1. Sedation and Analgesia for Diagnostic and Therapeutic Procedures Michael S. Mazurek, M.D. Associate Professor of Clinical Anesthesia Riley Hospital for Children

2. Overview Goals of Sedation Definitions of Levels of Sedation Risks and Complications Clarian Sedation Guidelines by Case Examples Specific Drugs

3. Goals of Sedation Guard the patient’s safety Minimize pain Provide anxiolysis Control behavior Return the patient to a state in which safe discharge is possible

5. Risks and Complications AIRWAY, AIRWAY, AIRWAY –airway obstruction –hypoventilation –apnea –aspiration Hemodynamic impairment

6. Risks and Complications Numerous case reports exist describing complications from sedation and analgesia Few large series exist involving a numerator (adverse events) and a denominator (total number of sedations)

7. Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors Pediatrics 2000; 105: 805-814 4 physicians reviewed adverse sedation events for probable causes 95 events were reviewed

8. Safety Conclusions Respiratory events are the most frequent initiating events All areas using sedation have reported adverse events Pediatrics 2000; 105: 805-814

9. Safety Conclusions Adverse events involved: –Multiple drugs –Drug overdose –Inadequate medical evaluation –Inadequate monitoring –Inadequate practitioner skills Pediatrics 2000; 105: 805-814

10. Medication Conclusions Adverse outcome was associated with all routes of drug adminstration Adverse outcome was associated with all classes of medication, even when given within the recommended dose range Drugs should not be given at home Avoid premature discharge Pediatrics 2000; 106: 633-644

11. Reappraisal of Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT) for the Sedation of Children Pediatrics 1995; 95: 598-602 “ The DPT cocktail remains a widely used sedative and analgesic for pediatric patients. Neither the combination itself nor its dosage is based on sound pharmacologic data. There is a high rate of therapeutic failure as well as a high rate of serious adverse reactions, including respiratory depression and death, associated with its use.”

12. Clarian Sedation Guidelines http://clarianweb.clarian.com/ Moderate Sedation Guidelines Deep Sedation Guidelines

13. 1 year old sedation for an MRI What equipment do you need available before you sedate this patient?

14. Equipment Oxygen supply Airway equipment of appropriate size Suction apparatus of appropriate size Age appropriate emergency cart Physiological monitoring equipment

15. 1 year old sedation for an MRI Do you need a consent for sedation? Is the MRI consent enough?

16. 1 year old sedation for MRI What is important for your presedation history?

17. Presedation Medical Evaluation History of sedation/anesthesia problems Airway problems (obstructive sleep apnea) Respiratory symptoms Current medications; drug allergies Review of systems NPO status

18. 1 year old sedation for MRI Would you sedate the child if they had formula 2 hours ago? What are appropriate NPO guidelines? –Clear liquids? –Breast milk? –Formula? –Big Mac?

19. AgeSolids and non- clear liquids Clear liquids Adults/Children > 36 months old 6 – 8 hours2 – 3 hours Children 6 – 36 months old 6 hours2 – 3 hours Children < 6 months old 4 – 6 hours2 hours Clarian Sedation Guidelines 1999

20. 1 year old sedation for MRI What physical evaluation are you going to perform before the sedation?

21. Preoperative Evaluation of the Upper Airway Tongue versus pharyngeal size Atlanto-occipital joint extension Anterior mandibular space (thyromental distance Dental examination

24. Risk Classification Low – Relatively healthy patient. Moderate – Patient with a significant pathologic process that is difficult to control. High – Patient with a severe pathologic process that has produced potentially irreversible end-organ damage.

25. Patients at Increased Risk Prior adverse response to sedation Airway problems: OSA, difficult intubation, or syndrome with airway abnormalities Significant respiratory symptoms High risk classification Delayed gastric emptying or aspiration risk

26. 1 year old sedation for MRI How are you going to monitor the patient?

