Pediatric Sedation Cindy Sanders, RN, MSN November 1, 2008.

Pediatric SedationPediatric SedationPediatric SedationPediatric Sedation

Cindy Sanders, RN, MSNCindy Sanders, RN, MSNNovember 1, 2008November 1, 2008

Kids are different• Goals for sedation to control behavior to allow

procedure to be completed successfully• Kids under age 5 or 6 (chronologically or

developmentally) may require deep sedation• Anatomical and physiological differences must

be considered• May be more vulnerable to respiratory

depression and may pass into deeper sedation state than was intended

“Rules” are the same• American Academy of Pediatrics,

(AAP) American Society of Anesthesiologists, (ASA) American Academy of Pediatric Dentists (AAPD) and Joint commission on Accrediation of Healthcare Organizations (JCAHO) issued guidelines for pediatric sedation

Safe sedation requirements

– Systematic approach – No administration of sedation with safety

net– Careful focused pre-sedation assessment– Appropriate NPO– Focused airway exam– Clear understanding of meds, interactions,

etc.

Goals of Pediatric Sedation

• Guard Patient safety• Minimize discomfort and pain• Control anxiety, minimize psychological

trauma, maximize amnesia• Control behavior to allow successful

completion of exam• Return patient to a state in which safe

discharge is possible

Who is an infant/ child?• AAP: birth to 21 years• PALS: infant to age 1, child 1yr to

puberty• Some institutions: to age 18

• Chronologic vs. developmental age

The Sedation Continuum

Moderate/conscious

Deep

Mild/conscious/anxiolysis

The sedation continuum

• Must be able to “rescue” patient from next level

• Failure to rescue may be more common in non hospital setting

• Conscious sedation may be an oxymoron for the young peds patient

Regardless of the medication given, the route of administration or the intended level of sedation, the sedation of a pediatric patient may result in respiratory depression and loss of airway protective reflexes

Candidates for pediatric sedation

• ASA class I and II generally good candidates

• ASA II and IV-require consideration, consultation with anesthesia, etc

• Pediatric specific considerations must be evaluated

Peds specific risks• Untreated severe GERD (Gastro-

esophageal reflux disease)• Recent apnea monitor/history• Congenital airway anomalies such

as macroglossia, micronathia, etc.• Extreme Tonsillar hypertrophy• Mitochondrial or metabolic disease

Sedation history• Prior sedation history• Medication history/allergies• Significant medical history• Does patient snore• Recent cold, asthma, etc.• NPO status• NPO status• Parent/guardian accompanying child

NPO guidelines• Elective procedures require fasting

guidelines• Risk of aspiration less than with general

anesthesia but absolute risk not known• Generally same guidelines as for general

anesthesia are followed• Solids 6-8 hours, breast milk (considered

semi-solid by some and clear by others-2-4 hours, clears 2 hours

Fluid status• Some patients will have been NPO for 12

or more hours.• May give pre-sedation bolus of 20cc/kg

of isotonic solution like Normal saline• This may decrease the risk of

hypotension and hemodynamic compromise

• May want to leave IV in at procedure end till patient awakens and drinks.

Pre sedation assessment

• Vital signs including heart rate, respirations, b/p, temperature

• Pulse oximetry reading• If using ETCO2 monitoring,

baseline reading• Accurate weight

Pre sedation assessment

• Focused physical exam including respiratory and cardiac rate rhythm and quality

• Renal or hepatic function ok?

• Ability of child to cooperate-is non sedation an option?

• Any contraindications to procedure (MRI, etc)

Pre sedation• Informed consent• Time out

procedure

IV access• Use of topical analgesia if possible

– EMLA, LMX, Synera (>3 years)-use care to follow age and duration guidelines

– New product on market called Zingo (>3 as well) being trialed at several pediatric institutions

• Take time to find best site• Secure well!• Consider contrast requirements if CT

Personnel and equipment

• Must have pediatric specific emergency equipment immediately available

• Sedation providers must be trained in he administration of sedation medications and the management of complications associated with these medications

• Must have skills necessary to rescue patient from next level of sedation

RN requirements• Institution specific but minimal

requirements include• BLS and PALS certifications• “Additional” competency based

training in sedation medications, procedural requirements and rescue skills that is ongoing

AZ State board of Nursing

• Employers must identify medication allowed for conscious sedation

• Licensed provider must be present in the dept from the time the medication is initiated to the completion of the procedure and must be readily available in the facility to assume care of the patient during the post-procedure period

AZ Board of Nursing• Registered nurse responsible must not

“leave patient unattended or engage in other tasks that compromise continuous monitoring”

• Specific list of educational requirements for RNs who administer sedation.

