Download Sedation for…….

Refresher Course
March 11th 2017 - Tilburg
Sedation for diagnostic and
therapeutic procedures
Michael Brackhahn, Kinder- und Jugendkrankenhaus auf der Bult, Hannover
What am I talking about?
 Where do we need sedation for?
 Why do we need sedation?
 What is sedation?
 How do we have to organize sedation?
 Clinical examples
Diagnostic and interventional procedures
Sedation:
 Radiology (MRI, CT scan, SPECT, US Exam)
Analgesia and sedation:
 Gastro-enterology
 Bronchoscopy
 Dental treatment / surgery
 Cardiac catheterization laboratory
 IV and CVC placement
Why do we need sedation?
Goals of sedation (Guideline AAP)
 To guard the patient’s safety and welfare
 To minimize physical discomfort and pain
 To control anxiety, minimize psychological trauma,
and maximize the potential for amnesia
 To modify behavior and/or movement so as to allow
the safe completion of the procedure
 To return the patient to a state in which discharge
from medical/dental supervision is safe
Coté C et al. Pediatrics 2016; 138:e20161212
Basic points
 Procedures: children need to be sedated

No tolerance
 Increasing number of procedures/sedations
 Sedation should be fast, safe and high-quality

Optimal preconditions for operator/surgeon

Prevention of adverse events
 Individual and institutional competence

Framework for all team members
 Children are at increased risk

Respiratory complications!
Definition
 Continuum of depth of sedation ASA 2014
?
 Preparation
 Precautions
 Monitoring
 Competences
Risks
www.asahq.org
Definition
Minimal sedation/anxiolysis
 Midazolam
 Single dose opioid (e.g. IN)
 Nitrous oxide (< 50%)
 Dexmedetomidine?
Deep sedation
 Propofol
 Ketamine
 Remifentanil
 Dexmedetomidine?
 Combinations
Adverse events
Pediatric Sedation Research Consortium

Prospective observation

50.000 sedations/anesthetics with propofol

37 centres, dedicated sedation teams

50% pediatric intensivists

36% pediatric emergency medicine MD

10% pediatric anesthesiologist
Cravero JP et al; Pediatric Sedation Research Consortium. 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.
Pediatric Sedation Research Consortium
 Procedures




60% radiology
15% oncology
10% GI
6% minor surgery
 Supplemental medication

Opioids (10%), midazolam (7%), ketamine (2%),
chloralhydrate (0,3%)
 No mortality


2x CPR (ICU-tracheal surgery, GI-bleeding)
4x aspirations (restitutio ad integrum), fasting times
Cravero JP et al; Pediatric Sedation Research Consortium. 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.
Adverse events
 1/65 respiratory complications

1/70 airway interventions
 Risk associated factors





Comorbidity ASA ≥ III
Age, particularly < 1 year
Inadequate fasting times, solids < 8 h
Opioids
(Absence pedi-anesthesiologist)
 Airway management is crucial



„More realistic training and testing than PALS“
Monitoring of ventilation, etCO2 measurement
Suction unit
Cravero JP et al; Pediatric Sedation Research Consortium. 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.
Qualification of the team?
 Minimal sedation, anxiolysis


Precautions/monitoring: low
Competences: low
 Nurse, dentists, pediatricians
 Deep sedation


Precautions/monitoring: high
Competences: high
 Anesthesiologists
 Sedation specialists
Cravero JP et al; Pediatric Sedation Research Consortium. 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.
Qualification of the team?
Defined competences
 Basic und advanced
pediatric life support
 Intravenous line
 Bag mask ventilation
 Airway management
Guidelines?
 German recommendation (WAKKA 2010, A&I)

„From anesthesiologists for anesthesiologists“
 Guideline AAP
Pediatrics 2016; 138:e20161212
www.ak-kinderanaesthesie.de
Organisation/processes
 Preoperative evaluation/preparation
 Same precautions like „general anesthesia“
 Information for patients and parents
 History


