Download Conscius sedation in children

Conscious Sedation
Central Hospital St-Juergen-Strasse
Institut für MR-Diagnostik
B. Terwey
Bremen
Germany
Wilhelm Buschs Pacifier
Linnen bag filled with Sugar or flavor with
added Beer or Wine or even Brandy
Who will be sedated?
Age classification
Newborn
1st month
„Infant“ (Suckling)
1st year
Toddler
1 – 3 (4) years
Preschool
3 - 6 years
School
7 - 16 years
Adult
>17 years
Optimal sedation
 easy performed procedure
 rapid onset
 free choice of duration at any time
 rapid recovery
 effective in all age groups
 effective in patients with all diseases
 no adverse affects
 cost is low
Sedation Management in Bremen
 1. Sleeping or cooperative patient
 2. Pacification by Meditation, Imaginery
 3. Conscious sedation
 4. Deep sedation
 5. General anaesthesia
Sedation procedures in Bremen
since1.10.1990: 148.365 Pat. (4451 Pat.: 0 -6 Years old)
age (years)
Normal, sleep,
meditation,
Imaginary
1600
1400
Conscious sedation
Deep sedation
No. of patients
1200
1000
800
600
400
200
General
anaesthesia
0
1
2
3
4
5
6
1. Scheduling
Foto von Anmeldung am Telefon
1. Scheduling questions
 Indication
 Age
 Risk factors
 Cooperability
1. Scheduling questions
 Objective:
Determine the
bedtime of your
patient
 Initial Question: “
“What time does
your child go to
bed?”
 Follow-up Questions:
 Is it difficult for your child
difficult to sleep in the
evening?
 How does your child act
when he/she is overtired?
 Does your child fall asleep
during the day? when and
where?
1. Scheduling: Information
 Preventative education for parents
 Proper Scheduling
 Scheduled awakenings in order to change sleep cycle
 Warm meal
 Cosy metallfree clothes and own music box
1. Cooperative or Sleep !
SLEEP
COOP
1. Natural sleep: Age related Sleep
times
1. Age related amount of REM
Sleep
1. Natural sleep: age related Stages of
Sleep
NonREM
Adults
REM
Newborn
1. Problems with natural sleep
 Protest
 Hunger
 Colic (infant)
 Allergy
 Acute illness (i.e. otitis media)
 Medications - antihistamines, antibiotics,
bronchodilators, anticonvulsants,
 Pain
 Seizures
1. Problems with natural sleep
Adverse effects of sleep deprevation
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Mood alteration
Reduced concentration and motivation
Increased irritability
Lapses in attention
Reduced motor skills
Sleep deprivation is not helpful!
Sanders BJ et al, The effect of sleep on conscius sedation, J Clin Pediatr Dent 1994; 28(3): 211-214
1. The cooperative child
 straight parents
 Child plays with mri console and technician
 Mothers warm arm
 Warm meal
 Cosy clothes and music
 cosy images and toys near to the child
 Extinction: “cry it out”, effective but of limited acceptance
 Avoid “double bind” situations
1. Sleep Test
Foto mit
Händeklatschen
Failure of natural sleep: rectal or oral Chloralhydrate
1. The cooperative Child
3 – 6 years old
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first contact outside of the MRI-Department
convincing the parents
talk about „how“ cooperation may be achieved
videoshow of the procedure
playing the procedure with the help of an MR-Model
first look to the magnet accompanied by one parent
demonstration of a video during the examination
parents or tecnician accompanies (prone position)
Bribary
1. The cooperative Child
3 – 6 years old
Foto Elten in Bauchlage mit Kind
1. The cooperative Child
3 – 6 years old
Bribary, Goldmedal
1. The cooperative Child
(3 – 6 years old)
Which are causes for refusion?
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reports of neighbours and friends
clinical and threatening atmosphere
narrow bore of the magnet
noise of the gradients
boring long procedure
1. The cooperative adult
Controlling Consciousness: Paradox Effects
 Paradox Processes in thinking
The harder you try to control thought, the
less likely you are to succeed! (i.e. for 30
seconds, do not think about bananas)
 Paradox Processes in controlling anxiety
The harder you try to control anxiety, the
less likely you are to succeed!
1. The cooperative adult
Sudden unexpected Panic?
