Procedural sedation (peds): Difference between revisions
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== | {{Peds top}} [[Procedural sedation]].'' | ||
[[ | ==Sedation levels== | ||
{{Sedation levels}} | |||
==Procedural Checklist<ref>http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf</ref>== | |||
*Consent in chart | |||
*PIV with fluids running | |||
*ETCO2 and NC connected to patient | |||
*Airway preparation | |||
**Suction with Yankauer attached | |||
**BVM attached to wall oxygen | |||
**Oral/nasal airways | |||
**Mac/Miller blades | |||
**ET tubes with stylets | |||
*Meds at bedside | |||
**Sedation Meds | |||
**[[Narcan]] 0.4mg if opioid being used, not drawn up | |||
**[[Epinephrine]], cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle | |||
**[[Glycopyrrolate]], 1 vial; not drawn up | |||
*Strongly consider child life | |||
==Fasting== | |||
*No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) <ref name="ACEP">ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department [http://www.acep.org/workarea/DownloadAsset.aspx?id=93816 full text]</ref> | |||
*Some specialty societies recommend: | |||
**2-hour fasting time for clear liquids | |||
**4-hour fasting time for breast milk | |||
**6-hour fasting time for solids | |||
==Airway Monitoring== | |||
*Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). <ref name="ACEP"></ref> | |||
*Placing the patient on ETCO2 + SpO2 is ideal<ref>Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.</ref> | |||
*Position the patient in a position you would intubate if needed (ear at level of sternal notch) | |||
*Consider nasal airway in patients with likely OSA | |||
==Sedation Medications== | |||
===Oral Sedation=== | |||
*Consider if only sedation without analgesia required | |||
*[[Midazolam]] 0.5-1mg/kg PO 10-20min prior to procedure | |||
*[[Chloral hydrate]] 50-75mg/kg PO 30min prior to procedure | |||
**May give additional 25-50mg/kg PO x 1 after 30min if needed | |||
#**[[Midazolam]] 0.5-1 mg/kg, Max 20mg (10-20 min before procddure) | |||
#**[[Chloral hydrate]] 50-70mg/kg PO 30 min prior to procedure, then repeat 25-50 mg/kg x 1 in 30 min if needed (max 1g/day infants; 2g/day older children) | |||
===Intranasal sedation=== | |||
*Give 1mL at a time alternating nare. Contraindicated if significant URI | |||
*[[Midazolam]] 0.2mg/kg IN | |||
*[[Fentanyl]] 2mcg/kg IN | |||
===Parenteral sedation agents=== | |||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Agent''' | |||
| align="center" style="background:#f0f0f0;"|'''Initial Dose''' | |||
| align="center" style="background:#f0f0f0;"|'''Repeat Dose''' | |||
| align="center" style="background:#f0f0f0;"|'''Max Dose''' | |||
| align="center" style="background:#f0f0f0;"|'''Onset''' | |||
| align="center" style="background:#f0f0f0;"|'''Duration''' | |||
| align="center" style="background:#f0f0f0;"|'''Contraindicaitons/Cautions''' | |||
| align="center" style="background:#f0f0f0;"|'''Notes''' | |||
|- | |||
| [[Ketamine]] (IV)||1 mg/kg||2-4 mg/kg||50-100 mg/dose||1 min||5-10 min||Excessive secretions; airway manipulation; concern for emergenc reaction|| | |||
|- | |||
| [[Ketamine]] (IM)||||||4mg/kg per dose||3-4 min||30 min||Excessive secretions; airway manipulation; concern for emergenc reaction|| | |||
|- | |||
| [[Midazolam]] (IV)||0.1 mg/kg||50% of original dose||2mg/dose; 3-4 doses max||||||Liver disease; kidney disease||Consider in | |||
|- | |||
| [[Fentanyl]] (IV)||1 mcg/kg||q3-5 min||||||||||May be reveresed with naloxone | |||
|- | |||
| [[Etomidate]]||0.15 mg/kg||||10 mg||30-60 sec||2-3 min||Apnea|| | |||
|- | |||
| [[Propofol]]||0.5-1 mg/kg||same at 3-5 min intervals||||30 sec||3-10 min|||| | |||
|- | |||
| [[Pentobarbital]]||1mg/kg||||||1 min||15 min||Hypovolemic shock, CHF, hepatic|| | |||
|} | |||
==Example Protocol<ref>Cincinnati Children's Hospital "The Pocket" 2010-2011</ref>== | |||
#Establish NPO status for at least 4 hours (non-emergent) | |||
#Obtain informed consent | |||
#AMPLE history | |||
#Prepare | |||
#*Estblish IV access, if necessary | |||
#*Apply topical anesthetics (e.g. EMLA); allow >30 min for onset | |||
#*Strongly consider Child Life consult, if available | |||
#*If only sedation without analgesia is required, consider oral sedation (see above) | |||
#*Intranasal dosing (can give 1mL per nostril at a time; contraindicated if signifiant URI) | |||
#**[[Midazolam]] 0.2/kg, max 10mg (10-20 min prior to procedure) | |||
#**[[Fentanyl]] 2mcg/kg, max 100mcg | |||
#Gather appropriate equipment and supplies | |||
#*BVM, airway equipment | |||
#*Suction | |||
#*[[Naloxone]] for rescue, if appropriate | |||
#Apply HR monitor, pulse-ox, BP cuff (on opposite side from pulse-ox); perform time out | |||
#Parenteral sedation agents (see above) | |||
#Perform procedure | |||
#Monitor for at least 30 min following last dose of IV medication | |||
==Side Effects== | |||
*Desaturation | |||
**Stimulate | |||
***Try pressure behind ear | |||
**[[Jaw thrust]] | |||
**Nasal airway | |||
**[[BVM]] | |||
**NIV | |||
**[[LMA]] | |||
**[[Intubation]] | |||
==Disposition== | |||
*Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs <ref> Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91 </ref> | |||
*Not necessary to tolerate oral challenge <ref> Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627 </ref> | |||
==See Also== | ==See Also== | ||
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[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:Procedures]] | |||
[[Category:Critical Care]] |
Latest revision as of 22:10, 29 March 2022
This page is for pediatric patients. For adult patients, see: Procedural sedation.
