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Why Not Sedate?

Pediatric Procedural Sedation Jana Stockwell, MD, FAAP Children’s Sedation Services Children’s Healthcare of Atlanta Emory University School of Medicine. Why Not Sedate?. “I’m gonna be so fast they won’t even feel it.” “They’re just crying because they’re being held down.”

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Why Not Sedate?

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  1. Pediatric Procedural SedationJana Stockwell, MD, FAAPChildren’s Sedation ServicesChildren’s Healthcare of AtlantaEmory University School of Medicine

  2. Why Not Sedate? • “I’m gonna be so fast they won’t even feel it.” • “They’re just crying because they’re being held down.” • “Children don’t feel pain” • “Children don’t remember pain”

  3. Why Sedate? • Efficacy • Satisfaction • Quality of study • Do unto others… • Same injury, adults sedated more

  4. Goals • Guard safety & welfare of child • Minimize physical discomfort & pain • Control anxiety, maximize potential for amnesia • Control behavior & movement to complete procedure • Return patient to state safe for discharge

  5. CHOA @ Egleston Program • CCM & ED physicians • Dedicated radiology & H/O sedation nurses • 4 locations • 2-3 docs/day • >3,000 sedations/year

  6. Overview • Definitions • Choose wisely • Pick your patient • Pick your drugs • Pick your “no’s” • Pick your battles • On the horizon

  7. Definitions • 1992 AAP (Peds 1992;898:110) • Conscious Sedation • Deep Sedation • 1998 ACEP (Ann Emer Med 1998;31:663) • Procedural Analgesia & Sedation • 2006 AAP & AAPD (Peds 2006;118:2587-2602) • Minimal = anxiolysis • Moderate = conscious • Deep • General anesthesia

  8. Joint Commission 2000 • Level 1: Minimal • Respond normally to verbal commands • Cognitive function and coordination impaired

  9. Joint Commission 2000 • Level 2: Moderate sedation / analgesia • Respond to verbal or gentle tactile stimuli • No intervention to maintain airway • Adequate spontaneous ventilation

  10. Joint Commission 2000 • Level 3: Deep sedation / analgesia • Respond purposefully following repeated or painful stimulation • Ability to maintain ventilatory function may be impaired

  11. Never Never Land • Level ~3.5 Dissociative Sedation • Cataleptic state • Maintain protective reflexes • Retain spontaneous respirations

  12. Joint Commission 2000 • Level 4: Anesthesia • Not arousable, even with painful stimuli • Independent ventilatory function often impaired

  13. Remember, it’s a… CONTINUUM

  14. Providers • “Licensed independent practitioner” • Know drugs and antidotes • Ability to monitor • Capable of rescue • Re-assess immediately before sedation • Immediately available • Not doing the procedure

  15. (Appropriate) Patients • Painful Procedures • Bone marrow Bx, BMA • Wound debridement • Renal Bx • Abscess I&D • Fracture reduction • Cardioversion • Movement an issue • Suture difficult area • Radiographic images • Auditory brain response • LP • Casting

  16. Inappropriate Patients • Airway issues • Small, tight jaw • Airway obstruction • Respiratory issues • “Super quick” • Lacerations to be fixed with Dermabond Primum non nocere

  17. Airway concerns • Down’s Syndrome • Macroglossia • Small mouth • Small trachea • Atlanto-axial instability

  18. Airway concerns Pierre-Robin Sequence Beckwith-Wiedemann Syndrome

  19. Other concerns • Pneumonia, asthma, BPD, tracheomalacia, OSA, tachypnea • CCHD, CHF, hypotension • Central apnea, seizures • GERD, hepatic disease • Renal disease, dehydration, abnormal electrolytes • Sepsis

  20. Patient Assessment • American Society Anesthesiology (ASA) class • Allergies • NPO status • Health evaluation

  21. ASA classes • ASA 1: Healthy • ASA 2: Controlled dz of 1 system; <1 yo & healthy • ASA 3: 1 major system, poorly controlled • ASA 4:≥1 severe dz, end-stage, constant threat to life • ASA 5: Moribund, imminent death

  22. Allergies • Medications allergies • Previous anesthesia events? • Food allergies (egg, soy) • Tape, skin prep, etc

  23. NPO duration & adverse events • Agrawal (2003) – 1,014 sedations • 8.1% in fasted, 6.9% unfasted • Roback (2004) – 2,085 sedations • No correlation by fasting time • Treston - 334 echos <6 mos (ketamine) • Fewer events if fasted <3 hours • Ingebo (1997)– 285 gastroscopies • No correlation of gastric volumes by times

  24. NPO Status “…because the absolute risk of aspiration during procedural sedation is not yet known, guidelines for fasting periods before elective sedation should generally follow those used for elective general anesthesia.” Pediatrics 2006;118:2587

  25. NPO status (ASA) • Solids, formula - 6 hours • Clear liquids - 2 hours • Breast milk - 4 hours • Can take sip with meds

