Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children

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Pediatric Procedural SedationJana
Stockwell, MD, FAAPChildrens Sedation
ServicesChildrens Healthcare of AtlantaEmory
University School of Medicine
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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

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Why Sedate?

• Efficacy
• Satisfaction
• Quality of study
• Do unto others
• Same injury, adults sedated more

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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

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CHOA _at_ Egleston Program

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

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Overview

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

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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

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Joint Commission 2000

• Level 1 Minimal
• Respond normally to verbal commands
• Cognitive function and coordination impaired

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Joint Commission 2000

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

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Joint Commission 2000

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

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Never Never Land

• Level 3.5 Dissociative Sedation
• Cataleptic state
• Maintain protective reflexes
• Retain spontaneous respirations

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Joint Commission 2000

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

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Remember, its a
CONTINUUM
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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

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(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

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Inappropriate Patients

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

Primum non nocere
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Airway concerns

• Downs Syndrome
• Macroglossia
• Small mouth
• Small trachea
• Atlanto-axial instability

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Airway concerns
Pierre-Robin Sequence
Beckwith-Wiedemann Syndrome
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Other concerns

• Pneumonia, asthma, BPD, tracheomalacia, OSA,
  tachypnea
• CCHD, CHF, hypotension
• Central apnea, seizures
• GERD, hepatic disease
• Renal disease, dehydration, abnormal electrolytes
• Sepsis

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Patient Assessment

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

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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

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Allergies

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

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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

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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
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NPO status (ASA)

• Solids, formula - 6 hours
• Clear liquids - 2 hours
• Breast milk - 4 hours
• Can take sip with meds

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Preparation

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

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Preparation

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

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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

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Documentation Monitoring

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

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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

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Git er done

• Hypnotics
• Sedatives
• Ketamine
• Etomidate
• Propofol
• Nitrous oxide

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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

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Hypnotics

• Chloral hydrate
• Pentobarbital
• Methohexital
• Etomidate

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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

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Chloral hydrate

• Amnesia?
• Gas
• Hyperactivity
• Deaths after discharge
• Carcinogen

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Barbiturates

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

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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

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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

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Methohexital

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

Pediatrics 2000105(5)1110-4
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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

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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

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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)
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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

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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

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Ketamine

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

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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 ? ??

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Propofol

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

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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
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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

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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
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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
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Reducing errors

• Fewer than 3 medications
• Experience
• Double check dosages
• Expect adverse events
• Ready to rescue!

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Just say no

• Music
• Video
• Quiet room
• Darken if possible
• Parents present

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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

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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

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Questions?