Pediatric Sedation by fjhuangjun

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									Pediatric Sedation
   Cindy Sanders, RN, MSN
      November 1, 2008
      Kids are different
• Goals for sedation to control behavior to allow
  procedure to be completed successfully
• Kids under age 5 or 6 (chronologically or
  developmentally) may require deep sedation
• Anatomical and physiological differences must be
  considered
• May be more vulnerable to respiratory depression
  and may pass into deeper sedation state than was
  intended
   “Rules” are the same
• American Academy of
  Pediatrics,(AAP) American Society of
  Anesthesiologists, (ASA) American
  Academy of Pediatric Dentists
  (AAPD) and Joint commission on
  Accrediation of Healthcare
  Organizations (JCAHO) issued
  guidelines for pediatric sedation
         Safe sedation
         requirements
–   Systematic approach
–   No administration of sedation with safety net
–   Careful focused pre-sedation assessment
–   Appropriate NPO
–   Focused airway exam
–   Clear understanding of meds, interactions, etc.
      Goals of Pediatric
          Sedation
• Guard Patient safety
• Minimize discomfort and pain
• Control anxiety, minimize psychological
  trauma, maximize amnesia
• Control behavior to allow successful
  completion of exam
• Return patient to a state in which safe
  discharge is possible
 Who is an infant/ child?
• AAP: birth to 21 years
• PALS: infant to age 1, child 1yr to
  puberty
• Some institutions: to age 18

• Chronologic vs. developmental age
The Sedation Continuum

   Mild/conscious/anxiolysis    Moderate/conscious




                         Deep
 The sedation continuum
• Must be able to “rescue” patient
  from next level
• Failure to rescue may be more
  common in non hospital setting
• Conscious sedation may be an
  oxymoron for the young peds patient
Regardless of the medication given, the
route of administration or the intended
level of sedation, the sedation of a
pediatric patient may result in
respiratory depression and loss of
airway protective reflexes
Candidates for pediatric
       sedation
• ASA class I and II generally good
  candidates
• ASA II and IV-require consideration,
  consultation with anesthesia, etc
• Pediatric specific considerations
  must be evaluated
    Peds specific risks
• Untreated severe GERD (Gastro-
  esophageal reflux disease)
• Recent apnea monitor/history
• Congenital airway anomalies such as
  macroglossia, micronathia, etc.
• Extreme Tonsillar hypertrophy
• Mitochondrial or metabolic disease
        Sedation history
•   Prior sedation history
•   Medication history/allergies
•   Significant medical history
•   Does patient snore
•   Recent cold, asthma, etc.
•   NPO status
•   NPO status
•   Parent/guardian accompanying child
        NPO guidelines
• Elective procedures require fasting
  guidelines
• Risk of aspiration less than with general
  anesthesia but absolute risk not known
• Generally same guidelines as for general
  anesthesia are followed
• Solids 6-8 hours, breast milk (considered
  semi-solid by some and clear by others-2-4
  hours, clears 2 hours
          Fluid status
• Some patients will have been NPO for 12
  or more hours.
• May give pre-sedation bolus of 20cc/kg of
  isotonic solution like Normal saline
• This may decrease the risk of hypotension
  and hemodynamic compromise
• May want to leave IV in at procedure end
  till patient awakens and drinks.
Pre sedation assessment
• Vital signs including heart rate,
  respirations, b/p, temperature
• Pulse oximetry reading
• If using ETCO2 monitoring, baseline
  reading
• Accurate weight
Pre sedation assessment
• Focused physical exam including
  respiratory and cardiac rate rhythm and
  quality
• Renal or hepatic function ok?

