Why Not Sedate?

Pediatric Procedural

Sedation

Jana Stockwell, MD, FAAPChildren’s Sedation Services

Children’s Healthcare of AtlantaEmory 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

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 @ Egleston Program

• CCM & ED physicians• Dedicated radiology & H/O sedation

nurses• 4 locations• 2-3 docs/day• >3,000 sedations/year

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

13

Remember, it’s a…

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 nocerePrimum non nocere

Down’s Syndrome•Macroglossia•Small mouth •Small trachea•Atlanto-axial instability

Airway concerns

Airway concerns

Beckwith-Wiedemann Syndrome

Pierre-Robin Sequence

19

Other concerns

• Pneumonia, asthma, BPD, tracheomalacia, OSA, tachypnea

• CCHD, CHF, hypotension• Central apnea, seizures• GERD, hepatic disease• Renal disease, dehydration, abnormal

electrolytes• Sepsis

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;

<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

22

Allergies

• Medications allergies– Previous anesthesia events?

• Food allergies (egg, soy)• Tape, skin prep, etc

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;118:2587Pediatrics 2006;118:2587

25

NPO status (ASA)

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

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

29

Documentation & Monitoring

• Time out • Time-based record: Q5 minutes• SPO2 & ETCO2

• HR• BP• LOC• O2 given• Medications• Interventions

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

34

Hypnotics

• Chloral hydrate• Pentobarbital• Methohexital• Etomidate

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):1110-4Pediatrics 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. 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)

Ketamine

• Dissociative state– Related to PCP– Disconnects limbic system– Brainstem RAS not affected

• Analgesia – Sedation – Amnesia• Does not impair laryngeal reflexes• Bronchodilationinotropy, 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 & 773Ann 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

52

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

53

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

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

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

Questions?