Transcript A case control study of findings resulting from sexual abuse

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.”
• “Children don’t feel pain”
• “Children don’t remember pain”
Why Sedate?
•
•
•
•
Efficacy
Satisfaction
Quality of study
Do unto others…
– Same injury, adults sedated more
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
4
CHOA @ Egleston Program
• CCM & ED physicians
• Dedicated radiology & H/O sedation
nurses
• 4 locations
• 2-3 docs/day
• >3,000 sedations/year
5
Overview
• Definitions
• Choose wisely
– Pick your patient
– Pick your drugs
– Pick your “no’s”
– Pick your battles
• On the horizon
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
Joint Commission 2000
• Level 1: Minimal
– Respond normally to
verbal commands
– Cognitive function
and coordination
impaired
Joint Commission 2000
• Level 2: Moderate
sedation / analgesia
– Respond to verbal or
gentle tactile stimuli
– No intervention to
maintain airway
– Adequate
spontaneous
ventilation
Joint Commission 2000
• Level 3: Deep sedation / analgesia
– Respond purposefully following repeated
or painful stimulation
– Ability to maintain ventilatory function may
be impaired
Never Never Land
• Level ~3.5
Dissociative
Sedation
– Cataleptic state
– Maintain
protective
reflexes
– Retain
spontaneous
respirations
Joint Commission 2000
• Level 4: Anesthesia
– Not arousable, even with painful stimuli
– Independent ventilatory function often
impaired
Remember, it’s a…
13
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
(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
Inappropriate Patients
• Airway issues
– Small, tight jaw
– Airway obstruction
• Respiratory issues
• “Super quick”
– Lacerations to be fixed with Dermabond
Primum non nocere
Airway concerns
Down’s Syndrome
•Macroglossia
•Small mouth
•Small trachea
•Atlanto-axial instability
Airway concerns
Pierre-Robin Sequence
Beckwith-Wiedemann Syndrome
Other concerns
• Pneumonia, asthma, BPD,
tracheomalacia, OSA, tachypnea
• CCHD, CHF, hypotension
• Central apnea, seizures
• GERD, hepatic disease
• Renal disease, dehydration, abnormal
electrolytes
• Sepsis
19
Patient Assessment
• American Society Anesthesiology (ASA)
class
• Allergies
• NPO status
• Health evaluation
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
21
Allergies
• Medications allergies
– Previous anesthesia events?
• Food allergies (egg, soy)
• Tape, skin prep, etc
22
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
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;118:2587
NPO status (ASA)
•
•
•
•
Solids, formula - 6 hours
Clear liquids - 2 hours
Breast milk - 4 hours
Can take sip with meds
25
Preparation
• Informed consent
• Health evaluation
– ROS
– History (sedations?)
– Medications (including herbals)
– Weight
– VS, sat
– Exam (airway, lungs, CV state, LOC)
Preparation
• Additional person
• “SOAPME”
– Suction
– Oxygen
– Airways (BVM, oral, LMA,
ETT)
– Pharmacy (meds)
– Monitors
– Equipment (defibrillator,
airway supplies, etc)
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
Documentation & Monitoring
•
•
•
•
•
•
•
•
•
Time out
Time-based record: Q5 minutes
SPO2 & ETCO2
HR
BP
LOC
O2 given
Medications
Interventions
29
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
Git ‘er done
•
•
•
•
•
•
Hypnotics
Sedatives
Ketamine
Etomidate
Propofol
Nitrous oxide
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
Hypnotics
•
•
•
•
Chloral hydrate
Pentobarbital
Methohexital
Etomidate
34
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
Chloral hydrate
•
•
•
•
•
Amnesia?
Gas
Hyperactivity
Deaths after discharge
Carcinogen
Barbiturates
•
•
•
•
Depress RAS
No analgesia
May be hyperesthetic
Amnesia
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%
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
Methohexital
• IV
– Myoclonus 10%
– Hiccups 10%
• Rectal
– 95% success
– 6% apnea / desaturation
– 3% hiccups
Pediatrics 2000;105(5):1110-4
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%
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
Pentobarbital vs. Etomidate
Adverse Event
Pentobarb
N = 396
Etomidate
N = 444
Relative Risk
(95% CI), p
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
144 (139,150)
34 (32,36)
Any Event* (p=.005)
Recovery time (min)
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
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
Ketamine
•  Secretions
– Consider glycopyrrolate
(Robinul)
• Vomiting
• Emergence 12%
• Contraindications
–  ICP, glaucoma, open
globe
– <3 months of age
– History of psychosis,
porphyria
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  
Propofol
•
•
•
•
Alkaline -- STINGS
Contraindicated - egg or soy allergy
Hypotension
Rare bradycardia, acidosis leading
to sudden death
• No analgesia
• Green urine
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 2003;42:783 & 773
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
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;6:435-9
52
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
53
Reducing errors
•
•
•
•
•
Fewer than 3 medications
Experience
Double check dosages
Expect adverse events
Ready to rescue!
“Just say no”
•
•
•
•
•
Music
Video
Quiet room
Darken if possible
Parents present
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
56
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
57
Questions?