Moderate Conscious SedationAnalgesia in the Pediatric Patient

1
Moderate Conscious Sedation/Analgesia in the
Pediatric Patient

• Cindy Asher, RN, CNS
• The Childrens Medical Center

2
You are preparing to sedate a 5-year-old girl for
bone marrow aspiration. The child has suspected
acute lymphoblastic leukemia.

• What information do you need to develop a safe
  plan for sedation of this child?
• Does this patient need sedation, analgesia, or
  both? What agents can you use to achieve your
  goals safely?
• What monitoring does this child require before,
  during, and after the procedure?

3
The objectives of this module are

• To identify components of a presedation
  assessment and plan appropriate monitoring of
  patients.
• To explain the difference between sedation and
  analgesia and the indications for each.

4
The objectives of this module are (cont.)

• To describe common adverse effects of sedative
  and analgesic agents.
• To explain the post procedure monitoring
  guide-lines including criteria for discharge.

5
Ill or injured children frequently require
sedation and analgesia. For many years
hospitalized young children, especially infants,
were inadequately treated for pain and anxiety.
Recent physiologic observations show that the
very young are actually more sensitive to pain
than adults.
6
Sedation and analgesia are not benign treatments
they can have adverse consequences, especially if
used incorrectly. The Joint Commission on
Accreditation of Hospital Organizations, American
Society of Anesthesiologists, American College of
Emergency Physicians, and American Academy of
Pediatrics emphasize that sedation should be
administered in a safe environment by personnel
with appropriate training and credentials.
7
There is a difference between sedation and
analgesia

• Sedation reduces the state of awareness. Many
  sedatives produce amnesia, the inability to
  remember. (Benzodiazepines, barbiturates -
  sedative agents have no analgesic effects)
• Analgesia reduces or eliminates the perception of
  pain and most have sedative effects.
• (Narcotics are primarily analgesics examples
  include Morphine and Fentanyl)

8
Types of Sedation The American Society of
Anesthesiologists and JCAHO Define 4 Levels of
Anesthesia

• Minimal sedation (anxiolysis) A drug-induced
  state during which patients respond to verbal
  commands. This level of sedation may impair
  cognitive function and coordination. Minimal
  sedation does not affect ventilatory or
  cardiovascular function.

9
Types of Sedation The American Society of
Anesthesiologists and JCAHO Define 4 Levels of
Anesthesia (cont.)

• Moderate sedation/analgesia (formerly called
  conscious sedation) A drug-induced depression
  of consciousness during which patients respond
  purposefully to verbal commands, either alone or
  with light tactile stimulation. The patient
  requires no interventions to maintain a patent
  airway, and spontaneous ventilation is adequate.
  Cardiovascular function is usually maintained.

10
Types of Sedation The American Society of
Anesthesiologists and JCAHO Define 4 Levels of
Anesthesia (cont.)

• Deep sedation/analgesia A drug-induced
  depression of consciousness during which patients
  cannot be easily aroused but respond purposely to
  repeated or painful stimulation. This level of
  sedation may impair the patients ability to
  independently maintain ventilatory function. A
  patient may require assistance to maintain a
  patent airway, and spontaneous ventilation may be
  inadequate. Cardiovascular function is usually
  maintained.

11
Types of Sedation The American Society of
Anesthesiologists and JCAHO Define 4 Levels of
Anesthesia (cont.)

• General anesthesia A drug-induced loss of
  consciousness during which patients cannot be
  aroused even by painful stimulation. This level
  of sedation includes general anesthesia and
  spinal or major regional anesthesia. It does not
  include local anesthesia. General anesthesia
  frequently impairs the ability to independently
  maintain ventilatory function. Patients often
  require assistance to keep their airway patent.
  Patients may need positive-pressure ventilation
  because general anesthetics may depress
  spontaneous ventilation and neuromuscular
  function. General anesthesia may impair
  cardiovascular function.

