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Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children

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Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children s Sedation Services Children s Healthcare of Atlanta Emory University School of Medicine – PowerPoint PPT presentation

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Title: Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children


1
Pediatric Procedural SedationJana
Stockwell, MD, FAAPChildrens Sedation
ServicesChildrens Healthcare of AtlantaEmory
University School of Medicine
2
Why Not Sedate?
  • Im gonna be so fast they wont even feel it.
  • Theyre just crying because theyre being held
    down.
  • Children dont feel pain
  • Children dont remember pain

3
Why Sedate?
  • Efficacy
  • Satisfaction
  • Quality of study
  • Do unto others
  • Same injury, adults sedated more

4
Goals
  • Guard safety welfare of child
  • Minimize physical discomfort pain
  • Control anxiety, maximize potential for amnesia
  • Control behavior movement to complete procedure
  • Return patient to state safe for discharge

5
CHOA _at_ Egleston Program
  • CCM ED physicians
  • Dedicated radiology H/O sedation nurses
  • 4 locations
  • 2-3 docs/day
  • gt3,000 sedations/year

6
Overview
  • Definitions
  • Choose wisely
  • Pick your patient
  • Pick your drugs
  • Pick your nos
  • Pick your battles
  • On the horizon

7
Definitions
  • 1992 AAP (Peds 1992898110)
  • Conscious Sedation
  • Deep Sedation
  • 1998 ACEP (Ann Emer Med 199831663)
  • Procedural Analgesia Sedation
  • 2006 AAP AAPD (Peds 20061182587-2602)
  • Minimal anxiolysis
  • Moderate conscious
  • Deep
  • General anesthesia

8
Joint Commission 2000
  • Level 1 Minimal
  • Respond normally to verbal commands
  • Cognitive function and coordination impaired

9
Joint Commission 2000
  • Level 2 Moderate sedation / analgesia
  • Respond to verbal or gentle tactile stimuli
  • No intervention to maintain airway
  • Adequate spontaneous ventilation

10
Joint Commission 2000
  • Level 3 Deep sedation / analgesia
  • Respond purposefully following repeated or
    painful stimulation
  • Ability to maintain ventilatory function may be
    impaired

11
Never Never Land
  • Level 3.5 Dissociative Sedation
  • Cataleptic state
  • Maintain protective reflexes
  • Retain spontaneous respirations

12
Joint Commission 2000
  • Level 4 Anesthesia
  • Not arousable, even with painful stimuli
  • Independent ventilatory function often impaired

13
Remember, its a
CONTINUUM
14
Providers
  • Licensed independent practitioner
  • Know drugs and antidotes
  • Ability to monitor
  • Capable of rescue
  • Re-assess immediately before sedation
  • Immediately available
  • Not doing the procedure

15
(Appropriate) Patients
  • Painful Procedures
  • Bone marrow Bx, BMA
  • Wound debridement
  • Renal Bx
  • Abscess ID
  • Fracture reduction
  • Cardioversion
  • Movement an issue
  • Suture difficult area
  • Radiographic images
  • Auditory brain response
  • LP
  • Casting

16
Inappropriate Patients
  • Airway issues
  • Small, tight jaw
  • Airway obstruction
  • Respiratory issues
  • Super quick
  • Lacerations to be fixed with Dermabond

Primum non nocere
17
Airway concerns
  • Downs Syndrome
  • Macroglossia
  • Small mouth
  • Small trachea
  • Atlanto-axial instability

18
Airway concerns
Pierre-Robin Sequence
Beckwith-Wiedemann Syndrome
19
Other concerns
  • Pneumonia, asthma, BPD, tracheomalacia, OSA,
    tachypnea
  • CCHD, CHF, hypotension
  • Central apnea, seizures
  • GERD, hepatic disease
  • Renal disease, dehydration, abnormal electrolytes
  • Sepsis

20
Patient Assessment
  • American Society Anesthesiology (ASA) class
  • Allergies
  • NPO status
  • Health evaluation

21
ASA classes
  • ASA 1 Healthy
  • ASA 2 Controlled dz of 1 system lt1 yo healthy
  • ASA 3 1 major system, poorly controlled
  • ASA 4 1 severe dz, end-stage, constant threat
    to life
  • ASA 5 Moribund, imminent death

22
Allergies
  • Medications allergies
  • Previous anesthesia events?
  • Food allergies (egg, soy)
  • Tape, skin prep, etc

23
NPO duration adverse events
  • Agrawal (2003) 1,014 sedations
  • 8.1 in fasted, 6.9 unfasted
  • Roback (2004) 2,085 sedations
  • No correlation by fasting time
  • Treston - 334 echos lt6 mos (ketamine)
  • Fewer events if fasted lt3 hours
  • Ingebo (1997) 285 gastroscopies
  • No correlation of gastric volumes by times

24
NPO Status
  • because the absolute risk of aspiration during
    procedural sedation is not yet known, guidelines
    for fasting periods before elective sedation
    should generally follow those used for elective
    general anesthesia.

