Transcript pediatric concscious sedation

Pediatric Sedation 2002:
The Safety Net
Kevin M. Creamer M.D. FAAP
Pediatric Critical Care
Walter Reed AMC
The good old days…
 Child
receives Demerol-Phenergan-Thorazine for
laceration repair in ED dies during procedure
 1yo
former preemie sedated with chloral hydrate at
home in preparation for BAER, dies in car en-route
to study
 Agitated
encephalopathic 7yo sedated for LP codes
in ICU during procedure
“Conscious sedation”: Time for this oxymoron to go
away! Charles Cote
Beware of “Eminence Based Medicine” - making the same mistakes
with increasing confidence over an impressive number of years
Sedation Overview
Study Type
Number of Complications
Procedures
Non-Invasive
6907
96
Invasive Deep
3038
297
Combined
3052
63
Grand total
12997
456
“Good judgement comes from experience. Experience
comes from bad judgement”
%
1.4
9.8
2.1
3.5
Definitions
Conscious sedation
vs
Deep Sedation
vs
Anesthesia
Non-distinct continuum which can change
over time
Wake Up Call : JCAHO 2001
Definitions
Sedation (anxiolysis) –drug induced state
which patients can respond normally to verbal
commands. Ventilatory and cardiovascular
function are unaffected.
 Minimal
 We
almost never do this
 Some Heme/Onc procedures
JCAHO 2001 Definitions
 Moderate
sedation/analgesia (“conscious
sedation”) – a drug induced depression of
consciousness during which patients respond
purposefully to verbal commands, either alone or
accompanied by light tactile stimulation. No
interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained.
JCAHO 2001 Definitions
 Deep
sedation/analgesia- a drug induced
depression of consciousness during which patients
cannot be easily aroused, but respond purposefully
followed repeated or painful stimulation.
Patients may require assistance in maintaining a
patent airway and spontaneous ventilation may be
inadequate. Cardiovascular function is usually
maintained.
JCAHO 2001 Definitions
 Anesthesia
- a drug induced loss consciousness
during which patients are not arousable, even by
painful stimuli. The ability to independently
maintain ventilatory function is often impaired.
Patients often require assistance in maintaining a
patent airway, and positive pressure ventilation may
be required because depressed ventilation or drug
induce impairment of neuromuscular function.
Cardiovascular function may be impaired.
Ability to Rescue
 The
Licensed independent practitioner must be
able to rescue those patients who unavoidably or
unintentionally slip into a deeper-than-desired
level of sedation
 Credentialed
to do moderate>> rescue from deep
 Manage
a compromised airway and to provide adequate
oxygenation and ventilation
 Credentialed
to do deep >> rescue from general
anesthesia
 Above
system
+ competent to manage an unstable cardiovascular
Sedation Continuum
9yo Colonoscopy
Modified
from
Enright
4yo BM Bx
2yo Head CT
Light
Moderate
Assessing a sleeping infant’s level of sedation
in the MRI scanner may be difficult !
Deep
General
Anesthesia
Model Application Reduces Risk

960 Peds Sedations (CHW)
Moderate planned 93%
 Deep achieved in 22%

Risk reduced by using all
guidelines, avoiding deep
sedation
 Chloral Hydrate associated
with higher risk

10.00%
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Planned
Actual
Moderate Sedation
Deep Sedation
Hoffman, Pediatrics, 2002
WRAMC Pediatric Sedation/
Analgesia Unit: 2002
 IAW WRAMC
 As
Pam 40-16 (rev 2/2002)
sanctioned by Chief of Anesthesia
 All patients should receive the same level of treatment,
monitoring, and desired outcome regardless of the site
of care
 Applicable to pediatric patients (age 0-18y) throughout
WRAMC (Ward, ED, PICU and Sedation Unit)
Safety Net
ASA
Appropriate patient selection
Screening for
contraindications
equipment available
Deep Sedation team
airway evaluation
PALS trained RN
classification and
Emergency
Physician or PNP present
Informed Consent
Better Monitoring
Safe Drug protocols
Pediatric Sedation Unit : 2002