Solution 1: oral Diazepam (0,5 – 3,0 mg)
Solution 2: oral Midazolam (
Onset:
2 -
18 min
Duration:
20 -
30 min
Antidot:
Flumazenil
2. Meditation (for Adults)
An altered state of consciousness characterized by a sense
of deep relaxation and a loss of selfawareness.
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Prayer
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Concentrative meditation: focus on one stimulus
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Opening-up meditation: focus on one stimulus
but then opens to encompass whole of
surroundings
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Mindfulness meditation: meditator focuses on
whatever is most prominent at moment
2. Effects of Meditation
 decreases stress,
 reduces tension and anxiety
 improves performance
 reduces oxygen consumption
 decreases heart rate
 decreases respiration rate
 lowers physiological arousal
2. Guided Imagenery
(for Children and Adults)
Immediate Rapport
Rapport is the foundation upon which all other elements of Anodyne are built.
Quick and predictable rapport establishes the trust necessary to effectively induce
and maintain the Anodyne State of relaxation and patient cooperation.
Effective use of language
The correct use of language is vital to the results we get, it enables us to address
both the conscious and unconscious mind of the patient. We directly affect the
outcome of the patient's experience with language because literally everything we
say is a suggestion to the unconscious mind.
Relaxation Breath
The "get you through anything" tool, the relaxation breath is easy to learn and
easy to teach to every patient. It's uses include: general relaxation, relief of pain
and anxiety, and control of physiological processes.
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2. Guided Imagenery
(for Children and Adults)
'Preferred Place' Imagery
The preferred place imagery technique easily allows the patient's mind to be
anywhere they choose while their body is comfortably undergoing the procedure.
Shifting Submodalities
Shifting submodalities is an extremely quick and effective imagery technique that
can literally dissolve any resistances the patient has to relaxation and/or
cooperation.
Control of Physiological Processes
Simple language techniques enable practitioners to help patients control
physiological processes such as bleeding, heart rate, blood pressure, peristalsis,
salivation, and swallowing
3. Conscious sedation: Definition
Pharmacological induced state of
depressed consciousness with the
defining characteristic that the patient
can make appropriate stimulation at
all times. This level of sedation is
accompanied by an intact airway and
maintenance of protective reflexes.
3. Conscious sedation
0 - 3 Monate
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after beeing awake about 3 - 4 hours
and after normal feeding and swaddling
and only if necessary
after rectal chloral hydrate (50 mg/kg)
wait up to 5 minutes after beginning of sleep
test for deep sleep
give earphones, a warm blanket, nuckle
use a vacuum cap
3. Conscious sedation
3 - 36 Monate
 well fed and dry clothes withpout metal
 change sleep cycle
 additional mild rectal chloral hydrate (50 mg/kg)
 wait until phase of deep sleep
3. Conscious sedation
Age 3 - 6 years:
friendly atmosphere and clear decisions
 parents are responsible
 emotional blackmail
 clear prospects
 choice with or without parents
3. Conscious sedation: Preparation
What the responsible physician has to know for the
optimal choice of time and procedure!
Risk classification
(American Society of Anaesthesiology Classification)
1. normaly healthy patient
2. mild systemic disease
3. severe systemic disease
4. severe systemic disease with threat to life
5. moribund patient (24 h)
3. Conscious sedation: Preparation
What the responsible physician has to tell
to the parents or nurse!
