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Sedation and Analgesia for Diagnostic and Therapeutic Procedures. Michael S. Mazurek, M.D. Associate Professor of Clinical Anesthesia Riley Hospital for Children. Overview. Goals of Sedation Definitions of Levels of Sedation Risks and Complications

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sedation and analgesia for diagnostic and therapeutic procedures

Sedation and Analgesia for Diagnostic and Therapeutic Procedures

Michael S. Mazurek, M.D.

Associate Professor of Clinical Anesthesia

Riley Hospital for Children

overview
Overview
  • Goals of Sedation
  • Definitions of Levels of Sedation
  • Risks and Complications
  • Clarian Sedation Guidelines by Case Examples
  • Specific Drugs
goals of sedation
Goals of Sedation
  • Guard the patient’s safety
  • Minimize pain
  • Provide anxiolysis
  • Control behavior
  • Return the patient to a state in which safe discharge is possible
risks and complications
Risks and Complications
  • AIRWAY, AIRWAY, AIRWAY
    • airway obstruction
    • hypoventilation
    • apnea
    • aspiration
  • Hemodynamic impairment
risks and complications6
Risks and Complications
  • Numerous case reports exist describing complications from sedation and analgesia
  • Few large series exist involving a numerator (adverse events) and a denominator (total number of sedations)
slide7

Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors

Pediatrics 2000; 105: 805-814

  • 4 physicians reviewed adverse sedation events for probable causes
  • 95 events were reviewed
safety conclusions
Safety Conclusions
  • Respiratory events are the most frequent initiating events
  • All areas using sedation have reported adverse events

Pediatrics 2000; 105: 805-814

safety conclusions9
Safety Conclusions
  • Adverse events involved:
    • Multiple drugs
    • Drug overdose
    • Inadequate medical evaluation
    • Inadequate monitoring
    • Inadequate practitioner skills

Pediatrics 2000; 105: 805-814

medication conclusions
Medication Conclusions
  • Adverse outcome was associated with all routes of drug adminstration
  • Adverse outcome was associated with all classes of medication, even when given within the recommended dose range
  • Drugs should not be given at home
  • Avoid premature discharge

Pediatrics 2000; 106: 633-644

slide11

Reappraisal of Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT) for the Sedation of Children

Pediatrics 1995; 95: 598-602

“ The DPT cocktail remains a widely used sedative and analgesic for pediatric patients. Neither the combination itself nor its dosage is based on sound pharmacologic data. There is a high rate of therapeutic failure as well as a high rate of serious adverse reactions, including respiratory depression and death, associated with its use.”

