Procedural Sedation in Pediatrics by wpr1947

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									PROCEDURAL
SEDATION
Stacey Chamberlain, MD, MPH
October 28, 2010
QUESTION #1
   If you were to give this
    boy (on the right)
    midazolam, what is his
    chance of having a
    paradoxical reaction:
    a. 1-15%
    b. 16-30%
    c. 31-45%
    d. >45%
QUESTION #2

   Which agent would be
    best to use with propofol
    for a painful procedure
    for this child?:
    a. fentanyl
    b. ketamine
    c. midazolam
    d. etomidate
QUESTION #3
 Which would likely
 cause this child
 greater respiratory
 depression in standard
 doses:
 a. methohexital
 b. etomidate
 c. propofol
 d. ketamine
QUESTION #4
 Which agent would
 be preferred for
 sedation for CT for
 this child?
 a. ketamine
 b. midazolam
 c. pentobarbital
 d. fentanyl
QUESTION #5
   Which of the following
    agents (given alone)
    would you consider for a
    fracture reduction in this
    child:
    a. chloral hydrate
    b. methohexital
    c. ketamine
    d. etomidate
QUESTION#6
   What might be the best
    agent to reduce vomiting
    when given with
    ketamine in this child?
    a. propofol
    b. midazolam
    c. ondansetron
    d. metoclopramide
QUESTION #7
   If this child just ate 3
    hours ago, how long
    should you wait before
    his procedural sedation?
    a. 1 hour
    b. 2 hours
    c. 3 hours
    d. Probably doesn’t
    matter
QUESTION #8
   Which agent would likely
    enable you to more
    quickly discharge this
    patient from your ED
    after procedural
    sedation?
    a. pentobarbital
    b. midazolam
    c. ketamine
    d. propofol
QUESTION #9
   Which method of
    midazolam
    administration would
    provide better sedation
    for a laceration repair in
    this patient?
    a. IM
    b. PO
    c. PR
    d. IN
QUESTION #10
 Which agent would
 be least likely to
 induce vomiting in
 this child?
 a. ketamine
 b. propofol
 c. etomidate
 d. morphine
PROCEDURAL SEDATION

   Indications
   Sedation  goals
   Preparation
   Monitoring
   Methods of drug
    administration
   Specific agents
SPECIAL CONSIDERATIONS IN
PEDIATRIC PATIENTS
   Even neonates demonstrate behavioral and hormonal
    changes in response to painful procedures
   Preemptive analgesia/anesthesia may decrease postinjury
    opioid requirements
   Sedation may be needed to control behavior; therefore,
    increased sedation for children < 6 yo and developmentally
    delayed
   Individualized dosing and titratable agents are often
    necessary due to internal and external factors
       Internal factors: age, developmental level, previous experience
       External factors: parental interactions with the child,
        preparation, physician skill, physical setting
UNDERTREATING PEDIATRIC PATIENTS

  Pain in children historically has
   been underreported,
   undertreated, and
   misunderstood
  Reasons for inadequate
   treatment
      Failure to recognize pain
      Ignorance about drugs and dosages
      Fear of adverse cardiovascular effects
      Fear of delay in treatment and
       disposition
SPECIAL CONSIDERATIONS IN ELDERLY
   At increased risk of complications –
    may be due to increased sensitivity
    to sedatives, medication
    interactions, higher peak serum
    levels of drugs
   Consider lower starting dose
    (reduce 20%) and less frequent
    intervals
   Consider ultra-short acting
    sedative
   In patients with cardiac morbidity
    or taking cardiodepressant
    medications (e.g. beta-blockers),
    consider hemodynamically neutral
    sedatives (e.g. etomidate)
SPECIAL CONSIDERATIONS IN PREGNANCY
 Preprocedural meds to improve
  GE sphincter tone, reduce gastric
  volume, and decrease stomach
  acidity (e.g. metoclopramide, H2
  blockers)
 Preprocedural hydration and left
  lateral displacement of uterus (to
  reduce risk of hypotension and
  uteroplacental insufficiency)
 Oxygen by face-mask due to
  increased risk of desat (due to
  decreased FRC)
 Consider fetal monitoring in 3rd
  trimester
GOALS OF SEDATION
 Anxiolysis    (relief of agitation)
 Amnesia

