Transcript The Pediatric Analgesia and Sedation Service (PASS)

The Pediatric Analgesia and
Sedation Service (PASS)
An ED/PICU Combined
Sedation Team
PASS Team Co-Directors
• Jill Fitch, MD
– Assistant Professor of Clinical Pediatrics
– Attending Physician, Pediatric Critical Care
• Marc S. Leder, MD
– Associate Professor of Clinical Pediatrics
– Attending Physician, Pediatric Emergency
Medicine
PASS Team - Composition
• 6 PICU Physicians
• 8 ED Physicians
• 1 Administrative Assistant
PASS Team – Sedation Numbers
• Average 310 sedations / year
– 2002 n = 351
– 2003 n = 272
• 26 per month
• 3 per day
• 2 – 2 ½ hours per sedation
PASS Team
• SEDATION LOCATIONS
MRI
NUCLEAR MEDICINE
RADIOLOGY
INTERVENTIONAL RADIOLOGY /
FLOUROSCOPY
ULTRASOUND
PEDIATRIC
INTENSIVE CARE
INTERVENTIONAL
CTUNIT
SCAN
EMERGENCY DEPARTMENT
CARDIAC CATH LAB
NEURODIAGNOSTICS
PASS Team
• Common Procedures Requiring
Sedation Services
• *most
patients have previously failed
Fentanyl/Nembutal sedations
MRI
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Brain – 20 to 45 minutes
Spine – 45 to 60 minutes
Brain + Spine – 90 minutes
Extremity – 60 to 90 minutes
• + or – Gadalidium (Magmevist) contrast
NUCLEAR MEDICINE
• Bone Scan – 60 min + 30 min for
– ? Spectroscopy (3D-Image) – patient must remain
completely still or restart image from the beginning
• MIBG – 60 min - isotope taken up by tumor (no Spec)
• NEUROENDOCRINE – 30 to 60 min
• PET SCAN – 60 min
INTERVENTIONAL RADIOLOGY FLOUROSCOPY
• VCUG
• Nephrostomy tube
placement
• Sclerotherapy
• Abscess Drains
– Peritoneal- ruptured
appendicitis
• JRA
– Kenalog joint injections
•Angiograms
•PICC lines
•Percutaneous GT
/ J tube placement
•Liver biopsy
•Cecostomy Tube
•Constipation for
ante-grade enemas
ULTRASOUND
• Renal biopsy
• Hip aspiration
– Toxic synovitis vs. Septic joint
INTERVENTIONAL CT
• 3D IMAGE ALLOWS
– Bone biopsy
– Tumor ablation
PICU
• LP
• SSEP
• Bone Marrow
biopsy / aspiration
• Bronchoscopy
•Endoscopy / PEG
placement
•Abscess dressing
changes / Wound Vac
•Halo placement
WOUND VAC
EMERGENCY DEPARTMENT
• Scheduled LP’s for Neurology
– Ex. Guillain-Barré Syndrome
NEURODIAGNOSTICS
• ABR
• BAER
• VER
CARDIAC CATH LAB
• Cardiac catherization
• Cardioversion
• Myocardial Biopsy for heart transplant
patients
PASS Team
• Scheduling Protocol
• Scheduling Coordinator:
• Merrilee Walker
PASS Team – Scheduling Protocol
• Completion of Intake Form by requesting
service
• Used for :
– Patient screening
Scheduling sedation date and time
PASS Team – Scheduling Protocol
• Intake form reviewed by PASS coordinator with MD consult if needed - to assess screening
criteria :
Weight to Height Ratio
History of upper airway problems / sleep apnea
– Allergies
• Soy
• Egg
PASS Team- Criteria Required for all
Sedations
Meet NPO Guidelines
Solids and Non- clear liquids
Adults
6-8 hours or none after midnight
Children >36 months
6 – 8 hours
Children 3-36 months 6 hours
Children <6 months
4 – 6 hours
Clear liquids
2 – 3 hours
2 – 3 hours
2 – 3 hours
2 hours
Signed Consent
 Pregnancy test for all post-menarchal teens
PASS Team - Scheduling
Coordinator notifies physicians via e-mail of
scheduled sedation
– Procedure
Date / Time
– Patient information
Location
Coordinator also enters research data /
completes physician billing
PASS Team – ED Physicians Sedation
Schedule
PASS Team – PICU Physicians
Sedation Schedule
PASS Team – Weekly Sedation
Schedule
PASS TEAM
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Hospital wide universal Sedation Form us
for all sedatio
PASS Team – Physician’s Typical Day
• Dress appropriately to meet MRI requirements
• Pick up sedation packets
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Records from previous sedations with drug dosing
requirements
Dosing cards
Pre-anesthetic history sheet
Consent form