  26. Preparation • Informed consent • Health evaluation • ROS • History (sedations?) • Medications (including herbals) • Weight • VS, sat • Exam (airway, lungs, CV state, LOC)

  27. Preparation • Additional person • “SOAPME” • Suction • Oxygen • Airways (BVM, oral, LMA, ETT) • Pharmacy (meds) • Monitors • Equipment (defibrillator, airway supplies, etc)

  28. Reversal Agents • Naloxone • Competitively binds all 3 opiate receptors • IV, IM, SC, SL, ETT • 0.1 mg/kg • Flumazenil • Can terminate paradoxical reactions • 0.02 mg/kg • Lowers seizure threshold

  29. Documentation & Monitoring • Time out • Time-based record: Q5 minutes • SPO2 & ETCO2 • HR • BP • LOC • O2 given • Medications • Interventions

  30. Recovery and Discharge • Continuous HR & sats until alert • 1 person dedicated to patient • Aldrete post-anesthetic score • Post-sedation evaluation • Baseline cardiopulmonary status (VS) • Drinking • Level of consciousness • Locomotion / sitting • Written & verbal instructions

  31. Git ‘er done • Hypnotics • Sedatives • Ketamine • Etomidate • Propofol • Nitrous oxide

  32. Midazolam (Versed) • Anxiolysis • Dose- • 0.05-0.1 mg/kg IV, onset min • 0.5-1 mg/kg PO, onset 20-30 min • 0.3-0.4 mg/kg IN, onset 5-15 min • Amnesia 92% - 98% • Paradoxical reactions • 1.4% emergence / atypical reaction • onset at 14 min • relieved with flumazenil

  33. Hypnotics • Chloral hydrate • Pentobarbital • Methohexital • Etomidate

  34. Chloral hydrate • “Mickey Finn” • 50-80 mg/kg PO • Onset approximately 15 minutes • Duration 1-2 hours • Total max dose of 120 mg/kg or 1 g total for infants and 2 g total for children

  35. Chloral hydrate • Amnesia? • Gas • Hyperactivity • Deaths after discharge • Carcinogen

  36. Barbiturates • Depress RAS • No analgesia • May be hyperesthetic • Amnesia

  37. Pentobarbital (Nembutal) • 1-3 mg/kg IV, up to total of 6 mg/kg • Sleep onset 1-2 minutes • Duration 30-60 minutes • Hypoxia, hypotension • May give IM 4-6 mg/kg • Rage reaction – 1.6%

  38. Methohexital (Brevital) • 1-3 mg/kg IV • Not painful • Additional doses at 0.5 mg/kg • Drip 3 mg/kg/hr • Sleep onset 1-2 min • Duration 10-20 min • IM, PR ~90 minutes • 25 mg/kg PR • 5-10 mg/kg IM

  39. Methohexital • IV • Myoclonus 10% • Hiccups 10% • Rectal • 95% success • 6% apnea / desaturation • 3% hiccups Pediatrics 2000;105(5):1110-4

  40. Etomidate • Ultrashort-acting non-barbiturate imidazole hypnotic • 0.2-0.3 mg/kg (<10 yrs), 0.2-0.6 >10 yrs • Give over 30-60 sec • Onset 30 sec • Duration 5-10 min • Negligible hemodynamic effects • Amnesia 80%

  41. Etomidate • Myoclonus up to 30% • Pain at injection site • No analgesia • Adrenal suppression • Blocks the normal stress-induced increase in adrenal cortisol production for 4-8 hours • Increases EEG activation

  42. Pentobarbital vs. Etomidate

  43. Ketamine • Dissociative state • Related to PCP • Disconnects limbic system • Brainstem RAS not affected • Analgesia – Sedation – Amnesia • Does not impair laryngeal reflexes • Bronchodilation • inotropy, BP, SVR

  44. Ketamine • 1-2 mg/kg IV, drip 1-2 mg/kg/hr • 3-7 mg/kg IM • Onset 1 min (nystagmus) • Duration 15 min to 1 hour

  45. Ketamine •  Secretions • Consider glycopyrrolate (Robinul) • Vomiting • Emergence 12% • Contraindications •  ICP, glaucoma, open globe • <3 months of age • History of psychosis, porphyria

  46. Propofol • Sedative-hypnotic • 1-3 mg/kg bolus over ~2 min • 5 mg/kg/hr • Infants need higher dose • Sedative • Profound relaxation • Anti-emetic • Antiepileptic properties Fidget  Yawn  Out  

  47. Propofol • Alkaline -- STINGS • Contraindicated - egg or soy allergy • Hypotension • Rare bradycardia, acidosis leading to sudden death • No analgesia • Green urine

  48. Guenther (p. 783) 291outpatients Median dose 3.5 mg/kg 4% jaw thrust 1% BVM 1 bradycardia to 57 Bassett (p. 773) 393 patients Median dose 2.7 mg/kg 3% jaw thrust 8% prolonged BP ↓ 0.8% BVM 5% hypoxia Propofol in kids Ann Emerg Med 2003;42:783 & 773

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