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Bhavani Shankar Kodali MD

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The American Academy of Pediatrics, American Academy of Pediatric Dentistry released guidelines for monitoring and managing pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. This is an update and is current, as is in 2016 and published in Pediatrics 2016;138(1)e20161212. Clinical care providers are strongly encouraged to read the original publication cited above by Cote CJ, Wilson S. 

This publication highlights step-by-step management of airway obstruction, layrngospasm, and apnea. This publication presents a systematic description of the goals of sedation, responsible care providers, facilities, back-up emergency services, on-site monitoring, rescue drugs and equipment, and documentation. 

The purpose of the updated report, as pointed out in the publication, is to unify the guidelines for sedation used by medical and dental practitioners; to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurements; to provide updated information from the medical and dental literature; and to suggest methods for further improvement in safety and outcomes. 

The recommended guidelines have been summarized with an acronym 'SOAPME' and capongraphy has been included in this acronym. 

 

S= Size-appropriated suction catheters

O= Adequate oxygen supply and functioning flow meters

A= Size appropriate airway equipment

P= All basic pharmacy drugs needed to support life during emergency

M= Monitors: functioning pulse oximeter with size appropriated oximeter probe, end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (ECG, non invasive blood pressure, stethescope)

E= Special equipment or drugs for a particular case (e.g., defibrillator).

Some of the highlights in the monitoring section are: 

1. All equipment and drugs must be checked and maintained on a scheduled basis. Appendices 3 and 4 offer descriptions of suggested drugs and emergency equipment to be considered before the need for rescue occurs. Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters with size appropriate probes, end-tidal carbon dioxide monitors, and defibrillators with size- appropriate patches / paddles, must have a safety and functionality check on regular basis, as required by local or state regulation.

2. It is also stated that expired carbon dioxide values should be recorded, at minimum, every 10 minutes, but preferably 5 minutes,  in a time based record.  It is correctly stated that exact values of expired carbon dioxide is less important than simple assessment of continuous respiratory gas exchange. This has been my standard when teaching the use of capnograhy to monitor ventilation during sedation. The differences in values and shape of capnograms from baseline measurements are more important than the actual values of End-tidal CO2 monitoring to determine changes in ventilation. Furthermore, as stated in the guidelines, if supplemental oxygen is administered, the capnograph may underestimate the true expired carbon dioxide value. However, exhaled carbon dioxide is the assurance of continuous respiratory gas exchange. This is where waveform capnography trumps numerical values of capnography.  

3. It is exhilarating to read extensive descriptions of capnography in the revised update.  In the monitoring section, its is noted that vital signs, including heart rate, respiratory rate blood pressure, oxygen saturation, and expired carbon dioxide must be documented every 5 minutes in a time-based record. It is also emphasized that capnography should be used in almost all deeply sedated children because of the increased risk of airway / ventilation compromise. 

4. The guidelines emphasize a great balance between the advantages and limitations of capnography under various clinical circumstances. As an example, it is stated "In some situations in which there is excessive patient agitation or lack of cooperation or during certain procedures such as bronchoscopy, dentistry, or repari of facial lacerations capnography may not be feasible, and this should be documented. For uncooperative children, it is often helpful to defer the initiation of capnography until the child becomes sedated." Similar suggestions regarding the extension of intervals between measurements of noninvasive blood pressure have been made to decrease disturbing a sedated child and producing movements.

 A good summary of capnography explicitly highlights its valuein clinical practice. They include:

1. Capnography monitoring is valuable to diagnose the simple presence or absence of respirations, airway obstruction, or respiratory depression, particularly in patients sedated in less accessible locations, such as MRI machines, or darkened rooms.  

2. In patients receiving supplemental oxygen, capnography facilitates the recognition of apnea or airway obstruction several minutes before the situation would be detected just by pulse oximetry. Under these circumstances, the desaturation would be delayed due to increased oxygen reserves and capnography facilitates earlier intervention.

3. The publication also highlights a study in children sedated in the emergency department that reduced the incidence of hypoventilation and desaturation (7 to 1%). 

4. In MRI, MRI compatible pulse oximeters and capnographs should be used.

 

 In summary the current guidelines on the practice of sedation in pediatric patients highlight and emphasize the benefits of capnograhy. Therefore, every effort has to be initiated to follow the guidelines and use capnography to monitor ventilation. 

 

References: 

1. Cote J, Wisons S. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. Pediattrics 2016;138(1):e20161212.

2. Lightdale JR, Goldmann DA, Feldman HA, Newburgh AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation.: a randomized, controlled trial. Pediatrics 2006;117(6). Available at: www.pediatrics.org/cgi/content/full/117/6/e1170

3. Langhan ML, Shabanova V, Li FY, Bernstein, SL, Shapiro ED. A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Am J Emerg Med. 2015;33(1):25-30. 

 

 

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