EMC El Paso Neonatal Moderate Sedation and Analgesia Self Study

Transcription

1 EMC El Paso Neonatal Moderate Sedation and Analgesia Self Study Self-Study Packet & Test A Professional Education Training Program Developed by: Mark Gates; CRNA Jeff Rubun, DO 1

2 Learning Objectives Upon completion of this course, the participant will be able to: 1. Summarize the continuum of sedation and the monitoring needs of each 2. Define the education, training, experience and skills required for those administering Successful completion of this module is one of the requirements prior to the Physician providing or RN assisting with moderate sedation of the neonate: moderate sedation to the neonate. 3. Describe the current state of neonatal procedural sedation from the pre-sedation risk assessment to the recovery phase. 4. Determine the effects of common sedative drugs on consciousness, anxiety and respiratory drive. 5. Explain the most common adverse events that occur during sedation and how effectively to manage them.

3 What is Moderate Sedation? Moderate Sedation: 1. protective reflexes are maintained 2. maintains a patent airway 3. appropriately responds to stimulation

4 Goals of Moderate Sedation I. Alteration in level of consciousness, but II. maintenance of consciousness and cooperation. III. Elevation of pain threshold. IV. Minimal variation of vital signs. V. Safe and prompt recovery.

5 Levels of Sedation 1.Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. 1.Moderate sedation / analgesia is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands (Note: Reflex withdrawal from painful stimulus is not considered a purposeful response) either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. The Continuum of Sedation No Sedation Minimal Sedation Moderate Sedation Deep Sedation Anesthesia Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. 1.Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained in the presence of adequate ventilation. 1.Anesthesia consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug - induced depression of neuromuscular function. Cardiovascular function may be impaired. 5

6 RN Staff Qualifications There must be a registered nurse present who has been deemed competent through the hospital s competency assessment and validation process to monitor and manage the care of sedated patient. Assessment of competency is intended to assure that the RN: 1.Understands the principles of oxygen delivery and respiratory physiology; 2.Demonstrates skill in airway management and resuscitation; 3.Identifies abnormal and life threatening cardiac rhythms; 4.Appreciates age-dependent heart rate and blood pressure ranges; 5.Understands action, side effects & potential complications of common sedatives & antidotes; 6.Is able to utilize emergency equipment; 7.Has completed NRP including mock code; 8.And can assess total patient care requirements during sedation 6 and recovery.

7 1. Skilled in the use of such techniques evidenced by completion of a training program in their specialty where the use of pharmacological agents for sedation was a routine part of performing those therapeutic or diagnostic procedures; 2. Has successfully sedated at least 12 neonatal patients over last 24 months, at least 2 over the previous 2 months; 3. Capable of managing complications and providing first line therapy which include establishing an airway, administering positive pressure ventilation and managing cardiovascular emergencies; 4. Agrees to comply with UMC El Paso Neonatal Sedation Policy in accordance with guidelines set forth in those policies. MD/DO Staff Qualifications Physicians must be granted clinical privileges for moderate sedation procedures through the hospital s medical staff credentialing process by showing they are Track A <OR> Track B 1. Knowledgeable about neonatal sedation as evidenced by completion of this module with a score of >80% on the exam; and 2. PALS and NALS certified; and 3. Completed 3 simulated sedation cases; proctored for same number; and 4. Capable of managing complications and providing first line therapy which include establishing an airway, administering positive pressure ventilation and managing cardiovascular emergencies; 5. Agrees to comply with UMC El Paso Neonatal Sedation Policy in accordance with guidelines set forth in those policies.

8 Physician s Responsibilities Include 1. Performing a pre sedation patient assessment 2. A focused physical examination with the determination of the patients current physical risk status; 3. Developing a sedation plan including notation of planned medications and weight-specific dosing; 4. Obtaining informed consent; 5. Continuous observation and evaluation of heart rate, rhythm & oxygen saturation and level of consciousness; and repeated evaluation of blood pressure no less frequently than every 4-5 minutes. 6. Recognize and be able to manage a compromised airway. 7. Be able to provide adequate oxygenation and ventilation. 8. Recognize and recover patients from deep sedation. 9. Be immediately available to provide rescue support until the patient has completed post-sedation recovery.

