1. Out-of-the Operating Room Pediatric Anesthesia
Updated 8/2019
Fiona Patrao, MBBS, MD
Corrie Anderson, MD, FAAP
Seattle Children’s Hospital Seattle, Washington, USA

2. Disclosures
No relevant financial relationships

3. Learning Objectives Describe levels of sedation/anesthesia
Risk assess patients
Define the challenges of different environments
Be prepared for a crisis
Pick the right anesthetic for the right patient
Assess each patient with the procedure and location in mind
Identify differences in set up for different locations and procedures
Describe the difficulties that come up with each different environment and location
Crisis preparation is key

4. Goals of Care for Out-of-OR Anesthesia
Achieve immobility
Avoid patient discomfort and injury
Provide anxiolysis, safe sedation and analgesia
Support patients as they transition from one level of sedation through another
Immobility is often needed for safe completion of pediatric procedures
Avoiding discomfort and injury helps to avoid prolonged adverse physiological or psychological responses to stress
Anxiolysis, safe sedation, analgesia- sometimes only one or the other is needed

5. Why sedate for out of OR procedures?
Ensures a cooperative and still patient
- Especially consider sedation in children < 6 years old or developmentally delayed
Reduces a child’s anxiety and stress
Repetitive stress and pain can lead to a lifetime of depression, anxiety, sleep disorders and fear of doctors

6. Levels of Sedation
Must know how to support patients as they transition from one level to another
Requires close monitoring of patients
Minimal
Moderate
Deep
General Anesthesia
Out of OR anesthesia requires close monitoring of patient and careful selection of the type of anesthesia.
With fewer resources in remote locations, anesthesiologists need to be very vigilant and anticipate changes in depth before they become difficult to manage.

7. MINIMAL SEDATION (previously “anxiolysis”)
Minimally depressed level of consciousness
Respond to tactile stimulation and verbal command.
MODERATE SEDATION (previously “conscious sedation”)
Further depression - respond purposefully to verbal commands alone or with light tactile stimulation
Patients independently and continuously maintain airway and ventilation
At these levels cardiovascular function is usually maintained

8. DEEP SEDATION GENERAL ANESTHESIA
NOT easily aroused but respond purposefully following repeated or painful stimulation.
Cardiovascular function is usually maintained.
GENERAL ANESTHESIA
NOT arousable
Cardiovascular function may be impaired.
Deep sedation may require airway support, and GA probably will require positive pressure ventilation
At these levels anesthesiologist may need to provide more support to manage hemodynamics, and airway. This may not be feasible in some remote locations.

9. What is MAC? Monitored Anesthesia Care
Anesthesia resources utilized to support life and provide patient comfort and safety during diagnostic/therapeutic procedures
Can range from only monitoring, to monitoring with sedation and can progress to GA and to resuscitation
It is a service provided by an anesthesiologist only. Even if one is only monitoring and the patient is awake, one must ensure that all resources are present to handle a crises or request for sedation.

10. Pharmacologic Interventions
Sedatives
Anxiolysis
Analgesics
One group or a combination of the three groups may be used.

11. Pharmacologic Options
Sedation
Propofol
Ketamine
Dexmedetomidine
Nitrous oxide
Volatile anesthetics
Anxiolysis
Midazolam
Analgesia
Opioids
Local anesthetics
If Dexmedetomidine is available consider using it as a bolus only or bolus followed by an infusion
When anesthesia machines are available - nitrous oxide and volatile agents are viable options
Always consider local anesthetic topically for field blocks or other regional anesthesia techniques with nerve blocks or catheters

12. IV Infusion dose 100–250 µg/kg/min IV
Drug
Dose and route
Propofol
IV Bolus: 1-3 mg/kg
IV Infusion dose 100–250 µg/kg/min IV
Dexmedetomidine
Intranasal: µg/kg, repeat after 30 min with µg/kg
IV bolus: µg/kg over min
IV infusion: µg/kg/h (start after giving above bolus dose)
Ketamine
Intramuscular: 3–4 mg/kg IM
IV: 0.5–2 mg/kg IV
N2O
Inhalation: 50% in 50% oxygen, up to 70% used by some
Midazolam
Oral: 0.5–0.75 mg/kg
Intranasal: 0.2 mg/kg
IV: 0.025–0.5 mg/kg IV
Fentanyl with Propofol
Fentanyl 1–2 mg/kg IV with Propofol mg/kg IV
Fentanyl with Midazolam
Fentanyl 1–2 mcg/kg IV with Midazolam 0.02 mg/kg IV
These are commonly used drugs with their doses

13. Pharmacologic Options
Combined sedative + analgesics
Ketamine
Dexmedetomidine
N2O
These medications have both sedative and analgesic properties and in addition will probably maintain spontaneous ventilation.