12
Continuum of Depths of Sedation
Level of consciousness
Awake
Minimal sedation (anxiolysis)
Moderate (conscious) sedation
Deep sedation
General anesthesia
?
?
?
?
?
Protective reflexes
Present
Present
Present/ potential loss
Probable loss
Total loss
?
?
?
?
?
Patients may move between states of sedation
based on medications administered and stimulation
received.
13
Consent

• Moderate conscious sedation must only be
  performed after appropriate consents are
  obtained. It is the responsibility of the
  physician, dentist or APN practitioner providing
  the sedation to initiate a conversation regarding
  informed consent. The discussion should be with
  the patients legal guardian and/or patient and
  the discussion should include the need for
  conscious sedation and the risk, benefits and
  alternatives (informed consent) to the sedation
  process. Documentation of the informed consent
  discussion should be included in the patients
  medical record.
• (The Written Consent Form Consent for Surgery,
  Anesthesia, Sedation, Blood Product
  Administration and/or other Special Procedure is
  utilized to document the patients or legal
  guardians signature.)

14
Pre-Sedation Evaluation Includes a
History/Physical and an Immediate Pre-Sedation
Assessment

• Before moderate conscious sedation is
  administered, an appropriate licensed
  practitioner shall perform a health evaluation,
  and significant findings recorded in the sedation
  record. This may be performed by the referring
  physician within 30 days prior to the sedation
  for the diagnostic of therapeutic procedure.

15
Pre-Sedation Evaluation Includes a
History/Physical and an Immediate Pre-Sedation
Assessment (cont.)

• If the history and physical is performed prior to
  the day of the moderate conscious sedation, it
  must be reviewed at the time of treatment and
  any interval changes in the patients status
  noted.
• The purpose of the evaluation is to identify
  patients at an increased risk for complications
  based on their past history, (previous sedation
  and/or anesthesia history) their current state of
  general health and any pertinent physical
  findings that may influence the safety, known
  drug reactions and success of their sedation.

16
Physical Examination(Airway/Breathing/Circulation
)

• The pre-sedation physical exam should include
  evaluation of the ABCs airway patency and the
  need for support, breathing pattern and breath
  sounds, and a cardiovascular exam focused on
  heart sounds and distal perfusion.

17
Physical Examination(Airway/Breathing/Circulation
) (cont.)

• When you evaluate the airway you should look for
  characteristics that increase the risk of airway
  obstruction during the procedure. In particular,
  you should check for a large tongue, micrognathia
  (small lower jaw), limited airway opening, severe
  obesity, excessive secretions, snoring, and
  decreased airway protective reflexes. Carefully
  evaluate breath sounds and work of breathing to
  ensure that the patients respiratory status is
  not compromised. Document baseline oxygen
  saturation by pulse oximetry.
• Assess baseline heart rate, heart sounds, and
  distal perfusion (skin temperature, color, and
  capillary refill.) Examine other organ systems
  if the patients history suggests potential
  problems.

18
Anesthesiologists often assess sedation risk
using the ASA system. This system classifies
risk on a scale of I to V (See Table 2). For
patients in ASA Class III or higher, consult an
airway or sedation specialist before elective
sedation.

• Class ASA Score Selection Criterion
• I A healthy patient.
• II A patient with mild systemic disease, no
  functional limitation.
• III A patient with severe systemic disease that
  limits activity but is not
• incapacitating.
• IV A patient with an incapacitating systemic
  disease that is a constant threat to life.
• V A moribund patient not expected to survive
  24 hours with or without operation.

19
An immediate pre-sedation assessment includes the
following information Allergies, Medications,
Past history (focus on airway/cardiopulmonary
reserve), Last meals and Events (leading to the
sedation). This mnemonic spells AMPLE.
20
In general, a patient should not undergo elective
sedation for a procedure within six hours of
eating solid foods or drinking milk.

• Clear Liquids 2 Hours
• Breast Milk 4 Hours
• Formula/Light Solids 6 Hours
• The above guidelines are recommended to allow
  gastric emptying prior to the procedure.
  Patients with known gastro-esophageal reflux,
  esophageal dysmotility, impaired or delayed
  gastric emptying (i.e., diabetics) or known of
  suspected airway problems may require a longer
  period of pre-procedure fasting in order to
  minimize risks of aspiration of gastric contents
  and may benefit from appropriate pharmacological
  treatment to reduce gastric volume and increase
  gastric pH.

21
Non-elective situations

• When proper fasting has not been assured, the
  increased risks of sedation must be carefully
  weighed against its benefits, and the lightest
  effective sedation should be used. An emergent
  patient may require protection of the airway
  before sedation. If the responsible physician
  has questions regarding the appropriateness of
  sedation in an emergent or non-elective
  situation, consultation with the anesthesia staff
  is strongly encouraged.

