Paediatric Procedural Sedation
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Transcript of Paediatric Procedural Sedation
INDICATIONS
• CT or MRI• Fracture reduction• Complex laceration repair• Lumbar puncture• Abscess incision and drainage• Instrumentation (e.g. endoscopy and bronchoscopy)• Burns dressing change• Chest tube placement• Central line placement
CONTRAINDICATIONS
• NO ABSOLUTE CONTRAINDICATIONS
• SIGNS OF DIFFICULT AIRWAY• SIGNIFICANT MEDICAL COMORBIDITIES (ASA III OR HIGHER)
PREPARATION
• FASTING STATUS• FOCUSSED MEDICAL EXAMINATION• ASSESSSMENT OF AIRWAY• ASA CLASSIFICATION• PROCEDURAL SEDATION HISTORY• FAMILY ANAESTHETIC HISTORY• PRE PROCEDURE MEDICATIONS• HEIGHT• WEIGHT
MONITORING
• INITIAL AND REPEATED VITAL SIGNS MEASUREMENT• END TIDAL CO2 MONITORING• VISUAL OBSERVATION OF FACE, MOUTH AND CHEST WALL
NON PHARMACOLOGICAL INTERVENTIONS
• DESENSITIZATION• DISTRACTION TECHNIQUES• POSITIVE REINFORCEMENT• RELAXATION TECHNIQUES
PHARMACOLOGICAL
• KETAMINE• PROPOFOL• DEXMEDETOMIDINE• ETOMIDATE• MIDAZOLAM• BARBITURATES• NITROUS OXIDE• TOPICAL, LOCAL AND REGIONAL ANAESTHETICS
KETAMINE
• PCP derivative• Binds NMDA receptors• No “sedation continuum”• Initial IV dose 1-1.5mg/kg, repeat dose of 0.5-1mg/kg after 10 min
as needed• Initial IM dose of 4-5mg/kg, repeat dose of 2-4mg/kg after 10 min as
needed• Onset 1-2 minutes• Duration of action 15-30 minutes
KETAMINEADVERSE REACTIONS
• VOMITING• EMERGENCE REACTION (RECOVERY AGITATION, DREAMS, HALLUCI-
NATIONS AND DEPERSONALIZATION). Less common in children than in adults(7.6% vs 20%)
• LARYNGOSPASM AND APNEA (MORE COMMON WITH IM)
KETAMINECONTRA-INDICATIONS
RELATIVE• Age younger than 12 months• Active pulmonary infections• Non communicating hydrocephalus (not raised ICP)• Increases intra ocular pressure• Porphyria• Thyroid disease
ABSOLUTE• Age younger than 3 months• Known or suspected psychosis
PROPOFOL
• Provides sedation but NO analgesia• 0.5-3mg/kg induction dose, halve the induction dose for top up dos-
ing• Onset <_ 0.5 minutes• Duration 5-15 minutes after single bolus dose, longer after infusions
or repeat dose
PROPOFOLADVERSE REACTIONS
• Peripheral injection site pain• Respiratory depression• Apnea• Hypotension• Deep sedation
KETOFOL
• Mixture of Ketamine/Propofol in 1:1 ratio• Medial dose of 0.75mg/kg of each drug (range 0.2-2.0) shown to be
safe• Fentanyl can be used as adjunct analgesia
NITROUS OXIDE
• ENTONOX (50% N2O AND 50%O2) usually delivered by demand valve system
• Limits use in younger or uncooperative patients• Oxygen should be administered after 3-5 minutes to prevent diffu-
sion hypoxia• Minor adverse effects include nausea, vomiting and dysphoria• Contraindications include nausea, vomiting, trapped gas within
body cavities (e.g. bowel obstruction, pneumothorax, middle ear in-fection) and pregnancy (increases risk of spontaneous abortion)
LOCAL AND TOPICAL ANAES-THETIC AGENTS
• EMLA• 2.5% Lidocaine and 2.5% Prilocaine• Long onset to peak effect (atleast one hour)• Vasoconstrcition effects may make cannulation difficult• Theoretical risk of methemoglobinemia• Not recommended in infants less than 3 months of age
LOCAL AND TOPICAL ANAES-THETIC AGENTS
• AMETHOCAINE
• AnGel (4% Amethocaine)• Quicker onset of action (30-45 minutes)• Vasodilating effects facilitate cannulation
LOCAL AND TOPICAL ANAES-THETIC AGENTS
• LACERAINE
• Laceraine (Adrenaline 1:1000, Lidocaine 4%, Tetracaine 0.5%)• Instilled in wound for 20-30 minutes provides sufficient anaesthesia
ORAL SUCROSE
• Provides analgesia for young infants up to 2 months of age• Stimulates endogenous opioid and non opioid pathways in brain • 2ml may be administered by oral syringe or on a pacifier
DISCHARGE CRITERIA
• Normal age-specific vital signs• Regained presedation conscious state and communication skills• Able to tolerate oral foods or fluids• Post-procedure analgesia is satisfactory