 Analgesia    (relief of pain)
     In some procedures, patients
      have little or no pain before
      and after (e.g. LP,
      cardioversion)
     Some procedures themselves
      lead to reduction of pain (e.g.
      dislocation reduction)
 Muscle relaxation
 Control behavior/movement
INDICATIONS
  Management   of anxiety,
   pain, and control of
   excessive motion
  Diagnostic procedures:
      Lumbar puncture
      Arthrocentesis
      Thoracentesis
      Sexual assault examination
      Radiological evaluation (CT,
       MRI)
INDICATIONS

 Therapeutic procedures:
   Suturing
   Wound care
   Abscess incision and drainage
   Fracture/dislocation reduction
   Hernia reduction
   Paraphimosis reduction
   Foreign body removal
   Burn debridement
   Tube thoracostomy
   Electrical cardioversion
   Any other painful procedure
CONTRAINDICATIONS
 No absolute contraindications
 Relative contraindications
  include:
     Older age
     Significant medical comorbidities
      (ASA classification III or greater)
     Signs of a difficult airway

   Important comorbidities are those
    that increase risk of
    cardiorespiratory depressant
    effects of drugs
       CHF, COPD, neuromuscular
        disease, dehydration, anemia
    DEFINITIONS OF SEDATION
 Sedation is a continuum, the
  depression of a patient's awareness
  to the environment and reduction of
  his or her responsiveness to external
  stimulation
 Minimal sedation
       Anxiolysis
       Minimal effect on sensorium
   Moderate sedation (formerly conscious sedation)
       Depression of consciousness
       Can respond to external stimuli (verbal or tactile)
       Airway reflexes, spontaneous ventilation, and
        cardiovascular function are maintained
DEFINITIONS OF SEDATION
 Deep sedation
   Depression of consciousness
   Patient cannot be aroused
   Responds purposefully to repeated or painful stimuli
   May not be able to maintain airway reflexes or spontaneous
    ventilation, but cardiovascular function is preserved
 General anesthesia
   State of unconsciousness
   Autonomic nervous system is unable to respond to surgical or
    procedural stimuli
 Dissociation (a type of moderate sedation)
   Disconnection between the thalamoneocortical system and the
    limbic systems, preventing higher centers from receiving sensory
    stimuli
   Airway reflexes, spontaneous ventilation, and cardiovascular
    function are all maintained
PROCEDURAL SEDATION
 Using  sedative or dissociative agents with or
  without analgesics
 Allows the patient to tolerate unpleasant
  procedures while maintaining cardiorespiratory
  function
 Depressed level of consciousness but one that
  allows the patient to maintain airway control
  independently and continuously
 Drugs, doses, and techniques used are not likely to
  produce a loss of protective airway reflexes
COMPONENTS OF PROCEDURAL SEDATION

 Presedation assessment
 Sedation during
  procedure
 Post-procedure recovery
  and discharge
GUIDELINES FOR SEDATION
 AAP  (American Association
  of Pediatrics)
 ASA (American Society of
  Anesthesiologists)
 ACEP (American College of
  Emergency Physicians)
 Attempts to standardize
  procedure and enhance
  patient safety
 Non-binding
JOINT COMMISSION REQUIREMENTS

 Passed in 2001
 Standards for pain management, sedation, and
  anesthesia care in U.S. hospitals
 Procedural sedation should be similar throughout an
  institution (no difference between OR, ED, endoscopy,
  etc.)
 Practitioners must be able to manage a compromised
  airway, can rescue patients from inadvertent deep
  sedation or general anesthesia
 Must have a “time-out” prior to sedation (confirm
  patient’s name, procedure, and site of procedure)
SAFETY
 Distinct personnel responsible for sedation,
  monitoring, and performing the procedure
 Recognize potential drug interactions (e.g.
  with fentanyl and midazolam, a synergistic
  effect on respiratory depression occurs)
 Use of 3 or more meds significantly increases
  the risk of an adverse reaction
 Must have monitoring including pulse-ox, age-
  appropriate equipment and personnel trained
  in resuscitation
MEDICATION REACTIONS
 Type 1 IgE allergic reactions to sedation and
  analgesia drugs rare
 Reactions due to histamine release (morphine,
  meperidine)
 Nasal pruritis (fentanyl)

 Paradoxical reactions (benzos, barbs)

