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Scenario and Checklist for Airway Rescue During Pediatric Sedation

Chen, Michael I. MD; Edler, Alice MD, MPH, MA, (education); Wald, Samuel MD; DuBois, Joshua MD; Huang, Yue Ming EdD, MHS

Simulation In Healthcare: The Journal of the Society for Simulation in Healthcare: October 2007 - Volume 2 - Issue 3 - p 194-198
doi: 10.1097/SIH.0b013e3181461b60
Case Report/Simulation Scenario
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Module: Airway Rescue for Sedation in Pediatric Patients

Patient File Name: Onka Hemmer

Scenario Name: Pediatric Sedation

Simulation Developers: Michael Chen, MD; Alice Elder, MD, MA (education), MPH; Samuel Wald, MD; Yue Ming Huang, EdD, MHS

Simulator: Laerdal Simbaby

Date of Development: October 22, 2006

Appropriate for the Following Learning Groups:

  • Faculty
  • Residents: Postgraduate years 1–7
  • Specialties (for faculty and residents): Anesthesia, Pediatrics, Radiology, Surgery, Dentistry, and Emergency Medicine
  • Nurse Anesthesia Faculty
  • Nurse Anesthesia Student: Years 1–2
  • Other: Dentists, dental students, and nurse practitioners
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Educational Rationale

With the rise in outpatient ambulatory surgery and less invasive interventional techniques, moderate or deep sedation is now used with increasing frequency. In comparison to general anesthesia, sedation provides shorter recovery time1 and can be performed in many non-operating room (OR) locations, such as private offices and diagnostic suites. The use of moderate or deep sedation can improve the quality of procedure results by providing practitioners better operating conditions, especially in cases with children who are unable to cooperate during frightening or painful experiences.

Despite the benefits, sedation is not free of complications. Such complications may include oversedation, inadequate sedation, airway compromise, aspiration, hypotension, bradycardia, permanent neurologic damage, and delayed recovery. Children are at particular risk for these complications due to differences in their airway anatomy and their immature metabolism and/or heightened sensitivity to sedative medication. It is estimated that approximately 10% of pediatric sedation patients have sedation-related complications.2,3 The most common causes of sedation-related complications in children are hypoxia and vomiting.4–6 It is critical that health care providers administering sedation for children demonstrate competency in the administration of these medications, the ability to recognize airway compromise, and the ability to perform rescue maneuvers.

This scenario was developed to further expand our current resources7–9 in pediatric airway management instruction for moderate or deep sedation. The associated assessment checklist was developed using expert opinion generated from a Delphi analysis of scripted and taped airway management scenarios during a moderate sedation performed by pediatric anesthesiologists. The Delphi method is a structured process that extracts independent experts' predictions and opinions to generate a group consensus. This checklist can be used as a tool to evaluate skills and behavior necessary for airway rescue during pediatric sedation. Raters should be skilled practitioners in pediatric sedation. The content was consistent with American Society of Anesthesiologist (ASA) guidelines, American Academy of Pediatrics (AAP) guidelines, and Pediatric Advanced Life Support (PALS) protocols. Additionally, the learning objectives are written in core competency format.

We have designed this scenario as a template for similar pediatric cases. For testing and global assessment purposes, the user should consult their local expert in educational measurement to determine the appropriate number of subjects, raters, and parallel scenarios based on this template for the desired reliability coefficient.

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At the conclusion of the simulation session, the participant will have an understanding of the following core competencies (learning domains are listed in parenthesis).

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Medical Knowledge

  1. Describe common etiologies for airway obstruction during pediatric sedation (cognitive domain–knowledge)
  2. Generate a plan for pediatric airway management and relief of airway obstruction during pediatric sedation (cognitive domain–synthesis)
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Patient Care

  1. Recognize complications in pediatric sedation (cognitive domain–analysis)
  2. Perform the common techniques of airway management in pediatric sedation and understand when to appropriately escalate care (psychomotor and cognitive domains)
  3. Apply and interpret necessary monitoring equipment, such as integrating the use capnography in addition to pulse oximetry and hemodynamic monitoring for pediatric patients undergoing sedation to aid in rapid recognition of airway compromise (psychomotor and cognitive domains)
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Interpersonal and Communications Skills

