20090607_1030_Pediat..

Report
Pediatric Procedural
Sedation
Dr. Marc N. Francis
MD, FRCPC
University of Calgary
Foothills Medical Centre
Alberta Children’s Hospital
Disclosure
I do not have an affiliation (financial or otherwise) with
any commercial organization that may have a direct or
indirect connection to the content of my presentation.
PSA in the ED


“Painful procedures are unavoidable in emergency
medicine”
“While anesthesiologists have unique qualifications to
provide sedation, their availability is variable and
unreliable, and is limited by commitments to the
operating room”
Procedural Sedation and Analgesia in the Emergency Department.
Canadian Consensus Guidelines
Journal of Emergency Medicine 1999; 17(1): 145-156
Learning Objectives

“Tools of the Trade”


“The Right Tool for the Job”


Some adjuncts and techniques that will make your job easier
Controversies


Discuss the variable needs for procedural sedation in the ED and
pharmaceutical options
“Tricks of the Trade”


Sedation medications that you should know well and be familiar with
A look at some of the more controversial aspects of procedural
sedation in children
The Future

What is coming down the pipe for the future of procedural sedation
Importance

Studies have shown that children are less likely than
adults to receive pain medications and sedation for
similar painful procedures*




Children cannot fully understand the medical necessity for
testing or therapeutics
Children’s anxiety can heighten the discomfort
Allows for control of behaviour for the safe and successful
completion of a procedure
Parental, patient and physician satisfaction
*Selbst SM Analgesic use in the Emergency Department. Ann Emerg Med 1990;19:1010-1013
Sedation Spectrum

Minimal Sedation



Moderate Sedation



Patient responds to verbal commands or with addition of mild
stimulus
Maintains airway and ventilation without required intervention
Deep Sedation



Patient responds appropriately to verbal commands
Cognitive processing affected but no cardiopulmonary effects
Not easily aroused but responds purposefully with uncomfortable
stimulus
May require medical intervention to maintain an airway and
ventilation
General Anesthesia


Unable to be aroused with a verbal or painful stimulus
Need help maintaining their airway
Indications for Pediatric Procedural
Sedation

Diagnostic






Urinary Catheterization
Lumbar puncture
Radiographic evaluation
(CT or MRI)
Joint aspiration
Sexual assault
examinations
Eye examinations

Therapeutic







IV starts
Laceration repair
Abscess I+D
Fracture Reductions
Dislocations reduction
Foreign body removal
Burn dressings
The Search Continues…

The ideal sedation protocol:
1)
2)
3)
4)
5)
6)
Rapid induction and emergence
Provides anxiolysis, analgesia and amnesia
Sufficient control of movement to allow for ease
of procedural completion
Maintain effective spontaneous ventilation and
airway control
Complete Cardiopulmonary stability throughout
Minimal to no side effects
“Tools of the Trade”
Nitrous Oxide



Dissociative gas with
mild to moderate
procedural anxiolysis,
analgesia and amnesia
Dosage


50% concentration
blended with oxygen
Ideally self administered
Advantages



Onset and offset within 5mins
Does not require an IV
Disadvantages



Requires special delivery device
Nausea and Vomiting
Well ventilated room with
scavenger system
Midazolam


Short-acting agent with
rapid onset of anxiolysis,
sedative and amnestic
properties


Interacts with GABA
receptors in the brain
Dosage




0.2-0.6mg/kg intranasally
0.05-0.2mg/kg IV
0.1-0.2mg/kg IM
0.5-0.75mg/kg PO
Advantages





Rapid onset
Anxiolysis
Profound retrograde amnesia
No IV required
Disadvantages



Does not provide analgesia
Disturbance in respiratory
function +/- hypoxemia
Paradoxical reactions
Fentanyl





Synthetic opiod which is
narcotic of choice in PSA

Rapid onset and short
duration make it easy to titrate
Does not cause histamine
release so minimal CV effects
Dosage


