1 Pediatric Sedation Desi Reddy ( MB ChB, FFA, FRCPC ) Department of Anesthesia McMaster University.
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Pediatric SedationPediatric Sedation
Desi Reddy (Desi Reddy (MB ChB, FFA, FRCPCMB ChB, FFA, FRCPC))
Department of AnesthesiaDepartment of Anesthesia
McMaster UniversityMcMaster University
STRUCTURESTRUCTURE
DefinitionDefinition
Pre-procedure PreparationPre-procedure Preparation
Monitoring and EquipmentMonitoring and Equipment
MedicationsMedications
Recovery and DischargeRecovery and Discharge
55
anxiolysisanxiolysis
analgesiaanalgesia
amnesiaamnesia
safetysafety
control behaviorcontrol behavior
return to baselinereturn to baseline
Sedation GoalsSedation Goals
66
ContinuumContinuum
minimally impaired consciousness to minimally impaired consciousness to complete unconsciousness complete unconsciousness
99
New SedationNew Sedation TerminologyTerminology
MinimalMinimal
ModerateModerate
DeepDeep
General anesthesiaGeneral anesthesia
Minimal SedationMinimal Sedation
ResponseResponse normal response to normal response to verbal stimulationverbal stimulation
AirwayAirway UnaffectedUnaffected
VentilationVentilation UnaffectedUnaffected
CV functionCV function UnaffectedUnaffected
Moderate SedationModerate Sedation
ResponseResponsePurposeful response Purposeful response
to verbal or tactile to verbal or tactile stimulationstimulation
AirwayAirway Intervention maybe Intervention maybe requiredrequired
VentilationVentilation AdequateAdequate
CV functionCV function Usually maintainedUsually maintained
Deep SedationDeep Sedation
ResponseResponsePurposeful response Purposeful response following repeated or following repeated or
painful stimulationpainful stimulation
AirwayAirway Intervention is Intervention is requiredrequired
VentilationVentilation May require supportMay require support
CV functionCV function Usually maintainedUsually maintained
General AnesthesiaGeneral Anesthesia
ResponseResponse Unarousable even to painful Unarousable even to painful stimulistimuli
AirwayAirway intervention requiredintervention required
VentilationVentilation frequently inadequatefrequently inadequate
CV FunctionCV Function maybe impairedmaybe impaired
ImplicationsImplications
Assume and prepare for Assume and prepare for Deep Deep SedationSedation
The level of vigilance = The level of vigilance = Maximal Maximal Appropriate Appropriate monitoringmonitoring equipmentequipment
and and personnelpersonnel
1717
mortality is very raremortality is very rare
morbidity is not uncommonmorbidity is not uncommon
Cote reviewed 95 adverse events Cote reviewed 95 adverse events • 51 deaths and 9 permanent neurological injuries51 deaths and 9 permanent neurological injuries
1818
CausesCauses
drug interaction 44drug interaction 44
overdose 34overdose 34
inadequate monitoring 27inadequate monitoring 27
inadequate CPR 19inadequate CPR 19
inadequate work-up 18inadequate work-up 18
premature discharge 11premature discharge 11
inadequate personnel 10inadequate personnel 10
1919
Drug CategoryDrug Category
opioid 22opioid 22
benzodiazepine 18benzodiazepine 18
barbiturate 19barbiturate 19
sedative 21sedative 21
chloral hydrate 13chloral hydrate 13
ketamine 1ketamine 1
2020
Route of AdministrationRoute of Administration
IntravenousIntravenous 6060
oral oral 3737
rectal rectal 99
nasal nasal 44
intramuscular intramuscular 3131
inhalation inhalation 1313
2121
Presenting EventPresenting Event
eventevent nnrespiratoryrespiratory 8080
cardiaccardiac 88
otherother 77
totaltotal 9595
Outcome vs MonitoringOutcome vs Monitoring
* P < 0.001 compared with pulse oximetry
Pediatrics 105:805-814, 2000
OutcomeOutcome OximeterOximeter(n=21)(n=21)
NoneNone(n=18)(n=18)
Death/InjuryDeath/Injury 44 **1414
No harmNo harm 1717 44
Causes of catastrophesCauses of catastrophes
Poor patient selectionPoor patient selectionDrug overdoseDrug overdoseLack of appreciation of drug Lack of appreciation of drug
interactions, pharmacokinetics and interactions, pharmacokinetics and dynamicsdynamics
Use of multiple medications to Use of multiple medications to sedate patientsedate patient
Lack of monitoring before, during, or Lack of monitoring before, during, or after procedureafter procedure
Inadequate CPR skills ’ failure to Inadequate CPR skills ’ failure to rescue’rescue’
ConclusionsConclusions
Most complications avoidableMost complications avoidable
Monitoring makes a differenceMonitoring makes a difference
Adverse events involved multiple drugsAdverse events involved multiple drugs
Children 1 to 6 years are at greatest Children 1 to 6 years are at greatest riskrisk
Need appropriate personnel skilled in Need appropriate personnel skilled in airway management and resuscitationairway management and resuscitation
2727
Factors Relating to ProcedureFactors Relating to Procedure