Difficult airway?!
Comorbidities?
 Fasting times



6h solids
4h breast milk/formula (children < 1 year)
All children should receive clear fluids up to 2 hours
before sedation
n = 68, 0.3-19.6 years, abdomen MRI
Gastric content volume
(GCV):
1. high variability
2. independent of fasting time
Fasting time for fluids
Schmitz A. et al. Pediatr Anesth 21, 85-90, 2011
Anesthesiology 124; 80-88, 2016

139.142 procedures, 2007-11

10 aspiration events

0.97/ 10.000 fasted; 0.79/10.000 non-fasted
 very rare occurrence

fasted or non-fasted is no predictor for aspiration
Fasting times/ reality
1382 children for elective out-patient procedure:
 2-16 years (median 7.7), 10-90 kg bw (median 25)
 26 children not fasted for food (< 6 h)
 4 children not fasted for fluid (< 2 h)
 12.05 h fasted for food (00.45-21.50 h)
 07.57 h fasted for fluid (00.05-22.50 h)
 56% very hungry/ starving
 26.7% very thirsty
Engelhardt T. et al Pediatr Anesth 21; 964-8, 2011
Dennhardt N. et al Pediatr Anesth 26; 383-43, 2016
Basics for sedation
Regardless of the intended level of sedation:
 continuous change between the levels of sedation
Potential of severe events:
 respiratory depression
 laryngospasm
 impaired airway patency
 apnea
 loss of protective airway reflexes
 cardiovascular instability
Coté C et al. Pediatrics 2016, 138, e20161212
20
Technical preparation
Ventilation equipment:

oral and nasal airway, bag-valve-mask device, LMA or
other supraglottic devices, laryngoscope, tracheal
tubes, face masks

Oxygen

suction unit, checked!
Monitoring equipment:

ECG, pulse oxymetry with size appropriate probes

blood pressure cuffs

defibrillators with size appropriate patches

Capnography
Back-up emergency services

Protocol for immediate access to back-up emergency
services

For nonhospital facilities – activation protocol for EMS
Preparation

fit for the sedation process

evaluation of procedure (lenght, depth of sedation)

obtaining informed consent of parents including nil per
os

out-patient or overnight admission

documentation of all informations and recommendations
Tobias J Curr Opin Anesthesiol 28; 478-85, 2015
Monitoring recommendations
 Monitoring


Sedation depth depending standards
Specific equipment for special needs
 MRI: telemetric monitoring, camera
 Radiation therapy: telemetric monitoring, camera
Monitoring – minimal sedation
Minimal sedation:
 patient responds normally to verbal commands
 ventilatory and cardiovascular functions uneffected
 observation and intermittent assessment of their level of
sedation
Coté C et al. Pediatrics 2016, 138, e20161212
25
Monitoring – moderate sedation
Moderate sedation:
 drug – induced depression of consciousness
 patients respond purposefully to verbal command
 usually no intervention to maintain a patent airway
 cardiovascular function maintained
 oxygen saturation, heart rate, ventilation
 bidirectional communication necessary
Coté C et al. Pediatrics 2016, 138, e20161212
Monitoring – deep sedation
Deep sedation:
 drug – induced depression of consciousness
 no easy arrousal, response to verbal or painful stimulation
 airway can be impaired, requirement of assistance
 loss of protective airway reflexes
 cardiovascular function maintained
Standard monitoring equivalent to general anesthesia:
 oxygen saturation, heart rate, ECG, capnography,
respiratory rate, non-invasive blood pressure
Coté C et al. Pediatrics 2016, 138, e20161212 27
Monitoring – capnography
 meta-analysis of 5 studies (adults), procedural sedation
 respiratory depression 17.6 times more likely to detect if
capnography monitoring was used
Combined O2 insufflation & Capnography
© Jochen Strauss
Acoustic impedance monitoring
 continous, noninvasive monitoring of
respiration rate
 integrated acoustic transducer
 external surface of the patient´s neck
 more easily tolerated than external
ETCO2 capturing devices as nasal
cannula
 preliminary validation
 further work to evaluate its role in
respiratory monitoring during sedation
Tobias J Curr Opin Anesthesiol 28; 478-85, 2015
http://www.masimo.com/rra/
Processed EEG
 BIS monitoring to assess depth of sedation
 some correlation with BIS values in moderate sedation
 no reliable ability to distinguish between moderate and deep
sedation or deep sedation and general anesthesia
 most useful information when propofol is used
 not recommended for routine use
Coté C et al. Pediatrics 2016, 138, e20161212
After the procedure
 suitably equipped recovery area after moderate sedation
 functioning suction apparatus
 oxygen deliver capacity
 positive-pressure ventilation
 age- and size-appropriate rescue equipment and devices
 recording and documentation of vital signs
 oxygen saturation and heart rate monitoring until
appropriate discharge criteria met
Coté C et al. Pediatrics 2016, 138, e20161212
SOP for clinical pathways

