11

Pediatric SedationPediatric Sedation

Desi Reddy (Desi Reddy (MB ChB, FFA, FRCPCMB ChB, FFA, FRCPC))

Department of AnesthesiaDepartment of Anesthesia

McMaster UniversityMcMaster University

STRUCTURESTRUCTURE

DefinitionDefinition

Pre-procedure PreparationPre-procedure Preparation

Monitoring and EquipmentMonitoring and Equipment

MedicationsMedications

Recovery and DischargeRecovery and Discharge

33

DEFINITIONSDEFINITIONS

55

anxiolysisanxiolysis

analgesiaanalgesia

amnesiaamnesia

safetysafety

control behaviorcontrol behavior

return to baselinereturn to baseline

Sedation GoalsSedation Goals

66

ContinuumContinuum

minimally impaired consciousness to minimally impaired consciousness to complete unconsciousness complete unconsciousness

““conscious sedation” conscious sedation” is an oxymoronis an oxymoron

88

99

New SedationNew Sedation TerminologyTerminology

MinimalMinimal

ModerateModerate

DeepDeep

General anesthesiaGeneral anesthesia

Minimal SedationMinimal Sedation

ResponseResponse normal response to normal response to verbal stimulationverbal stimulation

AirwayAirway UnaffectedUnaffected

VentilationVentilation UnaffectedUnaffected

CV functionCV function UnaffectedUnaffected

Moderate SedationModerate Sedation

ResponseResponsePurposeful response Purposeful response

to verbal or tactile to verbal or tactile stimulationstimulation

AirwayAirway Intervention maybe Intervention maybe requiredrequired

VentilationVentilation AdequateAdequate

CV functionCV function Usually maintainedUsually maintained

Deep SedationDeep Sedation

ResponseResponsePurposeful response Purposeful response following repeated or following repeated or

painful stimulationpainful stimulation

AirwayAirway Intervention is Intervention is requiredrequired

VentilationVentilation May require supportMay require support

CV functionCV function Usually maintainedUsually maintained

General AnesthesiaGeneral Anesthesia

ResponseResponse Unarousable even to painful Unarousable even to painful stimulistimuli

AirwayAirway intervention requiredintervention required

VentilationVentilation frequently inadequatefrequently inadequate

CV FunctionCV Function maybe impairedmaybe impaired

ImplicationsImplications

Assume and prepare for Assume and prepare for Deep Deep SedationSedation

The level of vigilance = The level of vigilance = Maximal Maximal Appropriate Appropriate monitoringmonitoring equipmentequipment

and and personnelpersonnel

1515

SEDATION MORBIDITY AND SEDATION MORBIDITY AND MORTALITYMORTALITY

1717

mortality is very raremortality is very rare

morbidity is not uncommonmorbidity is not uncommon

Cote reviewed 95 adverse events Cote reviewed 95 adverse events • 51 deaths and 9 permanent neurological injuries51 deaths and 9 permanent neurological injuries

1818

CausesCauses

drug interaction 44drug interaction 44

overdose 34overdose 34

inadequate monitoring 27inadequate monitoring 27

inadequate CPR 19inadequate CPR 19

inadequate work-up 18inadequate work-up 18

premature discharge 11premature discharge 11

inadequate personnel 10inadequate personnel 10

1919

Drug CategoryDrug Category

opioid 22opioid 22

benzodiazepine 18benzodiazepine 18

barbiturate 19barbiturate 19

sedative 21sedative 21

chloral hydrate 13chloral hydrate 13

ketamine 1ketamine 1

2020

Route of AdministrationRoute of Administration

IntravenousIntravenous 6060

oral oral 3737

rectal rectal 99

nasal nasal 44

intramuscular intramuscular 3131

inhalation inhalation 1313

2121

Presenting EventPresenting Event

eventevent nnrespiratoryrespiratory 8080

cardiaccardiac 88

otherother 77

totaltotal 9595

Outcome vs MonitoringOutcome vs Monitoring

* P < 0.001 compared with pulse oximetry

Pediatrics 105:805-814, 2000

OutcomeOutcome OximeterOximeter(n=21)(n=21)

NoneNone(n=18)(n=18)

Death/InjuryDeath/Injury 44 **1414

No harmNo harm 1717 44

Causes of catastrophesCauses of catastrophes

Poor patient selectionPoor patient selectionDrug overdoseDrug overdoseLack of appreciation of drug Lack of appreciation of drug

interactions, pharmacokinetics and interactions, pharmacokinetics and dynamicsdynamics

Use of multiple medications to Use of multiple medications to sedate patientsedate patient

Lack of monitoring before, during, or Lack of monitoring before, during, or after procedureafter procedure

Inadequate CPR skills ’ failure to Inadequate CPR skills ’ failure to rescue’rescue’

ConclusionsConclusions

Most complications avoidableMost complications avoidable

Monitoring makes a differenceMonitoring makes a difference

Adverse events involved multiple drugsAdverse events involved multiple drugs

Children 1 to 6 years are at greatest Children 1 to 6 years are at greatest riskrisk