14. Non-pharmacologic Options
Applicable for short, minimally invasive procedures
Calming and reassurance by parents
For older kids - Distraction techniques:
TV, video games or other devices
Play
hypnosis

15. Non-pharmacologic Options
For babies:
Swaddling, sugar drops
For infants < 6 months: keep baby fasted for 4 hours, swaddle and then feed right before procedure
“Feed and sleep”
“Fast and feed”
If a baby FAILS a fast and feed the procedure will need to be rescheduled at a different time or day (after following normal protocol for fasting)

16. Dose of ”sugar drops”
Administer 2 mL of 25% sucrose/dextrose solution by syringe into the infant’s mouth (1 mL in each cheek)
Or infant may suck solution from nipple (pacifier) 1-2 min before the start of the procedure

17. Challenges of Remote Locations
Patient challenges
Procedure challenges
Shared airway: GI, Dental clinic
Painful: burns, bone marrow aspirate
Immobility: MRI, Proton therapy
Environmental challenges
Lack of equipment
Metal free zones: MRI
Crowded spaces and difficulty to access patient
Lack of electrical/gas outlets
Remote location of hospital
Multiple challenges with each area:
Patient challenges are vast but may include: illness related issues, anxiety, inability to lie still, pain, critical condition, difficult airway or IV

18. Staffing Fully trained anesthesiologist
Trainees should be closely supervised
Additional staff to support anesthesiologist: nurses, technicians
A fully trained anesthesiologist to be with patient from induction to recovery
Additional staff is required to support the anesthesiologist to help with transport, managing equipment, calling for help if needed

19. Evaluate Your Patient Assess risk
ASA Status and Risk:
Organ systems
Development and maturity
Review: past anesthetics, labs, imaging
Airway assessment
Assess and plan appropriate size airway equipment
Difficult airway?
Physical exam
ASA status and risk:
- Do a complete preanesthetic evaluation.
- Evaluate all organ systems. Also assess for sleep apnea, aspiration risk which may make any level of sedation unsafe
- Assess the patient’s developmental milestones and maturity- Can the patient do this awake if he is mature and understands the procedure?
- Review: labs, fluid status, recent imaging relevant to your anesthetic
- Review past anesthetic records to assess what went well and what needs to be better
Airway assessment
- Assess and plan appropriate size airway equipment
- Difficult airway? - Have back-up airway plans: additional anesthesiologist, ETT, Video laryngoscope, FOB, bougie etc.
Physical Exam:
- Anxious or combative? Critically ill? Actively seizing or vomiting? Contractures or other positioning difficulties

20. Prepare Your Patient
Informed consent
Ensure adequate fasting
IV vs Inhalational induction
If need/prefer IV first, consider:
Sedation with oral/nasal midazolam or dexmedetomidine, or IM ketamine
EMLA cream (safe from 37 weeks of infancy onwards)
-Informed consent- discuss level of sedation, challenges specific to location and procedure
-Nil Per Oral: ENSURE adequately fasted for procedure
-IV vs Inhalational induction with volatile agent/N2O if anesthesia machine available.
-If no anesthesia machine- Consider placement of IV before or after sedation depending on risk of patient.

21. Prepare Your Patient
Prepare your anesthesia plan based on your risk assessment and YOUR skill set
Always work with the tools and the plan that you feel the most comfortable with- with the knowledge that you will be alone with minimal help and resources in a remote setting.

22. Prepare the Environment Visit the location in advance
Assess space and dimensions:
Can anesthesia equipment pass through the door?
Layout of room:
How will you access patient and equipment efficiently?
Ensure necessities:
Location of O2 outlets
Suction: central or need independent machines?
Piped vs cylinder gases
Electric outlets? Adequate battery charge?
Visit the location in advance of the procedure so that you can prepare, anticipate difficulties and set up

23. Prepare for a Crisis Establish Space: Be prepared:
for induction, emergence, management of crisis
Be prepared:
Identify location of defibrillator and emergency drugs
Battery powered source of light- flashlight
Communication- telephone, extra people
Have a space/area and communicate with everyone in the remote location, that in the event of a crisis the patient will need to quickly be relocated to this area for effective management.

