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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

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pediatric sedation 2002 the safety net

Pediatric Sedation 2002: The Safety Net

Kevin M. Creamer M.D. FAAP

Pediatric Critical Care

Walter Reed AMC

the good old days
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
“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
Sedation Overview

“Good judgement comes from experience. Experience comes from bad judgement”

definitions
Definitions

Conscious sedation

vs

Deep Sedation

vs

Anesthesia

Non-distinct continuum which can change

over time

wake up call jcaho 2001 definitions
Wake Up Call : JCAHO 2001 Definitions
  • Minimal Sedation (anxiolysis) –drug induced state which patients can respond normally to verbal commands. Ventilatory and cardiovascular function are unaffected.
    • We almost never do this
    • Some Heme/Onc procedures
jcaho 2001 definitions
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 definitions8
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 definitions9
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
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 + competent to manage an unstable cardiovascular system
sedation continuum
Sedation Continuum

9yo Colonoscopy

Modified from Enright

4yo BM Bx

RISK

2yo Head CT

Light Moderate Deep General

Anesthesia

Assessing a sleeping infant’s level of sedation

in the MRI scanner may be difficult !

model application reduces risk
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

Hoffman, Pediatrics, 2002

wramc pediatric sedation analgesia unit 2002
WRAMC Pediatric Sedation/Analgesia Unit: 2002
  • IAW WRAMC Pam 40-16 (rev 2/2002)
    • As 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
Safety Net

Appropriate patient selection

Better Monitoring

Informed Consent

Emergency equipment available

Deep Sedation team

ASA classification and airway evaluation

Screening for contraindications

PALS trained RN

Physician or PNP present

Safe Drug protocols

pediatric sedation unit 2002
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

D

E

E

P

D

E

E

P

  • * = MD/ PNP
  • Deep sedation offered by CC service
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

Moderate Sedation Training Requirements

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

Rapid, safe return to highest possible health status

Moderate Sedation/Analgesia

First Decide:

If patient really needs the study and needs to be sedated!

overview
Today’s Lecture

Sedation Prerequisites

Pre-evaluation 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

Overview
presedation history and physical
Presedation History and Physical
  • Patient status > ASA classifications
    • Class 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

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 cardio-pulmonary disease (cyanosis, or chronic hypoxemia)

Hx of Malignant hyperthermia

Anticipated difficulty in obtaining IV access in an emergency

Relative Contraindications
presedation history and physical21
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
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
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
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

monitoring requirements
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
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
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
slide29
Provide

supplemental O2

Airway obstruction

Head tilt

If laryngospasm suspected patient may need PPV or neuromuscular blockade and intubation

No

Jaw thrust

Successful

Successful

No

Call for help,

insert NP or

OP airway

Successful

No

Attempt

PPV

No

Prepare for

intubation

Successful

slide30
Drug Induced Respiratory Depression

No blowby

via Ambu bags!

Open Airway

Provide 100% supplemental O2

Is child breathing?

Did child

receive opioids

or benzodiazepines?

No!, Attempt

PPV

Opioids? Give Narcan

0.01mg/kg IV/IO/IM

may double and repeat

BZDs? Give Flumazenil

0.01mg/kg IV may

double and repeat(1mg Max)

physiology
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
physiology33
Physiology
  • Cardiovascular system
    • CO = HRx 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 blood-brain barrier and decreased metabolism
    • Clearance rates reach adult levels by 5-6 months of age
documentation
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
slide35
Preprinted

WRAMC

Overprint-433

slide36
WRAMC

Overprint 499

For documenting

sedated pt

scenarios
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
scenarios38
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!
scenarios39
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
scenarios40
Scenarios
  • 4yo with Asthma needs f/u head MRI for stable abnormality but on screening H+P he has night-time cough and wheezing and nasal congestion
  • Technically an ASA II but he is acutely ill and a sedation exposes him to higher risk. Reschedule.
scenarios41
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
scenarios42
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
Friendly reminder
  • “ Evidence is still a minor driving force in medical practice.” Rinaldo Bellamo
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