1. Pediatric Sedation Cindy Sanders, RN, MSN November 1, 2008

2. Kids are different Goals for sedation to control behavior to allow procedure to be completed successfully Kids under age 5 or 6 (chronologically or developmentally) may require deep sedation Anatomical and physiological differences must be considered May be more vulnerable to respiratory depression and may pass into deeper sedation state than was intended

3. “Rules” are the same American Academy of Pediatrics,(AAP) American Society of Anesthesiologists, (ASA) American Academy of Pediatric Dentists (AAPD) and Joint commission on Accrediation of Healthcare Organizations (JCAHO) issued guidelines for pediatric sedation

4. Safe sedation requirements –Systematic approach –No administration of sedation with safety net –Careful focused pre-sedation assessment –Appropriate NPO –Focused airway exam –Clear understanding of meds, interactions, etc.

5. Goals of Pediatric Sedation Guard Patient safety Minimize discomfort and pain Control anxiety, minimize psychological trauma, maximize amnesia Control behavior to allow successful completion of exam Return patient to a state in which safe discharge is possible

6. Who is an infant/ child? AAP: birth to 21 years PALS: infant to age 1, child 1yr to puberty Some institutions: to age 18 Chronologic vs. developmental age

7. The Sedation Continuum Moderate/conscious Deep Mild/conscious/anxiolysis

8. The sedation continuum Must be able to “rescue” patient from next level Failure to rescue may be more common in non hospital setting Conscious sedation may be an oxymoron for the young peds patient

9. Regardless of the medication given, the route of administration or the intended level of sedation, the sedation of a pediatric patient may result in respiratory depression and loss of airway protective reflexes

10. Candidates for pediatric sedation ASA class I and II generally good candidates ASA II and IV-require consideration, consultation with anesthesia, etc Pediatric specific considerations must be evaluated

11. Peds specific risks Untreated severe GERD (Gastro- esophageal reflux disease) Recent apnea monitor/history Congenital airway anomalies such as macroglossia, micronathia, etc. Extreme Tonsillar hypertrophy Mitochondrial or metabolic disease

13. Sedation history Prior sedation history Medication history/allergies Significant medical history Does patient snore Recent cold, asthma, etc. NPO status Parent/guardian accompanying child

14. NPO guidelines Elective procedures require fasting guidelines Risk of aspiration less than with general anesthesia but absolute risk not known Generally same guidelines as for general anesthesia are followed Solids 6-8 hours, breast milk (considered semi-solid by some and clear by others-2-4 hours, clears 2 hours

15. Fluid status Some patients will have been NPO for 12 or more hours. May give pre-sedation bolus of 20cc/kg of isotonic solution like Normal saline This may decrease the risk of hypotension and hemodynamic compromise May want to leave IV in at procedure end till patient awakens and drinks.

16. Pre sedation assessment Vital signs including heart rate, respirations, b/p, temperature Pulse oximetry reading If using ETCO2 monitoring, baseline reading Accurate weight

17. Pre sedation assessment Focused physical exam including respiratory and cardiac rate rhythm and quality Renal or hepatic function ok? Ability of child to cooperate-is non sedation an option? Any contraindications to procedure (MRI, etc)

18. Pre sedation Informed consent Time out procedure

19. IV access Use of topical analgesia if possible –EMLA, LMX, Synera (>3 years)-use care to follow age and duration guidelines –New product on market called Zingo (>3 as well) being trialed at several pediatric institutions Take time to find best site Secure well! Consider contrast requirements if CT

20. Personnel and equipment Must have pediatric specific emergency equipment immediately available Sedation providers must be trained in he administration of sedation medications and the management of complications associated with these medications Must have skills necessary to rescue patient from next level of sedation

21. RN requirements Institution specific but minimal requirements include BLS and PALS certifications “Additional” competency based training in sedation medications, procedural requirements and rescue skills that is ongoing

22. AZ State board of Nursing Employers must identify medication allowed for conscious sedation Licensed provider must be present in the dept from the time the medication is initiated to the completion of the procedure and must be readily available in the facility to assume care of the patient during the post-procedure period

23. AZ Board of Nursing Registered nurse responsible must not “leave patient unattended or engage in other tasks that compromise continuous monitoring” Specific list of educational requirements for RNs who administer sedation. Advisory opinion Conscious sedation for Diagnostic and Therapeutic Procedures revised 5/08.