1-3mcg/kg IM or IV
10-20mcg/kg oral or
transmucosal
Advantages



Excellent analgesic
Peak effect within 15-30mins
Reversible with naloxone
Disadvantages





Nausea and vomiting
Respiratory depression
Hypotension
No amnesia. Minimal sedation
Fentanyl Rigid Chest
Ketamine


Dissociative agent




Sedation, analgesia and
amnesia are maintained
Inhibits reuptake of
catecholamines
Stimulates salivary, tracheal
and bronchial secretions
Dosage



1-2mg/kg IV
2-5mg/kg IM
6-10mg/kg PO
Advantages




Reliably produces potent
analgesia, sedation and amnesia
Hemodynamic stability
Maintain airway reflexes
Disadvantages




Emergence phenomenon
Nausea and Vomiting
Increased secretions
Potentially serious respiratory
complications
Propofol


Potent hypnotic agent
with no analgesic
properties



Effects lipid membrane
Na-channel function and
Stimulates GABA
Rapid onset,
redistribution and
elimination
Dosage

1mg/kg IV bolus then
0.5mg/kg q45-60sec
Advantages





Rapid onset/offset
Easily titratable
Anti-emetic
Bronchodilator
Disadvantages




No analgesic properties
Potent cardiopulmonary
depressant
Pain on injection
Inadvertent oversedation
“The Right Tool for
the Job”
The Right tool for the Job





28mth ♀ presents with 4day hx of
fever, vomiting and flank pain
PMHX – Healthy
Temp 38.5, HR 121, RR 16,
BP 84/56, Sat 98% RA
Not toilet trained
Wanting to do an in/out cath





Nitrous Oxide
Midazolam
Fentanyl
Ketamine
Propofol
Sedation Spectrum:
Minimal Sedation
The Right tool for the Job




5yo ♂ fell onto wooden post
Extensive and complex facial
laceration requiring multilayer
closure
PMHX – Asthma well controlled
VSSA





Nitrous Oxide
Midazolam
Fentanyl
Ketamine
Propofol
Sedation Spectrum:
Dissociative
Sedation
The Right tool for the Job





 Nitrous Oxide
15yo ♂ playing soccer and collided
 Midazolam
with another player
 Fentanyl
Immediate pain to R shoulder which  Ketamine
 Propofol
is clinically consistent with anterior
dislocation
Sedation Spectrum:
Very Anxious!!!
Moderate Sedation
PMHX – Healthy
Normal Vital signs
The Right tool for the Job




7yo ♀ presents with patellar
dislocation while playing softball
Knee in “spasm” and patient
extremely anxious with any attempts
to examine or maneuver same
PMHx – Healthy
VSSA





Nitrous Oxide
Midazolam
Fentanyl
Ketamine
Propofol
Sedation Spectrum:
Minimal Sedation
The Right tool for the Job




3yo ♂ fell off the bed and refusing
to walk
Xray shows a displaced spiral tibial
fracture
PMHx – seizure disorder well
controlled
VSSA





Nitrous Oxide
Midazolam
Fentanyl
Ketamine
Propofol
Sedation Spectrum:
Dissociative
Sedation
“Tricks of the Trade”
Ondansetron with
Ketamine Sedation

Vomiting in the ED and upon discharge after
Ketamine sedation is common



Reported frequency of vomiting ranges from 4-19%
Increased vomiting associated with increasing
patient age
Vomiting
Decreases patient and parental satisfaction
 Delays discharge and consumes ED resources



Double-blind, randomized, placebo-controlled trial
N= 255 children randomized to



N= 128 IV Ondansetron 0.15mg/kg to max 4mg
N = 127 Placebo
Results

ED vomiting was less common with ondansetron 4.7% vs
12.6% p=0.02


NNT of 13
Vomiting in the ED or after discharge was less frequent with
ondansetron 7.8% vs 18.9% p=0.01

NNT of 9
Pre-oxygenation with
procedural sedation


Published adverse event rates during pediatric ED
procedural sedation vary between 2% and 18%
Consistently the most common adverse event is
transient hypoxia




