Transcript Pediatric Sedation - Arizona Radiology Nurses Home

Pediatric Sedation
Cindy Sanders, RN, MSN
November 1, 2008
Kids are different
• Goals for sedation to control behavior to allow
procedure to be completed successfully
• Kids under age 5 or 6 (chronologically or
developmentally) may require deep sedation
• Anatomical and physiological differences must be
considered
• May be more vulnerable to respiratory depression
and may pass into deeper sedation state than was
intended
“Rules” are the same
• American Academy of
Pediatrics,(AAP) American Society of
Anesthesiologists, (ASA) American
Academy of Pediatric Dentists
(AAPD) and Joint commission on
Accrediation of Healthcare
Organizations (JCAHO) issued
guidelines for pediatric sedation
Safe sedation
requirements
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Systematic approach
No administration of sedation with safety net
Careful focused pre-sedation assessment
Appropriate NPO
Focused airway exam
Clear understanding of meds, interactions, etc.
Goals of Pediatric
Sedation
• Guard Patient safety
• Minimize discomfort and pain
• Control anxiety, minimize psychological
trauma, maximize amnesia
• Control behavior to allow successful
completion of exam
• Return patient to a state in which safe
discharge is possible
Who is an infant/ child?
• AAP: birth to 21 years
• PALS: infant to age 1, child 1yr to
puberty
• Some institutions: to age 18
• Chronologic vs. developmental age
The Sedation Continuum
Mild/conscious/anxiolysis
Deep
Moderate/conscious
The sedation continuum
• Must be able to “rescue” patient
from next level
• Failure to rescue may be more
common in non hospital setting
• Conscious sedation may be an
oxymoron for the young peds patient
Regardless of the medication given, the
route of administration or the intended
level of sedation, the sedation of a
pediatric patient may result in
respiratory depression and loss of
airway protective reflexes
Candidates for pediatric
sedation
• ASA class I and II generally good
candidates
• ASA II and IV-require consideration,
consultation with anesthesia, etc
• Pediatric specific considerations
must be evaluated
Peds specific risks
• Untreated severe GERD (Gastroesophageal reflux disease)
• Recent apnea monitor/history
• Congenital airway anomalies such as
macroglossia, micronathia, etc.
• Extreme Tonsillar hypertrophy
• Mitochondrial or metabolic disease
Sedation history
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Prior sedation history
Medication history/allergies
Significant medical history
Does patient snore
Recent cold, asthma, etc.
NPO status
NPO status
Parent/guardian accompanying child
NPO guidelines
• Elective procedures require fasting
guidelines
• Risk of aspiration less than with general
anesthesia but absolute risk not known
• Generally same guidelines as for general
anesthesia are followed
• Solids 6-8 hours, breast milk (considered
semi-solid by some and clear by others-2-4
hours, clears 2 hours
Fluid status
• Some patients will have been NPO for 12
or more hours.
• May give pre-sedation bolus of 20cc/kg of
isotonic solution like Normal saline
• This may decrease the risk of hypotension
and hemodynamic compromise
• May want to leave IV in at procedure end
till patient awakens and drinks.
Pre sedation assessment
• Vital signs including heart rate,
respirations, b/p, temperature
• Pulse oximetry reading
• If using ETCO2 monitoring, baseline
reading
• Accurate weight
Pre sedation assessment
• Focused physical exam including
respiratory and cardiac rate rhythm and
quality
• Renal or hepatic function ok?
• Ability of child to cooperate-is non
sedation an option?
• Any contraindications to procedure (MRI,
etc)
Pre sedation
• Informed consent
• Time out
procedure
IV access
• Use of topical analgesia if possible
– EMLA, LMX, Synera (>3 years)-use care to
follow age and duration guidelines
– New product on market called Zingo (>3 as well)
being trialed at several pediatric institutions
• Take time to find best site
• Secure well!
• Consider contrast requirements if CT
Personnel and equipment
• Must have pediatric specific emergency
equipment immediately available
• Sedation providers must be trained in he
administration of sedation medications and
the management of complications
associated with these medications
• Must have skills necessary to rescue
patient from next level of sedation
RN requirements
• Institution specific but minimal
requirements include
• BLS and PALS certifications
• “Additional” competency based
training in sedation medications,
procedural requirements and rescue
skills that is ongoing
AZ State board of
Nursing
• Employers must identify medication
allowed for conscious sedation
• Licensed provider must be present in the
dept from the time the medication is
initiated to the completion of the
procedure and must be readily available in
the facility to assume care of the patient
during the post-procedure period
AZ Board of Nursing
• Registered nurse responsible must not
“leave patient unattended or engage in
other tasks that compromise continuous
monitoring”
• Specific list of educational requirements
for RNs who administer sedation.
