Pediatric Procedural Sedation

2. Pediatric Procedural Sedation Dr. Marc N. Francis MD, FRCPC University of Calgary Foothills Medical Centre Alberta Children’s Hospital

3. Disclosure I do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation.

4. PSA in the ED • “Painful procedures are unavoidable in emergency medicine” • “While anesthesiologists have unique qualifications to provide sedation, their availability is variable and unreliable, and is limited by commitments to the operating room” Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines Journal of Emergency Medicine 1999; 17(1): 145-156

5. Learning Objectives • “Tools of the Trade” • Sedation medications that you should know well and be familiar with • “The Right Tool for the Job” • Discuss the variable needs for procedural sedation in the ED and pharmaceutical options • “Tricks of the Trade” • Some adjuncts and techniques that will make your job easier • Controversies • A look at some of the more controversial aspects of procedural sedation in children • The Future • What is coming down the pipe for the future of procedural sedation

7. Importance • Studies have shown that children are less likely than adults to receive pain medications and sedation for similar painful procedures* • Children cannot fully understand the medical necessity for testing or therapeutics • Children’s anxiety can heighten the discomfort • Allows for control of behaviour for the safe and successful completion of a procedure • Parental, patient and physician satisfaction *Selbst SM Analgesic use in the Emergency Department. Ann Emerg Med 1990;19:1010-1013

8. Sedation Spectrum • Minimal Sedation • Patient responds appropriately to verbal commands • Cognitive processing affected but no cardiopulmonary effects • Moderate Sedation • Patient responds to verbal commands or with addition of mild stimulus • Maintains airway and ventilation without required intervention • Deep Sedation • Not easily aroused but responds purposefully with uncomfortable stimulus • May require medical intervention to maintain an airway and ventilation • General Anesthesia • Unable to be aroused with a verbal or painful stimulus • Need help maintaining their airway Dissociative Sedation

9. Diagnostic Urinary Catheterization Lumbar puncture Radiographic evaluation (CT or MRI) Joint aspiration Sexual assault examinations Eye examinations Therapeutic IV starts Laceration repair Abscess I+D Fracture Reductions Dislocations reduction Foreign body removal Burn dressings Indications for Pediatric Procedural Sedation

10. The Search Continues… • The ideal sedation protocol: • Rapid induction and emergence • Provides anxiolysis, analgesia and amnesia • Sufficient control of movement to allow for ease of procedural completion • Maintain effective spontaneous ventilation and airway control • Complete Cardiopulmonary stability throughout • Minimal to no side effects

11. “Tools of the Trade”

12. Nitrous Oxide • Dissociative gas with mild to moderate procedural anxiolysis, analgesia and amnesia • Dosage • 50% concentration blended with oxygen • Ideally self administered • Advantages • Onset and offset within 5mins • Does not require an IV • Disadvantages • Requires special delivery device • Nausea and Vomiting • Well ventilated room with scavenger system

13. Midazolam • Short-acting agent with rapid onset of anxiolysis, sedative and amnestic properties • Interacts with GABA receptors in the brain • Dosage • 0.2-0.6mg/kg intranasally • 0.05-0.2mg/kg IV • 0.1-0.2mg/kg IM • 0.5-0.75mg/kg PO • Advantages • Rapid onset • Anxiolysis • Profound retrograde amnesia • No IV required • Disadvantages • Does not provide analgesia • Disturbance in respiratory function +/- hypoxemia • Paradoxical reactions

14. Fentanyl • Synthetic opiod which is narcotic of choice in PSA • Rapid onset and short duration make it easy to titrate • Does not cause histamine release so minimal CV effects • Dosage • 1-3mcg/kg IM or IV • 10-20mcg/kg oral or transmucosal • Advantages • Excellent analgesic • Peak effect within 15-30mins • Reversible with naloxone • Disadvantages • Nausea and vomiting • Respiratory depression • Hypotension • No amnesia. Minimal sedation • Fentanyl Rigid Chest

15. Ketamine • Dissociative agent • Sedation, analgesia and amnesia are maintained • Inhibits reuptake of catecholamines • Stimulates salivary, tracheal and bronchial secretions • Dosage • 1-2mg/kg IV • 2-5mg/kg IM • 6-10mg/kg PO • Disadvantages • Emergence phenomenon • Nausea and Vomiting • Increased secretions • Potentially serious respiratory complications • Advantages • Reliably produces potent analgesia, sedation and amnesia • Hemodynamic stability • Maintain airway reflexes

