PEDIATRIC PROCEDURAL SEDATION

Ghazala Q. Sharieff, MD

Clinical Assistant Professor, Shands Jacksonville

Director Of Pediatric Emergency Medicine

Palomar-Pomerado Health System

LECTURE OBJECTIVES

• To be familiar with the common agents used for conscious sedation

• To recognize potential complications of these agents

PEDIATRIC SEDATION

• Underused

– Concern about respiratory depression

– Easy to overlook expression of pain in infants and small children

– Length of stay and nursing time is increased if sedation is used

ASSESSMENT OF PAIN IN PEDIATRICS

• Assessment of physiologic response

• Utilization of pain- analogue scales

– line drawings of faces with different facial expressions

DRUG CATEGORIES

• Analgesics

– Topical

– Infiltrative

– Systemic

• Sedatives

• Combination drugs

ANALGESICS

• NARCOTICS

– Morphine

– Meperidine

– Fentanyl

ANALGESICS

• NON-NARCOTIC AGENTS

– Ketamine

– Nitrous oxide

– NSAID’s

SEDATIVES

• Midazolam

• Diazepam

• Chloral hydrate

TOPICAL ANALGESIA

LET

– Lidocaine 4% gel, epinephrine 1:2000, tetracaine 0.5%

– Good for superficial lacerations on face/scalp

– Do not use on less vascular areas

TAC

– Tetracaine 0.5%, adrenaline 1:2000, cocaine 11.8%; or one-half strength

– Good for superficial lacerations- face/scalp

– Onset in 15-20 minutes

– Complications: Seizures, death, hallucinations

– Do not use on mucous membranes!

EMLA

• 2.5% lidocaine

• 2.5% prilocaine

• Useful for painful procedures on intact skin

• Must apply 60 minutes before procedure

INFILTRATIVE ANALGESIA

Lidocaine

– Maximum dose: 4-5mg/kg without epinephrine; 7mg/kg with epinephrine

– Do not use epinephrine on distal extremity, nose, penis or pinna of the ear.

Bupivicaine

– Maximum dose: 2-3mg/kg

– 4X more potent than lidocaine

– Duration up to 7 hours with epinephrine

CONSCIOUS SEDATION

Definition

• “ A minimally depressed level of consciousness that retains a patient’s ability to maintain a patent airway… and respond appropriately to physical stimulation and/or verbal commands”

DEEP SEDATION

Definition

•A medically controlled state of depressed consciousness or unconsciousness from which a child is difficult to arouse and during which he may not be able to respond purposefully to verbal or physical stimulation. Protective airway reflexes and the ability to maintain an open airway may be compromised.

GENERAL ANESTHESIA

Definition

•The state of unconsciousness is accompanied by a loss of protective airway reflexes requiring intervention by trained personnel to establish and maintain a patent airway.

PEDIATRIC SEDATION AND ANALGESIA (PSA)

–PSA is defined as “a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allow the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.

PRE-SEDATION ASSESSMENT

• PMH

• Allergies

• Medications

• NPO status

• Previous experience with anesthesia

NPO STATUS

For non-emergent procedures

– Prefer no intake for 6 hours

For emergency purposes:

– Solids: 3-4 hours, liquids 2 hours

ASA CLASSIFICATION

• ASA I: Healthy patient

• ASA II: Patient with mild, systemic disease

• ASA III: Patient with severe systemic disease that limits activity

• ASA IV: Incapacitating disease that is a constant threat to life

• ASA V: Moribund patient who is not expected to survive 24 hours

EQUIPMENT

• ECG monitor/ Code cart available

• pulse oximeter

• BP monitor

• Suction

• Bag-valve mask/ ETT tubes

• Nasal cannula

• Narcan/ flumazenil

DOCUMENTATION

• Vital signs and O2 saturation q5” during sedation, then 30” after last dose given, then q15” X2.