Need appropriate personnel skilled in Need appropriate personnel skilled in airway management and resuscitationairway management and resuscitation

Pulse Oximetry isPulse Oximetry is EssentialEssential

2626

2727

Factors Relating to ProcedureFactors Relating to Procedure

durationduration

painpain

positioningpositioning

anxiety/stress of procedureanxiety/stress of procedure

availability of rescue resourcesavailability of rescue resources

2828

Factors relating to PatientFactors relating to PatientPast experiencePast experience

AllergiesAllergies

Adverse reactionsAdverse reactions

Aspiration riskAspiration risk

URTIURTI

ASA classificationASA classification

Fasting GuidelinesFasting Guidelines

Fasting GuidelinesFasting Guidelines

Ingested materialIngested material Fasting period (hours)Fasting period (hours)

Clear liquids-Clear liquids-HH220,fruit 0,fruit

juices,clear tea,black juices,clear tea,black coffeecoffee

22

Breast milkBreast milk 44

Infant formulaInfant formula 66

Nonhuman milkNonhuman milk 66

Light mealLight meal 66

3030

General HealthGeneral Health

ASA 1ASA 1normal, healthy patientnormal, healthy patient

ASA 2ASA 2controlled medical condition without controlled medical condition without

significant systemic effectssignificant systemic effects

hypertension, DM, anemia, mild obesityhypertension, DM, anemia, mild obesity

3131

ASA ClassificationASA Classification

ASA 3ASA 3medical condition with significant effects medical condition with significant effects

and significant functional compromiseand significant functional compromise

Controlled CHF, stable angina, morbid Controlled CHF, stable angina, morbid obesity, chronic renal failureobesity, chronic renal failure

3232

ASA ClassificationASA Classification

ASA 4ASA 4poorly controlled medical condition, with poorly controlled medical condition, with

significant dysfunction and a potential threat significant dysfunction and a potential threat to lifeto life

unstable angina, symptomatic COPD, CHFunstable angina, symptomatic COPD, CHF

3333

ASA ClassificationASA Classification

ASA 5ASA 5critical medical condition associated with critical medical condition associated with

little chance of survivallittle chance of survival

multi-organ failure, sepsis syndromemulti-organ failure, sepsis syndrome

3434

3535

Provider FactorsProvider Factors

dedicated sedation monitordedicated sedation monitor

skills related to depth of sedationskills related to depth of sedation

back-up systems and ability to Rescueback-up systems and ability to Rescue

3636

EquipmentEquipment

SOAP MESOAP ME• SSuctionuction

• OOxygenxygen

• AAirwayirway

PPharmacyharmacy

MMonitoringonitoring

EEquipmentquipment

3737

3838

MedicationsMedications

3939

PharmacodynamicsPharmacodynamics

2 general groups2 general groupssedationsedation

analgesicsanalgesics

4040

PharmacokineticsPharmacokinetics

routerouteorally, intravenously, intramuscularly, intra-orally, intravenously, intramuscularly, intra-

nasally, rectallynasally, rectally

intravenousintravenoustitrate to effecttitrate to effect

combination of medications combination of medications

4141

PharmacokineticsPharmacokinetics

dose stackingdose stackingrepeated administration before peak effect repeated administration before peak effect

of previous dose reached.of previous dose reached.

synergismsynergismcombination of drugs increase risk of combination of drugs increase risk of

serious side effect, e.g.. benzodiazepine and serious side effect, e.g.. benzodiazepine and opiateopiate

4242

DrugsDrugs

sucrose pacifiersucrose pacifierreduced crying in neonates following heel reduced crying in neonates following heel

prickprick

should be used more frequently in infants should be used more frequently in infants undergoing brief painful proceduresundergoing brief painful procedures

4343

DrugsDrugs

Oral Chloral HydrateOral Chloral Hydrateused for painless procedures in kids for used for painless procedures in kids for

yearsyears

20 -75 mg/kg orally20 -75 mg/kg orally

bitter taste, not tolerated very wellbitter taste, not tolerated very well

peak effect up to 60 minutes with a half life peak effect up to 60 minutes with a half life of 4 - 9 hoursof 4 - 9 hours

4444

Chloral HydrateChloral Hydrate

prolonged sedationprolonged sedationneed prolonged supervision prior to need prolonged supervision prior to

dischargedischarge

advantage is lack of respiratory advantage is lack of respiratory depressiondepression

4646

Oral MidazolamOral Midazolam

short acting, water soluble short acting, water soluble benzodiazepinebenzodiazepine

no analgesic propertiesno analgesic properties

popular because of short duration, popular because of short duration, predictable onset, and lack of predictable onset, and lack of metabolitesmetabolites

get skeletal muscle relaxation, amnesia get skeletal muscle relaxation, amnesia and anxiolysisand anxiolysis

dose: 0.5 - 0.75 mg/kgdose: 0.5 - 0.75 mg/kg

4747

Oral MidazolamOral Midazolam

Recommended useRecommended use::sole agent for children who will drink liquid sole agent for children who will drink liquid

medication. medication.

