Pediatric Pediatric Procedural Procedural SedationSedation

Dr. Marc N. FrancisDr. Marc N. FrancisMD, FRCPCMD, FRCPCUniversity of CalgaryUniversity of CalgaryFoothills Medical CentreFoothills Medical CentreAlberta Children’s HospitalAlberta Children’s Hospital

DisclosureDisclosure

I do not have an affiliation (financial or otherwise) with any commercial

organization that may have a direct or indirect connection to the content of my

presentation.

PSA in the EDPSA in the ED

““Painful procedures are unavoidable in Painful procedures are unavoidable in emergency medicine”emergency medicine”

““While anesthesiologists have unique While anesthesiologists have unique qualifications to provide sedation, their qualifications to provide sedation, their availability is variable and unreliable, and availability is variable and unreliable, and is limited by commitments to the operating is limited by commitments to the operating room”room”

Procedural Sedation and Analgesia in the Emergency Department. Procedural Sedation and Analgesia in the Emergency Department.

Canadian Consensus GuidelinesCanadian Consensus Guidelines

Journal of Emergency Medicine 1999; 17(1): 145-156Journal of Emergency Medicine 1999; 17(1): 145-156

Learning ObjectivesLearning Objectives ““Tools of the Trade”Tools of the Trade”

Sedation medications that you should know well and be Sedation medications that you should know well and be familiar withfamiliar with

““The Right Tool for the Job”The Right Tool for the Job” Discuss the variable needs for procedural sedation in the Discuss the variable needs for procedural sedation in the

ED and pharmaceutical optionsED and pharmaceutical options ““Tricks of the Trade”Tricks of the Trade”

Some adjuncts and techniques that will make your job Some adjuncts and techniques that will make your job easiereasier

ControversiesControversies A look at some of the more controversial aspects of A look at some of the more controversial aspects of

procedural sedation in childrenprocedural sedation in children The FutureThe Future

What is coming down the pipe for the future of What is coming down the pipe for the future of procedural sedationprocedural sedation

ImportanceImportance

Studies have shown that children are less Studies have shown that children are less likely than adults to receive pain likely than adults to receive pain medications and sedation for similar medications and sedation for similar painful procedures*painful procedures* Children cannot fully understand the medical Children cannot fully understand the medical

necessity for testing or therapeuticsnecessity for testing or therapeutics Children’s anxiety can heighten the discomfortChildren’s anxiety can heighten the discomfort Allows for control of behaviour for the safe Allows for control of behaviour for the safe

and successful completion of a procedureand successful completion of a procedure Parental, patient and physician satisfactionParental, patient and physician satisfaction

*Selbst SM Analgesic use in the Emergency Department. *Selbst SM Analgesic use in the Emergency Department. Ann Emerg MedAnn Emerg Med 1990;19:1010-10131990;19:1010-1013

Sedation SpectrumSedation Spectrum Minimal SedationMinimal Sedation

Patient responds appropriately to verbal commandsPatient responds appropriately to verbal commands Cognitive processing affected but no cardiopulmonary Cognitive processing affected but no cardiopulmonary

effectseffects Moderate SedationModerate Sedation

Patient responds to verbal commands or with addition Patient responds to verbal commands or with addition of mild stimulusof mild stimulus

Maintains airway and ventilation without required Maintains airway and ventilation without required interventionintervention

Deep SedationDeep Sedation Not easily aroused but responds purposefully with Not easily aroused but responds purposefully with

uncomfortable stimulusuncomfortable stimulus May require medical intervention to maintain an airway May require medical intervention to maintain an airway

and ventilation and ventilation General AnesthesiaGeneral Anesthesia

Unable to be aroused with a verbal or painful stimulusUnable to be aroused with a verbal or painful stimulus Need help maintaining their airwayNeed help maintaining their airway

Indications for Pediatric Indications for Pediatric Procedural SedationProcedural Sedation DiagnosticDiagnostic

Urinary Urinary CatheterizationCatheterization

Lumbar punctureLumbar puncture Radiographic Radiographic

evaluation (CT or evaluation (CT or MRI)MRI)

Joint aspirationJoint aspiration Sexual assault Sexual assault

examinationsexaminations Eye examinationsEye examinations

TherapeuticTherapeutic IV startsIV starts Laceration repair Laceration repair Abscess I+DAbscess I+D Fracture ReductionsFracture Reductions Dislocations Dislocations

reductionreduction Foreign body Foreign body

removalremoval Burn dressingsBurn dressings

The Search Continues…The Search Continues…

The ideal sedation protocol:The ideal sedation protocol:1)1) Rapid induction and emergenceRapid induction and emergence