Confirm prescreen, informed consent,
NPO status, emergency drug sheet
print out
Re-evaluate for changes
2 trained personnel with child at all
times (1 PALS certified)
MD/ PNP(*) with child during time
out of sedation unit
Full monitoring while sedated (HR,
RR, SAT% continuous, BP q5-15
minutes)
Hypothetical template
time
M
T
8:00
*
9:00
W
Th
Fr
*D *
*
*D
*
*
*
*
*
10:00 *
*
*
*
*E
11:00 *
*E *
*
*E
12:00 *
*
*
*
*
13:00 *
*
*
*
*
E
P
* = MD/ PNP
•Deep sedation offered by CC
service
P
Moderate Sedation Training
Requirements

MD/ PNPs


PALS certification
This 2 hours block of instruction




Handouts for drug algorithms
Scenarios
Post test
Proof of recent experience
performing BVM ventilation or 1
day in OR performing BVM
ventilation

Nursing personnel
PALs highly encouraged for
RNs
 Nursing specific 2 hour
block of instruction

Handouts with practice
scenarios
 Hands on-training

Post test
Training for Deep sedation will require Critical care or anesthesia
training, possible grandfather clause for experience

Moderate Sedation/Analgesia

Indication
Immobility
•
•
Pain Control
Anti-anxiety
 Goals
Cooperation
• Alteration of mood
• Elevation of pain threshold
• Autonomic Stability
• Amnesia
First Decide:
• Rapid, safe return to highest
possible health status
If patient really needs the study and needs to be sedated!

Today’s Lecture
 Sedation
Prerequisites
 Pre-evaluation

Overview
H+P
Including ASA classification
and airway evaluation
 Informed
Consent
 NPO status
 Monitoring Equipment/
Personnel
 Sedation anatomy and
Physiology
 Documentation
 Screening Scenarios
Part II –next time
 Pharmacological
agents
 Drug Algorithms
 Teaching
points
 Scenarios and Post
test
Presedation History and Physical
 Patient
status > ASA classifications
I – normal healthy patient
 Class II – patient with mild to moderate systemic
disease, controlled
 Class III - patient with severe systemic disease
 Class IV – patient with severe systemic disease that is a
constant threat to life
 Class V – a moribund patient who is not expected to
survive without the procedure
 Class
Consult Critical care or anesthesia for anything below the red line!
Relative Contraindications
GERD (relative)
 Cerebral palsy with
abnormal swallowing
 History of apnea , sleep
apnea, snoring
 Neck instability
(osteogenesis imperfecta,
or Down’s syndrome)
 Poorly controlled seizure
disorder

Significant cardiopulmonary disease
(cyanosis, or chronic
hypoxemia)
 Hx of Malignant
hyperthermia
 Anticipated difficulty in
obtaining IV access in an
emergency

Presedation History and Physical

Any airway anomalies? (Nares to Lungs)
Ex. Pierre-Robin, Treacher-Collins
 Can they open their mouths and bend necks normally?
 What about neurological tone and dentition?
 “Would I be able to do BVM ventilation on this patient?”


Pt < 50 weeks post-conceptual age

Abnormal responses to hypercarbia and hypoxemia = APNEA!
Previous sedation problem or failure
 Current medications or drug allergies

Is the patient Acutely Ill?

Independent risk factors for adverse respiratory events
(during URI) include:

Copious secretions, Hx of prematurity (<37wks), nasal
congestion, Hx of RAD
Respiratory events almost doubled from baseline during
radiologic procedures
 Severe coughing found in 10% patients with URI during
procedure
 When in doubt cancel or consult before you sedate!

Tait, Anes, 2001
Other Prerequisites
Informed Consent
 Appropriate NPO status
 Re-evaluation on day of sedation to r/o significant
changes
 Pediatric weight based emergency drug sheet print
out from CHCS/CIS
 Pregnancy test?

Informed Consent
 Potential benefits
 Potential
risks
 Failure of sedation
 Aspiration
 Resp arrest and death
Use WRAMC OP 433
Note-Obtain separate consent for sedated procedure
ASA NPO Guidelines for All Age
Groups
Intake
Minimum NPO
Period
Clear liquids
2 hours
Breast milk
4 hours
Formula or solids
6 hours
Monitoring Requirements

Appropriate monitors, equipment and personnel for the
level of sedation until patient returns to baseline
Two dedicated observers - one must be PALS trained, the other
BLS minimum
 Continuous HR, RR and SaO2 monitoring
 BP q 5-15 m, including throughout the study
 Observe q5 min-record q15 min
 Suction, and age appropriate BVM and intubation equipment
 Vascular access readily available
 Reversal agents and crash cart with in close reach

