2/1/2013 Case 1: 2 year old complex facial laceration Pediatric Procedural Sedation Judith R. Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Department of Emergency Medicine Objectives: The ideal agent The ideal agent Perfect depth Immediate onset Risks and benefits Lasts only for length Monitoring/equipment of procedure Choosing an agent Safe Options Cases and pitfalls Benefits of procedural sedation Risks of procedural sedation Respiratory compromise Pain relief – Depression Immobility – Obstruction Amnesia – Aspiration Anxiolysis Hypotension/arrhyth Muscle relaxation mias Allergic reaction 1
2/1/2013 Procedural paraphernalia Choosing an agent: the procedure Preoxygenation Monitors – O 2 , HR, BP Painful? – End tidal CO 2 Immobility required? Airway equipment Duration? – O 2 , suction, BVM, NP/OP airway – <10-15 minutes – Intubation stuff? – Longer Pediatric crash cart Reversal/anaphylaxis agents Overview: types of agents Sedatives Sedatives Barbiturates – Pentobarbital Analgesics – Methohexital Dissociative Ultrashort: Inhalational – Etomidate Alternative – Propofol techniques – Dexmedetomidine Reversal agents (DXM) Benzodiazepines Analgesics Dissociative and Inhalational Topical: – EMLA /liposomal lido – LET Dissociative: Local: – Lidocaine – Ketamine – Bupivicaine Inhalational: Oral: – N 2 O – NSAID, APAP – Narcotics – Sucrose water IV: – Morphine – Fentanyl (IN) 2
2/1/2013 Reversal agents: keep them handy Alternatives: be good to your kids Cut the doctor talk Narcan: opiates Parental roles – Give any route – 0.1mg/kg up to 2 mg – Imagery Flumazenil: BDZ Music/audiobooks – 0.02mg/kg to 1 mg Comfort items Atipamezole: DXM Let them help – Not studied in Give them a choice kids Hypnosis Case 1: 2 year old complex facial Brutane? I think not….. laceration Patient: healthy, eye normal, airway normal Procedure: – Painful – Immobility key! – >15 minutes Just say Ketamine Ketamine contraindications Let’s talk ketamine… Trifecta: sedation, Increased ICP? analgesia, amnesia – 82 ketamine administrations Safe and effective in ICU with ICP monitor: ICP* Minimal cardiac/ Secretions? respiratory effects – Avoid if serious URI Airway reflexes preserved – 1090 kids: No evidence that premeds work # Minimum dissociative dose Psychiatric history – IV (1-1.5 mg/kg): lasts Under 3 months 15 min or – IM (3-4 mg/kg): lasts 45 to 60 min * Bar Joseph. J NSG Pediatr 2009 #Brown. Acad EM 2003 18 18 3
2/1/2013 Case 2: 8 year old distal radius More talk on ketamine fracture needs reduction Emergence reaction? – Versed doesn’t work – Quiet room better IV vs. IM? – IV “just in case”? – IV shorter recovery but... – IM more vomiting (>5 yrs)* Vomiting? : – Just say zofran (NNT 9-13) # 19 19 *Deasy, Ped Anesth 2010. #Langston, Annals EM 2008 Let’s talk propofol Oooowwwwieeeee! The patient: Sedative/no analgesia Pro : – Vomiting Rapid onset/offset – Anti-emetic The procedure IV: boluses (short) or – Short duration – Very painful bolus plus drip (longer) Con : – Some mobility OK Dosing: – A/B/C problems – Short (<15 min) – 1 mg/kg bolus – Sulfites (beware with asthma) The drug: – 0.5 mg/kg repeat bolus q – Egg/soy allergies 2-3 minutes or – Ketamine – Bolus hurts (use lidocaine) – 0.05-0.2 mg/kg/min drip – Propofol + fentanyl – Ketofol? Too much of a good thing Rescue preparedness Reposition 1 st dose IV push Suction no effect Oxygen 30 seconds later 2 nd BVM/NP airway dose IVP no effect Pitfalls: Then 2 doses – Avoid rapid med fentanyl administration RR 6, 94%, ET CO 2 – Avoid stacking meds sonorous breathing – Avoid alternating What now? opiate and propofol; give opiate pre procedure 4
2/1/2013 What about ketofol? More on ketofol... Groovy Let’s hang KETAMINE PROPOFOL 193 pt RCT: ketofol v out propofol* – Less propofol used emetogenic anti-emetic – More consistent sedation emergence rxn anxiolytic – Same rate of respiratory depression hypertension hypotension 136 pt RCT: ketofol v ketamine # preserves airway airway obstruction reflexes – Less vomiting – More MD satisfaction analgesic properties painful to inject *David, Annals EM 2011 #Shah, Annals EM 2011 Ketofol: 2 great tastes that taste Case 3: 12 month old febrile, great together?? irritable, dehydrated LP Dosing options: – Propofol 0.5 mg/kg + ketamine 0.5 mg/kg as boluses – Ketamine 0.5 first then propofol 0.5 boluses prn Ketamine an analgesic at these doses Is it really better? Did you have your Wheaties today? Let’s talk etomidate… The patient : Sedative – Dehydrated ( BP) Minimal cardiac – Neck flexed effects The procedure : Myoclonus – Painful common: up to – Reduced mobility 20%! – <15 minutes On/off: 1 min/10-15 The drug : min – Ketamine (ICP data) IV dose: 0.15 – Etomidate +/- mg/kg, titrate with fentanyl + EMLA/lidocaine 0.05 mg/kg q 1-2 minutes 5
2/1/2013 Should I use anything for an LP on a Mixed cocktails… neonate? Etomidate/fentanyl given Still moving around YES YES YES “ Not working ” add Sucrose water midazolam RR to 6 EMLA/lidocaine BVM/flumazenil Pitfall: – Avoid polypharmacy Case 4: 15 mo old fall/ You want him to stay still? vomiting head CT scan The patient : – Vomiting The procedure : – Painless – Immobility important – <15 minutes The location : – “Death begins in CT…” The drugs : – Ketamine – Propofol – Dexmedetomidine (DXM) – Rectal methohexital Why not versed? DXM: new kid on the block Alpha 2 agonist Large doses required – Rapid onset Up to 50% failure rate – Sedative and analgesic with imaging – Less resp depression but more arrhythmias Paradoxical agitation Dosing: – 1 mcg/kg IV bolus then 0.2-1 mcg/kg/hr – IM: 2-4 mcg/kg Autistic kids No real studies in ED Reversal agent available 35 35 6
2/1/2013 No IV? Let’s talk rectal Take home points methohexital... Rapid transmucosal Patient and procedure characteristics absorption Choose medications you know Minimal resp Monitor monitor monitor depression Dose: Sedate where you can rescue – 25 mg/kg Avoid polypharmacy and stacking – Use IV solution: tape the medications butt cheeks – Lasts 60-90 min Be patient Contraindication: Be kind to your patients seizure disorder 7
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