Conscius sedation in children

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Conscious Sedation
Central Hospital St-Juergen-Strasse Institut für
MR-Diagnostik B. Terwey Bremen Germany
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Wilhelm Buschs Pacifier
Linnen bag filled with Sugar or flavor with added
Beer or Wine or even Brandy
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Who will be sedated?Age classification
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Optimal sedation

• easy performed procedure
• rapid onset
• free choice of duration at any time
• rapid recovery
• effective in all age groups
• effective in patients with all diseases
• no adverse affects
• cost is low

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Sedation Management in Bremen

• 1. Sleeping or cooperative patient
• 2. Pacification by Meditation, Imaginery
• 3. Conscious sedation
• 4. Deep sedation
• 5. General anaesthesia

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Sedation procedures in Bremen since1.10.1990
148.365 Pat. (4451 Pat. 0 -6 Years old)
1 2 3 4 5
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1. Scheduling

• Foto von Anmeldung am Telefon

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1. Scheduling questions

• Indication
• Age
• Risk factors
• Cooperability

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1. Scheduling questions

• Follow-up Questions
• Is it difficult for your child difficult to sleep
  in the evening?
• How does your child act when he/she is
  overtired?
• Does your child fall asleep during the day? when
  and where?

• Objective Determine the bedtime of your patient
• Initial Question
• What time does your child go to bed?

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Scheduling Information

• Preventative education for parents
• Proper Scheduling
• Scheduled awakenings in order to change sleep
  cycle
• Warm meal
• Cosy metallfree clothes and own music box

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1. Cooperative or Sleep !
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1. Natural sleep Age related Sleep times
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1. Age related amount of REM Sleep
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1. Natural sleep age related Stages of Sleep
NonREM
Adults
REM
Newborn
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1. Problems with natural sleep

• Protest
• Hunger
• Colic (infant)
• Allergy
• Acute illness (i.e. otitis media)
• Medications - antihistamines, antibiotics,
  bronchodilators, anticonvulsants,
• Pain
• Seizures

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• Problems with natural sleepAdverse effects of
  sleep deprevation

• Mood alteration
• Reduced concentration and motivation
• Increased irritability
• Lapses in attention
• Reduced motor skills

Sleep deprivation is not helpful!
Sanders BJ et al, The effect of sleep on conscius
sedation, J Clin Pediatr Dent 1994 28(3) 211-214
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The cooperative child

• straight parents
• Child plays with mri console and technician
• Mothers warm arm
• Warm meal
• Cosy clothes and music
• cosy images and toys near to the child
• Extinction cry it out, effective but of
  limited acceptance
• Avoid double bind situations

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1. Sleep Test
Foto mit Händeklatschen
Failure of natural sleep rectal or oral
Chloralhydrate
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1. The cooperative Child 3 6 years old

• first contact outside of the MRI-Department
• convincing the parents
• talk about how cooperation may be achieved
• videoshow of the procedure
• playing the procedure with the help of an
  MR-Model
• first look to the magnet accompanied by one
  parent
• demonstration of a video during the examination
• parents or tecnician accompanies (prone
  position)
• Bribary

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1. The cooperative Child 3 6 years old
Foto Elten in Bauchlage mit Kind
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1. The cooperative Child 3 6 years old
Bribary, Goldmedal
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The cooperative Child (3 6 years old) Which
are causes for refusion?

• reports of neighbours and friends
• clinical and threatening atmosphere
• narrow bore of the magnet
• noise of the gradients
• boring long procedure

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1. The cooperative adult Controlling
Consciousness Paradox Effects

• Paradox Processes in thinking
• The harder you try to control thought, the
  less likely you are to succeed! (i.e. for 30
  seconds, do not think about bananas)
• Paradox Processes in controlling anxiety
• The harder you try to control anxiety, the
  less likely you are to succeed!

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1. The cooperative adult

• Solution 1 oral Diazepam (0,5 3,0 mg)
• Solution 2 oral Midazolam (

Sudden unexpected Panic?
Onset 2 - 18 min Duration 20 - 30
min Antidot Flumazenil
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2. Meditation (for Adults)
An altered state of consciousness characterized
by a sense of deep relaxation and a loss of
selfawareness.