24. Anesthesia Equipment Set Up
Airway support
CHECK and ENSURE a reliable O2 source
Have FULL O2 cylinder available as backup
Self inflating bag or Mapleson circuit
Suction
Face mask, oral/nasal airway, supraglottic airway, ETT, laryngoscope, difficult airway tools
Anesthesia machine if possible
If a difficult airway is anticipated, prepare for a difficult airway induction and intubation as you would do in the operating room and take ALL precautions. Have all the equipment you need available: including drugs for topical anesthesia for the airway, sedation as required, supraglottic airways, flexible fiberoptic bronchoscope or other video laryngoscopy tools including tracheostomy/ cricothyrotomy sets and (if needed) availability of an ENT surgeon.
An alternative approach for a difficult airway, is to secure the airway (intubation or supraglottic airway) in an operating room and then transport the patient safely to the remote location of choice (MRI/CT etc.)

25. Anesthesia Set Up… Anesthesia delivery
Monitors: ECG, BP, SpO2, ETCO2, temperature
Drugs
IV access
Airway and ventilation
Safe positioning
Temperature regulation
Documentation

26. Post Anesthesia Care Staff to monitor patient Safe transport Resources
nurse or anesthesiologist
Safe transport
Resources
O2, airway equipment
Suction
Emergency drugs
Monitors
Prepare for unexpected admissions
Staff to monitor patient: nurse or anesthesiologist until full recovery from anesthesia
Safe transport from location to recovery area with close monitoring of vital signs
Airway equipment and emergency drugs to be available during transport from procedure area to post anesthesia care unit
If overnight or ICU admission needed: early coordination and clear sign out/hand over of relevant information to admitting teams

27. Location Specific Discussions

28. Bedside Procedures Assess patient’s suitability.
Examples: Burns or wound dressings, line placements, chest tubes
Assess patient’s suitability.
May be suitable for older children (> 10 to 12 years)
Monitors: ECG, NIBP, SPO2, ETCO2
Airway and suction equipment
Consider PO, nasal or IM sedation prior to placing IV
Assess if patient is suitable for bedside procedure. If patient is critically ill, full stomach, hemodynamically unstable, has a difficult airway etc. this patient may be better suited to be done in the OR
Confirm or establish IV . If patient is not willing for awake IV, consider - prior PO/nasal/IM sedation
Monitors: ECG, NIBP, SPO2, ETCO2
Ensure normothermia

29. Repetitive procedures? Consider neuraxial or regional nerve catheters
Bedside Procedures…
Minimum to moderate sedation only
ketamine, midazolam, dexmedetomidine
Provide analgesia
opioids, NSAIDS, local anesthesia
Airway and O2 support as needed
Distraction techniques
Music, cartoons, play therapy, parental presence
Consider minimal to moderate sedation only
- ketamine, dexmedetomidine, midazolam, opioids, propofol may lead to very deep planes of anesthesia
- Airway and O2-> Spontaneous ventilation; nasal cannula, face mask
Distraction techniques
- Music, cartoons, play, parents, hypnosis, guided imagery
Regional anesthesia is a good alternative to sedation. Catheters can be bolused prior to procedures- be cautious of maximum dosing of local anesthetics.
Repetitive procedures?
Consider neuraxial or regional nerve catheters

30. Special considerations:
GI Suite
Special considerations:
Shared airway: for EGD (esophago- gastro-duodenoscopy), ERCP
Short procedures: not usually painful. Use short acting drugs
Full stomach risks

31. GI Suite… Options range from minimum sedation to GA:
Examples: EGD, Colonoscopy, Liver Biopsy
Options range from minimum sedation to GA:
Spontaneous breathing with boluses of propofol +/- short acting opioids
Spontaneous breathing with TIVA: propofol +/- dexmedetomidine infusions
GA with LMA or ETT
midazolam as needed for anxiety
Consider lidocaine gargles, swish and swallow for less sedated patients.

32. GI Suite… GA with ETT for: ERCP Gastro-jejunostomy
Any concern for full stomach or unstable airway?

33. CT Scans (Computed Tomography)
Special considerations:
Short procedures
Contrast injections
Requires IV placement
Allergic reactions
Exposure to radiation
Short procedures- plan to use short acting medications. Usually procedures are not painful
Contrast injections: will need IV placement, monitor for allergic reactions
Exposure to radiation: Anesthesiologists should us personal lead protective wear: lead aprons, thyroid shields, eye protection. Use lead screens or step into control room with visual inspection of patient.