• Advisory opinion Conscious sedation for Diagnostic and Therapeutic Proceduresrevised 5/08.

Monitoring Intraprocedure

• Continuous monitoring of heart rate and pulse oximetry and intermittent recording of respiratory rate and blood pressure

• Standard is within 5 minutes prior to sedation and every 5 minutes till procedure is complete

• Post procedure-vital signs at regular intervals (most often q 15 minutes)

End Tidal CO2• Anesthesia literature validate rapid

response in respiratory depression/hypoventilation

• Most guidelines recommend or state should be immediately available for moderate and esp. deep sedation

• In areas where can’t see patient (MRI) has become more of a standard of care

General pediatric medication

considerations• Dose must be individualized and double

checked• Give small increments and wait for effect• Expect variations in responses• Be prepared to assist respirations, etc.• Remember to consider other

medications and combinations

Pediatric sedatives• Standard pre-printed orders may

decrease potential for error in dosages

• Special care with route

Sedation medications• Goal:• Use the lowest dose of the medication

with the highest therapeutic index for the procedure

• Perfect drug: Causes no respiratory or cardiovascular compromise, effects last the exact length of the procedure and has no contraindications

Real medication choices

• Chloral hydrate• Benzodiazepines• Opiates • Barbiturates• Anesthetic agents• Dexmedetomidine

Chloral hydrate• Has been used for more than 100 years• Classified as a sedative/hypnotic• No analgesic properties• May be given orally or rectally• Sometimes referred to as “not really a

sedative” and therefore outside of the guidelines in any given institution

Chloral Hydrate• Doses range from 25-125mg/kg-most

common is 50mg/kg• Single dose max of 1000mg reported• Onset of action is very variable

ranging from 10-60 minutes• Long sedation has been reported• Premature discharge has led to death

Chloral Hydrate• Hepatic accumulation of metabolites

reported in premature infants• Unpleasant taste, nausea and vomiting

common• Many studies citing other drugs as

more efficient• Some data supporting increased

success if patient under 2 years.• No reversal agent

Benzodiazepines• Has sedative, anti -anxiety and

amnesic properties• No analgesic properties• Commonly used as pre-med• Often not able to provide adequate

sedation for procedures that require immobility as a single agent

• Versed most commonly used agent

Versed (Midazolam)• May be given in a variety of ways• Doses:

– IV 0.05-0.1mg/kg– Oral 0.5-0.7 mg/kg– Rectal 0.5-1.0 mg/kg– Nasal 0.2-0.4 mg/kg– Sublingual 0.2mg/kg

Midazolam• Concomitant use of opiate will increase

effects• Onset of action depends upon route-1-5

minutes IV up to 20-60 minutes orally• Can cause hypotension, respiratory

depression• Reversal agent is Flumazenil

(Romazicon)

Opiates• Used for painful procedures• Often combined with benzodiazepines• Fentanyl most common opiate used in

pediatric procedures due to relatively short half life

• Reversal agent is Naloxone (Narcan)• May need to repeat Narcan dose due to

short ½ life.

Fentanyl• IV form used for sedation (lollipop

and patch extended release)• Dose is usually 1 mcg/kg• Duration of action generally ½-1

hour• Can cause chest wall rigidity if

given as rapid bolus

Barbiturates• Pentobarbital historically used Radiology

sedative-is not an analgesic• Given IV up to 6mg/kg• Long half life a concern as related to

increased recovery times• Attempts to awaken early may

contribute to emergence reaction or pentobarb rage

• No reversal agent

Anesthetic agents• Ketamine• Propofal

Ketamine• Has dissociative properties and is

therefore somewhat unique• Used in human and vet medicine• Provides sedation and analgesia• At high doses is a general

anesthetic agent• May be given IV or IM

Ketamine• To be used only “under direct

supervision of a LIP with experience with anesthetic agents”

