pediatric sedation lecture

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Update in Pediatric Sedation

Corey E Collins DO FAAPDirector, Pediatric Anesthesiology

MEEI Boston [email protected]

2 Corey Collins, DO FAAP 2012

Conflict of Interest•Nothing to Declare

ObjectivesAt the end of this talk, the participant will be able to:

• Review the Current Guidelines applicable to Pediatric Sedation

• Summarize Risks and Morbidity data regarding Pediatric Sedation

• Describe common and uncommon sedation medications, their benefits and limitations


Case Presentation•4 year old Down’s Syndrome

Fractured Radius needs CT and likely Closed Reduction

•ED Doctor calls and asked for your help with a sedation plan

•NPO: lunch 4h ago


Sedation Guidelines


Familiar Points•Standard ASA PS Classification•Standard ASA NPO Guidelines unless

Emergency•Recommended Standards for Discharge,

Emergency Drugs and Emergency Equipment that should be available

•Recommends SpO2, etCo2, Local anesthetic toxicity training, “SOAPME”, Simulation’s role in training & competence


New Paradigm for Sedation Continuum??

Risk Based?Specific, Derived

Physiological ThresholdsDefine Required Training


World society of intravenous anesthesia: 10 specialties, 11 countries

Sentinel AE

Moderate AE

Minor AE

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Corey Collins, DO FAAP 2012

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26 Institutions30 037 sedation cases 7/04-11/05

no deaths, CPR in one caseSpO2<90% >30s: 157/ 10 000

Laryngospasm: 4.3/10 000Apnea: 24/ 10 000

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What is “NPO” for sedation?

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What is “NPO” for sedation in the ED?

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4 step assessment process...

•Patient Risk: Difficult airway, syndromes, bowel obstruction, age <6mo, ASA PS >2

•Timing & Nature of PO Intake•Urgency of Procedure•Determine Duration and Depth of

Sedation Needed....

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Who is giving Pediatric Sedation?

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What meds are being used?

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49 836 Propofol Sedations @ 37 sites1:65 rate of Adverse Airway events1:70 required Airway interventions

CPR x 2Aspirations x4

SpO2< 90 x 30s: 154/ 10kLaryngospasm: 96/ 10k

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Complications Related to:ASA PS III+ (1.75-2.26)

NPO Solids < 8h (1.17-1.39)Co-Administration of Narcotics (1.63-1.96)

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Conclusions from PSRC

•Adverse events occur 1:29•Airway events are managed with Bag

mask quite often (63.9/10k), reversal agents thankfully are infrequently used(1.7/ 10 000)

• Intubation needed (9.7/ 10 000)•Critical events are rare (CPR 0.3/10 000)•IV access can be an unexpected

challenge

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Conclusions from PSRC

•Suggestions for Credentialing Clinicians

•Propofol seems OK for Non-anesthesiologists

•NPO guidelines are Inconsistent

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• 1649 sedations 62mo (4mo - 28y) 99% success 99.6% for MRI

• 14 aborted. 2 required anesthesiologists.• Propofol: 2mg/kg bolus then 200ug/kg/min• 3 major complications: 2 aspirations, 1 ETT for

cough• Pedi hospitalists training: 4h class, 10d in OR,

Simulation, Written exam, 25 observed sedations

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Impact of Provider Specialty on Pediatric Procedural Sedation

Complication RatesCouloures et al. Pediatrics 2011; 127(5): e1154-60

•131,751 sedations at 38 centers 2004-2008

•Self reported, various techniques•No significant differences found•Accounted for ASA PS>2, Propofol

Use, Emergency Status, Site clustering

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Impact of Provider Specialty on Pediatric Procedural Sedation

Complication RatesCouloures et al. Pediatrics 2011; 127(5): e1154-60

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-Editorial-Recognizes need for “extensive and multimodal” team training-“professionalization” of pediatric sedation-infrastructure for rescue-Time for national standards for Deep Sedation training, credentials?

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279 kids 0.2-17.2y 100% successDexmedetomidine bolus technique: 3 ug/kg over10” repeated PRN

16% needed second bolus; 0.7% needed third bolusHypotension: 33% Bradycardia 5% Hypertension 3.2%

Mean sedation time: 7.8” +/- 3.8” (0-30” range)

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•65 kids 0.2-2.2y 100% success; MRI:21 CT: 44

•1-4 ug/kg IM deltoid; MRI: 3ug/kg; CT 2.5ug/kg

•7 children needed second IM injection•Sedation time: ~13” Discharge after

study: ~20”•14% Hypotension (Not related to dose)

Intramuscular Dexmedetomidine Sedation for Pediatric MRI and CT

Mason AJR 2011; 197: 720-25

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Compared Ketamine alone vs Ketamine+Propofol Closed reductions 1 mg/kg Ketamine vs 0.5mg/kg Ketamine + 0.5mg/kg Propofol

136pts. 97.8% successful reductionsKet+Propofol: Shorter Sedation (13” vs. 16”), less nausea

Propofol 0.75mg/kg vs. Propofol 0.375mg/kg + Ketamine 0.375mg/kg282 pt 14y- 95y, ASA 1-3, Fx/ dislocation/ cardioversion...No significant differences on adverse events, efficiency

Ketofol may provide more consistent Moderate Sedation Depth

Ann Emer Med March 2012 epub

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Is the addition of Dexmedetomidine to a Ketamine-Propofol Combination in Pediatric

Cardiac Catheterization useful?Ulgey, A. Pedi Cardiol 2012; Feb 16. epub ahead of print

Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural

sedation: a prospective observational pilot study of adverse events and depth of

sedation.Seith, R et al. Acad Emerg Med 2012;19: 31-6

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65 kids 3-74mo 10” infusion 0.5mg/kg96% success

22” induction, 72” sleep 104” discharge12 met “deep sedation” score

No Complications

Pedi Radiol 2012 Jan13 epub ahead of print

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Conclusions?•Dynamic Field, Shifting Delivery

Models•Large Safety Data sets remain

Incomplete•Minimal Rigorous Standards•“Professionalization”•Oversight, Credentialing, Quality....

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RESOURCES•www.pedsedation.org (Pedi

Sedation Society)•www.aapd.org/media/

Policies_Guidelines/G_sedation.pdf (Amer Acad Pedi Dentistry Guidelines 2006)

http://www.pedsedation.org/

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Key References• Cravero, JP Blike, GT. Review of Pediatric Sedation. Anesth

Analg 2004; 99:1355-64.

• Cravero, JP Havidich, JE. Pediatric sedation- Evolution and Revolution. Pedi Anesth 2011; 21:800-9.

• Cravero, JP et al.The Incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108: 795-804.

• Krauss, B Green, SM. Procedural Sedation and Analgesia in Children. Lancet 2006; 367: 766-80

pediatric sedation lecture

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