Pediatric Sedation Consent Form
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Pediatric Sedation Consent Form
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The Pediatric Sedation Consent Form documents parental or legal guardian authorization for procedural sedation in pediatric patients. This template addresses the spectrum of sedation depths defined by the American Academy of Pediatrics (AAP) and American Society of Anesthesiologists (ASA) including minimal sedation (anxiolysis), moderate sedation (conscious sedation), deep sedation, and general anesthesia. The form captures the indication for sedation, the planned sedation agent(s) and route of administration (oral, intranasal, intramuscular, intravenous), and the specific procedure requiring sedation such as MRI, CT, laceration repair, fracture reduction, lumbar puncture, or dental restoration.
The consent includes a mandatory pre-sedation safety checklist covering NPO (nil per os) fasting status verification according to AAP guidelines (clear liquids 2 hours, breast milk 4 hours, formula/solids 6-8 hours), ASA physical status classification, airway assessment (Mallampati score, history of obstructive sleep apnea or snoring), current medications, allergies with specific attention to latex and egg allergies (relevant for propofol), recent upper respiratory infection symptoms, and the child's weight in kilograms for dose calculation. The parent/guardian acknowledges the risks of sedation including respiratory depression, aspiration, paradoxical agitation, laryngospasm, bronchospasm, cardiovascular depression, and the rare possibility of progression to a deeper-than-intended sedation level.
Post-sedation discharge criteria are documented including the modified Aldrete scoring system, minimum observation period, and written discharge instructions for the parent/guardian covering activity restrictions, dietary advancement, and signs requiring immediate medical attention. The form requires signatures from both the parent/legal guardian and the sedation provider, with attestation that the informed consent discussion occurred and all questions were answered. This template meets the requirements of the Joint Commission Sedation and Anesthesia Care standards and state-specific pediatric sedation regulations.
What's included
- Sedation level and agent selection documentation
- NPO fasting verification per AAP guidelines
- Allergy screening and airway assessment
- Sedation-specific risk acknowledgment for parents
- Post-sedation discharge criteria and instructions
- Parent/guardian and provider dual signatures
- Allergy documentation with severity levels
Who uses this template
- Pediatric emergency departments and urgent care centers
- Pediatric radiology for MRI and CT sedation
- Pediatric dental offices and oral surgery practices
- Pediatric gastroenterology and procedural suites
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