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Conscious Sedation

Conscious Sedation. Central Hospital St-Juergen-Strasse Institut für MR-Diagnostik B. Terwey Bremen Germany. Wilhelm Buschs Pacifier. Linnen bag filled with Sugar or flavor with added Beer or Wine or even Brandy. Who will be sedated? Age classification. Optimal sedation.

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Conscious Sedation

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  1. Conscious Sedation Central Hospital St-Juergen-Strasse Institut für MR-Diagnostik B. Terwey Bremen Germany

  2. Wilhelm Buschs Pacifier Linnen bag filled with Sugar or flavor with added Beer or Wine or even Brandy

  3. Who will be sedated?Age classification

  4. Optimal sedation easy performed procedure rapid onset free choice of duration at any time rapid recovery effective in all age groups effective in patients with all diseases no adverse affects cost is low

  5. Sedation Management in Bremen 1. Sleeping or cooperative patient 2. Pacification by Meditation, Imaginery 3. Conscious sedation 4. Deep sedation 5. General anaesthesia

  6. Normal, sleep, meditation, Imaginary Conscious sedation Deep sedation General anaesthesia Sedation procedures in Bremen since1.10.1990: 148.365 Pat. (4451 Pat.: 0 -6 Years old) 1 2 3 4 5 6

  7. 1. Scheduling Foto von Anmeldung am Telefon

  8. 1. Scheduling questions Indication Age Risk factors Cooperability

  9. Objective: Determine the bedtime of your patient Initial Question: “ “What time does your child go to bed?” Follow-up Questions: Is it difficult for your child difficult to sleep in the evening? How does your child act when he/she is overtired? Does your child fall asleep during the day? when and where? 1. Scheduling questions

  10. Scheduling: Information • Preventative education for parents • Proper Scheduling • Scheduled awakenings in order to change sleep cycle • Warm meal • Cosy metallfree clothes and own music box

  11. SLEEP COOP 1. Cooperative or Sleep !

  12. 1. Natural sleep: Age related Sleep times

  13. 1. Age related amount of REM Sleep

  14. 1. Natural sleep: age related Stages of Sleep NonREM Adults REM Newborn

  15. 1. Problems with natural sleep • Protest • Hunger • Colic (infant) • Allergy • Acute illness(i.e. otitis media) • Medications- antihistamines, antibiotics, bronchodilators, anticonvulsants, • Pain • Seizures

  16. Problems with natural sleepAdverse effects of sleep deprevation • Mood alteration • Reduced concentration and motivation • Increased irritability • Lapses in attention • Reduced motor skills Sleep deprivation is not helpful! Sanders BJ et al, The effect of sleep on conscius sedation, J Clin Pediatr Dent 1994; 28(3): 211-214

  17. The cooperative child • straight parents • Child plays with mri console and technician • Mothers warm arm • Warm meal • Cosy clothes and music • cosy images and toys near to the child • Extinction: “cry it out”, effective but of limited acceptance • Avoid “double bind” situations

  18. 1. Sleep Test Foto mit Händeklatschen Failure of natural sleep: rectal or oral Chloralhydrate

  19. 1. The cooperative Child 3 – 6 years old first contact outside of the MRI-Department convincing the parents talk about „how“ cooperation may be achieved videoshow of the procedure playing the procedure with the help of an MR-Model first look to the magnet accompanied by one parent demonstration of a video during the examination parents or tecnician accompanies (prone position) Bribary

  20. 1. The cooperative Child 3 – 6 years old Foto Elten in Bauchlage mit Kind

  21. 1. The cooperative Child 3 – 6 years old Bribary, Goldmedal

  22. The cooperative Child(3 – 6 years old) Which are causes for refusion? reports of neighbours and friends clinical and threatening atmosphere narrow bore of the magnet noise of the gradients boring long procedure

  23. 1. The cooperative adult Controlling Consciousness: Paradox Effects • Paradox Processes in thinking The harder you try to control thought, the less likely you are to succeed! (i.e. for 30 seconds, do not think about bananas) • Paradox Processes in controlling anxiety The harder you try to control anxiety, the less likely you are to succeed!

  24. 1. The cooperative adult Sudden unexpected Panic? Solution 1: oral Diazepam (0,5 – 3,0 mg) Solution 2: oral Midazolam ( Onset: 2 - 18 min Duration: 20 - 30 min Antidot: Flumazenil

  25. 2. Meditation (for Adults) An altered state of consciousness characterized by a sense of deep relaxation and a loss of selfawareness. • Prayer • Concentrative meditation: focus on one stimulus • Opening-up meditation: focus on one stimulus but then opens to encompass whole of surroundings • Mindfulness meditation: meditator focuses on whatever is most prominent at moment

  26. 2. Effects of Meditation • decreases stress, • reduces tension and anxiety • improves performance • reduces oxygen consumption • decreases heart rate • decreases respiration rate • lowers physiological arousal

  27. 2. Guided Imagenery (for Children and Adults) Immediate Rapport Rapport is the foundation upon which all other elements of Anodyne are built. Quick and predictable rapport establishes the trust necessary to effectively induce and maintain the Anodyne State of relaxation and patient cooperation. Effective use of language The correct use of language is vital to the results we get, it enables us to address both the conscious and unconscious mind of the patient. We directly affect the outcome of the patient's experience with language because literally everything we say is a suggestion to the unconscious mind. Relaxation Breath The "get you through anything" tool, the relaxation breath is easy to learn and easy to teach to every patient. It's uses include: general relaxation, relief of pain and anxiety, and control of physiological processes. .

