Brief Slide Presentation on the major risks of pediatric sedation with references

1. 1
Update in Pediatric
Sedation
Corey E Collins DO FAAP
Director, Pediatric Anesthesiology
MEEI Boston MA
corey_collins@meei.harvard.edu1

2. 2 Corey Collins, DO FAAP 2012
Conflict of Interest
• Nothing to Declare
Objectives
At the end of this talk, the participant will be able to:
• Review the Current Guidelines applicable to Pediatric Sedation
• Summarize Risks and Morbidity data regarding Pediatric Sedation
• Describe common and uncommon sedation medications, their benefits
and limitations

3. 3 Corey Collins, DO FAAP 2012
Case Presentation
• 4 year old Down’s Syndrome Fractured
Radius needs CT and likely Closed
Reduction
• ED Doctor calls and asked for your help
with a sedation plan
• NPO: lunch 4h ago

4. 4 Corey Collins, DO FAAP 2012

5. 5 Corey Collins, DO FAAP 2012

6. 6 Corey Collins, DO FAAP 2012
Sedation Guidelines

7. 7 Corey Collins, DO FAAP 2012
Familiar Points
• Standard ASA PS Classification
• Standard ASA NPO Guidelines unless
Emergency
• Recommended Standards for Discharge,
Emergency Drugs and Emergency
Equipment that should be available
• Recommends SpO2, etCo2, Local
anesthetic toxicity training,“SOAPME”,
Simulation’s role in training & competence

8. 8 Corey Collins, DO FAAP 2012
New Paradigm for Sedation
Continuum??
Risk Based?
Specific, Derived Physiological
Thresholds
Define Required Training

9. 9 Corey Collins, DO FAAP 2012
World society of intravenous anesthesia: 10 specialties, 11 countries
Sentinel AE
Moderate AE
Minor AE
Minor AE
Minor AE

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11. 11 Corey Collins, DO FAAP 2012
26 Institutions
30 037 sedation cases 7/04-11/05
no deaths, CPR in one case
SpO2<90% >30s: 157/ 10 000
Laryngospasm: 4.3/10 000
Apnea: 24/ 10 000

12. 12 Corey Collins, DO FAAP 2012
What is “NPO” for sedation?

13. 13 Corey Collins, DO FAAP 2012
What is “NPO” for sedation in the ED?

14. 14 Corey Collins, DO FAAP 2012
4 step assessment
process...
• Patient Risk: Difficult airway, syndromes,
bowel obstruction, age <6mo,ASA PS >2
• Timing & Nature of PO Intake
• Urgency of Procedure
• Determine Duration and Depth of Sedation
Needed....

15. 15 Corey Collins, DO FAAP 2012
Who is giving Pediatric Sedation?

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What meds are being used?

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20. 20 Corey Collins, DO FAAP 2012
49 836 Propofol Sedations @ 37 sites
1:65 rate of Adverse Airway events
1:70 required Airway interventions
CPR x 2
Aspirations x4
SpO2< 90 x 30s: 154/ 10k
Laryngospasm: 96/ 10k

21. 21 Corey Collins, DO FAAP 2012
Complications Related to:
ASA PS III+ (1.75-2.26)
NPO Solids < 8h (1.17-1.39)
Co-Administration of Narcotics (1.63-1.96)

22. 22 Corey Collins, DO FAAP 2012
Conclusions from
PSRC
• Adverse events occur 1:29
• Airway events are managed with Bag mask
quite often (63.9/10k), reversal agents
thankfully are infrequently used(1.7/ 10
000)
• Intubation needed (9.7/ 10 000)
• Critical events are rare (CPR 0.3/10 000)
• IV access can be an unexpected challenge

23. 23 Corey Collins, DO FAAP 2012
Conclusions from
PSRC
• Suggestions for Credentialing Clinicians
• Propofol seems OK for Non-
anesthesiologists
• NPO guidelines are Inconsistent

24. 24 Corey Collins, DO FAAP 2012
• 1649 sedations 62mo (4mo - 28y) 99% success 99.6%
for MRI
• 14 aborted. 2 required anesthesiologists.
• Propofol: 2mg/kg bolus then 200ug/kg/min
• 3 major complications: 2 aspirations, 1 ETT for cough
• Pedi hospitalists training: 4h class, 10d in OR, Simulation,
Written exam, 25 observed sedations

