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Pediatric Sedation Newsletter – September/October 2001

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Pediatric Sedation Newsletter – September/October 2001

  1. 1. Pediatric Sedation Newsletter – September/October 2001 Departments of Anesthesiology and Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH Editors: Joseph Cravero MD (joseph.cravero@hitchcock.org), George Blike MD george.blike@hitchcock.org Website = http://an.hitchcock.org/PediSedation/ Circulation 3009 Hope everyone had a great Halloween!!! Pediatric Sedation issues continue to be featured in a number of journals during the past several months. We will highlight just a few in this issue and continue literature reviews in the next month. Rather than printing a formal editorial we would like to point you toward an interesting exchange of “invited commentaries” that was printed in the Journal of Pediatrics several months ago. The commentaries are printed consecutively in Volume 139, No 1, 2001 pp 15-19. We will summarize the content of these commentaries but we strongly recommend readers peruse these commentaries in total as they are quite informative and provide insight into the differences and similarities in the way in which the American Academy of Pediatric Dentistry (AAPD) and AAP/ASA have approached pediatric sedation issues. The first commentary was written by Charles Coté MD and was entitled “Conscious Sedation”: Time for this oxymoron to go away! The article begins by outlining the history of the development of the AAP sedation guidelines and the initial use of the phrase “conscious sedation” (as opposed to deep sedation and general anesthesia) in the 1983 version of the sedation guidelines. The 1992 version of these guidelines is discussed especially with respect to the 11 key recommendations that came out of this publication: 1) medical history 2) careful airway examination 3) informed consent 4) fasting guidelines 5) age and size appropriate equipment 6) calculation of drug doses on a per kilo basis 7) time based record keeping 8) separate observer 9) a recovery facility 10) emergency back-up systems 11) strict discharge criteria. Dr. Coté then goes on to describe the new terminology for sedation currently promoted by the JCAHO. Four levels of sedation are described: 1) minimal sedation (anxiolysis) 2) Moderate sedation/analgesia 3) deep sedation (patients may require airway intervention) 4) general anesthesia. He highlights the JCAHO mandate that sedation providers should be able to rescue patients from a level of sedation one stage deeper than that which they are attempting to achieve. This is followed by a discussion of sedation critical incident data he reported in Pediatrics last year. Of particular note is the fact that his analysis indicated that great risk was associated with the administration of sedation in environments where rescue capability and monitoring is not robust – for instance, tragic events related to administration of sedation at home are highlighted.
  2. 2. The fact that a disproportionate number of sedation accidents also occurred in the dental offices is also mentioned along with the fact that the current guidelines from the AAPD have a very different description of sedation levels - including three different levels of “conscious sedation” alone – inconsistent with the guidelines currently put forth be the AAP, and ASA, and JCAHO. AAPD guidelines are described as sufficiently vague as to allow sedation to be given at home and negate the need for an independent observer even at the deepest levels of conscious sedation. Dr Coté also takes particular care to point out the fact that many states do not provide dental insurance – a fact that adds to the problem of trying to provide professional sedation care in many instances. In conclusion Dr. Coté outlines the improvements in operative morbidity and mortality rates that accompanied the development of anesthesia practice guidelines years ago. He suggests that pediatric sedation would benefit if similar guidelines were developed and widely adopted across specialties. Finally he advocates abandoning the use of the term “conscious sedation” and proposes a meeting of the AAP and AAPD committees on sedation in order develop consensus concerning the development of terminology and guidelines for pediatric sedation. The twin commentary was written by Steven Wilson DMD – who has written widely on sedation issues in dentistry. Dr. Wilson begins by pointing out that the AAPD guidelines are actually very similar in terms of general categorization to the AAP and JCAHO guidelines. He also reminds us that the JCAHO does not regulate dental offices, dental boards do. There is a brief discussion of the different levels of the differences in the levels of conscious sedation as outlined by the AAPD. In essence Dr. Wilson feels that although the terminology is