Pediatric Sedation - McMaster Faculty of Health Sciences
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Transcript Pediatric Sedation - McMaster Faculty of Health Sciences
Pediatric Sedation
Desi Reddy (MB ChB, FFA, FRCPC)
Department of Anesthesia
McMaster University
1
STRUCTURE
Definition
Pre-procedure Preparation
Monitoring and Equipment
Medications
Recovery and Discharge
3
DEFINITIONS
Sedation Goals
anxiolysis
analgesia
amnesia
safety
control behavior
return to baseline
5
Continuum
minimally impaired consciousness to
complete unconsciousness
6
“conscious sedation”
is an oxymoron
8
New Sedation Terminology
Minimal
Moderate
Deep
General anesthesia
9
Minimal Sedation
Response
normal response to
verbal stimulation
Airway
Unaffected
Ventilation
Unaffected
CV function
Unaffected
Moderate Sedation
Response
Purposeful response
to verbal or tactile
stimulation
Airway
Intervention maybe
required
Ventilation
Adequate
CV function
Usually maintained
Deep Sedation
Response
Purposeful response
following repeated or
painful stimulation
Airway
Intervention is
required
Ventilation
May require support
CV function
Usually maintained
General Anesthesia
Response
Unarousable even to painful
stimuli
Airway
intervention required
Ventilation
frequently inadequate
CV Function
maybe impaired
Implications
Assume and prepare for Deep Sedation
The level of vigilance = Maximal
Appropriate monitoring equipment and
personnel
15
SEDATION MORBIDITY AND
MORTALITY
mortality is very rare
morbidity is not uncommon
Cote reviewed 95 adverse events
•
51 deaths and 9 permanent neurological injuries
17
Causes
drug interaction
overdose
inadequate monitoring
inadequate CPR
inadequate work-up
premature discharge
inadequate personnel
44
34
27
19
18
11
10
18
Drug Category
opioid
benzodiazepine
barbiturate
sedative
chloral hydrate
ketamine
22
18
19
21
13
1
19
Route of Administration
Intravenous
oral
rectal
nasal
intramuscular
inhalation
60
37
9
4
31
13
20
Presenting Event
event
n
respiratory
80
cardiac
8
other
7
total
95
21
Outcome vs Monitoring
Outcome
Oximeter
(n=21)
None
(n=18)
Death/Injury
4
*14
No harm
17
4
* P < 0.001 compared with pulse oximetry
Pediatrics 105:805-814, 2000
Causes of catastrophes
Poor patient selection
Drug overdose
Lack of appreciation of drug
interactions, pharmacokinetics and
dynamics
Use of multiple medications to
sedate patient
Lack of monitoring before, during,
or after procedure
Inadequate CPR skills ’ failure to
rescue’
Conclusions
Most complications avoidable
Monitoring makes a difference
Adverse events involved multiple
drugs
Children 1 to 6 years are at
greatest risk
Need appropriate personnel skilled
in airway management and
resuscitation
Pulse Oximetry is
Essential
26
Factors Relating to Procedure
duration
pain
positioning
anxiety/stress of procedure
availability of rescue resources
27
Factors relating to Patient
Past experience
Allergies
Adverse reactions
Aspiration risk
URTI
ASA classification
Fasting Guidelines
28
Fasting Guidelines
Ingested material
Clear liquids-H20,fruit
Fasting period (hours)
juices,clear tea,black
coffee
2
Breast milk
4
Infant formula
6
Nonhuman milk
6
Light meal
6
General Health
ASA 1
normal, healthy patient
ASA 2
controlled medical condition without
significant systemic effects
hypertension, DM, anemia, mild obesity
30
ASA Classification
ASA 3
medical condition with significant effects and
significant functional compromise
Controlled CHF, stable angina, morbid
obesity, chronic renal failure
31
ASA Classification
ASA 4
poorly controlled medical condition, with
significant dysfunction and a potential threat
to life
unstable angina, symptomatic COPD, CHF
32
ASA Classification
ASA 5
critical medical condition associated with
little chance of survival
multi-organ failure, sepsis syndrome
33
34
Provider Factors
dedicated sedation monitor
skills related to depth of sedation
back-up systems and ability to Rescue
35
Equipment
SOAP ME
•
•
•
Suction
Oxygen
Airway
Pharmacy
Monitoring
Equipment
36
37
Medications
38
Pharmacodynamics
2 general groups
sedation
analgesics
39
Pharmacokinetics
route
orally, intravenously, intramuscularly, intranasally, rectally
intravenous
titrate to effect
combination of medications
40
Pharmacokinetics
dose stacking
repeated administration before peak effect of
previous dose reached.