• Prayer
• Concentrative meditation focus on one stimulus
  
• Opening-up meditation focus on one stimulus
  but then opens to encompass whole of
  surroundings
• Mindfulness meditation meditator focuses on
  whatever is most prominent at moment

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2. Effects of Meditation

• decreases stress,
• reduces tension and anxiety
• improves performance
• reduces oxygen consumption
• decreases heart rate
• decreases respiration rate
• lowers physiological arousal

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2. Guided Imagenery (for Children and Adults)
Immediate Rapport Rapport is the foundation
upon which all other elements of Anodyne are
built. Quick and predictable rapport establishes
the trust necessary to effectively induce and
maintain the Anodyne State of relaxation and
patient cooperation.   Effective use of
language The correct use of language is vital to
the results we get, it enables us to address both
the conscious and unconscious mind of the
patient. We directly affect the outcome of the
patient's experience with language because
literally everything we say is a suggestion to
the unconscious mind.   Relaxation Breath The
"get you through anything" tool, the relaxation
breath is easy to learn and easy to teach to
every patient. It's uses include general
relaxation, relief of pain and anxiety, and
control of physiological processes.   .
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2. Guided Imagenery (for Children and Adults)
'Preferred Place' Imagery The preferred place
imagery technique easily allows the patient's
mind to be anywhere they choose while their body
is comfortably undergoing the procedure.  
Shifting Submodalities Shifting submodalities
is an extremely quick and effective imagery
technique that can literally dissolve any
resistances the patient has to relaxation and/or
cooperation.   Control of Physiological
Processes Simple language techniques enable
practitioners to help patients control
physiological processes such as bleeding, heart
rate, blood pressure, peristalsis, salivation,
and swallowing  
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3. Conscious sedation Definition

• Pharmacological induced state of depressed
  consciousness with the defining characteristic
  that the patient can make appropriate stimulation
  at all times. This level of sedation is
  accompanied by an intact airway and maintenance
  of protective reflexes.

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3. Conscious sedation 0 - 3 Monate

• after beeing awake about 3 - 4 hours
• and after normal feeding and swaddling
• and only if necessary
• after rectal chloral hydrate (50 mg/kg)
• wait up to 5 minutes after beginning of sleep
• test for deep sleep
• give earphones, a warm blanket, nuckle
• use a vacuum cap

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3. Conscious sedation3 - 36 Monate

• well fed and dry clothes withpout metal
• change sleep cycle
• additional mild rectal chloral hydrate (50
  mg/kg)
• wait until phase of deep sleep

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3. Conscious sedation Age 3 - 6 years friendly
atmosphere and clear decisions

• parents are responsible
• emotional blackmail
• clear prospects
• choice with or without parents

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3. Conscious sedation PreparationWhat the
responsible physician has to know for the optimal
choice of time and procedure!

• Risk classification
• (American Society of Anaesthesiology
  Classification)
• 1. normaly healthy patient
• 2. mild systemic disease
• 3. severe systemic disease
• 4. severe systemic disease with threat to life
• 5. moribund patient (24 h)

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3. Conscious sedation Preparation What the
responsible physician has to tell to the parents
or nurse!

• Nutrition before sedation
• 2 hr before sedation clear liquids (every age)
• 4 hr before sedation solid or semisolid food
  (under 6 M)
• 6 hr before sedation solid or semisolid food
  (under 6-36 M)
• 8 hr before sedation solid or semisolid food
  (more than 36 M

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3. Postprocedural care and discharge AAPCOD
discharge criteria

• cardiovascular system stable
• airways patent
• protective reflexes intact
• speech near to normal (if age-appropriate)
• responsiveness recovered
• sitting up is possible (if age-appropriate)
• hydration is adequate
• minimal or no nausea

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3. Postprocedural care and discharge AAPCOD
discharge criteria

• parent information about possible reactions
• phone number of the responsible physician

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3. Conscious sedation Age 3 - 6 years
Convincing by bribery

• soft toys
• other toys
• sweets
• favourite food
• medal for bravery

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Conscious sedation Age 3 - 6 years Convincing
by gifts

• Foto der Geschenke

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4. Deep sedation Advantages

• high successrate
• radiologist is free for his duty
• simple scheduling
• higher patient throughput
• good training for emergency cases

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4. Deep sedation Disadvantages

• risks to the patient
• food and liquid deprevation
• iv pathway needed
• anaesthesiologist and nurse is needed
• high cost (staff, material, time)

