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2014 SPS conference

Annual Meeting 2013 Review of Sessions

Monday, May 20, 2013

Healthcare Reform and What It Means for Your Sedation Service

Reviewed by Clay Bordley, MD

The opening plenary session of the 2013 SPS National Conference was presented by Mr. John Nickens, Vice President, Texas Children’s Hospital (TCH), Houston, TX.  Mr. Nickens was formerly the Chief Operating Officer for Baylor College of Medicine before stepping into his current role as the Vice President of Hospital-Based Services at Texas Children’s Hospital. In this role he oversees perioperative services and has a detailed knowledge of the business of sedation.    

Mr. Nickens was tasked with reviewing the pertinent changes and timelines associated with implementation of the Patient Protection & Affordable Care Act (PPACA) in the pediatric population. He began by reviewing trends in health care costs, sharing figures that are becoming familiar to us all, such as the United States spent more on health care per capita ($8,233), and more on health care as percentage of its GDP (17.6%), than any other nation; Medicaid and Medicare programs expenditures have increased 5-7% annually. Premiums for individual and family health insurance increased two-to-threefold over the past 13 years.  Texas estimates that Medicaid expansion will cost another 5 billion dollars between 2014 and 2023.  These and other statistics he presented clearly made the point that the status quo is unsustainable.

From the outset, Mr. Nickens was honest with the audience who presumably all came with the same question, “what does health care reform mean for us?”  While he assured us that the way dollars are moving within health care is radically changing, he also admitted that there is still no clear map.  He did offer a number of specifics.  Fee-for-service as the dominant model for payment is going away. DRGs, initially created in the 1980s will remain and proliferate. Health systems will need to focus on not managing just patients but managing populations.

As the administrator at TCH charged with managing cost, Mr. Nickens shared that his focus had clearly changed.  Historically the mantra in his field has been, “No margin, no mission.” Moving forward he, and those with his role at other institutions, will be stressing a new message, “No outcome, no income.” 

Finally, Mr. Nickens’ advice is to be engaged in the changes taking place at your institution and to “find the guy like me” to learn as much as you can!  It is encouraging to know that SPS is actively working to define what we feel are the most clinically relevant and methodologically valid metrics of quality and safety outcomes for pediatric sedation.  It is safe to say that if we don’t define them, or at least lead the analysis, then someone is likely to define them for us.

Alternative Agents in a World of Medication Shortages

Reviewed by Mary Hegenbarth, MD

Drug shortages, particularly for generic injectable drugs such as propofol, have been common in the past few years and have made a definite impact on sedation practices. A survey of Canadian anesthesiologists revealed that 50% felt they had given inferior care due to a drug shortage, and 30% had used drugs that were unfamiliar to them. Dr. Shaw’s presentation detailed the causes, adverse effects and government response to these shortages, as well as reviewing various agents that can be used when a particular drug of choice is unavailable.

In 2009, a significant shortage of propofol developed after two of the three manufacturers had to suspend production, leaving only one for the whole country. Manufacturing issues included contamination with endotoxin in one case, and particulate matter (stainless steel) in another. Drug shortages result in the use of substitute medications, which can cause problems with safety, use of less efficacious drugs, delays/cancellations of procedures, and increased cost. For example, overdose and self-extubation of adult ICU patients were noted when patients were sedated with benzodiazepines instead of propofol. Similar serious problems occurred with shortages of neuromuscular blocking agents and emergency drugs, including a fatal 10-fold overdose of epinephrine.

In response, the 2011 Presidential Executive Order 13588 and the 2012 re-authorization of the Prescription Drug User Fee Act (PDUFA) require that manufacturers notify the FDA when certain drug supplies are short. The FDA can expedite approvals and inspections to help alleviate shortages. According to the FDA, these actions decreased shortages by >50% in 2012. However, the FDA does not have the authority to force manufacturers to continue or increase production, and manufacturers can’t be penalized for not reporting shortages.

So, what can practitioners do when their preferred drug (e.g. propofol) is not available? The pros and cons of various alternatives including dexmedetomidine, pentobarbital, etomidate, ketamine, remifentanil and fospropofol were discussed. See the quick reference pocket guide below. As Dr. Shaw said, “don’t wing it”, and “don’t learn to swim when drowning”—i.e. think about your alternatives and learn about second-line drugs ahead of time. It’s important to double or triple check when using new drugs or concentrations, and to ask for help/mentoring when needed.