durationduration
painpain
positioningpositioning
anxiety/stress of procedureanxiety/stress of procedure
availability of rescue resourcesavailability of rescue resources
2828
Factors relating to PatientFactors relating to PatientPast experiencePast experience
AllergiesAllergies
Adverse reactionsAdverse reactions
Aspiration riskAspiration risk
URTIURTI
ASA classificationASA classification
Fasting GuidelinesFasting Guidelines
Fasting GuidelinesFasting Guidelines
Ingested materialIngested material Fasting period (hours)Fasting period (hours)
Clear liquids-Clear liquids-HH220,fruit 0,fruit
juices,clear tea,black juices,clear tea,black coffeecoffee
22
Breast milkBreast milk 44
Infant formulaInfant formula 66
Nonhuman milkNonhuman milk 66
Light mealLight meal 66
3030
General HealthGeneral Health
ASA 1ASA 1normal, healthy patientnormal, healthy patient
ASA 2ASA 2controlled medical condition without controlled medical condition without
significant systemic effectssignificant systemic effects
hypertension, DM, anemia, mild obesityhypertension, DM, anemia, mild obesity
3131
ASA ClassificationASA Classification
ASA 3ASA 3medical condition with significant effects medical condition with significant effects
and significant functional compromiseand significant functional compromise
Controlled CHF, stable angina, morbid Controlled CHF, stable angina, morbid obesity, chronic renal failureobesity, chronic renal failure
3232
ASA ClassificationASA Classification
ASA 4ASA 4poorly controlled medical condition, with poorly controlled medical condition, with
significant dysfunction and a potential threat significant dysfunction and a potential threat to lifeto life
unstable angina, symptomatic COPD, CHFunstable angina, symptomatic COPD, CHF
3333
ASA ClassificationASA Classification
ASA 5ASA 5critical medical condition associated with critical medical condition associated with
little chance of survivallittle chance of survival
multi-organ failure, sepsis syndromemulti-organ failure, sepsis syndrome
3535
Provider FactorsProvider Factors
dedicated sedation monitordedicated sedation monitor
skills related to depth of sedationskills related to depth of sedation
back-up systems and ability to Rescueback-up systems and ability to Rescue
3636
EquipmentEquipment
SOAP MESOAP ME• SSuctionuction
• OOxygenxygen
• AAirwayirway
PPharmacyharmacy
MMonitoringonitoring
EEquipmentquipment
3939
PharmacodynamicsPharmacodynamics
2 general groups2 general groupssedationsedation
analgesicsanalgesics
4040
PharmacokineticsPharmacokinetics
routerouteorally, intravenously, intramuscularly, intra-orally, intravenously, intramuscularly, intra-
nasally, rectallynasally, rectally
intravenousintravenoustitrate to effecttitrate to effect
combination of medications combination of medications
4141
PharmacokineticsPharmacokinetics
dose stackingdose stackingrepeated administration before peak effect repeated administration before peak effect
of previous dose reached.of previous dose reached.
synergismsynergismcombination of drugs increase risk of combination of drugs increase risk of
serious side effect, e.g.. benzodiazepine and serious side effect, e.g.. benzodiazepine and opiateopiate
4242
DrugsDrugs
sucrose pacifiersucrose pacifierreduced crying in neonates following heel reduced crying in neonates following heel
prickprick
should be used more frequently in infants should be used more frequently in infants undergoing brief painful proceduresundergoing brief painful procedures
4343
DrugsDrugs
Oral Chloral HydrateOral Chloral Hydrateused for painless procedures in kids for used for painless procedures in kids for
yearsyears
20 -75 mg/kg orally20 -75 mg/kg orally
bitter taste, not tolerated very wellbitter taste, not tolerated very well
peak effect up to 60 minutes with a half life peak effect up to 60 minutes with a half life of 4 - 9 hoursof 4 - 9 hours
4444
Chloral HydrateChloral Hydrate
prolonged sedationprolonged sedationneed prolonged supervision prior to need prolonged supervision prior to
dischargedischarge
advantage is lack of respiratory advantage is lack of respiratory depressiondepression
4646
Oral MidazolamOral Midazolam
short acting, water soluble short acting, water soluble benzodiazepinebenzodiazepine
no analgesic propertiesno analgesic properties
popular because of short duration, popular because of short duration, predictable onset, and lack of predictable onset, and lack of metabolitesmetabolites
get skeletal muscle relaxation, amnesia get skeletal muscle relaxation, amnesia and anxiolysisand anxiolysis
dose: 0.5 - 0.75 mg/kgdose: 0.5 - 0.75 mg/kg
4747
Oral MidazolamOral Midazolam
Recommended useRecommended use::sole agent for children who will drink liquid sole agent for children who will drink liquid
medication. medication.
