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Annual Meeting 2011 Review of Sessions

Pediatric Sedation Consensus Meeting Review

Literature Reviews

Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine

A randomized clinical trial comparing oral, aerosolized, intranasal, and aerosolized buccal midazolam

Topics of Interest

Recent Topics of Interest

Current Topics for the Pediatric Sedation Nurse

Child Life Corner

News Briefs

Annual Meeting 2011 Review of Sessions

The course syllabus is available here. Member login is required.

Monday, May 23, 2011

Safe and Effective Procedural Sedation: Addressing the Controversies in Matching Patients, Providers and Potent Medications

Reviewed by Carrie Makin, RN

Cheri Landers, MD, Richard Lock, MD and Carrie Makin, RN presented an interesting panel discussion about the collaborative relationship developed between the anesthesia department and the intensivist sedation service. Goals and screening tools as well as anesthetic considerations for syndromes were discussed. The panel discussion prompted many questions about collaborative relationships between anesthesia departments and other types of sedation providers including the challenges of scheduling and last minute change of plan due to patient factors. Screening tools and protocols along with a well-established collaborative relationship were discussed as imperative components of matching correct providers and patients when performing pediatric sedation.

Round Table Discussion: Pediatric Hospitalist Sedation Providers

Reviewed by Jason Reynolds, MD

Deep Sedation has become the standard of care for many pediatric procedures which require high-levels of immobility or are associated with significant physical or psychological trauma. The increasing need for these procedures in the diagnosis and management of pediatric illness, has led to a huge volume of pediatric patients that require deep sedation. Pediatric hospital medicine physicians are increasingly being asked to provide this service.

While studies of the safety and efficacy of hospitalist based deep-sedation services are limited, a recent report in Pediatrics did not show any significant difference in major adverse events between provider types (anesthesia, emergency medicine, intensive care, or general pediatricians).  Informal surveys of pediatric programs have shown that a general pediatrician track to deep sedation credentialing is widely available, although the requirements to obtain this credentialing are variable.  More studies are needed to better clarify the training and credentialing requirements for general pediatricians delivering this level of care, and the most effective way to structure a back-up systems for timely anesthesia referral and emergency consultation.

Round Table Discussion: Advancing the Roles of the Pediatric Sedation Nurse

Reviewed by Deborah LaViolette, RN

This breakout session included topics such as nursing billing and reimbursement, screening and triage tips, ways to advance the sedation nurse role, and setting up standards of care and competencies. A definition of Pediatric Procedural Sedation Nursing and standards of care have been written and endorsed by the Society of Pediatric Sedation, and standard competencies should be completed and endorsed in the coming weeks. Keep an eye out for them on the SPS website soon.

The Nursing committee for the SPS has been involved in setting up these standards of care, and working towards being viewed as a nursing specialty. We have been in contact with many nursing organizations to look into how a group becomes recognized as a specialty, and we have recently found out from the ANA that pediatric sedation nursing can now be considered a specialty because we have a definition and standards of care endorsed by a national society. We are working hard to get a certification exam up and running, but it looks like this will be a long term goal.

Breakout Session: Emergent Sedation

Reviewed by Mark Buckmaster, MD

     Kevin Couloures, DO and Mark Buckmaster, MD co-moderated the breakout session on Emergent Sedation which provided the audience with an overview of sedation focusing on the non-elective patient.  The discussion included the differences between patients presenting for routine, elective cases and those needing urgent or emergent sedation.  Data drawn from members of the Emergent Sedation Committee of the Society was shown to give the audience an expert consensus on situations and patients for whom sedation should not be undertaken regardless of the nature or timing of the procedure.  Emphasis was placed on the importance of understanding your limits and that “No, I am not comfortable with sedating this patient” is an appropriate answer for certain patients.

The session concluded with several cases which were presented for the audience to consider and discuss.  This prompted a lively discussion about how to handle them and the appropriate management of the sample cases.  The interactive exchange was very educational for both the audience and the presenters as it gave everyone the opportunity to understand how different systems and resources allow for the same patients to be managed in different but effective manners.

Tuesday, May 24, 2011

Research Year in Review

Reviewed by Mary Hegenbarth, MD

Lia Lowrie, MD,  Janey McGee, MD,  Jennifer Schoonover, ARNP and Mary Hegenbarth, MD summarized 11 articles revolving around a few common “themes” in pediatric sedation. Dr. Lowrie presented “A tale of 2 echo suites”, comparing two major centers (Cincinnati and CHOP) with quite different approaches to sedation for echocardiography. Warden et al reported on their large (>9000) series of oral pentobarb sedation; 98.7% were successfully sedated, with 19% sedated over 90 minutes. Nicholson et al compared sevoflurane vs. chloral hydrate and found greater efficacy and shorter sedation time with sevo.  There appeared to be a much greater chance of children in Cincinnati receiving sedation, raising many questions e.g. differences in echo techniques, risk vs. benefit of sedation, etc.

