1. 1 Pediatric Sedation Desi Reddy ( MB ChB, FFA, FRCPC ) Department of Anesthesia McMaster University

2. STRUCTURE  Definition  Pre-procedure Preparation  Monitoring and Equipment  Medications  Recovery and Discharge

3. 3

4. DEFINITIONS

5. 5  anxiolysis  analgesia  amnesia  safety  control behavior  return to baseline Sedation Goals

6. 6 Continuum  minimally impaired consciousness to complete unconsciousness

7. “conscious sedation” is an oxymoron

8. 8

9. 9 New Sedation Terminology  Minimal  Moderate  Deep  General anesthesia

10. Minimal Sedation Response normal response to verbal stimulation normal response to verbal stimulation AirwayUnaffected VentilationUnaffected CV function Unaffected

11. Moderate Sedation Response Purposeful response to verbal or tactile stimulation Airway Intervention maybe required Intervention maybe required VentilationAdequate CV function Usually maintained

12. Deep Sedation Response Purposeful response following repeated or painful stimulation Airway Intervention is required Ventilation May require support CV function Usually maintained

13. General Anesthesia Response Unarousable even to painful stimuli Airway intervention required Ventilation frequently inadequate CV Function maybe impaired

14. Implications  Assume and prepare for Deep Sedation  The level of vigilance = Maximal  Appropriate monitoring equipment and personnel

15. 15

16. SEDATION MORBIDITY AND MORTALITY

17. 17  mortality is very rare  morbidity is not uncommon  Cote reviewed 95 adverse events 51 deaths and 9 permanent neurological injuries 51 deaths and 9 permanent neurological injuries

18. 18 Causes  drug interaction 44  overdose 34  inadequate monitoring 27  inadequate CPR 19  inadequate work-up 18  premature discharge 11  inadequate personnel 10

19. 19 Drug Category  opioid 22  benzodiazepine 18  barbiturate 19  sedative 21  chloral hydrate 13  ketamine 1

20. 20 Route of Administration  Intravenous60  oral 37  rectal 9  nasal 4  intramuscular 31  inhalation 13

21. 21 Presenting Event eventn respiratory80 cardiac8 other7 total95

22. Outcome vs Monitoring * P < 0.001 compared with pulse oximetry Pediatrics 105:805-814, 2000 OutcomeOximeter(n=21)None(n=18) Death/Injury4 * 14 No harm 174

23. Causes of catastrophes  Poor patient selection  Drug overdose  Lack of appreciation of drug interactions, pharmacokinetics and dynamics  Use of multiple medications to sedate patient  Lack of monitoring before, during, or after procedure  Inadequate CPR skills ’ failure to rescue’

24. Conclusions  Most complications avoidable  Monitoring makes a difference  Adverse events involved multiple drugs  Children 1 to 6 years are at greatest risk  Need appropriate personnel skilled in airway management and resuscitation

25. Pulse Oximetry is Essential

26. 26

27. 27 Factors Relating to Procedure  duration  pain  positioning  anxiety/stress of procedure  availability of rescue resources

28. 28 Factors relating to Patient  Past experience  Allergies  Adverse reactions  Aspiration risk  URTI  ASA classification  Fasting Guidelines

29. Fasting Guidelines Ingested material Fasting period (hours) Clear liquids- H 2 0,fruit juices,clear tea,black coffee 2 Breast milk 4 Infant formula 6 Nonhuman milk 6 Light meal 6

30. 30 General Health  ASA 1 normal, healthy patient normal, healthy patient  ASA 2 controlled medical condition without significant systemic effects controlled medical condition without significant systemic effects hypertension, DM, anemia, mild obesity hypertension, DM, anemia, mild obesity

31. 31 ASA Classification  ASA 3 medical condition with significant effects and significant functional compromise medical condition with significant effects and significant functional compromise Controlled CHF, stable angina, morbid obesity, chronic renal failure Controlled CHF, stable angina, morbid obesity, chronic renal failure

32. 32 ASA Classification  ASA 4 poorly controlled medical condition, with significant dysfunction and a potential threat to life poorly controlled medical condition, with significant dysfunction and a potential threat to life unstable angina, symptomatic COPD, CHF unstable angina, symptomatic COPD, CHF

33. 33 ASA Classification  ASA 5 critical medical condition associated with little chance of survival critical medical condition associated with little chance of survival multi-organ failure, sepsis syndrome multi-organ failure, sepsis syndrome

34. 34

35. 35 Provider Factors  dedicated sedation monitor  skills related to depth of sedation  back-up systems and ability to Rescue

36. 36 Equipment  SOAP ME Suction Suction Oxygen Oxygen Airway Airway Pharmacy Pharmacy Monitoring Monitoring Equipment Equipment

37. 37

38. 38 Medications

39. 39 Pharmacodynamics  2 general groups sedation sedation analgesics analgesics

