Pediatric Procedural Sedation - PowerPoint PPT Presentation

About This Presentation
Title:

Pediatric Procedural Sedation

Description:

* * Opposing effects might be complimentary and minimize overall adverse events * Median recovery time was 15mins * Most of these were small studies and multiple ... – PowerPoint PPT presentation

Number of Views:141
Avg rating:3.0/5.0
Slides: 80
Provided by: anestesia7
Learn more at: https://anestesiar.org
Category:

less

Transcript and Presenter's Notes

Title: Pediatric Procedural Sedation


1
(No Transcript)
2
Pediatric Procedural Sedation
  • Dr. Marc N. Francis
  • MD, FRCPC
  • University of Calgary
  • Foothills Medical Centre
  • Alberta Childrens Hospital

3
Disclosure
  • I do not have an affiliation (financial or
    otherwise) with any commercial organization that
    may have a direct or indirect connection to the
    content of my presentation.

4
PSA in the ED
  • Painful procedures are unavoidable in emergency
    medicine
  • While anesthesiologists have unique
    qualifications to provide sedation, their
    availability is variable and unreliable, and is
    limited by commitments to the operating room
  • Procedural Sedation and Analgesia in the
    Emergency Department.
  • Canadian Consensus Guidelines
  • Journal of Emergency Medicine 1999 17(1)
    145-156

5
Learning Objectives
  • Tools of the Trade
  • Sedation medications that you should know well
    and be familiar with
  • The Right Tool for the Job
  • Discuss the variable needs for procedural
    sedation in the ED and pharmaceutical options
  • Tricks of the Trade
  • Some adjuncts and techniques that will make your
    job easier
  • Controversies
  • A look at some of the more controversial aspects
    of procedural sedation in children
  • The Future
  • What is coming down the pipe for the future of
    procedural sedation

6
(No Transcript)
7
Importance
  • Studies have shown that children are less likely
    than adults to receive pain medications and
    sedation for similar painful procedures
  • Children cannot fully understand the medical
    necessity for testing or therapeutics
  • Childrens anxiety can heighten the discomfort
  • Allows for control of behaviour for the safe and
    successful completion of a procedure
  • Parental, patient and physician satisfaction
  • Selbst SM Analgesic use in the Emergency
    Department. Ann Emerg Med 1990191010-1013

8
Sedation Spectrum
  • Minimal Sedation
  • Patient responds appropriately to verbal commands
  • Cognitive processing affected but no
    cardiopulmonary effects
  • Moderate Sedation
  • Patient responds to verbal commands or with
    addition of mild stimulus
  • Maintains airway and ventilation without required
    intervention
  • Deep Sedation
  • Not easily aroused but responds purposefully with
    uncomfortable stimulus
  • May require medical intervention to maintain an
    airway and ventilation
  • General Anesthesia
  • Unable to be aroused with a verbal or painful
    stimulus
  • Need help maintaining their airway

Dissociative Sedation
9
Indications for Pediatric Procedural Sedation
  • Diagnostic
  • Urinary Catheterization
  • Lumbar puncture
  • Radiographic evaluation (CT or MRI)
  • Joint aspiration
  • Sexual assault examinations
  • Eye examinations
  • Therapeutic
  • IV starts
  • Laceration repair
  • Abscess ID
  • Fracture Reductions
  • Dislocations reduction
  • Foreign body removal
  • Burn dressings

10
The Search Continues
  • The ideal sedation protocol
  • Rapid induction and emergence
  • Provides anxiolysis, analgesia and amnesia
  • Sufficient control of movement to allow for ease
    of procedural completion
  • Maintain effective spontaneous ventilation and
    airway control
  • Complete Cardiopulmonary stability throughout
  • Minimal to no side effects

11
Tools of the Trade
12
Nitrous Oxide
  • Dissociative gas with mild to moderate procedural
    anxiolysis, analgesia and amnesia
  • Dosage
  • 50 concentration blended with oxygen
  • Ideally self administered
  • Advantages
  • Onset and offset within 5mins
  • Does not require an IV
  • Disadvantages
  • Requires special delivery device
  • Nausea and Vomiting
  • Well ventilated room with scavenger system

13
Midazolam
  • Short-acting agent with rapid onset of
    anxiolysis, sedative and amnestic properties
  • Interacts with GABA receptors in the brain
  • Dosage
  • 0.2-0.6mg/kg intranasally
  • 0.05-0.2mg/kg IV
  • 0.1-0.2mg/kg IM
  • 0.5-0.75mg/kg PO
  • Advantages
  • Rapid onset
  • Anxiolysis
  • Profound retrograde amnesia
  • No IV required
  • Disadvantages
  • Does not provide analgesia
  • Disturbance in respiratory function /- hypoxemia
  • Paradoxical reactions

