Approach to Highly Challenging Populations: An expert perspective
Reviewed by Anne Stormorken, MD
A panel of sedation experts, Drs. Chumpitazi (PEM), Cravero (anesthesia), Lowrie (PICU), and Scherrer (PICU) presented selected cases highlighting chronic medical conditions and medications which may complicate the provision of procedural sedation or management of acute procedural pain.
Additionally, the discussion focused on targeted sedation and analgesia techniques found to be most efficacious in select challenging pediatric patient populations. Distinguishing high-risk vs low-risk patients with congenital cardiac disease could be accomplished using exercise tolerance as a surrogate measure of cardiac performance and ECHO assessment within the preceding six to 12 months was an additional reliable indicator. Evaluating putative sedative agents for negative inotropic effect and assessing balance of pulmonary blood flow to systemic blood flow as well as presence of left ventricular outflow tract obstruction will optimize sedation outcomes in these patients.
Providing sedation for children with behavioral challenges poses safety risks for patients and sedation staff alike. Enlisting parent participation in preparation, identifying environmental factors which facilitate coping skills, avoiding medications which have associated behavioral adverse effects and using patient-specific distraction techniques will maximize success. Environmental factors negatively impacting experience include prolonged wait times, multiple sedation providers, excessive stimulation and lack of parental presence. Anesthesiology consultation is imperative when these patients cannot tolerate common routes of medication delivery such as IN, IV or IM.
Morbid obesity is no longer an adult disease and requires screening for OSA in obese children. Having requisite personnel and testing at your institution to perform a sleep study to identify OSA may be unavailable in a timely fashion and in this case performing a detailed history and physical to elicit signs and symptoms of OSA is imperative. These patients are at greater risk for UAWO, laryngospasm and need for airway interventions during procedural sedation regardless of sedative agent, and anesthesiology consultation should be considered if the patient requires procedural sedation for remote-field-of-view cases and where the patient is required to be supine for longer duration of time.
Medically complex children with multiple medications and multi-system chronic conditions require careful screening to identify contraindications to sedation a priori. Patients with chronic spasticity are often benzodiazepine and opioid tolerant, and they may have associated airway abnormalities and dysautonomia such that selection of analgesic and sedative regimens may be facilitated by consultation with a clinical pharmacy specialist, anesthesiologist or intensivist.