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Editor,—We agree with Murphy1that a considerable number of children undergo painful procedures for which anaesthesia services are not available. As a gastroenterologist Murphy has to provide sedation for endoscopy in children and rightly draws attention to the problem of the definition of a safe level of sedation for the non-anaesthetist. We accept that definitions of sedation published by the Royal Colleges of Anaesthetists and Radiologists (that is, conscious sedation)2 are not appropriate for paediatric endoscopy, as children are not usually sufficiently cooperative if they are awake enough to respond sensibly to verbal commands. Children often need to be more deeply sedated. Nevertheless, the definition of conscious sedation is safe, easy to understand, and practical in many other situations, whereas deep sedation, as defined by the American Academy of Pediatrics,3 can easily become unintentional anaesthesia and therefore submits the patient to the risks of hypoxia.
The Royal Colleges’ report does not adequately address the issue of sedation of young children by non-anaesthetists, where the undeniable problem is that there are not enough anaesthetists to provide a service. We support the need to develop a policy for sedation of children with the priority to ensure safety.
We have some experience in helping non-anaesthetists sedate children and we wish to make some suggestions on how sedation could be organised in the absence of anaesthetists.
Reduce the chance of airway obstruction and hypoxia
The Royal Colleges state that “The drugs and techniques should carry a margin of safety wide enough to render unintended loss of consciousness unlikely”. For young children this requires modification, restricting non-anaesthetists to using drugs that are unlikely to obtund airway reflexes. Sedative drugs that fall into this category, unlike the more potent anaesthetics, are relatively unpredictable. This means that for a chosen recommended dose, some children will not be sedated enough and a few may be sedated too deeply. Any sedation regimen must have a reasonable success rate, but to be safe a failure rate must be accepted, agreed maximum doses must not be exceeded, and continuous monitoring is essential. A clear policy should be developed in collaboration with the anaesthetic department for the management of failed sedation.
Sedation is particularly hazardous in several well known conditions (for example, upper airway obstruction and high intracranial pressure) and in these children sedation must be supervised by anaesthetists.
Be able to correct airway obstruction or hypoxia if it occurs
Having reduced the chance of a respiratory event to a minimum, if it does occur there must be personnel with suitable skills, monitoring equipment, and assistance to detect it early and prevent hypoxia. Teaching basic life support, designing protocols, and purchasing equipment can be achieved relatively easily but the most difficult and important part is to select someone to take responsibility. In our view, a competent sedationist needs the practical skills, knowledge, judgment, and status to be able to ensure the safety of the child. Whether this person is a doctor or a nurse, they must have had suitable training and experience: although this has yet to be defined. There is no sedation qualification or registration authority to ensure a safe standard.
Find a lead clinician and build a sedation team
Despite these reservations, we believe that safe sedation can be delivered based on practices already developed within many units. Multidisciplinary sedation teams comprising the necessary skills, knowledge, judgment, and leadership could be established within large paediatric hospitals with the support of anaesthetists. However, if experienced personnel cannot be found, as is more likely in a small hospital, anaesthesia may be the safer option.