22
Monitoring and Training of Personnel

• The level of monitoring required during the
  procedure depends on the anticipated and
  subsequently observed level of sedation. In all
  cases a clinical staff member trained in sedation
  practice must be present to observe the patient
  and document his/her status this designated
  provider should not perform the procedure. This
  staff member must be able to recognize airway
  compromise and provide airway and breathing
  support (open the airway, administer oxygen, and
  begin noninvasive ventilation) if required.
• The clinical staff member must complete PALS
  (Pediatric Advanced Life Support) and the
  Moderate Conscious Sedation module.

23
Equipment - Any area of the hospital where
sedation is administered must have appropriate
equipment available. This equipment includes

• Emergency code cart in immediate vicinity.
• Oxygen delivery system including ventilation bag,
  appropriate sized masks, oxygen, wall suction
  equipment.

24
Equipment - Any area of the hospital where
sedation is administered must have appropriate
equipment available. This equipment includes
(cont.)

• Monitoring equipment, which includes a
  stethoscope, automated blood pressure machine,
  cardiac monitor with rhythm preferred, and pulse
  oximeter.
• Defibrillator readily available.
• Drug antagonist readily available (available in
  Code Carts).

25
Sedation Method

• Non-Pharmacologic Measures
• A number of nonpharmacologic adjunctive
  techniques can decrease anxiety and pain
  perception in children. These techniques include
  explanation and preparation before the procedure,
  distraction, visual imagery, and hypnosis.
• Many of these techniques are used at The
  Childrens Medical Center. Child Life may be
  available to assist as needed.

26
Medications

• Selecting a Sedative Agent
• There are a number of features to consider when
  selecting a sedative agent. Sedatives can
  provide three distinct effects sedation,
  analgesia or amnesia. Select a sedative to treat
  anxiety, an analgesic to treat pain, and an
  amnesic to prevent memory of the procedure.

27
Medications (cont.)

• Medications Sedation Analgesic Amnesia
• Barbiturates - -
• Benzodiazepines -
• Narcotics -
• Ketamine
• Ketorolac - -
• Propofol -
• Chloral Hydrate - -
• Different narcotics produce different levels
  of sedation. For example, when given in an
• equi-analgesic dose, morphine provides
  deeper sedation then fentanyl.
• The sedation medication is titrated as indicated
  to the patients response and the planned
  procedure. The Sedation Formulary provides
  suggested guidelines for dosing. The final order
  for medication rests ultimately with the ordering
  physician. The Sedation Formulary offers
  suggested dosing ranges and intervals between
  doses. Because the sedation response is a
  continuum, individual patient requirements may
  exceed the suggested ranges. (Refer to the CMC
  Policy - Moderate Conscious Sedation/Analgesia)

28
Barbiturates

• Short-acting barbiturates (i.e., pentobarbital)
  are sedative-hypnotic agents. They have a rapid
  onset of action when given intravenously (1 to 5
  minutes) and a short duration of action (15 to 60
  minutes). None has analgesic properties.
• A short-acting barbiturate is typically the
  sedative of choice for patients with head trauma,
  status epilepticus, or suspected increased
  intracranial pressure (ICP) because they decrease
  brain oxygen consumption and ICP.
• Side effects of barbiturates include
  dose-dependent myocardial depression and
  hypotension. You can reduce these adverse
  effects by decreasing the rate of administration
  and by providing isotonic crystalloid volume
  infusion.

29
Barbiturates (cont.)

• You should generally avoid use of these drugs in
  hypotensive or hypovolemic patients. If you use
  barbiturates in these patients, decrease the dose
  by at least half.
• Other adverse effects include respiratory
  depression (enhanced by benzodiazepines and
  narcotics), bronchospasm, cough, laryngospasm and
  anaphylaxis.
• You should usually avoid use of barbiturates in
  children with severe or acute asthma because
  these drugs stimulate histamine release.

30
Benzodiazepines

• Benzodiazepines are sedative-hypnotic agents with
  potent amnestic effects. When used alone, they
  are very safe because their mechanism of action
  is to accentuate inhibitory pathways in the
  brain.
• Benzodiazepines potentiate narcotics. As a
  result, it may be possible to decrease the dose
  of the narcotic and still provide an effective
  sedation. However, when combined with other
  agents, benzodiazepines may have potent sedative
  effects and may suppress ventilation.

