1626 SECTION XIV Pediatric Critical Care Anesthesia Principles in the Pediatric Intensive Care Unit cardiopulmonary disease (such as unrepaired congenital heart disease) may not be suitable candidates[.]
1626 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit TABLE Modified Fasting Periods for Pediatric 135.2 Procedural Sedationa Food/Beverage Fasting Period (hours) Clear liquids (water, clear beverages, nonpulp fruit juice, tea/coffee without milk) Breast milk Infant formula/nonhuman milk Meal (light meal or a meal with fried or fatty foods) 6–8 a Recent studies suggest minimal to low risk of aspiration with shorter duration of fasting Fasting periods may be reduced under appropriate circumstances or per institutional policies cardiopulmonary disease (such as unrepaired congenital heart disease) may not be suitable candidates for outpatient procedural sedation and are best discussed with the anesthesiologist.13 Once a patient is deemed to be a candidate for natural airway sedation, instructions for nil per os (NPO; nothing by mouth) status should be given Most institutions follow the American Academy of Pediatrics (AAP) fasting guidelines for procedural sedation.6 Table 135.2 shows the modified NPO guidelines commonly used in this setting Recent evidence reporting minimal to no aspiration risk with a reduced fasting duration prior to procedural sedation will likely result in future changes in NPO guidelines.14–16 On the day of sedation, the pediatric intensivist must perform a focused medical history that, at a minimum, includes history of current illness, past medical history, current medications, allergies, adherence to fasting guidelines, and a family history of adverse reactions to anesthesia.17 An informed consent should be obtained from the parents or the legal guardian prior to procedural sedation The physical examination on the day of sedation must include vital signs and a focused evaluation of the airway anatomy, including Mallampati scoring (see Fig 127.5), cervical range of motion, and detailed cardiopulmonary assessment Before sedation is initiated, intensivists should have a systematic approach so as not to overlook vital equipment, monitors, and rescue drugs SOAP-ME is a commonly used acronym for presedation planning It stands for suction (including age-appropriate catheters and a suction apparatus), oxygen (ensuring a functioning delivery device), airway (including bag-valve-mask, oral and nasopharyngeal airways, LMA, endotracheal tubes, and laryngoscope blades), pharmacy (sedation drugs, emergency lifesupport drugs, and reversal agents), monitors (functional pulse oximetry, end-tidal monitoring, noninvasive blood pressure, telemetry, and a stethoscope), equipment (including a nearby defibrillator).6 The sedationist should also have a backup emergency plan in the event of a life-threatening complication Most sedation programs use a sedation rescue kit composed of flumazenil, naloxone, succinylcholine (for laryngospasm), and an anticholinergic agent (atropine or glycopyrrolate) Considerations in Choosing Commonly Used Medications Before making medication choices, one must clearly identify the specific goals of a particular procedural sedation The objectives of procedural sedation are to (1) maintain patient safety, (2) minimize pain (i.e., provide analgesia), (3) decrease anxiety and psychological trauma (i.e., provide anxiolysis/amnesia), (4) provide immobility if required (i.e., adjust sedation depth), and (5) return child to a baseline state for safe discharge (follow AAP or institutional guidelines for discharge).6 Key properties of sedative, analgesic, and hypnotic agents used in outpatient procedural sedation are rapid onset, short duration of action, and preservation of airway/respiratory reflexes at appropriate weight-based doses For this reason, most sedationists have embraced propofol, fentanyl, ketamine, and dexmedetomidine as pharmacologic agents of choice (Table 135.3) Recent studies from the Pediatric Sedation Research Consortium have demonstrated decreasing trends in the use of chloral hydrate and pentobarbital over the past 10 years, as agents with faster onset and recovery time are now available for use outside the operating room for nonanesthesiology providers Propofol is particularly valuable in children because of its predictable pharmacokinetics and favorable adverse effect profile Propofol provides amnesia, deep sedation, and immobility but no analgesia Fentanyl is an excellent analgesic but can cause apnea