 Respiratory depression (benzos, barbs, opioids,
  etomidate, propofol)
 Emergence reactions (ketamine)
    ADVERSE EVENTS
 Most events are preventable
 Adverse events associated with:
       Out-of-hospital-base setting
       Inadequate monitoring
       Lack of adequate presedation evaluation
       Lack of standard recovery procedures
       Medication errors
       Lack of independent observer
   Most common reasons for error:
       Operator error
       Lack of familiarity with agents being used
       Lack of rescue systems
       Delay in airway and ventilatory support
ADVERSE EVENTS
   Most common are respiratory complications
       Desats can be minimized by cautious, unhurried medication
        administration
   Pena and Krauss. Ann Emerg Med. 1999.
     Prospective case series of 1180 ED patients
     No difference between doses of meds, drug regimens, ages of
      patients, procedural indications
     2.3% with adverse events (10 pts with desat, 7 with paradoxical
      reaction, 3 with emesis); no serious complications
   Hoffman et al. Pediatrics. 2002.
     4.2% complication rate; complications reduced by performance
      of risk assessment, adherence to all guidelines, and avoiding
      deep sedation (not affected by fasting status)
     More complications with multi-drug regimens and with chloral
      hydrate; fewer complications with midazolam
PRESEDATION ASSESSMENT
 Discussion about the risks, benefits, and
  alternatives
 Having written consent is not absolutely
  needed (Joint Commission does not require)
 Type and route of medication determined by:
     Age of patient
     Nature of procedure
     Length of procedure
     Potential for the medication's
      side effects
 KEY ASPECTS OF H&P
 Assessing key elements of the H&P lowers the risk
  of complications
 Past medical history:
       Prior sedation/anesthesia history
       Last solid and liquid PO intake
       Recent illness
       Medication or drug use
       Allergies or adverse reaction
       Pertinent family history
       Pregnancy status
       Upper respiratory infection (URI) symptoms, history of
        reactive airway disease
   Risk of laryngospasm 5.5x higher with URI and
    3.7x higher with active asthma
NPO STATUS – DOES IT MATTER?
   AAP and ASA recommendations (guidelines for general
    anesthesia extrapolated to emergency care):
      2 hours for clear liquids
      4 hours for breast milk
      6 hours for other non-clear liquids and solids
   No association between fasting and
    adverse effects
        Green at al. Acad Emerg Med. 2002.
            Patients who fast for 2 hours have same gastric volume and pH as those who
             fast for longer
        Agrawal et al. Ann Emerg Med. 2003.
            Prospective case series of ED patients undergoing procedural sedation
            No difference in fasting in pts who had vomiting
        Roback et al. Ann Emerg Med. 2004.
            Prospective analysis of ED patients comparing adverse events to fasting
             time
            No association between adverse events and fasting time
FASTING GUIDELINES
 ACEP: “Recent food intake is not a
  contraindication for administering procedural
  sedation…but should be considered in choosing
  the timing and target of sedation.”
 Green et al. Ann Emerg Med. 2007.
       Consensus-based clinical practice advisory
   Consider risks and benefits:
     Conditions predisposing to reflux (e.g. hiatal hernia)
     Extremes of age (<6 months or >70 years old)
     Severe systemic disease (ASA III or greater)
     Depressed mental status

   Preprocedural antacids or motility agents have
    NOT been shown to reduce risk
KEY ASPECTS OF PHYSICAL EXAM
  Physical   exam:
      Age
      Weight
      Vital signs
      Airway exam
      Cardiovascular exam
      Neurological/mental status
      Size and location of injury
       and neurological status
       distal to it
  Mallampati     classification
ASA CLASSIFICATION
 Class I and II patients are best candidates for
  general endotracheal anesthesia
 Unknown if this classification can be accurately
  extrapolated for procedural sedations in the ED