clarian sedation guidelines
Clarian Sedation Guidelines
  • http://clarianweb.clarian.com/
  • Moderate Sedation Guidelines
  • Deep Sedation Guidelines
1 year old sedation for an mri
1 year old sedation for an MRI
  • What equipment do you need available before you sedate this patient?
equipment
Equipment
  • Oxygen supply
  • Airway equipment of appropriate size
  • Suction apparatus of appropriate size
  • Age appropriate emergency cart
  • Physiological monitoring equipment
1 year old sedation for an mri15
1 year old sedation for an MRI
  • Do you need a consent for sedation?
  • Is the MRI consent enough?
1 year old sedation for mri
1 year old sedation for MRI
  • What is important for your presedation history?
presedation medical evaluation
Presedation Medical Evaluation
  • History of sedation/anesthesia problems
  • Airway problems (obstructive sleep apnea)
  • Respiratory symptoms
  • Current medications; drug allergies
  • Review of systems
  • NPO status
1 year old sedation for mri18
1 year old sedation for MRI
  • Would you sedate the child if they had formula 2 hours ago?
  • What are appropriate NPO guidelines?
    • Clear liquids?
    • Breast milk?
    • Formula?
    • Big Mac?
1 year old sedation for mri20
1 year old sedation for MRI
  • What physical evaluation are you going to perform before the sedation?
preoperative evaluation of the upper airway
Preoperative Evaluation of the Upper Airway
  • Tongue versus pharyngeal size
  • Atlanto-occipital joint extension
  • Anterior mandibular space (thyromental distance
  • Dental examination
risk classification
Risk Classification
  • Low – Relatively healthy patient.
  • Moderate – Patient with a significant pathologic process that is difficult to control.
  • High – Patient with a severe pathologic process that has produced potentially irreversible end-organ damage.
patients at increased risk
Patients at Increased Risk
  • Prior adverse response to sedation
  • Airway problems: OSA, difficult intubation, or syndrome with airway abnormalities
  • Significant respiratory symptoms
  • High risk classification
  • Delayed gastric emptying or aspiration risk
1 year old sedation for mri26
1 year old sedation for MRI
  • How are you going to monitor the patient?
monitoring
Monitoring
  • Patient response as a guide to level of sedation
    • Children may be an exception
  • Continuous pulse oximetry
  • Ventilation
    • Observation, auscultation, or ETCO2
  • ECG and BP for all patients under deep sedation and when indicated for moderate sedation
ventilation
Ventilation
  • Pulse oximeter is not a ventilation monitor
  • Impedence Pneumography does not monitor ventilation
  • Observation and auscultation for the uncovered patient
  • ETCO2 for the covered patient
manpower
Manpower
  • Minimum of two persons:
    • One to perform the procedure
    • Another to monitor the patient
  • The monitoring person may assist with short, interruptible tasks during moderate sedation
  • The monitoring person may have no other duties during deep sedation
documentation
Documentation
  • Clarian Sedation Flowsheet
  • Medicines
    • Dosages, times, and routes
  • Vital signs every 5 minutes
    • Minimum SaO2 and RR
    • BP and HR if indicated
post sedation
Post - Sedation
  • Observe in quiet environment for resedation
  • Impaired patients should be back to presedation status
  • Normal patients should be fully awake
post sedation32
Post - Sedation
  • Observe for minimum 1 hour if reversal agent given
  • Physician must perform a post-procedure evaluation
  • Adverse outcomes documented on flowsheet:
    • Conversion to GA, emergency intervention, respiratory complications, death
1 year old for sedation for mri
1 year old for sedation for MRI
  • How are you going to sedate this kid?
3 year old for sedation for head laceration in the er
3 year old for sedation for head laceration in the ER
  • How are you going to sedate this kid?
10 year old for bone marrow aspirate
10 year old for bone marrow aspirate
  • How are you going to sedate this kid?
8 year old for abdominal ct
8 year old for abdominal CT
  • How are you going to sedate?
specific drugs
Specific Drugs
  • Study the pharmacology of the drugs you plan on using
  • Become an expert on a few, appropriate drugs
  • Start with small doses and titrate to effect
  • When combining drugs, decrease the dose of each component
specific drugs38
Specific Drugs
  • Sufficient time should elapse before redosing
  • Tailor your drugs to need – if you don’t need analgesia, don’t give a narcotic
other considerations
Other Considerations
  • Consult a specialist for high risk patients
  • Maintain your airway skills
specific drugs40
Specific Drugs
  • Local Anesthetics
  • Chloral hydrate
  • Midazolam, Flumazenil
  • Fentanyl, Morphine, Naloxone
  • Propofol
  • Ketamine
local anesthetics
Local Anesthetics
  • Use for analgesia
    • Greatly reduces need for systemic narcotics
  • EMLA (lidocaine 2.5%, prilocaine 2.5%)
    • Need 45 – 60 minutes for efficacy
  • Epinephrine 1:200,000 (5 mcg/cc)
    • Prolongs duration of block
    • Decreases bleeding
    • Slows systemic uptake
chloral hydrate
Chloral Hydrate
  • Oral/Rectal dose: 25-100 mg/kg, max 100mg/kg or 2gm
  • Onset: 15 – 30 minutes
  • Peak effect: 30 – 60 minutes
  • Duration of action: variable – may persist for 10 – 20 hours in neonates and toddlers
midazolam
Midazolam
  • Benzodiazepine
    • Sedative with no analgesia
  • Oral dose: 0.25 – 0.75 mg/kg, max 15 mg
  • Pediatric IV dose: 25 – 50 mcg/kg every 5 minutes, max dose 0.4 mg/kg
  • Adult IV dose: 1-2 mg every 5 minutes, max 10mg
  • Onset: oral 10 – 30 minutes
    • IV 3 – 5 minutes
  • Duration of action: oral 60 minutes
    • IV 20 – 60 minutes
flumazenil
Flumazenil
  • Benzodiazepine antagonist for benzodiazepine overdose
  • IV dose: 0.01 mg/kg every 1 minute, no more than 0.2 mg per dose, max dose 1 mg
  • Onset: 1 – 3 minutes
  • Duration of action: < 1 hour
fentanyl
Fentanyl
  • Pediatric IV dose: 0.5 – 2 mcg/kg every 5 minutes, max dose 3 mcg/kg
  • Adult IV dose: 50 – 100 mcg every 5 minutes, max dose 200 mcg
  • Onset: 2 – 3 minutes
  • Duration of action: 30 – 45 minutes
morphine
Morphine
  • Pediatric IV dose: 50 – 100 mcg/kg every 5 minutes, max dose 0.2 mg/kg
  • Adult IV dose: 2 – 4 mg every 5 minutes, max dose 12 – 14 mg
  • Onset: 5 minutes
  • Duration of action: 3 – 5 hours
naloxone
Naloxone
  • Narcotic antagonist for narcotic reversal
  • IV dose: 0.1 mg/kg every 2 –3 minutes , no more than 2 mg per dose with a maximum dose of 10 mg
  • Onset: 1 – 2 minutes
  • Duration of action: 45 minutes
propofol
Propofol
  • Can very quickly induce general anesthesia and apnea
  • Need to give as a continuous infusion
  • IV dose: 0.5 – 1.0 mg/kg loading dose followed by infusion of 25 – 100 mcg/kg/min, titrating to effect
  • Onset: < 1 minute after loading dose
  • Duration of action: depends on duration of infusion
ketamine
Ketamine
  • Produces a dissociative state
  • Provides intense analgesia
  • IM dose: 2 – 4 mg/kg
    • Onset: 5 – 10 minutes
    • Duration: 30 – 90 minutes
  • IV dose: 0.25 – 0.5 mg/kg
    • Onset: 1 – 2 minutes
    • Duration: 20 – 60 minutes