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

Newborn 1st month

„Infant“ (Suckling) 1st year

Toddler 1 – 3 (4) years

Preschool 3 - 6 years

School 7 - 16 years

Adult >17 years

Who will be sedated?Age classification

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)

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Normal, sleep, meditation, Imaginary

Deep sedation

Conscious sedation

General anaesthesia

Foto von Anmeldung am Telefon

1. Scheduling

Indication Age Risk factors Cooperability

1. Scheduling questions

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

Adults

Newborn

REM

NonREM

1. Problems with natural sleep Protest

Hunger

Colic (infant)

Allergy

Acute illness (i.e. otitis media)

Medications - antihistamines, antibiotics, bronchodilators, anticonvulsants,

Pain

Seizures

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. Problems with natural sleepAdverse effects of sleep deprevation

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

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?

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

Solution 1: oral Diazepam (0,5 – 3,0 mg)

Solution 2: oral Midazolam (

Onset: 2 - 18 min

Duration: 20 - 30 min

Antidot: Flumazenil

Sudden unexpected Panic?

An altered state of consciousness characterized by a sense of deep relaxation and a loss of selfawareness.

2. Meditation (for Adults)

Prayer

Concentrative meditation: focus on one stimulus

Opening-up meditation: focus on one stimulus but then opens to encompass whole of

surroundings

Mindfulness meditation: meditator focuses on whatever is most prominent at moment

decreases stress, reduces tension and anxiety improves performance reduces oxygen consumption decreases heart rate decreases respiration rate lowers physiological arousal

2. Effects of Meditation

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

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 sedation3 - 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

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: PreparationWhat the responsible physician has to know for the

optimal choice of time and procedure!

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. Conscious sedation: PreparationWhat the responsible physician has to tell

to the parents or nurse!

3. Postprocedural care and discharge: AAPCOD discharge criteria

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

high successrate radiologist is free for his duty simple scheduling higher patient throughput good training for emergency cases

4. Deep sedation: Disadvantages

risks to the patient food and liquid deprevation iv pathway needed anaesthesiologist and nurse is needed high cost (staff, material, time)

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 warmed vacuum cap, blankets

Term warmed vaccum cap, blankets

Toddler earphones,

Infants earphones, music, video

4. Deep sedation: Preparation

4. Deep sedation: Different MethodsDosis: 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 Methodsintranasal, oral,rectal Midazolam

0,2-0,5 mg/kg(reduced dosis with hepatic dysfunction)

Sucessrate: 95 - 100 %Onset: 5 - 12 minDuration: 20 - 30 min

Antidot: Flumazenil 0,3 -1,0 mg

Latson LA et al. : Midazolam Nose Drops for ..in Infants. AHJ 121(1), 209-210,1991Adrain 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/kgslowly injection (2 -4 min) with 1/2 of the total dosis

(reduced dosis with hepatic dysfunction)

Sucessrate: 95 - 100 %

Onset: 1 - 5 min

Duration: 20 - 30 min

4. Deep sedation: Different MethodsAdverse effects: Midazolam

hypotension vomiting (10%) decreased tidal volume decreased respiratory rate Apnea drowsiness antidot:Flumazenil

4. Deep sedation: Different MethodsDosis: intravenous profonol

Induction dose of 2,5 mg/kgslowly 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 sedationAdvantages: intravenous profonol

high success rate rapid onset rapid recovery

4. Deep sedation: Risks

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

radiologist anaesthesiologist neurosurgeon pediactritian nurse

Design of a formal sedation policy

Foto der 5 Leute am Tisch

Identified for each version