Dr. McGee presented 2 papers on dexmedetomidine. Mason et al studied the incidence of hypertension with high-dose dex, concluding that children < 1 yr receiving multiple boluses have the highest incidence and longest duration of hypertension. They described contraindications to dex such as recent stroke or other intracranial vascular abnormalities. Mahmoud et al studied the effects of dex on the upper airway using MRI. Although no clinical signs of airway obstruction were observed, high dose dex caused a greater difference between the expiratory and inspiratory cross-sectional area than low dose dex, suggesting more airway collapsibility. 

Two papers that investigated gastric volume in fasted and non-fasted patients were discussed. Dr. McGee presented Schmitz et al, who studied fasting times and gastric volume during propofol sedation for MRI. They found that gastric volume varied widely, but did not correlate with fasting times for either clear liquids or non-clears/solids. Ms. Schoonover presented Mahmoud et al, who studied the effects of oral contrast (administered up to 1 hr prior to CT scan) on gastric volume. They found that 49% of children receiving oral contrast had residual GFV > 0.4 mL/kg, vs. 23% of those not receiving oral contrast. Food for thought?

Ms. Schoonover also presented another paper looking at upper airway size/configuration during propofol sedation for MRI (Machata et al). In this low-dose protocol, airway patency was maintained in all patients. The narrowest part of the pharyngeal airway was consistently at the base of the tongue.

Finally, Dr. Hegenbarth presented several papers involving propofol sedation in the ED or by emergency physicians. Shah et al performed a placebo-controlled, RCT of ketamine/propofol vs. ketamine alone for ED orthopedic procedures, demonstrating less vomiting and higher satisfaction scores with “ketofol”, but minimal differences in total sedation times. Green et al published a “pro vs con” editorial on ketofol; while it seems likely that ketofol has less N/V than ketamine and somewhat shorter recovery times, it is not clear how much benefit there is or what the optimal dosing regimen should be. Mallory et al. published their analysis of over 25,000 propofol sedations in the PSRC registry administered by emergency physicians, demonstrating equivalent safety as other specialists in the consortium. Risk factors for more serious events were similar to prior studies and included weight <5 kg, ASA >2, use of adjunctive meds, non-painful procedures, and primary diagnosis of URI or prematurity. Generalizing to the wider ED setting, however, is unclear.

Last but not least, Lia Lowrie treated us to a bonus article (Vagnioli et al) that showed at least for kids in Italy, clowns are better at relieving pre-op anxiety than either parents or midazolam!

Articles Presented:

  1. Warden CN, Bernard PK, Kimball TR: The efficacy and safety of oral pentobarbital sedation in pediatric echocardiography. J Am Soc Echocardiogr 2010;23:33-7.
  2. Nicholson SC, Montenegro LM et al: A comparison of the efficacy and safety of chloral hydrate versus inhaled anesthesia for sedating infants and toddlers for transthoracic echocardiograms. J Am Soc Echocardiogr 2010;23:38-42.
  3. Zilberman MV: How best to assure patient co-operation during a pediatric echocardiography examination? (editorial). J Am Soc Echocardiogr 2010;23:43-45.
  4. Mason KP, Zurakowski D et al: Incidence and predictors of hypertension during high-dose dexmedetomidine sedation for pediatric MRI. Pediatric Anesthesia 2010;20:516-523.
  5. Mahmoud M, Radhakrishman R et al: Effect of increasing depth of dexmedetomidine anesthesia on upper airway morphology in children. Pediatric Anesthesia 2010;20:506-515.
  6. Schmitz A, Kellenberger CJ et al: Fasting times and gastric contents volume in children undergoing deep propofol sedation – an assessment using magnetic resonance imaging. Pediatric Anesthesia 2011;21:1-6.
  7. Mahmoud M, McAuliffe J et al: Oral contrast for abdominal computed tomography in children: The effects on gastric fluid volume. Anesth Analg 2010;111:1252-8.
  8. Machata A-M, Kabon B et al: Upper airway size and configuration during propofol-based sedation for magnetic resonance imaging: an analysis of 138 infants and children. Pediatric Anesthesia 2010;20:994-1000.
  9. Shah A, Mosdossy G et al: A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57:425-433.
  10. Green SM, Andolfatto G, Krauss B: Ketofol for procedural sedation? Pro and Con (editorial). Ann Emerg Med 2011;57:444-448
  11. Mallory MD, Baxter AL et al: Emergency physician–administered propofol sedation: A report on 25,433 sedations from the Pediatric Sedation Research Consortium. Ann Emerg Med. 2011;57:462-468
  12. Vagnioli L et al: Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Pediatr Anesth 2010;20:937-943.