9 Airway Anatomy The most important aspect of safe sedation in the neonatal population is the ability to assess and manage the airway. Adult vs.child Anatomy The upper airway is composed of three segments; the supraglottic, laryngeal and intrathoracic area. A.Supraglottic larynx is the most poorly supported and the most collapsible segment of the upper airway. It is comprised of the pharyngeal structures and is the most impacted portion of the airway during sedation. B.Larynx or glottis is comprised of the vocal cords, the subglottic area and the cervical trachea; C.Intrathoracic consists of the thoracic trachea and bronchi. Airway - Smaller upper & lower airways - Bigger tongue - Obligate nose breathers -Cartilage of larynx is softer -Increased proportion of soft tissue (obstruction) -Larynx is more anterior and towards the heart -Epiglottis is floppy, shorter trachea -Cricoid cartilage = narrowest part of trachea

10 Adult vs. Neonatal Anatomy Circulation 1. Infants and children have less oxygen reserve 2. Myocardium less compliant 3. Small stroke volume-> CO is HR dependent 4. Bradycardia most common terminal rhythm 5. Children with HR <60 often requires chest compressions, especially if perfusion is poor and on high flow oxygen Airway 1. Smaller upper & lower airways but bigger tongue 2. Obligate nose breathers 3. Cartilage of larynx is softer 4. Increased proportion of soft tissue (obstruction) 5. Larynx is more anterior and towards the heart 6. Epiglottis is floppy, shorter trachea 7. Cricoid cartilage = narrowest part of trachea Soft Palate, floppy epiglottis are culprits behind airway obstruction. Laryngospasm is muscular spasm of small laryngeal muscles. 1. Exposure = heat/water loss Thermoregulation 2. Higher body surface area to weight ratio 3. Proportionally larger heads 4. Infants less than 3 months are unable to produce heat through shivering Breathing 1. Less compensatory reserve (Fewer and smaller alveoli) 2. Sternum, ribs, chest wall softer and more compliant 3. Abdominal breathers 1. Ribs more horizontal 2. Rib cage / structures poorly developed and compliant 3. Poor intercostal muscle tone 4. Sternum, ribs, chest wall softer and more compliant 5. Infants predominantly abdominal breathers

11 Adverse Events 1. The vast majority of adverse outcomes during sedation are preceded by a respiratory event. 2. The greater the depth of sedation, the greater the risk of complications. 3. The majority of poor outcomes related to adverse sedation events are due to a rule violation or insufficient education and skills of the practitioner. 4. Adverse sedation events are not associated with either a specific sedative drug class or route of administration.

12 Rescue Airway Management M: Adjust the mask on the face. R: Reposition the head to ensure an open airway. Re-attempt ventilation. If Not Effective S: Suction the mouth and nose O: Ventilate with the baby s mouth slightly open and lift the jaw forward. If Not Effective P: Gradually increase pressure every few breaths, (cautiously, and to a maximum of 40 cm H20), until there are bilateral breath sounds and visible chest movement. If Not Effective A: Consider airway alternative (endotracheal tube or laryngeal mask airway)

13 Patient Evaluation Adverse reactions to meds, especially sedatives. (Paradoxical reactions to sedatives) Allergies to medications or foods (rare in neonates) Current medications and dosage Sedation/anesthesia history, especially airway NPO status with specific comments on what was consumed last Recent acute illnesses especially respiratory and cardiac Family history (MH, reactions to anesthesia.) Review of systems

14 Review of system considerations Developmental delays can change sedation requirements Patients with congenital heart disease who are thriving should tolerate sedation; Serious cardiac defects with shunts, sedatives can directly or indirectly (through increase C02 or reduced O2) cause changes in Systemic vascular resistance Pulmonary vascular resistance Pulmonary blood flow Flow across a shunt Patients with reactive airways, upper respiratory infections, underdeveloped pulmonary systems are susceptible to hypoxia Aspiration risk is related to volume, acidity, and impacted by what was consumed and gastric emptying times

15 ASA 1 and ASA 2 Generally Considered Low Risk

16 Procedure Considerations If the procedure does not involve pain, a pure sedative is a good choice If the procedure is painful, a narcotic is a reasonable choice Sedatives do not have analgesic properties Analgesics do not have sedative properties Positioning matters, airway obstruction Extended head, prone or lateral decubitus positions are associated with less obstruction Flexed head might be more susceptible to obstruction