34. CT Scans… Anesthetic options:
If anesthesia machine available: Can consider using volatile agent for induction and maintenance
Other options: propofol, midazolam, ketamine, dexmedetomidine boluses

35. CT Scans… Other considerations Babies:
Soothing: swaddling, sugar on pacifier
”Fast and Feed”
Some scans require breath holds, prone positioning
May require ETT/ LMA
Inspiratory breath hold- with positive pressure ventilation (PPV)
Expiratory hold or apneic pause: following hyperventilation +/- propofol bolus
For breath holds under anesthesia: one can achieve this with a mask or ETT or supraglottic airway. Discuss with the CT technician if they need a breath hold in inspiration or expiration.
For an inspiratory breath hold, hyperventilate the patient with positive pressure ventilation (PPV) for a minute or so before the breath hold to reduce patient’s respiratory drive. When CT is ready for a hold deliver and hold a breath with sustained positive pressure.
For an expiratory breath hold, patient can be made apneic with an additional bolus dose of propofol and hyperventilation (to reduce respiratory drive). To ensure patient does not desaturate rapidly and develop atelectasis with frequent breath holds, provide PPV with 100% FiO2 prior to and in between breath holds.

36. MRI Special considerations Immobility Confined space
No ferromagnetic materials
Programmable VP shunts-reprogram after MRI
Noise protection
Contrast injections
Immobility crucial to good images
Confined space in closed MRI scanners- Concern for claustrophobia, accidental injury
No ferromagnetic materials near MRI scanner : NO pacemakers, cochlear implants, neurostimulators, infusion pumps . Check WITH magnet!
Programmable VP shunts and baclofen pumps must be reprogrammed after the MRI.
Noise protection required - ear plugs for patients and providers
Contrast injections: patients may need IV, monitor for allergic reaction

37. MRI… Anesthesia set up: Monitors No monitors?
Do not use regular monitors. ALL wires can cause burns
Use only MRI compatible ECG, NIBP, SPO2 and ETCO2
No monitors?
Proceed with caution
Visual inspection of patient and “HAND on PULSE”
Some “MRI-compatible” equipment cannot be taken too close to the scanner.
If there is no availability for MRI compatible monitors, an anesthesiologist may have to sit inside the MRI suite with the patient.
- Be very cautious sedating patients without monitors, and ALWAYS advocate for the safety of your patients including purchase of monitors by imaging suite or hospital
If the patient is old/ large enough, monitor patient with a hand on available pulse and monitor breathing with visual inspection of chest rise. Lightly sedated patients should be responsive to verbal stimulus.
For smaller children, sicker patients: Consider intubating or placing a supraglottic airway and using a transport bag connected to O2 from an MRI compatible O2 cylinder/ source. The transport bag will be also be a means to monitor ventilation
MRI’s are noisy! Use ear plugs if staying inside MRI suite.

38. MRI…
Infusions managed and patient monitored from control room.
Infusions tunneled through copper channel in wall of control room
Small copper channel on side of door to allow long infusion tubing of critical medications
Size of copper channel to be determined by MRI manufacturers
Other options include running tubing under the door, or MRI compatible pumps.

39. MRI… Anesthetic techniques: Sedation vs GA Infants
Sedation with midazolam, propofol or ketamine boluses
GA with LMA/ETT with volatile gent
GA with TIVA (Propofol): nasal cannula vs LMA/ETT
Infants
Swaddle
“Fast and Feed”
Multiple different options for sedation:
Minimum sedation with Midazolam or Propofol boluses: if providing intermittent boluses and staying in MRI suite with patient, ensure anesthesiologist has ear plugs/ ear phones for noise protection
Anesthetic plans can include: GA with Propofol infusion with patient spontaneously breathing with nasal cannula or GA with spontaneous vs PPV with LMA/ ETT for more secure airway

40. Oncology Patients Using central lines -> ensure strict asepsis
Example: Bone marrow aspirate, lumbar puncture, line or drain placement
Using central lines -> ensure strict asepsis
Check anticoagulation status
Minimum to moderate sedation only with spontaneous ventilation
Midazolam, propofol or ketamine will lead to deeper level of sedation and require airway support.
Analgesia with opioids
Liberal local anesthesia infiltration

