Opioid Safety, Respiratory Compromise

3 Keys to Safer Pediatric Sedation

The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) recently released “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016”.

There are three keys to this update which offers “pediatric providers updated information and guidance in delivering safe sedation to children”:

Key #1 – Monitor with Capnography

The lead author of these 2016 Guidelines, Charles J. Coté, MD, FAAP (professor of anesthesiology, Harvard Medical School), says the first major update is to monitor with capnography all children who are deeply sedated and to encourage capnography for children who are moderately sedated. Capnography measures the concentration of carbon dioxide that a person breathes out in exhaled air and displays on a numerical readout and waveform tracing.

Melissa Langhan, MD (Assistant Professor of Pediatrics, Emergency Medicine, Yale School of Medicine) emphasizes that the safety of children could be enhanced by monitoring with capnography:

“Medical guidelines for monitoring during general anesthesia recognize the importance of monitoring with capnography. Unfortunately, continuous capnography is not routinely used outside of the operating room. Capnography can really enhance patient safety, and healthcare professionals need to think about using it more often.

In the study published in Pediatric Emergency Care, Dr. Langhan and her colleagues found that 72% of the episodes of prolonged hypoxia were preceded by decreases in ETco2 as measured by capnography. This suggests that the use of capnography would enhance patient safety by decreasing the frequency of hypoxia during sedation in children.

In the YouTube video, “Using Capnography to Reduce Risk in Children”, Dr. Langhan describes how capnography could improve patient safety:

Please click on Dr Langhan's picture to view her YouTube video describing how capnography could improve patient safety.

Please click on Dr Langhan’s picture to view her YouTube video describing how capnography could improve patient safety.

Dr Langhan is a member of the board of advisors at the Physician-Patient Alliance for Health & Safety.

Key #2 – Ensure Clinicians Possess Sedation Training

The Guidelines caution that “it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation”. Consequently, clinicians must recognize the signs of respiratory compromise and have the necessary rescue skills:

Rescue techniques require specific training and skills. The maintenance of the skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction include the ability to open the airway, suction secretions, provide continuous positive airway pressure (CPAP), perform successful bag-valve-mask ventilation, insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA), and, rarely, perform tracheal intubation. These skills are likely best maintained with frequent simulation and team training for the management of rare events. Competency with emergency airway management procedure algorithms is fundamental for safe sedation practice and successful patient rescue.

Key #3 – Make Sure Your Process Meets High Standards

The Guidelines emphasize that having a systematic approach is essential to maintaining the safety of patients:

A commonly used acronym useful in planning and preparation for a procedure is SOAPME, which represents the following:

S = Size-appropriate suction catheters and a functioning suction apparatus (eg, Yankauer type suction)

 O = an adequate Oxygen supply and functioning flow meters or other devices to allow its delivery

 A = size-appropriate Airway equipment (eg, bag-valve-mask or equivalent device [functioning]), nasopharyngeal and oropharyngeal airways, LMA, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask

 P = Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated

 M = Monitors: functioning pulse oximeter with size-appropriate oximeter probes, 361,362 end-tidal carbon dioxide monitor, and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, ECG, stethoscope)

E = special Equipment or drugs for a particular case (eg, defibrillator)

In reflecting on the death of her 17-year old son Logan who successfully underwent routine surgery to correct his sleep apnea, Pamela Parker, BSN, RN, CAPA encourages the improvement of process:

Medical interventions shouldn’t be based on human heroics – and, yet, that was the only avenue left to save Logan. Moreover, although individuals clearly play a role in any medical process, the Institute of Medicine report, “To Err is Human: Building a Safer Health System,” reminds us:

The majority of medical errors do not result from individual recklessness or the actions of a particular group – this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. 

The healthcare process from Logan’s admission to discharge was flawed.

In the YouTube video, “6 Nursing Lessons to Avoid Respiratory Compromise,” Ms. Parker discusses Logan’s death and lessons she has learned from it.

Click on the image to listen to an interview with his mother, Pamela Parker

Click on the image to listen to an interview with his mother, Pamela Parker

 

 

 

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