Pediatric Sedation

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Pediatric Sedation

• November 29th, 2004
• Presenter SU HUNG CHANG

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Outlines

• The History
• Definition
• Before Sedation
• During Sedation
• After Sedation

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• Before 1980 few involvements
• 1983 3 children died in a single dental office
  in California.
• 1985 first guideline from American Academy of
  Pediatrics (AAP)
• Radiology, dentistry, pediatric impatient
  service, emergency department, nuclear medicine,
  etc.
• Odds between different guidelines.

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Why Sedation ?

• Cooperation needed
• Pressure
• Postoperative maladaptive behaviors
• Post-traumatic stress syndrome
• Economic issues

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Depth of Sedation

• What is the depth required?
• What is the procedure arranged?
• What is the condition of patient?
• Who performes this sedative service?

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Kaplan R. F. ASA annu rev 200354286

• Recommended doses ? safe dose
• All areas
• Children 1-5 yr of age
• Respiratory depression and obstruction
• Rescue skill affects survival

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Continuum of Sedation
Airway may be impaired
Airway Maintained
American Society of Anesthesiology
Joint Commission on Accreditation of Heathcare
Organization
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Minimal Sedation Moderate Sedation/Analgesia Deep Sedation Analgesia General Anesthesia
Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile sstimulation purposeful Response following repeated or painful stimulation Unarousable, even with painful stimulus
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous ventilation Unaffected Adequate May be adequate Frequently inadequate
Cardiovacular function Unaffected Usually maintained Usually maintained May be impaired
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Ideal Sedation

• Safe
• Smooth
• Stress free
• Smooth and early emergence
• Sufficient sedative level

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Before Sedation

• Presedation Assessment
• Children with ICP, VP shunts, asthma, congenital
  heart disease, GERD.
• Expremature infants higher risk of apnea
• Relationship between incidence of oxygen
  desaturation and failed sedation and ASA status

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Is fasting necessary?

• ASA NPO guideline
• Agrawal et al. 509/905 patients, no episodes of
  aspiration, no higher adverse events in
  nonfasting cohort. (2003)
• Ziegler et al. 367 cases with oral contrast
  prior to CT, no problem with emesis or aspiration
  noted.

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Route for sedation

• No relathionship with adverse outcomes.
• Crock et al. BM aspiration/lumbar puncture

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Trends of Medication

• Propofol and nonanesthesiologists
• Dexmedetomidine and anesthesiologists
• Many drugs used today are not approved by the FDA
  for use in young children.
• Pediatric Rule in USA

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What had been approved?

• Fentanyl 2 yrs
• Morphine 12 yrs
• Bupivacaine 12 yrs
• Propofol 3 yrs induction, 2 mos maintenance
  of anesthesia

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Popular Propofol

• Extremely useful in non-painful pediatric
  procedures.
• Antiemetic effect.
• More and more nonanesthesiologists use propofol
  for sedation.
• May produece deep sedation.

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But propofol...

• Significant decreases and changes in airway
  dimensions in sedative doses.
• Unpredictable loss of airway reflexes in sedative
  doses.
• 2003 PDR does not recommend its use in pediatric
  sedation in ICU.

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Nonanesthesiologists said...
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Adverse Events and Procedure type

• Barbi et al. different adverse events incidence
  in different procedures in 1059 procedures
• Upper endoscopy 0.8 required bag-mask
  ventilation 2.1 with laryngospasm noted.
• Colonoscopy no airway intervention needed in
  289 cases.

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And the Future...

• Propofol would still be popular.
• Large, multi-center, prospective trials involving
  the use of propofol outside OR by
  nonanesthesiologists would be extremely helpful
  in establishing the true "safety" of its use.

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Dexmedetomidine (Precedex)

• An a2 agonist with a short half life.
• Bolus followed by constant infusion.
• It produces sedation, pain relief, anxiety
  reduction, stable respiratory rates, and
  predictable cardiovascular responses as a single
  agent.
• Major adverse effect hypotension, bradycardia

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Anesthesiologists and Precedex

• Effective use in pediatric sedation reported.
• Ard et al. for awake craniotomies in children
• Adverse effect relatively infrequent in
  children.

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When the sedation is over

• Traditionally, subjective assessment.
• Malviya et al. Can we improve the assessment of
  discharge readiness? Anesthesiology Feb. 2004
  compared BIS with UMSS, MMWT

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Malviya et al.

• UMSS(University of Michigan Sedation Score)
  0-4 observational scale
• MMWT(Modified Maintenance of Wakefulness Test)
  visual observation of the time the child is able
  to stay awake
• Discharge Criteria UMSS of 0 or 1, MMWT over 20
  minutes
• Baseline BIS comparison 92 55

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Reference

• Cravero J. Review of pediatric sedation. Anesth
  Analg 2004991355
• Krauss B. Sedation and analgesia for procedures
  in children. N Engl J Med 2000342938
• Cravero J. Pediatric Sedation. Curr Opin
  Anesthesiol 200417247
• Kaplan R. F. Sedation and Analgesia in Pediatric
  Patients for Procedures Outside the Operating
  Room. ASA annu rev 200354286
• Cote C. J. Sedation disasters in pediatrics and
  concerns for office based practice. Can J Anesth
  200249R10
• Malviya S. Sedation/Analgesia for diagnostic and
  therapeutic procedures in children. J Perianesth
  Nurs 200015415
• Malviya S. Can we improve the assessment of
  discharge readiness? Anesthesiol 2004100218

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Wake up, it's over.
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