Pediatric sedation
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This document discusses pediatric procedural sedation. It covers preparation, medications commonly used for sedation including midazolam, fentanyl, ketamine and propofol, monitoring during sedation, and techniques to aid in safe and effective sedation like pre-oxygenation and use of adjuncts with ketamine. The right agent is chosen based on the procedure and patient needs, aiming for a level of sedation allowing the procedure while maintaining safety. Close monitoring both during and after is emphasized.
Pediatric sedation
- 1. Pediatric Procedural Sedation Ramin Nazari MD Pediatric Critical Care Fellow St. Christopher Hospital for Children July 2012
- 2. Learning Objectives Preparation “Tools for sedation of the Trade” Sedation medications that you should know well and be familiar with “The Right Tool for the Job” Discuss the variable needs for procedural sedation “Tricks of the Trade” Some adjuncts and techniques that will make your job easier Monitoring
- 3. You are preparing to sedate a 5-year-old girl for bone marrow aspiration. The child has suspected acute lymphoblastic leukemia. What information do you need to develop a safe plan for sedation of this child? Does this patient need sedation, analgesia, or both? What agents can you use to achieve your goals safely? What monitoring does this child require before, during, and after the procedure?
- 4. Importance Studies have shown that children are less likely than adults to receive pain medications and sedation for similar painful procedures ◦ Children cannot fully understand the medical necessity for testing or therapeutics ◦ Children’s anxiety can heighten the discomfort ◦ Allows for control of behavior for the safe and successful completion of a procedure ◦ Parental, patient and physician satisfaction
- 5. Sedation vs. Analgesia Sedation reduces the state of awareness. Many sedatives produce amnesia(Benzodiazepines, barbiturates) Sedative agents have no analgesic effects Analgesia reduces or eliminates the perception of pain and most have sedative effects. Narcotics are primarily analgesics ◦ Morphine ◦ Fentanyl
- 7. History AMPLE ◦ Allergies ◦ Medications ◦ Past history (focus on airway/cardiopulmonary reserve) ◦ Last meals ◦ Events (leading to the sedation)
- 8. Physical Exam Airway Risk of airway obstruction ◦ Large tongue ◦ Micrognathia (small lower jaw) ◦ Limited airway opening (Mallampati score) ◦ Severe obesity ◦ Excessive secretions ◦ Snoring ◦ Decreased airway protective reflexes
- 9. The Mallampati score The Mallampati score
- 10. Physical Exam Breathing ◦ Evaluate breath sounds ◦ Work of breathing to ensure respiratory status is not compromised ◦ Baseline oxygen saturation by pulse oximetry. Circulation ◦ Baseline heart rate ◦ Heart sounds ◦ Distal perfusion (skin temperature, color, and capillary refill.) Examine other organ systems if the patient’s history suggests potential problems
- 11. Fasting for sedation Clear Liquids Breast Milk Formula/Light Solids Solid food 2 Hours 4 Hours 6 Hours 8 Hours
- 12. Sedation Spectrum Minimal Sedation ◦ Patient responds appropriately to verbal commands ◦ Cognitive processing affected but no cardiopulmonary effects Moderate Sedation ◦ Patient responds to verbal commands or with addition of mild stimulus ◦ Maintains airway and ventilation without required intervention Deep Sedation ◦ Not easily aroused but responds purposefully with uncomfortable stimulus ◦ May require medical intervention to maintain an airway and ventilation General Anesthesia ◦ Unable to be aroused with a verbal or painful stimulus ◦ Need help maintaining their airway