  1. Conduct a safe and systematic review of patient care information during transfer of care for pediatric sedation (affective domain–organization)
  2. Communicate difficulty with pediatric airway management (cognitive and affective domains)
  3. Recognize the need to call for additional support in the face of pediatric airway compromise (affective domain–responding to phenomenon)
  4. Effectively engage other providers to assist in patient care management during a sedation crisis (affective domain–valuing, internalizing values)
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Systems-Based Medicine

  1. Recognize the need for personnel and equipment for the management of airway complications in non-OR and nonhospital settings (affective domain–responding to phenomenon)
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  1. What are the common complications arising from pediatric sedation outside of the operating room?4–6
  2. What are the available resources for a healthcare provider to aid in the prevention and management of complications from sedation? (See Guidelines for Pediatric Sedation).
  3. What are the recommendations from the ASA and the AAP regarding moderate or deep sedation in children? (See Guidelines for Pediatric Sedation).
  4. What Are the PALS recommendations for airway management in children? (See Guidelines for Pediatric Sedation).
  5. What is essential information that you need to know prior to initiating moderate or deep sedation in pediatric patients? (See Guidelines for Pediatric Sedation).
  6. Did you effectively communicate your concerns about the patient to the peripheral inserted central catheter (PICC) nurse? What could you have done differently? 10
  7. What technical or communication skills would you like to improve upon?
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Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.11

Practice guidelines for sedation and analgesia by non-anesthesiologists.12

Clinical policy: procedural sedation and analgesia in the emergency department.13

Part 12: Pediatric Advanced Life Support.14

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See Checklist for Airway Rescue During Pediatric Sedation (Checklist Assessment and Global Assessment).

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Monitors Required: See Table 1.

Table 1

Table 1

Other Equipment Required: See Table 2.

Table 2

Table 2

Personnel Required:

  1. Simulator operator
  2. Nurse (instructor can also play this role)
  3. Instructor/facilitator qualified in pediatric sedation for rating

Time Duration: See Table 3.

Table 3

Table 3

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In this scenario, the case is already underway and the nurse will give the participant the pertinent information.

The patient is a 2-year-old child with newly diagnosed acute lymphoblastic leukemia (ALL) and is scheduled for a PICC insertion in a procedure room in a remote location. Following hospital protocol, the PICC nurse has attempted to sedate the patient using intravenous fentanyl (5 g) and midazolam (0.5 mg). Local anesthetic was given at the site of the catheter insertion. The nurse has successfully cannulated the vein but is unable to complete the catheter insertion due to inadequate sedation. He/she is not allowed to give any additional sedative and must obtain physician support per hospital protocol. The child is crying and inconsolable.

The participant is called to assist the nurse with the sedation. The nurse underscores the urgency of the procedure and how close they are to completion. The child is crying and the SaO2 is 98%.

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Facilitator/Coordinator's Background and Briefing Information

The PICC nurse is following the hospital's standard protocol. Under the protocol, sedation may be attempted, but a physician must be present if additional sedation is required. The nurse encourages the participant to sedate the patient by stating that the child urgently needs the PICC to begin his chemotherapy and by telling the participant that the procedure is very close to completion (the guide wire is in place but seems stuck at the level of the axilla). Airway supplies and sedation drugs are available.

When the participant gives some sedation, the child will stop crying and the nurse should provide positive feedback. If the participant attempts to lift the drapes, the nurse will chastise him for contaminating the sterile field. The participant will be told that the child needs increasing amounts of sedation to complete the procedure. The nurse will then ask the participant to perform a maneuver to facilitate the passage of guide wire by rotating he patient's head to the side. Repositioning the patient's head will trigger the patient's airway loss. Deep sedation and airway compromise will also occur when a total of 15 g of fentanyl and/or 1.5 mg of midazolam and/or 20 mg of propofol is administered. Over the next 5 minutes, the O2 saturation will slowly fall to 60%. This will give the participant ample time to try different rescue techniques such as repositioning, oral airway placement, and attempts at bag-valve-mask ventilation. These interventions will only improve the patient's oxygenation partially, up to a saturation in the low 90s, because of partial or complete glottic obstruction. When asked to assist, the nurse will be resistant to suggestion of aborting the procedure; however, when the SaO2 falls below 90%, he/she will be amicable to the participant's suggestions. The scenario will end when the participant intubates or places an LMA in the patient. Ideally, the participant should try multiple airway maneuvers prior to intubation.

