Pediatric Procedural Sedation

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Pediatric Procedural Sedation

• Dr. Marc N. Francis
• MD, FRCPC
• University of Calgary
• Foothills Medical Centre
• Alberta Childrens Hospital

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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.

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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

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Learning Objectives

• Tools of the Trade
• Sedation medications that you should know well
  and be familiar with
• The Right Tool for the Job
• Discuss the variable needs for procedural
  sedation in the ED and pharmaceutical options
• Tricks of the Trade
• Some adjuncts and techniques that will make your
  job easier
• Controversies
• 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

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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
• Childrens 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 1990191010-1013

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Sedation Spectrum

• Minimal Sedation
• Patient responds appropriately to verbal commands
• Cognitive processing affected but no
  cardiopulmonary effects
• Moderate Sedation
• Patient responds to verbal commands or with
  addition of mild stimulus
• Maintains airway and ventilation without required
  intervention
• Deep Sedation
• 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

Dissociative Sedation
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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 ID
• Fracture Reductions
• Dislocations reduction
• Foreign body removal
• Burn dressings

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The Search Continues

• The ideal sedation protocol
• 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

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Tools of the Trade
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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

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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

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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

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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

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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

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The Right Tool for the Job
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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

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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

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The Right tool for the Job

• 15yo ? playing soccer and collided with another
  player
• Immediate pain to R shoulder which is clinically
  consistent with anterior dislocation
• Very Anxious!!!
• PMHX Healthy
• Normal Vital signs

• Nitrous Oxide
• Midazolam
• Fentanyl
• Ketamine
• Propofol
• Sedation Spectrum
• Moderate Sedation

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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

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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

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Tricks of the Trade
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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

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• 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 p0.02
• NNT of 13
• Vomiting in the ED or after discharge was less
  frequent with ondansetron 7.8 vs 18.9 p0.01
• NNT of 9

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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
• Childrens 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

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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

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• 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 gt50mm
• 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

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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

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Controversies
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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?

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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
  200749462-464
• Extrapolation from general anesthesia literature
• Incidence of aspiration is low (13,420)
• Mortality is rare (1125,109)

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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

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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

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• 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

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Assess Patient risk

• Difficult airway?
• High risk for esophageal reflux?
• Esophageal disease
• Hiatal hernia
• PUD
• Bowel obstruction
• Extremes of age?
• gt70
• lt6mths
• Severe Systemic disease?
• ASA III

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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

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Urgency of the procedure

• Emergency
• Cardioversion for life threatening arrythmia
• Reduction of markedly angulated fracture
• Urgent
• Care of dirty wounds and lacerations
• Abscess ID
• Semiurgent
• Care of clean wounds and lacerations
• Shoulder reduction
• Nonurgent or elective
• Foreign body in external ear canal
• Ingrown toenail

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Depth of sedation

• Procedure Duration
• Brief lt10mins
• Intermediate 10-20mins
• Extended gt20mins

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Standard-risk patient
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Higher-risk Patient
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Capnography monitoring during procedural sedation

• Non-invasive measurement of the partial pressure
  of CO2 from the airway during inspiration and
  expiration

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Capnography monitoring

• Traditional monitoring
• Pulse oximetry oxygenation
• RR and clinical observation ventilation
• Capnography
• More precise and direct assessment of the
  patients ventilatory status
• Assessment of airway patency and respiratory
  pattern
• Early warning system for prehypoxic respiratory
  depression
• Assessment of depth of sedation

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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 gt50 of cases and nearly 25
  fulfilled criteria for apnea

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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

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Future

• where were going we dont
• need roads Dr. Emmett Brown

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Ketofol

• Propofol
• Pros
• Antinauseant effects
• Amnestic
• Smooth recovery profile
• Cons
• Cardiovascular and respiratory depression
• Bradycardia
• Non-analgesic

• Ketamine
• Pros
• Analgesia
• Amnesia
• Respiratory and cardiovascular stability
• Cons
• Emergence phenomena
• Vomiting

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• Prospective case series
• 114 ED procedural sedations
• 11 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

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• 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

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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

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BIS
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Bispectral Index

• BIS
• Uses processed EEG signals to measure the depth
  of sedation
• Validated with children undergoing general
  anesthesia in the OR

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• 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

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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-and-white and each situation is unique
• Consider the additional information provided by
  capnography if it is available to you
• Ketofol not ready for primetime.. yet

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Questions?
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Additional References

• Green SM et al. Intramuscular ketamine for
  pediatric sedation in the emergency department
  safety profile with 1022 cases. Ann Emerg Med.
  199831688-97
• 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 199713(3)189-93
• Lightdale JR et al. Microstream capnography
  improves patient monitoring during moderate
  sedation a randomized, controlled trial.
  Pediatrics 2006117(6)e1170-8
• Lopez MD et al. Pediatric Procedural Sedation.
  Emergency Medicine Reports 200813(12)145-156

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Additional Slides
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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

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Prevention of Fentanyl Rigid Chest
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Propofol epilepsy
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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

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• Prospective study
• Effects of IV propofol on EEG
• 25 children with epilepsy
• 25 children with learning disorders
• Undergoing elective sedation for MRI

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• 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

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Aspiration case in literature
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• 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

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• Sats were 86 initially
• Airway was suctioned and BVM was started with
  improvement to sats 97
• Patient remained hypoxic with sats 84 on RA
• 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

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Etomidate
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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

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• Only randomized control trial evaluating
  etomidate for pediatric PSA in the ED
• Randomized double-blind study out of Montreal
• N100 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

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• 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

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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?

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Propofol infusion syndrome
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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 gt48hrs in
  children lt4yo
• Thought to be related to a mitochondrial defect
• Not an issue for brief ED sedation

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Preoxygenation protocol
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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
• Childrens 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

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• 1244 procedural sedations
• Median age 5.9yrs
• Complications in 17.9
• No preoxygenation protocol

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