  I. Normal healthy pt
  II. Pt with mild systemic disease
  III. Pt with severe systemic disease
  IV. Pt with severe systemic disease
  that is constant threat to life
  V. Moribund pt not expected to
  survive without operation
  E. Emergent procedure
PREPARATION (SOAPME)
   Suction
   Oxygen (must be available, may decrease
    incidence and severity of hypoxemia but may
    delay detection of apnea with pulse ox)
   Airway: age-appropriate nasopharyngeal and
    oropharyngeal airways, face mask, bag-valve
    mask, ETT, laryngoscope
   Pharmacy (drugs for sedation and reversal
    agents)
   Monitors (continuous pulse ox, blood pressure,
    HR)
   Equipment (special equipment e.g. debrillator
    in patient with cardiovascular disease)
MONITORING
   Continuous pulse ox and heart rate
   Record vital signs every 15 min for
    conscious sedation and every 5 min for
    deep sedation
   Record drug dose and time
    administered
   Record state of consciousness and
    response to stimulation
   Consider end-tidal CO2 monitoring
   Noxious stimuli can lighten sedation;
    withdrawal of stimuli at end of
    procedure can deepen sedation
   Highest risk for complications 5-10
    min after IV meds and in
    immediate post-procedure period
    when external stimuli
    discontinued
POSTPROCEDURE CARE
   Continue recording vital signs until the patient responds
    appropriately to voice or gentle stimulation.
   Newman et al. Ann Emerg Med. 2003.
     Prospective study of adverse effects in ED procedural sedations to
      determine optimal timing of ED discharge
     13.7% adverse effects, 92% during procedure, most 2 min after final med
      dose
     Rare serious effects > 25 min after final med dose; all (.002% overall)
      were repeat occurrences in pts with hypoxia during peak drug effect
   In general, discharge criteria should be:
     Vital signs within 15% (plus or minus) of admission
     Patient should talk and sit unassisted, according to age (walking not a
      requirement)
     Should be able to take and retain oral fluids
     Can discharge 30 minutes after last dose assuming no significant adverse
      events during procedure and patient did not receive reversal agent
   Some agents have specific aftercare needs (e.g. ketamine may
    cause ataxia for 12-24 hours, and children should be activity
    restricted to prevent further injury)
PHASES OF PROCEDURAL SEDATION
   1980-1990            Available agents are used (e.g. Demerol,
                         Phenergan, Thorazine, diazepam, morphine,
                         barbiturates, chloral hydrate)
   1985-1990            Non-histamine-releasing short-acting opioids
                         (e.g. fentanyl), short-acting benzodiazepines
                         (e.g. midazolam), use of reversal agents, pulse
                         oximetry
   1990-2000            Newer agents part of routine practice,
                         rediscovery of older agents (e.g. ketamine, n
                         itrous oxide)
   2000-2005            ultra-short acting agents part of ED
                         procedural sedation (e.g. etomidate, propofol),
                         advanced technology for assessing sedation
                         depth (e.g. capnography)

(Adapted from Miner et al. “Procedural Sedation and Analgesia Research: State of the Art.” Acad
   Emerg Med. 2007.)
GENERATIONS OF AGENTS
   First generation:
       Chloral hydrate
       Pentobarbital
       Methohexital and thiopental
       Diazepam (Valium)
       Morphine and meperidine
        (Demerol)
   Second generation:
       Midazolam (Versed)
       Fentanyl                      o Fourth generation?
                                         • Ketofol
       Ketamine                         • Fospropofol
       Nitrous oxide                    • Dexmedetomidine
   Third generation
       Propofol
       Etomidate
OPIOIDS
  Frequently  used to control pain
  Used as a single agent or as a
   combination with
   sedative/anxiolytic agents
  Evaluate endpoints by observing
   for:
      Miosis
      Decreased responsiveness to verbal
       stimuli
      Altered respiratory pattern
      Slightly impaired speech
      Diminished pain on questioning
OPIOIDS
   Fentanyl preferred due to faster onset, shorter
    recovery, and lack of histamine release
    (compared to morphine and meperidine)
       Peak onset IV 2-3 minutes
       Duration 20-40 minutes
   Remifentanil and Alfentanil
     Rapid onset, duration of 5 minutes
     Remifentanil studied with propofol and alone
     Alfentanil
        Increased respiratory depression when used with
         propofol
        (Annals 2010 article) 39% of patients with airway

         or respiratory events leading to intervention
         (although clinically insignificant)
     Neither proven superior to fentanyl
BENZODIAZEPINES
   Used as sedative-hypnotic agents
   Anxiolytic, amnestic, and skeletal muscle relaxant
    properties
   No analgesic properties
   Options:
     Midazolam (Versed) is commonly used because of its short half-life
      and prompt onset of action
     Diazepam (Valium) may be given but has a long half-life and active
      metabolites
     Lorazepam (Ativan) is a poor choice because of its long duration of
      action
   Evaluate for endpoints by observing:
     Ptosis
     Somnolence
     Slurred speech
     Gaze alteration
MIDAZOLAM

 Benzo of choice due to shorter duration of action and
  multiple routes of administration
 Peak onset IV is 2-3 minutes
 Duration 30-60 minutes
 Can be given IV, IM, PR, PO, IN (but PO leads to
  unreliable concentrations, IN causes mucosal
  irritation, IN/PR may not be as effective)
 Paradoxical reactions in 1-15% of children
 Accumulates in adipose tissue which may lead to
  prolonged sedation
       Use lower doses and longer intervals in elderly, obese, and
        those with renal/hepatic disease
FENTANYL/MIDAZOLAM LITERATURE

