Download Pre-Sedation Screening Checklist

Sedation prescreening for pediatric hospital medicine/ general pediatrics
provider
In order to provide safe and effective sedation for pediatric patients in the hospital setting,
several factors must evaluated prior to making the decision about executing the sedation by
hospitalist provider versus consultation/ referral to anesthesiology service.
A systematic approach to pre screening of these patients is needed to avoid sedation of
patients with potential difficult airway or ventilation problems, hemodynamic instability or a
combination of these that could lead to serious adverse events or death.
The following information should be routinely and consistently evaluated:
1.
2.
3.
4.
5.
6.
7.
Type of procedure and level of sedation required
NPO times
ASA physical status
Targeted review of history
Sedation/ anesthesia history
Medication and allergies
Physical exam
In general risks of sedation and level of sedation should be weighed based on optimal back up
systems in any locations from either anesthesia service or emergency medicine or critical care
service. Time to arrival of emergency teams/ help should always be considered when choosing
patients and level of sedation.
Type of procedure and level of sedation required
Determine the length of procedure, level of pain and discomfort anticipated and degree of
mobility permitted during the study to determine the depth of sedation and choice in sedation
regimen. Generally highly painful procedures, procedures lasting > 2hours or those requiring
complete immobility in a painful procedure should be considered for general anesthesia and
referred appropriately.
Consciousness
Responsiveness
Minimal
Relaxed,
impaired
cognition likely
Verbal response,
tactile response
Moderate
Light sleeping or
very drowsy
Deep
Asleep
Anesthesia
Unconscious
Verbally
unresponsive,
responds to
painful stimuli
Unresponsive
+/- impaired
Decrease tidal
volume and rate
Stable
Impaired
Impaired
Airway
Ventilation
Unaffected
Unaffected
Verbally
awakens or with
light tactile
stimuli,
purposeful
movement to
painful stimuli
Patent
Adequate
CV
Unaffected
Stable
Can be impaired
NPO times
For all non urgent and non emergent procedures, generally follow ASA (American Society of
Anesthesiologists) recommended fasting times for moderate to deep sedation. Minimal
sedation NPO times do not have to be followed strictly.
Food
Hours of fasting required
Clear liquids (water, juice w/o pulp, carbonated beverages,
clear tea)
Breast milk
2
Formula, non-human milk or light meal (toast and clears)
6
Full meal (include fried or fatty foods or meats)
8
4
In ER settings fasting rules have been altered by guidelines released from by ACEP (American
College of Emergency Physicians). One should exercise caution at all times with patients with
gastroparesis. Literature has found that significant aspiration seems to be more highly
correlated with ASA class rather than NPO times.
ASA status
This is used mainly to stratify the risk of sedation and anesthesia for patients and gives a
common language to convey the severity of illness of the patient. It is appropriate for generalist
to sedate ASA 1 and 2 however, class 3 should be addressed on case by case basis and referral
or consultation with anesthesiologist is recommended. ASA class 4 and above are not generally
acceptable for outside OR sedation.
Class
Definition
I
II
Healthy patient
Mild systemic disease
III
Severe systemic disease
IV
Severe systemic disease that is a
constant threat to life
V
Moribund patient not expected to
survive without the operation
Examples
Age < 12mo
Well controlled asthma
Well controlled epilepsy
Morbid obesity
ALL in maintenance
Renal disease on dialysis
Acute heart failure
Sepsis
DIC
Active intracranial bleed with mass
effect
Targeted review of history
1. Recent illness
a. Upper respiratory infection – hyper reactive airways persists for 6 weeks. Any
ongoing rhinorrhea, congestion are potential risks for laryngospasm during deep
sedation.
b. Gastrointestinal infection with recent dehydration – consider prehydration if
using medications with potential hypotension as a side effect.
2. Respiratory disease
a. Asthma type and level of control – consider using bronchodilators prior to the
procedure if poor control or recent flair. In acute exacerbation would defer to
anesthesia.
b. Chronic lung disease, severity – generally not done by general peds, esp if
actively followed by pulmonary or on home oxygen.
c. Obstructive pattern of breathing or sleep apnea – snoring a common concern,
not typically documented clearly as OSA. Would avoid deep sedation esp.
propofol due to significant loss of airway tone.
d. Allergies and severity of symptoms – exercise extreme caution with deep
sedation, secretions a definite risk factor for laryngospasm and severe airway
compromise.
e. Larygomalacia and tracheomalacia not candidates for deep sedation
3. CV
a. CHF, myocarditis and pulmonary hypertension not candidates for sedation.
b. Arrhythmias, unrepaired defects with hemodynamic impact. Small ASD, VSD
might be acceptable for moderate to deep sedation in an otherwise healthy
child.
c. Unexplained syncope or pending evaluation by cardiology as well as true
diagnosis of dysautonomia should not be done by a generalist.
