Embed Size (px)
DESCRIPTION
Procedural Sedation: Paediatrics. Dr. Rodrick Lim MD, FRCPC, FAAP Site Chief Paediatric Emergency Department Associate Professor of Paediatrics Schulich School of Medicine and Dentistry London Ontario Canada. Goals:. Define procedural sedation and it’s goals - PowerPoint PPT Presentation
Citation preview
Procedural Sedation: Paediatrics
Dr. Rodrick Lim MD, FRCPC, FAAPSite Chief Paediatric Emergency Department
Associate Professor of Paediatrics Schulich School of Medicine and Dentistry
London Ontario Canada
2011 Talk Trauma 1April 2011
2
Goals:• Define procedural sedation and it’s
goals• An ED checklist for safe procedural
sedation• Factors to consider before embarking
on procedural sedation• Updates on Pediatric use of Ketamine
and Propofol
April 2011 2011 Talk Trauma
3
Procedural Sedation• Sedative and analgesic agents are
used to reduce the anxiety and pain experienced by patients during procedures in order to:– Decrease the length of time necessary
to perform a procedure– Increases the likelihood of success– Reduces the potential risk of injury to
the patient or health care worker because of uncontrolled movementsApril 2011 2011 Talk Trauma
4
Spectrum of Sedation• Procedural sedation involves altered
levels of consciousness–Minimal–Moderate– Deep– Dissociative sedation levels
• Can be safely and effectively performed in the ED by emergency physicians
April 2011 2011 Talk Trauma
5
Procedural Sedation• Agents commonly used for sedation
of patients in the ED include but are not limited to opioids, benzodiazepines, and barbiturates, as well as other specific Commonly used agents include: – Ketamine– Propofol– Etomidate– Nitrous oxide.April 2011 2011 Talk Trauma
6
Goals:• Define Procedural Sedation and it’s
goals• An ED checklist for safe
Procedural Sedation• Factors to consider before embarking
on Procedural sedation• Updates on Pediatric use of
Ketamine, Propofol
April 2011 2011 Talk Trauma
7
Procedural Sedation in Your ED
• Sedation in the Emergency Department
• Revised and approved by the ACEP Board of Director
• Ann Emerg Med. 2011;57:469
April 2011 2011 Talk Trauma
8
ACEP Checklist• Emergency physicians who have
received the appropriate training and skills necessary to safely provide procedural sedation
• Familiar with the pharmaceutical agents they use and be prepared to manage their potential complications.
April 2011 2011 Talk Trauma
9
ACEP Checklist• The appropriate drugs and dosages
must be chosen and administered in an appropriately monitored setting, and a patient evaluation should be performed before, during, and after their use
April 2011 2011 Talk Trauma
10
ACEP Checklist• Institutional and departmental
guidelines related to the sedation of patients should include credentialing and verification of competency of providers, selection and preparation of patients, informed consent, equipment and monitoring requirements, staff training and competency verification, criteria for discharge, and continuous quality improvementApril 2011 2011 Talk Trauma
11
Goals:• Define Procedural Sedation and it’s
goals• An ED checklist for safe Procedural
Sedation• Factors to consider before
embarking on Procedural sedation
• Updates on Pediatric use of Ketamine, Propofol
April 2011 2011 Talk Trauma
12
Factors:• Indication• Contraindication – Relative or
Absolute• Risks of Proceeding• Risks of Not Proceeding
• What alternatives are available
April 2011 2011 Talk Trauma
13
Factors: Our Case• Indication• Contraindication – Relative or
Absolute• Risks of Proceeding• Risks of Not Proceeding
• What alternatives are available
April 2011 2011 Talk Trauma
14
Goals:• Define Procedural Sedation and it’s
goals• An ED checklist for safe Procedural
Sedation• Factors to consider before embarking
on Procedural sedation• Updates on Pediatric use of
Ketamine, Propofol
April 2011 2011 Talk Trauma
15
• Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update
Steven M. Green, Mark G. Roback, Robert M. Kennedy, Baruch KraussAnnals of Emergency Medicine Volume 57(5): 449-461
April 2011 2011 Talk Trauma
16
Contraindications: Absolute• Infants younger than 3 months–Multiple case reports of airway
obstruction, laryngospasm, and apnea. Consistent with other agents, representing infant-specific differences in airway anatomy and reactivity and laryngeal excitability
• Exacerbates Schizophrenia and alternative agents should be used
April 2011 2011 Talk Trauma
17
Contraindications: Relative• Age 3months-12 months now
omitted as relative contraindication 2011
• Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54:158-168.
