1. Procedural Sedation: Paediatrics Dr. Rodrick Lim MD, FRCPC, FAAP Site Chief Paediatric Emergency Department Associate Professor of Paediatrics Schulich School of Medicine and Dentistry London Ontario Canada 2011 Talk Trauma1 April 2011

2. Goals: Define procedural sedation and it’s goals An ED checklist for safe procedural sedation Factors to consider before embarking on procedural sedation Updates on Pediatric use of Ketamine and Propofol April 2011 2011 Talk Trauma2

3. Procedural Sedation Sedative and analgesic agents are used to reduce the anxiety and pain experienced by patients during procedures in order to: – Decrease the length of time necessary to perform a procedure – Increases the likelihood of success – Reduces the potential risk of injury to the patient or health care worker because of uncontrolled movements April 2011 2011 Talk Trauma3

4. Spectrum of Sedation Procedural sedation involves altered levels of consciousness – Minimal – Moderate – Deep – Dissociative sedation levels Can be safely and effectively performed in the ED by emergency physicians April 2011 42011 Talk Trauma

5. Procedural Sedation Agents commonly used for sedation of patients in the ED include but are not limited to opioids, benzodiazepines, and barbiturates, as well as other specific Commonly used agents include: – Ketamine – Propofol – Etomidate – Nitrous oxide. April 2011 52011 Talk Trauma

6. Goals: Define Procedural Sedation and it’s goals An ED checklist for safe Procedural Sedation Factors to consider before embarking on Procedural sedation Updates on Pediatric use of Ketamine, Propofol April 2011 2011 Talk Trauma6

7. Procedural Sedation in Your ED Sedation in the Emergency Department Revised and approved by the ACEP Board of Director Ann Emerg Med. 2011;57:469 April 2011 2011 Talk Trauma7

8. ACEP Checklist Emergency physicians who have received the appropriate training and skills necessary to safely provide procedural sedation Familiar with the pharmaceutical agents they use and be prepared to manage their potential complications. April 2011 82011 Talk Trauma

9. ACEP Checklist The appropriate drugs and dosages must be chosen and administered in an appropriately monitored setting, and a patient evaluation should be performed before, during, and after their use April 2011 92011 Talk Trauma

10. ACEP Checklist Institutional and departmental guidelines related to the sedation of patients should include credentialing and verification of competency of providers, selection and preparation of patients, informed consent, equipment and monitoring requirements, staff training and competency verification, criteria for discharge, and continuous quality improvement April 2011 2011 Talk Trauma10

11. Goals: Define Procedural Sedation and it’s goals An ED checklist for safe Procedural Sedation Factors to consider before embarking on Procedural sedation Updates on Pediatric use of Ketamine, Propofol April 2011 2011 Talk Trauma11

12. Factors: Indication Contraindication – Relative or Absolute Risks of Proceeding Risks of Not Proceeding What alternatives are available April 2011 2011 Talk Trauma12

13. Factors: Our Case Indication Contraindication – Relative or Absolute Risks of Proceeding Risks of Not Proceeding What alternatives are available April 2011 2011 Talk Trauma13

14. Goals: Define Procedural Sedation and it’s goals An ED checklist for safe Procedural Sedation Factors to consider before embarking on Procedural sedation Updates on Pediatric use of Ketamine, Propofol April 2011 2011 Talk Trauma14

15. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update Steven M. Green, Mark G. Roback, Robert M. Kennedy, Baruch Krauss Annals of Emergency Medicine Volume 57(5): 449-461 April 2011 152011 Talk Trauma

16. Contraindications: Absolute Infants younger than 3 months – Multiple case reports of airway obstruction, laryngospasm, and apnea. Consistent with other agents, representing infant-specific differences in airway anatomy and reactivity and laryngeal excitability Exacerbates Schizophrenia and alternative agents should be used April 2011 2011 Talk Trauma16

17. Contraindications: Relative Age 3months-12 months now omitted as relative contraindication 2011 Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54:158-168. April 2011 2011 Talk Trauma17

18. Contraindications: Relative Major procedures stimulating the posterior pharynx (eg. endoscopy) increase the risk of laryngospasm, whereas typical minor ED oropharyngeal procedures do not (New to 2011) History of airway instability, tracheal surgery, or tracheal stenosis (presumed higher risk of airway complications) April 2011 2011 Talk Trauma18

19. Contraindications: Relative Active pulmonary infection or disease, including upper respiratory infection or asthma (higher risk of laryngospasm) Known or suspected cardiovascular disease, including angina, heart failure, or hypertension (exacerbation caused by sympathomimetic properties of ketamine) April 2011 2011 Talk Trauma19

20. Contraindications: Relative Avoid ketamine in patients who are already hypertensive Central nervous system masses, abnormalities, or hydrocephalus (increased intracranial pressure with ketamine) Head Injury removed as Relative Contraindication 2011 April 2011 2011 Talk Trauma20

21. Contraindications: Relative Glaucoma or acute globe injury (increased intraocular pressure with ketamine) Porphyria, thyroid disorder, or thyroid medication (enhanced sympathomimetic effect) April 2011 2011 Talk Trauma21

22. Other Highlights Route of Administration – Emphasis on IV over IM route when feasible Coadministered Medications – Routine prophylactic anticholinergics no longer recommended – Routine prophylactic benzodiazepines may benefit adults but not children – Prophylactic ondansetron can slightly reduce vomiting April 2011 2011 Talk Trauma22

23. Emergency Physician- Administered Propofol Sedation: A Report of 25,433 Sedations from the Pediatric Sedation Research Consortium Michael D. Mallory, Amy L. Baxter, Daniel J. Yanosky, Joseph P. Cravero and Pediatric Sedation Research Consortium Annals of Emergency Medicine Volume 57(5): 462-468 April 2011 2011 Talk Trauma23

24. Propofol: Pediatrics More serious adverse events occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%). There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest. April 2011 2011 Talk Trauma24

25. Propofol: Pediatrics Significant predictors of serious adverse events were: – weight less than or equal to 5 kg – American Society of Anesthesiologists classification greater than 2 – Adjunctive medications (benzodiazepines, ketamine, opioids, or anticholinergics) – Nonpainful procedures, and primary diagnoses of upper respiratory illness or prematurity April 2011 2011 Talk Trauma25

26. Back To Case: Important Points: – Procedural Sedation is Safe and Effective when used properly, with mechanisms in place to ensure proper training, monitoring and continual quality improvement – If/When/What are best answered when considering individuals patients indications, contraindications, urgency and potential risks of proceeding vs. not proceeding April 2011 2011 Talk Trauma26