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Conscius sedation in children

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Linnen bag filled with Sugar or flavor with added Beer or Wine or even ... (American Society of Anaesthesiology Classification) 1. normaly healthy patient ... – PowerPoint PPT presentation

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Title: Conscius sedation in children


1
Conscious Sedation
Central Hospital St-Juergen-Strasse Institut für
MR-Diagnostik B. Terwey Bremen Germany
2
Wilhelm Buschs Pacifier
Linnen bag filled with Sugar or flavor with added
Beer or Wine or even Brandy
3
Who will be sedated?Age classification
4
Optimal sedation
  • easy performed procedure
  • rapid onset
  • free choice of duration at any time
  • rapid recovery
  • effective in all age groups
  • effective in patients with all diseases
  • no adverse affects
  • cost is low

5
Sedation Management in Bremen
  • 1. Sleeping or cooperative patient
  • 2. Pacification by Meditation, Imaginery
  • 3. Conscious sedation
  • 4. Deep sedation
  • 5. General anaesthesia

6
Sedation procedures in Bremen since1.10.1990
148.365 Pat. (4451 Pat. 0 -6 Years old)
1 2 3 4 5
6
7
1. Scheduling
  • Foto von Anmeldung am Telefon

8
1. Scheduling questions
  • Indication
  • Age
  • Risk factors
  • Cooperability

9
1. Scheduling questions
  • Follow-up Questions
  • Is it difficult for your child difficult to sleep
    in the evening?
  • How does your child act when he/she is
    overtired?
  • Does your child fall asleep during the day? when
    and where?
  • Objective Determine the bedtime of your patient
  • Initial Question
  • What time does your child go to bed?

10
Scheduling Information
  • Preventative education for parents
  • Proper Scheduling
  • Scheduled awakenings in order to change sleep
    cycle
  • Warm meal
  • Cosy metallfree clothes and own music box

11
1. Cooperative or Sleep !
12
1. Natural sleep Age related Sleep times
13
1. Age related amount of REM Sleep
14
1. Natural sleep age related Stages of Sleep
NonREM
Adults
REM
Newborn
15
1. Problems with natural sleep
  • Protest
  • Hunger
  • Colic (infant)
  • Allergy
  • Acute illness (i.e. otitis media)
  • Medications - antihistamines, antibiotics,
    bronchodilators, anticonvulsants,
  • Pain
  • Seizures

16
  • Problems with natural sleepAdverse effects of
    sleep deprevation
  • Mood alteration
  • Reduced concentration and motivation
  • Increased irritability
  • Lapses in attention
  • Reduced motor skills

Sleep deprivation is not helpful!
Sanders BJ et al, The effect of sleep on conscius
sedation, J Clin Pediatr Dent 1994 28(3) 211-214
17
The cooperative child
  • straight parents
  • Child plays with mri console and technician
  • Mothers warm arm
  • Warm meal
  • Cosy clothes and music
  • cosy images and toys near to the child
  • Extinction cry it out, effective but of
    limited acceptance
  • Avoid double bind situations

18
1. Sleep Test
Foto mit Händeklatschen
Failure of natural sleep rectal or oral
Chloralhydrate
19
1. The cooperative Child 3 6 years old
  • first contact outside of the MRI-Department
  • convincing the parents
  • talk about how cooperation may be achieved
  • videoshow of the procedure
  • playing the procedure with the help of an
    MR-Model
  • first look to the magnet accompanied by one
    parent
  • demonstration of a video during the examination
  • parents or tecnician accompanies (prone
    position)
  • Bribary

20
1. The cooperative Child 3 6 years old
Foto Elten in Bauchlage mit Kind
21
1. The cooperative Child 3 6 years old
Bribary, Goldmedal
22
The cooperative Child (3 6 years old) Which
are causes for refusion?
  • reports of neighbours and friends
  • clinical and threatening atmosphere
  • narrow bore of the magnet
  • noise of the gradients
  • boring long procedure

23
1. The cooperative adult Controlling
Consciousness Paradox Effects
  • Paradox Processes in thinking
  • The harder you try to control thought, the
    less likely you are to succeed! (i.e. for 30
    seconds, do not think about bananas)
  • Paradox Processes in controlling anxiety
  • The harder you try to control anxiety, the
    less likely you are to succeed!