Documentation


PACU, recovery room


General anesthesia
Post sedational monitoring
Discharge

Defined Criteria for discharge (mod. Aldrete score)

Outpatients: information
 Behaviour at home
 Complications
 Contact/ telephone number
Procedure specific SOP









Needles, catheters, sutures, dressings
Radiology
 MRI, CT, PET, Scinti, radiation, MCU etc.
GI endoscopy
Punctures/injections
 BMA, LP; Botox Injections
Bronchoscopy (flexible/rigid)
Cardiac catheter examination
Dental treatment
Fractures
 Reposition, plasters
Etc.
Special considerations for MRI

powerful magnetic field, special anesthesia equipment

MRI compatible monitoring

pulse oxymetry and capnography for any sedated child

thermal injuries (avoid coiling of all wires)

all wires as fare as possible away from magnetic coil
MRI monitoring
MRI

Radiology (MRI, CT, PET, Scinti, radiation, etc.)
 Propofol sedation
 Magnetic field checklist
 Noise  ear protection
 Images  if necessary apnoe
MRI sedation

deep sedation with propofol

bolus of 1-2 mg/kg titrating until the child sleeps

positioning in the MRI suite, continous monitoring
including expiratory capnography and respiration rate

example:
continuous infusion of propofol 10 mg/kg/h
without comedication
CT scan/ SPECT
CT scan

procedure very short (< 5 min), positioning (> 5 min)

bolus of propofol or ketamine+midazolam

monitoring for deep sedation
SPECT

long, painless procedure (> 60 min)

continuous infusion of propofol 10 mg/kg/h
without comedication

monitoring for deep sedation
Endoscopy




Propofol sedation + ketamine/remifentanil
Airway? Intubation (< 3J.)
Air insufflation  suction
Postoperative analgesia (e.g. non-opioids)
Gastroscopy, colonoscopy
Gastroscopy

short (painful) procedure (10-20 min), special position

airway impairment due to gastroscope

general anesthesia/ deep sedation age dependent

in any case standard monitoring
Colonoscopy

long, painful procedure (> 60 min)

special position

continuous infusion of propofol/ remifentanil

in any case standard monitoring
Bronchoscopy

diagnostic or intervention, flexible or rigid

airway management dependent on disease
(facial mask, laryngeal mask, endotracheal tube)

time difficult to predict

airway impairment

continuous infusion of propofol/ remifentanil

deep sedation / general anesthesia

in any case standard monitoring
Remifentanil
Dosage
 Moderate sedation
 0,05 – 0,1 µg/kg/min continuously
Dilution scheme:
 Adult:
50 µg/ml
 Paediatric:
20 µg/ml
 Paediatric sedation:
6 µg/ml
Always on syringe pump – risk of thorax rigidity
Radiation therapy

very remote location

procedure very short (< 5 min), positioning (> 5 min)

daily procedure over some weeks

Left alone in therapy room without access!

complete immobilisation

moderate or deep sedation = monitoring

propofol sedation, increase of dosing over time (TCI!)

side effects of radiation therapy (mucositis..)
Radiation therapy
Oxygen
Paul Scherrer Institut, Switzerland

long diagnostic or interventional procedure

cardiac catheterization lab = satellite OR

increased patient and procedure complexity

very high risk for any adverse event

standard monitoring = general anesthesia
Taylor KL, Laussen PC Curr Opin Anesthesiol 28; 453-7, 2015
Diagnostic punctures / Dialysis