4. Renal and Liver disease – significant in terms of choosing your drugs based on
metabolism of the medications/ clearance pathways.
5. Heme – Anemia of Hgb less than 8 consider transfusion, for sickle cell patients very clear
protocol for pre-hydration should be in place and avoiding hypoxia is critical, or ideally
patient referred to anesthesia.
6. GI – consider referral for vomiting patients, those with significant gastroparesis,
increased abdominal girth and ascites.
7. Genetic syndromes that should be avoided
a. Achondroplasia - difficult airway secondary to narrow nasal passages,
macroglossia, prominent mandible and OSA as well as cervical spine instability
b. Beckers and Duchene muscular dystrophy – hypoventilation and aspiration risk,
Succinylcholine can cause hyperkalemic cardiac arrest.
c. CHARGE - choanal atresia or stenosis, micrognathia, short neck, laryngomalacia,
subglottic stenosis and CV disease.
d. Cornelia De Lange - choanal atresia, micrognathia, short neck and aspiration.
e. Cri du Chat - micrognathia, long/floppy epiglottis, laryngeal deformity with
diamond-shaped vocal cords, pharyngeal muscle hypotonia, CV defects
f. DiGeorge - choanal atresia, micrognathia, laryngo/tracheomalacia and short
trachea, conotruncal heart defects.
g. Downs - macroglossia, pharyngeal muscle hypotonia = OSA, micrognathia,
atlantoaxial instability (8.5% incidence) and hypotonia
h. Familial Periodic Paralysis – Arrhythmia secondary to K abnormalities.
i. Ehlers-Danlos – aortic root abnormalities, TMJ dysfunction, atlanto-axial
j. Goldenhar - Unilateral/asymmetric hypoplasia of the facial bones and muscles,
limited mouth opening, deviation/hypoplasia of the mandible, micrognathia.
k. Homocystinurea – pectus, spontaneous pneumothorax, thrombotic embolic
events, coronary artery disease
l. Hunters and Hurlers – Critical airway – DO NOT sedate these patients
m. Klippel – Feil - Facial asymmetry, micrognathia, torticollis, short/webbed neck
with limited mobility/progressive fusion of upper cervical spine, or more rarely
hypermobility that can lead to neuro impairment = careful manipulation
n. Marfan’s - OSA from pharyngeal laxity, atlanto axial instability, TMJ joint
laxity=damage to cervical spine and TMJ with distraction, spontaneous
pneumothoraces, Aortic or pulmonary artery dilation.
o. Nager – critical airway, DO NOT sedated these patients
p. Noonan’s – micrognathia, pulmonic stenosis and HOCM
q. Pierre – Robin – spectrum of microglossia, vagal hyperactivity
r. Treacher – Collins - micrognathia, microstomia, choanal atresia, mandibular
hypoplasia, pharyngeal hypoplasia, OSA, and narrow airway may necessitate a
trach.
s. Turner – micrognathia, short webbed neck, aortic coarctation
t. VACTERL – airway and cardiac abnormalities
u. Williams - Distorted aortic valve leaflets can obstruct either main coronary
artery, abdominal aortic coarctation, prolonged QTc, 3% sudden death
Sedation/ Anesthesia History
I.
II.
III.
IV.
Need for general anesthesia in the past – any complications
Any history of emergence reactions or paradoxical reactions, what medications
used. Vomiting or prolong recovery times?
Previous failed sedation
Family history of malignant hyperthermia or severe adverse effects/ anaphylaxis.
Medications and Allergies
Medications – establish if the child is on any baseline sedating medications.
Allergies – true allergy to sedative versus adverse effect. Propofol should not be used in
patients with anaphylaxis to eggs and soy.
Physical Exam
General
Body mass index above 95% generally considered high risk for airway
management and ventilation difficulties.
Airway/ HEENT
Ability to open mouth fully (history of XRT to face/ neck area)
Mandibular length
Mallampati classification
Class
I
II
III
IV
Structures Visualized
Soft palate, fauces, uvula, anterior and posterior pillars
Soft palate, fauces, uvula
Soft palate and base of the uvula
Soft palate is not visible at all
Mallampati, SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal
intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-434
Remainder of exam to cover CV, GI, CNS and Respiratory.
For comments questions and suggestions contact [email protected]
Krista Preisberga, MD FAAP
Assistant Professor of Pediatrics
Sedation Provider
Department of Pediatrics and Anesthesiology
Baylor College of Medicine