Paediatric Procedural Sedation

PEDIATRIC PROCEDURAL SEDATION

SAQIB RANA14/01/16

INDICATIONS

• CT or MRI• Fracture reduction• Complex laceration repair• Lumbar puncture• Abscess incision and drainage• Instrumentation (e.g. endoscopy and bronchoscopy)• Burns dressing change• Chest tube placement• Central line placement

CONTRAINDICATIONS

• NO ABSOLUTE CONTRAINDICATIONS

• SIGNS OF DIFFICULT AIRWAY• SIGNIFICANT MEDICAL COMORBIDITIES (ASA III OR HIGHER)

SCORING SYSTEMSUNIVERSITY OF MICHIGAN SEDATION SCORE

INFORMED CONSENT

• PROPOSED BENEFITS• POSSIBLE RISKS

PREPARATION

• FASTING STATUS• FOCUSSED MEDICAL EXAMINATION• ASSESSSMENT OF AIRWAY• ASA CLASSIFICATION• PROCEDURAL SEDATION HISTORY• FAMILY ANAESTHETIC HISTORY• PRE PROCEDURE MEDICATIONS• HEIGHT• WEIGHT

MONITORING

• INITIAL AND REPEATED VITAL SIGNS MEASUREMENT• END TIDAL CO2 MONITORING• VISUAL OBSERVATION OF FACE, MOUTH AND CHEST WALL

NON PHARMACOLOGICAL INTERVENTIONS

• DESENSITIZATION• DISTRACTION TECHNIQUES• POSITIVE REINFORCEMENT• RELAXATION TECHNIQUES

PHARMACOLOGICAL

• KETAMINE• PROPOFOL• DEXMEDETOMIDINE• ETOMIDATE• MIDAZOLAM• BARBITURATES• NITROUS OXIDE• TOPICAL, LOCAL AND REGIONAL ANAESTHETICS

KETAMINE

• PCP derivative• Binds NMDA receptors• No “sedation continuum”• Initial IV dose 1-1.5mg/kg, repeat dose of 0.5-1mg/kg after 10 min

as needed• Initial IM dose of 4-5mg/kg, repeat dose of 2-4mg/kg after 10 min as

needed• Onset 1-2 minutes• Duration of action 15-30 minutes

KETAMINEADVERSE REACTIONS

• VOMITING• EMERGENCE REACTION (RECOVERY AGITATION, DREAMS, HALLUCI-

NATIONS AND DEPERSONALIZATION). Less common in children than in adults(7.6% vs 20%)

• LARYNGOSPASM AND APNEA (MORE COMMON WITH IM)

KETAMINECONTRA-INDICATIONS

RELATIVE• Age younger than 12 months• Active pulmonary infections• Non communicating hydrocephalus (not raised ICP)• Increases intra ocular pressure• Porphyria• Thyroid disease

ABSOLUTE• Age younger than 3 months• Known or suspected psychosis

PROPOFOL

• Provides sedation but NO analgesia• 0.5-3mg/kg induction dose, halve the induction dose for top up dos-

ing• Onset <_ 0.5 minutes• Duration 5-15 minutes after single bolus dose, longer after infusions

or repeat dose

PROPOFOLADVERSE REACTIONS

• Peripheral injection site pain• Respiratory depression• Apnea• Hypotension• Deep sedation

PROPOFOLCONTRAINDICATIONS

• EGG OR SOY ALLERGY• PORPHYRIAS

KETOFOL

• Mixture of Ketamine/Propofol in 1:1 ratio• Medial dose of 0.75mg/kg of each drug (range 0.2-2.0) shown to be

safe• Fentanyl can be used as adjunct analgesia

NITROUS OXIDE

• ENTONOX (50% N2O AND 50%O2) usually delivered by demand valve system

• Limits use in younger or uncooperative patients• Oxygen should be administered after 3-5 minutes to prevent diffu-

sion hypoxia• Minor adverse effects include nausea, vomiting and dysphoria• Contraindications include nausea, vomiting, trapped gas within

body cavities (e.g. bowel obstruction, pneumothorax, middle ear in-fection) and pregnancy (increases risk of spontaneous abortion)

LOCAL AND TOPICAL ANAES-THETIC AGENTS

• EMLA• 2.5% Lidocaine and 2.5% Prilocaine• Long onset to peak effect (atleast one hour)• Vasoconstrcition effects may make cannulation difficult• Theoretical risk of methemoglobinemia• Not recommended in infants less than 3 months of age

LOCAL AND TOPICAL ANAES-THETIC AGENTS

• AMETHOCAINE

• AnGel (4% Amethocaine)• Quicker onset of action (30-45 minutes)• Vasodilating effects facilitate cannulation

LOCAL AND TOPICAL ANAES-THETIC AGENTS

• LACERAINE

• Laceraine (Adrenaline 1:1000, Lidocaine 4%, Tetracaine 0.5%)• Instilled in wound for 20-30 minutes provides sufficient anaesthesia

ORAL SUCROSE

• Provides analgesia for young infants up to 2 months of age• Stimulates endogenous opioid and non opioid pathways in brain • 2ml may be administered by oral syringe or on a pacifier

DISCHARGE CRITERIA

• Normal age-specific vital signs• Regained presedation conscious state and communication skills• Able to tolerate oral foods or fluids• Post-procedure analgesia is satisfactory