal, moderate, and deep. Recently, the AAP adopted the ASA definitions for their sedation guidelines; now the AAP, ASA, and JCAHO are speaking the same language. In addition, the JCAHO introduced the essential concept of rescue, i.e., the practitioner must have the skills to rescue should the patient progress to a deeper level of sedation than intended. The JCAHO has been our friend by forcing conformity in the sedation process and the required airway management skills throughout many institutions. Unfortunately, these regulations do not yet apply to private practitioners’ offices. Our specialty is uniquely positioned to improve the sedation process. Now that the language is uniform and the definitions are clear, it is time to examine safety concerns and to explore issues not addressed in any guidelines. What qualifications are needed to administer sedation? How do individuals gain credentials to administer sedation? What drugs have the best efficacy and safety profile? Several years ago, I had the good fortune to be granted access to the adverse medication reports associated with pediatric sedation accidents collected by the Food and Drug Administration. Sixty of 95 cases were associated with death or neurologic injury. Contributory factors included drug overdose, drug interactions (e.g., opioid and benzodiazepine), inadequate monitoring, inadequate medical evaluation, premature discharge, inadequate resuscitation skills, and others. Barbiturates, opioids, benzodiazepines, and sedatives were equally represented, suggesting that one class of drugs did not seem to offer advantage over another. Adverse events were associated with intravenous, intramuscular, oral, rectal, nasal, and inhalational routes of This Editorial View accompanies the following article: Malviya S, Voepel-Lewis T, Ludomirsky A, Marshall J, Tait AR: Can we improve the assessment of discharge readiness? A comparative study of observational and objective measures of depth of sedation in children. ANESTHESIOLOGY 2004; 100:218–24.