Sedation record / monitoring form
Billing form
PASS Team – Physician’s Typical Day
• Review patient histories
Choose sedation drugs and calculate drug
dosages with total volume of drug to be drawn
up – account for:
– Bolus syringes
– Infusion pump
Length of case (cc/hr)
• IV tube priming – as much as 12cc (120mg propofol)
• Drug dosing used for previous sedations
Typical calculations
• 15 kg patient
– Bolus = 1mg/kg over 1 minute then .5 to 1mg/kg/min
• 15 mg = 1.5cc then .75cc/min until asleep
• Volume = 5cc syringe (prepare extra 1 to 2 syringes for re-boluses
as needed)
– Infusion
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4mg/kg/hr = 4 X 15kg = 60mg = 6 cc/hr
5 = 5 X 15 = 75 = 7.5 cc/hr
6 = 6 X 15 = 90 = 9 cc/hr
12= X 15 = 180 = 18 cc/hr
Volume = 1 hour case = 18cc + 12cc for prime = 30cc
Total volume for case = 15cc (3 5cc syringes) + 30cc =45cc
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45 cc= 450 mg of propofol use 500 mg bottle
PASS Team - Physician
• PICU pharmacy to
obtain locked
Red Drug Box
Contents of Drug Box
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ChloralHydrate 500mg/5cc 4
Fentanyl 50mcg/ml 2ml 3
Ketamine 10mg/cc 20cc 2
Versed 1mg/cc
3
Atropine 0.4mg/ml 1ml 2
Flumazenil 0.1mg/ml 1
Glycopyrrolate 1ml
3
Lidocaine 10mg/cc 5ml 1
•Narcan 0.4 mg/ml 1ml 2
•Propofol 10mg/cc 20cc 3
•Propofol 10mg/cc 50cc 2
•Propofol 10mg/cc 100cc 1
•Vecuronium 10mg
2
•0.9% NaCl 500cc
1
•Heparin 100u/ml 2ml 4
•Saline flushes 10cc
5
Contents of Drug Box
• Syringes
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60cc
30cc
20cc
10cc
5cc
3cc
1cc
2
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3
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• Padlock & Key
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Needles 18g
10
Needles 20g
10
Vial Access Canulas 10
Blunt Plastic Canulas 10
Betadine Swabs
6
Alcohol Swabs
6
Disposition Sheet
1
Premarked drug labels
PASS Team - Physician
Go to sedation location
• Assure presence of hospital-wide universal
airway box
PASS Team – Physician
• Assure adequacy of RN set-up of sedation
equipment
• At bedside: O2 Suction BVM
• IV lines
– 3 access ports :
• Bolus
infusion
saline
– Distance of ports from skin entry site
– IV fluids
PASS Team - Physician
• Review Pre-anesthetic history sheet
– Present illness – fever
– Allergies
 NPO Status
PARADIGM SHIFT – may actually have to cancel the
case !
Patient / parent expectations after long drive
Sub–specialty pressure to complete the case
PASS Team - Physician
• Confirm sedation plan
• Discuss / educate parents to plans, risks,
alternatives and benefits of sedation
Sign consent form
• Complete sedation
– Med-fusion pump for propofol infusion
PASS Team - Physician
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Recovery
Discharge
Waste Meds
Complete billing card and sedation record
Return drug box to pharmacy
PASS Team
• Nuances Of Sedation That You Will
Not Read In Any Books
MRI
• Completion of MRI screening form
• Clothing - minimal - scrubs
– N0:
• Beepers
• ID
• Metal stethoscopes
• Book bags
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Learn location of emergency stop button and
handles to remove patient quickly from scanner
Follow above rules OR ELSE :
Dr. Leder,
I am concerned that two of the ED doctors walked into the magnet room
with ALL their personal belongings and equipment. THIS IS NOT
SAFE!! Could you please re-inform your doctors that THE MAGNET
IS ALWAYS ON!All your doctors filled out an MR screening sheet
before entering the magnet room. Did they read it? Did they understand
the importance of complying? There is a section “important
instructions” that says to remove all personal belongings. By signing
the form you are agreeing to follow the instructions. Today may be a
serious mistake but we do not want a serious incident to occur.