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4. Deep sedation Preparation

• Nutrition before sedation
• - 2 hr before sedation clear liquids (every age)
• - 4 hr before sedation solid or semisolid food
  (under 6 M)
• - 6 hr before sedation solid or semisolid food
  (under 6-36 M)
• - 8 hr before sedation solid or semisolid food
  (over 36 M)

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4. Deep sedation Preparation

• Premature warmed vacuum cap, blankets
• Term warmed vaccum cap, blankets
• Toddler earphones,
• Infants earphones, music, video

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4. Deep sedation Different MethodsDosis
oral/rectal chloral hydrate

• Chloral hydrate 25-75 mg/kg up to
• maximum of 2000 mg
• Successrate 85 - 98
• Onset 20 - 100 min
• Duration 30 - 90 min

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4. Deep sedation Different Methods
Disadvantages oral chloral hydrate

• Vomiting (5-7)
• hyperactivity (2-5)
• minor oxygen desaturation (4)
• rare severe respiratory depresssion
• drowsiness and lack of coordination for hours
• some unproven concern over carcinogenesis

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4. Deep sedation Different Methods Advantages
oral chloral hydrate

• wide range of safety
• long working time

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4. Deep sedation Different Methods Dosis oral
Diazepam

• 0,05 -0,3 mg/kg
• Successrate 50 - 85
• Onset 5 - 15 min
• Duration 30 - 120 min
• Half-Life 20 - 50 hours
• Antidot Flumazenil 0,3 -1,0 mg

Attention Because of its shorter half-life (app.
1 hour) , patients may show some residual
sedation after flumazenil administration
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4. Deep sedation Different Methodsintranasal,
oral,rectal Midazolam

• 0,2-0,5 mg/kg
• (reduced dosis with hepatic dysfunction)
• Sucessrate 95 - 100
• Onset 5 - 12 min
• Duration 20 - 30 min
• Antidot Flumazenil 0,3 -1,0 mg

Latson LA et al. Midazolam Nose Drops for ..in
Infants. AHJ 121(1), 209-210,1991 Adrain ER
Intranasal Versed the Future of ......sedation.
Pediatric Nursing 20(3) 287-292, 1994
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4. Deep sedation Different Methods intravenous
Midazolam

• 0,02 -0,05 mg/kg
• slowly injection (2 -4 min) with 1/2 of the total
  dosis
• (reduced dosis with hepatic dysfunction)
• Sucessrate 95 - 100
• Onset 1 - 5 min
• Duration 20 - 30 min

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4. Deep sedation Different MethodsAdverse
effects Midazolam

• hypotension
• vomiting (10)
• decreased tidal volume
• decreased respiratory rate
• Apnea
• drowsiness
• antidotFlumazenil

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4. Deep sedation Different MethodsDosis
intravenous profonol

• Induction dose of 2,5 mg/kg
• slowly continous infusion
• Sucessrate 97 - 100
• Onset 1 - 2 min
• Duration 1 - 5 min

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4. Deep sedationDisadvantages intravenous
profonol

• possible respiratory depression
• possible O²-desaturation
• no analgesie

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4. Deep sedationAdvantages intravenous profonol

• high success rate
• rapid onset
• rapid recovery

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4. Deep sedation Risks

• Aspiration
• O²-Desaturation
• Apnea
• Dehydration
• Hypoglycaemia
• Seizures
• Hypotension

You may have no iv pathway in case of nasal,
oral, rectal or intramuscular sedation!
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4. Deep sedation and general Anaesthesia
Monitoring

• continuous pulse oximetry
• plethysmography
• ECG
• Bloodpressure (oscillometry)
• airway-monitoring (side-stream spirometry)
• end tidal CO2
• temperature
• recordings of all parameters

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5. General anaesthesia

• Reserved for critical ill and/or incooperative
  patients of all ages, who cannot be sedated
  sufficiently without the risk of loss of
  protective reflexes
• newborn spine and abdominal studies
• long examinations (cortical dysplasia)
• restless patients, movement disorder

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Design of a formal sedation policy I

• Who designs?

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Design of a formal sedation policy

• radiologist
• anaesthesiologist
• neurosurgeon
• pediactritian
• nurse

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Design of a formal sedation policy

• Foto der 5 Leute am Tisch
• Identified for each version