Pediatrics 20061182587
25
NPO status (ASA)
  • Solids, formula - 6 hours
  • Clear liquids - 2 hours
  • Breast milk - 4 hours
  • Can take sip with meds

26
Preparation
  • Informed consent
  • Health evaluation
  • ROS
  • History (sedations?)
  • Medications (including herbals)
  • Weight
  • VS, sat
  • Exam (airway, lungs, CV state, LOC)

27
Preparation
  • Additional person
  • SOAPME
  • Suction
  • Oxygen
  • Airways (BVM, oral, LMA, ETT)
  • Pharmacy (meds)
  • Monitors
  • Equipment (defibrillator, airway supplies, etc)

28
Reversal Agents
  • Naloxone
  • Competitively binds all 3 opiate receptors
  • IV, IM, SC, SL, ETT
  • 0.1 mg/kg
  • Flumazenil
  • Can terminate paradoxical reactions
  • 0.02 mg/kg
  • Lowers seizure threshold

29
Documentation Monitoring
  • Time out
  • Time-based record Q5 minutes
  • SPO2 ETCO2
  • HR
  • BP
  • LOC
  • O2 given
  • Medications
  • Interventions

30
Recovery and Discharge
  • Continuous HR sats until alert
  • 1 person dedicated to patient
  • Aldrete post-anesthetic score
  • Post-sedation evaluation
  • Baseline cardiopulmonary status (VS)
  • Drinking
  • Level of consciousness
  • Locomotion / sitting
  • Written verbal instructions

31
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32
Git er done
  • Hypnotics
  • Sedatives
  • Ketamine
  • Etomidate
  • Propofol
  • Nitrous oxide

33
Midazolam (Versed)
  • Anxiolysis
  • Dose-
  • 0.05-0.1 mg/kg IV, onset min
  • 0.5-1 mg/kg PO, onset 20-30 min
  • 0.3-0.4 mg/kg IN, onset 5-15 min
  • Amnesia 92 - 98
  • Paradoxical reactions
  • 1.4 emergence / atypical reaction
  • onset at 14 min
  • relieved with flumazenil

34
Hypnotics
  • Chloral hydrate
  • Pentobarbital
  • Methohexital
  • Etomidate

35
Chloral hydrate
  • Mickey Finn
  • 50-80 mg/kg PO
  • Onset approximately 15 minutes
  • Duration 1-2 hours
  • Total max dose of 120 mg/kg or 1 g total for
    infants and 2 g total for children

36
Chloral hydrate
  • Amnesia?
  • Gas
  • Hyperactivity
  • Deaths after discharge
  • Carcinogen

37
Barbiturates
  • Depress RAS
  • No analgesia
  • May be hyperesthetic
  • Amnesia

38
Pentobarbital (Nembutal)
  • 1-3 mg/kg IV, up to total of 6 mg/kg
  • Sleep onset 1-2 minutes
  • Duration 30-60 minutes
  • Hypoxia, hypotension
  • May give IM 4-6 mg/kg
  • Rage reaction 1.6

39
Methohexital (Brevital)
  • 1-3 mg/kg IV
  • Not painful
  • Additional doses at 0.5 mg/kg
  • Drip 3 mg/kg/hr
  • Sleep onset 1-2 min
  • Duration 10-20 min
  • IM, PR 90 minutes
  • 25 mg/kg PR
  • 5-10 mg/kg IM

40
Methohexital
  • IV
  • Myoclonus 10
  • Hiccups 10
  • Rectal
  • 95 success
  • 6 apnea / desaturation
  • 3 hiccups

Pediatrics 2000105(5)1110-4
41
Etomidate
  • Ultrashort-acting non-barbiturate imidazole
    hypnotic
  • 0.2-0.3 mg/kg (lt10 yrs), 0.2-0.6 gt10 yrs
  • Give over 30-60 sec
  • Onset 30 sec
  • Duration 5-10 min
  • Negligible hemodynamic effects
  • Amnesia 80

