1. The Pediatric Analgesia and Sedation Service(PASS) An ED/PICU Combined Sedation Team

2. PASS Team Co-Directors • Jill Fitch, MD • Assistant Professor of Clinical Pediatrics • Attending Physician, Pediatric Critical Care • Marc S. Leder, MD • Associate Professor of Clinical Pediatrics • Attending Physician, Pediatric Emergency Medicine

3. PASS Team - Composition • 6 PICU Physicians • 8 ED Physicians • 1 Administrative Assistant

4. PASS Team – Sedation Numbers • Average 310 sedations / year • 2002 n = 351 • 2003 n = 272 • 26 per month • 3 per day • 2 – 2 ½ hours per sedation

5. PASS Team • SEDATION LOCATIONS

6. RADIOLOGY MRI NUCLEAR MEDICINE

7. INTERVENTIONAL RADIOLOGY / FLOUROSCOPY ULTRASOUND PEDIATRIC INTENSIVE CARE UNIT INTERVENTIONAL CT SCAN

8. EMERGENCY DEPARTMENT CARDIAC CATH LAB

9. NEURODIAGNOSTICS

10. PASS Team • Common Procedures Requiring Sedation Services • *most patients have previously failed Fentanyl/Nembutal sedations

11. MRI • Brain – 20 to 45 minutes • Spine – 45 to 60 minutes • Brain + Spine – 90 minutes • Extremity – 60 to 90 minutes • + or – Gadalidium (Magmevist) contrast

12. NUCLEAR MEDICINE • Bone Scan – 60 min + 30 min for • ?Spectroscopy (3D-Image) – patient must remain completely still or restart image from the beginning • MIBG – 60 min - isotope taken up by tumor (no Spec) • NEUROENDOCRINE – 30 to 60 min • PET SCAN – 60 min

13. INTERVENTIONAL RADIOLOGY - FLOUROSCOPY • VCUG • Nephrostomy tube placement • Sclerotherapy • Abscess Drains • Peritoneal- ruptured appendicitis • JRA • Kenalog joint injections • Angiograms • PICC lines • Percutaneous GT / J tube placement • Liver biopsy • Cecostomy Tube • Constipation for ante-grade enemas

14. ULTRASOUND • Renal biopsy • Hip aspiration • Toxic synovitis vs. Septic joint

15. INTERVENTIONAL CT • 3D IMAGE ALLOWS • Bone biopsy • Tumor ablation

16. PICU • LP • SSEP • Bone Marrow biopsy / aspiration • Bronchoscopy • Endoscopy / PEG placement • Abscess dressing changes / Wound Vac • Halo placement

17. WOUND VAC

18. EMERGENCY DEPARTMENT • Scheduled LP’s for Neurology • Ex. Guillain-Barré Syndrome

19. NEURODIAGNOSTICS • ABR • BAER • VER

20. CARDIAC CATH LAB • Cardiac catherization • Cardioversion • Myocardial Biopsy for heart transplant patients

21. PASS Team • Scheduling Protocol • Scheduling Coordinator: • Merrilee Walker

22. PASS Team– Scheduling Protocol • Completion of Intake Form by requesting service • Used for : • Patient screening • Scheduling sedation date and time

24. PASS Team– Scheduling Protocol • Intake form reviewed by PASS coordinator - with MD consult if needed - to assess screening criteria : • Weight to Height Ratio • History of upper airway problems / sleep apnea • Allergies • Soy • Egg

25. PASS Team- Criteria Required for all Sedations • Meet NPO Guidelines Solids and Non- clear liquidsClear liquids Adults 6-8 hours or none after midnight 2 – 3 hours Children >36 months6 – 8 hours 2 – 3 hours Children 3-36 months6 hours 2 – 3 hours Children <6 months4 – 6 hours 2 hours • Signed Consent • Pregnancy test for all post-menarchal teens

26. PASS Team- Scheduling • Coordinator notifies physicians via e-mail of scheduled sedation • Procedure • Date / Time • Patient information • Location • Coordinator also enters research data / completes physician billing