Thanks,
MRI safety officer
MRI
Noise
 Ear Plugs
 May sit in tech area and monitor patient via
video camera
– Can only enter / exit scanning room between
images
MRI – The Sedation
• Poor access to patient
– May compromise ability to evaluate and provide attention to
airway
Can not hear airway obstruction
– Increased reliance on monitors
Stuffed animal on chest to assess chest rise / RR
– May choose empiric use of O2
• IV issues
– 3 ports
– Port proximity to IV insertion site at skin
• Backflow issues
MRI – The Sedation
• Need to change patients position mid – scan
– Brain
Spine
Patient often awakens requiring repeat boluses to
complete procedure
Prolonged nature of sedation
MRI – The Sedation
• Requires new knowledge base
– Med – fusion pump
– Shadowing experiences at team start-up
– 2 physician teams until comfort level achieved with
med-fusion pump
MRI – The Sedation
• Propofol Dosing
– Patients may require dosing greater than commonly
published parameters
• Ex. 3 – 6 mg/kg/hr : not uncommon to use
6 – 10mg/kg/hr
– Expect hypotension and
?
heart rate
Clinical significance
? Need for treatment – Options include:
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saline drip
 give saline bolus
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propofol infusion rate
Nuclear Medicine
• Easy patient access
• No movement tolerated during spec
– And they don’t decide if they need spec until mid-way
through the case !
Start spec as radiologist reviews
films
• If patient voids during study they must be
changed as isotope accumulates in the urine
stimulates patient
movement
Nuclear Medicine
• Not as much IV tubing needed to prime as
med-fusion pump closer to patient
 No noise !
• Atmosphere seems more “low-key “ than MRI
Patients usually arrive 1 to 2 hours prior to case
for isotope injection
Interventional Radiology
• Drug choices may vary – painful procedures
– Fentanyl / propofol
– Atropine / Ketamine
• Exposure to fluoroscopy
– Wear lead
Multiple Interventionalists
adjust to their
nuances
• Lack of knowledge of sedating drug choices by
staff
PICU AND ED
• Patience” – procedures being completed by other
services
Heme / Onc
Neurosurgery
Neurology
GI
General Surgery
• Procedures being completed by residents, fellows or
Sub-Specialty Attendings
“Do it this way”
“I can do this more efficiently”
• Need for special equipment and people
– SSEP - techs
– Halo – company Reps for placement
– Child Life
Neurodiagnostics
• Exposure to unfamiliar procedures
– SSEP
VEP
BAER
• Location needed to be redesigned to meet
sedation needs
– Suction
Monitors
BVM
Effects of sedatives on Evoked Potentials
PASS Team - Issues
• Institutional politics may vary
– Need for P & T committee approval of propofol
and ketamine usage prior to team start - up
• “If you build it they will come”
• Be prepared for new services requesting
sedation support :
– ABR – added 2 / week
– SSEP – added 150 / year
PASS Team - Issues
• Difficulty meeting emergent needs of subspecialists
• Difficulty meeting expectations of subspecialists
– Ex. SSEP and transport of equipment
• Lack of understanding by sub-specialists of
sedation issues
– RN not for IV access only
PASS Team - Benefits
• Schedule variety
Increased day time hours
New knowledge base
– Viewing procedures
– Sedation expertise
• More visible in the hospital and increased
respect / prestige as sedation experts
• Patient satisfaction - “Thank you”
PASS Team - Benefits
• Fostering new relationships
– Patients and families
– Staff :
• Nurses
Radiologists
Sub-specialists
• Scheduled day
Time for lunch / bathroom etc.
Ability to work independently
PASS Team – New Stressors
• Steep learning curve and start – up stress
• Adjustment to sedating for long procedures
• Change of thought process
– Cases are elective and can be cancelled
• Working out of comfort zone of ED / PICU
– Unfamiliar people and environment
PASS Team – New Stressors
• Developing new skills to accommodate for
poor patient access
• Unpredictability
– Cases may be canceled for reasons out of your
control
• Being away from primary area of interest
– Particularly for Junior staff
PASS Team - Finances
PASS Team - QI
• All charts are reviewed by PASS Team CoDirector
• Follow-up provided to individual physicians
• Complications reviewed
• Protocol changes made as needed
• Hospital wide QI component
• Child life QI component assesses parent
satisfaction with procedure/sedation
?s