anxiolysis and cooperation are excellentanxiolysis and cooperation are excellent
administer local anesthetic for painful administer local anesthetic for painful proceduresprocedures
4949
MidazolamMidazolam
rectal midazolamrectal midazolam0.3 - 0.7 mg/kg0.3 - 0.7 mg/kg
effect within 15 minuteseffect within 15 minutes
nasal midazolamnasal midazolam0.2 - 0.4 mg/kg0.2 - 0.4 mg/kg
onset 10 -15 minutes, burning onset 10 -15 minutes, burning sensation to mucosasensation to mucosa
5050
Intravenous MidazolamIntravenous Midazolam
dose: 0.05-0.1 mg/kg every 3-5 dose: 0.05-0.1 mg/kg every 3-5 minutes up to a max. of 0.7 mg/kgminutes up to a max. of 0.7 mg/kg
peak effect in 2-3 minutespeak effect in 2-3 minutes
synergistic reaction with opiates. synergistic reaction with opiates. Limit dose to 0.05 mg/kg. Severe Limit dose to 0.05 mg/kg. Severe respiratory depression.respiratory depression.
anterograde and retrograde (at anterograde and retrograde (at times) amnesiatimes) amnesia
5151
Intravenous MidazolamIntravenous Midazolam
Recommended Use:Recommended Use:excellent agent for sedation and anxiolysisexcellent agent for sedation and anxiolysis
provides complementary sedation with provides complementary sedation with opiates for painful proceduresopiates for painful procedures
caution with combinationcaution with combination
5353
PropofolPropofol
potent sedative and hypnoticpotent sedative and hypnotic
onset it very rapid. 60 - 90 secondsonset it very rapid. 60 - 90 seconds
induction of anesthesia at doses = 2-induction of anesthesia at doses = 2-3 mg/kg3 mg/kg
recovery rapid = 2-3 minutes recovery rapid = 2-3 minutes redistributionredistribution
prolonged sedation and vomiting is prolonged sedation and vomiting is very lowvery low
disadvantage is pain on injectiondisadvantage is pain on injection
5454
PropofolPropofol
Recommended use:Recommended use:ideal agent for brief periods of deep ideal agent for brief periods of deep
sedationsedation
minimal adverse effects and rapid minimal adverse effects and rapid awakening are uniqueawakening are unique
get rapid induction of anesthesia and get rapid induction of anesthesia and hence should only be used by hence should only be used by anesthesia personnel or intensivistsanesthesia personnel or intensivists
5555
FentanylFentanyl
potent synthetic opioid (100 x Morphine)potent synthetic opioid (100 x Morphine)
peak effect= 5 min and lasts for 30 - 40 peak effect= 5 min and lasts for 30 - 40 min.min.
respiratory depressant effect is much respiratory depressant effect is much longer (4 hrs) than analgesic effectlonger (4 hrs) than analgesic effect
Dose: 0.5 - 1.0 mcg/kg up to 5 mcg/kgDose: 0.5 - 1.0 mcg/kg up to 5 mcg/kg
5656
FentanylFentanyl
minimal hemodynamic effectsminimal hemodynamic effects
reversible with Naloxonereversible with Naloxone
Recommended use:Recommended use:excellent analgesia and mild sedation with excellent analgesia and mild sedation with
short duration of action. Careful respiratory short duration of action. Careful respiratory monitoring when combined with other monitoring when combined with other sedativessedatives
5858
KetamineKetamine
produces intense analgesia, sedation produces intense analgesia, sedation and amnestic qualitiesand amnestic qualities
Oral dose: 5-6 mg/kg Oral dose: 5-6 mg/kg
IV dose :1 - 2 mg/kgIV dose :1 - 2 mg/kg
IM dose: 2 - 5 mg /kgIM dose: 2 - 5 mg /kg
5959
KetamineKetamine
less pronounced respiratory depressionless pronounced respiratory depression
airway protective reflexes usually intactairway protective reflexes usually intact
side effectsside effectsexcessive salivation and airway secretionsexcessive salivation and airway secretions
emergence dysphoriaemergence dysphoria
6161
OxygenOxygen DeliveryDelivery
nasal cannulanasal cannulaprovides up to 44% oxygenprovides up to 44% oxygen
inspired oxygen depends on flow rateinspired oxygen depends on flow rate
each liter of flow-increases FiO2 by 4%each liter of flow-increases FiO2 by 4%
usual settings= 1-4 lusual settings= 1-4 l
6262
OxygenOxygen DeliveryDelivery
simple face maskssimple face masksprovides up to 60% oxygenprovides up to 60% oxygen
flow rate set between 6-10 lflow rate set between 6-10 l
liter flow must be > 6 l to prevent CO2 liter flow must be > 6 l to prevent CO2 accumulationaccumulation
non rebreather masknon rebreather mask - provide 60-90% - provide 60-90% oxygen at flows of 10-12 l\minoxygen at flows of 10-12 l\min
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