Children’s basal oxygen use/kg is twice that of adults
Smaller FRC
Shorter “safe apnea” period before desaturation
Transient hypoxia is predictably seen with propofol


Very common with Midazolam and Fentanyl
Less likely with Ketamine unless co-administration with other resp
depressants
Adjunctive Atropine with
Ketamine Sedation

Ketamine stimulates oral secretions


In rare circumstances this has been implicated in
airway compromise1
Historically prophylactic anticholinergic agents
have been given with ketamine to blunt
hypersalivation
Glycopyrrolate 0.2mg
 Atropine 0.02mg/kg



Prospective observational study of ED pediatric
patients receiving ketamine sedation
N= 1090 patients over a 3yr period



947 (87%) were performed without adjunctive atropine
Assessed for salivation on a 100mm visual analog scale and
documented complications
Results




92% of patients had salivation rated at 0mm or “none”
Only 1.3% were rated >50mm
Transient airway complications in 3.2% of which only one
was thought to be related to hypersalivation (incidence 0.11%
95% CI 0.003% - 0.59%)
No occurrence of assisted ventilation or intubation
Adjunctive Atropine with Ketamine
Sedation




Omission of atropine is safe
Routine prophylaxis is unnecessary
There is minimal added risk presented with its
administration
Possible subsets of patients which may benefit
Very young children
 Those undergoing oropharyngeal procedures

Controversies
In your local ED….


9yo M previously healthy with no meds/allergies
Fell mountain biking 40mins ago and has
deformed and partially angulated radius/ulnar #
Neurovascularly intact distally
 Wearing helmet and no issues with potential HI



Bag of chips 2hrs ago with bottle of Gatorade
Survey
Would you sedate this child now?
 What would you use?

Pre-sedation Fasting guidelines


Minimal scientific evidence to support fasting
Risk of aspiration during ED PSA has not been
studied

Only single case of pulmonary aspiration with ED
sedation has been reported
Cheung K, et al. 2007. Ann Emerg Med 2007;49:462-464

Extrapolation from general anesthesia literature
Incidence of aspiration is low (1:3,420)
 Mortality is rare (1:125,109)

Relative risk of aspiration

Good reason to believe that aspiration risk with
PSA may be lower than GA
2/3 of aspiration occurs during airway manipulation
 Deeper level of sedation with GA
 Generally younger and healthier patients (ASA I-II)
 Inhalational agents are more emetogenic
 Ketamine sedation preserves protective airway
reflexes

What we are told
CAEP

No specific guidelines


“Insufficient data to show
that fasting improves
outcomes in patients
undergoing ED
procedural sedation”
In elective situations
consider NPO x 2hrs
(liquids) and 6hrs (solids)
ACEP

No specific guidelines


“No study has determined
a necessary fasting period
before initiation of PSA”
“Recent food intake is not
a contraindication for
PSA but should be
considered in choosing
the timing and target of
sedation”

ED specific clinical practice advisory


Goal to create a tool to permit ED physician to identify prudent
limits of sedation depth and timing in light of fasting status
Developed a 4-step assessment prior to sedation
1) Asses patient risk
2) Assess the timing and nature of recent oral intake
3) Assess the urgency of the procedure
4) Determine the prudent limit of targeted depth and
length of procedural sedation and analgesia
Assess Patient risk


Difficult airway?
High risk for esophageal reflux?





Extremes of age?



Esophageal disease
Hiatal hernia
PUD
Bowel obstruction
>70
<6mths
Severe Systemic disease?