24. Monitoring Intraprocedure Continuous monitoring of heart rate and pulse oximetry and intermittent recording of respiratory rate and blood pressure Standard is within 5 minutes prior to sedation and every 5 minutes till procedure is complete Post procedure-vital signs at regular intervals (most often q 15 minutes)

25. End Tidal CO2 Anesthesia literature validate rapid response in respiratory depression/hypoventilation Most guidelines recommend or state should be immediately available for moderate and esp. deep sedation In areas where can’t see patient (MRI) has become more of a standard of care

26. General pediatric medication considerations Dose must be individualized and double checked Give small increments and wait for effect Expect variations in responses Be prepared to assist respirations, etc. Remember to consider other medications and combinations

27. Pediatric sedatives Standard pre-printed orders may decrease potential for error in dosages Special care with route

28. Sedation medications Goal: Use the lowest dose of the medication with the highest therapeutic index for the procedure Perfect drug: Causes no respiratory or cardiovascular compromise, effects last the exact length of the procedure and has no contraindications

29. Real medication choices Chloral hydrate Benzodiazepines Opiates Barbiturates Anesthetic agents Dexmedetomidine

30. Chloral hydrate Has been used for more than 100 years Classified as a sedative/hypnotic No analgesic properties May be given orally or rectally Sometimes referred to as “not really a sedative” and therefore outside of the guidelines in any given institution

31. Chloral Hydrate Doses range from 25-125mg/kg-most common is 50mg/kg Single dose max of 1000mg reported Onset of action is very variable ranging from 10-60 minutes Long sedation has been reported Premature discharge has led to death

32. Chloral Hydrate Hepatic accumulation of metabolites reported in premature infants Unpleasant taste, nausea and vomiting common Many studies citing other drugs as more efficient Some data supporting increased success if patient under 2 years. No reversal agent

33. Benzodiazepines Has sedative, anti -anxiety and amnesic properties No analgesic properties Commonly used as pre-med Often not able to provide adequate sedation for procedures that require immobility as a single agent Versed most commonly used agent

34. Versed (Midazolam) May be given in a variety of ways Doses: –IV0.05-0.1mg/kg –Oral 0.5-0.7 mg/kg –Rectal 0.5-1.0 mg/kg –Nasal 0.2-0.4 mg/kg –Sublingual 0.2mg/kg

35. Midazolam Concomitant use of opiate will increase effects Onset of action depends upon route-1-5 minutes IV up to 20-60 minutes orally Can cause hypotension, respiratory depression Reversal agent is Flumazenil (Romazicon)

36. Opiates Used for painful procedures Often combined with benzodiazepines Fentanyl most common opiate used in pediatric procedures due to relatively short half life Reversal agent is Naloxone (Narcan) May need to repeat Narcan dose due to short ½ life.

37. Fentanyl IV form used for sedation (lollipop and patch extended release) Dose is usually 1 mcg/kg Duration of action generally ½-1 hour Can cause chest wall rigidity if given as rapid bolus

38. Barbiturates Pentobarbital historically used Radiology sedative-is not an analgesic Given IV up to 6mg/kg Long half life a concern as related to increased recovery times Attempts to awaken early may contribute to emergence reaction or pentobarb rage No reversal agent

39. Anesthetic agents Ketamine Propofal

40. Ketamine Has dissociative properties and is therefore somewhat unique Used in human and vet medicine Provides sedation and analgesia At high doses is a general anesthetic agent May be given IV or IM