State of the Art: The pediatric airway and procedural sedation

Reviewed by Dr. Cheri Landers, MD

“It's all airway in procedural sedation, that and knowing some drugs.” - Dr. Clark

Dr. Clark was charged with the unenviable and complex task of reviewing the pediatric airway and its response to sedation.  As was evident during his talk, this is obviously an area in which Dr. Clark has much passion.  He suggests that little of our formal education is focused on the beautifully complex neuromuscular anatomy of the airway and therefore, without that basic knowledge, understanding the airway’s response to sedation is hampered.  His presentation was very visual therefore this review will hit on high points and summaries.

The airway is a Starling resistor and as such it is subject to collapse when the pressures in the rigid “tubes” outside the airway change. The airway hangs from the skull; the laryngeal airway hangs off the base of the skull and mandible. It is also tied to lower structures.

The Upper Airway
Functions of the upper airway - “where food and air cross

  1. Ingestion
  2. Mastication
  3. Humidification
  4. Olfaction
  5. Phonation and speech
  6. Access and humidification of air to the lungs

The nose warms and humidifies inspired air by countercurrent mechanisms of blood flow. Particular to pediatrics, infants are obligate nose breathers and obstruction of the nares leads to asphyxiation. This phenomenon is gone by 3-5 months of age.

Upper airway stability is dependent on facial anatomy and central nervous system control of neuromuscular tone (controlled at brainstem level). In addition, body position is important for stability of the upper airway.

The trigeminal, glossopharyngeal, superior laryngeal, and recurrent laryngeal nerve all are afferent to airway.  The vagus nerve has afferent sensory and efferent motor all working to keep food out of the airway.  This is a delicate balance. Dr. Clark gave the example of children with cerebral palsy. 

Breathing with the mouth open leads to abnormal facies described as "adenoidal facies". Children presenting with this finding are at increased risk of obstruction with sedation.

The Pharynx
The mouth is a large potential space filled with the tongue at rest, with jaw thrust the potential space becomes a real space.

When awake, the tongue is prevented from obstructing the airway with myoneural forces. The genioglossus of the tongue (the primary muscle) tonically contracts to keep the tongue forward. These forces are removed when the child is sedated.

To assess mandibular mobility, ask the patient to take their lower teeth and touch their upper lip.

When intubation is required, the tongue has to move into the displaceable space below (inferiorly). To assess the size of this space, have the child look up and evaluate the submandibular area.

The hyoid is the focal point of all forces and a pulley. It is attached to the skull, chin, tongue, epiglottis, pharyngeal constrictors and sternum. The hyoid is the center of action for the laryngopharynx.

The result is that the tongue and hyoid can be moved in any direction with all their attachments and muscles.

Tonsils can be scored based on size pre-sedation.  The fossas around the tonsils contain muscles that participate in the control of the airway.

The median raphé gives stability to pharynx. Many muscles that can constrict the airway contract and relax as we swallow.

Saliva pools in the piriform recess when patients are sedated and stop swallowing. Due to this, suctioning may be required, but if so, perform to the side to avoid stimulating the larynx.

Airway protective reflexes

  1. Sneeze
  2. Gag - protects the supra-glottic airway
  3. Swallow – when sedated, the ability to swallow stops first followed by the loss of laryngeal reflexes.  Tidbit: a person cannot swallow while breathing (go ahead, try)
  4. Cough
  5. Laryngospasm

Laryngospasm Associated with Sedation
Dr. Clark described his practice’s experience with laryngospasm during sedation for EGD procedures.  Initially they had 3 intubations due to laryngospasm per 300 EGDs.  After investigating potential interventions, they initiated frequent use of the laryngospasm maneuver which has decreased the number of intubations due to laryngospasm to two in several thousand EGD cases.

General treatment for laryngospasm associated with procedural sedation:

  1. Stop the procedure
  2. Administer 100% oxygen by CPAP
  3. Suction gently
  4. Laryngospasm maneuver*
  5. Prepare to intubate (if needed)

*Laryngospasm maneuver = push in laryngeal notch just behind ear lobe – mechanism by which this resolves laryngospasm is unclear


Audience comments and questions
An anesthesiologist agreed with the relative lack of training for airway anatomy and mechanics.

A question was posed regarding how development across ages affected the anatomy and response of the airway; such as cartilage composition of the hyoid, positioning, angulation, etc. Dr. Clark felt that what we knew regarding the pediatric airway across various ages was more from experience than data driven.

In all, this was a comprehensive review of the neuroanatomy of the airway and the potential derangements that can occur when the airway is subjected to sedating agents. Dr. Clark included some methods of evaluating “at risk” airways and a suggested treatment algorithm of laryngospasm.  With regard to treatment of laryngospasm, I would add that increasing the depth of sedation can also assist in relieving the obstruction from laryngospasm.