2)2) Provides anxiolysis, analgesia and amnesiaProvides anxiolysis, analgesia and amnesia

3)3) Sufficient control of movement to allow for Sufficient control of movement to allow for ease of procedural completionease of procedural completion

4)4) Maintain effective spontaneous ventilation Maintain effective spontaneous ventilation and airway controland airway control

5)5) Complete Cardiopulmonary stability Complete Cardiopulmonary stability throughoutthroughout

6)6) Minimal to no side effectsMinimal to no side effects

““Tools of the Tools of the Trade”Trade”

Nitrous OxideNitrous Oxide

Dissociative gas with Dissociative gas with mild to moderate mild to moderate procedural procedural anxiolysis, analgesia anxiolysis, analgesia and amnesiaand amnesia

DosageDosage 50% concentration 50% concentration

blended with oxygenblended with oxygen Ideally self Ideally self

administeredadministered

AdvantagesAdvantages Onset and offset within Onset and offset within

5mins5mins Does not require an IVDoes not require an IV

DisadvantagesDisadvantages Requires special Requires special

delivery devicedelivery device Nausea and VomitingNausea and Vomiting Well ventilated room Well ventilated room

with scavenger systemwith scavenger system

MidazolamMidazolam

Short-acting agent Short-acting agent with rapid onset of with rapid onset of anxiolysis, sedative anxiolysis, sedative and amnestic and amnestic propertiesproperties Interacts with GABA Interacts with GABA

receptors in the brainreceptors in the brain DosageDosage

0.2-0.6mg/kg 0.2-0.6mg/kg intranasallyintranasally

0.05-0.2mg/kg IV0.05-0.2mg/kg IV 0.1-0.2mg/kg IM0.1-0.2mg/kg IM 0.5-0.75mg/kg PO0.5-0.75mg/kg PO

AdvantagesAdvantages Rapid onsetRapid onset AnxiolysisAnxiolysis Profound retrograde Profound retrograde

amnesiaamnesia No IV requiredNo IV required

DisadvantagesDisadvantages Does not provide analgesiaDoes not provide analgesia Disturbance in respiratory Disturbance in respiratory

function +/- hypoxemiafunction +/- hypoxemia Paradoxical reactionsParadoxical reactions

FentanylFentanyl

Synthetic opiod which is Synthetic opiod which is narcotic of choice in PSAnarcotic of choice in PSA Rapid onset and short Rapid onset and short

duration make it easy to duration make it easy to titratetitrate

Does not cause histamine Does not cause histamine release so minimal CV release so minimal CV effectseffects

DosageDosage 1-3mcg/kg IM or IV1-3mcg/kg IM or IV 10-20mcg/kg oral or 10-20mcg/kg oral or

transmucosaltransmucosal

AdvantagesAdvantages Excellent analgesicExcellent analgesic Peak effect within 15-Peak effect within 15-

30mins30mins Reversible with Reversible with

naloxonenaloxone

DisadvantagesDisadvantages Nausea and vomitingNausea and vomiting Respiratory depressionRespiratory depression HypotensionHypotension No amnesia. Minimal No amnesia. Minimal

sedationsedation Fentanyl Rigid ChestFentanyl Rigid Chest

KetamineKetamine

Dissociative agentDissociative agent Sedation, analgesia Sedation, analgesia

and amnesia are and amnesia are maintainedmaintained

Inhibits reuptake of Inhibits reuptake of catecholaminescatecholamines

Stimulates salivary, Stimulates salivary, tracheal and tracheal and bronchial secretionsbronchial secretions

DosageDosage 1-2mg/kg IV1-2mg/kg IV 2-5mg/kg IM2-5mg/kg IM 6-10mg/kg PO6-10mg/kg PO

DisadvantagesDisadvantages Emergence phenomenonEmergence phenomenon Nausea and VomitingNausea and Vomiting Increased secretionsIncreased secretions Potentially serious Potentially serious

respiratory complicationsrespiratory complications

AdvantagesAdvantages Reliably produces Reliably produces

potent analgesia, potent analgesia, sedation and amnesiasedation and amnesia

Hemodynamic stabilityHemodynamic stability Maintain airway reflexesMaintain airway reflexes

PropofolPropofol

Potent hypnotic Potent hypnotic agent with no agent with no analgesic propertiesanalgesic properties Effects lipid Effects lipid

membrane Na-membrane Na-channel function and channel function and Stimulates GABAStimulates GABA

Rapid onset, Rapid onset, redistribution and redistribution and eliminationelimination