- 13. Indications for Pediatric Procedural Sedation Diagnostic ◦ Urinary Catheterization ◦ Lumbar puncture ◦ Radiographic evaluation (CT or MRI) ◦ Joint aspiration ◦ Sexual assault examinations ◦ Eye examinations ◦ BM aspiration,biopsy ◦ Vascular access Therapeutic ◦ ◦ ◦ ◦ ◦ ◦ ◦ IV starts Laceration repair Abscess I+D Fracture Reductions Dislocations reduction Foreign body removal Burn dressings
- 14. The Search Continues… The ideal sedation protocol: 1) Rapid induction and emergence 2) Provides anxiolysis, analgesia and amnesia 3) Sufficient control of movement to allow for ease of procedural completion 4) Maintain effective spontaneous ventilation and airway control 5) Complete Cardiopulmonary stability throughout 6) Minimal to no side effects
- 15. “Tools of the Trade”
- 16. Midazolam Short-acting agent with rapid onset of anxiolysis, sedative and amnestic properties ◦ Interacts with GABA receptors in the brain Dosage ◦ ◦ ◦ ◦ 0.2-0.6mg/kg intranasally 0.05-0.2mg/kg IV 0.1-0.2mg/kg IM 0.5-0.75mg/kg PO Advantages ◦ ◦ ◦ ◦ Rapid onset Anxiolysis Profound retrograde amnesia No IV required Disadvantages ◦ Does not provide analgesia ◦ Disturbance in respiratory function +/- hypoxemia ◦ Paradoxical reactions
- 17. Fentanyl Synthetic opiod which is narcotic of choice in PSA ◦ Rapid onset and short duration make it easy to titrate ◦ Does not cause histamine release so minimal CV effects Dosage ◦ 1-3mcg/kg IM or IV ◦ 10-20mcg/kg oral or transmucosal Advantages ◦ Excellent analgesic ◦ Peak effect within 15-30mins ◦ Reversible with Naloxone Disadvantages ◦ ◦ ◦ ◦ ◦ Nausea and vomiting Respiratory depression Hypotension No amnesia. Minimal sedation Fentanyl Rigid Chest
- 18. Fentanyl Rigid Chest Believed to be due to a central agonist effect of narcotics The pediatric population is more vulnerable to the syndrome ◦ Reported with doses from 2.5-6.5mcg/kg ◦ Fast injection should be avoided Treatment: Rapid neuromuscular blocking medication
- 19. Ketamine Dissociative agent ◦ Sedation, analgesia and amnesia are maintained ◦ Inhibits reuptake of catecholamines ◦ Stimulates salivary, tracheal and bronchial secretions Dosage ◦ 1-2mg/kg IV ◦ 2-5mg/kg IM ◦ 6-10mg/kg PO Advantages ◦ Reliably produces potent analgesia, sedation and amnesia ◦ Hemodynamic stability ◦ Maintain airway reflexes Disadvantages ◦ ◦ ◦ ◦ Emergence phenomenon Nausea and Vomiting Increased secretions Potentially serious respiratory complications
- 20. Propofol Potent hypnotic agent with no analgesic properties ◦ Effects lipid membrane Na-channel function and Stimulates GABA ◦ Rapid onset, redistribution and elimination Dosage ◦ 1-2mg/kg IV bolus then 50-200mcg/kg/ min Advantages ◦ ◦ ◦ ◦ Rapid onset/offset Easily titratable Anti-emetic Bronchodilator Disadvantages ◦ No analgesic properties ◦ Potent cardiopulmonary depressant ◦ Pain on injection ◦ Inadvertent oversedation
- 22. Propofol Infusion Syndrome Many case reports of fatalities ◦ High and escalating doses of propofol infusions ◦ Severe metabolic acidosis, lipidemia, rhabdo and refractory heart failure Associated with long-term infusions >48hrs in children <4yo Thought to be related to a mitochondrial defect Not an issue for brief ED sedation
- 23. Dexmedetomidine(Precedex) α2-adrenergic agonist with Advantages mild analgesic properties ◦ Minimal respiratory ◦ Similar to Clonidine but 8 X depression more selective for α2 ◦ Analgesic sparing ◦ Act on Locus Ceruleus in ◦ Induce less delirium the brain stem ◦ No need to stop for ◦ Decrease release of NE extubation from nerve terminals Dosage Disadvantages ICU sedation ◦ No adequate & reliable ◦ Load: 1 mcg/kg IV over 10 amnesia minutes ◦ Hypotension (24-54%) ◦ Maintenance: 0.5-0.1 ◦ Bradycardia (5-14%) mcg/kg/hr IV ◦ Hyperglycemia ◦ ◦ Atrial Fibrilation
- 24. Pentobarbital Short acting barbiturate Sedative and hypnotic Adjuvants, Anesthesia Suppression of glutamatergic neurotransmission Dose: ◦ IV: Initial 1 to 2 mg/kg ◦ Additional doses of 1 to 2 mg/kg every 3 to 5 minutes ◦ IV Maximum dose: 100 mg/dose Advantages ◦ Short acting ◦ Sedative and hypnotic ◦ Decrease brain oxygen consumption and ICP Disadvantages ◦ No anti-anxiety effect ◦ No analgesic properties ◦ Half life: 5-50Hours(dose dependent) ◦ Bradycardia and hypotension ◦ weak or shallow breathing
