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atricia D. Scherrer M.D. Vice-President, Society for Pediatric Sedation Medical Director, Sedation Services Children s Hospitals and Clinics of Minnesota 5 1

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

3 The Evolution of Pediatric Procedural Sedation Disclosure!" I do not have any affiliation (financial or otherwise) with any commercial organization that would have a direct or indirect connection to the content of my presentation Patricia D. Scherrer MD Vice-President, Society for Pediatric Sedation Medical Director, Sedation Services Children s Hospitals and Clinics of Minnesota Background Children s sedated procedures!" Diagnostic!" Radiographic tests (CT/MRI)!" ABRs (hearing)!" Urinary catheterization!" Lumbar puncture!" Bone marrow aspirate/ biopsy!" Therapeutic!" PIVs!" Laceration repair!" Abscess I&D!" Fracture reductions!" Foreign body removals!" Burn/wound cleaning and dressings!" How did we get here?!" A history of cocktails!" Where are we now?!" Medications!" Sedation teams!" Research!" Education!" Where are we going?!" Quality Objectives What used to happen?!" First descriptions of pediatric dental sedation in 1940s (and perhaps earlier )!"!" Barbiturates!" Chloral hydrate ( Mickey Finn ) 3

4 What used to happen? What used to happen?!" First pediatric radiology sedations described in 1970s!" Chloral hydrate!" Anderson, Radiology, 1977 IM demerol, phenergan, thorazine ( DPT )!" Thompson, Radiology, 1982 IM atropine, meperidine, promethazine, secobarbital ( AMPS )!" First descriptions of pediatric PSA in ED began to appear in late 1980s!" IM DPT!" Terndrup, Ann Emerg Med 1989!"!" Garris, Ann Emerg Med 1989!" Then things really got going!" Many more medications!" Guidelines!" Monitoring modalities What happens now?!" State-of-the-art monitoring!" Lots of guidelines!" Child life!!!!" Many medications!" Expert teams How do we provide sedation?!" Distraction!" Topical and local anesthetics!"!" Intranasal medications!" Ketamine!" Dexmedetomidine!" Propofol Distraction Distraction!" 35% decrease in sedation need for MRI, 45% for CT!" Khan, Applied Radiology

5 Distraction!" >50% success rate without sedation for MRI in children under 7 years after practicing in mock scanner with child life!" debie, Eur J Pediatr 2010 Distraction!" Decreased child anxiety, increased family satisfaction with child life distraction for suturing!" Alcock, Pediatr Emerg Care 1985!" Gursky, J Dev Behav Pediatr 2010!" Decreased anxiety during peripheral IV placement!" Stevenson, Pediatr Emerg Care 2005 Distraction Topical anesthetics!" Commonly utilized formulations!" LET gel!" EMLA cream!" LMX cream!" Synera!" Vapocoolant!" J-tip Topical anesthetics Topical anesthetics!" LET gel!" Provides adequate analgesia for 75-90% of facial and scalp laceration repairs in children!" Singer, Acad Emerg Med 2000!" Standing orders at ER arrival!" Zempsky, Pediatrics

6 Local anesthetics Local anesthetics!" Needle-free lidocaine delivery!" J-Tip!" Carbon dioxide propelled jet injection system!" Administers 0.25 ml of 1% lidocaine!" Cost similar to EMLA and LMX!" Little or no pain at injection!" Popping sound can be distressing!" Similar efficacy to LMX for PIVs in children!" Jiminez, Anesth Analg 2006!" History!" Discovered in 1771!" First anesthetic use in 1845!" Properties!" Sweet smelling, colorless gas!" Rapid onset of clinical action!" Rapid equilibrium between alveolus and capillary!" Crosses blood brain barrier quickly!" Properties!" Rapid return to normal function!" No significant hepatic metabolism or renal excretion!" Remains unchanged in blood!" Not stored in tissues!" Eliminated through lungs!" Cannot achieve anesthesia!" Airway reflexes and hemodynamics remain intact!" Characteristics!" Anxiolytic!" Analgesic!" Amnestic!" Titratable!" Patient experience!" Comfortable and relaxed!" Aware of surroundings!" Eyes less active with glazed look!" Other!" Tingling in extremities and/or near mouth!" Heaviness in arms and legs!" Warm and light feeling!" Vasodilation in face and neck 6

7 !" Contraindications!" Any condition where air may be trapped in the body!" Pneumothorax!" Intestinal obstruction!" Bullous emphysema (ie cystic fibrosis)!" Maxillofacial injuries!" Recent intraocular or intracranial surgery!" Contraindications!" Vitamin B12 deficiency!" Potential for megaloblastic anemia and myeloneuropathy!" Pregnancy!" Impaired fetal development, especially in 1 st trimester!" Increased risk of spontaneous abortions with chronic exposure!" Side effects!" Nausea and vomiting 2%!" Inadequate sedation 0.5%!" Other (<0.1%)!" Diaphoresis!" Hallucinations!" Agitation!" Brief generalized tonic clonic seizure activity!" Zier, Anesth Analg 2010 Intranasal medications Intranasal medications 7