DosageDosage 1mg/kg IV bolus then 1mg/kg IV bolus then

0.5mg/kg q45-60sec0.5mg/kg q45-60sec

AdvantagesAdvantages Rapid onset/offsetRapid onset/offset Easily titratableEasily titratable Anti-emeticAnti-emetic BronchodilatorBronchodilator

DisadvantagesDisadvantages No analgesic propertiesNo analgesic properties Potent cardiopulmonary Potent cardiopulmonary

depressantdepressant Pain on injectionPain on injection Inadvertent oversedationInadvertent oversedation

““The Right Tool The Right Tool for the Job”for the Job”

The Right tool for the The Right tool for the JobJob

28mth ♀ presents with 4day 28mth ♀ presents with 4day hx of fever, vomiting and hx of fever, vomiting and flank painflank pain

PMHX – HealthyPMHX – Healthy Temp 38.5, HR 121, RR 16, Temp 38.5, HR 121, RR 16,

BP 84/56, Sat 98% RA BP 84/56, Sat 98% RA Not toilet trained Not toilet trained Wanting to do an in/out cathWanting to do an in/out cath

Nitrous OxideNitrous Oxide MidazolamMidazolam FentanylFentanyl KetamineKetamine PropofolPropofol

Sedation Sedation Spectrum:Spectrum:

Minimal Minimal SedationSedation

The Right tool for the The Right tool for the JobJob

5yo ♂ fell onto wooden 5yo ♂ fell onto wooden postpost

Extensive and complex Extensive and complex facial laceration requiring facial laceration requiring multilayer closuremultilayer closure

PMHX – Asthma well PMHX – Asthma well controlledcontrolled

VSSAVSSA

Nitrous OxideNitrous Oxide MidazolamMidazolam FentanylFentanyl KetamineKetamine PropofolPropofol

Sedation Sedation Spectrum:Spectrum:

Dissociative Dissociative SedationSedation

The Right tool for the The Right tool for the JobJob

15yo ♂ playing soccer and 15yo ♂ playing soccer and collided with another player collided with another player

Immediate pain to R Immediate pain to R shoulder which is clinically shoulder which is clinically consistent with anterior consistent with anterior dislocationdislocation

Very Anxious!!!Very Anxious!!! PMHX – HealthyPMHX – Healthy Normal Vital signsNormal Vital signs

Nitrous OxideNitrous Oxide MidazolamMidazolam FentanylFentanyl KetamineKetamine PropofolPropofol

Sedation Sedation Spectrum:Spectrum:

Moderate Moderate SedationSedation

The Right tool for the The Right tool for the JobJob

7yo ♀ presents with 7yo ♀ presents with patellar dislocation while patellar dislocation while playing softballplaying softball

Knee in “spasm” and Knee in “spasm” and patient extremely anxious patient extremely anxious with any attempts to with any attempts to examine or maneuver sameexamine or maneuver same

PMHx – HealthyPMHx – Healthy VSSAVSSA

Nitrous OxideNitrous Oxide MidazolamMidazolam FentanylFentanyl KetamineKetamine PropofolPropofol

Sedation Sedation Spectrum:Spectrum:

Minimal Minimal SedationSedation

The Right tool for the The Right tool for the JobJob

3yo ♂ fell off the bed and 3yo ♂ fell off the bed and refusing to walkrefusing to walk

Xray shows a displaced Xray shows a displaced spiral tibial fracturespiral tibial fracture

PMHx – seizure disorder PMHx – seizure disorder well controlledwell controlled

VSSAVSSA

Nitrous OxideNitrous Oxide MidazolamMidazolam FentanylFentanyl KetamineKetamine PropofolPropofol

Sedation Sedation Spectrum:Spectrum:

Dissociative Dissociative SedationSedation

““Tricks of the Tricks of the Trade”Trade”

Ondansetron with Ondansetron with Ketamine SedationKetamine Sedation

Vomiting in the ED and upon discharge Vomiting in the ED and upon discharge after Ketamine sedation is commonafter Ketamine sedation is common Reported frequency of vomiting ranges from Reported frequency of vomiting ranges from

4-19%4-19% Increased vomiting associated with Increased vomiting associated with

increasing patient ageincreasing patient age Vomiting Vomiting

Decreases patient and parental satisfactionDecreases patient and parental satisfaction Delays discharge and consumes ED Delays discharge and consumes ED

resourcesresources

Double-blind, randomized, placebo-controlled Double-blind, randomized, placebo-controlled trialtrial

N= 255 children randomized to N= 255 children randomized to N= 128 IV Ondansetron 0.15mg/kg to max 4mg N= 128 IV Ondansetron 0.15mg/kg to max 4mg N = 127 PlaceboN = 127 Placebo

