Pediatric Anesthesia outside the OR

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Pediatric Anesthesia outside the OR

  1. 1. Anesthesia Outside the Anesthesia Outside the OR Operating Room History: • Pre-1990 few anesthetics were given by Anesthesiologists outside the OR • Several factors changed in the late 80's: Jerrold Lerman BASc, MD, FRCPC, FANZCA • Awareness of deaths from sedation Clinical Professor of Anesthesiology Women’s & Children’s Hospital of Buffalo, SUNY, & • Increase demand for more compassionate Strong Memorial Hospital, University of Rochester, New York care • Adoption of practise guidelines • Increase demand for outpatient procedures • Popularity of propofol Pediatric Oncology Centres % of centres responding Hain RDW, Campbell C Procedure Arch Dis Child 2001:85;12 Adverse Drug Events Sedation by Nonanesthesiologists Sedation in children: How effective is the sedation? • Systematic review of reported events • Observational study (1h) of 86 children • 60/95 events resulted in death/neurologic injury <12 years of age • Factors: • often due to medication overdose • Cath Lab, Endoscopy, CAT and dental • associated with meds given by non-medicals or at home • Using BIS and UMSS • 3 medications compared to 1 - 2 medications • Blinded to BIS reading • all classes of sedation/routes of administration • usually outside of medical supervision/monitoring • To achieve: conscious or deep sedation Cote et al Pediatrics 2000:106;633 Cont'd 1
  2. 2. Sedation by Nonanesthesiologists Prolonged recovery How effective were they? • 53% (BIS) and 72% (UMSS) reached goal • 35% (BIS) and 0% (UMSS) reached GA! • 12% (BIS) and 28% (UMSS) were awake! • 8% developed airway difficulties and desaturation at deeper levels of sedation Motas D, et al Malviya S, et al Ped Anesth 2004:14;256 Pediatrics 2000:105;42 Anesthesia Outside the OR Anesthesia outside the OR Considerations: • Personnel • Physical Plant • Sites • Techniques To go where no other anesthesiologist • Tailored to the procedure has dared go before... • Recovery For a good reason! Sedation by non-anesth Anesthesia Outside the OR A Pediatric sedation/anesthesia program with For sedation: dedicated care by Anesthesiologists and • Hem/Onc procedures: P ± morphine vs. M/K Nurses for procedures outside the operating • 50 children undergoing minor procedures room • Cardiorespiratory complications noted Gozal D, et al • 100% P and 92% M/K completed procedure J Pediatr 2004:145;47 • 56% P and 16% M/K had side effects, most common: desaturation Sedation by non-anesthesiologists • Induction/recovery faster with P • Recommend: sedation by airway/CPR experts Litman RS Curr Opin Anaesth 2005:18;263 Gottschling S, et al Pediatr Hematol Oncol 2005:27;471 2
  3. 3. Anesthesia Outside the OR Who should give anesthesia? Pedi Outside the OR: g a tr ic n ia n • Nursing si s Conscious sedation Deep sedation • Non-Anesthesiology MDs ur • Anesthesiologists a N si Considerations: he • Types of patients st • Personnel availability: monitor, sedation, procedure ne • Turf protection: iv vs. inhalational General anaesthesia • Financial: pro-con A Sedation by Nurses/MD Anesthesia Outside the OR Who should NOT be sedated by nursing: Pharmacology: Complications: • Airway problems: congenital/acquired, snoring, craniofacial, • young age apneas • Pentobarbital • Neonates and infants with complex diseases • Chloral hydrate (infants) • dosing • Neurological problems: raised ICP, handicapped, seizures • 1% overall. not controlled • Diazepam/midazolam • Cardiovascular disease: ie., cyanotic CHD • Opioids • Oncology: mediastinal masses, chest mets and abscesses • Emergency cases • CM3 (IM). • Multi-system organ dysfunction/failure. Anesthesia Outside the OR Anesthesia Outside the OR Reasons to involve anesthesia: Sites: • Recovery/near OR areas • Increase efficiency/throughput in the unit. • Radiology: CT scan, MRI, IGT • Conscious sedation/local anesthetic poorly • Cardiac catheterization laboratory tolerated by children • Emergency department: ie., orthopedics • Unco-operative, handicapped children • Medical procedures: • Avoid unfriendliness/cost of Operating Room and • GI: endoscopy PACU • Plastics: burns every am • Oncololgy: bone marrow, LP, chemotherapy • Transfer responsibility for sedation • Cardiology: echocardiograph 3