42
Etomidate
  • Myoclonus up to 30
  • Pain at injection site
  • No analgesia
  • Adrenal suppression
  • Blocks the normal stress-induced increase in
    adrenal cortisol production for 4-8 hours
  • Increases EEG activation

43
Pentobarbital vs. Etomidate
Adverse Event Pentobarb N 396 Etomidate N 444 Relative Risk (95 CI), p
Any Event (p.005) 18 (4.5) 6 (0.9) 1.03 (1.01,1.05)
Desaturation 4 0 p0.03
Inadequate sedation 3 2 NS
Apnea 2 1 NS
Allergy/cough/secretions 4 0 NS
Prolonged sedation 3 1 NS
Stridor 1 0 NS
Emesis 0 1 NS
Too Deep 1 0 NS
not ideal 11 1 plt0.003
Recovery time (min) 144 (139,150) 34 (32,36)
44
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45
Ketamine
  • Dissociative state
  • Related to PCP
  • Disconnects limbic system
  • Brainstem RAS not affected
  • Analgesia Sedation Amnesia
  • Does not impair laryngeal reflexes
  • Bronchodilation
  • ?inotropy, ?BP, ?SVR

46
Ketamine
  • 1-2 mg/kg IV, drip 1-2 mg/kg/hr
  • 3-7 mg/kg IM
  • Onset 1 min (nystagmus)
  • Duration 15 min to 1 hour

47
Ketamine
  • ? Secretions
  • Consider glycopyrrolate (Robinul)
  • Vomiting
  • Emergence 12
  • Contraindications
  • ? ICP, glaucoma, open globe
  • lt3 months of age
  • History of psychosis, porphyria

48
Propofol
  • Sedative-hypnotic
  • 1-3 mg/kg bolus over 2 min
  • 5 mg/kg/hr
  • Infants need higher dose
  • Sedative
  • Profound relaxation
  • Anti-emetic
  • Antiepileptic properties
  • Fidget ? Yawn ? Out ? ??

49
Propofol
  • Alkaline -- STINGS
  • Contraindicated - egg or soy allergy
  • Hypotension
  • Rare bradycardia, acidosis leading to sudden
    death
  • No analgesia
  • Green urine

50
Propofol in kids
  • Guenther (p. 783)
  • 291outpatients
  • Median dose 3.5 mg/kg
  • 4 jaw thrust
  • 1 BVM
  • 1 bradycardia to 57
  • Bassett (p. 773)
  • 393 patients
  • Median dose 2.7 mg/kg
  • 3 jaw thrust
  • 8 prolonged BP ?
  • 0.8 BVM
  • 5 hypoxia

Ann Emerg Med 200342783 773
51
Nitrous Oxide (NO2)
  • Sedative analgesic
  • FiO2 0.25-1.0
  • 50 nitrous maximum
  • In combo with ANY other sedation or narcotic
    deep sedation
  • Need scavenger equipment
  • 1015 vomiting

52
Dexmedetomidine
  • a2-adrenergic receptor agonist
  • Sedative analgesic effects
  • Non-invasive procedures in 48 kids
  • 15 after failing CH and/or midazolam
  • Dosage
  • 0.5-1.0 mcg/kg over 5-10 min
  • Infusion 0.5-1.0 mcg/kg/hr
  • Recovery (w/o other med) 69 34 min
  • Minimal cardio-respiratory effect

PCCM 20056435-9
53
Adverse events
  • gt30,000 ped sedations (26 hospitals)
  • All providers, non-OR
  • 50 propofol
  • Docs 28 ER, 28 ICU, 19 anesth.
  • 0 deaths, 1 arrest, 1 aspiration
  • Per 10,000 sedations
  • 24 apnea
  • 2 airway consult
  • 10 intubation
  • 27 oral airway
  • 7 admitted
  • 64 BVM

Peds 20061181087
54
Reducing errors
  • Fewer than 3 medications
  • Experience
  • Double check dosages
  • Expect adverse events
  • Ready to rescue!

55
Just say no
  • Music
  • Video
  • Quiet room
  • Darken if possible
  • Parents present

56
Goals Sedation outside the OR
  • Guard safety welfare of child
  • Minimize physical discomfort pain
  • Control anxiety, maximize potential for amnesia
  • Control behavior movement to complete procedure
  • Return patient to state safe for discharge

57
Meetings
  • Pediatric Sedation Outside the Operating Room
  • Boston
  • September 15-16, 2007
  • 2nd International Multidisciplinary Conference on
    Pediatric Sedation
  • Savannah, GA
  • March, 2008
  • Society for Pediatric Sedation

58
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