• Advisory opinion Conscious sedation for
Diagnostic and Therapeutic Procedures
revised 5/08.
Monitoring
Intraprocedure
• Continuous monitoring of heart rate and
pulse oximetry and intermittent recording
of respiratory rate and blood pressure
• Standard is within 5 minutes prior to
sedation and every 5 minutes till
procedure is complete
• Post procedure-vital signs at regular
intervals (most often q 15 minutes)
End Tidal CO2
• Anesthesia literature validate rapid
response in respiratory
depression/hypoventilation
• Most guidelines recommend or state
should be immediately available for
moderate and esp. deep sedation
• In areas where can’t see patient (MRI) has
become more of a standard of care
General pediatric
medication considerations
• Dose must be individualized and double
checked
• Give small increments and wait for effect
• Expect variations in responses
• Be prepared to assist respirations, etc.
• Remember to consider other medications
and combinations
Pediatric sedatives
• Standard pre-printed orders may
decrease potential for error in
dosages
• Special care with route
Sedation medications
• Goal:
• Use the lowest dose of the medication
with the highest therapeutic index for the
procedure
• Perfect drug: Causes no respiratory or
cardiovascular compromise, effects last
the exact length of the procedure and has
no contraindications
Real medication choices
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Chloral hydrate
Benzodiazepines
Opiates
Barbiturates
Anesthetic agents
Dexmedetomidine
Chloral hydrate
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Has been used for more than 100 years
Classified as a sedative/hypnotic
No analgesic properties
May be given orally or rectally
Sometimes referred to as “not really a
sedative” and therefore outside of the
guidelines in any given institution
Chloral Hydrate
• Doses range from 25-125mg/kg-most
common is 50mg/kg
• Single dose max of 1000mg reported
• Onset of action is very variable
ranging from 10-60 minutes
• Long sedation has been reported
• Premature discharge has led to death
Chloral Hydrate
• Hepatic accumulation of metabolites
reported in premature infants
• Unpleasant taste, nausea and vomiting
common
• Many studies citing other drugs as more
efficient
• Some data supporting increased success if
patient under 2 years.
• No reversal agent
Benzodiazepines
• Has sedative, anti -anxiety and amnesic
properties
• No analgesic properties
• Commonly used as pre-med
• Often not able to provide adequate
sedation for procedures that require
immobility as a single agent
• Versed most commonly used agent
Versed (Midazolam)
• May be given in a variety of ways
• Doses:
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IV
Oral
Rectal
Nasal
Sublingual
0.05-0.1mg/kg
0.5-0.7 mg/kg
0.5-1.0 mg/kg
0.2-0.4 mg/kg
0.2mg/kg
Midazolam
• Concomitant use of opiate will increase
effects
• Onset of action depends upon route-1-5
minutes IV up to 20-60 minutes orally
• Can cause hypotension, respiratory
depression
• Reversal agent is Flumazenil (Romazicon)
Opiates
• Used for painful procedures
• Often combined with benzodiazepines
• Fentanyl most common opiate used in
pediatric procedures due to relatively
short half life
• Reversal agent is Naloxone (Narcan)
• May need to repeat Narcan dose due to
short ½ life.