  4. 4. Anesthesia Outside the OR Monitoring for Apnea Anesthetic Equipment: • Machine/gas tanks/suction • Walled gas outlets, scavenging • Room air exchanges? • Airway equipment (baffled nasal prongs (Salter)) • Monitors (including slave) • Drugs: • IV access (port or N2O or EMLA®) • Propofol and N2 O (no ketamine) • Midazolam and fentanyl • Inhaled agents Keidan I, et al. Pediatrics 2008:122;293 Emergency Equipment Anesthesia Outside the OR Anesthesia: • all procedures are vetted by anesthesia: minor medical procedures • no airway, sick or complex children or < 1 year • General anesthesia: short-acting meds • avoid ALL long-acting meds, opioids • Recovery: patient room, clinic bed or elsewhere. ASA Task Force on Sedation and Analgesia by non-Anesthesiologists Anesthesiology 2002:96;1004 Anesthesia Outside the OR Anesthesia Outside the OR Recovery: Anesthetic Plan: In the procedure room: • Booking schedule (start and finish times) • Airway reflexes • Fasting guidelines (2, 4, 6, 8 hours) • Purposeful movement • Preoperative investigations • Responds to commands • Preoperative anesthetic questionnaire • Vital signs including weight! Kg or lbs? In the short-stay unit or patient’s room: • Information pamphlet/consent • Oxygen by mask • Avoid premed; parents may accompany child • 30 minutes minimum of nursing supervision: stable VS, minimal N &V, hydrated, discharge instructions. 4
  5. 5. Depth of Sedation s tric dia pe e in rol No ASA Task Force on Sedation and Analgesia by non-Anesthesiologists Anesthesiology 2002:96;1004 Anesthesia by GI MDs Anesthesia by GI MDs Survey of 51 endoscopy centres: Results: • How do they conduct upper endoscopy in • <6 mo: 35% conscious, 22% GA, 43% nada children • >6 mo: 45% conscious, 47% GA, 8% nada • 33 University, 8 community, 10 private • 1-3 yr: 12% N2O for conscious, 24% • Response rate of 84% lidocaine • 14% routinely use GA, 40% offer choice • >5 yr: 19% N2O for conscious, 42% • Choices: conscious sedation or GA lidocaine Michaud L, et al Cont'd Endoscopy 2005:37;167 Anesthesia by GI MDs Adverse Events from PSRC Which strategy? Between 2004 & 2007: • Retrospective review 402 sedations • >49,000 propofol sedations/anesthesia • EGDs and colonoscopies • CPR x 2, aspirn x 4, no deaths • Sedation and complications (airway, agitation, N/V, • Satn <90% x 30 s 154 muscle twitch) • Airway obstrn apnea 575 Per 10,000 children • Midaz/Dem (192), Midaz/Dem/Ket (82), • Laryngospasm 96 Midaz/Ket (128) • Unexpected admissions 7.1 • Complications: M/D > M/D/K > M/K (P<0.001) • M/K most sedation, P<0.07 • No differences between anesthesiologists and non-anesthesiologists Gilger MA, et al Cravero JP, et al. Gastrointest Endosc 2004:59;659 Anesth Analg 2009:108;795 5
  6. 6. Anesthesia Outside the OR Regimen for upper endoscopy: • Fasted, unpremedicated • Parents, monitors, semi-decubitus, no airway • Limitation for size: • < 1 yr or < 10 kg, trachea must be intubated • > 1 yr or > 10 kg, no airway • No opioids, long-acting sedatives! Anesthesia Outside the OR Anesthesia Outside the OR Indications for EGD: Regimen for upper endoscopy: • Abdominal pain • Should their tracheas be intubated? • Fasted • Esophageal pain/heartburn • Positioned in lateral decubitus • Vomiting/regurgitation/diarrhea • Scope in the stomach • Gastric or rectal bleeding • Suction in the stomach • Suspected IBD • Anesthesia at the head • After 25 years…no regurgitations Anesthesia Outside the OR Regimen for endoscopy: • For upper endoscopy -- iv with mask/N2 O then d/c N2O • Apply baffled NP, 2 lpm O2, iv propofol (2 mg/kg). • Insert bite block, scope, repeat doses of propofol (1-2 mg/kg) to prevent movement prn. • Monitor respiration using visually and using capnography. • Alternatives include propofol & remifentanil or tracheal intubation/GA 6