8 Intranasal medications Intranasal midazolam!" Variety of uses!" Single agent for CT scans!" With topical/local anesthetics for IV starts, simple laceration repairs!" Lane, Pediatr Emerg Care 2008!" Klein, Ann Emerg Med 2011!" As initial agent in preparation for deeper sedation Intranasal fentanyl!" Mainstay for analgesic administration!" Improves time to first analgesic dose!" Holdgate, Acad Emerg Med 2010!" Many many references!" Borland, Ann Emerg Med 2007!" Saunders, Acad Emerg Med 2010!" Borland, Burns 2005 Ketamine!" The drug for ER PSA in children!" Sedative, analgesic, amnestic, and dissociative!" Less respiratory depression and better airway reflex preservation than with opioids!" Multiple potential routes of administration!" Many unique effects and side effects!" Green, Ann Emerg Med 2004!" Dissociative sedation!" Trance like state!" Eyes often remain open, disconnected stare!" Nystagmus!" Non-purposeful random movements!" Vivid dreams Ketamine Ketamine!" Sympathomimetic!" Increases in BP, HR, and cardiac output!" Increased intraocular and intracranial pressure (?)!" Bar-Joseph, J Neurosurg Pediatr 2009!" Sensitizes the gag reflex!" Higher incidence of laryngospasm!" 0.4% in 1022 pediatric ER patients!" Green, Ann Emerg Med

9 Ketamine!" Sialogogue!" Stimulates tracheal and bronchial secretions!" Pre-treatment with atropine unnecessary!" 1090 ketamine sedations in Loma Linda University pediatric ER!" 947 untreated patients had 4.2% incidence of suctioning, one brief desaturation related to hypersalivation!" Brown, Acad Emerg Med 2008 Ketamine!" Nausea and vomiting!" Incidence %!" Increasing incidence with increasing age!" Decreased with IV ondansetron!" 255 pediatric ER patients 128 received ondansetron!" Incidence of ER vomiting 4.7% versus 12.6% with placebo!" Langston, Ann Emerg Med 2008!" Enteral not helpful KSPEM Ketamine!" Emergence reactions!" Associated with agitation and hallucinations!" Attenuated by picking a dream!" Not altered by midazolam co-administration!" 236 pediatric ER patients receiving ketamine!" 137 also received midazolam!" Incidence of emergence reactions 7.1% in ketamine group, 6.2% in KM group!" Wathen, Ann Emerg Med 2000 Dexmedetomidine!"! 2 receptor agonist!" Centrally mediated sedation!" Spinal cord mediated analgesia!" No significant respiratory effects!" Normal response to CO2!" No decrease in Vt or resp drive Dexmedetomidine!" Advantages!" Fewer resp effects!" Koroglu, Anesth Analg 2006!" No recovery related agitation!" Berkenbosch, PCCM 2005!" No effect on EEG!" Mason, Pediatr Anaesth 2009!" Intranasal!" Yuen, Anesth Analg

10 !" Disadvantages!" Slower onset Dexmedetomidine!" Slightly higher risk of failed sedation!" Mason, Pediatr Anaesth 2008!" Longer recovery!" Lubisch, Pediatr Neurol 2009!" Bradydysrhythmias!" Berkenbosch, PCCM 2003 Propofol!" Sedative, hypnotic, amnestic!" No inherent analgesic properties!" Transient deep sedation!" Rapid onset and offset!" Plasma concentration rapidly equilibrates with CNS!" Plasma levels fall quickly secondary to redistribution and metabolic clearance Propofol!" Adverse effects!" Significant risk of apnea, hypoventilation, loss of airway reflexes!" Impaired CO 2 responsiveness!" Risk of hypotension and bradycardia!" Myoclonus!" Burning in peripheral IVs!" Anaphylaxis Propofol!" Disadvantages!" Higher incidence of apnea = higher incidence of need for BVM ventilation!" Cravero, Anesth Analg 2009!" Must consider NPO times more carefully in the ER!" Increased monitoring and personnel requirements, including capnography!" Anderson, Ann Emerg Med 2007 Propofol Who provides sedation?!" Advantages!" Rapid onset and offset!" Hasan, PCCM 2003!" Godambe, Pediatrics 2003!" High success rate!" Vespasiano, Pediatrics 2007!" No nausea/vomiting!" Burton, Acad Emerg Med

11 !" Formed in 2003!" 26 institutions then, 39 now 2004 PICU PEM anesthesiology ped hospitalist general peds PICU/hosp/peds PICU/PEM Cravero, Pediatrics 2006 PICU/PEM/anesth Cravero, Anesth Analg

12 Mallory, Ann Emerg Med 2011 Baxter, Pediatr Emerg Care 2007!" Risk factor evaluation!" Prematurity!" Young age (< 3 months)!" URI!" Asthma!" Obesity!" Obstructive sleep apnea!" GERD!" NPO status Non-obese (n=17902) Obese (n=3912) n (%) n (%) None <0.001 Airway obstruction Unexpected need for BVM Desaturation Coughing Secretions requiring treatment Other Agitation Unexpected change in HR/BP/RR p Scherrer, in press 12

13 SPS SPS SPS Sedation Provider Course SPS Sedation Provider Course SPS Quality Summit!" Procedural sedation care should be:!" Safe!" Effective!" Timely!" Efficient!" Equitable!" Patient- and family-centered 13

14 SPS Quality Summit Conclusion Thank you! Question Has anyone looked at the economics of this quality initiative? I would assume that it is costeffective. Thank you for viewing this presentation! To receive CME credit, please click the Post Test button on the interface below, and complete the post test. 14