40. 40 Pharmacokinetics  route orally, intravenously, intramuscularly, intra- nasally, rectally orally, intravenously, intramuscularly, intra- nasally, rectally  intravenous titrate to effect titrate to effect combination of medications combination of medications

41. 41 Pharmacokinetics  dose stacking repeated administration before peak effect of previous dose reached. repeated administration before peak effect of previous dose reached.  synergism combination of drugs increase risk of serious side effect, e.g.. benzodiazepine and opiate combination of drugs increase risk of serious side effect, e.g.. benzodiazepine and opiate

42. 42 Drugs  sucrose pacifier reduced crying in neonates following heel prick reduced crying in neonates following heel prick should be used more frequently in infants undergoing brief painful procedures should be used more frequently in infants undergoing brief painful procedures

43. 43 Drugs  Oral Chloral Hydrate used for painless procedures in kids for years used for painless procedures in kids for years 20 -75 mg/kg orally 20 -75 mg/kg orally bitter taste, not tolerated very well bitter taste, not tolerated very well peak effect up to 60 minutes with a half life of 4 - 9 hours peak effect up to 60 minutes with a half life of 4 - 9 hours

44. 44 Chloral Hydrate  prolonged sedation need prolonged supervision prior to discharge need prolonged supervision prior to discharge  advantage is lack of respiratory depression

46. 46 Oral Midazolam  short acting, water soluble benzodiazepine  no analgesic properties  popular because of short duration, predictable onset, and lack of metabolites  get skeletal muscle relaxation, amnesia and anxiolysis  dose: 0.5 - 0.75 mg/kg

47. 47 Oral Midazolam  Recommended use: sole agent for children who will drink liquid medication. sole agent for children who will drink liquid medication. anxiolysis and cooperation are excellent anxiolysis and cooperation are excellent administer local anesthetic for painful procedures administer local anesthetic for painful procedures

49. 49 Midazolam  rectal midazolam 0.3 - 0.7 mg/kg 0.3 - 0.7 mg/kg effect within 15 minutes effect within 15 minutes  nasal midazolam 0.2 - 0.4 mg/kg 0.2 - 0.4 mg/kg onset 10 -15 minutes, burning sensation to mucosa onset 10 -15 minutes, burning sensation to mucosa

50. 50 Intravenous Midazolam  dose: 0.05-0.1 mg/kg every 3-5 minutes up to a max. of 0.7 mg/kg  peak effect in 2-3 minutes  synergistic reaction with opiates. Limit dose to 0.05 mg/kg. Severe respiratory depression.  anterograde and retrograde (at times) amnesia

51. 51 Intravenous Midazolam  Recommended Use: excellent agent for sedation and anxiolysis excellent agent for sedation and anxiolysis provides complementary sedation with opiates for painful procedures provides complementary sedation with opiates for painful procedures caution with combination caution with combination

53. 53 Propofol  potent sedative and hypnotic  onset it very rapid. 60 - 90 seconds  induction of anesthesia at doses = 2-3 mg/kg  recovery rapid = 2-3 minutes redistribution  prolonged sedation and vomiting is very low  disadvantage is pain on injection

54. 54 Propofol  Recommended use: ideal agent for brief periods of deep sedation ideal agent for brief periods of deep sedation minimal adverse effects and rapid awakening are unique minimal adverse effects and rapid awakening are unique get rapid induction of anesthesia and hence should only be used by anesthesia personnel or intensivists get rapid induction of anesthesia and hence should only be used by anesthesia personnel or intensivists

55. 55 Fentanyl  potent synthetic opioid (100 x Morphine)  peak effect= 5 min and lasts for 30 - 40 min.  respiratory depressant effect is much longer (4 hrs) than analgesic effect  Dose: 0.5 - 1.0 mcg/kg up to 5 mcg/kg

56. 56 Fentanyl  minimal hemodynamic effects  reversible with Naloxone  Recommended use: excellent analgesia and mild sedation with short duration of action. Careful respiratory monitoring when combined with other sedatives excellent analgesia and mild sedation with short duration of action. Careful respiratory monitoring when combined with other sedatives

58. 58 Ketamine  produces intense analgesia, sedation and amnestic qualities  Oral dose: 5-6 mg/kg  IV dose :1 - 2 mg/kg  IM dose: 2 - 5 mg /kg

59. 59 Ketamine  less pronounced respiratory depression  airway protective reflexes usually intact  side effects excessive salivation and airway secretions excessive salivation and airway secretions emergence dysphoria emergence dysphoria

61. 61 Oxygen Delivery  nasal cannula provides up to 44% oxygen provides up to 44% oxygen inspired oxygen depends on flow rate inspired 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 l usual settings= 1-4 l

62. 62 Oxygen Delivery  simple face masks provides up to 60% oxygen provides up to 60% oxygen flow rate set between 6-10 l flow rate set between 6-10 l liter flow must be > 6 l to prevent CO2 accumulation liter flow must be > 6 l to prevent CO2 accumulation  non rebreather mask - provide 60-90% oxygen at flows of 10-12 l\min