24
1. The cooperative adult
  • Solution 1 oral Diazepam (0,5 3,0 mg)
  • Solution 2 oral Midazolam (

Sudden unexpected Panic?
Onset 2 - 18 min Duration 20 - 30
min Antidot Flumazenil
25
2. Meditation (for Adults)
An altered state of consciousness characterized
by a sense of deep relaxation and a loss of
selfawareness.
  • Prayer
  • Concentrative meditation focus on one stimulus
  • Opening-up meditation focus on one stimulus
    but then opens to encompass whole of
    surroundings
  • Mindfulness meditation meditator focuses on
    whatever is most prominent at moment

26
2. Effects of Meditation
  • decreases stress,
  • reduces tension and anxiety
  • improves performance
  • reduces oxygen consumption
  • decreases heart rate
  • decreases respiration rate
  • lowers physiological arousal

27
2. Guided Imagenery (for Children and Adults)
Immediate Rapport Rapport is the foundation
upon which all other elements of Anodyne are
built. Quick and predictable rapport establishes
the trust necessary to effectively induce and
maintain the Anodyne State of relaxation and
patient cooperation.   Effective use of
language The correct use of language is vital to
the results we get, it enables us to address both
the conscious and unconscious mind of the
patient. We directly affect the outcome of the
patient's experience with language because
literally everything we say is a suggestion to
the unconscious mind.   Relaxation Breath The
"get you through anything" tool, the relaxation
breath is easy to learn and easy to teach to
every patient. It's uses include general
relaxation, relief of pain and anxiety, and
control of physiological processes.   .
28
2. Guided Imagenery (for Children and Adults)
'Preferred Place' Imagery The preferred place
imagery technique easily allows the patient's
mind to be anywhere they choose while their body
is comfortably undergoing the procedure.  
Shifting Submodalities Shifting submodalities
is an extremely quick and effective imagery
technique that can literally dissolve any
resistances the patient has to relaxation and/or
cooperation.   Control of Physiological
Processes Simple language techniques enable
practitioners to help patients control
physiological processes such as bleeding, heart
rate, blood pressure, peristalsis, salivation,
and swallowing  
29
3. Conscious sedation Definition
  • Pharmacological induced state of depressed
    consciousness with the defining characteristic
    that the patient can make appropriate stimulation
    at all times. This level of sedation is
    accompanied by an intact airway and maintenance
    of protective reflexes.

30
3. Conscious sedation 0 - 3 Monate
  • after beeing awake about 3 - 4 hours
  • and after normal feeding and swaddling
  • and only if necessary
  • after rectal chloral hydrate (50 mg/kg)
  • wait up to 5 minutes after beginning of sleep
  • test for deep sleep
  • give earphones, a warm blanket, nuckle
  • use a vacuum cap

31
3. Conscious sedation3 - 36 Monate
  • well fed and dry clothes withpout metal
  • change sleep cycle
  • additional mild rectal chloral hydrate (50
    mg/kg)
  • wait until phase of deep sleep

32
3. Conscious sedation Age 3 - 6 years friendly
atmosphere and clear decisions
  • parents are responsible
  • emotional blackmail
  • clear prospects
  • choice with or without parents

33
3. Conscious sedation PreparationWhat the
responsible physician has to know for the optimal
choice of time and procedure!
  • Risk classification
  • (American Society of Anaesthesiology
    Classification)
  • 1. normaly healthy patient
  • 2. mild systemic disease
  • 3. severe systemic disease
  • 4. severe systemic disease with threat to life
  • 5. moribund patient (24 h)

34
3. Conscious sedation Preparation What the
responsible physician has to tell to the parents
or nurse!
  • Nutrition before sedation
  • 2 hr before sedation clear liquids (every age)
  • 4 hr before sedation solid or semisolid food
    (under 6 M)
  • 6 hr before sedation solid or semisolid food
    (under 6-36 M)
  • 8 hr before sedation solid or semisolid food
    (more than 36 M

35
3. Postprocedural care and discharge AAPCOD
discharge criteria
  • cardiovascular system stable
  • airways patent
  • protective reflexes intact
  • speech near to normal (if age-appropriate)
  • responsiveness recovered
  • sitting up is possible (if age-appropriate)
  • hydration is adequate
  • minimal or no nausea

36
3. Postprocedural care and discharge AAPCOD
discharge criteria
  • parent information about possible reactions
  • phone number of the responsible physician

37
3. Conscious sedation Age 3 - 6 years
Convincing by bribery
  • soft toys
  • other toys
  • sweets
  • favourite food
  • medal for bravery

38
Conscious sedation Age 3 - 6 years Convincing
by gifts
  • Foto der Geschenke

39
4. Deep sedation Advantages
  • high successrate
  • radiologist is free for his duty
  • simple scheduling
  • higher patient throughput
  • good training for emergency cases

40
4. Deep sedation Disadvantages
  • risks to the patient
  • food and liquid deprevation
  • iv pathway needed
  • anaesthesiologist and nurse is needed
  • high cost (staff, material, time)

