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Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial.

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Presentation on theme: "Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial."— Presentation transcript:

1 Charles J. Coté, MD Professor of Anesthesiology & Pediatrics Northwestern University Vice Chairman Department of Pediatric Anesthesiology Children’s Memorial Hospital Chicago Illinois

2 Sedation Guidelines: where have we been & where are we headed

3 Sedation Goals Anxiolysis Analgesia Amnesia Safety Control behavior Return to baseline

4

5 American Academy of Pediatrics Guidelines Response to Dental Accidents

6 Guidelines for the Elective use of: Conscious sedation Deep sedation General anesthesia Pediatrics 76: , 1985

7 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)

8 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)

9 Guidelines for Monitoring and Management of Pediatric Patients during and after Sedation for Diagnostic and Therapeutic Procedures Pediatrics 99: , 1992

10 Guideline Emphasis Pre-sedation evaluation Appropriate fasting Informed consent Monitoring Time-based record Recovery facility Discharge criteria No out of facility prescriptions

11 Source of data: FDA adverse drug reports (629) USP Survey Pediatric  Anesthesiologists (310)  Intensivists (470)  Emergency Medicine (575) Anonymous

12 Outcome Measures: Death Neurologic Injury Prolonged Hospitalization No Harm Pediatrics 105: , 2000

13 Critical Incident Analysis What went wrong? Why? How can we prevent it from happening again?

14 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

15 Source of Data - Final Set

16 Quotable quotes in reports !!!!

17 “The patient was not on any monitors” Self evident  death

18 “The patient received tablespoons instead of teaspoons” Dispensing error  death

19 “If they made nurses stay after 5 PM they would all quit” Inadequate recovery procedures  rescued by a friend!

20 “Physician administered medication and left facility leaving the patient with a technician” Inadequate personnel  death

21 “patient given 175 µg fentanyl IV  chest wall rigidity” They did not understand pharmacodynamics  neurologic injury

22 “6-wk old infant received Demerol Phenergan and Thorazine for a circumcision  found dead in bed” Drug-drug interaction Poor drug selection

23 “Drug given at home by a parent” Lack of medical supervision  death

24 “Anesthesia given by a gynecologist” You can’t do two things at the same time  death

25 “The child received 6,000 mg of chloral hydrate” Drug overdose  death

26 “Child became stridorous and cyanotic on the way home” Premature discharge  rescued

27 “An oxygen outlet available but no flow meter…no oxygen for 10 minutes” Inadequate equipment  Neurologic injury

28 Age Distribution

29 ASA Physical Status

30 Outcome Death / Neurologic Injury Prolonged hospitalization or No Harm 60 35

31 Causes

32 Drug Category

33 Number of Medications

34 Route of Administration (Death)

35 Presenting Event (1st - 2nd - 3rd)

36 Outcomes by Specialty SpecialtyDeath/InjuryPercent Dental2991 Radiology1173 Cardiology360 ER00

37 Venue of Event

38 Outcome vs Monitoring OutcomeOximeter (N = 21) None (N = 18) Death/Injury414* No harm174 * P < compared with pulse oximetry Pediatrics 105: , 2000

39 Outcome vs Monitoring (Oximetry vs. Venue) RescueNo Rescue Hospital150 Office14* * P < 0.01 Office vs. Hospital Pediatrics 105: , 2000

40 Demographics vs Venue HospitalNon-HospitalP value Age (years) 3.8   Weight (kg) 16  1226  ASA status <0.001 Pediatrics 105: , 2000

41 Cardiac Arrest Pediatrics 105: , 2000 * P < * *

42 Pediatrics 105: , 2000 Death / Injury vs. Venue * * P < 0.001

43 Non-hospital Patients Older Heavier Healthier (lower ASA status) Deader !!!!!!!!!!!!!

44 Non-Hospital vs. Hospital FAILURE TO RESCUE INADEQUATE CPR SKILLS

45 CONCLUSIONS Not the drugs, route of administration, or the patient population Monitoring makes a difference Need Systems approach Need CPR skills to rescue patients

46 Coté’s Caveats

47 Infants and children require pharmacologic coma to remain still for a procedure

48 Drug effects are the same regardless of: Route of administration Who gives them Where they are given

49 “conscious sedation” is an oxymoron

50 The intended sedation level is difficult to achieve IntendedDeepGeneral Anesthesia Moderate32260 Deep General Anesthesia Dial S, et al: Pediatr Emerg Care 17: , 2001 – 301 sedations

51 Pulse oximetry is essential

52 First Diagnosis of Desaturation, 1991 Coté et al: Anesthesiology 74: , 1991

53 ASA & JCAHO Practice Guidelines for Sedation and Analgesia by Non- Anesthesiologists 1996 Did not address deep sedation !!

54 ASA & JCAHO Working together  new definitions

55 New Sedation Terminology Minimal = “anxiolysis” Moderate = “conscious sedation” or “sedation/analgesia” Deep = deep sedation/analgesia

56 The concept of RESCUE

57 Minimal = Rescue from Moderate Sedation Moderate = Rescue from Deep Sedation Deep = Rescue from General Anesthesia What does rescue mean?

58 Rescue Airway

59 Rescue Observation Timely recognition of event Timely diagnosis of event Skills needed for intervention  Advanced airway skills  CPR skills

60 Further ASA Responses 2002

61 Minimal Sedation ResponseNormal response to verbal stimulation AirwayUnaffected VentilationUnaffected CV functionUnaffected

62 Moderate Sedation ResponsePurposeful response to verbal or tactile stimulation  AirwayNO intervention required VentilationAdequate CV functionUsually maintained  Reflex withdrawal is NOT considered purposeful

63 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

64 Pediatrics 110: , 2002 (October issue) The Most Recent AAP Addendum

65 All practitioners must use the same monitoring guidelines including all office based settings (AAP)

66 Now ASA, AAP and JCAHO are all using the same language and definitions

67 Victory?

68 Almost!

69 Sources of Controversy American Academy of Pediatric Dentists

70 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)

71 There is hope An AAP/AAPD taskforce exists 2 Revisions so far!

72 It will be a state to state battle to change dental practice laws

73 This is what has to stop!

74 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?

75 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??

76 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

77 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

78 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

79 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

80 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

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