14
Fentanyl
  • Synthetic opiod which is narcotic of choice in
    PSA
  • Rapid onset and short duration make it easy to
    titrate
  • Does not cause histamine release so minimal CV
    effects
  • Dosage
  • 1-3mcg/kg IM or IV
  • 10-20mcg/kg oral or transmucosal
  • Advantages
  • Excellent analgesic
  • Peak effect within 15-30mins
  • Reversible with naloxone
  • Disadvantages
  • Nausea and vomiting
  • Respiratory depression
  • Hypotension
  • No amnesia. Minimal sedation
  • Fentanyl Rigid Chest

15
Ketamine
  • Dissociative agent
  • Sedation, analgesia and amnesia are maintained
  • Inhibits reuptake of catecholamines
  • Stimulates salivary, tracheal and bronchial
    secretions
  • Dosage
  • 1-2mg/kg IV
  • 2-5mg/kg IM
  • 6-10mg/kg PO
  • Advantages
  • Reliably produces potent analgesia, sedation and
    amnesia
  • Hemodynamic stability
  • Maintain airway reflexes
  • Disadvantages
  • Emergence phenomenon
  • Nausea and Vomiting
  • Increased secretions
  • Potentially serious respiratory complications

16
Propofol
  • Potent hypnotic agent with no analgesic
    properties
  • Effects lipid membrane Na-channel function and
    Stimulates GABA
  • Rapid onset, redistribution and elimination
  • Dosage
  • 1mg/kg IV bolus then 0.5mg/kg q45-60sec
  • Advantages
  • Rapid onset/offset
  • Easily titratable
  • Anti-emetic
  • Bronchodilator
  • Disadvantages
  • No analgesic properties
  • Potent cardiopulmonary depressant
  • Pain on injection
  • Inadvertent oversedation

17
The Right Tool for the Job
18
The Right tool for the Job
  • 28mth ? presents with 4day hx of fever, vomiting
    and flank pain
  • PMHX Healthy
  • Temp 38.5, HR 121, RR 16, BP 84/56, Sat
    98 RA
  • Not toilet trained
  • Wanting to do an in/out cath
  • Nitrous Oxide
  • Midazolam
  • Fentanyl
  • Ketamine
  • Propofol
  • Sedation Spectrum
  • Minimal Sedation

19
The Right tool for the Job
  • 5yo ? fell onto wooden post
  • Extensive and complex facial laceration requiring
    multilayer closure
  • PMHX Asthma well controlled
  • VSSA
  • Nitrous Oxide
  • Midazolam
  • Fentanyl
  • Ketamine
  • Propofol
  • Sedation Spectrum
  • Dissociative Sedation

20
The Right tool for the Job
  • 15yo ? playing soccer and collided with another
    player
  • Immediate pain to R shoulder which is clinically
    consistent with anterior dislocation
  • Very Anxious!!!
  • PMHX Healthy
  • Normal Vital signs
  • Nitrous Oxide
  • Midazolam
  • Fentanyl
  • Ketamine
  • Propofol
  • Sedation Spectrum
  • Moderate Sedation

21
The Right tool for the Job
  • 7yo ? presents with patellar dislocation while
    playing softball
  • Knee in spasm and patient extremely anxious
    with any attempts to examine or maneuver same
  • PMHx Healthy
  • VSSA
  • Nitrous Oxide
  • Midazolam
  • Fentanyl
  • Ketamine
  • Propofol
  • Sedation Spectrum
  • Minimal Sedation

22
The Right tool for the Job
  • 3yo ? fell off the bed and refusing to walk
  • Xray shows a displaced spiral tibial fracture
  • PMHx seizure disorder well controlled
  • VSSA
  • Nitrous Oxide
  • Midazolam
  • Fentanyl
  • Ketamine
  • Propofol
  • Sedation Spectrum
  • Dissociative Sedation

23
Tricks of the Trade
24
Ondansetron with Ketamine Sedation
  • Vomiting in the ED and upon discharge after
    Ketamine sedation is common
  • Reported frequency of vomiting ranges from 4-19
  • Increased vomiting associated with increasing
    patient age
  • Vomiting
  • Decreases patient and parental satisfaction
  • Delays discharge and consumes ED resources

25
  • Double-blind, randomized, placebo-controlled
    trial
  • N 255 children randomized to
  • N 128 IV Ondansetron 0.15mg/kg to max 4mg
  • N 127 Placebo
  • Results
  • ED vomiting was less common with ondansetron 4.7
    vs 12.6 p0.02
  • NNT of 13
  • Vomiting in the ED or after discharge was less
    frequent with ondansetron 7.8 vs 18.9 p0.01
  • NNT of 9

