Pediatric Sedation Lecture
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This document summarizes a presentation on updates to pediatric sedation guidelines. It reviews current sedation guidelines, risks and safety data, and common and uncommon sedation medications. Safety data from studies on sedation with propofol and dexmedetomidine are presented. New evidence and paradigms around who can provide sedation and credentialing requirements are discussed. The talk concludes that pediatric sedation is a dynamic field still lacking rigorous standards and oversight.
Pediatric Sedation Lecture
- 1. 1 Update in Pediatric Sedation Corey E Collins DO FAAP Director, Pediatric Anesthesiology MEEI Boston MA corey_collins@meei.harvard.edu1
- 2. 2 Corey Collins, DO FAAP 2012 Conflict of Interest • Nothing to Declare Objectives At 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
- 3. 3 Corey Collins, DO FAAP 2012 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
- 4. 4 Corey Collins, DO FAAP 2012
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- 6. 6 Corey Collins, DO FAAP 2012 Sedation Guidelines
- 7. 7 Corey Collins, DO FAAP 2012 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
- 8. 8 Corey Collins, DO FAAP 2012 New Paradigm for Sedation Continuum?? Risk Based? Specific, Derived Physiological Thresholds Define Required Training
- 9. 9 Corey Collins, DO FAAP 2012 World society of intravenous anesthesia: 10 specialties, 11 countries Sentinel AE Moderate AE Minor AE Minor AE Minor AE
- 10. 10 Corey Collins, DO FAAP 2012
- 11. 11 Corey Collins, DO FAAP 2012 26 Institutions 30 037 sedation cases 7/04-11/05 no deaths, CPR in one case SpO2<90% >30s: 157/ 10 000 Laryngospasm: 4.3/10 000 Apnea: 24/ 10 000
- 12. 12 Corey Collins, DO FAAP 2012 What is “NPO” for sedation?
- 13. 13 Corey Collins, DO FAAP 2012 What is “NPO” for sedation in the ED?
- 14. 14 Corey Collins, DO FAAP 2012 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....
- 15. 15 Corey Collins, DO FAAP 2012 Who is giving Pediatric Sedation?
- 16. 16 Corey Collins, DO FAAP 2012 What meds are being used?
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- 20. 20 Corey Collins, DO FAAP 2012 49 836 Propofol Sedations @ 37 sites 1:65 rate of Adverse Airway events 1:70 required Airway interventions CPR x 2 Aspirations x4 SpO2< 90 x 30s: 154/ 10k Laryngospasm: 96/ 10k
- 21. 21 Corey Collins, DO FAAP 2012 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)
- 22. 22 Corey Collins, DO FAAP 2012 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
- 23. 23 Corey Collins, DO FAAP 2012 Conclusions from PSRC • Suggestions for Credentialing Clinicians • Propofol seems OK for Non- anesthesiologists • NPO guidelines are Inconsistent
- 24. 24 Corey Collins, DO FAAP 2012 • 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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- 26. 26 Corey Collins, DO FAAP 2012 Impact of Provider Specialty on Pediatric Procedural Sedation Complication Rates Couloures et al. Pediatrics 2011; 127(5): e1154-60 Couloures 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
- 27. 27 Corey Collins, DO FAAP 2012 Impact of Provider Specialty on Pediatric Procedural Sedation Complication Rates Couloures et al. Pediatrics 2011; 127(5): e1154-60 Couloures et al. Pediatrics 2011; 127(5): e1154-60
- 28. 28 Corey Collins, DO FAAP 2012 -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?
- 29. 29 Corey Collins, DO FAAP 2012
- 30. 30 Corey Collins, DO FAAP 2012 279 kids 0.2-17.2y 100% success Dexmedetomidine bolus technique: 3 ug/kg over10” repeated PRN 16% needed second bolus; 0.7% needed third bolus Hypotension: 33% Bradycardia 5% Hypertension 3.2% Mean sedation time: 7.8” +/- 3.8” (0-30” range)
- 31. 31 Corey Collins, DO FAAP 2012
- 32. 32 Corey Collins, DO FAAP 2012 • 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
- 33. 33 Corey Collins, DO FAAP 2012 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 reductions Ket+Propofol: Shorter Sedation (13” vs. 16”), less nausea Propofol 0.75mg/kg vs. Propofol 0.375mg/kg + Ketamine 0.375mg/kg 282 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
- 34. 34 Corey Collins, DO FAAP 2012 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 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 Seith, R et al. Acad Emerg Med 2012;19: 31-6
- 35. 35 Corey Collins, DO FAAP 2012 65 kids 3-74mo 10” infusion 0.5mg/kg 96% success 22” induction, 72” sleep 104” discharge 12 met “deep sedation” score No Complications Pedi Radiol 2012 Jan13 epub ahead of print
- 36. 36 Corey Collins, DO FAAP 2012 Conclusions? • Dynamic Field, Shifting Delivery Models • Large Safety Data sets remain Incomplete • Minimal Rigorous Standards • “Professionalization” • Oversight, Credentialing, Quality....
- 37. 37 Corey Collins, DO FAAP 2012 RESOURCES • www.pedsedation.org (Pedi Sedation Society) • www.aapd.org/media/Policies_Guidelines/G _sedation.pdf (Amer Acad Pedi Dentistry Guidelines 2006)
- 38. 38 Corey Collins, DO FAAP 2012 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
Editor's Notes
- #10: 3 catagories. Sentinel: Desats or apnea arrest requiring CPR, ETT, paralytic, vasopressors Moderate: less severe desats, transient apnea or obstruction, failed sedation, allergy, tachy/ brady cardia, hyper/hypo tension treated with BMV, LMA, OPA/ NPA insertion; CPAP, reversal administration, rapid IVF, antiseizure meds Minor: vomit retching, subclinical resp depression, saliorrhea, paradoxical rxn, prolonged recovery. Treated by Higher FiO2, tactile stimulation, airway repositioning, antisialogogue