1.6. Painless imaging

The evidence from the following studies supports the recommendations:

• Evidence suggests that a single dose of propofol may be suitable for magnetic resonance imaging (MRI) procedures lasting up to 30 minutes (Cho et al. 2010).
• Continuous propofol infusion may be better than intermittent dosing for longer procedures (Hassan et al. 2011).
• Oral chloral hydrate may be effective for sedation during auditory brainstem response testing (Avlonitou et al. 2011).

1.8. Painful procedures

• Evidence suggests that propofol is suitable for procedural sedation in children and young people (Lamond 2010; Mallory et al. 2011). Evidence from these studies supports the guideline.
• Propofol and ketamine may be suitable as a specialist sedation regimen in children and young people (Andolfatto and Willman 2010; David and Shipp 2011; Shah et al. 2011). NICE guideline CG112 does not make specific recommendations about specialist techniques for procedural sedation, a specialist could choose to use ketamine with propofol, so this evidence does not contradict current guidance; however this combination remains a technique for specialist use only.
• Limited evidence suggests that midazolam may be more effective given by buccal aerosol than given orally or by intranasal aerosol (Klein et al. 2011). Further evidence would be needed to determine the optimum method of administration of midazolam before changing the guideline.
• Limited evidence suggests that nitrous oxide may be preferable to midazolam in sedation in children and young people in whom establishing an intravenous line is expected to be difficult (Ekbom et al. 2011). Further studies comparing midazolam with nitrous oxide may be useful to
• determine the preferred first-line drug for procedural sedation in children and young people.

1.9. Dental procedures

• Limited evidence suggests that ketamine may be associated with a higher rate of successful dental procedures than midazolam (Bahetwar et al. 2010). Using ketamine for dental sedation is an advanced technique, which is likely to be used only by specialist teams, so this study is unlikely to affect NICE guideline CG112.
• Limited evidence suggests that midazolam plus fentanyl may result in a higher rate of successful dental procedures than midazolam alone (Pandey et al. 2010). This evidence is unlikely to affect NICE guideline CG112, because the combination of midazolam and fentanyl would be considered a specialist sedation technique, which is not covered in the guideline.
• Limited evidence suggests that adding sevoflurane to nitrous oxide does not improve the rate of successful dental procedures (Soldani et al. 2010), so this study is unlikely to affect NICE guideline CG112.

1.10. Endoscopy

• Limited evidence suggests that propofol plus remifentanil may be associated with shorter time to waking and using lower doses of propofol, but may be associated with more respiratory events compared with propofol plus fentanyl (Hirsh et al. 2010). Further studies are needed to establish the safety of remifentanil with propofol for procedural sedation in children, thus this limited evidence is unlikely to affect an update to the guidance.
  Overall, the evidence from the evidence update in 2012 did not have an impact on the recommendations and we found no new evidence in these areas to suggest an update.

First consultation (17 to 28 September 2018)

Overall, 6 stakeholders commented; of these, 2 were government organisations and 4 were professional bodies. One stakeholder agreed with the decision to not update the guideline, 1 disagreed and 4 did not state a response.

One stakeholder suggested that that the guideline should include new drugs relevant to paediatric sedation, noting dexmedetomidine. Additionally, a stakeholder advised that pre-sedation assessment, covered by recommendation 1.1, should include growth assessment by BMI (body mass index) rather than weight alone. However, a strong signal was not identified through this surveillance review to indicate that the recommendations relating to issues highlighted by stakeholders need updating. We will monitor these areas and consider again at the next surveillance review of the guideline.

We received feedback from 2 stakeholders about recommendation 1.2.3, which mentions applying the 2-4-6 fasting rule for elective procedures; for further information see the details below provided in the second consultation.

See appendix A for full details of the first consultation stakeholders’ comments and our responses.

Second consultation (15 to 26 October 2018)

During the first consultation on the proposal not to update NICE guideline CG112, we received feedback from 2 stakeholders about recommendation 1.2.3, which mentions applying the 2-4-6 fasting rule for elective procedures:

• Apply the 2-4-6 fasting rule^[1] for elective procedures using any sedation technique other than those in recommendation 1.2.2 (that is, apply the 2-4-6 fasting rule for deep sedation and moderate sedation during which the child or young person might not maintain verbal contact with the healthcare professional).

The stakeholders highlighted that preoperative fasting of clear fluids for children, currently 2 hours in NICE guideline CG112, should be revised to be in line with current practice and recent guidance which supports a reduction to 1 hour. We also noted the Association of Paediatric Anaesthetists of Great Britain and Ireland consensus statement on clear fluids fasting for elective pediatric general anesthesia was published in April 2018.

To address this issue, we consulted stakeholders on refreshing recommendation 1.2.3 to highlight changes in professional guidance supporting a reduction to 1 hour of the fasting period for clear fluids.

Six stakeholders provided a response and 4 agreed that the text should be revised, 2 did not state a response. See editorial amendments for details of the change that will be made.

See appendix B for full details of the second consultation stakeholders’ comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

No equalities issues were identified during the surveillance process.