2 Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline (see section 5).
For children and young people under the age of 19 having diagnostic and therapeutic procedures under sedation, what factors should be assessed to establish the need for sedation and reduce the risk of adverse events?
Some children need sedation, some need anaesthesia, and some need behavioural management alone. There is wide variation in how this choice is made. A recommended standard method of assessment could reduce variation and improve both success and safety when sedation is chosen. Furthermore, an assessment tool could help prevent unsuitable choices and improve the overall management of procedures in children. The Guideline Development Group suggests an observational study to determine the important factors, followed by a consensus study to develop a tool. The assessment tool should be tested by a randomised comparison of children and young people who have been assessed routinely with those who have been assessed using the tool. The aim is for the assessment tool to improve sedation success and quality, and reduce any complications.
For personnel involved in delivering sedation to children and young people under the age of 19 having diagnostic and therapeutic procedures, what training is required to achieve and maintain essential skills?
Potent drugs can cause unintended airway obstruction. Anaesthetists are skilled at managing airway obstruction because they practise the skills regularly. However, anaesthetists are a scarce resource so non‑anaesthetists need to learn how to manage airway obstruction. The skills that are needed have been identified but can these skills be attained and maintained by professionals who need them only occasionally? The Guideline Development Group suggests that a standard teaching method and assessment tool are developed. This would involve an observational study of a cohort of trainees, who can be assessed, trained and then reassessed at intervals to determine whether the training is successful and how often it is necessary.
For children and young people under the age of 19 having minor painful procedures, what potent analgesic drugs can be combined with midazolam to provide safe moderate sedation?
Midazolam has a strong safety profile in inducing either minimal or moderate sedation. For painful procedures midazolam should be combined with analgesia. Ideally, analgesia is achieved by local anaesthesia. Sometimes local analgesia is insufficient and potent opioid analgesia is necessary. The combination of potent opioid and midazolam can cause deep sedation and airway obstruction. These effects can be managed safely but involve extra resources. If would be safer if a technique could be developed that was both reliable and had a wide margin of safety. Prospective and retrospective audit data are available to help guide the choice of opioid and the doses. A randomised controlled trial is needed to test the efficacy and safety of these combinations.
What are the safety and efficacy profiles of sedation techniques in current practice?
There are no data on the safety of sedation in the UK. A large prospective database of sedation cases, that includes data on drugs, procedures, the depth of sedation and complications, would help to define the safety of sedation and actively promote safe practice. The Guideline Development Group suggests that a national registry for paediatric sedation is established to help create a database with sufficient data.