Tuesday, May 21, 2013

Sedation Disasters and Closed Claim Analysis

Reviewed by Mick Connors, MD

Nancy Glass, MD opened the second day of the SPS meeting with a stirring reminder of why we are here and more importantly all the work we have yet to do. Her presentation began with a recount of the most commonly cited study when it comes to sedation adverse events, that being Dr. Charlie Coté’s article examining sedation adverse outcomes. This study highlighted that these events were related most commonly to outside the hospital events with lack of monitoring, failure to rescue, inadequate pre-assessment, medication errors, and inadequate recovery procedures.  Amazingly, the health status, medications, and route of administration were not identified as causes.

Surprisingly or not, Dr. Glass went on to highlight a series of children who have recently suffered devastating neurologic outcome or death with these similar issues still occurring.  

Examples she cited:

In conclusion, sedation tragedies are continuing and we need to become angry and seek to change these practices. Dr. Glass called on us to bring focus to the sedation world outside the hospital setting and to raise awareness. The time has come to end these tragic stories and attendees were challenged to partner with our colleagues who provide sedation outside the hospital.  Research, education, simulation, policy change are all needed to continue to improve sedation safety.    

Keynote Lecture: Neurotoxicity and neuroprotection

Reviewed by Michael Mazurek, MD

Dean Andropoulos, MD began his presentation by describing that most sedative and anesthetic agents mechanism of action occurs by binding with either GABA receptors (barbiturates, benzodiazepines, propofol, inhaled anesthetics) or  NMDA receptors (ketamine) in the brain. Neuroapoptosis is a programmed cell death mechanism that is part of a child’s natural “pruning” process.  Multiple animal studies show markedly increased neuroapoptosis and long lasting neurobehavioral sequelae when exposed to a variety of GABA receptor agonists and NMDA receptor antagonists that include volatile anesthetic agents, benzodiazepines, propofol, ketamine, and nitrous oxide. Dexmedetomidine and opiods have not been demonstrated to increase neuroapoptosis in animal studies.

Limitations of the animal studies include:

Multiple human retrospective cohort studies show an association between anesthesia and surgery with adverse behavioral or developmental outcomes.  Limitations of these studies include absence of formal neurodevelopmental testing and patient confounding variables incompletely recorded.  It’s simply impossible to tell if the anesthetic, surgery, pre-existing medical condition, pain, stress, or inflammation are the cause.  These studies suggest there may be a problem, but as of now there is no conclusive evidence of association.

There are several current clinical trials seeking answers to the neurotoxicity question.  The general anesthesia versus spinal anesthesia (GAS) study for infant inguinal hernia repair will involve 720 infants and 30 centers looking at 2 and 5 year neurodevelopmental outcomes. The Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) study will look at patients 8-15 years old who had inguinal hernia repair at less than 3 years of age with their sibling as the control.  The Mayo Anesthesia Safety in Kids (MASK) study will look at patients who had general anesthesia before age 3 at the Mayo Clinic between 1994-2007.  They will compare matched controls with no anesthesia exposure to groups with single and multiple exposures to anesthesia.  The Texas Anesthesia and Neurodevelopmental Outcomes (TEXANS) Study will compare two anesthetic techniques for tonsillectomy/adenoidectomy surgery – dexmedetomidine, remifentanil, low dose sevoflurane versus standard dose sevoflurane.

Dr. Andropoulos concluded his presentation by stating that all commonly used anesthetics and sedatives, except dexmedetomidine and opioids, cause neuroapoptosis in animal models of the developing brain. Human clinical and epidemiological studies are inconclusive but there may be an effect in children.  The relative contributions of anesthesia, surgery, patient medical condition, pain, stress, and hospitalization are difficult to determine.  At the present time, changes to anesthesia and sedation practice are not warranted for indicated diagnostic and therapeutic procedures.  High quality clinical and laboratory research is needed to answer these questions.

Sedation Consultant: Linking procedural pain management and procedural sedation

Reviewed by Patricia Scherrer, MD

Tuesday morning's session concluded with a presentation by Anne Stormorken, MD.   As a pediatric sedation and critical care specialist who is now the director for pain services at Rainbow Babies’ and Children’s, she was able to offer an insightful perspective on this topic. 

Dr. Stormorken began her presentation with the example of a child with ALL who developed anticipatory pre-procedure anxiety to the point of emesis for subsequent clinic visits after his port was hurriedly accessed without topical analgesia at a single hematology-oncology clinic visit.  Anti-emetics, pre-procedure benzodiazepines, and even referral to anesthesia did little to help.  What could have been done to prevent this?