ASA ≥ III
Timing and nature of oral intake


Single time point for sake of simplicity = 3hrs
From lowest to highest theoretical risk
1) Nothing
2) Clear liquids
3) Light snack
4) Heavier snack or meal
Urgency of the procedure

Emergency



Urgent



Care of dirty wounds and lacerations
Abscess I+D
Semiurgent



Cardioversion for life threatening arrythmia
Reduction of markedly angulated fracture
Care of clean wounds and lacerations
Shoulder reduction
Nonurgent or elective


Foreign body in external ear canal
Ingrown toenail
Depth of sedation

Procedure Duration



Brief: <10mins
Intermediate: 10-20mins
Extended: >20mins
Standard-risk patient
Higher-risk Patient
Capnography monitoring during
procedural sedation

Non-invasive
measurement of the
partial pressure of CO2
from the airway during
inspiration and
expiration
Capnography monitoring

Traditional monitoring



Pulse oximetry = oxygenation
RR and clinical observation = ventilation
Capnography




More precise and direct assessment of the patient’s
ventilatory status
Assessment of airway patency and respiratory pattern
Early warning system for prehypoxic respiratory depression
Assessment of depth of sedation
Show me the evidence!!!

Comparison of oximetry, capnography and clinical
observation in the ED2


75% of pediatric patients with respiratory compromise were
noted by EtCO2 monitoring only
Pediatric RCT comparing capnography to clinical
observation in detecting resp events3
Clinical assessment identified hypoventilation in 3% and did
not identify any patients with apnea
 Capnography data showed ventilation was compromised in
>50% of cases and nearly 25% fulfilled criteria for apnea

Recommendations

Good evidence that capnography provides a
means for early detection of sedation-related
hypoventilation

Clinical significance with regards to improved
patient outcomes has not been shown
Future
“where we’re going we don’t
need roads” – Dr. Emmett Brown
Ketofol
Propofol
 Pros




Antinauseant effects
Amnestic
Smooth recovery profile
Cons



Ketamine
 Pros
Cardiovascular and
respiratory depression
Bradycardia
Non-analgesic




Analgesia
Amnesia
Respiratory and
cardiovascular stability
Cons


Emergence phenomena
Vomiting

Prospective case series



114 ED procedural
sedations
1:1 mixture of ketamine
10mg/ml and propofol
10mg/ml
All age groups including
children as young as 4

Results


97% success rate with
procedures
3 patients with transient
hypoxia




1 required BVM
3 patients with emergence
No hypotension or
vomiting
Patient satisfaction scores
were 10 on a 1-10 scale

Systematic review of the literature

8 clinical trials were included


Adult and pediatric studies were included
Results




Ketofol was not superior to propofol monotherapy
Conflicting data exist regarding hemodynamic and respiratory
complications
At higher doses addition of ketamine to propofol may incur
more adverse effects
Compatability data for the two agents combined in a syringe
are limited
Ketofol



Theoretical benefits that have not been demonstrated
in the literature
Optimum ratio of ketamine and propofol remains to be
determined
Dosing regiments currently are highly variable
Not ready for
Primetime………….Yet
BIS
Bispectral Index

BIS


Uses processed EEG
signals to measure the
depth of sedation
Validated with children
undergoing general
anesthesia in the OR


Determine if the BIS monitor could be used to
guide physicians in titrating propofol for safe
levels of deep sedation in children
Results
BIS score of 45 determined to provide deep sedation
for 95% of the population
 Useful objective tool to guide effective titration of
propofol for children

Conclusions






Familiarize yourself with your pharmaceutical options
and “pick the right tool for the job”
Pre-oxygenation is your friend
Atropine is out and ondansetron is in for routine
ketamine sedations
Pre-procedural fasting guidelines are not black-andwhite and each situation is unique
Consider the additional information provided by
capnography if it is available to you
Ketofol not ready for primetime….. yet
Questions?
Additional References
1)
2)
3)
4)
Green SM et al. Intramuscular ketamine for pediatric sedation
in the emergency department: safety profile with 1022 cases.
Ann Emerg Med. 1998;31:688-97
Hart LS et al. The value of end-tidal CO2 monitoring when
comparing three methods of conscious sedation in children
undergoing painful procedures in the emergency department.
Pediatr Emerg Care 1997;13(3):189-93
Lightdale JR et al. Microstream capnography improves patient
monitoring during moderate sedation: a randomized, controlled
trial. Pediatrics 2006;117(6):e1170-8
Lopez MD et al. Pediatric Procedural Sedation. Emergency
Medicine Reports 2008;13(12):145-156
Additional Slides
Fentanyl Rigid Chest