ResultsResults ED vomiting was less common with ondansetron ED vomiting was less common with ondansetron

4.7% vs 12.6% p=0.02 4.7% vs 12.6% p=0.02 NNT of 13NNT of 13

Vomiting in the ED or after discharge was less Vomiting in the ED or after discharge was less frequent with ondansetron 7.8% vs 18.9% p=0.01frequent with ondansetron 7.8% vs 18.9% p=0.01

NNT of 9NNT of 9

Pre-oxygenation with Pre-oxygenation with procedural sedationprocedural sedation

Published adverse event rates during Published adverse event rates during pediatric ED procedural sedation vary pediatric ED procedural sedation vary between 2% and 18% between 2% and 18%

Consistently the most common adverse event Consistently the most common adverse event is transient hypoxiais transient hypoxia

Children’s basal oxygen use/kg is twice that of adultsChildren’s basal oxygen use/kg is twice that of adults Smaller FRCSmaller FRC Shorter “safe apnea” period before desaturationShorter “safe apnea” period before desaturation

Transient hypoxia is predictably seen with Transient hypoxia is predictably seen with propofolpropofol

Very common with Midazolam and FentanylVery common with Midazolam and Fentanyl Less likely with Ketamine unless co-administration with Less likely with Ketamine unless co-administration with

other resp depressantsother resp depressants

Adjunctive Atropine with Adjunctive Atropine with Ketamine SedationKetamine Sedation

Ketamine stimulates oral secretionsKetamine stimulates oral secretions In rare circumstances this has been In rare circumstances this has been

implicated in airway compromiseimplicated in airway compromise11

Historically prophylactic Historically prophylactic anticholinergic agents have been anticholinergic agents have been given with ketamine to blunt given with ketamine to blunt hypersalivationhypersalivation

Glycopyrrolate 0.2mgGlycopyrrolate 0.2mg Atropine 0.02mg/kgAtropine 0.02mg/kg

Prospective observational study of ED Prospective observational study of ED pediatric patients receiving ketamine sedationpediatric patients receiving ketamine sedation

N= 1090 patients over a 3yr periodN= 1090 patients over a 3yr period 947 (87%) were performed without adjunctive atropine947 (87%) were performed without adjunctive atropine Assessed for salivation on a 100mm visual analog scale Assessed for salivation on a 100mm visual analog scale

and documented complicationsand documented complications ResultsResults

92% of patients had salivation rated at 0mm or 92% of patients had salivation rated at 0mm or “none”“none”

Only 1.3% were rated >50mm Only 1.3% were rated >50mm Transient airway complications in 3.2% of which Transient airway complications in 3.2% of which

only one was thought to be related to only one was thought to be related to hypersalivation (incidence 0.11% 95% CI 0.003% - hypersalivation (incidence 0.11% 95% CI 0.003% - 0.59%)0.59%)

No occurrence of assisted ventilation or intubationNo occurrence of assisted ventilation or intubation

Adjunctive Atropine with Adjunctive Atropine with Ketamine SedationKetamine Sedation

Omission of atropine is safeOmission of atropine is safe Routine prophylaxis is unnecessaryRoutine prophylaxis is unnecessary There is minimal added risk There is minimal added risk

presented with its administrationpresented with its administration Possible subsets of patients which Possible subsets of patients which

may benefitmay benefit Very young childrenVery young children Those undergoing oropharyngeal Those undergoing oropharyngeal

proceduresprocedures

ControversiesControversies

In your local ED….In your local ED…. 9yo M previously healthy with no 9yo M previously healthy with no

meds/allergiesmeds/allergies Fell mountain biking 40mins ago and has Fell mountain biking 40mins ago and has

deformed and partially angulated deformed and partially angulated radius/ulnar #radius/ulnar # Neurovascularly intact distallyNeurovascularly intact distally Wearing helmet and no issues with potential HIWearing helmet and no issues with potential HI

Bag of chips 2hrs ago with bottle of GatoradeBag of chips 2hrs ago with bottle of Gatorade SurveySurvey

Would you sedate this child now? Would you sedate this child now? What would you use?What would you use?

