Top 5 things you need to know about pediatric procedural sedation

Transcription

1 Top 5 things you need to know about pediatric procedural sedation Dr. Marc N. Francis MD, FRCPC ACH/FMC Emergency Physician Clinical Lecturer University of Calgary Assistant Program Director FRCPC-EM STARS Flight Physician

2 Faculty/Presenter Disclosure Faculty: Marc N. Francis MD, FRCPC Relationships with commercial interests: None No disclosures No conflicts of interest

3 Disclosure of Financial Support This program has received no financial support in any form Potential for conflict(s) of interest: None

4 Mitigating Potential Bias I like sedating kids including my own on occasion I am an adult trained FRCPC emergency medicine physician

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7 Intranasal Medications Rock!!!

8 Intranasal Medication Excellent option for PSA drug administration in children Easy to administer No IV required Rapid and predictable bioavailability

9 Intranasal Medications Which Drugs? Fentanyl 1.5 mcg/kg IN Repeat 0.5mcg/kg at 15mins PRN Midazolam 0.3mg/kg IN Ketamine??? Exclusions Children <10kg Children >50kg Nasal fractures Epistaxsis Altered LOC Head injury

10 Pediatric laceration repair Oral Midazolam 0.5mg/kg Max dose 15mg IN Midazolam 0.3mg/kg Max dose 10mg Buccal Midazolam 0.3mg/kg Max dose 10mg

11 Pediatric long bone fractures IV morphine 0.1mg/kg IN placebo IN Fentanyl 1.7ug/kg IV placebo

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13 When to use Ketamine vs Propofol in Kids?

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15 Prospective multicentre observational cohort 6 Canadian Pediatric EDs 6295 children Mean age 8 (SD 4.6) 15% < 2yo Use of ketamine alone had the lowest risk of adverse outcomes

16 Ketamine or Propofol? 12 years old? Ketamine Side Effects Propofol Age

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18 Your Dosing your Ketamine Wrong.

19 Prospective, double blind RCT N= 125 children undergoing ED procedural sedation Randomized to 1mg/kg IV ketamine 1.5mg/kg IV ketamine 2.0mg/kg IV ketamine

20 Results: Need for ketamine re-dosing was higher in the 1mg/kg group OR of 6.74 ( ) for need to re-dose Physician satisfaction was lower in the 1mg/kg group 79.6% vs 94.1% vs 97.3% No benefit of higher dosing (2mg/kg) over 1.5mg/kg dosing

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22 Where are we now with NPO status in procedural sedation in kids?

23 Pre-sedation Fasting Guidelines

24 Finally an answer..?

25 Pediatric Sedation Research consortium N = 139,142 procedural sedation encounters 42 participating institutions Prospectively collected data Evaluated the following with respect to NPO status: 1) Aspiration episodes 2) Major adverse events Aspiration, death, cardiac arrest, or unplanned hospital admission

26 NPO status known for 107,947 patients 25,401 (23.5%) were not NPO Complications Deaths = 0 Aspirations = 10 Major complications = 75

27 Multivariate adjustment did not appreciably impact the effect of NPO status

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29 6183 children 0-18yo Procedural sedation for painful procedures 6 Canadian Peds EDs Examined the association between fasting and adverse outcomes

30 NPO status and adverse events

31 NPO status Conclusions Aspiration is uncommon regardless of NPO status <1/10,000 ED procedural sedations NPO status for liquids and solids in NOT an independent predictor of major complications or aspiration events

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33 Dexmedetomidine. the future of pediatric procedural sedation?

34 Dexmedetomidine Selective α 2 -adrenergic agonist Has sedative, anxiolytic and analgesic properties o Selective binding of adrenoreceptors in the locus coeruleus in the CNS Mimics endogenous sleep EEG resembles REM sleep

35 Dexmedetomidine Advantages Respiratory stability even at high doses Lasts about 20-30mins after cessation of administration Neutral ph allows for IN administration Disadvantages Hypotension and Bradycardia 30% decrease from baseline Minimal studies looking at painful procedures CT/MRI imaging mostly Appears to require co-administration of analgesics for painful procedures

36 Conclusions 1. Think about using the intranasal route in kids 2. Transition from ketamine to propofol in your young adults 3. Dose your ketamine at 1.5mg/kg initially 4. NPO status finally going the way of the dinosaurs? 5. Dexmedetomidine coming soon to an ED near you

37 Thank you!