26
Pre-oxygenation with procedural sedation
  • Published adverse event rates during pediatric
    ED procedural sedation vary between 2 and 18
  • Consistently the most common adverse event is
    transient hypoxia
  • Childrens basal oxygen use/kg is twice that of
    adults
  • Smaller FRC
  • Shorter safe apnea period before desaturation
  • Transient hypoxia is predictably seen with
    propofol
  • Very common with Midazolam and Fentanyl
  • Less likely with Ketamine unless
    co-administration with other resp depressants

27
Adjunctive Atropine with Ketamine Sedation
  • Ketamine stimulates oral secretions
  • In rare circumstances this has been implicated in
    airway compromise1
  • Historically prophylactic anticholinergic agents
    have been given with ketamine to blunt
    hypersalivation
  • Glycopyrrolate 0.2mg
  • Atropine 0.02mg/kg

28
  • Prospective observational study of ED pediatric
    patients receiving ketamine sedation
  • N 1090 patients over a 3yr period
  • 947 (87) were performed without adjunctive
    atropine
  • Assessed for salivation on a 100mm visual analog
    scale and documented complications
  • Results
  • 92 of patients had salivation rated at 0mm or
    none
  • Only 1.3 were rated gt50mm
  • Transient airway complications in 3.2 of which
    only one was thought to be related to
    hypersalivation (incidence 0.11 95 CI 0.003 -
    0.59)
  • No occurrence of assisted ventilation or
    intubation

29
Adjunctive Atropine with Ketamine Sedation
  • Omission of atropine is safe
  • Routine prophylaxis is unnecessary
  • There is minimal added risk presented with its
    administration
  • Possible subsets of patients which may benefit
  • Very young children
  • Those undergoing oropharyngeal procedures

30
Controversies
31
In your local ED.
  • 9yo M previously healthy with no meds/allergies
  • Fell mountain biking 40mins ago and has deformed
    and partially angulated radius/ulnar
  • Neurovascularly intact distally
  • Wearing helmet and no issues with potential HI
  • Bag of chips 2hrs ago with bottle of Gatorade
  • Survey
  • Would you sedate this child now?
  • What would you use?

32
Pre-sedation Fasting guidelines
  • Minimal scientific evidence to support fasting
  • Risk of aspiration during ED PSA has not been
    studied
  • Only single case of pulmonary aspiration with ED
    sedation has been reported
  • Cheung K, et al. 2007. Ann Emerg Med
    200749462-464
  • Extrapolation from general anesthesia literature
  • Incidence of aspiration is low (13,420)
  • Mortality is rare (1125,109)

33
Relative risk of aspiration
  • Good reason to believe that aspiration risk with
    PSA may be lower than GA
  • 2/3 of aspiration occurs during airway
    manipulation
  • Deeper level of sedation with GA
  • Generally younger and healthier patients (ASA
    I-II)
  • Inhalational agents are more emetogenic
  • Ketamine sedation preserves protective airway
    reflexes

34
What we are told
  • CAEP
  • No specific guidelines
  • Insufficient data to show that fasting improves
    outcomes in patients undergoing ED procedural
    sedation
  • In elective situations consider NPO x 2hrs
    (liquids) and 6hrs (solids)
  • ACEP
  • No specific guidelines
  • No study has determined a necessary fasting
    period before initiation of PSA
  • Recent food intake is not a contraindication for
    PSA but should be considered in choosing the
    timing and target of sedation

35
  • ED specific clinical practice advisory
  • Goal to create a tool to permit ED physician to
    identify prudent limits of sedation depth and
    timing in light of fasting status
  • Developed a 4-step assessment prior to sedation
  • 1) Asses patient risk
  • 2) Assess the timing and nature of recent oral
    intake
  • 3) Assess the urgency of the procedure
  • 4) Determine the prudent limit of targeted depth
    and length of procedural sedation and analgesia

36
Assess Patient risk
  • Difficult airway?
  • High risk for esophageal reflux?
  • Esophageal disease
  • Hiatal hernia
  • PUD
  • Bowel obstruction
  • Extremes of age?
  • gt70
  • lt6mths
  • Severe Systemic disease?
  • ASA III

37
Timing and nature of oral intake
  • Single time point for sake of simplicity 3hrs
  • From lowest to highest theoretical risk
  • 1) Nothing
  • 2) Clear liquids
  • 3) Light snack
  • 4) Heavier snack or meal