- 25. Etomidate Initially described for RSI in peds Rapid onset of sedation, brief half-life, short recovery period and minimal effects on cardiopulmonary systems Adverse effects ◦ ◦ ◦ ◦ Potential for adrenal suppression Pain at injection site Myoclonus Quickly and easily induce deep sedation and/or general anesthesia.
- 26. “The Right Tool for the Job”
- 27. The Right tool for the Job ♀ presents with 4day hx of fever, vomiting and flank pain PMHX – Healthy Temp 38.5, HR 121, RR 16, BP 84/56, Sat 98% RA Not toilet trained Wanting to do an in/out cath 28mth Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Minimal Sedation
- 28. The Right tool for the Job Nitrous Oxide ♂ fell onto wooden post Midazolam Extensive and complex facial Fentanyl laceration requiring multilayer Ketamine closure Propofol PMHX – Asthma well Sedation controlled Spectrum: VSSA Deep sedtion 5yo
- 29. The Right tool for the Job ♂ playing soccer and collided with another player Immediate pain to R shoulder which is clinically consistent with anterior dislocation Very Anxious!!! PMHX – Healthy Normal Vital signs 15yo Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Moderate Sedation
- 30. The Right tool for the Job ♀ presents with patellar dislocation while playing softball Knee in “spasm” and patient extremely anxious with any attempts to examine or maneuver same PMHx – Healthy VSSA 7yo Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Minimal Sedation
- 31. The Right tool for the Job ♂ fell off the bed and refusing to walk Xray shows a displaced spiral tibial fracture PMHx – seizure disorder well controlled VSSA 3yo Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Deep Sedation
- 32. “Tricks of the Trade”
- 33. Ondansetron with Ketamine Sedation Vomiting in the ED and upon discharge after Ketamine sedation is common ◦ Reported frequency of vomiting ranges from 419% Increased vomiting associated with increasing patient age Vomiting ◦ Decreases patient and parental satisfaction ◦ Delays discharge and consumes ED resources
- 34. Pre-oxygenation with procedural sedation Published adverse event rates during pediatric ED procedural sedation vary between 2% and 18% Consistently the most common adverse event is transient hypoxia Children’s basal oxygen use/kg is twice that of adults Smaller FRC Shorter “safe apnea” period before desaturation Transient hypoxia is predictably seen with propofol Very common with Midazolam and Fentanyl Less likely with Ketamine unless co-administration with other resp depressants
- 35. Adjunctive Atropine with Ketamine Sedation Ketamine stimulates oral secretions ◦ In rare circumstances this has been implicated in airway compromise1 Historically prophylactic anticholinergic agents have been given with ketamine to blunt hypersalivation Glycopyrrolate 0.2mg Atropine 0.02mg/kg
- 36. Adjunctive Atropine with Ketamine Sedation Omission of atropine is safe Routine prophylaxis is unnecessary There is minimal added risk presented with its administration Possible subsets of patients which may benefit Very young children Those undergoing oropharyngeal procedures
- 37. Monitoring & equipment Traditional monitoring ◦ Pulse oximetry = oxygenation ◦ RR and clinical observation = ventilation ◦ EKG monitoring ◦ BP Capnography ◦ More precise and direct assessment of the patient’s ventilatory status ◦ Assessment of airway patency and respiratory pattern ◦ Early warning system for prehypoxic respiratory depression Emergency code cart in immediate vicinity. Oxygen delivery system including ventilation bag, appropriate sized masks, oxygen, wall suction equipment.