Sedation levels
Sedation levels
Level | Definition | Comments |
Minimal Sedation | Standard pain medications | |
Moderate Sedation | Awake and able to respond to questions | use in: LP, I+D |
Dissociative Sedation | Trance-like state, airway reflexes preserved | |
Deep Sedation | React purposefully to painful stimuli | use in: Reduction |
General Anesthesia | Unarousable, requires intubation/advanced airway |
Procedural Checklist[1]
- Consent in chart
- PIV with fluids running
- ETCO2 and NC connected to patient
- Airway preparation
- Suction with Yankauer attached
- BVM attached to wall oxygen
- Oral/nasal airways
- Mac/Miller blades
- ET tubes with stylets
- Meds at bedside
- Sedation Meds
- Narcan 0.4mg if opioid being used, not drawn up
- Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
- Glycopyrrolate, 1 vial; not drawn up
- Strongly consider child life
Fasting
- No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) [2]
- Some specialty societies recommend:
- 2-hour fasting time for clear liquids
- 4-hour fasting time for breast milk
- 6-hour fasting time for solids
Airway Monitoring
- Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). [2]
- Placing the patient on ETCO2 + SpO2 is ideal[3]
- Position the patient in a position you would intubate if needed (ear at level of sternal notch)
- Consider nasal airway in patients with likely OSA
Sedation Medications
Oral Sedation
- Consider if only sedation without analgesia required
- Midazolam 0.5-1mg/kg PO 10-20min prior to procedure
- Chloral hydrate 50-75mg/kg PO 30min prior to procedure
- May give additional 25-50mg/kg PO x 1 after 30min if needed
- Midazolam 0.5-1 mg/kg, Max 20mg (10-20 min before procddure)
- Chloral hydrate 50-70mg/kg PO 30 min prior to procedure, then repeat 25-50 mg/kg x 1 in 30 min if needed (max 1g/day infants; 2g/day older children)
Intranasal sedation
- Give 1mL at a time alternating nare. Contraindicated if significant URI
- Midazolam 0.2mg/kg IN
- Fentanyl 2mcg/kg IN
Parenteral sedation agents
Agent | Initial Dose | Repeat Dose | Max Dose | Onset | Duration | Contraindicaitons/Cautions | Notes |
Ketamine (IV) | 1 mg/kg | 2-4 mg/kg | 50-100 mg/dose | 1 min | 5-10 min | Excessive secretions; airway manipulation; concern for emergenc reaction | |
Ketamine (IM) | 4mg/kg per dose | 3-4 min | 30 min | Excessive secretions; airway manipulation; concern for emergenc reaction | |||
Midazolam (IV) | 0.1 mg/kg | 50% of original dose | 2mg/dose; 3-4 doses max | Liver disease; kidney disease | Consider in | ||
Fentanyl (IV) | 1 mcg/kg | q3-5 min | May be reveresed with naloxone | ||||
Etomidate | 0.15 mg/kg | 10 mg | 30-60 sec | 2-3 min | Apnea | ||
Propofol | 0.5-1 mg/kg | same at 3-5 min intervals | 30 sec | 3-10 min | |||
Pentobarbital | 1mg/kg | 1 min | 15 min | Hypovolemic shock, CHF, hepatic |
Example Protocol[4]
- Establish NPO status for at least 4 hours (non-emergent)
- Obtain informed consent
- AMPLE history
- Prepare
- Estblish IV access, if necessary
- Apply topical anesthetics (e.g. EMLA); allow >30 min for onset
- Strongly consider Child Life consult, if available
- If only sedation without analgesia is required, consider oral sedation (see above)
- Intranasal dosing (can give 1mL per nostril at a time; contraindicated if signifiant URI)
- Gather appropriate equipment and supplies
- BVM, airway equipment
- Suction
- Naloxone for rescue, if appropriate
- Apply HR monitor, pulse-ox, BP cuff (on opposite side from pulse-ox); perform time out
- Parenteral sedation agents (see above)
- Perform procedure
- Monitor for at least 30 min following last dose of IV medication
Side Effects
- Desaturation
- Stimulate
- Try pressure behind ear
- Jaw thrust
- Nasal airway
- BVM
- NIV
- LMA
- Intubation
- Stimulate
Disposition
- Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs [5]
- Not necessary to tolerate oral challenge [6]
See Also
References
- ↑ http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
- ↑ 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
- ↑ Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
- ↑ Cincinnati Children's Hospital "The Pocket" 2010-2011
- ↑ Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91
- ↑ Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627