38
Urgency of the procedure
  • Emergency
  • Cardioversion for life threatening arrythmia
  • Reduction of markedly angulated fracture
  • Urgent
  • Care of dirty wounds and lacerations
  • Abscess ID
  • Semiurgent
  • Care of clean wounds and lacerations
  • Shoulder reduction
  • Nonurgent or elective
  • Foreign body in external ear canal
  • Ingrown toenail

39
Depth of sedation
  • Procedure Duration
  • Brief lt10mins
  • Intermediate 10-20mins
  • Extended gt20mins

40
Standard-risk patient
41
Higher-risk Patient
42
Capnography monitoring during procedural sedation
  • Non-invasive measurement of the partial pressure
    of CO2 from the airway during inspiration and
    expiration

43
Capnography monitoring
  • Traditional monitoring
  • Pulse oximetry oxygenation
  • RR and clinical observation ventilation
  • Capnography
  • More precise and direct assessment of the
    patients ventilatory status
  • Assessment of airway patency and respiratory
    pattern
  • Early warning system for prehypoxic respiratory
    depression
  • Assessment of depth of sedation

44
(No Transcript)
45
Show me the evidence!!!
  • Comparison of oximetry, capnography and clinical
    observation in the ED2
  • 75 of pediatric patients with respiratory
    compromise were noted by EtCO2 monitoring only
  • Pediatric RCT comparing capnography to clinical
    observation in detecting resp events3
  • Clinical assessment identified hypoventilation in
    3 and did not identify any patients with apnea
  • Capnography data showed ventilation was
    compromised in gt50 of cases and nearly 25
    fulfilled criteria for apnea

46
Recommendations
  • Good evidence that capnography provides a means
    for early detection of sedation-related
    hypoventilation
  • Clinical significance with regards to improved
    patient outcomes has not been shown

47
(No Transcript)
48
Future
  • where were going we dont
  • need roads Dr. Emmett Brown

49
Ketofol
  • Propofol
  • Pros
  • Antinauseant effects
  • Amnestic
  • Smooth recovery profile
  • Cons
  • Cardiovascular and respiratory depression
  • Bradycardia
  • Non-analgesic
  • Ketamine
  • Pros
  • Analgesia
  • Amnesia
  • Respiratory and cardiovascular stability
  • Cons
  • Emergence phenomena
  • Vomiting

50
  • Prospective case series
  • 114 ED procedural sedations
  • 11 mixture of ketamine 10mg/ml and propofol
    10mg/ml
  • All age groups including children as young as 4
  • Results
  • 97 success rate with procedures
  • 3 patients with transient hypoxia
  • 1 required BVM
  • 3 patients with emergence
  • No hypotension or vomiting
  • Patient satisfaction scores were 10 on a 1-10
    scale

51
  • Systematic review of the literature
  • 8 clinical trials were included
  • Adult and pediatric studies were included
  • Results
  • Ketofol was not superior to propofol monotherapy
  • Conflicting data exist regarding hemodynamic and
    respiratory complications
  • At higher doses addition of ketamine to propofol
    may incur more adverse effects
  • Compatability data for the two agents combined in
    a syringe are limited

52
Ketofol
  • Theoretical benefits that have not been
    demonstrated in the literature
  • Optimum ratio of ketamine and propofol remains to
    be determined
  • Dosing regiments currently are highly variable
  • Not ready for Primetime.Yet

53
BIS
54
Bispectral Index
  • BIS
  • Uses processed EEG signals to measure the depth
    of sedation
  • Validated with children undergoing general
    anesthesia in the OR

55
  • Determine if the BIS monitor could be used to
    guide physicians in titrating propofol for safe
    levels of deep sedation in children
  • Results
  • BIS score of 45 determined to provide deep
    sedation for 95 of the population
  • Useful objective tool to guide effective
    titration of propofol for children

56
Conclusions
  • Familiarize yourself with your pharmaceutical
    options and pick the right tool for the job
  • Pre-oxygenation is your friend
  • Atropine is out and ondansetron is in for routine
    ketamine sedations
  • Pre-procedural fasting guidelines are not
    black-and-white and each situation is unique
  • Consider the additional information provided by
    capnography if it is available to you
  • Ketofol not ready for primetime.. yet

57
Questions?
58
Additional References
  • Green SM et al. Intramuscular ketamine for
    pediatric sedation in the emergency department
    safety profile with 1022 cases. Ann Emerg Med.
    199831688-97
  • Hart LS et al. The value of end-tidal CO2
    monitoring when comparing three methods of
    conscious sedation in children undergoing painful
    procedures in the emergency department. Pediatr
    Emerg Care 199713(3)189-93
  • Lightdale JR et al. Microstream capnography
    improves patient monitoring during moderate
    sedation a randomized, controlled trial.
    Pediatrics 2006117(6)e1170-8
  • Lopez MD et al. Pediatric Procedural Sedation.
    Emergency Medicine Reports 200813(12)145-156