anxiolysis and cooperation are excellentanxiolysis and cooperation are excellent

administer local anesthetic for painful administer local anesthetic for painful proceduresprocedures

4949

MidazolamMidazolam

rectal midazolamrectal midazolam0.3 - 0.7 mg/kg0.3 - 0.7 mg/kg

effect within 15 minuteseffect within 15 minutes

nasal midazolamnasal midazolam0.2 - 0.4 mg/kg0.2 - 0.4 mg/kg

onset 10 -15 minutes, burning onset 10 -15 minutes, burning sensation to mucosasensation to mucosa

5050

Intravenous MidazolamIntravenous Midazolam

dose: 0.05-0.1 mg/kg every 3-5 dose: 0.05-0.1 mg/kg every 3-5 minutes up to a max. of 0.7 mg/kgminutes up to a max. of 0.7 mg/kg

peak effect in 2-3 minutespeak effect in 2-3 minutes

synergistic reaction with opiates. synergistic reaction with opiates. Limit dose to 0.05 mg/kg. Severe Limit dose to 0.05 mg/kg. Severe respiratory depression.respiratory depression.

anterograde and retrograde (at anterograde and retrograde (at times) amnesiatimes) amnesia

5151

Intravenous MidazolamIntravenous Midazolam

Recommended Use:Recommended Use:excellent agent for sedation and anxiolysisexcellent agent for sedation and anxiolysis

provides complementary sedation with provides complementary sedation with opiates for painful proceduresopiates for painful procedures

caution with combinationcaution with combination

5353

PropofolPropofol

potent sedative and hypnoticpotent sedative and hypnotic

onset it very rapid. 60 - 90 secondsonset it very rapid. 60 - 90 seconds

induction of anesthesia at doses = 2-induction of anesthesia at doses = 2-3 mg/kg3 mg/kg

recovery rapid = 2-3 minutes recovery rapid = 2-3 minutes redistributionredistribution

prolonged sedation and vomiting is prolonged sedation and vomiting is very lowvery low

disadvantage is pain on injectiondisadvantage is pain on injection

5454

PropofolPropofol

Recommended use:Recommended use:ideal agent for brief periods of deep ideal agent for brief periods of deep

sedationsedation

minimal adverse effects and rapid minimal adverse effects and rapid awakening are uniqueawakening are unique

get rapid induction of anesthesia and get rapid induction of anesthesia and hence should only be used by hence should only be used by anesthesia personnel or intensivistsanesthesia personnel or intensivists

5555

FentanylFentanyl

potent synthetic opioid (100 x Morphine)potent synthetic opioid (100 x Morphine)

peak effect= 5 min and lasts for 30 - 40 peak effect= 5 min and lasts for 30 - 40 min.min.

respiratory depressant effect is much respiratory depressant effect is much longer (4 hrs) than analgesic effectlonger (4 hrs) than analgesic effect

Dose: 0.5 - 1.0 mcg/kg up to 5 mcg/kgDose: 0.5 - 1.0 mcg/kg up to 5 mcg/kg

5656

FentanylFentanyl

minimal hemodynamic effectsminimal hemodynamic effects

reversible with Naloxonereversible with Naloxone

Recommended use:Recommended use:excellent analgesia and mild sedation with excellent analgesia and mild sedation with

short duration of action. Careful respiratory short duration of action. Careful respiratory monitoring when combined with other monitoring when combined with other sedativessedatives

5858

KetamineKetamine

produces intense analgesia, sedation produces intense analgesia, sedation and amnestic qualitiesand amnestic qualities

Oral dose: 5-6 mg/kg Oral dose: 5-6 mg/kg

IV dose :1 - 2 mg/kgIV dose :1 - 2 mg/kg

IM dose: 2 - 5 mg /kgIM dose: 2 - 5 mg /kg

5959

KetamineKetamine

less pronounced respiratory depressionless pronounced respiratory depression

airway protective reflexes usually intactairway protective reflexes usually intact

side effectsside effectsexcessive salivation and airway secretionsexcessive salivation and airway secretions

emergence dysphoriaemergence dysphoria

6161

OxygenOxygen DeliveryDelivery

nasal cannulanasal cannulaprovides up to 44% oxygenprovides up to 44% oxygen

inspired oxygen depends on flow rateinspired oxygen depends on flow rate

each liter of flow-increases FiO2 by 4%each liter of flow-increases FiO2 by 4%

usual settings= 1-4 lusual settings= 1-4 l

6262

OxygenOxygen DeliveryDelivery

simple face maskssimple face masksprovides up to 60% oxygenprovides up to 60% oxygen

flow rate set between 6-10 lflow rate set between 6-10 l

liter flow must be > 6 l to prevent CO2 liter flow must be > 6 l to prevent CO2 accumulationaccumulation

non rebreather masknon rebreather mask - provide 60-90% - provide 60-90% oxygen at flows of 10-12 l\minoxygen at flows of 10-12 l\min