and, when rapidly administered, a rigid chest Naloxone is a fentanyl reversal agent that should be included in the emergency kit Ketamine has the advantage of maintaining an excellent hemodynamic profile while providing potent analgesia and amnesia.12 Dexmedetomidine induces an arousable sleep state By itself, it is not a good sedative for long or painful procedures but may be useful for short radiologic imaging.18–20 Recent studies have demonstrated the potentially advantageous role of dexmedetomidine as an adjuvant in procedural sedation The use of a dexmedetomidine infusion followed by a propofol infusion (without propofol bolus) resulted in fewer adverse airway events and interventions when compared with propofol alone during procedural sedation for MRI.21 Much consideration should be given to the choice of sedation agent For example, painless procedures, such as radiology imaging, may require propofol or dexmedetomidine Painful procedures, such as bone marrow aspiration/biopsy or renal biopsy (both of which require immobility), may require a combination of propofol and fentanyl or ketamine.22,23 Last, providers should be facile in the use of inhaled nitrous oxide or an intranasal sedative (midazolam or dexmedetomidine) for anxiolysis prior to intravenous catheter placement, Foley catheter insertion, and other distressing procedures.24 Topical anesthetics—such as lidocaine-prilocaine cream, lidocaine jelly, and anesthetic skin refrigerant—are useful adjuncts Midazolam may be a suitable alternative when nitrous oxide is contraindicated or not available Intranasal dexmedetomidine or midazolam have been used successfully for short imaging procedures without injection of contrast when a peripheral intravenous catheter is not necessary.25 Useful information on intranasal medications is available at www.intranasal.net Nonpharmacologic Approach to Outpatient Sedation The involvement of a child life specialist during procedural sedation is invaluable The specialist can help prepare the child for sedation and decrease anxiety through distraction, among other techniques Certain vulnerable pediatric populations—including children with special needs, autism, and developmental delay— greatly benefit from coping plans put in place by child life specialists CHAPTER 135 Procedural Sedation for the Pediatric Intensivist 1627 TABLE 135.3 Summary of Medications, Adjuncts, and Reversal Agents Commonly Used in Procedural Sedation Agent Route Dose Onset (min) Duration (min) Applications/Commentsa Propofol IV 1–2 mg/kg every 2–3 Infusion 125–300 mg/kg/min 2–3 10–15 Procedures requiring immobility Add analgesic for painful procedure Ketamine IV mg/kg initial 0.5 mg/kg subsequent 1–2 10–15 IM 4–6 mg/kg initial 2–4 mg/kg subsequent 10–15 30–40 Generally increases blood pressure and heart rate May increase secretions Provides short to medium duration sedation and analgesia for painful procedures Fentanyl IV 0.5–1 mg/kg initial 0.5 mg/kg subsequent 2–3 30–45 Analgesia with good hemodynamic profile Rapid intravenous administration can result in rigid chest Dexmedetomidine IV Induction 1–3 mg/kg Infusion 1–2 mg/ kg/h 0–15 30–45 Noninvasive procedures Does not blunt respiratory drive IN 2–4 mg/kg 30–45 45–60 IV 0.05–0.1 mg/kg (maximum mg/dose) 2–5 30–45 PO 0.5–0.7 mg/kg 15–20 Up to 60 IN 0.2–0.4 mg/kg 5–10 30–45 Inhaled 50%–70% 3–5 5–10 Short noninvasive or minimally invasive Naloxone IV 0.01–0.02 mg/kg 1–2 30–45 Opioid overdose Reverses sedation and respiratory depression Flumazenil IV 0.01–0.02 mg/kg 1–2 30–45 Benzodiazepine overdose Reverses sedation and paradoxical reaction to benzodiazepines IV 1–2 mg/kg Rapid 4–6 Risk of malignant hyperthermia IM 3–4 mg/kg 2–3 10–30 IV 0.02 mg/kg (minimum 0.1 mg/dose) Rapid 1–4 Sedatives Midazolam Nitrous oxide Anxiolysis prior to procedure Adjunct/premedication for deeper regimens Reversal Laryngospasm Succinylcholine Atropine Antimuscarinic Increases heart rate and decreases secretions a Applies to all routes unless otherwise specified IM, Intramuscular; IN, intranasal; IV, intravenous; PO, oral created in collaboration with families.26 Distraction by means of virtual reality goggles, tablet computers, and video games have been used across the entire age spectrum.27 Neonates can have short, nonpainful procedures performed using feeding and bundling, swaddling, or pneumatic papoose.28 Sedation Adverse Events Sedation adverse events can be classified as minor without intervention, minor with intervention, and major/serious Minor events