Editor's Notes
- #12: In general, a patient should not undergo elective sedation for a procedure within six hours of eating solid foods or drinking milk. The above guidelines are recommended to allow gastric emptying prior to the procedure. Patient’s with known gastro-esophageal reflux, esophageal dysmotility, impaired or delayed gastric emptying (i.e., diabetics) or known of suspected airway problems may require a longer period of pre-procedure fasting in order to minimize risks of aspiration of gastric contents and may benefit from appropriate pharmacological treatment to reduce gastric volume and increase gastric pH.
- #13: Dissociative Sedation : Trance like state in which significant analgesia and amnesia is achieved while the patient maintains protective airway reflexes, spontaneous respiratory drive and cardiovascular stability. In all but GA the cardiopulmonary function should be maintained Minimal sedation is equivalent to anxiolysis
- #16: Like a mechanic, any job is going to be far more difficult unless you have the right tool to do the right job. Trying to fix a car with an adjustable wrench is going to be frustrating and difficult if not impossible So what are the pharmaceutical tools available to and the advantages and disadvantages of each….
- #17: Disturbance in respiratory function and hypoxemia observed in 5% in one study Intranasal midaz is preferred to oral as bioavailability is 55% compared to 15% and onset and recovery are more rapid with no need to swallow or hold bitter preparations in their mouth Uses: in combination with midazolam for moderate sedation or on it’s own for anxiolysis. Simple lacerations, urine catheterization,
- #18: Uses: Not indicated alone for procedural sedation. Used in combination with other medications that do not have analgesic properties
- #20: -Dissociation between the Thalamoneocortical and limbic systems preventing the higher centers from perceiving visual, auditory or painful stimuli -Inhibition of re-uptake of catecholamines = mild-mod increase in blood pressure, HR and CO -Potentially serious respiratory complications include: laryngospasm, apnea, respiratory depression. Incidence = 5%(particulary in combination with other resp depressants) -Benzodiazepines can be used for emergency phenomenon but they suppress ketamine metabolism through competition for degradation enzymes in the liver and may prolong the ketamine recovery time Uses: Go to drug for painful procedures in the younger pediatric population
- #21: -Very smooth recovery profile -Pain on injection can be relieved with 0.1cc of 1% injected IV prior to administration of propfol Depth of sedation approaching general anesthesia transiently is reported in up to 90% of patients
- #25: Pentobarbital binds at a distinct binding site associated with a Cl- ionopore at the GABAA receptor, increasing the duration of time for which the Cl- ionopore is open. The post-synaptic inhibitory effect of GABA in the thalamus is, therefore, prolonged. All of these effects are associated with marked decreases in GABA-sensitive neuronal calcium conductance (gCa). The net result of barbiturate action is acute potentiation of inhibitory GABAergic tone. Barbiturates also act through potent (if less well characterized) and direct inhibition of excitatory AMPA-type glutamate receptors, resulting in a profound suppression of glutamatergic neurotransmission.
- #26: Pediatric PSA dosing = 0.2mg/kg + 1ug/kg fentanyl
- #34: Age >5yo
- #35: Pay attention to other reason of hypoxia that could be relieved only by position correction and suctioning Propofol significant desaturation (Sat <88%) was 12% without pre-oxygenation and 2% with preoxygenation
- #36: The only RCT on this subject showed less hypersalivation but was not powered to show differences in adverse effects from this
- #38: Preoxygenation and supplemental O2 administration further limits the utility of pulse oximetry as an early warning system for resp compromise