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Pediatric Emergence Delirium and The Use of Precedex

Pediatric Emergence Delirium and The Use of Precedex. Adrienne Domanico RN, MSN, CRNA SOFA Conference Fall 2018. Objectives. Define emergence delirium and its importance to anesthesia providers Identify risk factors for development of emergence delirium

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Pediatric Emergence Delirium and The Use of Precedex

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  1. Pediatric Emergence Delirium and The Use of Precedex Adrienne Domanico RN, MSN, CRNA SOFA Conference Fall 2018

  2. Objectives • Define emergence delirium and its importance to anesthesia providers • Identify risk factors for development of emergence delirium • Illustrate pharmacological properties of Precedex • Explain the use of Precedex in the treatment of pediatric emergence delirium

  3. Definitions Agitation • “To move or force into violent, irregular action; impart regular motion too; • to disturb or excite emotionally, arouse, perturb; to call attention to with speech or writing; ruffle, fluster, roil” – www.dictionary.com So, what does the literature say….. “A more or less temporary disorder of the mental faculties, as in fevers, disturbances of consciousness, or intoxication, characterized by restlessness, excitement, delusions, hallucinations, etc.; a state of violent excitement and emotion” – www.dictionary.com “A neuropsychiatric condition that is secondary to a general medical condition and/or its treatments” (Schieveld and Janssen, 2014) Delirium

  4. … It says this WHAT DOES IT ALL MEAN?!?! “A wide variety of behavioral disturbances seen in children following emergence from anesthesia” (Chandler et al 2012) “Amental disturbance common in children during recovery of general anesthesia” (Mountain et al 2011) “Characterized by a variety of presentations… during the early stage of emergence from anesthesia” (Dahmani et al., 2010) “A mental disturbance during the recovery from general anesthesia…” (Locatelli et al, 2012) “Adissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolably crying, moaning, kicking, or thrashing” (Reduque and Verghese, 2012)

  5. Importance • “Children get delirious so often and • quickly that this is of no importance • to us” - Bleuler (1857-1939) • So what does ED mean to us?

  6. Pediatric vs Adult • Pediatrics • can last up to 30 minutes, in about 80% of pediatric cases!!! • Most commonly in ages 2-8 • Adult • can be seen at any age • an incidence around 40% but this includes ICU psychosis, chronic illness, etc in addition to emergence

  7. Theories • Stress induced • Disinhibition • Acetylcholine • Circadian rhythm disruption

  8. Risk Factors • Children from ages 2-8 • Short acting anesthetics/ rapid emergence • Relatively painful procedures/ Sites of surgery • Patients with separation anxiety • Child’s temperament

  9. Stages of Anesthesia

  10. Instead of this…. … We want this!!!

  11. PAED Scale

  12. How can you tell if it’s Pain?

  13. Let’s review some A & P

  14. Alpha 2 receptors • Mediates sedation • Cause fluctuations in BP • Postsynaptic locations: pancreas, kidney, fat • Mostly found in CNS • Agonists have benefits for us

  15. Alpha 2 receptors

  16. … Or sitting through this presentation

  17. Precedex (dexmedetomidine) Pharmacodynamics • Highly selective alpha 2:alpha 1 1600:1 • Sedation and analgesia sparing respiratory drive • Less pain medication use in PACU • Less postop delirium • Approved for MAC sedation in 2010 • “arousable” sedation • Mood enhancing effects

  18. Precedex Pharmacokinetics • Distribution half life = 6 mins • Terminal elimination half life = 2-3 hrs • Plasma binding is 94% and significantly decreased in hepatic impaired subjects • Metabolism = glucuronodation and cytochrome p450 metabolism to undergo almost complete biotransformation and excreted almost entirely through kidneys • No difference in pharmacokinetics for impaired renal patients

  19. Precedex • Dose: • IV bolus ED treatment: 0.3 – 0.5 mcg/kg (slow IV push) • Sedation bolus: 1mcg/kg over 10 minutes • Infusion Dosage 0.3-1.2 mcg/kg/hr • Concentration: must be mixed 4mcg/ml • Onset: 5 minutes • Peak: 15-20 minutes • Elimination half life: 2-3 hours • Analgesic length of time: 24 hrs • Side effects: Hypotension/Hypertension, bradycardia • Costs about $40-50/vial of 200 mcg/ 2mL, single use