Hemato-oncologie (LP, BMA etc.)
 Propofol sedation + LA
 EMLA® cream
 „Frequent flyer“
 Immunosuppression, handling catheters
„Old drug“ - propofol

most commonly used agent by pediatric anesthesiologists
for moderate and deep sedation

short recovery time

hemodynamic and respiratory events, easily treated

careful use in case of aortic or mitral stenosis/ pulmonary
hypertension due to vasodilation effect
 induction with 1-2 mg/kg
 continous infusion 6-10 mg/kg/h without
comedication
Tobias J Curr Opin Anesth 28: 478-85, 2015
Dexmedetomidine

α2-adrenergic receptor agonist

high protein binding after intravenous application (93%)

in healthy children older > 2 years:
clearance 15 ml/kg/min
elimination half life time 120 min
 bioavailability intranasal 65%, buccal 82%
 helpful in patients with challenging venous access
Mason K, Lerman J. Anesth Analg 113; 1129-42, 2011
Effects and side effects of
dexmedetomidine

anxiolysis

sympathicolysis

analgesia

sedation with less upper airway changes, no airway
obstruction

bradycardia, hypotension

cardiac conduction delay (prolong QT interval), less with
continous infusion than bolus application
Mason K, Lerman J. Anesth Analg 113; 1129-42, 2011
Cravero J. Pediatr Anesth 25; 868-70, 2015

77 children, 5 ± 3.5 years

2 µg/kg bolus and 1µg/kg/h continous infusion

in 22 children (29%) additional medication
(ketamine, fentanyl, midazolam)

10.5% bradycardia, 7.9% hypotension

no airway adverse event
Pediatr Anesth 21; 153-8, 2011

95 children, 1-7 years, MRI > 75 min

Dex 2 µg/kg bolus, 2 µg/kg/h continous infusion

Propofol 2 mg/kg bolus, 12 mg/kg/h continous infusion

quality of induction, failure rate, emergence delir, parental
satisfaction positive for propofol

retrospective study, 615 children (5 ± 3 years)

out-patient procedural sedation, midazolam for premedication

2 µg/kg bolus infusion (IV) 10 min

1 µg/kg/h and after 1 year 1.5 µg/kg/h

2.4% insufficient sedation, 29% bradycardia, 0.2% hypoxia

prolonged recovery time, discharge after 80/ 100 min
Dexmedetomidine and ketamine

Dex insufficient for painful procedures

increase of dosis prolongs recovery and increase side effects

combination with ketamine very helpful
Example:
 bolus dex 1 µg/kg + ketamine 1-2 mg/kg
 continous infusion
dex 1-2 µg/kg/h + ketamine 0.5 -1 mg/kg/h
Mahmoud MA, Meason KP. Curr Opin Anesthesiol 29; S 56-67,
2016
sufficient but delayed effect with dexmedetomidine compared
to midazolam
Pediatr Anesth 24; 181-9, 2014
Procedural Sedation in children
© www.rippenspreizer.com
Take home messages
Summary
 Paediatric sedation: quality and safety
 Keep it simple: minimal  deep sedation
 Careful evaluation, proper preparation
 Standardized working place
 Team competence
 Adequate monitoring (etCO2)
 Post-sedational management
 Procedure specific SOP
Summary Monitoring
Minimal sedation:
 oxygen saturation, heart rate, NIBP
 bidirectional communication necessary
Deep sedation = general anesthesia:
 Standard monitoring: SaO2, ECG, capnography,
respiratory rate, NIBP
59
Areas of improvement
 fasting times are safe, but not tight controlled
 monitoring like for general anesthesia except
minimal sedation, no compromises !
 propofol as an „old drug“ very common and secure
in anesthetists hands
 dexmedetomide as a „new drug“ an alternative in
difficult airway situations
60
Thank you for your attention!
And in the left corner
with 2782 knockouts…
© www.rippenspreizer.com
Thanks to:
Claudia Höhne
Karin Becke
www.auf-der-bult.de
[email protected]
www.euroespa.com