Pre-sedation Fasting Pre-sedation Fasting guidelinesguidelines

Minimal scientific evidence to support Minimal scientific evidence to support fastingfasting

Risk of aspiration during ED PSA has not Risk of aspiration during ED PSA has not been studiedbeen studied

Only single case of pulmonary aspiration with ED Only single case of pulmonary aspiration with ED sedation has been reportedsedation has been reported

Cheung K, et al. 2007. Ann Emerg Med 2007;49:462-464Cheung K, et al. 2007. Ann Emerg Med 2007;49:462-464

Extrapolation from general anesthesia Extrapolation from general anesthesia literatureliterature

Incidence of aspiration is low (1:3,420)Incidence of aspiration is low (1:3,420) Mortality is rare (1:125,109)Mortality is rare (1:125,109)

Relative risk of Relative risk of aspirationaspiration

Good reason to believe that aspiration Good reason to believe that aspiration risk with PSA may be lower than GArisk with PSA may be lower than GA 2/3 of aspiration occurs during airway 2/3 of aspiration occurs during airway

manipulationmanipulation Deeper level of sedation with GADeeper level of sedation with GA Generally younger and healthier patients Generally younger and healthier patients

(ASA I-II)(ASA I-II) Inhalational agents are more emetogenicInhalational agents are more emetogenic Ketamine sedation preserves protective Ketamine sedation preserves protective

airway reflexesairway reflexes

What we are toldWhat we are told

CAEPCAEP No specific guidelinesNo specific guidelines

““Insufficient data to Insufficient data to show that fasting show that fasting improves outcomes in improves outcomes in patients undergoing patients undergoing ED procedural ED procedural sedation”sedation”

In elective situations In elective situations consider NPO x 2hrs consider NPO x 2hrs (liquids) and 6hrs (liquids) and 6hrs (solids)(solids)

ACEPACEP No specific guidelinesNo specific guidelines

““No study has No study has determined a determined a necessary fasting necessary fasting period before initiation period before initiation of PSA”of PSA”

““Recent food intake is Recent food intake is not a contraindication not a contraindication for PSA but should be for PSA but should be considered in choosing considered in choosing the timing and target the timing and target of sedation”of sedation”

ED specific clinical practice advisoryED specific clinical practice advisory Goal to create a tool to permit ED physician to identify prudent Goal to create a tool to permit ED physician to identify prudent

limits of sedation depth and timing in light of fasting statuslimits of sedation depth and timing in light of fasting status

Developed a 4-step assessment prior to sedationDeveloped a 4-step assessment prior to sedation

1) Asses patient risk1) Asses patient risk

2) Assess the timing and nature of recent oral 2) Assess the timing and nature of recent oral intakeintake

3) Assess the urgency of the procedure3) Assess the urgency of the procedure

4) Determine the prudent limit of targeted depth 4) Determine the prudent limit of targeted depth and and length of procedural sedation and length of procedural sedation and analgesiaanalgesia

Assess Patient riskAssess Patient risk

Difficult airway?Difficult airway? High risk for esophageal reflux?High risk for esophageal reflux?

Esophageal diseaseEsophageal disease Hiatal herniaHiatal hernia PUDPUD Bowel obstructionBowel obstruction

Extremes of age?Extremes of age? >70>70 <6mths<6mths

Severe Systemic disease?Severe Systemic disease? ASA ≥ IIIASA ≥ III

Timing and nature of Timing and nature of oral intakeoral intake

Single time point for sake of Single time point for sake of simplicity = 3hrssimplicity = 3hrs

From lowest to highest theoretical From lowest to highest theoretical riskrisk1) Nothing1) Nothing

2) Clear liquids2) Clear liquids

3) Light snack3) Light snack

4) Heavier snack or meal4) Heavier snack or meal

Urgency of the procedureUrgency of the procedure EmergencyEmergency

Cardioversion for life threatening arrythmiaCardioversion for life threatening arrythmia Reduction of markedly angulated fractureReduction of markedly angulated fracture

UrgentUrgent Care of dirty wounds and lacerationsCare of dirty wounds and lacerations Abscess I+DAbscess I+D

SemiurgentSemiurgent Care of clean wounds and lacerationsCare of clean wounds and lacerations Shoulder reductionShoulder reduction

Nonurgent or electiveNonurgent or elective Foreign body in external ear canalForeign body in external ear canal Ingrown toenailIngrown toenail

Depth of sedationDepth of sedation

Procedure DurationProcedure Duration Brief: <10minsBrief: <10mins Intermediate: 10-Intermediate: 10-

20mins20mins Extended: >20minsExtended: >20mins

Standard-risk patientStandard-risk patient

Higher-risk PatientHigher-risk Patient

Capnography monitoring Capnography monitoring during procedural sedationduring procedural sedation

Non-invasive Non-invasive measurement of measurement of the partial the partial pressure of COpressure of CO2 2

from the airway from the airway during inspiration during inspiration and expirationand expiration

Capnography monitoringCapnography monitoring

Traditional monitoringTraditional monitoring Pulse oximetry = oxygenationPulse oximetry = oxygenation RR and clinical observation = ventilationRR and clinical observation = ventilation

