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  1. 1. Pedi at r i c Sedat i o n • November 29th, 2004 • Presenter SU HUNG CHANG
  2. 2. Outlines • The History • Definition • Before Sedation • During Sedation • After Sedation
  3. 3. • 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.
  4. 4. • Cooperation needed • Pressure • Postoperative maladaptive behaviors • Post-traumatic stress syndrome • Economic issues Why Sedation ?
  5. 5. Depth of Sedation • What is the depth required? • What is the procedure arranged? • What is the condition of patient? • Who performes this sedative service?
  6. 6. • Recommended doses ≠ safe dose • All areas • Children 1-5 yr of age • Respiratory depression and obstruction • Rescue skill affects survival Kapl an R. F. ASA annu rev 2003; 54: 286
  7. 7. Continuum of Sedation i mal at i on xi ol ysi s" Moder at e Sed/ Anal g " Consci ous Sedat i on" Deep Sedat i on/ Anal gesi a Gener al Anest hes Ai r wa y Mai nt Ai r way may be i mpai r ed Soci et y of Anest h Joi nt Commi ssi on
  8. 8. Mi ni mal Sedat i on Moder at e Sedat i on/ Anal gesi a Deep Sedat i on Anal gesi a Gener al Anest hesi a Responsi v eness Nor mal r esponse t o ver bal st i mul at i on Pur posef u l r esponse t o ver bal or t act i l e sst i mul at i on pur posef u l Response f ol l owi ng r epeat ed or pai nf ul st i mul at i on Unar ousab l e, even wi t h pai nf ul st i mul us Ai r way Unaf f ect e d No i nt er vent i on r equi r ed I nt er vent i on may be r equi r ed I nt er vent i on of t en r equi r ed Spont aneo us vent i l at i Unaf f ect e d Adequat e May be adequat e Fr equent l y i nadequat
  9. 9. Ideal Sedation • Safe • Smooth • Stress free • Smooth and early emergence • Sufficient sedative level
  10. 10. 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
  11. 11. 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. 2 h 4h 6h
  12. 12. Route for sedation • No relathionship with adverse outcomes. • Crock et al. :BM aspiration/lumbar puncture Rest r ai n t Pai n Fami l y sat i sf ac t i onSevof l ur ane 102 cases Or al / Nasal mi dazol am 80 cases
  13. 13. • 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 Trends of Medication
  14. 14. • Fentanyl ≥ 2 yrs • Morphine ≥ 12 yrs • Bupivacaine ≥ 12 yrs • Propofol ≥ 3 yrs induction, ≥ 2 mos maintenance of anesthesia What had been approved?
  15. 15. Popular Propofol • Extremely useful in non-painful pediatric procedures. • Antiemetic effect. • More and more nonanesthesiologists use propofol for sedation. • May produece deep sedation.
  16. 16. 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.
  17. 17. Nonanesthesiologists said... No. Ai r way adj ust ment Bag- mask vent i l at i on Guent h er et al . 291 4% 1% Basset t et al . 393 3% 0. 8%
  18. 18. 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.
  19. 19. • 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. And the Future...
  20. 20. Dexmedetomidine (Precedex) • An α2 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
  21. 21. Anesthesiologists and Precedex • Effective use in pediatric sedation reported. • Ard et al. : for awake craniotomies in children • Adverse effect : relatively infrequent in children.
  22. 22. 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
  23. 23. 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%
  24. 24. • Cravero J. Review of pediatric sedation. Anesth Analg 2004;99:1355 • Krauss B. Sedation and analgesia for procedures in children. N Engl J Med 2000;342:938 • Cravero J. Pediatric Sedation. Curr Opin Anesthesiol 2004;17:247 • Kaplan R. F. Sedation and Analgesia in Pediatric Patients for Procedures Outside the Operating Room. ASA annu rev 2003;54:286 • Cote C. J. Sedation disasters in pediatrics and concerns for office based practice. Can J Anesth 2002;49:R10 • Malviya S. Sedation/Analgesia for diagnostic and therapeutic procedures in children. J Perianesth Nurs 2000;15:415 • Malviya S. Can we improve the assessment of discharge readiness? Anesthesiol 2004;100:218 Reference
  25. 25. Wake up, i t ' s over . i ons & An

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