31
Benzodiazepines (cont.)

• Benzodiazepines can cause respiratory depression,
  especially with concomitant use of barbiturates
  or narcotics. Occasionally a paradoxical
  excitatory reaction occurs. Hypotension occurs
  less frequently with these drugs than with
  barbiturates.
• For patients who are hemodynamically unstable
  (i.e., hypotensive or hypovolemic), you should
  decrease the recommended dose (typically by 50).
  Like barbiturates, benzodiazepines possess no
  analgesic properties.

32
Narcotics

• Narcotics remain the gold standard for treatment
  of severe pain.
• Morphine is a common choice. It has been widely
  and safely used in infants and children.
  Pruritus occurs in some patients.
  Hemodynamically compromised patients may develop
  hypotension. Both effects are mediated by
  histamine release. Use caution in patients with
  severe or acute asthma because of the histamine
  release.

33
Narcotics (cont.)

• Fentanyl, a synthetic narcotic, also has been
  widely used in children. It is 50 to 100 times
  more potent and has a shorter duration than
  morphine, and it produces less histamine release.
  The hemodynamic stability associated with
  fentanyl and its closely related analogs makes it
  a preferred agent in cardiovascular surgery. An
  unusual complication, chest wall rigidity, may
  occur with large doses (usually 5 microgram/kg)
  given rapidly, especially in infants. You may
  need to use neuromuscular blockade and tracheal
  intubation to treat this complication.

34
Narcotics (cont.)

• Meperidine has also been used in children. One
  of its metabolites causes central nervous system
  excitation and may cause seizures. Use of other
  narcotics is preferable.
• The most common adverse effects of narcotics are
  hypoventilation, apnea, and hypotension. The
  incidence of apnea is higher in very young
  infants (less than 2 months old) than in older
  infants and children. To support a patient with
  apnea or hypoventilation, open the airway as
  needed, provide assisted ventilation, and give
  naloxone, a specific narcotic reversal agent.
  Other potential side effects of all narcotics
  include nausea, vomiting and constipation.

35
Other Medications

• Dissociative anesthetics (Ketamine)
• Ketamine is a dissociative anesthetic that
  produces a cataleptic (i.e., trancelike) state in
  which the eyes remain open with a slow nystagmic
  gaze. Patients are non-communicative but they
  appear awake.
• Ketamine, a phencyclidine derivative, produces
  potent analgesia and rapid sedation it preserves
  respiratory drive and airway protective reflexes
  when used in appropriate doses.
• Ketamine can produce general anesthesia when
  given in sufficient doses. Its duration of
  action is variable (15 to 60 minutes). Use the
  lower dose range for hemodynamically compromised
  patients.

36
Other Medications (cont.)

• Ketamine-induced catecholamine release helps
  maintain blood pressure. It may decrease or
  protect against bronchospasm and improve
  ventilation in asthmatic patients. These
  beneficial effects may not occur in
  catecholamine-depleted, chronically ill patients.
• Adverse effects of ketamine include increased
  systemic, intracranial, and intraocular
  pressures hallucinogenic emergence reactions
  (more frequent in adults than children)
  laryngospasm and excessive airway secretions.

37
Chloral Hydrate

• Chloral hydrate is a hypnotic (sleep-inducing)
  agent that has been used extensively for sedation
  of children. Chloral hydrate has no analgesic
  activity and it has minimal respiratory
  depressant effect when appropriate doses are
  used.
• For these reasons it is a frequent choice for
  children who require a prolonged diagnostic
  imaging study ( i.e., nuclear medicine or MRI
  scan). It is most useful in children less than 3
  years old.

38
Chloral Hydrate (cont.)

• In some children chloral hydrate may have a
  paradoxical excitatory effect. The onset of
  action is relatively slow and sometimes
  unreliable.
• Some children experience prolonged sedation,
  necessitating prolonged observation and
  monitoring. Because of these limitations,
  short-acting barbiturates are often preferable
  for sedation for radiographic procedures.

