Paediatric Procedural Sedationv.2011Royal Children HospitalECIICNVictorian Managed Insurance Authority

Program

Talk

Read handout on nitrous connections

Nitrous machine practical set up

Goal

Physical and psychological distress

Optimal environment for success

Analgesia

Anxiolysis

Amnesia

Awareness

Who is this talk for ?

Deliver quality care consistent with evidence base

Minimise risk and adverse events

Able to administer procedural sedation safely

Able to recognise and address undesirable events (rescue capacity)

http://www.youtube.com/watch?v=tGNyWDluELQ

http://www.youtube.com/watch?v=gmNwpJf1zUQ

Beware in asthmatics / RTI

General principles

Will my sedation plan achieve the best outcome for THIS patient ? Successful sedation doesn’t always guarantee

success of procedure or best outcome

What simple things can I do to reduce anxiety and need for sedation?

Preparation and post-procedural issues Patient, Staff, Place

Levels of sedationLevels of sedation

Minimal

Moderate

Deep

GA

American Society of Anesthesiologist (ASA) Classification (circle one)

1 A normal healthy patient

2 A patient with mild systemic disease

3 A patient with severe systemic disease

4 Moribund patient who is not expected to survive without the operation

*Class 3 or greater: Benefit of procedure outweighs risk of anesthesia

Reducing need for sedation

Early systemic analgesia Paracetamol, painstop, nurofen, IN fentanyl (1.5mcg/kg)

ALA (adr/lig/ameth) vs EMLA (lig/prilo)

Infants : Sucrose (5-8min), non-nutritional sucking

Non-pharmacological : distraction, balloon, bubbles, “safe person”, build rapport

Alternatives : glue, theatre (avoids repeat sedation)

Encourage coping behaviours

Modify environment

Parents

Reduce anxiety

Risk assessment

Disease factors Cerebral palsy, NM disorders, airway risk

(Prader-willi, Down’s)

Obvious contraindications / drug int

Previous sedation failure

Age < 1yo

IN fentanyl enhances NO2 sedation

The decision to sedate an unfasted patient for emergency procedures should be based on a careful assessment of the urgency of the procedure, the desired sedation depth, the fasting status and individual patient risk factors

The more urgent, the less fasting required, when less urgent, stick to minimum fasting guidelines

NO2: 2hrs Ketamine: 2hrs clear liquid

4hrs solids/milk

*consensus

Know your age-specific obs

Observations 5 minly if child deeply sedated 15 minly once improve

Discharge instructions Can child sit up/walk unaided? Tolerating fluids? Back to baseline consious state? Address carer concerns

N20

Inert colourless odourless

First synthesized in 1772 Joseph Priestley

“laughing gas” – Sir Humphry Davy

Promotes opioid peptide release from midbrain

Weak anaesthetic

Low solubility => rapid onset

N20 pros ?

Short acting, titratable

Fast onset 3-5 mins, fast offset

Inhalational analgesia and anasthesia

Safe

Requires a good seal with dedicated administrator

N20 cons ?

Vomiting (6% at home), light-headedness

Excessive sedation (caution URTI)

Requires cooperative child

Pregnant staff exclusion

Efficacy – not for all

Not useful for certain procedures

BM / Neurotoxicity, B12 def (rare)

N20 tips

Check supply

Check connections

Scavenger – medium flow

Suction

Bag : encourage blowing, hose : elephant nose

Additional O2 mask/BVM

Flavoured scents

Familiarise child with equipment

OK to apply obs postNO2 taking effect

Dose ?

Handout “Use of Nitrous Oxide in the ED”

“Vitamin K”

Dissociative anaesthetic

Hallucinatory reactions abused

Nightmares

Delirium

Ketamine pros

Major advantages Immobilisation Maintenance of airway and resp drive Profound analgesia

Mechanism of action

Cardiac stable

Ketamine cons?

Overall uncommon and minor Vomiting 8.6% Emergence 7.6% Airway / Resp 3.9%

No association with fasting

IV vs IM Longer onset and longer LOS with IM Balanced with distress of IV insertion

Respiratory

Resp depression (very young, rapid push)

Stridor (malpositioning of the airway)

Laryngospasm 0.002-0.3% incidence, 1/22 cases required ETT Idiosyncratic Airway support, PEEP and wait

Hypersalivation (X atropine, may increase events)

Emergence phenomenon

Range of behaviours

More common in adolescents, not an absolute CI

Responds well to midazolam but not as prophylaxis

Manage as per acute agitation

Others

Modest rise in HR, BP, metabolism

Hypertonicity, tremor, random movements Does not reflect depth of sedation

Seizures (case reports)

ICP/IOP elevation

Rash

Ataxia

CI

Children < one year / >12 years

Previous adverse reaction to ketamine

Active respiratory tract infection or disease

Procedures involving the lower airway or pharynx

Heart disease

Bowel obstruction

Psychosis / ADHD

Porphyria

Thyrotoxicosis

Unstable epilepsy

Glaucoma

Central nervous system masses, hydrocephalus

Practical tips

Full resus area with airway backup

Take time to explain to parents

Lights are on, but no one’s home

Saliva/tears not sign of pain or distress

Parents present

Rash spontaneously resolve

Dose