  28. 2. Guided Imagenery (for Children and Adults) 'Preferred Place' Imagery The preferred place imagery technique easily allows the patient's mind to be anywhere they choose while their body is comfortably undergoing the procedure. Shifting Submodalities Shifting submodalities is an extremely quick and effective imagery technique that can literally dissolve any resistances the patient has to relaxation and/or cooperation. Control of Physiological Processes Simple language techniques enable practitioners to help patients control physiological processes such as bleeding, heart rate, blood pressure, peristalsis, salivation, and swallowing

  29. 3. Conscious sedation: Definition Pharmacological induced state of depressed consciousness with the defining characteristic that the patient can makeappropriate stimulation at all times. This level of sedation is accompanied by an intact airway andmaintenance of protective reflexes.

  30. 3. Conscious sedation 0 - 3 Monate after beeing awake about 3 - 4 hours and after normal feeding and swaddling and only if necessary after rectal chloral hydrate (50 mg/kg) wait up to 5 minutes after beginning of sleep test for deep sleep give earphones, a warm blanket, nuckle use a vacuum cap

  31. 3. Conscious sedation3 - 36 Monate well fed and dry clothes withpout metal change sleep cycle additional mild rectal chloral hydrate (50 mg/kg) wait until phase of deep sleep

  32. 3. Conscious sedation Age 3 - 6 years: friendly atmosphere and clear decisions parents are responsible emotional blackmail clear prospects choice with or without parents

  33. 3. Conscious sedation: PreparationWhat the responsible physician has to know for the optimal choice of time and procedure! Risk classification (American Society of Anaesthesiology Classification) 1. normaly healthy patient 2. mild systemic disease 3. severe systemic disease 4. severe systemic disease with threat to life 5. moribund patient (24 h)

  34. 3. Conscious sedation: Preparation What the responsible physician has to tell to the parents or nurse! Nutrition before sedation 2 hr before sedation: clear liquids (every age) 4 hr before sedation: solid or semisolid food (under 6 M) 6 hr before sedation: solid or semisolid food (under 6-36 M) 8 hr before sedation: solid or semisolid food (more than 36 M

  35. 3. Postprocedural care and discharge: AAPCOD discharge criteria • cardiovascular system stable • airways patent • protective reflexes intact • speech near to normal (if age-appropriate) • responsiveness recovered • sitting up is possible (if age-appropriate) • hydration is adequate • minimal or no nausea

  36. 3. Postprocedural care and discharge: AAPCOD discharge criteria • parent information about possible reactions • phone number of the responsible physician

  37. 3. Conscious sedation: Age 3 - 6 years: Convincing by bribery soft toys other toys sweets favourite food medal for bravery

  38. Conscious sedation: Age 3 - 6 years: Convincing by gifts Foto der Geschenke

  39. 4. Deep sedation: Advantages high successrate radiologist is free for his duty simple scheduling higher patient throughput good training for emergency cases

  40. 4. Deep sedation:Disadvantages risks to the patient food and liquid deprevation iv pathway needed anaesthesiologist and nurse is needed high cost (staff, material, time)

  41. 4. Deep sedation: Preparation Nutrition before sedation - 2 hr before sedation: clear liquids (every age) - 4 hr before sedation: solid or semisolid food (under 6 M) - 6 hr before sedation: solid or semisolid food (under 6-36 M) - 8 hr before sedation: solid or semisolid food (over 36 M)

  42. 4. Deep sedation: Preparation Premature warmed vacuum cap, blankets Term warmed vaccum cap, blankets Toddler earphones, Infants earphones, music, video

  43. 4. Deep sedation: Different MethodsDosis: oral/rectal chloral hydrate Chloral hydrate: 25-75 mg/kg up to maximum of 2000 mg Successrate: 85 - 98 % Onset: 20 - 100 min Duration: 30 - 90 min

  44. 4. Deep sedation: Different Methods Disadvantages: oral chloral hydrate Vomiting (5-7%) hyperactivity (2-5%) minor oxygen desaturation (4%) rare severe respiratory depresssion drowsiness and lack of coordination for hours some unproven concern over carcinogenesis

  45. 4. Deep sedation: Different Methods Advantages: oral chloral hydrate wide range of safety long working time

  46. 4. Deep sedation: Different Methods Dosis: oral Diazepam 0,05 -0,3 mg/kg Successrate: 50 - 85 % Onset: 5 - 15 min Duration: 30 - 120 min Half-Life: 20 - 50 hours Antidot: Flumazenil 0,3 -1,0 mg Attention: Because of its shorter half-life (app. 1 hour) , patients may show some residual sedation after flumazenil administration

  47. 4. Deep sedation: Different Methodsintranasal, oral,rectal Midazolam 0,2-0,5 mg/kg (reduced dosis with hepatic dysfunction) Sucessrate: 95 - 100 % Onset: 5 - 12 min Duration: 20 - 30 min Antidot: Flumazenil 0,3 -1,0 mg Latson LA et al. : Midazolam Nose Drops for ..in Infants. AHJ 121(1), 209-210,1991 Adrain ER : Intranasal Versed: the Future of ......sedation. Pediatric Nursing 20(3) 287-292, 1994

  48. 4. Deep sedation: Different Methods intravenous Midazolam 0,02 -0,05 mg/kg slowly injection (2 -4 min) with 1/2 of the total dosis (reduced dosis with hepatic dysfunction) Sucessrate: 95 - 100 % Onset: 1 - 5 min Duration: 20 - 30 min

  49. 4. Deep sedation: Different MethodsAdverse effects: Midazolam hypotension vomiting (10%) decreased tidal volume decreased respiratory rate Apnea drowsiness antidot:Flumazenil

  50. 4. Deep sedation: Different MethodsDosis: intravenous profonol Induction dose of 2,5 mg/kg slowly continous infusion Sucessrate: 97 - 100 % Onset: 1 - 2 min Duration: 1 - 5 min

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