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History of Present Illness

Patient is a 2-year-old child scheduled for a PICC insertion. The child was previously healthy until he developed a fever of unknown origin and lymphadenopathy. Blood work showed that he has leukemia and will need chemotherapy.

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Past Medical History

Term, uncomplicated pregnancy and delivery

Newly diagnosed ALL

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Past Family History


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Review of Systems

Plays and walks with normal childhood development prior to current illness

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Past Surgical History


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Physical Examination

General: Crying

Weight: 12 kg

Vital Signs: HR: 140, BP: 105/55, RR: 30, SaO2: 98% (room air)

Airway: Grossly normal, but unable to perform Mallampati examination

Lungs: Clear to auscultation

Heart: Regular rate and rhythm

Abdomen: Soft, nontender, and nondistended

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CBC: white cell count, 2.3

Hemoglobin: 9.1

Platelets: 60,000

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See Table 4.

Table 4

Table 4

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Checklist for Airway Rescue During Pediatric Sedation

Name of Evaluator:


Subject no. (DVD/scenario):

Subject Level of Training (Specify Year and Specialty):

Fully Trained: __________ Resident: ___________ Student: __________

Instructions: On the checklist assessment simply and without critique note if the subject did not attempt the maneuver, tried but was unsuccessful, or completed the maneuver successfully. Comment only if you think necessary. This is not a qualitative critique of how well he/she did but rather if he/she made an effort to use this skill.

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See Table 5.

Table 5

Table 5

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Assessment Key

Serious Flaws in Skills

Omits essential management techniques or unable to interpret monitoring danger signals which could result in serious harm to patient.

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Satisfactory Skills

Able to perform simple skills and interpretation of monitoring danger signals. No harm comes to patient; able to maintain an airway until a more experienced person arrives for assistance

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Competent Skills

Able to correct airway problem, quickly recognizes monitoring danger signals and intervenes.

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Outstanding Skills

Proceeds in a logical and organized manor to correct airway problem, quickly recognizes monitoring danger signals and intervenes, interacts professionally and effectively with other team members

  1. How would you rate this person's overall performance?
  2. Based on this scenario, did this person demonstrate appropriate airway management skills for pediatric patients?
  3. Based on this scenario, did this person demonstrate appropriate use of medications for pediatric sedation?
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1. Keeter S, Benator RM, Weinberg SM, Hartenberg MA: Sedation in pediatric CT: national survey of current practice. Radiology 1990;175:745–752.
2. Hoffman GM, Nowakowski R, Troshynski TJ, et al.: Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics 2002;109:236–243.
3. Cravero JP, Blike GT: Pediatric anesthesia in the non-operating room setting. Curr Opin Anaesthesiol 2002;19:443–449.
4. Cravero JP, Blike GT, Beach M, et al.: Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006;118:1087–1096.
5. Pitetti RD, Singh S, Pierce MC: Safe and efficacious use of procedural sedation and analgesia by non-anesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med 2003;157:1090–1096.
6. Sanborn PA, Michna E, Zurakowski D, et al.: Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 2005; 237:288–294.
7. Overly FL, Sudikoff SN, Shapiro MJ: High-fidelity medical simulation as an assessment tool for pediatric residents' airway management skills. Pediatr Emerg Care 2007;23:11–15.
8. Schaefer JJ 3rd. Simulators and difficult airway management skills. Paediatr Anaesth 2004;4:28–37.
9. Walls RM: Airway management. Emerg Med Clin North Am 1993;11:53–60.
10. Sexton JB, Helmreich RL, Glenn D, Wilhelm JA, Merritt AC: Operating Room Management Attitudes Questionnaire (ORMAQ), Technical report 00-2, University of Texas Austin: Human Factors Research Project, 2000.
11. Cote CJ, Wilson S: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118:2587–2602.
12. Practice guidelines for sedation and analgesia by non-anesthesiologists. An updated report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002; 96:1004–1017.
13. Clinical policy: procedural sedation and analgesia in the emergency department. American College of Emergency Physicians Clinical Policies Subcommittee, Ann Emerg Med 2005; 45:177–196.
14. Part 12: Pediatric Advanced Life Support. Circulation 2005; 112(Suppl 1): 167–187.
© 2007 Society for Simulation in Healthcare