Inside this Edition

Newsmaker Interview
Dr. Mick Connors
Children’s Hospital of Eastern Tennessee

Harvard Sedation Service Conference San Francisco

Literature Reviews:
Davis CL. Does Your Facility Have a Pediatric Sedation Team? If Not, Why Not?
Pediatric Nursing/ July-August 2008. Vol.34. No. 4

Gravenstein D, Berkenstadt H, Ziv A, Shavit I, Keidan I, Sidi A. Supplemental oxygen compromises the use of pulse oximetry for detection of apnea and hypoventilation during sedation in simulated pediatric patients.
Pediatrics. 2008 Aug;122(2):293-8

 

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Harvard Sedation Service Conference San Francisco

Our roving reporter Amy Baxter, MD, from Children’s Healthcare Atlanta, Scottish Rite Campus, gave us the following outline of the recent pediatric sedation conference in San Francisco which she attended.  The outline is essentially some brief notes she took from various lectures.  Contact the conference organizers for more information.

Harvard Medical School
Dept. of Continuing Education
617-384-8600
hms-cme@hms.harvard.edu


Clinical Procedural Sedation: snapshots of sedation services in different venues

Steve Selbst, MD, Professor of Emergency Medicine, AI DuPont Hospital for Children, Wilmington, DE: ED-run sedation service, 3000 sedations/year: In addition to obvious radiology and ED sedations, they provide a ketamine ‘kick it up a notch’ service for dental, ENT foreign bodies, and appliance removal in orthopedics. 

    1. Credentialing involves five proctored sedations and computer sedation training model completion; it’s assumed after these that sedation is a core privilege of PEM thus no re-certifications are needed. 
    2. Age limits: They require children younger than four months to be observed at least four hours after completion of sedation. 
    3. Underscored that JCAHO mandates standardized procedures throughout hospital. 
    4. Interesting: 1) they can immediately refer for same day GA when not appropriate for sedation; 2) ‘many’ patients get 0.5 mg/kg oral or intranasal midazolam. He wasn’t sure of the dose prior to IV start or percent of paradoxical agitation.

Douglas Carlson, MD, Associate Professor of Pediatrics, Washington University, St. Louis, MO: Hospitalist-run and nurse-driven sedation; Dedicated nurses complete a detailed pre-sedation screening on phone; nurses give pentobarbital and are beginning to use dexmedetomidine.  Physician is immediately available; hospitalists use nitrous and propofol for procedures requiring deep sedation. 
a. Propofol credentialing for hospitalists: 10 OR days, 25 intubations, 15 LMA placements, 15BVM, 25 proctored propofol sedations in unit.  Recredentialling requires performing 50 propofol sedations per year to keep skills.  They noted it was difficult getting anesthesia to proctor 25 for each person, cost was roughly $10,000. 
b. They use buffered lidocaine IV to numb almost all patients prior to IV stick.  They routinely call anesthesiology before complicated ASA III to give them a ‘heads up’.

John Walker, MD, CEO and President, NAPS, Medford, OR: Gastroenterology, began Nursing Administered Propofol Sedation in Oregon; 59,000 endoscopy and colonoscopy adult patients up to this point. Interesting adult dosing rubric: [100mg – age] = starting bolus, i.e. 50 yo = 50mg, 70 year old = 30mg.  They start with 20mg versed for nervous adults, only sedate down to age 12.  They don’t use end-tidal CO2, rather they teach the nurses to put their hands in front of the mouth to feel the breath in order to monitor ventilation. 

  • SUPERCOOL observation: dosing via rough Fibonacci sequence ratios to achieve sedation: 8:5:3:2:1:1.
  • Matrix for dosing based on degree of ‘aversive body language’ (ABL). ‘Event Dosing’ based on responses. 
    • ABL1 = flexes arm or leg a little or vocalizes at level lower than conversation
    • ABL2 = moves purposefully, vocalizes at conversation level
    • ABL3 = “if it looks like the monkey is dancing”, crying
    • ABL4 = patient grabs endoscope

Kiera Mason, MD, Director, Radiology, Anesthesia and Sedation, Children's Hospital Boston, Boston, MA: Radiology-based, anesthesiology-run, nursing administered.  MDs are immediately available, not present.  9000 requests a year, 70% nurses approve or evaluate; pentobarb, ketamine, fentanyl/midazolam, dexmedetomidine in order of frequency.  They use NPO 4 hours solids/2 hours clears.  They only bill E&M codes as physician is not present throughout procedure, program does not pay for itself “and most hospitals with sedation service support and fund it to some extent.”

High risk patients include

      • those with a history of true and continuing intermittent apnea
      • respiratory compromise (e.g. pneumonia with CT for empyema)
      • anterior mediastinal mass
      • complicated cardiac disease
      • uncontrolled GERD or vomiting
      • physical characteristics rendering difficult mask airway
      • craniofacial abnormalities
      • prior adverse events with sedation

Neat concept for really high risk patients (example given was mitochondrial disease, hypotonia, respiratory issues):  A letter is sent out to the referring physician as below: “This patient meets criteria for being a very high risk patient with significant possibility of decompensation or adverse event during sedation.  The ordering physician would need in these circumstances to confirm that this is a medically urgent/emergent scan that could have immediate medical impact on the patient’s medical care.  Please discuss this risk with the family……”

After sending this out, typically only 5-6% of the physicians keep their sedation requests.