  7. 7. Anesthesia Outside the OR Anesthesia Outside the OR Regimen for isolated colonoscopy: Anesthesia for MRI: • N2O by mask, iv then propofol (1-2 mg/kg) • Consent for GA • Face mask or LMA with N2O • Physical plant: • Maintenance: • MRI compatible machine • Intermittent propofol--may be required at • Monitor in MRI and remote splenic and hepatic flexures • MRI bed detachable or not? • Wide awake after N2O discontinued • Anesthetic equipment…laryngoscope • AVOID opioids • Preoperative preparation: admit, orders etc Anesthesia Outside the OR Anesthesia Outside the OR Anesthesia for MRI: Anesthesia for MRI: • Airway algorithm: • Nasal prongs; baffled, O2 and CO2 sampling • Indications for airway support: • Position head, neck, roll, taped forehead • Craniofacial or airway anomalies • Oral airway • Chronic lung disease or myopathy • Nasopharyngeal airway • Preterm/immature infant • LMA • OSA, obese • Tracheal tube • Multisystem failure Propofol for TIVA CSHT and Drugs Manual parameters in children: • Infusion rates: • adults: 10-8-6 mg/kg/h 50% greater dose • children 3-11 yr: 15-13-11-10-9 mg/kg/h in kids! • ↑ dosing for Infants & cognitively impaired • Larger doses in children, termination by Remi redistribution ⇒ increased CSHT = slower recovery Hughes MA, et al McFarlan CS, et al. McFarlan CS, et al. Anesthesiology 1992:76;336 Pediatr Anaesth 1999:9;209 Pediatr Anaesth 1999:9;209 7
  8. 8. Sedation for Cog. Impaired Kannikeswaran N, et al. Kamibayashi T, et al Pedaitr Anesth 2009:19;250 Anesthesiology 2000:93;1345 Kinetics <2 and >2 yr High Dose Dex: CV effects Retrospective analysis: t1/2β = 1.6 h • 747 children for radiologic studies • Dex loading dose: 1 mcg/kg • <2 yr need ↑ loading • ↑ dose from 2 to 3 mcg/kg, and ↑ infusion 0 dose due to ↑ VD, from 1 to 1.5-2 mcg/kg/h • similar clearance, thus similar • ↑ sedation success from 92% to 98% t1/2β = 2.3 h maintenance infusion rates • Recovery ↓ from 35 min to 24 min✻ • However, bradycardia 16%! Mason K, et al. Vilo S, et al. ✻ Aldrete score ≥ 9 Pediatr Anesth 2008:18, 403 Br J Anaesth 2008: 100, 697 High Dose Dex: CV effects Dex vs Propofol for MRI After sevoflurane induction: • Dex 1 mcg/kg IV, midazolam 0.1 mg/kg then Dex 0.5 mcg/kg/h • Propofol 2 mg/kg IV, then 300 mcg/kg/min x 10 min followed by 250 mcg/kg/min • Fully responsive: Dex 44 min vs. P 30 min✻ • PACU d/c: Dex 50 min vs. P 36 min❉ • End scan to hospital d/c: Dex 98 min vs. P 80 min✻ Mason K, et al. ✻ P<0.05 Heard C, et al. Pediatr Anesth 2008:18, 403 Anesth Analg 2008;107, 1832 8
  9. 9. Dex for MRI: CV effects Anesthesia outside the OR Discharge criteria: • Awake • UMSS yielded better assessment of suitability for discharge than observational scores Malviya S, et al Anesthesiology 2004:100, 218 • Maintains oxygenation • Returned to pre-sedation activity level • No vomiting, no pain Heard C, et al. Anesth Analg 2008;107, 1832 Anesthesia Outside the OR Anesthesia Outside the OR After all is said and done… Popularity of the service: • before anesthesia, there was inadequate • Profile of anaesthesia has been sedation for these minor procedures heightened • protocols, infrastructure and personnel must • Doctors, parents and children ask for the anaesthetic service be approved by all stakeholders • Work efficiency has increased since the • preoperative preparation and anticipation of introduction of this program unexpected events must be thorough • But can we control/limit the rate of growth of this service? • there is no such thing as a “minor anesthetic” 9

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