Pediatric Sedation
Desi Reddy (MB ChB, FFA, FRCPC)
Department of Anesthesia
McMaster University
1
STRUCTURE
Definition
Pre-procedure Preparation
Monitoring and Equipment
Medications
Recovery and Discharge
3
DEFINITIONS
Sedation Goals
anxiolysis
analgesia
amnesia
safety
control behavior
return to baseline
5
Continuum
minimally impaired consciousness to
complete unconsciousness
6
“conscious sedation”
is an oxymoron
8
New Sedation Terminology
Minimal
Moderate
Deep
General anesthesia
9
Minimal Sedation
Response
normal response to
verbal stimulation
Airway
Unaffected
Ventilation
Unaffected
CV function
Unaffected
Moderate Sedation
Response
Purposeful response
to verbal or tactile
stimulation
Airway
Intervention maybe
required
Ventilation
Adequate
CV function
Usually maintained
Deep Sedation
Response
Purposeful response
following repeated or
painful stimulation
Airway
Intervention is
required
Ventilation
May require support
CV function
Usually maintained
General Anesthesia
Response
Unarousable even to painful
stimuli
Airway
intervention required
Ventilation
frequently inadequate
CV Function
maybe impaired
Implications
Assume and prepare for Deep Sedation
The level of vigilance = Maximal
Appropriate monitoring equipment and
personnel
15
SEDATION MORBIDITY AND
MORTALITY
mortality is very rare
morbidity is not uncommon
Cote reviewed 95 adverse events
•
51 deaths and 9 permanent neurological injuries
17
Causes
drug interaction
overdose
inadequate monitoring
inadequate CPR
inadequate work-up
premature discharge
inadequate personnel
44
34
27
19
18
11
10
18
Drug Category
opioid
benzodiazepine
barbiturate
sedative
chloral hydrate
ketamine
22
18
19
21
13
1
19
Route of Administration
Intravenous
 oral
rectal
nasal
intramuscular
inhalation
60
37
9
4
31
13
20
Presenting Event
event
n
respiratory
80
cardiac
8
other
7
total
95
21
Outcome vs Monitoring
Outcome
Oximeter
(n=21)
None
(n=18)
Death/Injury
4
*14
No harm
17
4
* P < 0.001 compared with pulse oximetry
Pediatrics 105:805-814, 2000
Causes of catastrophes
Poor patient selection
Drug overdose
Lack of appreciation of drug
interactions, pharmacokinetics and
dynamics
Use of multiple medications to
sedate patient
Lack of monitoring before, during,
or after procedure
Inadequate CPR skills ’ failure to
rescue’



Conclusions
Most complications avoidable
Monitoring makes a difference
Adverse events involved multiple
drugs
Children 1 to 6 years are at
greatest risk
Need appropriate personnel skilled
in airway management and
resuscitation


Pulse Oximetry is
Essential
26
Factors Relating to Procedure
duration
pain
positioning
anxiety/stress of procedure
availability of rescue resources
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Factors relating to Patient
Past experience
Allergies
Adverse reactions
Aspiration risk
URTI
ASA classification
Fasting Guidelines
28
Fasting Guidelines
Ingested material
Clear liquids-H20,fruit
Fasting period (hours)
juices,clear tea,black
coffee
2
Breast milk
4
Infant formula
6
Nonhuman milk
6
Light meal
6
General Health
ASA 1
normal, healthy patient
ASA 2
controlled medical condition without
significant systemic effects
hypertension, DM, anemia, mild obesity

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ASA Classification
ASA 3
medical condition with significant effects and
significant functional compromise
Controlled CHF, stable angina, morbid
obesity, chronic renal failure

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ASA Classification
ASA 4
poorly controlled medical condition, with
significant dysfunction and a potential threat
to life
unstable angina, symptomatic COPD, CHF

32
ASA Classification
ASA 5
critical medical condition associated with
little chance of survival
multi-organ failure, sepsis syndrome