different, the requirement for monitoring is still present and the standard of care is not compromised. He goes on to point out that the dental guidelines do not allow agents like chloral hydrate to be given outside the dental facility but only minor tranquilizers should be given at home (such as valium or hydroxyzine). Dr. Wilson goes on to clarify some of the issues concerning dental offices and the critical incident data cited by Dr. Coté. He points out that the data used in the retrospective analysis was collected over a number of years – including almost twenty years before there were any shared sedation guidelines from the AAP or the AAPD. He also points out that the critical incident reports also lack information about the types of dental practitioners involved in each incident and the compliance with sedation guidelines in each case. He goes on to point out that there is not a single case report of a dental pediatric sedation death that occurred when appropriate AAPD guidelines were being followed. Dr. Wilson agrees with Dr. Coté that the lack of universal dental insurance has contributed to the problem of providing high quality pediatric dental sedation. He enumerates various problems caused by the current lack of dental insurance. Among other difficulties, he points out lack of access to pediatric OR time for procedures with waiting times as much as 7 to 9 months. He concludes by agreeing with Coté that “conscious sedation” should be removed from the lexicon of pediatric sedation and that future emphasis should be placed on appropriate monitoring and responsiveness to patient needs.
  3. 3. Please read these commentaries if you have not already seen them and send us any response. Ketamine Survey: In the Summer Newsletter we asked for readers to send in their current protocols for the use of ketamine by non-anesthesia providers. We received about 25 responses and I will try to summarize the responses below. In the past several months we have been receiving numerous requests to clarify the issue of the “appropriate” use of ketamine by non- anesthesia providers. While I do not think there has evolved a general consensus on what is safe and effective, we can provide our readers with a glimpse of what other institutions in the USA and around the world are doing about this at this time. The responses contained a general trend toward having the drug restricted to certain locations and for certain providers. A typical report from Denver Children’s Hospital stated that ketamine use outside the OR and ICU was restricted to the ED. A strict protocol is in place with requirements for monitoring and personnel. This institution also reported two recent studies of the drug as used in the ED - including one by an orthopedic resident looking at long-term behavioral/emotional side effects of this type of sedation!! We find this particularly interesting since most of the interest in the ketamine sedation at our medical center was initiated by orthopedic residents looking for better sedation for fracture reduction and (?) avoidance of the long wait for an OR. From California we received a report of an institution which has instituted a hospital wide policy which categorizes ketamine sedation separately from the other JCAHO sedation levels as “dissociative sedation”. Emergency physicians and intensivists have automatic privileges although if individuals in these specialties transfer into the institution who have little experience with the drug they receive specific training and proctoring (no detail provided) by their department. Other specialists can apply for ketamine privileges and must demonstrate their knowledge of the drug and proficiency with airway management. Several responses were sent from Boston Children’s Hospital. There each department decides on which agents are appropriate for their needs and sends to the hospital sedation committee the names of the physicians in the department that they want credentialed to perform sedation with the medications they desire. The sedation committee then decides if the request is appropriate and then proceeds with credentialing providers and follows up on any adverse events. To date the emergency department, ICU, and interventional radiology are the only areas using ketamine with regularity. Interestingly, the anesthesiology and radiology departments from BCH (Keira Mason MD lead author) presented an abstract (Anesthesiology 2001;95:A1244) at the American Society of Anesthesiologists Annual Meeting describing the trial use of ketamine by highly trained nurses in the interventional radiology suite (with anesthesiology back-up) for painful procedures. – We will highlight that work in a future newsletter. One letter from Australia describes a protocol very much like the one in place at our own institution. There is a specific protocol for the use of ketamine which requires a complete