• Ability of child to cooperate-is non
  sedation an option?
• Any contraindications to procedure (MRI,
  etc)
         Pre sedation
• Informed consent
• Time out
  procedure
             IV access
• Use of topical analgesia if possible
  – EMLA, LMX, Synera (>3 years)-use care to
    follow age and duration guidelines
  – New product on market called Zingo (>3 as well)
    being trialed at several pediatric institutions
• Take time to find best site
• Secure well!
• Consider contrast requirements if CT
 Personnel and equipment
• Must have pediatric specific emergency
  equipment immediately available
• Sedation providers must be trained in he
  administration of sedation medications and
  the management of complications
  associated with these medications
• Must have skills necessary to rescue
  patient from next level of sedation
     RN requirements
• Institution specific but minimal
  requirements include
• BLS and PALS certifications
• “Additional” competency based
  training in sedation medications,
  procedural requirements and rescue
  skills that is ongoing
     AZ State board of
         Nursing
• Employers must identify medication
  allowed for conscious sedation
• Licensed provider must be present in the
  dept from the time the medication is
  initiated to the completion of the
  procedure and must be readily available in
  the facility to assume care of the patient
  during the post-procedure period
   AZ Board of Nursing
• Registered nurse responsible must not
  “leave patient unattended or engage in
  other tasks that compromise continuous
  monitoring”
• Specific list of educational requirements
  for RNs who administer sedation.
• Advisory opinion Conscious sedation for
  Diagnostic and Therapeutic Procedures
  revised 5/08.
         Monitoring
       Intraprocedure
• Continuous monitoring of heart rate and
  pulse oximetry and intermittent recording
  of respiratory rate and blood pressure
• Standard is within 5 minutes prior to
  sedation and every 5 minutes till
  procedure is complete
• Post procedure-vital signs at regular
  intervals (most often q 15 minutes)
        End Tidal CO2
• Anesthesia literature validate rapid
  response in respiratory
  depression/hypoventilation
• Most guidelines recommend or state
  should be immediately available for
  moderate and esp. deep sedation
• In areas where can’t see patient (MRI) has
  become more of a standard of care
    General pediatric
 medication considerations
• Dose must be individualized and double
  checked
• Give small increments and wait for effect
• Expect variations in responses
• Be prepared to assist respirations, etc.
• Remember to consider other medications
  and combinations
    Pediatric sedatives
• Standard pre-printed orders may
  decrease potential for error in
  dosages
• Special care with route
   Sedation medications
• Goal:
• Use the lowest dose of the medication
  with the highest therapeutic index for the
  procedure
• Perfect drug: Causes no respiratory or
  cardiovascular compromise, effects last
  the exact length of the procedure and has
  no contraindications
    Real medication choices
•   Chloral hydrate
•   Benzodiazepines
•   Opiates
•   Barbiturates
•   Anesthetic agents
•   Dexmedetomidine
         Chloral hydrate
•   Has been used for more than 100 years
•   Classified as a sedative/hypnotic
•   No analgesic properties
•   May be given orally or rectally
•   Sometimes referred to as “not really a
    sedative” and therefore outside of the
    guidelines in any given institution
      Chloral Hydrate
• Doses range from 25-125mg/kg-most
  common is 50mg/kg
• Single dose max of 1000mg reported
• Onset of action is very variable
  ranging from 10-60 minutes
• Long sedation has been reported
• Premature discharge has led to death
       Chloral Hydrate
• Hepatic accumulation of metabolites
  reported in premature infants
• Unpleasant taste, nausea and vomiting
  common
• Many studies citing other drugs as more
  efficient
• Some data supporting increased success if
  patient under 2 years.
• No reversal agent
       Benzodiazepines
• Has sedative, anti -anxiety and amnesic
  properties
• No analgesic properties
• Commonly used as pre-med
• Often not able to provide adequate
  sedation for procedures that require
  immobility as a single agent
• Versed most commonly used agent
      Versed (Midazolam)
• May be given in a variety of ways
• Doses:
  –   IV           0.05-0.1mg/kg
  –   Oral         0.5-0.7 mg/kg
  –   Rectal       0.5-1.0 mg/kg
  –   Nasal        0.2-0.4 mg/kg
  –   Sublingual   0.2mg/kg
           Midazolam
• Concomitant use of opiate will increase
  effects
• Onset of action depends upon route-1-5
  minutes IV up to 20-60 minutes orally
• Can cause hypotension, respiratory
  depression
• Reversal agent is Flumazenil (Romazicon)
             Opiates
• Used for painful procedures
• Often combined with benzodiazepines
• Fentanyl most common opiate used in
  pediatric procedures due to relatively
  short half life
• Reversal agent is Naloxone (Narcan)
• May need to repeat Narcan dose due to
  short ½ life.
            Fentanyl
• IV form used for sedation (lollipop
  and patch extended release)
• Dose is usually 1 mcg/kg
• Duration of action generally ½-1 hour
• Can cause chest wall rigidity if given
  as rapid bolus
         Barbiturates
• Pentobarbital historically used Radiology
  sedative-is not an analgesic
• Given IV up to 6mg/kg
• Long half life a concern as related to
  increased recovery times
• Attempts to awaken early may contribute
  to emergence reaction or pentobarb rage
• No reversal agent
    Anesthetic agents
• Ketamine
• Propofal
           Ketamine
• Has dissociative properties and is
  therefore somewhat unique
• Used in human and vet medicine
• Provides sedation and analgesia
• At high doses is a general anesthetic
  agent
• May be given IV or IM
           Ketamine
• To be used only “under direct
  supervision of a LIP with experience
  with anesthetic agents”
• Causes discongigant eye movements
• Can cause hallucinations (visual and
  auditory) usually at emergence-
  versed given in combination to reduce
             Ketamine

