ICU Sedation ModelsHome in the PICU

James Hertzog, MDNemours Children’s ClinicAlfred I. duPont Hospital for Children

Why a PICU Sedation Service?• increasing number of subspecialty

procedures• increasing recognition of

advantages of deep sedation: patient comfort, ideal operating conditions, efficiency

• desire to optimize patient safety

Why a PICU Sedation Service?• limitations in Anesthesia personnel

availability• desire to avoid the OR/parent

satisfaction?/practitioner satisfaction?

• AAP/ASA guidelines• increasing JCAHO attention

Getting Started

• involve the Department of Anesthesiology and the Department of Pediatrics

• be consistent with published guidelines: AAP, ASA, JCAHO

Personnel

• Pediatric Intensivist• Pediatric CCM Fellow• Pediatric CCM APN/PA• PICU RN• PICU RRT

Scheduling

• elective procedures for ambulatory, ward, and PICU patients

• defined time slots during the day M-F that can be booked

• urgent/emergent procedures for ward and PICU patients at discretion of team

Screening

• current and past medical history• ASA physical status• experience with

anesthetics/sedatives• intercurrent illness• occurrence of allergic reactions to

medications or soy and egg proteins• fasting status

Screening

• PE of airway, cardiorespiratory, neurologic

• significant labs

• screening done at time of procedure• fasting guidelines, time of procedure

provided by subspecialist beforehand

Pre-Procedure

• informed consent for anesthesia/sedation and procedure

• intravenous access-peripheral canula inserted or CVL accessed

Procedure

• cardiorespiratory monitoring: continuous ECG, respiratory, SpO2, intermittent (q1-3 min) NIBP

• pediatric intensivist – monitors CR, neurologic status continuously– administers propofol/other agent to

maintain desired level of sedation/anesthesia

– provides supportive measures as needed

Procedure

• PICU RN – monitors vital signs– provides written documentation of

course of sedation/anesthesia on a standardized form

– assists with supportive measures as needed

• neither involved directly with procedure

Procedure

• equipment at bedside– BVM– tonsillar suction catheter– equipment for maintaining airway

patency and tracheal intubation

• supplemental oxygen via blow-by

Post-Procedure

• monitoring continues after the procedure until patient awake and able to ingest clear liquids

Post-Procedure

• discharge when meet predefined criteria defined by AAP– stable and satisfactory airway

patency and hemodynamics– intact protective airway reflexes– able to talk and sit unaided if age

appropriate– adequate state of hydration

Billing

• Anesthesia CPT codes– 01999 (unlisted procedure)– 00520 (bronchoscopy)– 00532 (central venous access)– 00740 (upper GI endoscopy)– 00810 (lower GI endoscopy)

Billing

• Anesthesia CPT codes– 00702 (percutaneous liver biopsy)– 01112 (bone marrow

aspiration/biopsy)– 00635 (diagnostic or therapeutic

lumbar puncture)

Billing

• other CPT codes– 99141: sedation (moderate) ± analgesia-

IV, IM, inhalational– 99241: office consultation new or

established patient– 99251: inpatient consultation new or

established patient• key components: problem focused hx and PE,

straightforward decision making, 15-20 min

Billing

• other CPT codes– 90780: IV infusion for

therapy/diagnosis, administered by MD or under direct supervision of MD, up to 1 hour

– 90781: IV infusion for therapy/diagnosis, administered by MD or under direct supervision of MD, each additional hour, up to 8 hours

Advantages

• geographically localized-all done in one place

• resource utilization-all of the components are already available

• flexibility-PICU open 24/7• comfort level

Challenges

• geographically localized-can’t provide service for procedures that can’t be brought to the PICU

• resource utilization-what if all the beds are full or the RNs have assignments?

• managing the scheduling

Challenges

• pre and post procedure evaluation• QAI• credentialing• reimbursement