why not sedate?
DESCRIPTION
Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children’s Sedation Services Children’s Healthcare of Atlanta Emory University School of Medicine. Why Not Sedate?. “I’m gonna be so fast they won’t even feel it.” “They’re just crying because they’re being held down.” - PowerPoint PPT PresentationTRANSCRIPT
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Pediatric Procedural
Sedation
Jana Stockwell, MD, FAAPChildren’s Sedation Services
Children’s Healthcare of AtlantaEmory University School of Medicine
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Why Not Sedate?
• “I’m gonna be so fast they won’t even feel it.”
• “They’re just crying because they’re being held down.”
• “Children don’t feel pain”• “Children don’t 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 @ Egleston Program
• CCM & ED physicians• Dedicated radiology & H/O sedation
nurses• 4 locations• 2-3 docs/day• >3,000 sedations/year
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Overview
• Definitions• Choose wisely
– Pick your patient– Pick your drugs– Pick your “no’s”– Pick your battles
• On the horizon
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Definitions
• 1992 AAP (Peds 1992;898:110)
– Conscious Sedation– Deep Sedation
• 1998 ACEP (Ann Emer Med 1998;31:663)
– Procedural Analgesia & Sedation• 2006 AAP & AAPD (Peds 2006;118:2587-2602)
– 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, it’s a…
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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 I&D– 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 nocerePrimum non nocere
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Down’s Syndrome•Macroglossia•Small mouth •Small trachea•Atlanto-axial instability
Airway concerns
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Airway concerns
Beckwith-Wiedemann Syndrome
Pierre-Robin Sequence
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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;
<1 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 <6 mos (ketamine)– Fewer events if fasted <3 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 2006;118:2587Pediatrics 2006;118:2587
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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 2000;105(5):1110-4Pediatrics 2000;105(5):1110-4
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Etomidate
• Ultrashort-acting non-barbiturate imidazole hypnotic
• 0.2-0.3 mg/kg (<10 yrs), 0.2-0.6 >10 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. EtomidateAdverse Event Pentobarb
N = 396Etomidate
N = 444Relative Risk (95% CI), p
Any Event* (p=.005) 18 (4.5%) 6 (0.9%) 1.03 (1.01,1.05)
Desaturation 4 0 p=0.03
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 p<0.003
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• Bronchodilationinotropy, 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
– <3 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
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• 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 2003;42:783 & 773Ann Emerg Med 2003;42:783 & 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• 10–15% vomiting
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Dexmedetomidine
• α2-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 2005;6:435-9PCCM 2005;6:435-9
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Adverse events
• >30,000 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 2006;118:1087
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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?