Nutrition before sedation
2 hr before sedation: clear liquids (every age)
4 hr before sedation: solid or semisolid food (under 6 M)
6 hr before sedation: solid or semisolid food (under 6-36 M)
8 hr before sedation: solid or semisolid food (more than 36 M
3. Postprocedural care and discharge:
AAPCOD discharge criteria
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cardiovascular system stable
airways patent
protective reflexes intact
speech near to normal (if age-appropriate)
responsiveness recovered
sitting up is possible (if age-appropriate)
hydration is adequate
minimal or no nausea
3. Postprocedural care and discharge:
AAPCOD discharge criteria
 parent information about possible reactions
 phone number of the responsible physician
3. Conscious sedation: Age 3 - 6 years:
Convincing by bribery
 soft toys
 other toys
 sweets
 favourite food
 medal for bravery
Conscious sedation: Age 3 - 6 years:
Convincing by gifts
Foto der Geschenke
4. Deep sedation: Advantages
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high successrate
radiologist is free for his duty
simple scheduling
higher patient throughput
good training for emergency cases
4. Deep sedation: Disadvantages
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risks to the patient
food and liquid deprevation
iv pathway needed
anaesthesiologist and nurse is needed
high cost (staff, material, time)
4. Deep sedation: Preparation
Nutrition before sedation
- 2 hr before sedation: clear liquids (every age)
- 4 hr before sedation: solid or semisolid food (under 6 M)
- 6 hr before sedation: solid or semisolid food (under 6-36 M)
- 8 hr before sedation: solid or semisolid food (over 36 M)
4. Deep sedation: Preparation
Premature
Term
Toddler
Infants
warmed vacuum cap, blankets
warmed vaccum cap, blankets
earphones,
earphones, music, video
4. Deep sedation: Different Methods
Dosis: oral/rectal chloral hydrate
Chloral hydrate: 25-75 mg/kg up to
maximum of 2000 mg
Successrate: 85 - 98 %
Onset:
20 - 100 min
Duration:
30 - 90 min
4. Deep sedation: Different Methods
Disadvantages: oral chloral hydrate
 Vomiting (5-7%)
 hyperactivity (2-5%)
 minor oxygen desaturation (4%)
 rare severe respiratory depresssion
 drowsiness and lack of coordination for hours
 some unproven concern over carcinogenesis
4. Deep sedation: Different Methods
Advantages: oral chloral hydrate
 wide range of safety
 long working time
4. Deep sedation: Different Methods
Dosis: oral Diazepam
0,05 -0,3 mg/kg
Successrate:
50 - 85 %
Onset:
5 - 15 min
Duration: 30 - 120 min
Half-Life: 20 - 50 hours
Antidot:
Flumazenil 0,3 -1,0 mg
Attention: Because of its shorter half-life (app. 1 hour) , patients may show some residual sedation after flumazenil
administration
4. Deep sedation: Different Methods
intranasal, oral,rectal Midazolam
0,2-0,5 mg/kg
(reduced dosis with hepatic dysfunction)
Sucessrate: 95 - 100 %
Onset:
5 - 12 min
Duration:
20 - 30 min
Antidot: Flumazenil 0,3 -1,0 mg
Latson LA et al. : Midazolam Nose Drops for ..in Infants. AHJ 121(1), 209-210,1991
Adrain ER : Intranasal Versed: the Future of ......sedation. Pediatric Nursing 20(3)
287-292, 1994
4. Deep sedation: Different Methods
intravenous Midazolam
0,02 -0,05 mg/kg
slowly injection (2 -4 min) with 1/2 of the total dosis
(reduced dosis with hepatic dysfunction)
Sucessrate: 95 - 100 %
Onset:
15 min
Duration:
20 - 30 min
4. Deep sedation: Different Methods
Adverse effects: Midazolam
 hypotension
 vomiting (10%)
 decreased tidal volume
 decreased respiratory rate
 Apnea
 drowsiness
 antidot:Flumazenil
4. Deep sedation: Different Methods
Dosis: intravenous profonol
Induction dose of 2,5 mg/kg
slowly continous infusion
Sucessrate: 97 - 100 %
Onset:
1 2 min
Duration:
1 5 min
4. Deep sedation:
Disadvantages: intravenous profonol
 possible respiratory depression
 possible O²-desaturation
 no analgesie
4. Deep sedation
Advantages: intravenous profonol
 high success rate
 rapid onset
 rapid recovery
4. Deep sedation: Risks
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Aspiration
O²-Desaturation
Apnea
Dehydration
Hypoglycaemia
Seizures
Hypotension
You may have no iv pathway in case of nasal, oral, rectal or
intramuscular sedation!
4. Deep sedation and general
Anaesthesia Monitoring
 continuous pulse oximetry
 plethysmography
 ECG
 Bloodpressure (oscillometry)
 airway-monitoring (side-stream spirometry)
 end tidal CO2
 temperature
 recordings of all parameters
5. General anaesthesia
Reserved for critical ill and/or incooperative patients of
all ages, who cannot be sedated sufficiently without the
risk of loss of protective reflexes:
 newborn spine and abdominal studies
 long examinations (cortical dysplasia)
 restless patients, movement disorder
Design of a formal sedation policy I
Who designs?
Design of a formal sedation policy
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radiologist
anaesthesiologist
neurosurgeon
pediactritian
nurse
Design of a formal sedation policy
Foto der 5 Leute am
Tisch
Identified for each
version