Pediatric Sedation 2002: The Safety Net

1. Pediatric Sedation 2002: The Safety Net Kevin M. Creamer M.D. FAAP Pediatric Critical Care Walter Reed AMC

2. 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

3. “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

4. Sedation Overview “Good judgement comes from experience. Experience comes from bad judgement”

5. Definitions Conscious sedation vs Deep Sedation vs Anesthesia Non-distinct continuum which can change over time

6. 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

7. 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.

8. 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.

9. 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.

10. 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

11. 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 !

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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!

18. 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

19. 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!

20. 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

21. 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

22. 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

23. 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?

24. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

31. Advanced airway maneuvers

32. 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

33. 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

34. 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

35. Preprinted WRAMC Overprint-433

36. WRAMC Overprint 499 For documenting sedated pt

37. 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

38. 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!

39. 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

40. 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.

41. 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

42. 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

43. Friendly reminder • “ Evidence is still a minor driving force in medical practice.” Rinaldo Bellamo