 Efficacy from 91-100% (multiple studies)
 Multiple studies showing hypoxemia and
  subclinical respiratory depression with combo
 Recommendation:
     Give midazolam first (0.02 mg/kg, max 2mg)
     After 2 minutes, give 2nd dose if necessary
     Give fentanyl (0.5 mcg/kg)
     Repeat fentanyl q2 min prn
     Use smaller doses and longer intervals with elderly
      and those with renal/liver disease
BARBITURATES
    Produce sedation and amnesia and
     reduce anxiety
    No analgesic effects
    Reproducible dose-response effect,
     based on weight
    Neuroprotective properties by
     lowering ICP and anticonvulsant
     properties
    Disadvantages include hypotension,
     hypoventilation, and apnea
BARBITURATES

 Pentobarbital
     With IV, sedation in 3-5 min; with PO 15-20 min
     Duration of 30-40 min (however, one study showed
      sedation > 8 hours in 19%)
     One study showed high complication rate (14.7%);
      another showed high failure rate (8%) in pediatrics for
      those >12yo or >50kg
 Methohexital        (Brevital)
     With IV, sedation within one minute
     Recovery in 15 min
     Given rectally can reliably produce anxiolysis and
      sedation for CT/MRIs
METHOHEXITAL LITERATURE

   Most studies evaluate for use for painless diagnostic
    studies (CT/MRI)
   Efficacy IV (1mg/kg) of 99-100%, IM (10mg/kg) 92%, PR
    (25 mg/kg) 95%
   Incidence of hypoxia from 1-6%
   Transient hypotension in up to 17% when given IV
   Avoid in patients with seizure disorder
OTHER AGENTS
 Chloral hydrate
 Nitrous oxide
 Ketamine
     Sedative-hypnotic
     Also has analgesia and
      amnestic effects
 Etomidate
     Ultra-short acting
     Neuroprotective properties and minimal
      cardiovascular effects
 Propofol
     Ultra-short acting
CHLORAL HYDRATE
 Sedative-hypnotic, no analgesia
 Average 30 min to peak sedation
 Recovery time 1-2 hours
 Motor imbalance and agitation can last for several
  more hours
 Most reliable in children < 3 y.o.
 Given PO or PR, no IV needed (some prefer for
  children < 18 mo for this reason)
 Can cause airway obstruction, respiratory
  depression; in France restricted due to potential
  carcinogenicity
 Contraindicated in patients with hepatic, renal, or
  cardiac disease
CHLORAL HYDRATE LITERATURE

 AAP   Committee on Drugs. Pediatrics. 1993.
   Low incidence of acute toxicity when given orally in
    recommended doses for short-term sedation
   Repetitive dosing not recommended
   Two mice studies indicate potential carcinogenicity but
    animal studies for benzos and barbs also indicate
    potential carcinogenicity as well
 Hoffman   et al. Pediatrics. 2002.
   Prospective evaluation of adherence to AAP/ASA
    guidelines and complications
   Chloral hydrate associated with more adverse events
    (odds ratio 2.13)
KETAMINE
   Produces analgesia, sedation, amnesia, and immobilization
   Dissociative state produced not consistent with JC definitions of
    moderate or deep sedation; unique effects
   Above critical dosage threshold (1.5 mg/kg IV or 4-5 mg/kg IM)
    produces effects, not titratable
   IV effect one minute, duration 5-10 minutes (give over 60s to
    prevent respiratory depression)
   IM effect 3-5 minutes, duration 20-30 minutes
   Time to dischargeable recovery 50-110 minutes IV, 60-140
    minutes IM
   Can give anticholinergics (atropine?, glycopyrrolate) to prevent
    salivation
   Emergence reaction uncommon (<1% in adults and children); no
    benefit from concurrent benzos
   Good for painful procedures, less desirable for imaging due to
    occasional random movements
KETAMINE
   Excellent safety profile
      Preserves cardiopulmonary stability
      Preserves spontaneous respiration
   Contraindications:
      Absolute
           Children < 3 months (higher incidence of airway compromise)
           Known or suspected psychosis
       Relative
           Age < 12 months
           Procedures involving stimulation of posterior pharynx
           H/o tracheal surgery or stenosis
           Active pulmonary infection or disease (including URI)
           Head injury associated with LOC
           Altered mental status
           Hypertension
           Heart failure
           Emesis
           CNS masses, abnormalities, hydrocephalus
           Glaucoma or acute globe injury
           Porphyria
           Thyroid disorder or thyroid medication
KETAMINE EFFECTS – MIXED MESSAGES?
   Pros
       Increases BP and CO
       Neuroprotective, increases cerebral blood flow
       Bronchodilation
   Cons
       Laryngospasm?
           Severe in 0.02% (other agents at 1.75%); mild in 0.29%-0.4%
       Potential increased ICP?
           Only seen in case series of patients with CSF obstruction
           One study showed decrease in ICP compared with fentanyl
       Increased IOP?
           In animal studies, but not in human studies
       Psychotic effects
           May precipitate psychosis in patients with known schizophrenia but doesn’t
            cause psychosis in otherwise healthy patients
       Thyroid disease
           HTN and SVT in 2 patients on levothyroxine
KETAMINE LITERATURE
 1.5 mg/kg IV more effective than 1mg/kg (5.5%
  required additional dose vs 54%)
 IM associated with more vomiting, more
  laryngospasm, and longer recovery times than IV
 Similar hypersalivation scores with and without
  atropine
 Green et al. Ann Emerg Med. 1998.
       9 year retrospective cohort in children receiving IM
        ketamine
       Low rate of significant adverse events; no serious
        sequelae; transient laryngospasm in only 0.4%
   Langston, et al. Ann Emerg Med. 2008.
       7.9% absolute risk reduction of post-procedural vomiting
        in children pretreated with ondansetron
KETAMINE PLUS MIDAZOLAM?

