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Charles J. Cot é, MD Professor of Anesthesiology & Pediatrics Northwestern University

Charles J. Cot é, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial Hospital Chicago Illinois. Sedation Guidelines: where have we been & where are we headed. Sedation Goals. Anxiolysis

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Charles J. Cot é, MD Professor of Anesthesiology & Pediatrics Northwestern University

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  1. Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial Hospital Chicago Illinois

  2. Sedation Guidelines: where have we been & where are we headed

  3. SedationGoals • Anxiolysis • Analgesia • Amnesia • Safety • Control behavior • Return to baseline

  4. American Academy of Pediatrics Guidelines Response to Dental Accidents

  5. Guidelines for the Elective use of: • Conscious sedation • Deep sedation • General anesthesia Pediatrics 76:317-321, 1985

  6. Conscious Sedation Medically controlled state of depressed consciousness • protective reflexes maintained • maintain airway independently • appropriate response to verbal command or physical stimulation (NOT REFLEX WITHDRAWAL)

  7. Deep Sedation Medically controlled state of depressed consciousness: • not easily aroused • may not maintain airway • may not respond to verbal command • may not respond to physical stimulation (EASILY MOVES TO GENERAL ANESTHESIA)

  8. Guidelines for Monitoring and Management of Pediatric Patients during and after Sedation for Diagnostic and Therapeutic Procedures Pediatrics 99:1110-1115, 1992

  9. Guideline Emphasis • Pre-sedation evaluation • Appropriate fasting • Informed consent • Monitoring • Time-based record • Recovery facility • Discharge criteria • No out of facility prescriptions

  10. Source of data: • FDA adverse drug reports (629) • USP • Survey Pediatric • Anesthesiologists (310) • Intensivists (470) • Emergency Medicine (575) • Anonymous

  11. Outcome Measures: • Death • Neurologic Injury • Prolonged Hospitalization • No Harm Pediatrics 105:805-814, 2000

  12. Critical Incident Analysis What went wrong? Why? How can we prevent it from happening again?

  13. Methodology: • Each case reviewed independently • Daniel Notterman MD • Helen Karl MD • Joseph Weinberg MD • Charles Coté MD • All cases debated • Only cases accepted = total agreement Supported by Roche Pharmaceuticals

  14. Source of Data - Final Set

  15. Quotable quotes in reports !!!!

  16. “The patient was not on any monitors” Self evident death

  17. “The patient received tablespoons instead of teaspoons” Dispensing error  death

  18. “If they made nurses stay after 5 PM they would all quit” Inadequate recovery procedures  rescued by a friend!

  19. “Physician administered medication and left facility leaving the patient with a technician” Inadequate personnel  death

  20. “patient given 175 µg fentanyl IV  chest wall rigidity” They did not understand pharmacodynamics  neurologic injury

  21. “6-wk old infant received Demerol Phenergan and Thorazine for a circumcision  found dead in bed” Drug-drug interaction Poor drug selection

  22. “Drug given at home by a parent” Lack of medical supervision  death

  23. “Anesthesia given by a gynecologist” You can’t do two things at the same time death

  24. “The child received 6,000 mg of chloral hydrate” Drug overdose  death

  25. “Child became stridorous and cyanotic on the way home” Premature discharge  rescued

  26. “An oxygen outlet available but no flow meter…no oxygen for 10 minutes” Inadequate equipment  Neurologic injury

  27. Age Distribution

  28. ASA Physical Status

  29. Death / Neurologic Injury Prolonged hospitalization or No Harm 60 35 Outcome

  30. Causes

  31. Drug Category

  32. Number of Medications

  33. Route of Administration (Death)

  34. Presenting Event(1st - 2nd - 3rd)

  35. Outcomes by Specialty

  36. Venue of Event

  37. Outcome vs Monitoring * P < 0.001 compared with pulse oximetry Pediatrics 105:805-814, 2000

  38. Outcome vs Monitoring (Oximetry vs. Venue) * P < 0.01 Office vs. Hospital Pediatrics 105:805-814, 2000

  39. Demographics vs Venue Pediatrics 105:805-814, 2000

  40. Cardiac Arrest * * P < 0.001 * Pediatrics 105:805-814, 2000

  41. Death / Injury vs. Venue * * P < 0.001 Pediatrics 105:805-814, 2000

  42. Non-hospital Patients • Older • Heavier • Healthier (lower ASA status) • Deader !!!!!!!!!!!!!

  43. Non-Hospital vs. Hospital • FAILURE TO RESCUE • INADEQUATE CPR SKILLS

  44. CONCLUSIONS • Not the drugs, route of administration, or the patient population • Monitoring makes a difference • Need Systems approach • Need CPR skills to rescue patients

  45. Coté’s Caveats

  46. Infants and children require pharmacologic coma to remain still for a procedure

  47. Drug effects are the same regardless of: • Route of administration • Who gives them • Where they are given

  48. “conscious sedation” is an oxymoron

  49. The intended sedation level is difficult to achieve Dial S, et al: Pediatr Emerg Care 17:414-420, 2001 – 301 sedations

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