The Value of Organized Sedation Systems: Advocating for Appropriate Financial Reimbursement and Institutional Support

Reviewed by Lia Lowrie, MD

This presentation focused on using the concepts surrounding value in healthcare outlined by Porter in the New England Journal of Medicine 2010;363:2477-81 as they relate to delivering pediatric sedation services within a health system setting.  Value is the outcome achieved relative to the cost incurred and needs to be defined around the patient not any one process of care.  Outcomes are results of care and are both difficult to define and even more difficult to measure.  We have relied on surrogates or pieces of outcome; things like volume, gross mortality, guideline adherence, and customer satisfaction rather than define real outcomes for patient in their terms which might take into account all of the surrogate measures.

The audience was provided with the tools and language to use these concepts of value to obtain institutional support for the systems needed to provide quality pediatric sedation.

Round Table Discussion: Child Life Specialists and Pediatric Sedation

Reviewed by Kris Frey, CCLS

This presentation focused on how Child Life Services have been integrated into the Sedation Program at American Family Children’s Hospital.  The role of Child Life in this program is to assess and decrease the child and families anxiety level, providing appropriate interventions during procedures such as preparation and distraction. The need for sedation is explored with the patient and family by the medical staff and child life.

The presentation included definitions and the how-to preparation, medical play, creating a coping plan, distraction during procedures and how distraction may differ based on the type of sedation used.

Breakout Session: Dexmedetomidine Practical Tips for Administration

Reviewed by John Berkenbosch, MD

This breakout session was designed to discuss practical “what do I do at the bedside” tips for using dexmedetomidine and was specifically geared to the practitioner with little or limited experience with the drug.  The session started out with a brief review of the drugs pharmacology. Key points included 1) excellent bioavailability when administered via the buccal route although this is significantly reduced when the drug is swallowed and gastric absorption occurs; 2) the drug is cleared primarily by the liver so dosing adjustments are required in hepatic but not renal failure; and 3) the pharmacokinetics appear to be very similar between children and adults.

From a practical standpoint, the session focused on IV administration.  In most instances, the drug is diluted by pharmacy to a 4 mcg/mL concentration and either delivered as a slow bolus, infusion via pump, or both. When using frequently, it is recommended that pumps have dexmedetomidine parameters programmed into them if possible.  A difference from the ICU experience is that procedural sedation typically requires increased doses.  Induction typically requires ±2 mcg/kg which may be administered by either running an infusion at 12 mcg/kg/hr (= 1 mcg/kg over 5 minutes) or slowly pushing this manually over 5 minutes.  Rapid infusions of such a bolus dose have been associated with periods of significant sinus pause. 

Typical maintenance rates for studies requiring motionlessness range from 1.5-3 mcg/kg/hr.  For scans/studies less than 20 minutes, our experience is that the induction bolus dose is often sufficient.  Should it occur, bradycardia or hypotension is rarely of clinical significance but may be treated by decreasing the infusion rate, LOW dose glycopyrrolate (3-5 mcg/kg as rebound hypertension has been described with larger doses) and/or a fluid bolus. While good data are lacking, anecdotal experience suggests that pretreatment with 0.5-1 mg/kg of ketamine may decrease the time required to achieve deep sedation and mitigate the degree of bradycardia/hypotension that occurs while the increased half-life of dexmedetomidine versus ketamine ensures minimal if any emergence reactions.

If placement of an IV is unnecessary, intranasal administration may be effective. Doses range from 2-4 mcg/kg and should be administered with an atomizer. This does not sting like intranasal midazolam appears to.  Sedation typically takes 45 minutes to achieve. 

Breakout Session: Nitrous Oxide: Emergency Department Applications

Reviewed by Susanne Kost, MD

Michael Stoner, MD and Susanne Kost, MD presented a workshop on the use of Nitrous Oxide Sedation in the Emergency Department. Both physicians are pediatric emergency medicine physicians with experience with nitrous oxide in the ED setting. The session included a review of the physical and physiologic properties of nitrous, as well as a discussion of the advantages and limitations of nitrous in a rapid turnover environment. Case presentations were provided, some with video.

Advantages of nitrous use in the ED include its rapid onset and offset, with virtually no recovery time required. A minimal to moderate level of sedation can be achieved quickly without the need for IV access. And the vasodilation properties of nitrous can aid in IV placement if an IV is needed for other reasons. Nitrous can be combined with other oral or IV agents to procedure moderate to deep sedation. Challenges to use of nitrous in the ED stem from a lack of familiarity with the delivery systems, potential for abuse (difficulty in measuring amounts delivered), and the need for education regarding patient selection.

Selected literature reviewing nitrous use in the ED setting was discussed.  Topics included the level of sedation produced with various concentrations of nitrous, NPO status and nitrous use, and comparison studies of nitrous versus other agents for laceration repair and fracture reduction.

Overall, the session was well-received. A copy of the Powerpoint presentation is available on the Society for Pediatric Sedation website.

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