   Wathen et al. Ann Emerg Med. 2000.
     Randomized controlled trial of ketamine +/- midazolam
     Adding midazolam does not decrease recovery agitation; in
      fact, recovery agitation increased with midazolam if age
      > 10yo (35.7% vs. 5.7%)
     Emesis decreased in midazolam group (9.6% vs. 19.4%)

   Sherwin et al. Ann Emerg Med. 2000.
       Randomized controlled trial of ketamine +/- midazolam
       No difference in recovery agitation; decreased emesis
        in midazolam group (2% vs. 12%)
   HOWEVER
     Addition of midazolam increased O2 desats
     Newer study shows ondansetron decreases vomiting (13%
      to 5%) – (Langston et al. Ann Emerg Med. 2008.)
PROPOFOL
 High satisfaction to patients due
  to antiemetic and euphoric properties
 Extremely rapid onset, extremely short recovery (5-
  27 minutes)
 Good efficacy and safety in adults and pediatrics
 Most serious adverse effect is respiratory depression
  (6-30%) and hypotension (by direct negative
  inotropy and arterial and venous dilatation)
 No analgesia
      If giving fentanyl with it, reduce dose (no single dose
       more than 0.5 mcg/kg)
      Can give with subdissociative dose of ketamine (0.3
       mg/kg)
   Contraindicated in patients with sensitivity to egg lecithin and soybean
    oil
   Can be painful through PIV (use larger catheter in larger vein)
PROPOFOL LITERATURE
 Hypoxia in 2-31% of patients, usually responding to
  supplemental oxygen or jaw thrusts
 Clinically insignificant transient decreases in blood
  pressure; no patients required intervention
 Safe and effective
 Mean recovery time 27 min
 Should have monitoring with capnography as well as
  pulse oximetry
ETOMIDATE
 Sedation, anxiolysis, and amnesia
  equivalent to barbiturates but fewer
  adverse hemodynamic effects
 No analgesia
 Rapid onset and recovery
 Clinically insignificant transient adrenal suppression
 Pain with injection (1.9% when given with opioids,
  17% given alone)
 Myoclonus (7.8% - 37.9%); reduced when given with
  opioids
 Can also cause respiratory depression (10%), nausea
  and vomiting
ETOMIDATE LITERATURE
 No major adverse effects; may be used safely in
  children
 Effective (93% procedural success) and safe (20% minor
    complication rate)
   Adverse reactions greater in older patients (>55 yo) with
    relatively higher doses of etomidate (0.23 mg/kg compared
    with 0.19 mg/kg in pts w/o resp compromise)
   Procedural success may be improved with reducing
    myoclonus
     Pretreatment  dose (0.03-0.03 mg/kg given 50 sec before)
     Small dose of concomitant midazolam (0.015mg/kg)
     Magnesium sulfate given 90 sec before
“EVIDENCE-BASED APPROACH TO
PEDIATRIC PROCEDURAL SEDATION”
 Comprehensive     review of literature
 Focuses    on:
     Etomidate
     Fentanyl/midazolam
     Ketamine
     Methohexital
     Pentobarbital
     Propofol
         rated on strength of evidence
 Articles
 (Classes I, II, III) and recommendations
 made (Levels A, B, C)
 Mace et al. Ann Emerg Med. 2004 Oct.
RECOMMENDATIONS
   Etomidate effective and safe?: yes, level C
   Fentanyl/midazolam effective and safe?: yes, level B (greater
    risk of respiratory depression, so close monitoring needed)
   Ketamine effective and safe?: yes, alone or with benzo, level A
    (may require head positioning, O2, BVM support, measures to
    address laryngospasm)
   Midazolam plus ketamine reduce agitation/vomiting?: does not
    reduce agitation, level A; does reduce emesis, level B
   Methohexital effective and safe?: yes, level B (but may require
    head positioning, O2, BVM support)
   Pentobarbital effective and safe?: yes, level B (best results < 8
    yo; may require head positioning, O2, BVM support)
   Propofol effective and safe?: yes, combined with opiates, level B;
    yes, if used alone for painless procedures, level C (may require
    head positioning, O2, BVM support)
COMPARISON STUDIES