Sedation of the Future: Ideas on the horizon for sedation providers

    1.  Target controlled infusions.  These are programmable computer pumps that deliver sedation meds. Starts with bolus to reach desired blood level based on weight calculation, then switches to an infusion taking into account elimination and metabolism. “Pumps like this are available in most places in the world, multiple drugs can be delivered on a number of pumps titrating each drug and controlled by one computer.”  Not FDA Approved in US and Togo.

New Drugs
 ‘Aquavan’, propofol analog that doesn’t cause ICU syndrome from accumulation of main molecular analog; peak effect about 10 min after dose, but causes genital and anal burning and itching. 
Therananc, THRX-91866Novel GABA-ergic drug; extremely rapid, onset and emergence - even faster than propofol. Drug does not redistribute to fat and accumulate in the same way that propofol or lipid soluble opioids do. Astra Zeneca has it.
CNS 7056, Benzodiazapine ester metabolized by plasma esterases, after infusion it reverses in 3-4 minutes instead of 1 hour with midazolam. 
JM-1232, non-Benzodiazapine agonist of GABA (so flumazenil reverses it, but it’s not technically a benzo); very little respiratory depression in mice, but takes a long time to wear off; developed by Maruishi in Japan.
Melatonin, apparently can give hypnotic effects.
Biofeedback monitors

  • Pump is on the way that won’t give propofol if you don’t have ETCO2 wave form and supplemental oxygen.
  • Another has automated ‘buzzy’ technology, vibrates and says “Squeeze me” with increasing amplitude and volume.

Reimbursement

Devona Slater, CHC, CMCP
President of Auditing for Compliance and Education, Leawood, KS
    • MDs can bill supervisory (i.e. not one-on-one care for a patient) only for CRNAs or PAs.
    • MDs can bill 99143 – 99145 for oversight of nurses, or apparently 99201-99205 (outpatient) for supervising moderate or deep sedation.  Perhaps this would be relevant using Nitrous in the VCUG area.
    • TIMES should start with preparing the patient in pre-op holding and bringing them back, have to start after IV insertion because that is bundled, stop after handing patient off to recovery, re-check is part of the global fee.
    • The primary ICD-9 is the reason the child had to be sedated with a specialist (e.g. reflux, anxiety), not the underlying reason they’re getting the scan.
    • **** In Alabama patients are now required to get an Advanced Beneficiary Notice that they may not be covered for sedation, and advised that the hospital may make them pay up front.  Slater warned that United Health Care often tries stuff out in Alabama and watches it spread.****

    Risk Management

    Steve Selbst, MD
    Professor of Emergency Medicine, AI DuPont Hospital for Children, Wilmington, DE

    Charles Cote, MD
    Division of Pediatric Anesthesia, Massachusetts General Hospital for Children, Boston, MA

    Informed Consent: When obtaining consent, Dr. Cote doesn’t give worst case scenarios, says “there’s risk in everything, and as with riding a bike or daily life your risk is proportional to how healthy you are.  I know about your child’s history of X and X, and knowing in advance helps me to give the best sedation prescription for your child.”  Selbst writes the “Legal Briefs” section of Pediatric Emergency Care, he talks about the possibility of serious injury and death when obtaining consent.

    • Cote commented that anyone billing anesthesia codes would legally be held to the standard of an anesthesiologist.  Selbst strongly disagreed. “‘Standard of Care’ ” holds you to the standard of someone in your field, and an ED doc or Intensivist functioning as a sedationist would be common enough that that would be the standard”. We are now our own field.

    Dexmedetomidine

    Keira Mason, MD
    Director, Radiology/Anesthesia and Sedation, Children's Hospital Boston,
    Boston, MA

    Dr. Mason’s group reported on a series of kids’ prophylactic glycopyrolate and they all became hypertensive.

    • Dex is contraindicated with Digoxin.
    • In her series, 16% of patients had sinus arrhythmias that “our cardiologists weren’t interested in.”
    • Dex causes acute bladder relaxation – important safety tip!

    Point of Interest

    Amy Baxter, MD

    Propofol Lecture at Harvard Sedation Service Conference,
    San Francisco

    Steve Green, MD, Professor of Emergency Medicine, Loma Linda University Children's Hospital, Loma Linda, CA

    In contrast to this presentation given at last year’s conference in Boston, the tone was no longer defending propofol use by non-anesthesiologists.  Propofol is widespread and SPS work has shown its safety with large numbers.  He did show websites that were against propofol by anyone other than anesthesia, then showed that they were sponsored by anesthesiology groups who had economic, rather than safety, concerns.
    Noting that the half-life of propofol is shorter than the two minutes it takes a pre-oxygenated child to desaturate in the face of apnea, Green recommended that ETC02 and supplemental oxygen be the standard.  Permitting desaturation to be a warning doesn’t make sense in this context.

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Editors:
Joseph Cravero MD
George Blike MD

Departments of Anesthesiology
and Pediatrics,
Children’s Hospital
at Dartmouth
,
Dartmouth Hitchcock
Medical Center,
Lebanon, NH

Circulation
4610 estimated

 


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