• Dose-
  – IV 0.5-2mg/kg-usually use 0.5-1 for procedural
    sedation
  – IM 3-7mg/kg

• Onset of action 30 secs. IV. 3-4 minutes
  IM
• Duration 12-25 minutes IM, 5-10 minutes
  IV
               Propofal
• No analgesic properties
• General anesthetic agent with very rapid onset
  and potential for apnea
• State and institution guidelines vary as to RNs
  ability to manage infusions
• Bolus dosing by LIP
• Study in 2005 showed that 42% of 54 pediatric
  hospitals were using propofal outside of the OR
  given by non anesthesiologists
             Propofal

• Bolus then drip essential as drug is
  degradated in single pass through the liver
• Bolus is usually 1-2mg/kg
• Infusion rates of 50-250mcg/kg/min for
  short term procedural sedation
• Pediatric specific mortality reported from
  irreversible metabolic acidosis in 1999
  from long term high dose infusions
      Dexmedetomidine
         (Precedex)
• Highly selective alpha2 adrenoceptor
  agonist with both analgesic and sedative
  effects
• Classified as anesthetic agent
• Mechanism of action is induction of stage
  2 (non REM sleep)
• Bolus then infusion delivery
• Short ½ life and lack of respiratory
  depression reported
             Precedex
• Advantages
  – Less interference with EEG waves so therefore
    more diagnostic quality
  – Promising results for consistency in achieving
    adequate sedation for imaging studies
  – Large on-going study at Boston Children’s
    Hospital demonstrating positive safety profile
           Precedex
• Hemodynamic changes can occur but
  are not usually clinically significant
• Specifically, bradycardia is common
  but without hemodynamic compromise
• Contraindications include patients on
  Digoxin (cardiac arrest reported in
  adults) and other cardiac conditions
         Post Sedation
         Considerations
• Patients may still be at significant risk for
  complications
• Removal of stimulation (pain, MRI noise)
  may cause deeper sedation level especially
  if multiple doses have been given
• Delayed drug absorption (oral, rectal, IM)
  and slow drug elimination also may
  contribute
         Post Sedation
         Considerations
• Continued monitoring and observation
  necessary
• Pre-determined discharged criteria
  – Aldrete most common
  – Score of 9 or back to baseline usual criteria
• With kids, ability to drink also important
  to avoid dehydration and hypoglycemia
  (infants)
        Post Sedation
        Considerations
• Written discharge instructions that
  are age specific desirable
• Toddlers especially at risk for falls,
  etc
• Positioning in car seats, etc with
  infants also very important due to
  pediatric airway anatomy
  QA/QI outcome data
• Guidelines state there should be an
  analysis of any adverse events
• Collecting data regarding success
  rates, etc helps drive practice
  change
• One Benchmark: Pediatric Sedation
  Research Consortium
Take home points
     Take home points
• Kids are not little adults
• Know age specific vital sign norms
• Know where your pediatric airway
  equipment is and how to use it
• Remember airway position
• Double check your meds
  Remember if your intent is to
sedate a patient, irregardless of
 the medication or dose you use,
    sedation guidelines apply
Any Questions?????
                             Pediatric Sedation References


Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for
Therapeutic and Diagnostic Procedures: An Update. American Academy of Pediatrics, American Academy of
Pediatric Dentists, Cote, C.J, MD, Wilson, S/ DMD, MA, PhD the WorkGroup on Sedation. Pediatrics Vol 118 No.6
December 2006 pp 2587-2602.

Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: an updates report by the
American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists.
Anesthesiology. V 96 No. 4, April 2002

Incidence and Nature of Adverse Events During Pediatric Sedation /Anesthesia for Procedures Outside
the Operating Room: Report from the pediatric Research Consortium. Cravero, J.P. MD, Blike, G.T. MD,
Beach, M. MD, Gallagher, S. M. BS, Hertzog, J.H. MD, Havidich, J.E. MD, Gelman, B.MD, and the Pediatric
Sedation Consortium. Pediatrics Vol. 118, No 3. September 2006, PP 1087-1096.

Advisory Opinion Conscious sedation for Diagnostic and Therapeutic procedures. Arizona State Board of
Nursing.

								
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