that not require intervention may include crying during propofol administration or oxygen desaturation below baseline but greater than 90% on pulse oximetry Minor adverse events with intervention commonly include agitation, brief apnea, desaturation (oxygen saturation ,90% for 30 seconds), coughing, hypotension, and stridor Serious adverse events include airway obstruction (lack of air movement despite respiratory effort), laryngospasm (lack of air movement with respiratory effort not relieved by repositioning or airway adjuncts), need for emergency anesthesia consultation, unplanned hospital admission, cardiac arrest, or death Serious adverse events can cause irreversible neurologic injury and are best anticipated and acted on quickly.1,22 A large series of approximately 91,000 sedation encounters from the Pediatric Sedation Research Consortium reported a low overall serious adverse event rate of 2.5% when propofol was used by pediatric intensivists for procedural sedation.1 More recently, using trends data from 432,842 encounters, overall, the serious adverse events by all providers (including pediatric intensivists) was reported to be even lower, at 1.78% Recent studies have also highlighted the potential for neurotoxicity that sedation and anesthesia may pose in the developing brain of infants and children under years of age.29,30 Therefore, every effort should be made to minimize duration of sedation and exposure to multiple agents Key References American Society of Anesthesiologists Task Force on Sedation, Analgesia by Non-Anesthesiologists Practice guidelines for sedation and analgesia by non-anesthesiologists Anesthesiology 2002;96(4):1004-1017 1628 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit Green SM, Leroy PL, Roback MG, et al An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children Anaesthesia 2020;75(3):374-385 Kamat PP, Ayestaran FW, Gillespie SE, et al Deep procedural sedation by a sedationist team for outpatient pediatric renal biopsies Pediatr Transplant 2016;20(3):372-377 Kamat PP, McCracken CE, Simon HK, et al Trends in outpatient procedural sedation: 2007-2018 Pediatrics 2020;145(5):e20193559 Kudchadkar SR Pediatric intensivists and elective procedural sedation: paradox or perfect pair? Pediatr Crit Care Med 2015;16(1):77-78 Mason KP, Zurakowski D, Zgleszewski SE, et al High dose dexmedetomidine as the sole sedative for pediatric MRI Paediatr Anaesth 2008;18(5):403-411 Sulton C, Kamat P, Mallory M, Reynolds J The use of intranasal dexmedetomidine and midazolam for sedated magnetic resonance imaging in children: a report from the Pediatric Sedation Research Consortium Pediatr Emerg Care 2020;36(3):138-142 The full reference list for this chapter is available at ExpertConsult.com e1 References Kamat PP, McCracken CE, Gillespie SE, et al Pediatric critical care physician-administered procedural sedation using propofol: a report from the Pediatric Sedation Research Consortium Database Pediatr Crit Care Med 2015;16(1):11-20 Kamat PP, McCracken CE, Simon HK, et al Trends in outpatient procedural sedation: 2007-2018 Pediatrics 2020;145(5):e20193559 Kudchadkar SR Pediatric intensivists and elective procedural sedation: paradox or perfect pair? Pediatr Crit Care Med 2015;16(1):77-78 Kamat PP, Hollman GA, Simon HK, Fortenberry JD, McCracken CE, Stockwell JA Current state of institutional privileging profiles for pediatric procedural sedation providers Hosp Pediatr 2015;5(9):487-494 Cravero JP Pediatric sedation with propofol-continuing evolution of procedural sedation practice J Pediatr 2012;160(5):714-716 Cote CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures Pediatrics 2019;143(6): e20191000 Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J, Pediatric Sedation Research Consortium Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium Arch Pediatr Adolesc Med 2012; 166(11):990-998 Hooper MC, Kamat PP, Couloures KG Evaluating the need for pediatric procedural sedation training in pediatric critical care medicine fellowship Pediatr Crit Care Med 2019;20(3):259-261 Nadkarni V Our survey says pediatric procedural sedation training should not be a postscript! Pediatr Crit Care Med 2019;20(3):296-297 10 Hollman GA, Banks DM, Berkenbosch JW, et al Development, implementation, and initial participant feedback of a pediatric sedation provider course Teach Learn Med 2013;25(3):249-257 11 American Society of Anesthesiologists Task Force on Sedation, Analgesia by Non-Anesthesiologists Practice guidelines for sedation