Fentanyl
• IV form used for sedation (lollipop
and patch extended release)
• Dose is usually 1 mcg/kg
• Duration of action generally ½-1 hour
• Can cause chest wall rigidity if given
as rapid bolus
Barbiturates
• Pentobarbital historically used Radiology
sedative-is not an analgesic
• Given IV up to 6mg/kg
• Long half life a concern as related to
increased recovery times
• Attempts to awaken early may contribute
to emergence reaction or pentobarb rage
• No reversal agent
Anesthetic agents
• Ketamine
• Propofal
Ketamine
• Has dissociative properties and is
therefore somewhat unique
• Used in human and vet medicine
• Provides sedation and analgesia
• At high doses is a general anesthetic
agent
• May be given IV or IM
Ketamine
• To be used only “under direct
supervision of a LIP with experience
with anesthetic agents”
• Causes discongigant eye movements
• Can cause hallucinations (visual and
auditory) usually at emergenceversed given in combination to reduce
Ketamine
• Dose-
– IV 0.5-2mg/kg-usually use 0.5-1 for procedural
sedation
– IM 3-7mg/kg
• Onset of action 30 secs. IV. 3-4 minutes
IM
• Duration 12-25 minutes IM, 5-10 minutes
IV
Propofal
• No analgesic properties
• General anesthetic agent with very rapid onset
and potential for apnea
• State and institution guidelines vary as to RNs
ability to manage infusions
• Bolus dosing by LIP
• Study in 2005 showed that 42% of 54 pediatric
hospitals were using propofal outside of the OR
given by non anesthesiologists
Propofal
• Bolus then drip essential as drug is
degradated in single pass through the liver
• Bolus is usually 1-2mg/kg
• Infusion rates of 50-250mcg/kg/min for
short term procedural sedation
• Pediatric specific mortality reported from
irreversible metabolic acidosis in 1999
from long term high dose infusions
Dexmedetomidine
(Precedex)
• Highly selective alpha2 adrenoceptor
agonist with both analgesic and sedative
effects
• Classified as anesthetic agent
• Mechanism of action is induction of stage
2 (non REM sleep)
• Bolus then infusion delivery
• Short ½ life and lack of respiratory
depression reported
Precedex
• Advantages
– Less interference with EEG waves so therefore
more diagnostic quality
– Promising results for consistency in achieving
adequate sedation for imaging studies
– Large on-going study at Boston Children’s
Hospital demonstrating positive safety profile
Precedex
• Hemodynamic changes can occur but
are not usually clinically significant
• Specifically, bradycardia is common
but without hemodynamic compromise
• Contraindications include patients on
Digoxin (cardiac arrest reported in
adults) and other cardiac conditions
Post Sedation
Considerations
• Patients may still be at significant risk for
complications
• Removal of stimulation (pain, MRI noise)
may cause deeper sedation level especially
if multiple doses have been given
• Delayed drug absorption (oral, rectal, IM)
and slow drug elimination also may
contribute
Post Sedation
Considerations
• Continued monitoring and observation
necessary
• Pre-determined discharged criteria
– Aldrete most common
– Score of 9 or back to baseline usual criteria
• With kids, ability to drink also important
to avoid dehydration and hypoglycemia
(infants)
Post Sedation
Considerations
• Written discharge instructions that
are age specific desirable
• Toddlers especially at risk for falls,
etc
• Positioning in car seats, etc with
infants also very important due to
pediatric airway anatomy
QA/QI outcome data
• Guidelines state there should be an
analysis of any adverse events
• Collecting data regarding success
rates, etc helps drive practice
change
• One Benchmark: Pediatric Sedation
Research Consortium
Take home points
Take home points
• Kids are not little adults
• Know age specific vital sign norms
• Know where your pediatric airway
equipment is and how to use it
• Remember airway position
• Double check your meds
Remember if your intent is to
sedate a patient, irregardless of
the medication or dose you use,
sedation guidelines apply
Any Questions?????
Pediatric Sedation References
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for
Therapeutic and Diagnostic Procedures: An Update. American Academy of Pediatrics, American Academy of
Pediatric Dentists, Cote, C.J, MD, Wilson, S/ DMD, MA, PhD the WorkGroup on Sedation. Pediatrics Vol 118 No.6
December 2006 pp 2587-2602.
Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: an updates report by the
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists.
Anesthesiology. V 96 No. 4, April 2002
Incidence and Nature of Adverse Events During Pediatric Sedation /Anesthesia for Procedures Outside
the Operating Room: Report from the pediatric Research Consortium. Cravero, J.P. MD, Blike, G.T. MD,
Beach, M. MD, Gallagher, S. M. BS, Hertzog, J.H. MD, Havidich, J.E. MD, Gelman, B.MD, and the Pediatric
Sedation Consortium. Pediatrics Vol. 118, No 3. September 2006, PP 1087-1096.
Advisory Opinion Conscious sedation for Diagnostic and Therapeutic procedures. Arizona State Board of
Nursing.