  4. 4. presedation assessment followed by sedation given by (and monitored by) a certified emergency physician (who is not performing the procedure). Recovery then takes place in the emergency department and is carefully followed until strict discharge criteria are met. All sedation providers in this setting went through a training program (no details given) which included criteria for failed sedation. To summarize, there was general agreement among the respondents that ketamine sedation is considered somehow different from other forms of “conscious” sedation. Use is restricted in almost all the institutions that responded – with the ICU and ED being the locations outside the OR where the drug is used (radiology in few locations). Respondents also clearly indicated that providers had to show some increased proficiency in sedation knowledge and airway skills in order to be credentialed to use ketamine. Finally almost all institutions had specific protocols for the use of the drug (mg/kg doses, recovery requirements etc.). Unfortunately we did not receive a lot of information on exactly what the “training” providers received to become credentialed to use ketamine – we assume it varies greatly from one location to another. We also did not ask for (or receive) much information on what the “back-up” or “rescue” services that were immediately available in each location. For our purposes, the idea of liberalizing the use of ketamine (such as with trained radiology nurses) seems only wise in institutions where immediate help is available or even prearranged. Literature Reviews Hain RDW, Campbell C. Invasive procedures carried out in conscious children: contrast between North American and European paediatric oncology centres. Archives of Disease in Childhood. Vol 85 (1), July 1,2001 pp12-14 Abstract Excerpted: The aim of this study was to define practice in managing repeated painful procedures in a select group of oncology centers in North America and Europe, especially the United Kingdom. The authors also sought to define and contrast concerns that shape policy making, and to contrast practice, particularly with regard to procedures performed on conscious patients. The study consisted of a postal survey involving 118 centers of the Pediatric Oncology Group and the United Kingdom Children's Cancer Study Group. Sixty eight questionnaires (58%) were returned (52 from North America, 12 from Europe). For all procedures, North American centers tended to use less effective techniques than European, especially for bone marrow procedures. North American centers reported performing these on conscious patients on at least three quarters (25%) or half (30%) the occasions. In contrast, corresponding figures for the European centers were 6% and 0%. The authors conclude that many bone marrow procedures are still carried out in the conscious patient despite the apparent safety and effectiveness of modern anesthetic and
  5. 5. deep sedation techniques. There appears to be a greater reluctance to offer these to patients in North American centers than in European ones. Several non-pharmacological techniques are used, but they remain uncommon. Commentary: This survey of a relatively small number of centers may or may not represent an accurate picture of the situation regarding sedation for procedures in the US and Europe. The relatively small number of responding centers from Europe is particularly notable. With this limitation in mind, this study at attempts to shed light on the variety of sedation practice which is unusual and worthy of note. The data presented indicate that North American oncology centers are less likely to use deep sedation and seem to prefer minimal sedation combined with local anesthesia or no sedation at all. They are however more likely to use non-pharmacological techniques to aid in decreasing the stress and anxiety associated with the procedures. The stated reasons for avoiding sedation include concerns about the effects of repeated sedations. Providers also voiced concerns about the dangers of respiratory depression with benzodiazepines or any combination of benzodiazepines and opiates – preventing their use. Many centers mentioned the lack of availability of anesthesia services in preventing access to improved sedation care. The authors correctly point out that while inadequate sedation for repeated painful procedures has clearly been associated with complications of emotional and psychological stress, evidence for adverse effects caused by repeated sedations with modern agents is lacking. Their conclusion that deep sedation is not offered to many oncology patients because of misconceptions about the effects of sedation is disturbing - if indeed accurate. Many patients and parents are fearful of cumulative effects of a series of anesthetics. We clinicians must correct this fallacy--THE RISKS ARE MINISCULE COMPARED TO THE BENEFITS. Their final statement that complementary methods for pain and stress control are underutilized is worthy of note (see below). 2. Harned RK 2nd, Strain JD. MRI-compatible audio/visual system: impact on pediatric sedation Pediatric Radiology. 31(4):247-50, 2001 Apr Abstract excerpted: The authors point out that there are new technologies available to assist with accomplishing procedures without sedation. The effect of a new audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI). MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated. The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to