16. Propofol • Potent hypnotic agent with no analgesic properties • Effects lipid membrane Na-channel function and Stimulates GABA • Rapid onset, redistribution and elimination • Dosage • 1mg/kg IV bolus then 0.5mg/kg q45-60sec • Advantages • Rapid onset/offset • Easily titratable • Anti-emetic • Bronchodilator • Disadvantages • No analgesic properties • Potent cardiopulmonary depressant • Pain on injection • Inadvertent oversedation

17. “The Right Tool for the Job”

18. 28mth ♀ presents with 4day hx of fever, vomiting and flank pain PMHX – Healthy Temp 38.5, HR 121, RR 16, BP 84/56, Sat 98% RA Not toilet trained Wanting to do an in/out cath Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Minimal Sedation The Right tool for the Job

19. 5yo ♂ fell onto wooden post Extensive and complex facial laceration requiring multilayer closure PMHX – Asthma well controlled VSSA Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Dissociative Sedation The Right tool for the Job

20. 15yo ♂ playing soccer and collided with another player Immediate pain to R shoulder which is clinically consistent with anterior dislocation Very Anxious!!! PMHX – Healthy Normal Vital signs Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Moderate Sedation The Right tool for the Job

21. 7yo ♀ presents with patellar dislocation while playing softball Knee in “spasm” and patient extremely anxious with any attempts to examine or maneuver same PMHx – Healthy VSSA Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Minimal Sedation The Right tool for the Job

22. 3yo ♂ fell off the bed and refusing to walk Xray shows a displaced spiral tibial fracture PMHx – seizure disorder well controlled VSSA Nitrous Oxide Midazolam Fentanyl Ketamine Propofol Sedation Spectrum: Dissociative Sedation The Right tool for the Job

23. “Tricks of the Trade”

24. Ondansetron with Ketamine Sedation • Vomiting in the ED and upon discharge after Ketamine sedation is common • Reported frequency of vomiting ranges from 4-19% • Increased vomiting associated with increasing patient age • Vomiting • Decreases patient and parental satisfaction • Delays discharge and consumes ED resources

25. Double-blind, randomized, placebo-controlled trial • N= 255 children randomized to • N= 128 IV Ondansetron 0.15mg/kg to max 4mg • N = 127 Placebo • Results • ED vomiting was less common with ondansetron 4.7% vs 12.6% p=0.02 • NNT of 13 • Vomiting in the ED or after discharge was less frequent with ondansetron 7.8% vs 18.9% p=0.01 • NNT of 9

26. Pre-oxygenation with procedural sedation • Published adverse event rates during pediatric ED procedural sedation vary between 2% and 18% • Consistently the most common adverse event is transient hypoxia • Children’s basal oxygen use/kg is twice that of adults • Smaller FRC • Shorter “safe apnea” period before desaturation • Transient hypoxia is predictably seen with propofol • Very common with Midazolam and Fentanyl • Less likely with Ketamine unless co-administration with other resp depressants

27. Adjunctive Atropine with Ketamine Sedation • Ketamine stimulates oral secretions • In rare circumstances this has been implicated in airway compromise1 • Historically prophylactic anticholinergic agents have been given with ketamine to blunt hypersalivation • Glycopyrrolate 0.2mg • Atropine 0.02mg/kg

28. Prospective observational study of ED pediatric patients receiving ketamine sedation • N= 1090 patients over a 3yr period • 947 (87%) were performed without adjunctive atropine • Assessed for salivation on a 100mm visual analog scale and documented complications • Results • 92% of patients had salivation rated at 0mm or “none” • Only 1.3% were rated >50mm • Transient airway complications in 3.2% of which only one was thought to be related to hypersalivation (incidence 0.11% 95% CI 0.003% - 0.59%) • No occurrence of assisted ventilation or intubation

29. Adjunctive Atropine with Ketamine Sedation • Omission of atropine is safe • Routine prophylaxis is unnecessary • There is minimal added risk presented with its administration • Possible subsets of patients which may benefit • Very young children • Those undergoing oropharyngeal procedures

30. Controversies

31. In your local ED…. • 9yo M previously healthy with no meds/allergies • Fell mountain biking 40mins ago and has deformed and partially angulated radius/ulnar # • Neurovascularly intact distally • Wearing helmet and no issues with potential HI • Bag of chips 2hrs ago with bottle of Gatorade • Survey • Would you sedate this child now? • What would you use?