39
Reversal Agents

• Although you should be familiar with specific
  reversal agents of
• narcotics and benzodiazepines to provide safe
  sedation, you
• should rarely need to used these agents.
• If respiratory depression occurs during sedation,
  you should immediately open and clear the airway.
  Then provide assisted ventilation and 100
  oxygen as needed.
• Beware of the adverse effects of reversal agents.
  Weigh the benefit of immediate reversal against
  provision of respiratory assistance until the
  adverse effects of the narcotic or benzodiazepine
  dissipate. If you decide to give a reversal
  agent, consider the following agents.
• For narcotic reversal Naloxone
• For benzodiazepine reversal Flumazenil
• Note that the half-life of the reversal agent is
  frequently shorter
• than the half-life of the sedative agent.
  Observe for recurrence of
• sedation after the effects of the reversal agent
  dissipate.

40
Naloxone

• Naloxone is the prototypical narcotic receptor
  antagonist. When
• you suspect that respiratory depression is caused
  by narcotic
• effect, use naloxone in small doses (1 to 10
  microgram/kg). This
• dose will maintain some analgesia for the
  underlying pain. Note
• that this dose is intentionally much lower than
  the dose
• recommended for immediate and full reversal of
  narcotic
• poisoning (i.e., 100 microgram/kg or 0.1
  microgram/kg). If the
• initial dose is ineffective, repeat titrated
  doses every 1 to 2
• minutes. You may give naloxone by the IV, IM or
  tracheal route.

41
Naloxone (cont.)

• Potential Adverse Effects of Naloxone
• Naloxone may cause adverse effects. For example,
  naloxone
• may cause acute pain in patients receiving
  analgesics. It can
• result in sudden hypertension and acute pulmonary
  edema.
• Correction of hypercarbia before administration
  of naloxone may
• minimize the risk of this complication. Naloxone
  has a shorter
• duration of action than many narcotics, so you
  may need to give
• repeated doses of naloxone to treat the narcotic
  overdose.

42
Flumazenil

• Flumazenil, a benzodiazepine receptor antagonist,
  can reverse
• benzodiazepine-induced respiratory depression and
• paradoxical excitatory reactions. It is
  ineffective for narcotic
• reversal. Providers generally give flumazenil in
  doses of
• 0.01 to 0.02 mg/kg you may repeat these doses
  every 1 to 2
• minutes up to a maximum dose of 1 mg. Like
  naloxone,
• flumazenil may have a shorter duration of action
  than the
• sedative. The patient will require prolonged
  observation to
• ensure that respiratory depression does not
  recur. Use
• caution if the patient has a history of seizures
  because
• flumazenil may induce seizures.

43
Pre-Procedure Assessment by the Clinical Staff

• The initial assessment must be completed by a
  registered nurse.
• The goals of the pre-procedure assessment
  include collection of data through assessment
  and interview provision of accurate information
  to the patient and family assurance of
  appropriate pre-procedure compliance improving
  lines of communication between the
  physician/other clinical staff and the
  patient/family, provide emotional support reduce
  anxiety verify patient identification and
  planned procedure review history and physical
  interview patient/family for relevant
  medical/surgical/ adverse medication history
  obtain written consent and develop the nursing
  care treatment plan.
• All documentation occurs on the Moderate
  Conscious Sedation record.

44
The registered nurse is responsible for
initiating the prescribed plan for the patient

• Vital signs including heart rate with rhythm
  (preferred), level of consciousness, respiration
  rate and oxygen saturation.
• Medication allergies, and sensitivities.
• Medication history.
• Patients current weight.
• NPO status.
• Level of consciousness.

45
The registered nurse is responsible for
initiating the prescribed plan for the patient
(cont.)

• Medical problems.
• Physical assessment.
• IV access, if indicated, and document location
  with type of IV fluid.
• Determines physiological evaluation utilizing
  modified Aldrete guidelines. Any category score
  2 must be addressed in the nursing record. Any
  category score 1, evaluate patient assessment
  with the shift coordinator/charge nurse or
  designee. No patient is sedated if any score is
  0 without physician notification and
  documentation.
• Verifies pertinent labs.

46
The registered nurse is responsible for
initiating the prescribed plan for the patient
(cont.)

• Specific medical equipment needs (trachs, pumps).
• Pregnancy screening. (Female oncology patients
  who are medically amenorrheic are excluded from
  pregnancy evaluation.)
• Written consent documentation.
• Patient/parent education.

