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

4. DEFINITIONS

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

6. Continuum • minimally impaired consciousness to complete unconsciousness

7. “conscious sedation” is an oxymoron

9. New SedationTerminology • Minimal • Moderate • Deep • General anesthesia

10. Minimal Sedation

11. Moderate Sedation

12. Deep Sedation

13. General Anesthesia

14. Implications • Assume and prepare for Deep Sedation • The level of vigilance = Maximal • Appropriate monitoringequipment and personnel

16. SEDATION MORBIDITY AND MORTALITY

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

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

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

20. Route of Administration • Intravenous 60 • oral 37 • rectal 9 • nasal 4 • intramuscular 31 • inhalation 13

21. Presenting Event

22. Outcome vs Monitoring * P < 0.001 compared with pulse oximetry Pediatrics 105:805-814, 2000

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 isEssential

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

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

29. Fasting Guidelines

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

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

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

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

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

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

38. Medications

39. Pharmacodynamics • 2 general groups • sedation • analgesics

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

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

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

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

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

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

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

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