Pediatric Sedation - Pediatric - Lecture Slides, Slides of Pediatrics

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Pediatric Sedation:

The Safety Net

The good old days…

 Child receives Demerol-Phenergan-Thorazine for

laceration repair in ED dies during procedure

 1yo former preemie sedated with chloral hydrate at

home in preparation for BAER, dies in car en-route

to study

 Agitated encephalopathic 7yo sedated for LP codes

in ICU during procedure

Sedation Overview

Study Type Number of Complications %

Procedures

Non-Invasive 6907 96 1.

Invasive Deep 3038 297 9.

Combined 3052 63 2.

Grand total 12997 456 3.

“Good judgement comes from experience. Experience

comes from bad judgement”

Definitions

Conscious sedation

vs

Deep Sedation

vs

Anesthesia

Non-distinct continuum which can change

over time

JCAHO 2001 Definitions

 Moderate sedation/analgesia (“conscious

sedation”) – a drug induced depression of

consciousness during which patients respond

purposefully to verbal commands, either alone or

accompanied by light tactile stimulation. No

interventions are required to maintain a patent

airway, and spontaneous ventilation is adequate.

Cardiovascular function is usually maintained.

JCAHO 2001 Definitions

 Deep sedation/analgesia - a drug induced

depression of consciousness during which patients

cannot be easily aroused, but respond purposefully

followed repeated or painful stimulation.

Patients may require assistance in maintaining a

patent airway and spontaneous ventilation may be

inadequate. Cardiovascular function is usually

maintained.

Ability to Rescue

 The Licensed independent practitioner must be

able to rescue those patients who unavoidably or

unintentionally slip into a deeper-than-desired

level of sedation

 Credentialed to do moderate>> rescue from deep

 Manage a compromised airway and to provide adequate

oxygenation and ventilation

 Credentialed to do deep >> rescue from general anesthesia

 Above + competent to manage an unstable cardiovascular

system

Sedation Continuum

Light Moderate Deep General

Anesthesia

Modified

from

Enright

2yo Head CT

4yo BM Bx

9yo Colonoscopy

Assessing a sleeping infant’s level of sedation in the MRI scanner may be difficult! docsity.com

WRAMC Pediatric Sedation/

Analgesia Unit: 2002

 IAW WRAMC Pam 40-16 (rev 2/2002)

 As sanctioned by Chief of Anesthesia

 All patients should receive the same level of treatment, monitoring, and desired outcome regardless of the site

of care

 Applicable to pediatric patients (age 0-18y) throughout

WRAMC (Ward, ED, PICU and Sedation Unit)

Safety Net

Better Monitoring

Physician or PNP present

Screening for

contraindications

ASA

classification and

Deep Sedation teamairway evaluation

Emergency

equipment available

Informed Consent

Safe Drug protocols

PALS trained RN

Appropriate patient selection

Moderate Sedation Training

Requirements

 MD/ PNPs

 PALS certification

 This 2 hours block of instruction

 Handouts for drug algorithms  Scenarios

 Post test

 Proof of recent experience

performing BVM ventilation or 1

day in OR performing BVM

ventilation

 Nursing personnel

 PALs highly encouraged

for RNs

 Nursing specific 2 hour

block of instruction

 Handouts with practice

scenarios

 Hands on-training

 Post test

Training for Deep sedation will require Critical care or anesthesia

training, possible grandfather clause for experience

Moderate Sedation/Analgesia

 Indication

 Immobility

• Pain Control
• Anti-anxiety

 Goals

 Cooperation

• Alteration of mood
• Elevation of pain threshold
• Autonomic Stability
• Amnesia
• Rapid, safe return to highest

possible health status

If patient really needs the study and needs to be sedated!

First Decide:

Presedation History and Physical

 Patient status > ASA classifications

 Class I – normal healthy patient

 Class II – patient with mild to moderate systemic disease, controlled

 Class III - patient with severe systemic disease

 Class IV – patient with severe systemic disease that is a constant threat to life

 Class V – a moribund patient who is not expected to survive without the procedure

Consult Critical care or anesthesia for anything below the red line!

Relative Contraindications

 GERD (relative)

 Cerebral palsy with

abnormal swallowing

 History of apnea , sleep

apnea, snoring

 Neck instability

(osteogenesis imperfecta, or Down’s syndrome)

 Poorly controlled seizure

disorder

 Significant cardio-

pulmonary disease

(cyanosis, or chronic hypoxemia)

 Hx of Malignant

hyperthermia

 Anticipated difficulty in

obtaining IV access in an

emergency