• Causes discongigant eye movements • Can cause hallucinations (visual and

auditory) usually at emergence-versed given in combination to reduce

Ketamine

• Dose-– IV 0.5-2mg/kg-usually use 0.5-1 for

procedural sedation– IM 3-7mg/kg

• Onset of action 30 secs. IV. 3-4 minutes IM

• Duration 12-25 minutes IM, 5-10 minutes IV

Propofal• No analgesic properties• General anesthetic agent with very rapid

onset and potential for apnea• State and institution guidelines vary as to RNs

ability to manage infusions• Bolus dosing by LIP• Study in 2005 showed that 42% of 54

pediatric hospitals were using propofal outside of the OR given by non anesthesiologists

Propofal

• Bolus then drip essential as drug is degradated in single pass through the liver

• Bolus is usually 1-2mg/kg• Infusion rates of 50-250mcg/kg/min for

short term procedural sedation• Pediatric specific mortality reported from

irreversible metabolic acidosis in 1999 from long term high dose infusions

Dexmedetomidine (Precedex)

• Highly selective alpha2 adrenoceptor agonist with both analgesic and sedative effects

• Classified as anesthetic agent• Mechanism of action is induction of

stage 2 (non REM sleep)• Bolus then infusion delivery• Short ½ life and lack of respiratory

depression reported

Precedex• Advantages

– Less interference with EEG waves so therefore more diagnostic quality

– Promising results for consistency in achieving adequate sedation for imaging studies

– Large on-going study at Boston Children’s Hospital demonstrating positive safety profile

Precedex• Hemodynamic changes can occur but

are not usually clinically significant• Specifically, bradycardia is common but

without hemodynamic compromise• Contraindications include patients on

Digoxin (cardiac arrest reported in adults) and other cardiac conditions

Post Sedation Considerations

• Patients may still be at significant risk for complications

• Removal of stimulation (pain, MRI noise) may cause deeper sedation level especially if multiple doses have been given

• Delayed drug absorption (oral, rectal, IM) and slow drug elimination also may contribute

Post Sedation Considerations

• Continued monitoring and observation necessary

• Pre-determined discharged criteria – Aldrete most common– Score of 9 or back to baseline usual criteria

• With kids, ability to drink also important to avoid dehydration and hypoglycemia (infants)

Post Sedation Considerations

• Written discharge instructions that are age specific desirable

• Toddlers especially at risk for falls, etc

• Positioning in car seats, etc with infants also very important due to pediatric airway anatomy

QA/QI outcome data• Guidelines state there should be

an analysis of any adverse events• Collecting data regarding success

rates, etc helps drive practice change

• One Benchmark: Pediatric Sedation Research Consortium

Take home points

Take home points• Kids are not little adults• Know age specific vital sign norms• Know where your pediatric airway

equipment is and how to use it• Remember airway position• Double check your meds

Remember if your intent is to Remember if your intent is to sedate a patient, irregardless sedate a patient, irregardless of the medication or dose you of the medication or dose you use, sedation guidelines applyuse, sedation guidelines apply

Remember if your intent is to Remember if your intent is to sedate a patient, irregardless sedate a patient, irregardless of the medication or dose you of the medication or dose you use, sedation guidelines applyuse, sedation guidelines apply

Any Questions?????

Pediatric Sedation References  

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Therapeutic and Diagnostic Procedures: An Update. American Academy of Pediatrics, American Academy of Pediatric Dentists, Cote, C.J, MD, Wilson, S/ DMD, MA, PhD the WorkGroup on Sedation. Pediatrics Vol 118 No.6 December 2006 pp 2587-2602. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: an updates report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. V 96 No. 4, April 2002 Incidence and Nature of Adverse Events During Pediatric Sedation /Anesthesia for Procedures Outside the Operating Room: Report from the pediatric Research Consortium. Cravero, J.P. MD, Blike, G.T. MD, Beach, M. MD, Gallagher, S. M. BS, Hertzog, J.H. MD, Havidich, J.E. MD, Gelman, B.MD, and the Pediatric Sedation Consortium. Pediatrics Vol. 118, No 3. September 2006, PP 1087-1096. Advisory Opinion Conscious sedation for Diagnostic and Therapeutic procedures. Arizona State Board of Nursing.