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26. 26 Corey Collins, DO FAAP 2012
Impact of Provider Specialty on Pediatric
Procedural Sedation Complication Rates
Couloures et al. Pediatrics 2011; 127(5): e1154-60
Couloures et al. Pediatrics 2011; 127(5): e1154-60
• 131,751 sedations at 38 centers 2004-2008
• Self reported, various techniques
• No significant differences found
• Accounted for ASA PS>2, Propofol Use,
Emergency Status, Site clustering

27. 27 Corey Collins, DO FAAP 2012
Impact of Provider Specialty on Pediatric
Procedural Sedation Complication Rates
Couloures et al. Pediatrics 2011; 127(5): e1154-60
Couloures et al. Pediatrics 2011; 127(5): e1154-60

28. 28 Corey Collins, DO FAAP 2012
-Editorial
-Recognizes need for “extensive and multimodal”
team training
-“professionalization” of pediatric sedation
-infrastructure for rescue
-Time for national standards for Deep Sedation training,
credentials?

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30. 30 Corey Collins, DO FAAP 2012
279 kids 0.2-17.2y 100% success
Dexmedetomidine bolus technique: 3 ug/kg over10” repeated PRN
16% needed second bolus; 0.7% needed third bolus
Hypotension: 33% Bradycardia 5% Hypertension 3.2%
Mean sedation time: 7.8” +/- 3.8” (0-30” range)

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• 65 kids 0.2-2.2y 100% success; MRI:21 CT: 44
• 1-4 ug/kg IM deltoid; MRI: 3ug/kg; CT 2.5ug/kg
• 7 children needed second IM injection
• Sedation time: ~13” Discharge after study:
~20”
• 14% Hypotension (Not related to dose)
Intramuscular Dexmedetomidine Sedation for
Pediatric MRI and CT
Mason AJR 2011; 197: 720-25

33. 33 Corey Collins, DO FAAP 2012
Compared Ketamine alone vs Ketamine+Propofol Closed reductions
1 mg/kg Ketamine vs 0.5mg/kg Ketamine + 0.5mg/kg Propofol
136pts. 97.8% successful reductions
Ket+Propofol: Shorter Sedation (13” vs. 16”), less nausea
Propofol 0.75mg/kg vs. Propofol 0.375mg/kg + Ketamine 0.375mg/kg
282 pt 14y- 95y, ASA 1-3, Fx/ dislocation/ cardioversion...
No significant differences on adverse events, efficiency
Ketofol may provide more consistent Moderate Sedation Depth
Ann Emer Med March 2012 epub

34. 34 Corey Collins, DO FAAP 2012
Is the addition of Dexmedetomidine to a Ketamine-
Propofol Combination in Pediatric Cardiac
Catheterization useful?
Ulgey,A. Pedi Cardiol 2012; Feb 16. epub ahead of print
Ulgey,A. Pedi Cardiol 2012; Feb 16. epub ahead of print
Intranasal fentanyl and high-concentration inhaled
nitrous oxide for procedural sedation: a prospective
observational pilot study of adverse events and depth
of sedation.Seith, R et al. Acad Emerg Med 2012;19: 31-6
Seith, R et al. Acad Emerg Med 2012;19: 31-6

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65 kids 3-74mo 10” infusion 0.5mg/kg
96% success
22” induction, 72” sleep 104” discharge
12 met “deep sedation” score
No Complications
Pedi Radiol 2012 Jan13 epub ahead of print

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Conclusions?
• Dynamic Field, Shifting Delivery Models
• Large Safety Data sets remain Incomplete
• Minimal Rigorous Standards
• “Professionalization”
• Oversight, Credentialing, Quality....

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RESOURCES
• www.pedsedation.org (Pedi Sedation
Society)
• www.aapd.org/media/Policies_Guidelines/G
_sedation.pdf (Amer Acad Pedi Dentistry
Guidelines 2006)

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Key References
• Cravero, JP Blike, GT. Review of Pediatric Sedation. Anesth Analg 2004;
99:1355-64.
• Cravero, JP Havidich, JE. Pediatric sedation- Evolution and Revolution.
Pedi Anesth 2011; 21:800-9.
• Cravero, JP et al.The Incidence and nature of adverse events during
pediatric sedation/anesthesia with propofol for procedures outside the
operating room: a report from the Pediatric Sedation Research
Consortium. Anesth Analg 2009; 108: 795-804.
• Krauss, B Green, SM. Procedural Sedation and Analgesia in Children.
Lancet 2006; 367: 766-80