  6. 6. 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies. The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost. Commentary: As always, we would prefer a randomized prospective study that compared similar aged patients in blocked groups. Having said this, the study offers reasonable numbers and an interesting intervention that has generally been underreported. At our own center we have found the use of DVD videos attached to 3-D goggles with 5 channel stereo to be a powerful tool for distraction of children during all sorts of procedures both painful and non-painful (lazy man’s hypnosis). The availability of high quality goggles for MRI use is a natural progression of this technique – we were not aware of their availability. A couple of points deserve mentioning: 1) certain age groups are more susceptible to this type of distraction than others – it is no surprise that success varied with age. 2) Preparation for the studies is not really addressed. Like many centers, we have found that extensive preparation and “modeling” of the MRI (in our case by child life specialists) has resulted in a significant increase in success of our non-sedated scans. We conclude that while there may not be anything earth shattering about this report, it reminds us all that there continue to be emerging entertainment technologies that can be extremely useful as sedation adjuncts or replacements. Fortunately we have found the charitable arm of our organization very interested in this type of acquisition. Close Call and Critical Incident Reports We invite those receiving the newsletter to submit cases to this "Close Calls" section aimed at the key safety issues associated with providing pediatric procedural sedation. The cases have been "sanitized" such that the date, patient identifiers, institutional identifiers, provider information, etc. will not violate the privacy of the patient or care providers. Case #8 A 4yo child with h/o abdominal pain needed an elective CT scan with contrast. Pediatric house staff in the hospital (a children’s hospital within the main hospital) sedated the child with IV midazolam. The child became agitated and the sedation provider supplemented the sedation with IV Fentanyl. The child was being monitored only with a pulse oximeter since the child pulled at the EKG cables and the child screamed when the team attempted to apply a BP cuff. Even the pulse ox was hard to keep on the child. As Fentanyl was given IV, the child became sedated. Pulse oximetry was then tolerated. SpO2 readings were in the low 90’s and the HR 110. Supplemental O2 was provided at 5L/min via facemask. During the CT scan the child acutely desaturated from 98% to 45% and resuscitation with bag mask ventilation was attempted. A code was called and the child responded to bag mask ventilation and IV Narcan, with improved oxygenation.
  7. 7. However, the child vomited and aspirated contrast agent. Ultimately the child recovered without injury and was rescheduled for sedation/anesthesia by the anesthesia service for the CT scan. Comments: This case is a good one for discussing event management. To prevent an event (in this case synergy between a benzodiazepine and an opium producing respiratory depression) from progressing to result in injury to a patient, the clinician needs to detect the event, diagnose the cause and initiate appropriate therapy (see graphic). 100% Probability of Injury 0% Start of time Event Detection Diagnosis Treatment The time course of an event must be considered when developing a strategy for detection, diagnosis, and intervention. Central apnea will progress to cause hypoxia and cardiovascular depression ultimately brain injury and/or death over the course of minutes. We are in the process of reviewing monitors of respiratory depression. The use of careful titration when combining benzodiazepines and opiods cannot be stressed enough as a method of avoiding respiratory depression. However, we will focus this Close Calls section on event management, rather than event prevention. Detection of apnea is our focus. Auscultation, pulse oximetry, and capnometry: Auscultation using a precordial stethoscope is an old method of monitoring respiration practiced by anesthesiologists. Often the device is a steel bell with an adhesive ring that connects the bell to the patient’s chest. Many clinicians place the stethoscope over the left main-stem bronchus or over the trachea in the supra-sternal notch. While many anesthesiologists will report that a “vigilante” anesthesiologist listening to respiratory sounds is a sensitive and specific monitor for apnea (both obstructive and central), studies suggest that clinicians can take minutes to notice apnea when distracted by other