CapnographyCapnography More precise and direct assessment of the More precise and direct assessment of the

patient’s ventilatory statuspatient’s ventilatory status Assessment of airway patency and respiratory Assessment of airway patency and respiratory

patternpattern Early warning system for prehypoxic Early warning system for prehypoxic

respiratory depressionrespiratory depression Assessment of depth of sedationAssessment of depth of sedation

Show me the evidence!!!Show me the evidence!!! Comparison of oximetry, capnography Comparison of oximetry, capnography

and clinical observation in the EDand clinical observation in the ED22

75% of pediatric patients with respiratory 75% of pediatric patients with respiratory compromise were noted by EtCOcompromise were noted by EtCO22 monitoring only monitoring only

Pediatric RCT comparing capnography to Pediatric RCT comparing capnography to clinical observation in detecting resp clinical observation in detecting resp eventsevents33

Clinical assessment identified hypoventilation in Clinical assessment identified hypoventilation in 3% and did not identify any patients with apnea3% and did not identify any patients with apnea

Capnography data showed ventilation was Capnography data showed ventilation was compromised in >50% of cases and nearly 25% compromised in >50% of cases and nearly 25% fulfilled criteria for apneafulfilled criteria for apnea

RecommendationsRecommendations

Good evidence that capnography Good evidence that capnography provides a means for early detection provides a means for early detection of sedation-related hypoventilationof sedation-related hypoventilation Clinical significance with regards to Clinical significance with regards to

improved patient outcomes has not improved patient outcomes has not been shownbeen shown

FutureFuture

““where we’re going we don’t where we’re going we don’t need roads” need roads” – Dr. Emmett – Dr. Emmett

BrownBrown

KetofolKetofol

PropofolPropofol ProsPros

Antinauseant effectsAntinauseant effects AmnesticAmnestic Smooth recovery Smooth recovery

profileprofile

ConsCons Cardiovascular and Cardiovascular and

respiratory respiratory depressiondepression

BradycardiaBradycardia Non-analgesicNon-analgesic

KetamineKetamine ProsPros

AnalgesiaAnalgesia AmnesiaAmnesia Respiratory and Respiratory and

cardiovascular cardiovascular stabilitystability

ConsCons Emergence Emergence

phenomenaphenomena VomitingVomiting

Prospective case Prospective case seriesseries 114 ED procedural 114 ED procedural

sedationssedations 1:1 mixture of 1:1 mixture of

ketamine 10mg/ml ketamine 10mg/ml and propofol and propofol 10mg/ml10mg/ml

All age groups All age groups including children including children as young as 4as young as 4

ResultsResults 97% success rate 97% success rate

with procedureswith procedures 3 patients with 3 patients with

transient hypoxiatransient hypoxia 1 required BVM1 required BVM

3 patients with 3 patients with emergenceemergence

No hypotension or No hypotension or vomitingvomiting

Patient satisfaction Patient satisfaction scores were 10 on a scores were 10 on a 1-10 scale1-10 scale

Systematic review of the literatureSystematic review of the literature 8 clinical trials were included 8 clinical trials were included

Adult and pediatric studies were includedAdult and pediatric studies were included

ResultsResults Ketofol was not superior to propofol Ketofol was not superior to propofol

monotherapymonotherapy Conflicting data exist regarding hemodynamic Conflicting data exist regarding hemodynamic

and respiratory complicationsand respiratory complications At higher doses addition of ketamine to At higher doses addition of ketamine to

propofol may incur more adverse effectspropofol may incur more adverse effects Compatability data for the two agents Compatability data for the two agents

combined in a syringe are limitedcombined in a syringe are limited

KetofolKetofol

Theoretical benefits that have not been Theoretical benefits that have not been demonstrated in the literaturedemonstrated in the literature

Optimum ratio of ketamine and propofol Optimum ratio of ketamine and propofol remains to be determinedremains to be determined

Dosing regiments currently are highly Dosing regiments currently are highly variablevariable

Not ready for Not ready for Primetime………….YetPrimetime………….Yet

BISBIS

Bispectral IndexBispectral Index

BIS BIS Uses processed Uses processed

EEG signals to EEG signals to measure the depth measure the depth of sedationof sedation

Validated with Validated with children children undergoing undergoing general anesthesia general anesthesia in the ORin the OR

Determine if the BIS monitor could Determine if the BIS monitor could be used to guide physicians in be used to guide physicians in titrating propofol for safe levels of titrating propofol for safe levels of deep sedation in childrendeep sedation in children