27. Monitoring Patient response as a guide to level of sedation –Children may be an exception Continuous pulse oximetry Ventilation –Observation, auscultation, or ETCO2 ECG and BP for all patients under deep sedation and when indicated for moderate sedation

28. Ventilation Pulse oximeter is not a ventilation monitor Impedence Pneumography does not monitor ventilation Observation and auscultation for the uncovered patient ETCO2 for the covered patient

29. Manpower Minimum of two persons: –One to perform the procedure –Another to monitor the patient The monitoring person may assist with short, interruptible tasks during moderate sedation The monitoring person may have no other duties during deep sedation

30. Documentation Clarian Sedation Flowsheet Medicines –Dosages, times, and routes Vital signs every 5 minutes –Minimum SaO2 and RR –BP and HR if indicated

31. Post - Sedation Observe in quiet environment for resedation Impaired patients should be back to presedation status Normal patients should be fully awake

32. Post - Sedation Observe for minimum 1 hour if reversal agent given Physician must perform a post-procedure evaluation Adverse outcomes documented on flowsheet: –Conversion to GA, emergency intervention, respiratory complications, death

33. 1 year old for sedation for MRI How are you going to sedate this kid?

34. 3 year old for sedation for head laceration in the ER How are you going to sedate this kid?

35. 10 year old for bone marrow aspirate How are you going to sedate this kid?

36. 8 year old for abdominal CT How are you going to sedate?

37. Specific Drugs Study the pharmacology of the drugs you plan on using Become an expert on a few, appropriate drugs Start with small doses and titrate to effect When combining drugs, decrease the dose of each component

38. Specific Drugs Sufficient time should elapse before redosing Tailor your drugs to need – if you don’t need analgesia, don’t give a narcotic

39. Other Considerations Consult a specialist for high risk patients Maintain your airway skills

40. Specific Drugs Local Anesthetics Chloral hydrate Midazolam, Flumazenil Fentanyl, Morphine, Naloxone Propofol Ketamine

41. Local Anesthetics Use for analgesia –Greatly reduces need for systemic narcotics EMLA (lidocaine 2.5%, prilocaine 2.5%) –Need 45 – 60 minutes for efficacy Epinephrine 1:200,000 (5 mcg/cc) –Prolongs duration of block –Decreases bleeding –Slows systemic uptake

43. Chloral Hydrate Oral/Rectal dose: 25-100 mg/kg, max 100mg/kg or 2gm Onset: 15 – 30 minutes Peak effect: 30 – 60 minutes Duration of action: variable – may persist for 10 – 20 hours in neonates and toddlers

44. Midazolam Benzodiazepine –Sedative with no analgesia Oral dose: 0.25 – 0.75 mg/kg, max 15 mg Pediatric IV dose: 25 – 50 mcg/kg every 5 minutes, max dose 0.4 mg/kg Adult IV dose: 1-2 mg every 5 minutes, max 10mg Onset: oral 10 – 30 minutes –IV 3 – 5 minutes Duration of action: oral 60 minutes –IV 20 – 60 minutes

45. Flumazenil Benzodiazepine antagonist for benzodiazepine overdose IV dose: 0.01 mg/kg every 1 minute, no more than 0.2 mg per dose, max dose 1 mg Onset: 1 – 3 minutes Duration of action: < 1 hour

46. Fentanyl Pediatric IV dose: 0.5 – 2 mcg/kg every 5 minutes, max dose 3 mcg/kg Adult IV dose: 50 – 100 mcg every 5 minutes, max dose 200 mcg Onset: 2 – 3 minutes Duration of action: 30 – 45 minutes

47. Morphine Pediatric IV dose: 50 – 100 mcg/kg every 5 minutes, max dose 0.2 mg/kg Adult IV dose: 2 – 4 mg every 5 minutes, max dose 12 – 14 mg Onset: 5 minutes Duration of action: 3 – 5 hours

48. Naloxone Narcotic antagonist for narcotic reversal IV dose: 0.1 mg/kg every 2 –3 minutes, no more than 2 mg per dose with a maximum dose of 10 mg Onset: 1 – 2 minutes Duration of action: 45 minutes

49. Propofol Can very quickly induce general anesthesia and apnea Need to give as a continuous infusion IV dose: 0.5 – 1.0 mg/kg loading dose followed by infusion of 25 – 100 mcg/kg/min, titrating to effect Onset: < 1 minute after loading dose Duration of action: depends on duration of infusion

50. Ketamine Produces a dissociative state Provides intense analgesia IM dose: 2 – 4 mg/kg –Onset: 5 – 10 minutes –Duration: 30 – 90 minutes IV dose: 0.25 – 0.5 mg/kg –Onset: 1 – 2 minutes –Duration: 20 – 60 minutes