   Propofol/fentanyl vs propofol/ketamine
     Fentanyl group with 5x risk of serious adverse event
      (e.g.hypoxia)
     Ketamine reduces pain and need for post-procedure
      analgesics
   Midazolam/fentanyl vs midazolam/ketamine
       Midazolam/ketamine more efficacious, causes less
        hypoxia (6% vs. 25%), fewer respiratory complications,
        but more vomiting in 2 weeks after procedure (4% vs.
        0%)
       No significant difference in adverse events
       Midazolam/fentanyl causes more CO2 retention
       Midazolam/fentanyl has longer recovery time
COMPARISON STUDIES WITH PROPOFOL

   Pentobarbital vs. propofol
       Greater recovery time, longer time to discharge for
        pentobarbital but fewer adverse reactions
   Etomidate vs. propofol
       More vomiting (9.9%) and agitation (4%) compared with
        propofol (0.5% and 1.2%) but less hypoxia (2% vs 15.7%)
   Midazolam vs. propofol
       Propofol is effective, safe and has a shorter recovery time
COMPARISON STUDIES
   Roback, et al. Acad Emerg Med. 2005.
       Retrospective analysis ketamine vs ketamine/midazolam
        vs fentanyl/midazolam vs midazolam alone (median age
        6.7 yo)
       total adverse events 17%; ketamine with fewer
        respiratory adverse events but more vomiting
                   Percent   Respiratory          Vomiting (% of
                   of pts    adverse events       patients receiving
                             (% of pts            that tx)
                             receiving that tx)
Ketamine alone     59.7      6.1                  10.1
Ketamine/          12.0      10                   5.4
midazolam
Midazolam/         13.4      19.3                 1.8
fentanyl
Midazolam alone    10.4      5.8                  0.8
SEDATION FOR IMAGING
   Pomeranz et al. Pediatrics. 2000.
       Evaluation of rectal methohexital for imaging
       Effective (95%), rapid onset (8 min), but relatively long duration (79 min) and
        significant transient respiratory depression (10%)
   Sedik. Arch Pediatr Adolesc Med. 2001.
       Evaluation of IV methohexital for imaging
       Rapid onset (1 min), short duration (12-14 min), transient respiratory
        depression (5%)
   Moro-Sutherland et al. Acad Emerg Med. 2000.
       Compared IV midazolam to IV pentobarbital for sedation for CT
       Success rate 97% for pentobarbital (compared to 19%)
   Malviya et al. Pediatr Anesth. 2004
     Comparison of IV pentobarbital and PO chloral hydrate for children getting
      MRIs
     Quicker sedation onset and reduced suppl. sedation with pentobarbital but
      more paradoxical reactions, longer recovery, and increased failure rate
   Rooks et al. AJR Am J Roentgenol. 2003.
       Comparison of PO pentobarbital and PO chloral hydrate
       Similar time to sedation, time to discharge, length of sedation and adverse
        reactions
   Baxter et al. Pediatr Emerg Care. 2007.
       Comparison of etomidate and pentobarbital
       Etomidate more effective, sedation shorter, and fewer adverse effects
NEWER AGENTS
   Dexmedetomidine
     Alpha 2 agonist (similar to clonidine) with sedative and
      analgesic effects
     Most studies to date in critically ill patients