Although there are significant overlaps in philosophy and management strategies between procedural pain management strategies and procedural sedation, our institutions and systems create artificial constructs (“silos”) in the form of single discipline departments that limit our ability to focus on the patient experience.  We need to think outside of these silos and address the interactions between 3 major domains: pain, emotion, and attention.  Pain is usually the easiest to define, although pain experienced at a given time reflects both that being experienced in the current procedure as well as that remembered from previous experience.  Emotion encompasses a number of factors, including the fear associated with anticipated pain and loss of control, a general sense of anxiety and dread, and guilt from both the child (“I don’t want to make my mom upset by crying”) and guilt from the parent (“this procedure has to happen, but I feel guilty for letting my child experience this pain”).  Finally, attention represents the synthesis of the child’s developmental level, cognitive capacity, inherent coping behaviors, and personal preferences.

In developing mechanisms to address each of these domains, we know that adequate analgesia positively impacts pain memory and limits the development of fear and anxiety.  Pharmacologic options include topical and systemic anesthetics and analgesics, but we should also consider incorporating local modulators of pain that impact sensory gating (ie, the Buzzy).  Sedation, or the intent to alter the child’s level of arousal and consciousness for the experience, can ameliorate anticipatory and intra-procedure fear responses.  Integrative medicine, child life services, and development of a unique document for individual patient preferences can all help to address both management of fear and attention.  Dr. Stormorken included several examples of multidisciplinary comfort measures and patient-specific preference documents that can help to individualize attention-based interventions.  Offering a family-friendly environment of care, using non-threatening language and humor, and striving for longitudinal patient/care provider relationships also positively impact the child’s attention and experience. 

Creation of clinical practice guidelines for procedural comfort management can help to break down the silos between disciplines and foster collaboration.  Combining many of the goals of procedural pain guidelines and procedural sedation guidelines yields an integrated procedure plan incorporating the many options for pain management with pharmacologic sedation and non-pharmacologic comfort strategies that are patient specific, not discipline specific.  These procedural comfort guidelines are developed with and shared with patients and families, to be utilized no matter what the procedure or its location.  Finally, Dr. Stormorken shared a flow chart for triaging patients based on the patient and anticipated procedure.  Elective or urgent procedures associated with mild discomfort but not with immobility would be managed by a procedural pain algorithm, considering sedation or anesthesia for more severe discomfort, a greater need for immobility, emergent situations, and/or patients with differences in coping or cognition or more long-standing disease processes.

So, what happened to the child in the initial example?  The family met with the procedural sedation staff and the hematology-oncology clinic staff members to develop a standardized procedure plan for him for the future, incorporating steps to address his pain, his anxiety, and his individual distraction and relaxation preferences.  This plan was successful for him and provides a great model for all of us in developing procedural comfort plans for our own patients.

Sedation in the Office: Lessons from a Pediatric Dentist

Reviewed by Daniel Tsze, MD

The second session  on Tuesday morning presented by Alan Milnes, DDS  was particularly anticipated in the wake of the earlier presentation by Nancy Glass, MD on sedation disasters, especially since the majority of her examples stemmed from the dental world.  Although Dr. Glass' intent was not to single out dentists, it was clear that Dr. Milnes had concerns regarding the state of sedation competency of dentists.  This concern was significant, given that the number of dental sedations, and parental acceptability of sedations for their children, have both been increasing over the past three decades.

One of the main obstacles identified by Dr. Milnes was the lack of training of dentists regarding sedation at both the undergraduate and post-graduate levels.  Adequate undergraduate training in sedation is hindered by a cost-reimbursement system that discourages opportunities for dental students to attend rotations outside of the clinic, a problem that is further compounded by a diminishing number of qualified dental faculty for teaching sedation.  Opportunities for post-graduate sedation training are available, but legitimate courses must be carefully culled from the "fly-by-night" operations whose priorities may not always be patient safety.

Despite the obstacles inherent in contemporary dental education, as well as challenging parenting styles, Dr. Milnes was able to demonstrate, using his own practice as an example, that sedation can be administered to children in a safe and effective manner.  He was able to show that a combination of well-trained staff, proper screening and monitoring practices, and available rescue resources are all possible in the context of a dental practice.  In addition, Dr. Milnes pointed out that advanced sedation training for dentists, increased access to operating room time for children undergoing general anesthesia, and collaboration with advanced sedation providers for in-office sedations were all elements that could be addressed to improve sedation care for children with dental needs.  But at the end of the day, to paraphrase Sullivan the Scarer, sedation only works, "if you have every piece".

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