  20. Safety Margin

  21. Safety Margin

  22. What about other treatment options?

  23. Team Propofol… maybe

  24. No, Really. Dex > Prop

  25. Besides EA/ED treatment, can Dex do anything else?

  26. Pearls I’ve Learned • 0.3- 0.4 mcg/kg is the sweet spot • Time it for extubation • Works really well in patients with MR, autism, ADHD • Careful with a pre-med • There is no alligator rolling • Some providers are still not comfortable with it but…

  27. References Ali, M. A., & Abdellatif, A. A. (2013). Prevention of sevoflurane related emergence agitation in children undergoing adenotonsillectomy: A comparison of dexmedetomidine and propofol. Saudi journal of anaesthesia. 7(3), 296. Chen, J. Y., Jia, J. E., Liu, T. J., Qin, M. J., & Li, W. X. (2013). Comparison of the effects of dexmedetomidine, ketamine, and placebo on emergence agitation after strabismus surgery in children. Canadian Journal of Anesthesia, 60(4), 385-392 Dawes, J., Myers, D., Görges, M., Zhou, G., Ansermino, J. M., & Montgomery, C. J. (2014). Identifying a rapid bolus dose of dexmedetomidine (ED50) with acceptable hemodynamic outcomes in children. Pediatric Anesthesia24(12), 1260-1267 Enlow, W. M., & Ardizzone, L. L. (2008). A systematic review: dexmedetomidine versus placebo to decrease the incidence of emergence delirium/emergence agitation (ED/EA) in pediatric patients. Clinical Scholars Review, 1(2). 89-94 Ergul, Y., Unsal, S., Ozyilmaz, I., Ozturk, E., Carus, H., & Guzeltas, A. (2015). Electrocardiographic and electrophysiologiceffects of dexmedetomidine on children. Pacing and Clinical Electrophysiology, 38(6), 682-687 Hauber, J. A., Davis, P. J., Bendel, L. P., Martyn, S. V., McCarthy, D. L., ... & Tuchman, J. B. (2015) Dexmedetomidine as a rapid bolus for treatment and prophylactic prevention of emergence agitation in anesthetized children. Anesthesia & Analgesia, 121(5). 1308-1315 Hoff, S. L., O'Neill, E. S., Cohen, L. C., & Collins, B. A. (2015). Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta‐analysis. Pediatric Anesthesia, 25(7). 668-676 Lee, C. J., Lee, S. E., Oh, M. K., Shin, C. M., Kim, Y. J., Choe, Y. K., ... & Kim, Y. H. (2010). The effect of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy. Korean journal of anesthesiology, 59(2). 75-81 Sato, M., Shirakami, G., Tazuke-Nishimura, M., Matsuura, S., Tanimoto, K., & Fukuda, K. (2010). Effect of single-dose dexmedetomidine on emergence agitation and recovery profiles after sevoflurane anesthesia in pediatric ambulatory surgery. Journal of anesthesia, 24(5). 675-682 Sun, L., & Guo, R. (2014). Dexmedetomidine for preventing sevoflurane‐related emergence agitation in children: a meta‐analysis of randomized controlled trials. ActaAnaesthesiologicaScandinavica, 58(6), 642-650 Tobias, J. D. (2006). Clinical uses of dexmedetomidine in pediatric anesthesiology and critical care. Seminars in Anesthesia, Perioperative Medicine and Pain. 25(2) 57-64 Viswanath O, Kerner B, Jean Y-K, Soto R and Rosen G. (2015) Emergence delirium: a narrative review. Journal of Anesthesiolical Clinical Science. 4(2) Wagner, D. S., & Brummett, C. M. (2006). Dexmedetomidine: as safe as safe can be. Seminars in Anesthesia, Perioperative Medicine and Pain.25(2) 77-83) Wilson, J. T. (2014). Pharmacologic, physiologic, and psychological characteristics associated with emergence delirium in combat veterans. AANA journal, 82(5) Yu, M., Han, C., Jiang, X., Wu, X., Yu, L., & Ding, Z. (2015). Effect and placental transfer of dexmedetomidine during caesarean section under general anaesthesia. Basic and clinical pharmacology & toxicology. 117(3). 204-208 Zhang, C., Hu, J., Liu, X., & Yan, J. (2014). Effects of intravenous dexmedetomidine on emergence agitation in children under sevoflurane anesthesia: a meta-analysis of randomized controlled trials. PloS one, 9(6)

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