and analgesia by non-anesthesiologists Anesthesiology 2002;96(4):1004-1017 12 Berkenbosch JW Options and considerations for procedural sedation in pediatric imaging Paediatr Drugs 2015;17(5):385-399 13 Grunwell JR, Marupudi NK, Gupta RV, et al Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies Paediatr Anaesth 2016;26(6):628-636 14 Beach ML, Cohen DM, Gallagher SM, Cravero JP Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: a report of the Pediatric Sedation Research Consortium Anesthesiology 2016;124(1):80-88 15 Bhatt M, Johnson DW, Taljaard M, et al Association of preprocedural fasting with outcomes of emergency department sedation in children JAMA Pediatr 2018;172(7):678-685 16 Green SM, Leroy PL, Roback MG, et al An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children Anaesthesia 2020;75(3):374-385 17 Daud YN, Carlson DW Pediatric sedation Pediatr Clin North Am 2014;61(4):703-717 18 Mason KP, Robinson F, Fontaine P, Prescilla R Dexmedetomidine offers an option for safe and effective sedation for nuclear medicine imaging in children Radiology 2013;267(3):911-917 19 Mason KP, Zgleszewski SE, Dearden JL, et al Dexmedetomidine for pediatric sedation for computed tomography imaging studies Anesth Analg 2006;103(1):57-62, table of contents 20 Mason KP, Zurakowski D, Zgleszewski SE, et al High dose dexmedetomidine as the sole sedative for pediatric MRI Paediatr Anaesth 2008;18(5):403-411 21 Boriosi JP, Eickhoff JC, Klein KB, Hollman GA A retrospective comparison of propofol alone to propofol in combination with dexmedetomidine for pediatric 3T MRI sedation Paediatr Anaesth 2017;27(1):52-59 22 Kamat PP, Ayestaran FW, Gillespie SE, et al Deep procedural sedation by a sedationist team for outpatient pediatric renal biopsies Pediatr Transplant 2016;20(3):372-377 23 Patel KN, Simon HK, Stockwell CA, et al Pediatric procedural sedation by a dedicated nonanesthesiology pediatric sedation service using propofol Pediatr Emerg Care 2009;25(3):133-138 24 Tsze DS, Mallory MD, Cravero JP Practice patterns and adverse events of nitrous oxide sedation and analgesia: a report from the Pediatric Sedation Research Consortium J Pediatr 2016;169:260265.e262 25 Sulton C, Kamat P, Mallory M, Reynolds J The use of intranasal dexmedetomidine and midazolam for sedated magnetic resonance imaging in children: a report from the Pediatric Sedation Research Consortium Pediatr Emerg Care 2020;36(3):138-142 26 Kamat PP, Bryan LN, McCracken CE, Simon HK, Berkenbosch JW, Grunwell JR Procedural sedation in children with autism spectrum disorders: a survey of current practice patterns of the society for pediatric sedation members Paediatr Anaesth 2018;28(6):552-557 27 Salas M Using Technology for distraction during imaging in a pediatric population Clin J Oncol Nurs 2015;19(4):409-410 28 Parad RB Non-sedation of the neonate for radiologic procedures Pediatr Radiol 2018;48(4):524-530 29 Kamat PP, Sulton C, Kudchadkar SR, et al Procedural sedation outside the operating room and potential neurotoxicity: analysis of an at-risk pediatric population Acad Pediatr 2019;19(8):978-984 30 Kamat PP, Kudchadkar SR, Simon HK Sedative and anesthetic neurotoxicity in infants and young children: not just an operating room concern J Pediatr 2019;204:285-290 e2 Abstract: Pediatric intensivists are comprehensively trained in airway management techniques, experts in pediatric cardiorespiratory physiology, and independently responsible for routine airway management in the pediatric intensive care unit Therefore, it follows that the pediatric intensivist may also have a role in outpatient procedural sedation This chapter outlines the intensivist’s role in outpatient procedural sedation, the sedation team structure, types of procedures for which sedation is provided, medications, and adverse events encountered in procedural sedation It also discusses nuances of sedation prescreening since not every patient is a candidate for routine procedural sedation and some require referral to the anesthesiologist Key words: Procedural sedation, natural airway sedation, deep sedation, outpatient, sedation prescreening ... Sedation Research Consortium Pediatr Emerg Care 2020;36(3):138-142 The full reference list for this chapter is available at ExpertConsult.com e1 References Kamat PP, McCracken CE, Gillespie... it follows that the pediatric intensivist may also have a role in outpatient procedural sedation This chapter outlines the intensivist’s role in outpatient procedural sedation, the sedation team