Believed to be due to a central agonist effect of
narcotics
The pediatric population is more vulnerable to the
syndrome


Reported with doses from 2.5-6.5mcg/kg
Difficulty in ventilating is largely due to upper airway
(glottis) closure


Not thoracoabdominal tone as originally thought
In kids thoracoabdominal tone plays a larger role
Prevention of Fentanyl Rigid Chest
Propofol epilepsy
Is Propofol a pro- or anticonvulsant?


81 reported cases of presumed propofol induced
seizure like activity
Agonist-antagonist effect on Glycine which is a major
inhibitory neurotransmitter


Prospective study
Effects of IV propofol on EEG
25 children with epilepsy
 25 children with learning disorders
 Undergoing elective sedation for MRI


Results
No child in either group had increased spike-wave
pattern with propofol
 Depression in spike-wave pattern in the children
with epilepsy was seen


Supported the concept of propofol being a
sedative-hypnotic agent with anticonvulsant
properties
Aspiration case in
literature




65yoF with HTN
Trimalleolar fracture
Morphine/fentanyl/Propofol for first PSA with
no significant complications
Second PSA in attempt to improve the
reduction
6hrs after last meal
 Propofol/fentanyl


10 mins after propofol bolus the patient
vomited into the mask and aspirated

Sats were 86% initially


Patient remained hypoxic with sats 84% on RA



Airway was suctioned and BVM was started with
improvement to sats 97%
Inspiratory and expiratory wheezes throughout
RSI was performed and admitted to ICU where
she was ventilated for 12hrs then slowly weaned
No long-term complications
Etomidate
Etomidate



Initially described for RSI in peds
Rapid onset of sedation, brief half-life, short recovery
period and minimal effects on cardiopulmonary
systems
Adverse effects





Potential for adrenal suppression
Pain at injection site
Myoclonus
Quickly and easily induce deep sedation and/or general
anesthesia.
More studied for PSA in the adult population in United
States



Only randomized control trial evaluating etomidate for
pediatric PSA in the ED
Randomized double-blind study out of Montreal
N=100 patients 2-18yo



50 = IV Etomidate 0.2mg/kg + Fentanyl 1mcg/kg
50 = IV Midazolam 0.1mg/kg + Fentanyl 1mcg/kg
Outcomes



Induction and recovery times
Efficacy of sedation
Adverse event rates

Results
Time taken for induction and recovery were lower
among those receiving etomidate
 Success rates were not different
 Adverse event rates were similar with the exception
of

Pain at injection site 46% vs 12%
 Myoclonus 22% vs 0%

Etomidate


Need a large series to better establish the safety
profile of etomidate for PSA in pediatrics
A randomized trial comparing etomidate,
propofol and ketamine would be of great
interest…..
Any takers?
Propofol infusion
syndrome
Propofol Infusion Syndrome

1992 case reports of fatalities
High and escalating doses of propofol infusions
 Severe metabolic acidosis, lipidemia, rhabdo and
refractory heart failure




Associated with long-term infusions >48hrs in
children <4yo
Thought to be related to a mitochondrial defect
Not an issue for brief ED sedation
Preoxygenation
protocol
Pre-oxygenation with
procedural sedation


Published adverse event rates during pediatric ED
procedural sedation vary between 2% and 18%
Consistently the most common adverse event is
transient hypoxia




Children’s basal oxygen use/kg is twice that of adults
Smaller FRC
Shorter “safe apnea” period before desaturation
Transient hypoxia is predictably seen with propofol


Very common with Midazolam and Fentanyl
Less likely with Ketamine unless co-administration with other resp
depressants




1244 procedural
sedations
Median age
5.9yrs
Complications
in 17.9%
No
preoxygenation
protocol

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