32. Pre-sedation Fasting guidelines • Minimal scientific evidence to support fasting • Risk of aspiration during ED PSA has not been studied • Only single case of pulmonary aspiration with ED sedation has been reported Cheung K, et al. 2007. Ann Emerg Med 2007;49:462-464 • Extrapolation from general anesthesia literature • Incidence of aspiration is low (1:3,420) • Mortality is rare (1:125,109)

33. Relative risk of aspiration • Good reason to believe that aspiration risk with PSA may be lower than GA • 2/3 of aspiration occurs during airway manipulation • Deeper level of sedation with GA • Generally younger and healthier patients (ASA I-II) • Inhalational agents are more emetogenic • Ketamine sedation preserves protective airway reflexes

34. CAEP No specific guidelines “Insufficient data to show that fasting improves outcomes in patients undergoing ED procedural sedation” In elective situations consider NPO x 2hrs (liquids) and 6hrs (solids) ACEP No specific guidelines “No study has determined a necessary fasting period before initiation of PSA” “Recent food intake is not a contraindication for PSA but should be considered in choosing the timing and target of sedation” What we are told

35. ED specific clinical practice advisory • Goal to create a tool to permit ED physician to identify prudent limits of sedation depth and timing in light of fasting status • Developed a 4-step assessment prior to sedation 1) Asses patient risk 2) Assess the timing and nature of recent oral intake 3) Assess the urgency of the procedure 4) Determine the prudent limit of targeted depth and length of procedural sedation and analgesia

36. Assess Patient risk • Difficult airway? • High risk for esophageal reflux? • Esophageal disease • Hiatal hernia • PUD • Bowel obstruction • Extremes of age? • >70 • <6mths • Severe Systemic disease? • ASA ≥ III

37. Timing and nature of oral intake • Single time point for sake of simplicity = 3hrs • From lowest to highest theoretical risk 1) Nothing 2) Clear liquids 3) Light snack 4) Heavier snack or meal

38. Urgency of the procedure • Emergency • Cardioversion for life threatening arrythmia • Reduction of markedly angulated fracture • Urgent • Care of dirty wounds and lacerations • Abscess I+D • Semiurgent • Care of clean wounds and lacerations • Shoulder reduction • Nonurgent or elective • Foreign body in external ear canal • Ingrown toenail

39. Depth of sedation • Procedure Duration • Brief: <10mins • Intermediate: 10-20mins • Extended: >20mins

40. Standard-risk patient

41. Higher-risk Patient

42. Capnography monitoring during procedural sedation • Non-invasive measurement of the partial pressure of CO2 from the airway during inspiration and expiration

43. Capnography monitoring • Traditional monitoring • Pulse oximetry = oxygenation • RR and clinical observation = ventilation • Capnography • More precise and direct assessment of the patient’s ventilatory status • Assessment of airway patency and respiratory pattern • Early warning system for prehypoxic respiratory depression • Assessment of depth of sedation

45. Show me the evidence!!! • Comparison of oximetry, capnography and clinical observation in the ED2 • 75% of pediatric patients with respiratory compromise were noted by EtCO2 monitoring only • Pediatric RCT comparing capnography to clinical observation in detecting resp events3 • Clinical assessment identified hypoventilation in 3% and did not identify any patients with apnea • Capnography data showed ventilation was compromised in >50% of cases and nearly 25% fulfilled criteria for apnea

46. Recommendations • Good evidence that capnography provides a means for early detection of sedation-related hypoventilation • Clinical significance with regards to improved patient outcomes has not been shown

48. “where we’re going we don’t need roads” – Dr. Emmett Brown Future

49. Propofol Pros Antinauseant effects Amnestic Smooth recovery profile Cons Cardiovascular and respiratory depression Bradycardia Non-analgesic Ketamine Pros Analgesia Amnesia Respiratory and cardiovascular stability Cons Emergence phenomena Vomiting Ketofol

50. Prospective case series 114 ED procedural sedations 1:1 mixture of ketamine 10mg/ml and propofol 10mg/ml All age groups including children as young as 4 Results 97% success rate with procedures 3 patients with transient hypoxia 1 required BVM 3 patients with emergence No hypotension or vomiting Patient satisfaction scores were 10 on a 1-10 scale