   Fospropofol
     Prodrug to propofol
     May provide more sustained and consistent effects than
      propofol
     Most studies to date are for colonoscopy, bronchoscopy,
      endoscopy
   Ketofol
     Lower doses of each could reduce propofol-induced
      hypotension and ketamine-induced vomiting and emergence
      reactions
     So far, has not been shown to be more efficacious or safer than
      either agent alone
REVERSAL AGENTS
   Naloxone (Narcan)
     Dose is 0.1 mg/kg IV, IM, SC, ET, SL q2-3min until
      response for children <5 years or <20 kg
     2 mg for children > 5 y (or >20 kg)
     Half-life 1-2 h (rebound sedation and apnea may occur)
     Can give Nalmefene (t½ 4-8 h) which lasts longer than
      fentanyl but then can’t treat post-procedure pain)
   Flumazenil
     Dose is 0.01-0.02 mg/kg IV, may repeat every min to max
      total dose of 1 mg
     Can precipitate seizures in patients with TCA overdose,
      chronic benzo use, seizure disorder, elevated ICP
NONPHARMACOLOGICAL APPROACHES
TO SEDATION
   Behavioral treatments
       Desensitization
       Relaxation
       Distraction
   Cognitive treatments
       Role playing
   Allowing family members to
    remain with the child
QUESTION #1
   If you were to give this
    child midazolam, what is
    his chance of having a
    paradoxical reaction:
    a. 1-15%
    b. 16-30%
    c. 31-45%
    d. >45%
QUESTION #2

   Which agent would be
    best to use with propofol
    for a painful procedure
    for this child?:
    a. fentanyl
    b. ketamine
    c. midazolam
    d. etomidate
QUESTION #3
 Which would likely
 cause this child greater
 respiratory depression
 in standard doses (best
 answer):
 a. methohexital 1-6%
 b. etomidate       Up to 10%

 c. propofol        Up to 30%

 d. ketamine        negligible
QUESTION #4
 Which agent would be
 preferred for sedation
 for CT for this child?
 a. ketamine
 b. midazolam
 c. pentobarbital
 d. fentanyl
QUESTION #5
   Which of the following
    agents (given alone)
    would you consider for a
    fracture reduction in this
    child:
    a. chloral hydrate
    b. methohexital
    c. ketamine
    d. etomidate
QUESTION #6
   What might be the best
    agent to reduce vomiting
    when given with ketamine
    in this child?
    a. propofol
    b. midazolam
    c. ondansetron
    d. metoclopramide
QUESTION #7
   If this child just ate 3 hours
    ago, how long should you
    wait before his procedural
    sedation?
    a. 1 hour
    b. 2 hours
    c. 3 hours
    d. Probably doesn’t matter

    (But current UIC guidelines and AAP
    recommendations suggest to wait 3
    more hours if feasible depending on
    the emergent need for the procedure)
QUESTION #8
   Which agent would likely
    enable you to more
    quickly discharge this
    patient from your ED
    after procedural
    sedation?
    a. pentobarbital
    b. midazolam
    c. ketamine
    d. propofol
QUESTION #9
   Which method of
    midazolam
    administration would
    provide better sedation
    for a laceration repair in
    this girl?
    a. IM
    b. PO
    c. PR
    d. IN
QUESTION #10
 Which agent would
 be least likely to
 induce vomiting in
 this child?
 a. ketamine
 b. propofol
 c. etomidate
 d. morphine
CONCLUSIONS
 NPO status probably doesn’t matter; preparation does
 IN and PR midazolam not as effective as other options
 Ketamine and etomidate can cause vomiting (propofol
  is an antiemetic)
 Midazolam/fentanyl, propofol, etomidate, chloral
  hydrate, barbiturates can all cause respiratory
  depression (ketamine and nitrous oxide generally do
  not)
 Etomidate and propofol have shorter recovery times
CONCLUSIONS

 PO options: choral hydrate, pentobarbital
 IM options: midazolam, methohexital, ketamine
 Treat pain: fentanyl, ketamine
 For shorter painful procedures:
     Consider propofol/fentanyl, etomidate/fentanyl, ketamine
 For   longer painful procedures:
     Consider midazolam/fentanyl, ketamine
 For   imaging only:
     Consider pentobarbital, methohexital, chloral hydrate,
      propofol, etomidate
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THANKS!!




           (Gabriel at 7 weeks)

								
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