synergism
combination of drugs increase risk of serious
side effect, e.g.. benzodiazepine and opiate
41
Drugs
sucrose pacifier
reduced crying in neonates following heel
prick
should be used more frequently in infants
undergoing brief painful procedures
42
Drugs
Oral Chloral Hydrate
used for painless procedures in kids for
years
20 -75 mg/kg orally
bitter taste, not tolerated very well
peak effect up to 60 minutes with a half life
of 4 - 9 hours
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Chloral Hydrate
prolonged sedation
need prolonged supervision prior to
discharge
advantage is lack of respiratory
depression
44
Oral Midazolam
short acting, water soluble
benzodiazepine
no analgesic properties
popular because of short duration,
predictable onset, and lack of
metabolites
get skeletal muscle relaxation,
amnesia and anxiolysis
dose: 0.5 - 0.75 mg/kg
46
Oral Midazolam
Recommended use:
sole agent for children who will drink liquid
medication.
anxiolysis and cooperation are excellent
administer local anesthetic for painful
procedures
47
Midazolam
rectal midazolam
0.3 - 0.7 mg/kg
effect within 15 minutes
nasal midazolam
0.2 - 0.4 mg/kg
onset 10 -15 minutes, burning
sensation to mucosa
49
Intravenous Midazolam
dose: 0.05-0.1 mg/kg every 3-5
minutes up to a max. of 0.7 mg/kg
peak effect in 2-3 minutes
synergistic reaction with opiates.
Limit dose to 0.05 mg/kg. Severe
respiratory depression.
anterograde and retrograde (at
times) amnesia
50
Intravenous Midazolam
Recommended Use:
excellent agent for sedation and anxiolysis
provides complementary sedation with
opiates for painful procedures
caution with combination
51
Propofol
potent sedative and hypnotic
onset it very rapid. 60 - 90 seconds
induction of anesthesia at doses =
2-3 mg/kg
recovery rapid = 2-3 minutes
redistribution
prolonged sedation and vomiting is
very low
disadvantage is pain on injection
53
Propofol
Recommended use:
ideal agent for brief periods of deep
sedation
minimal adverse effects and rapid
awakening are unique
get rapid induction of anesthesia and
hence should only be used by
anesthesia personnel or intensivists
54
Fentanyl
potent synthetic opioid (100 x Morphine)
peak effect= 5 min and lasts for 30 - 40
min.
respiratory depressant effect is much
longer (4 hrs) than analgesic effect
Dose: 0.5 - 1.0 mcg/kg up to 5 mcg/kg
55
Fentanyl
minimal hemodynamic effects
reversible with Naloxone
Recommended use:
excellent analgesia and mild sedation with
short duration of action. Careful respiratory
monitoring when combined with other
sedatives
56
Ketamine
produces intense analgesia, sedation
and amnestic qualities
Oral dose: 5-6 mg/kg
IV dose :1 - 2 mg/kg
IM dose: 2 - 5 mg /kg
58
Ketamine
less pronounced respiratory depression
airway protective reflexes usually intact
side effects
excessive salivation and airway secretions
emergence dysphoria
59
Oxygen Delivery
nasal cannula
provides up to 44% oxygen
inspired oxygen depends on flow rate
each liter of flow-increases FiO2 by 4%
usual settings= 1-4 l
61
Oxygen Delivery
simple face masks
provides up to 60% oxygen
flow rate set between 6-10 l
liter flow must be > 6 l to prevent CO2
accumulation
non rebreather mask - provide 60-90%
oxygen at flows of 10-12 l\min
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