27. PASS Team– ED Physicians Sedation Schedule

28. PASS Team– PICU Physicians Sedation Schedule

29. PASS Team– Weekly Sedation Schedule

30. PASS Team - Monitor • Radiology Services • Radiology Sedation Nurse (RN) • PICU • PICU Sedation Nurse (RN) • ED • ED Nurse (RN) • Cardiac Cath Suite • Cardiology Nurse (RN) • Neurodiagnostics • Neurodiagnostics provides LPN • Chloral Hydrate sedations only in this location • Goal ultimately is to have a dedicated PASS Team Sedation Nurse (RN)

31. PASS TEAM– Monitoring Record • Hospital wide universal Sedation Form used for all sedations

32. PASS Team– Physician’s Typical Day • Dress appropriately to meet MRIrequirements • Pick up sedation packets - contents include: • Intake form • Records from previous sedations with drug dosing requirements • Dosing cards • Pre-anesthetic history sheet • Consent form • Sedation record / monitoring form • Billing form

38. PASS Team– Physician’sTypicalDay • Review patient histories • Choose sedation drugs and calculate drug dosages with total volume of drug to be drawn up – account for: • Bolus syringes • Infusion pump • Length of case (cc/hr) • IV tube priming – as much as 12cc (120mg propofol) • Drug dosing used for previous sedations

39. Typical calculations • 15 kg patient • Bolus = 1mg/kg over 1 minute then .5 to 1mg/kg/min • 15 mg = 1.5cc then .75cc/min until asleep • Volume = 5cc syringe (prepare extra 1 to 2 syringes for re-boluses as needed) • Infusion • 4mg/kg/hr = 4 X 15kg = 60mg = 6 cc/hr • 5 = 5 X 15 = 75 = 7.5 cc/hr • 6 = 6 X 15 = 90 = 9 cc/hr • 12= X 15 = 180 = 18 cc/hr • Volume = 1 hour case = 18cc + 12cc for prime = 30cc • Total volume for case = 15cc (3 5cc syringes) + 30cc =45cc • 45 cc= 450 mg of propofol use 500 mg bottle

40. PASS Team - Physician • PICU pharmacy to obtain lockedRed Drug Box

42. Contents of Drug Box • ChloralHydrate 500mg/5cc 4 • Fentanyl 50mcg/ml 2ml 3 • Ketamine 10mg/cc 20cc 2 • Versed 1mg/cc 3 • Atropine 0.4mg/ml 1ml 2 • Flumazenil 0.1mg/ml 1 • Glycopyrrolate 1ml 3 • Lidocaine 10mg/cc 5ml 1 • Narcan 0.4 mg/ml 1ml 2 • Propofol 10mg/cc 20cc 3 • Propofol 10mg/cc 50cc 2 • Propofol 10mg/cc 100cc 1 • Vecuronium 10mg 2 • 0.9% NaCl 500cc 1 • Heparin 100u/ml 2ml 4 • Saline flushes 10cc 5

43. Syringes 60cc 2 30cc 2 20cc 2 10cc 3 5cc 3 3cc 3 1cc 3 Padlock & Key 1 Contents of Drug Box • Needles 18g 10 • Needles 20g 10 • Vial Access Canulas 10 • Blunt Plastic Canulas 10 • Betadine Swabs 6 • Alcohol Swabs 6 • Disposition Sheet 1 • Premarked drug labels

44. PASS Team - Physician • Go to sedation location • Assure presence of hospital-wide universal airway box

46. PASS Team – Physician • Assure adequacy of RN set-up of sedation equipment • At bedside: O2 Suction BVM • IV lines • 3 access ports : • Bolus infusion saline • Distance of ports from skin entry site • IV fluids

47. PASS Team - Physician • Review Pre-anesthetic history sheet • Present illness – fever • Allergies • NPO Status • PARADIGM SHIFT – may actually have to cancel the case ! • Patient / parent expectations after long drive • Sub–specialty pressure to complete the case

48. PASS Team - Physician • Confirm sedation plan • Discuss / educate parents to plans, risks, alternatives and benefits of sedation • Sign consent form • Complete sedation • Med-fusion pump for propofol infusion

50. PASS Team - Physician • Recovery • Discharge • Waste Meds • Complete billing card and sedation record • Return drug box to pharmacy