• Continuous ECG and pulse-oximetry

• Document all times and routes of administration

ANALGESIA FOR BRIEF, PAINFUL PROCEDURES

Fentanyl

– 100X more potent than morphine

– Onset: 2 minutes

– Duration: 30 minutes

– Initial dose: 2-3ug/kg IV

--- Complications: Respiratory depression, rigid chest, hypotension

plications: Respiratory depression, chest wall rigidity, bradycardia

Nitrous Oxide

– Dissociative, euphoric , sedative agent

– Onset: 1-2 minutes

– Initial Dose: 30-50% mixture with O2

– Administration: self-administered

– Contraindications: Pneumothorax, eye injuries, obstructed viscus, ALOC

Ketamine- (dissociative/sedative)

– Onset: 1-5 minutes depending on route

– Duration: IV-10 minutes; IM 20-30 minutes

– Initial Dose: IV 1 mg/kg: IM 4mg/kg

Complications:

– Laryngospasm

– Increased ICP & intraocular pressure

– Hypertension

– Hallucinations/ emergence reactions

– Increased salivation

– use atropine 0.01mg

#33

Wathen J, Roback M et al. Ann Emerg Med, December 2000

Does Midazolam Alter the Clinical Effects of Intravenous Ketamine Sedation in Children? A Double-Blind, Randomized, Controlled Emergency Department Trial

Summary: 266 patients age 4.5 months to 16 years receiving IV ketamine sedation were enrolled. All pts received ketamine 1 mg/kg and glycopyrrolate 5 ug/kg. Pts were then randomized to receive midazolam 0.1mg/kg IV or placebo. 129 pts received ketamine alone, and 137 received ketamine plus midazolam. 12 pts had respiratory events, 50 had vomiting, and 71 had emergency phenomena in the ED, 60 had emergence phenomena at home. Significant emergence phenomena such as hallucinations and nightmares occurred in 7.1% of the ketamine only pts and 6.2% of the ketamine-midazolam group- rate difference of 0.8. The addition of midazolam led to an increase in O2 desaturation 7.3% vs 1.6% with ketamine alone- particularly in the less than 10 year old age group. But, midazolam addition resulted in a decreased incidence of vomiting 9.6% vs 19.4%. The incidence of emergence phenomena was not affected by the addition of midazolam, but the incidence of agitation was increased in the ketamine-midazolam group- 35.7% vs 5.7%.

Sherwin T, Green S, Khan A et al. Annals of Emergency Medicine, March 2000

Does Adjunctive Midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double blind, placebo-controlled trial

Summary: 104 children between 12 months to 15 years of age enrolled. Median age in control group 6 years, median age in study group 7.3 years. Pts either received ketamine plus placebo or ketamine and midazolam 0.05mg/kg up to 2 mg 2 minutes after ketamine was administered. Physicians and nurses recorded recovery agitation and graded their responses on a 100-mm visual analog scale. Preprocedural agitation and external stimulation during recovery were also graded. 53 pts received midazolam and 51 pts received placebo. Median physician assessment of recovery agitation was 4mm in the versed group and 5 mm in the placebo group. This was felt to be clinically insignificant with a p-value of 0.705. Recovery agitation was moderately correlated with preprocedural agitation, but not with external stimulation during recovery. Authors conclude that concurrent versed did not diminish recovery agitation and had no “measurably beneficial effect.” Furthermore, addition of benzodiazepines with ketamine appears unnecessary.

Green S, Rothrock S, Lynch E et al. Annals of Emergency Medicine, April l999

Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases

Summary: IM ketamine was administered 1,022 times. Data forms completed for 431 treated patients. Adequate sedation in 98% of pts. The following complications were observed:

1) Transient airway complications in 1.4%. No pts required intubation

a. Apnea in 2 pts

b. Laryngospasm in 4 pts

c. Airway malalignment in 7 pts

d. Respiratory depression in 1 pt

2) Emesis in 6.7%- no evidence of aspiration

3) Mild recovery agitation in 17.6%

4) Moderate to severe recovery agitation in 1.6%

ANALGESIA FOR LONGER, PAINFUL PROCEDURES

Morphine

– Onset: 5-10 minutes

– Duration: 3-4 hours

– Initial Dose: 0.1mg/kg IV

– Complications: respiratory depression, hypotension

Demerol

– 10X less potent than morphine

– Onset: Rapid IV; 10-15 minutes IM

– Duration 2-3 hours

– Initial Dose:1mg/kg IV/ IM

– Complications: respiratory depression, hypotension, seizures

SEDATION FOR NONPAINFUL PROCEDURES

Midazolam

– Benzodiazepine with amnestic property

– Onset: 2 minutes IV; 10-15 “ IM, PR, PO, IN

– Duration: 30” IV; 45” IM, PR, I N, PO

– Initial Dosage: 0.1mg/kg IV

– 0.2-0.5mg/kg PO, IN, PR

– Complications: apnea, hypotension, paradoxical agitation

Pentobarbital

– Great for head CT or MRI

-Duration is 45-60 minutes

– Dose is 2-5mg/kg

– Give 2mg/kg bolus over 30 s, then additional 1mg/kg over 30s q one minute to a maximum of 5 mg/kg