41. Oncology Patients
For radiation and gamma knife therapy
Frequent treatments – Long procedures that require immobility and stereotactic head frames
Anesthetic risks and considerations vary
For more information refer to:
- McFadyen JG, Pelly N, Orr RJ. Sedation and anesthesia for the pediatric patient undergoing radiation therapy. Curr Opin Anaesthesiol 2011; 24:433–8
- Edler A. Special anesthetic considerations for stereotactic radiosurgery in children. J Clin Anesth 2007;19:616-8

42. Dental Clinics Special considerations: Shared airway
Often anxious/phobic or developmentally delayed patients
If considering sedation -> MAINTAIN airway reflexes to protect from aspiration of blood/oral secretions

43. Dental Clinics… Anesthetic techniques: Oral/ Nasal Intramuscular
Midazolam, ketamine, dexmedetomidine
Intramuscular
Ketamine
Inhalational
With N2O nasal mask – titrated mixture of up to 70%
Intravenous
Titrating dose of midazolam and/or propofol
GA with ETT
Preferably in hospital with adequate resources
Oral vs nasal ETT with throat pack

44. Other considerations…

45. Crisis Management Identify how to activate emergency system
Support staff, phones
Identify location of defibrillator and emergency drugs
Ensure defibrillator working
Battery charged, plugged in and routine testing
Transfer patient to safe location during crisis
Crowd control

46. Complications Hypoxic episodes: Aspiration Failed sedation
Laryngospasm
Bronchospasm
Aspiration
Failed sedation
Prolonged recovery
Allergic reactions and anaphylaxis

47. Management of anaphylaxis
Severity of symptoms
Intervention
MILD
(Urticaria, flushing)
Remove offending agent
Consider oral dose of diphenhydramine
MODERATE to SEVERE
(Bronchospasm, facial or laryngeal edema, hypotension with tachycardia/bradycardia)
100 % high flow O2
IM Epinephrine (10 µg/kg) – repeat 10 to 15 mins as needed
IV hydrocortisone
2 agonist for bronchospasm
Antihistamine: IV diphenhydramine (H1 blocker), IV ranitidine (H2 blocker)
Intubate for stridor/airway compromise
Treat hypotension
Supine as tolerated, legs elevated
20 ml/kg isotonic fluid bolus, repeat as needed

48. Occupational Hazards
Exposure to radiation: use lead aprons, thyroid lead shields, lead screens
Noise damage: use ear plugs in MRI
Tripping
Inadequate lighting
Accidental injuries to self

49. Safety and Improvement
Posters with checklists and reminders
Protocols for using checklists before start of procedure
Emergency phone numbers should be easily visible

50. Sample Checklist Verification Response Details Patient identity
Name/ DOB/Hospital number
Patient weight
….. kg
Allergies
Yes/No
List allergies
Procedure
Described by surgeon/proceduralist
Consent
O2 and airway equipment
Available and adequate
Suction
On and working
Medications
Available
Monitors on
Yes/ No
Special precautions?
labs, metal free area
Adequate nursing/physician staff
Defibrillator/emergency cart available

51. Safety and Improvement
Consider QI (Quality Improvement) projects to test and improve protocols
Simulation sessions
Simulate crises in remote locations to identify weaknesses and improve awareness

52. Conclusion Evaluate, assess and prepare the patient
Plan an anesthetic based on patient, location, procedure, available equipment and YOUR skill set
Prepare for:
Changing levels of sedation
Critical events

53. References
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018; 128:437–79
Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update Pediatrics. July 2016; Vol 138: e
Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010;23:
Cravero JP et al and the Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118:1087–96
Cantlay K, Williamson S, Hawkings J. Anaesthesia for Dentistry. Br J Anaesth. 2005; 5: 71-5
Bell C, Sequeira PM. Nonoperating room anesthesia for children. Curr Opin Anaesthesiol 2005, 18:271-6
Cravero JP, George TB. Review of Pediatric Sedation. Anesth Analg 2004;99:1355–64
Fein JA, Zempsky WT, Cravero JP and the Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of Pan and Anxiety in Pediatric Patients in Emergency Medical Systems. Pediatrics 2012;130;e1391
Sottas CE, Anderson B. Dexmedetomidine: the new all-in-one drug in paediatric anaesthesia? Curr Opin Anaesthesiol 2017;30:441-51