ResultsResults BIS score of 45 determined to provide BIS score of 45 determined to provide

deep sedation for 95% of the populationdeep sedation for 95% of the population Useful objective tool to guide effective Useful objective tool to guide effective

titration of propofol for childrentitration of propofol for children

ConclusionsConclusions Familiarize yourself with your pharmaceutical Familiarize yourself with your pharmaceutical

options and “pick the right tool for the job”options and “pick the right tool for the job” Pre-oxygenation is your friendPre-oxygenation is your friend Atropine is out and ondansetron is in for Atropine is out and ondansetron is in for

routine ketamine sedationsroutine ketamine sedations Pre-procedural fasting guidelines are not Pre-procedural fasting guidelines are not

black-and-white and each situation is uniqueblack-and-white and each situation is unique Consider the additional information provided Consider the additional information provided

by capnography if it is available to youby capnography if it is available to you Ketofol not ready for primetime….. yetKetofol not ready for primetime….. yet

Questions?Questions?

Additional ReferencesAdditional References

1)1) Green SM et al. Intramuscular ketamine for pediatric Green SM et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile sedation in the emergency department: safety profile with 1022 cases. Ann Emerg Med. 1998;31:688-97with 1022 cases. Ann Emerg Med. 1998;31:688-97

2)2) Hart LS et al. The value of end-tidal CO2 monitoring Hart LS et al. The value of end-tidal CO2 monitoring when comparing three methods of conscious when comparing three methods of conscious sedation in children undergoing painful procedures sedation in children undergoing painful procedures in the emergency department. Pediatr Emerg Care in the emergency department. Pediatr Emerg Care 1997;13(3):189-93 1997;13(3):189-93

3)3) Lightdale JR et al. Microstream capnography Lightdale JR et al. Microstream capnography improves patient monitoring during moderate improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics sedation: a randomized, controlled trial. Pediatrics 2006;117(6):e1170-82006;117(6):e1170-8

4)4) Lopez MD et al. Pediatric Procedural Sedation. Lopez MD et al. Pediatric Procedural Sedation. Emergency Medicine Reports 2008;13(12):145-156Emergency Medicine Reports 2008;13(12):145-156

Additional SlidesAdditional Slides

Fentanyl Rigid ChestFentanyl Rigid Chest

Believed to be due to a central agonist Believed to be due to a central agonist effect of narcoticseffect of narcotics

The pediatric population is more vulnerable The pediatric population is more vulnerable to the syndrometo the syndrome Reported with doses from 2.5-6.5mcg/kgReported with doses from 2.5-6.5mcg/kg

Difficulty in ventilating is largely due to Difficulty in ventilating is largely due to upper airway (glottis) closureupper airway (glottis) closure Not thoracoabdominal tone as originally thoughtNot thoracoabdominal tone as originally thought In kids thoracoabdominal tone plays a larger In kids thoracoabdominal tone plays a larger

rolerole

Prevention of Fentanyl Prevention of Fentanyl Rigid ChestRigid Chest

Propofol epilepsyPropofol epilepsy

Is Propofol a pro- or Is Propofol a pro- or anticonvulsant?anticonvulsant?

81 reported cases of presumed propofol 81 reported cases of presumed propofol induced seizure like activityinduced seizure like activity

Agonist-antagonist effect on Glycine which Agonist-antagonist effect on Glycine which is a major inhibitory neurotransmitteris a major inhibitory neurotransmitter

Prospective studyProspective study Effects of IV propofol on EEGEffects of IV propofol on EEG

25 children with epilepsy25 children with epilepsy 25 children with learning disorders25 children with learning disorders Undergoing elective sedation for MRIUndergoing elective sedation for MRI

ResultsResults No child in either group had increased No child in either group had increased

spike-wave pattern with propofolspike-wave pattern with propofol Depression in spike-wave pattern in the Depression in spike-wave pattern in the

children with epilepsy was seenchildren with epilepsy was seen Supported the concept of propofol Supported the concept of propofol

being a sedative-hypnotic agent with being a sedative-hypnotic agent with anticonvulsant propertiesanticonvulsant properties

Aspiration case Aspiration case in literaturein literature

65yoF with HTN65yoF with HTN Trimalleolar fractureTrimalleolar fracture Morphine/fentanyl/Propofol for first Morphine/fentanyl/Propofol for first

PSA with no significant complicationsPSA with no significant complications Second PSA in attempt to improve Second PSA in attempt to improve

the reductionthe reduction 6hrs after last meal6hrs after last meal Propofol/fentanylPropofol/fentanyl

10 mins after propofol bolus the 10 mins after propofol bolus the patient vomited into the mask and patient vomited into the mask and aspiratedaspirated