Moro-Sutherland DM, Algren JT, Louis PT et al. Academic Emergency Medicine, December 2000. Comparison of Intravenous Midazolam with Pentobarbital for Sedation for Head Computed Tomography Imaging

Summary: Over a 2 ½ year period, 55 patients were enrolled ( mean age 26 months). 21/55 pts had CT for head trauma, 17/55 for CNS pathology, 6/55 for VP shunt, 6/55 for periorbital cellulitis, and 5/55 for retropharyngeal abscess. 29 received pentobarbital with a mean dose of 3.75mg/kg and 26 received midazolam- mean dose 0.2mg/kg. 97% of the pentobarbital group were scanned and successfully sedated with a mean induction time of 6 minutes and duration of sedation of up to 86 minutes. In the midazolam group, only 5 pts ( 19%) were successfully scanned with midazolam alone. 12 ( 61%) were subsequently sedated with the addition of pentobarbital. O2 sat of 90-94% seen in only 4 patients given pentobarbital who responded to blow-by 02. Protocol: IV versed- 0.1mg/kg over 2 minutes with subsequent doses of 0.05mg/kg after 2 minutes- repeated as necessary. IV pentobarbital- 2.5mg/kg over 30 seconds, after 1 minute give 1.25mg/kg X2 doses. Authors conclude that pentobarbital is more effective than IV midazolam for sedation in children requiring CT imaging.

Methohexital

Sedik, H. Use of intravenous methohexital as a sedative in pediatric emergency departments.

Arch Pediatr Adolesc Med, 2001; 155:665-668

Summary: A total of 55 pediatric patients were studied. 35 retrospectively and 20 prospectively. IV methohexital was administered in a dose range of 0.5-2mg/kg for CT sedation. Results showed that time to sedation was 1-2 minutes, adequate sedation lasted from 5-21 minutes, total time from onset of sedation to return to preprocedural state was 5-26 minutes, and scan time ranged from 4-24 minutes with a total procedure time of 7-27 minutes. Sedation failed in two patients, and 3 patients experienced a transient drop in their O2 saturation. No pts required intubation and only a chin-lift maneuver was required to increase the O2 saturation to above 95%.

Propofol

– Ultra short acting hypnotic, unrelated to barbiturates or benzodiazepines

– Initial Dosage: 0.5-3mg/kg IV

– 25-300 ug/kg/min.

– Complications: apnea, respiratory depression

Etomidate

– Ultra short acting sedative-hypnotic, imidazole

– Initial Dosage: 0.1-0.2mg/kg IV

– Less hypotension than benzodiazepines, protects ICP

Complications: adrenal suppression

Chloral hydrate

– Onset: 30-60 minutes

– Duration: 3-4 hours

– Dosage: 50-75 mg/kg PO/PR; max 2 grams

– Complications: GI irritation, seizures, cardiac arrhythmia's

COMMONLY USED COMBINATIONS

1) Fentanyl and Versed

2) Ketamine, atropine and ? Versed

3) Ketamine and propofol- new pilot study with good success

ANTAGONIST AGENTS

NALOXONE( Narcan)

• Dose: .01-0.1mg/kg

• Indicated for reversal of narcotic agents

• In chronic drug users, may cause seizures, agitation

• Titrate reversal slowly to avoid: tachycardia, hypertension, arrhythmia's, and abrupt loss of sedation

FLUMAZENIL

– Dose: not clear in pediatrics, may use 0.01mg/kg

– Indicated for benzodiazepine overdose

– In chronic benzodiazepine users, can cause seizures

DISCHARGE CRITERIA

• Stable vital signs

• Oriented with return to pre-procedural state

• Able to take fluids without emesis

• Able to ambulate

CASE STUDIES

Scenario #1

• A 2 year-old boy needs sedation for reduction of a both bone distal radius and ulna fracture.

• What drug(s) would you use?