47
Intra-Procedure Monitoring

• The clinical staff monitoring the patient has no
  responsibilities other than attending the patient
  receiving sedation.
• Prior to the administration of any sedation
  medication, an assessment is completed. The
  clinical staff is available to evaluate the
  patients condition every 5 to 15 minutes during
  the sedation procedure.

48
Intra-Procedure Monitoring(cont.)

• This monitoring consists of respiratory
  rate/rhythm, pulse rate/rhythm, peripheral
  perfusion, pulse oximetry, and blood pressure.
• Observation and/or pulse oximetry are utilized
  instead of blood pressures in certain procedures
  including, but not limited to, MRI, and CT Scan.
• The frequency of monitoring depends on the
  patients condition, and is at the discretion of
  the physician performing the procedure.

49

• The clinical staff assesses the level of comfort
  and patients tolerance of the procedure. Also,
  occurrence of significant events including blood
  loss, nausea, vomiting, respiratory distress,
  vagal reaction or diaphoresis must be documented.
• Patient Positioning - Patient positioning should
  be checked frequently to ensure a patent airway
  and to prevent chest restriction. Extremities
  should be checked as indicated to ensure proper
  positioning and adequate circulation.

50
Post Procedure Monitoring/Discharge

• One of the highest-risk periods for
  sedation-related complications is the recovery
  phase. For this reason physiologic monitoring
  should continue during this period.
• To be discharged, patients should be arousable,
  at their baseline level of verbal ability, able
  to sit unassisted (if appropriate for age), and
  able to follow age-appropriate commands.

51
Post Procedure Monitoring/Discharge(cont.)

• Pulse oximeter readings and vital signs should be
  normal or baseline for that patient.
• You should document airway patency, protective
  reflexes, and adequate hydration.

52
Post Procedure Monitoring/Discharge(cont.)

• You should document if the patient received any
  reversal agents (i.e., naloxone of flumazenil),
  you must observe the patient for at least 2 hours
  after the last dose of the reversal agent,
• Other discharge criteria, such as the ability to
  tolerate fluids, are site specific.

53
The CMC Discharge/Routine Patient Care Status
Criteria

• Before discharge to home or to routine patient
  care status after sedation and/or or a
• procedure, the patient must
• Have a modified Aldrete score recorded Pre and
  Post procedure in the first five categories and
  any other pertinent categories as indicated.
  (See addendum 2 Moderate Conscious Sedation
  Record)
• Meet a minimal Post Procedure modified Aldrete
  score in the following categories
• Consciousness - 1
• Respirations - 2
• O2 Saturation - 2
• Activity - 1
• Circulation - 2
• Obtain a total Score for the above categories
  must be at least 9 in order to meet discharge
  criteria.

54
The CMC Discharge/Routine Patient Care Status
Criteria (cont.)

• Meet the minimal Post Procedure modified Aldrete
  score in the following categories, if applicable
• Temperature - 1
• Nausea Vomiting - 1
• Surgical Site - 1
• Pain - 2
• Have any modified Aldrete category score addressed in the nursing record. Any category
  score 1, must be evaluated with shift
  coordinator/charge nurse or designee prior to
  discharge and must be addressed in the nursing
  record. No patient will be discharged if any
  score is 0 without physician notification and
  documentation.
• The Total Modified Score must be at least 16 in
  order to meet discharge criteria.

55
Patient Education/Legal Guardian

• It is important to instruct patients and
  caretakers to restrict
• activities such as walking or crawling alone in
  the first few
• hours after sedation. Patients should not
  participate in high-
• risk activities such as bicycling, skateboarding,
  skating,
• roller-blading, or operating any motorized
  equipment (car,
• lawnmower, etc.) for at least 8-10 hours after
  sedation.
• Patients and families are given CHI sheets which
  describe
• post sedation care.

56
Summary Points

• Safe sedation and analgesia for procedures
  require careful assessment before administration
  of any agent. The AMPLE mnemonic is useful to
  recall the key points of this assessment.
• Patients with significant ongoing medical or
  surgical issues (ASA class III or above) should
  receive sedation under the supervision of an
  anesthesiologist or other expert sedation
  provider.