  8. 8. activities. Since our brains are not truly capable of multi-tasking, we must consider auscultation and observation to be intermittent, rather than continuous monitors of respiration. Pulse oximetry, which measures blood oxygen saturation, with an alarm setting that triggers an audible alert at the onset of hypoxia is indeed a continuous monitor. However, this mode of monitoring is not without problems. Many sources of artifact exist (notably motion artifact, poor perfusion, peripheral vasoconstriction…) that limit the time that a signal is available. In addition, this signal (oxygen saturation) is an indirect measure of ventilation. Mature patients breathing room air will desaturate about one minute after an apnea event occurs, while patients breathing oxygen may take several minutes to desaturate. The detection time is about 1 to 5min after the beginning of an apneic event for older children. For this reason, we refer to it as a “lag” monitor for hypo-ventilation and/or apnea. Capnometry measures exhaled carbon dioxide. Most are continuous and display a waveform termed capnography. There are two methods of sampling CO2 - side-stream and in-line. Side-stream capnography works by continuously sampling a small amount of air from a nasal cannula or mask and sending that air through a small sample tubing to a monitor where the CO2 concentration is measured and displayed. In-line capnography has a sensor for CO2 actually in the breathing circuit or oxygen supply apparatus – with a hard wire to a read-out monitor. Multiple technologies exist for measuring a quantitative CO2 (infra-red, Raman spectroscopy, mass spectroscopy…). Many of the initial problems with this technology which included sample line blockage and humidity interference have been addressed by the newest technologies. In addition, cost and size have limited the setting in which this monitoring could be applied. In recent years several hand-held side-stream (and one in- line) capnometers have become available. The key advantage of capnography in sedation lies in the concept that CO2 monitoring will detect apnea within seconds of its onset. Airway adjustments or positive pressure ventilation can be provided immediately (as lack of expired CO2 is noted) – and before oxygen desaturation occurs. The American Society of Anesthesiology has made continuous monitoring of ventilation a “standard” of care. For practical purposes we believe that small, affordable, very portable, capnography represents the current best available ventilation monitor. Capnography should be thought of as a real-time continuous monitor of qualitative ventilation (i.e. is the patient breathing or not?). Depending on the method of oxygen delivery used and how exhaled CO2 is sampled, the quantitative information derived may or may not be absolutely accurate. For an excellent introduction and review of capnometry/capnography we recommend the web-site http://www.capnography.com/ We have found several papers on the use of capnography in pediatric sedation – as of yet there is no data on outcome improvement for sedation with this monitor but various aspects of the measurement and technical issues are discussed. However, one would
  9. 9. expect the benefits of this monitor in the anesthesia domain would translate to the sedation care setting. 1. Tobias JD. End-tidal carbon dioxide monitoring during sedation with a combination of midazolam and ketamine for children undergoing painful, invasive procedures. Pediatric Emergency Care. 15(3):173-5, 1999 Jun 2. McQuillen KK. Steele DW. Capnography during sedation/analgesia in the pediatric emergency department. [Journal Article] Pediatric Emergency Care. 16(6):401-4, 2000 Dec 3. Mason KP, Burrows PE, Dorsey MM, Zurakowski D, Krauss B. Accuracy of capnography with a 30 foot nasal cannula for monitoring respiratory rate and end-tidal CO2 in children. Journal of Clinical Monitoring and Computing 16:259-262,2000. 4. Colman Y, Krauss B. Microstream capnography technology: A new approach to an old problem. J Clin Monit 1999;15:403-409 We are in the process making capnometry/capnography and pulse oximetry monitoring standard for non-anesthesiology sedation providers at our institution. We are assessing multiple vendors of portable combination oximetery and capnometery devices. Oridion, Novametrix, Datex Ohmeda, Criticare and BCI technology is being evaluated (examples below). If anyone is aware of other vendors please let us know. Look for a thorough technical review in a future issue this newsletter. As always your thoughts and additions are welcome.