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34
Provider Factors
dedicated sedation monitor
skills related to depth of sedation
back-up systems and ability to Rescue
35
Equipment
SOAP ME
•
•
•
Suction
Oxygen
Airway
 Pharmacy
 Monitoring
 Equipment
36
37
Medications
38
Pharmacodynamics
2 general groups
sedation
analgesics
39
Pharmacokinetics
route
orally, intravenously, intramuscularly, intranasally, rectally
intravenous
titrate to effect
combination of medications
40
Pharmacokinetics
dose stacking
repeated administration before peak effect of
previous dose reached.
synergism
combination of drugs increase risk of serious
side effect, e.g.. benzodiazepine and opiate
41
Drugs
sucrose pacifier
reduced crying in neonates following heel
prick
should be used more frequently in infants
undergoing brief painful procedures

42
Drugs
Oral Chloral Hydrate
used for painless procedures in kids for
years
20 -75 mg/kg orally
bitter taste, not tolerated very well
peak effect up to 60 minutes with a half life
of 4 - 9 hours



43
Chloral Hydrate
prolonged sedation
need prolonged supervision prior to
discharge
advantage is lack of respiratory
depression
44
Oral Midazolam
short acting, water soluble
benzodiazepine
no analgesic properties
popular because of short duration,
predictable onset, and lack of
metabolites
get skeletal muscle relaxation,
amnesia and anxiolysis
dose: 0.5 - 0.75 mg/kg


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46
Oral Midazolam
Recommended use:
sole agent for children who will drink liquid
medication.
anxiolysis and cooperation are excellent
administer local anesthetic for painful
procedures


47
Midazolam
rectal midazolam
0.3 - 0.7 mg/kg
effect within 15 minutes
nasal midazolam
0.2 - 0.4 mg/kg
onset 10 -15 minutes, burning
sensation to mucosa
49
Intravenous Midazolam
dose: 0.05-0.1 mg/kg every 3-5
minutes up to a max. of 0.7 mg/kg
peak effect in 2-3 minutes
synergistic reaction with opiates.
Limit dose to 0.05 mg/kg. Severe
respiratory depression.
anterograde and retrograde (at
times) amnesia



50
Intravenous Midazolam
Recommended Use:
excellent agent for sedation and anxiolysis
provides complementary sedation with
opiates for painful procedures
caution with combination

51
Propofol
potent sedative and hypnotic
onset it very rapid. 60 - 90 seconds
induction of anesthesia at doses =
2-3 mg/kg
recovery rapid = 2-3 minutes
redistribution
prolonged sedation and vomiting is
very low
disadvantage is pain on injection
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

53
Propofol
Recommended use:
ideal agent for brief periods of deep
sedation
minimal adverse effects and rapid
awakening are unique
get rapid induction of anesthesia and
hence should only be used by
anesthesia personnel or intensivists


54
Fentanyl
potent synthetic opioid (100 x Morphine)
peak effect= 5 min and lasts for 30 - 40
min.
respiratory depressant effect is much
longer (4 hrs) than analgesic effect
Dose: 0.5 - 1.0 mcg/kg up to 5 mcg/kg


55
Fentanyl
minimal hemodynamic effects
reversible with Naloxone
Recommended use:
excellent analgesia and mild sedation with
short duration of action. Careful respiratory
monitoring when combined with other
sedatives
56
Ketamine
produces intense analgesia, sedation
and amnestic qualities
Oral dose: 5-6 mg/kg
IV dose :1 - 2 mg/kg
IM dose: 2 - 5 mg /kg



58
Ketamine
less pronounced respiratory depression
airway protective reflexes usually intact
side effects
excessive salivation and airway secretions
emergence dysphoria
59
Oxygen Delivery
nasal cannula
provides up to 44% oxygen
inspired oxygen depends on flow rate
each liter of flow-increases FiO2 by 4%
usual settings= 1-4 l
61
Oxygen Delivery
simple face masks
provides up to 60% oxygen
flow rate set between 6-10 l
liter flow must be > 6 l to prevent CO2
accumulation
non rebreather mask - provide 60-90%
oxygen at flows of 10-12 l\min
62