57
Summary Points (cont.)

• The level of sedation desired (light, moderate,
  or deep) and achieved determines the intensity of
  required monitoring. For all levels of sedation
  a trained provider should be designated to
  monitor the patient. Monitoring the patient
  should be this providers only responsibility.
• There is no one correct agent for all scenarios
  requiring sedation and analgesia. Providers
  should be familiar with various agents and
  alternatives and specific reversal agents.

58
References

• ? PALS manual, AHA, 2002
• The CMC Moderate Conscious Sedation/Analgesia
• Email-asherc_at_childrensdayton.org

59
Questions

• 1. You need to sedate a child for a procedure.
  You do not yet know about the child or the
  specific procedure. Which of the following
  should be part of all pre-sedation assessments?
• a. complete blood count
• b. 12-lead EKG
• c. chest x-ray
• d. oxygen saturation by pulse oximetry
• 2. You are gathering equipment to sedate a
  child for a painful procedure. Which of the
  following equipment or personnel is essential for
  this sedation?
• a. one provider assigned to both assist in the
  procedure and monitor the patient
• b. capnograph (exhaled CO2 monitor)
• c. appropriately sized resuscitative equipment
  such as endotracheal tubes, suction catheters, iv
  equipment.
• d. soft, flexible suction catheters in sizes 6F
  and 8F

60

• 3. You cared for a child with acute
  lymphoblastic leukemia who was sedated for bone
  marrow aspiration. The child is now awake, and
  her mother asks when she can take her daughter
  home. Which of the following criteria should the
  patient meet before discharge after recovery from
  sedation.
• a. ability to ambulate unassisted
• b. ability to follow age appropriate commands
• c. 1 hour has passed since any reversal agent
  (i.e., naloxone) was given
• d. ability to tolerate solids without vomiting
• 4. You must sedate a child for a painful
  procedure. The child has a possible closed head
  injury. Which of the following medications
  should you avoid in patients with increased
  intracranial pressure?
• a. thiopental
• b. midazolam
• c. ketamine
• d. pentobarbital

61

• 5. A 5-year-old boy is sedated for bone marrow
  aspiration. After the child receives midazolam
  and fentanyl, gurgling respirations develop and
  oxygen saturation falls to 83. Which of the
  following is the most appropriate initial
  intervention.
• a. open the airway and provide suction
• b. perform tracheal intubation using rapid
  sequence intubation
• c. administer IV naloxone
• d. administer IV flumazenil
• 6. A 4-year old girl requires long term
  parenteral nutrition. She is scheduled for
  placement of a central venous catheter. You need
  to sedate her for the procedure. Essential
  preparations include
• a. a review of the patients history, and to
  obtain a baseline of vital signs
• b. the administration of a sedative agent only
  to calm the patient
• c. making sure that the general consent to admit
  is signed no other consent form is required
• d. identifying that a second health care
  provider is available to assist if needed

62

• 7. A targeted physical exam for sedation
  includes the following
• a. weight for appropriate mediation dosage
• b. airway assessment
• c. assessment of cardiac function including
  heart sounds and skin perfusion
• d. all of the above
• 8. Chloral hydrate is a medication used for
  non-painful procedures primarily in children
  under 3 years of age.
• True False
• 9. Fentanyl is a potent narcotic analgesic which
  is very useful for painful procedures because it
  has a shorter duration then other narcotics.
• True False

63

• 10. When administering Fentanyl it is important
  to remember that
• a. it does not have the risk of causing
  respiratory depression
• b. an amnesic effect is produced
• c. rapid administration may cause chest wall
  muscle rigidity
• d. the only method of reversing respiratory
  depression induced by Fentanyl is ventilation
• 11. Ketamine, a disassociative agent, is
• a. likely to cause depression of ventilation
• b. a drug which doesnt produce amnesia
• c. frequently administered in the neonatal
  period
• d. contraindicated in patients with a head
  injury
• 12. Midazolam (Versed) is an amnesic which may
  be used alone for painful procedures
• True False

64

• 13. Morphine is potentiated by the following
  medications
• a. antihypertensives
• b. antibiotics
• c. benzodiazepines
• d. Diuretics
• 14. Pentobarbital (Nembutal) is a barbiturate
  which causes drowsiness leading to a deep sleep.
• True False
• 15. All sedation medications are titrated to the
  patients response and given in incremental
  dosages.
• True False