41
4. Deep sedation Preparation
  • Nutrition before sedation
  • - 2 hr before sedation clear liquids (every age)
  • - 4 hr before sedation solid or semisolid food
    (under 6 M)
  • - 6 hr before sedation solid or semisolid food
    (under 6-36 M)
  • - 8 hr before sedation solid or semisolid food
    (over 36 M)

42
4. Deep sedation Preparation
  • Premature warmed vacuum cap, blankets
  • Term warmed vaccum cap, blankets
  • Toddler earphones,
  • Infants earphones, music, video

43
4. Deep sedation Different MethodsDosis
oral/rectal chloral hydrate
  • Chloral hydrate 25-75 mg/kg up to
  • maximum of 2000 mg
  • Successrate 85 - 98
  • Onset 20 - 100 min
  • Duration 30 - 90 min

44
4. Deep sedation Different Methods
Disadvantages oral chloral hydrate
  • Vomiting (5-7)
  • hyperactivity (2-5)
  • minor oxygen desaturation (4)
  • rare severe respiratory depresssion
  • drowsiness and lack of coordination for hours
  • some unproven concern over carcinogenesis

45
4. Deep sedation Different Methods Advantages
oral chloral hydrate
  • wide range of safety
  • long working time

46
4. Deep sedation Different Methods Dosis oral
Diazepam
  • 0,05 -0,3 mg/kg
  • Successrate 50 - 85
  • Onset 5 - 15 min
  • Duration 30 - 120 min
  • Half-Life 20 - 50 hours
  • Antidot Flumazenil 0,3 -1,0 mg

Attention Because of its shorter half-life (app.
1 hour) , patients may show some residual
sedation after flumazenil administration
47
4. Deep sedation Different Methodsintranasal,
oral,rectal Midazolam
  • 0,2-0,5 mg/kg
  • (reduced dosis with hepatic dysfunction)
  • Sucessrate 95 - 100
  • Onset 5 - 12 min
  • Duration 20 - 30 min
  • Antidot Flumazenil 0,3 -1,0 mg

Latson LA et al. Midazolam Nose Drops for ..in
Infants. AHJ 121(1), 209-210,1991 Adrain ER
Intranasal Versed the Future of ......sedation.
Pediatric Nursing 20(3) 287-292, 1994
48
4. Deep sedation Different Methods intravenous
Midazolam
  • 0,02 -0,05 mg/kg
  • slowly injection (2 -4 min) with 1/2 of the total
    dosis
  • (reduced dosis with hepatic dysfunction)
  • Sucessrate 95 - 100
  • Onset 1 - 5 min
  • Duration 20 - 30 min

49
4. Deep sedation Different MethodsAdverse
effects Midazolam
  • hypotension
  • vomiting (10)
  • decreased tidal volume
  • decreased respiratory rate
  • Apnea
  • drowsiness
  • antidotFlumazenil

50
4. Deep sedation Different MethodsDosis
intravenous profonol
  • Induction dose of 2,5 mg/kg
  • slowly continous infusion
  • Sucessrate 97 - 100
  • Onset 1 - 2 min
  • Duration 1 - 5 min

51
4. Deep sedationDisadvantages intravenous
profonol
  • possible respiratory depression
  • possible O²-desaturation
  • no analgesie

52
4. Deep sedationAdvantages intravenous profonol
  • high success rate
  • rapid onset
  • rapid recovery

53
4. Deep sedation Risks
  • Aspiration
  • O²-Desaturation
  • Apnea
  • Dehydration
  • Hypoglycaemia
  • Seizures
  • Hypotension

You may have no iv pathway in case of nasal,
oral, rectal or intramuscular sedation!
54
4. Deep sedation and general Anaesthesia
Monitoring
  • continuous pulse oximetry
  • plethysmography
  • ECG
  • Bloodpressure (oscillometry)
  • airway-monitoring (side-stream spirometry)
  • end tidal CO2
  • temperature
  • recordings of all parameters

55
5. General anaesthesia
  • Reserved for critical ill and/or incooperative
    patients of all ages, who cannot be sedated
    sufficiently without the risk of loss of
    protective reflexes
  • newborn spine and abdominal studies
  • long examinations (cortical dysplasia)
  • restless patients, movement disorder

56
Design of a formal sedation policy I
  • Who designs?

57
Design of a formal sedation policy
  • radiologist
  • anaesthesiologist
  • neurosurgeon
  • pediactritian
  • nurse

58
Design of a formal sedation policy
  • Foto der 5 Leute am Tisch
  • Identified for each version
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