17 Provider Considerations Neonatal Resuscitation Program as well as completion of this module. One person to manage patient and another to observe monitors Skills should be for a level of sedation higher than intended Core skills: effective bag-mask ventilation, intubation, suction & intravenous access. Sedation accidents are most common in instances without a good back-up system NICU Team needs to be clearly identified Physician should be available to help in the event of an emergency

18 Equipment Considerations S (suction): appropriate size suction catheters & functioning suction apparatus O (oxygen) adequate oxygen supply and functioning flow meters A (airway): appropriate size airway equipment: P (pharmacy): resuscitation meds for emergencies, sedatives & antagonists M (monitors): pulse ox with size-appropriate probes, EKG, noninvasive blood pressure, end-tidal carbon dioxide (if available). E (extra equipment)

19 Ventilation Considerations (exchange of CO2) Continuous Monitoring of Ventilation must be performed. Spo2 monitoring is necessary, however it provides delayed feedback. Other methods of monitoring ventilation include: chest movement (watching for a rocking chest and abdomen as evidence of obstruction; Misting in a O2 mask if being used; Air-movement felt on hand placed near the patients mouth; End Tidal CO2 (ETCO2) ETCO2 should always be used if available. It is a reliable indicator of ventilation and provides immediate feedback. Familiarization of ETCO2 waveforms, as noted below, is critical to proper sedation management. Components of the normal capnogram: A (near zero baseline) Exhalation of CO2 free gas contained in dead space. B (rapid sharp rise) Exhalation of mixed dead space and alveolar gas C (alveolar plateau) Exhalation of mostly alveolar gas D (rapid sharp down stroke) Inhalation Increases in respiratory rate, reduce arterial C02 concentration. Reductions in respiratory rates, increase C02 arrythmias

20 Common Medication Classes Polypharmacy can make for a confusing clinical picture where adverse sequelae are additive.

21 Common Sedatives induces lessening of anxiety Reversal Agent: FLUMAZENIL Flumazenil Precautions: (1) AVOID IN PATIENTS WITH BDZ-DEPENDENT SEIZURE DISORDER (2) CAUTION WHEN GIVEN TO PATIENTS ON OTHER MEDS THAT ARE KNOWN TO REDUCE THE SEIZURE THRESHOLD (tricyclic antidepressants, theophylline, isoniazid or lithium.

22 Common Hypnotics- induces sleep Chloral Hydrate: - Dose: PO/PR does = mg/kg: max 1 gram/dose, repeat mg/kg after minutes - Onset : min, may be as long as 60 min - Duration: minute - Side effects: N/V, diarrhea, residual sedation, nightmares - Reversal: NONE Infant Deaths d/t slumping (airway obstruction) forward in car seats on way to facility have been reported. Pentobarbital: - Dose: IV 2-4 mg/kg over seconds: repeat 1-2 mg/kg after 5-10 minutes - Onset : 1-2 minutes - Duration: 60 minutes - Side effects: N/V, respiratory depression, laryngospasm, hypotension, bronchospasm, pre-sleep excitement - Reversal: NONE Polypharmacy can make for a confusing clinical picture where adverse sequelae are additive. Generally, the utility of using two medications from the same class is unclear.

23 Common Analgesics- reduce pain - Side effects: marked reduction in respiratory rate, hypercarbia, hypoxemia arrhythmias - Reversal: Narcan (1 mg/kg) Polypharmacy can make for a confusing clinical picture where adverse sequelae are additive. Generally, the utility of using two medications from the same class is unclear.

24 Dissociative Agents- reduce pain, out of body experiences, nightmares KETAMINE - Side effects: Potent hallucinogen (blunted by benzodiazepines) Cerebral vasodilation increased ICP Copious secretions (anticholinergics can reduce), N/V, diarrhea, nightmares - Reversal: NONE Polypharmacy can make for a confusing clinical picture where adverse sequelae are additive. Generally, the utility of using two medications from the same class is unclear.

25 RECOVERY - Aldrete Post Anesthesia Scoring System (PARS) Modified Post Anesthesia Discharge Scoring System (MPADS) A return to baseline must be achieved to be eligible for discharge AND DOCUMENTED

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