41. Ketamine To be used only “under direct supervision of a LIP with experience with anesthetic agents” Causes discongigant eye movements Can cause hallucinations (visual and auditory) usually at emergence- versed given in combination to reduce

42. Ketamine Dose- –IV 0.5-2mg/kg-usually use 0.5-1 for procedural sedation –IM 3-7mg/kg Onset of action 30 secs. IV. 3-4 minutes IM Duration 12-25 minutes IM, 5-10 minutes IV

43. Propofal No analgesic properties General anesthetic agent with very rapid onset and potential for apnea State and institution guidelines vary as to RNs ability to manage infusions Bolus dosing by LIP Study in 2005 showed that 42% of 54 pediatric hospitals were using propofal outside of the OR given by non anesthesiologists

44. Propofal Bolus then drip essential as drug is degradated in single pass through the liver Bolus is usually 1-2mg/kg Infusion rates of 50-250mcg/kg/min for short term procedural sedation Pediatric specific mortality reported from irreversible metabolic acidosis in 1999 from long term high dose infusions

45. Dexmedetomidine (Precedex) Highly selective alpha2 adrenoceptor agonist with both analgesic and sedative effects Classified as anesthetic agent Mechanism of action is induction of stage 2 (non REM sleep) Bolus then infusion delivery Short ½ life and lack of respiratory depression reported

46. Precedex Advantages –Less interference with EEG waves so therefore more diagnostic quality –Promising results for consistency in achieving adequate sedation for imaging studies –Large on-going study at Boston Children’s Hospital demonstrating positive safety profile

47. Precedex Hemodynamic changes can occur but are not usually clinically significant Specifically, bradycardia is common but without hemodynamic compromise Contraindications include patients on Digoxin (cardiac arrest reported in adults) and other cardiac conditions

48. Post Sedation Considerations Patients may still be at significant risk for complications Removal of stimulation (pain, MRI noise) may cause deeper sedation level especially if multiple doses have been given Delayed drug absorption (oral, rectal, IM) and slow drug elimination also may contribute

49. Post Sedation Considerations Continued monitoring and observation necessary Pre-determined discharged criteria –Aldrete most common –Score of 9 or back to baseline usual criteria With kids, ability to drink also important to avoid dehydration and hypoglycemia (infants)

50. Post Sedation Considerations Written discharge instructions that are age specific desirable Toddlers especially at risk for falls, etc Positioning in car seats, etc with infants also very important due to pediatric airway anatomy

51. QA/QI outcome data Guidelines state there should be an analysis of any adverse events Collecting data regarding success rates, etc helps drive practice change One Benchmark: Pediatric Sedation Research Consortium

52. Take home points

53. Kids are not little adults Know age specific vital sign norms Know where your pediatric airway equipment is and how to use it Remember airway position Double check your meds

54. Remember if your intent is to sedate a patient, irregardless of the medication or dose you use, sedation guidelines apply

55. Any Questions?????

56. Pediatric Sedation References Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Therapeutic and Diagnostic Procedures: An Update. American Academy of Pediatrics, American Academy of Pediatric Dentists, Cote, C.J, MD, Wilson, S/ DMD, MA, PhD the WorkGroup on Sedation. Pediatrics Vol 118 No.6 December 2006 pp 2587-2602. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: an updates report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. V 96 No. 4, April 2002 Incidence and Nature of Adverse Events During Pediatric Sedation /Anesthesia for Procedures Outside the Operating Room: Report from the pediatric Research Consortium. Cravero, J.P. MD, Blike, G.T. MD, Beach, M. MD, Gallagher, S. M. BS, Hertzog, J.H. MD, Havidich, J.E. MD, Gelman, B.MD, and the Pediatric Sedation Consortium. Pediatrics Vol. 118, No 3. September 2006, PP 1087-1096. Advisory Opinion Conscious sedation for Diagnostic and Therapeutic procedures. Arizona State Board of Nursing.