The patient is sedated with fentanyl and versed. During the procedure the patient’s O2 sat drops and he has respiratory distress. You are unable to effectively ventilate him.

• What has happened, and what should you do now?

Scenario #2

• The patient is sedated with fentanyl and versed. The procedure is performed without difficulty. However, the patient is noted to have a decreased respiratory rate and his pupils are pinpoint.

• What should you do now?

Scenario #3

• The patient is given a total of 5ug/kg of fentanyl and 0.1mg/kg of versed. He is still in a lot of pain and the reduction cannot be performed without more medication.

• What should you do now? What further medication would you give?

Scenario #4

• A 4 year-old patient sustained a large tongue laceration that needs repair. What is your choice for sedation?

• How long should the patient be NPO before sedation?

Scenario #5

• A 2 year old female sustained a large leg laceration. She is anesthetized with a total of 8 cc of 1% lidocaine without epinephrine. The patient has a tonic-clonic seizure.

• What happened?

• If the patient weighed 12 kg, she was injected with 80 mg of lidocaine. The toxic dose of lidocaine without epinephrine is 4-5mg/kg. Each 1cc of 1% lidocaine contains 10 mg of lidocaine.

Scenario #6

• A 4 year-old male was sedated with IM ketamine. He becomes stridorous.

• What important history should have been obtained?

• What should you do now?

CONSCIOUS SEDATION SELECTED REFERENCES

General Sedation

Krauss B, Green SM. Sedation and analgesia for procedures in children. NEJM, 2000;342:938-945.

Pena BM, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med, l999;34:483-497.

Ingebo KR, et al. Sedation in children: Adequacy of two-hour fasting. J Peds, l997;131:155-1159.

American Society of Anesthesiologist. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesth, l996;84:459-471.

AAP Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic purpose. Pediatrics l992; 89:1110-1115.

Proudfoot J et al. Analgesia, anesthesia, and conscious sedation. Emerg Med Clinics of North America. May 1995. 13(2):357-379.

Ketamine

Sherwin TS, Green SM, Khan A, et al. Does adjuctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial. Ann Emerg Med, 2000;35:229-238.

Green SM, Hummel C, Wittlake WA, et al. What is the optimal dose of Intramuscular ketamine for pediatric sedation? Acad Emerg Med, l999; 6:21-26.

Green SM, Clark R, Hostetler, et al Inadvertent Ketamine Overdose in Children: Clinical Manifestations and Outcome. Ann Emerg Med. Oct, l999 ; 34: 492-497.

Slonim AD, Ognibene F. Sedation for pediatric procedures, using ketamine and midazolam, in a primarly adult intesive care unit: A retrospective evaluation. Cric Care Med, l998;26:1900-1904.

Dachs RJ et al. Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med. Jan 1997 (1):146-150.

Petrack EM et al. Intramuscular ketamine is superior to meperidine, promethazine, and chlorpromazine for pediatric emergency department sedation. Arch Peds and Adol Med. July 1996 150(7):676-681.

Green SM et al. Ketamine sedation for pediatric procedures. Part 1 &2. Ann Emerg Med. Sept 1990. (9) 1024-1046.

Etomidate

Dickinson R et al. Etomidate for pediatric sedation prior to fracture reduction. Acad Emerg Med. Jan 2001. (8):74-77.

Vinson DR et al. Etomidate for procedural sedation in the emergency department. Ann Emerg Med, Jun 2002. (6):592-598.

Sokolove P et al. The safety of Etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. Feb 2000. (16):18-21.

Other agents

Trocinski, Fisher, Kanegaye, Harley, Sharieff. Propofol and Ketamine versus Fentanyl and Versed Sedation in the Pediatric Emergency Department. Abstract presented at ACEP 1999 Scientific Assembly. Submitted for publication.

Pohlgeers AP et al. Combination of fentanyl and diazepam for pediatric conscious sedation. Acad Emerg Med. Oct l995. (10): 879-883.

Wright SE et al. Comparison of midazolam and diazepam for conscious in the emergency department. Ann Emerg Med. Feb l993. 22(2): 201-205.

Ordog GJ et al. The efficacy of TAC with various wound-application durations. Acad Emerg Med. July/Aug l994 1(4):360-363.

Chudnofsky CR et al. The safety of fentanyl use in the emergency department. Ann Emerg Med. 1989;18:635-639.

Gamis AS et al. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med, l989:18:177-181.