59
Additional Slides
60
Fentanyl Rigid Chest
  • Believed to be due to a central agonist effect of
    narcotics
  • The pediatric population is more vulnerable to
    the syndrome
  • Reported with doses from 2.5-6.5mcg/kg
  • Difficulty in ventilating is largely due to upper
    airway (glottis) closure
  • Not thoracoabdominal tone as originally thought
  • In kids thoracoabdominal tone plays a larger
    role

61
Prevention of Fentanyl Rigid Chest
62
Propofol epilepsy
63
Is Propofol a pro- or anticonvulsant?
  • 81 reported cases of presumed propofol induced
    seizure like activity
  • Agonist-antagonist effect on Glycine which is a
    major inhibitory neurotransmitter

64
  • Prospective study
  • Effects of IV propofol on EEG
  • 25 children with epilepsy
  • 25 children with learning disorders
  • Undergoing elective sedation for MRI

65
  • Results
  • No child in either group had increased spike-wave
    pattern with propofol
  • Depression in spike-wave pattern in the children
    with epilepsy was seen
  • Supported the concept of propofol being a
    sedative-hypnotic agent with anticonvulsant
    properties

66
Aspiration case in literature
67
  • 65yoF with HTN
  • Trimalleolar fracture
  • Morphine/fentanyl/Propofol for first PSA with no
    significant complications
  • Second PSA in attempt to improve the reduction
  • 6hrs after last meal
  • Propofol/fentanyl
  • 10 mins after propofol bolus the patient vomited
    into the mask and aspirated

68
  • Sats were 86 initially
  • Airway was suctioned and BVM was started with
    improvement to sats 97
  • Patient remained hypoxic with sats 84 on RA
  • Inspiratory and expiratory wheezes throughout
  • RSI was performed and admitted to ICU where she
    was ventilated for 12hrs then slowly weaned
  • No long-term complications

69
Etomidate
70
Etomidate
  • Initially described for RSI in peds
  • Rapid onset of sedation, brief half-life, short
    recovery period and minimal effects on
    cardiopulmonary systems
  • Adverse effects
  • Potential for adrenal suppression
  • Pain at injection site
  • Myoclonus
  • Quickly and easily induce deep sedation and/or
    general anesthesia.
  • More studied for PSA in the adult population in
    United States

71
  • Only randomized control trial evaluating
    etomidate for pediatric PSA in the ED
  • Randomized double-blind study out of Montreal
  • N100 patients 2-18yo
  • 50 IV Etomidate 0.2mg/kg Fentanyl 1mcg/kg
  • 50 IV Midazolam 0.1mg/kg Fentanyl 1mcg/kg
  • Outcomes
  • Induction and recovery times
  • Efficacy of sedation
  • Adverse event rates

72
  • Results
  • Time taken for induction and recovery were lower
    among those receiving etomidate
  • Success rates were not different
  • Adverse event rates were similar with the
    exception of
  • Pain at injection site 46 vs 12
  • Myoclonus 22 vs 0

73
Etomidate
  • Need a large series to better establish the
    safety profile of etomidate for PSA in pediatrics
  • A randomized trial comparing etomidate, propofol
    and ketamine would be of great interest..
  • Any takers?

74
Propofol infusion syndrome
75
Propofol Infusion Syndrome
  • 1992 case reports of fatalities
  • High and escalating doses of propofol infusions
  • Severe metabolic acidosis, lipidemia, rhabdo and
    refractory heart failure
  • Associated with long-term infusions gt48hrs in
    children lt4yo
  • Thought to be related to a mitochondrial defect
  • Not an issue for brief ED sedation

76
Preoxygenation protocol
77
Pre-oxygenation with procedural sedation
  • Published adverse event rates during pediatric
    ED procedural sedation vary between 2 and 18
  • Consistently the most common adverse event is
    transient hypoxia
  • Childrens basal oxygen use/kg is twice that of
    adults
  • Smaller FRC
  • Shorter safe apnea period before desaturation
  • Transient hypoxia is predictably seen with
    propofol
  • Very common with Midazolam and Fentanyl
  • Less likely with Ketamine unless
    co-administration with other resp depressants

78
  • 1244 procedural sedations
  • Median age 5.9yrs
  • Complications in 17.9
  • No preoxygenation protocol

79
(No Transcript)
Write a Comment
User Comments (0)
About PowerShow.com