Sats were 86% initiallySats were 86% initially Airway was suctioned and BVM was started Airway was suctioned and BVM was started

with improvement to sats 97%with improvement to sats 97% Patient remained hypoxic with sats 84% Patient remained hypoxic with sats 84%

on RAon RA Inspiratory and expiratory wheezes Inspiratory and expiratory wheezes

throughoutthroughout RSI was performed and admitted to ICU RSI was performed and admitted to ICU

where she was ventilated for 12hrs then where she was ventilated for 12hrs then slowly weanedslowly weaned

No long-term complicationsNo long-term complications

EtomidateEtomidate

EtomidateEtomidate Initially described for RSI in pedsInitially described for RSI in peds Rapid onset of sedation, brief half-life, Rapid onset of sedation, brief half-life,

short recovery period and minimal effects short recovery period and minimal effects on cardiopulmonary systemson cardiopulmonary systems

Adverse effectsAdverse effects Potential for adrenal suppressionPotential for adrenal suppression Pain at injection sitePain at injection site MyoclonusMyoclonus Quickly and easily induce deep sedation Quickly and easily induce deep sedation

and/or general anesthesia.and/or general anesthesia. More studied for PSA in the adult More studied for PSA in the adult

population in United Statespopulation in United States

Only randomized control trial evaluating Only randomized control trial evaluating etomidate for pediatric PSA in the EDetomidate for pediatric PSA in the ED

Randomized double-blind study out of Randomized double-blind study out of MontrealMontreal

N=100 patients 2-18yoN=100 patients 2-18yo 50 = IV Etomidate 0.2mg/kg + Fentanyl 1mcg/kg50 = IV Etomidate 0.2mg/kg + Fentanyl 1mcg/kg 50 = IV Midazolam 0.1mg/kg + Fentanyl 1mcg/kg50 = IV Midazolam 0.1mg/kg + Fentanyl 1mcg/kg

OutcomesOutcomes Induction and recovery timesInduction and recovery times Efficacy of sedationEfficacy of sedation Adverse event ratesAdverse event rates

ResultsResults Time taken for induction and recovery Time taken for induction and recovery

were lower among those receiving were lower among those receiving etomidateetomidate

Success rates were not differentSuccess rates were not different Adverse event rates were similar with Adverse event rates were similar with

the exception of the exception of Pain at injection site 46% vs 12%Pain at injection site 46% vs 12% Myoclonus 22% vs 0%Myoclonus 22% vs 0%

EtomidateEtomidate

Need a large series to better Need a large series to better establish the safety profile of establish the safety profile of etomidate for PSA in pediatricsetomidate for PSA in pediatrics

A randomized trial comparing A randomized trial comparing etomidate, propofol and ketamine etomidate, propofol and ketamine would be of great interest…..would be of great interest…..

Any takers?Any takers?

Propofol infusion Propofol infusion syndromesyndrome

Propofol Infusion Propofol Infusion SyndromeSyndrome

1992 case reports of fatalities 1992 case reports of fatalities High and escalating doses of propofol High and escalating doses of propofol

infusionsinfusions Severe metabolic acidosis, lipidemia, rhabdo Severe metabolic acidosis, lipidemia, rhabdo

and refractory heart failureand refractory heart failure Associated with long-term infusions Associated with long-term infusions

>48hrs in children <4yo>48hrs in children <4yo Thought to be related to a mitochondrial Thought to be related to a mitochondrial

defectdefect Not an issue for brief ED sedationNot an issue for brief ED sedation

Preoxygenation Preoxygenation protocolprotocol

Pre-oxygenation with Pre-oxygenation with procedural sedationprocedural sedation

Published adverse event rates during Published adverse event rates during pediatric ED procedural sedation vary pediatric ED procedural sedation vary between 2% and 18% between 2% and 18%

Consistently the most common adverse event Consistently the most common adverse event is transient hypoxiais transient hypoxia

Children’s basal oxygen use/kg is twice that of adultsChildren’s basal oxygen use/kg is twice that of adults Smaller FRCSmaller FRC Shorter “safe apnea” period before desaturationShorter “safe apnea” period before desaturation

Transient hypoxia is predictably seen with Transient hypoxia is predictably seen with propofolpropofol

Very common with Midazolam and FentanylVery common with Midazolam and Fentanyl Less likely with Ketamine unless co-administration with Less likely with Ketamine unless co-administration with

other resp depressantsother resp depressants

1244 1244 procedural procedural sedationssedations

Median age Median age 5.9yrs5.9yrs

ComplicatioComplications in 17.9%ns in 17.9%

No No preoxygenapreoxygenation tion protocolprotocol