Pediatric Sedation –Anatomy and
Physiology
 AIRWAY
 Airway
is much smaller in children
 Larynx is more cephalad and more anterior
 Larger tongue
 Mobile epiglottis
 Narrowest portion of larynx is the cricoid cartilage
 Prominent occiput often places head in flexion
Sedation Implications of the anatomy

Airway obstruction from:
Malalignment
 Posterior displacement of
tongue mall amounts of
obstruction can cause
significant reduction in
airway diameter


Intubation technically more
DIIFICULT

Tube size must be based on
the size of the cricoid ring
rather than the glottic
opening
Airway obstruction
Provide
supplemental O2
Head tilt
Successful
No
Jaw thrust
Successful
No
Successful
Call for help,
insert NP or
OP airway
Successful
If laryngospasm
suspected
patient may
need PPV or
neuromuscular
blockade and
intubation
No
No
Attempt
PPV
Prepare for
intubation
Drug Induced Respiratory Depression
Open Airway
No blowby
via Ambu bags!
Provide 100% supplemental O2
Is child breathing?
No!, Attempt
PPV
Opioids? Give Narcan
0.01mg/kg IV/IO/IM
may double and repeat
Did child
receive opioids
or benzodiazepines?
BZDs? Give Flumazenil
0.01mg/kg IV may
double and repeat(1mg Max)
Advanced airway maneuvers
Physiology
 Respiratory
System
 Oxygen
consumption is higher
 CO2 production in the neonate is double that in the
adult
 Tidal volume is the same.

Minute ventilation is increased by increased breathing rates
 Functional
residual capacity is reduced
 Apnea in children results in quicker desaturation and
bradycardia
Physiology
 Cardiovascular
 CO
system
= HR x SV
 Relatively
fixed stroke volume
 Neonates
often demonstrate bradycardia in response to
hypoxemia
 Older
children get tachycardic first
 Pharmacology
 Neonate
more sensitive to drugs 2° immature bloodbrain barrier and decreased metabolism

Clearance rates reach adult levels by 5-6 months of age
Documentation
 Inpatients
• Coordinate with Sedation Unit whenever possible for
assistance
• Document in CIS
• Pertinent H+P and informed consent on day of sedation
• Patient underwent sedation with/without problems
• Use WRAMC OP 499 to monitor patient and place in
"blue" chart
Insure nurses are aware of sedation protocol and will
monitor patient until return to baseline
Preprinted
WRAMC
Overprint-433
WRAMC
Overprint 499
For documenting
sedated pt
Scenarios
2
mo former 32 week preemie with Pierre-Robin
on apnea monitor needs Head CT to f/u Grade II
IVH
 Doesn’t
need a CT when Head US would do
without the risk of sedation , given < 50week PCA,
abnl airway, and apnea history
Scenarios
 11mo
fell from couch on to tile floor and cried
immediately. PE reveals red mark on forehead, no
skull hematoma, nl activity since fall, no vomiting,
nl neuro exam. ED wants you to sedate for Head
CT
 Patient
doesn’t need to be imaged!
Scenarios
 3yo
whiny child with WBC 50,000, +blasts, CXR
with wide mediastinum, and Ant fullness on Lat
CXR. The fellow wants you to get a Chest CT,
sedated if necessary
 Do
not sedate this child!, Call anesthesia! You
could loose the airway even if you’re lucky enough
to get an ET tube in
Scenarios
 4yo
with Asthma needs f/u head MRI for stable
abnormality but on screening H+P he has nighttime cough and wheezing and nasal congestion
 Technically
an ASA II but he is acutely ill and a
sedation exposes him to higher risk. Reschedule.
Scenarios
 4yo
air/evac with abdominal distension, HSM,
vomiting, metabolic acidosis with electrolyte
abnormalities, Bil. pleural effusions, and 40% O2
requirement needs Abdominal CT
 This
patient is an ASAIII and requires critical care
or anesthesia input, preferably for them to do study
 Ask radiology if US sufficient
Scenarios
 2yo
with multiple medical problems and poor
peripheral access. Pt has had difficult sedations in
past with desaturation and vomiting post sedation.
Plan is for Chloral hydrate for MRI
 Patient’s
track record would suggest need for IV
upfront. Take steps to assure access before it’s a
crisis
Friendly reminder
“
Evidence is still a minor driving force
in medical practice.” Rinaldo Bellamo