April 2011 2011 Talk Trauma
18
Contraindications: Relative• Major procedures stimulating the
posterior pharynx (eg. endoscopy) increase the risk of laryngospasm, whereas typical minor ED oropharyngeal procedures do not (New to 2011)
• History of airway instability, tracheal surgery, or tracheal stenosis (presumed higher risk of airway complications)April 2011 2011 Talk Trauma
19
Contraindications: Relative• Active pulmonary infection or
disease, including upper respiratory infection or asthma (higher risk of laryngospasm)
• Known or suspected cardiovascular disease, including angina, heart failure, or hypertension (exacerbation caused by sympathomimetic properties of ketamine)April 2011 2011 Talk Trauma
20
Contraindications: Relative• Avoid ketamine in patients who are
already hypertensive • Central nervous system masses,
abnormalities, or hydrocephalus (increased intracranial pressure with ketamine)
• Head Injury removed as Relative Contraindication 2011
April 2011 2011 Talk Trauma
21
Contraindications: Relative• Glaucoma or acute globe injury
(increased intraocular pressure with ketamine)
• Porphyria, thyroid disorder, or thyroid medication (enhanced sympathomimetic effect)
April 2011 2011 Talk Trauma
22
Other Highlights• Route of Administration– Emphasis on IV over IM route when
feasible• Coadministered Medications– Routine prophylactic anticholinergics no
longer recommended– Routine prophylactic benzodiazepines
may benefit adults but not children– Prophylactic ondansetron can slightly
reduce vomitingApril 2011 2011 Talk Trauma
23
Emergency Physician- Administered Propofol Sedation: A Report of 25,433 Sedations from the Pediatric Sedation Research ConsortiumMichael D. Mallory, Amy L. Baxter, Daniel J. Yanosky, Joseph P. Cravero and Pediatric Sedation Research Consortium
Annals of Emergency Medicine Volume 57(5): 462-468
April 2011 2011 Talk Trauma
24
Propofol: Pediatrics• More serious adverse events
occurred in 581 sedations (2.28%; 95% confidence interval 2.1% to 2.5%).
• There were 2 instances of aspiration, 1 unplanned intubation, and 1 cardiac arrest.
April 2011 2011 Talk Trauma
25
Propofol: Pediatrics• Significant predictors of serious
adverse events were:– weight less than or equal to 5 kg– American Society of Anesthesiologists
classification greater than 2– Adjunctive medications (benzodiazepines,
ketamine, opioids, or anticholinergics)– Nonpainful procedures, and primary diagnoses
of upper respiratory illness or prematurity
April 2011 2011 Talk Trauma
26
Back To Case:• Important Points:– Procedural Sedation is Safe and
Effective when used properly, with mechanisms in place to ensure proper training, monitoring and continual quality improvement
– If/When/What are best answered when considering individuals patients indications, contraindications, urgency and potential risks of proceeding vs. not proceedingApril 2011 2011 Talk Trauma
![procedural sedation 2009.ppt [Read-Only] · PDF fileProcedural Sedation Emergency Principles Brian Levine, MD ... Ketamine • “the safest ... procedural sedation 2009.ppt](https://img.pdfslide.net/doc/110x75/5abe33597f8b9ad8278cdc83/procedural-sedation-2009ppt-read-only-sedation-emergency-principles-brian-levine.jpg)
