Presentation on theme: "Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial."— Presentation transcript:
Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial Hospital Chicago Illinois
Sedation Guidelines: where have we been & where are we headed
Sedation Goals Anxiolysis Analgesia Amnesia Safety Control behavior Return to baseline
American Academy of Pediatrics Guidelines Response to Dental Accidents
Guidelines for the Elective use of: Conscious sedation Deep sedation General anesthesia Pediatrics 76: , 1985
Conscious Sedation Medically controlled state of depressed consciousness protective reflexes maintained maintain airway independently appropriate response to verbal command or physical stimulation (NOT REFLEX WITHDRAWAL)
Deep Sedation Medically controlled state of depressed consciousness: not easily aroused may not maintain airway may not respond to verbal command may not respond to physical stimulation (EASILY MOVES TO GENERAL ANESTHESIA)
Guidelines for Monitoring and Management of Pediatric Patients during and after Sedation for Diagnostic and Therapeutic Procedures Pediatrics 99: , 1992
Guideline Emphasis Pre-sedation evaluation Appropriate fasting Informed consent Monitoring Time-based record Recovery facility Discharge criteria No out of facility prescriptions
Source of data: FDA adverse drug reports (629) USP Survey Pediatric Anesthesiologists (310) Intensivists (470) Emergency Medicine (575) Anonymous
Outcome Measures: Death Neurologic Injury Prolonged Hospitalization No Harm Pediatrics 105: , 2000
Critical Incident Analysis What went wrong? Why? How can we prevent it from happening again?
Methodology: Each case reviewed independently Daniel Notterman MD Helen Karl MD Joseph Weinberg MD Charles Coté MD All cases debated Only cases accepted = total agreement Supported by Roche Pharmaceuticals
Source of Data - Final Set
Quotable quotes in reports !!!!
“The patient was not on any monitors” Self evident death
“The patient received tablespoons instead of teaspoons” Dispensing error death
“If they made nurses stay after 5 PM they would all quit” Inadequate recovery procedures rescued by a friend!
“Physician administered medication and left facility leaving the patient with a technician” Inadequate personnel death
“patient given 175 µg fentanyl IV chest wall rigidity” They did not understand pharmacodynamics neurologic injury
“6-wk old infant received Demerol Phenergan and Thorazine for a circumcision found dead in bed” Drug-drug interaction Poor drug selection
“Drug given at home by a parent” Lack of medical supervision death
“Anesthesia given by a gynecologist” You can’t do two things at the same time death
“The child received 6,000 mg of chloral hydrate” Drug overdose death
“Child became stridorous and cyanotic on the way home” Premature discharge rescued
“An oxygen outlet available but no flow meter…no oxygen for 10 minutes” Inadequate equipment Neurologic injury
ASA Physical Status
Outcome Death / Neurologic Injury Prolonged hospitalization or No Harm 60 35
Number of Medications
Route of Administration (Death)
Presenting Event (1st - 2nd - 3rd)
Outcomes by Specialty SpecialtyDeath/InjuryPercent Dental2991 Radiology1173 Cardiology360 ER00
Venue of Event
Outcome vs Monitoring OutcomeOximeter (N = 21) None (N = 18) Death/Injury414* No harm174 * P < compared with pulse oximetry Pediatrics 105: , 2000
Outcome vs Monitoring (Oximetry vs. Venue) RescueNo Rescue Hospital150 Office14* * P < 0.01 Office vs. Hospital Pediatrics 105: , 2000
Demographics vs Venue HospitalNon-HospitalP value Age (years) 3.8 Weight (kg) 16 1226 ASA status <0.001 Pediatrics 105: , 2000
Moderate Sedation ResponsePurposeful response to verbal or tactile stimulation AirwayNO intervention required VentilationAdequate CV functionUsually maintained Reflex withdrawal is NOT considered purposeful
Deep Sedation ResponsePurposeful response following repeated or painful stimulation AirwayIntervention may be required VentilationMay be adequate CV functionUsually maintained Reflex withdrawal is NOT considered purposeful
Pediatrics 110: , 2002 (October issue) The Most Recent AAP Addendum
All practitioners must use the same monitoring guidelines including all office based settings (AAP)
Now ASA, AAP and JCAHO are all using the same language and definitions
Sources of Controversy American Academy of Pediatric Dentists
Sources of Controversy AAPD definitions: “conscious sedation levels 1, 2, 3” Use of home prescriptions Need to join other major medical organizations (AAP) (ASA) (JCAHO)
There is hope An AAP/AAPD taskforce exists 2 Revisions so far!
It will be a state to state battle to change dental practice laws
This is what has to stop!
Controversial Issues KetamineFull stomach? Definition? PropofolWho should use it? Who should not use it? RemifentanilWho should use it? Who should not use it? CapnographyWhen is it needed? RecoveryHow long? Which drugs? FastingHow long? Quality of evidence? Sedation ScoreConsistent AAP & ASA?
Controversial Issues KetamineNo aspiration in 1000 sedations – power? “Dissociative state” Different from minimal, moderate, deep sedation or even general anesthesia ??? Does not depress respirations?? 1-2% Apnea, laryngospasm??
Controversial Issues PropofolWho should use it? Who should not use it? Guenther et al: 2003 ER: 4% jaw thrust, 1% apnea (291 sedations) Bassett et al: 2003 ER: 5% hypoxia, 3% jaw thrust, 0.8% apnea (399 sedations) Barbi et al: 2003 ER: 1059 sedations (483 EGD) 10 laryngospasms, 4 major desaturations Seigler et al: 2001 ICU: 261 MRI sedations 1 unplanned intubation
Controversial Issues CapnographyWhen is it needed? Yldzdas et al: 2004 ER: 126 sedations MDZ/K v. propofol (52% prop = ETCO 2 > 50) Connor et al: 2003 MRI: 165 sedations pentobarbital = normal ETCO 2 Coté et al: 2004 Cardiac Cath 44 sedations R 2 =.8 ETCO 2 v. PaCO 2
Controversial Issues RecoveryHow long? Which drugs? Coté et al 2000CH, DPT, IM- Pentobarbatol Malviya et al: 2004 CH Kao et al:1999CH Terndrup et al: 1991 DPT
Controversial Issues FastingHow long? Quality of evidence? Agrawal et al: 2003 ER: 905 sedations 56% inadequate fasting no aspiration events Pena et al: 1999 ER: 1180 sedations 5 vomiting no aspirations Kennedy et al: 1998 ER: 260 sedations no aspirations
Controversial Issues Sedation Score Is it consistent with AAP & ASA?? 1Anxious, agitated, restless 2Cooperative, oriented, tranquil 3Asleep, brisk response to cheek stroke 4Asleep, sluggish response to cheek stroke 5No response cheek stroke, responds to painful stimuli 6No response to painful stimuli