Procedural sedation (peds): Difference between revisions
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**[[Epinephrine]], cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle | **[[Epinephrine]], cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle | ||
**[[Glycopyrrolate]], 1 vial; not drawn up | **[[Glycopyrrolate]], 1 vial; not drawn up | ||
*Strongly consider child life | |||
==Fasting== | ==Fasting== | ||
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*Position the patient in a position you would intubate if needed (ear at level of sternal notch) | *Position the patient in a position you would intubate if needed (ear at level of sternal notch) | ||
*Consider nasal airway in patients with likely OSA | *Consider nasal airway in patients with likely OSA | ||
==Sedation Medications== | |||
===Oral Sedation=== | |||
*Consider if only sedation without analgesia required | |||
*[[Midazolam]] 0.5-1mg/kg PO 10-20min prior to procedure | |||
*[[Chloral hydrate]] 50-75mg/kg PO 30min prior to procedure | |||
**May give additional 25-50mg/kg PO x 1 after 30min if needed | |||
===Intranasal sedation=== | |||
*Give 1mL at a time alternating nare. Contraindicated if significant URI | |||
*[[Midazolam]] 0.2mg/kg IN | |||
*[[Fentanyl]] 2mcg/kg IN | |||
==Cincinnati Children's Hospital Protocol== | ==Cincinnati Children's Hospital Protocol== | ||
Revision as of 22:40, 22 September 2019
Sedation levels
Sedation levels
| Level | Definition | Comments |
| Minimal Sedation | Standard pain medications | |
| Moderate Sedation | Awake and able to respond to questions | use in: LP, I+D |
| Dissociative Sedation | Trance-like state, airway reflexes preserved | |
| Deep Sedation | React purposefully to painful stimuli | use in: Reduction |
| General Anesthesia | Unarousable, requires intubation/advanced airway |
Procedural Checklist[1]
- Consent in chart
- PIV with fluids running
- ETCO2 and NC connected to patient
- Airway preparation
- Suction with Yankauer attached
- BVM attached to wall oxygen
- Oral/nasal airways
- Mac/Miller blades
- ET tubes with stylets
- Meds at bedside
- Sedation Meds
- Narcan 0.4mg if opioid being used, not drawn up
- Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
- Glycopyrrolate, 1 vial; not drawn up
- Strongly consider child life
Fasting
- No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) [2]
- Some specialty societies recommend:
- 2-hour fasting time for clear liquids
- 4-hour fasting time for breast milk
- 6-hour fasting time for solids
Airway Monitoring
- Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). [2]
- Placing the patient on ETCO2 + SpO2 is ideal[3]
- Position the patient in a position you would intubate if needed (ear at level of sternal notch)
- Consider nasal airway in patients with likely OSA
Sedation Medications
Oral Sedation
- Consider if only sedation without analgesia required
- Midazolam 0.5-1mg/kg PO 10-20min prior to procedure
- Chloral hydrate 50-75mg/kg PO 30min prior to procedure
- May give additional 25-50mg/kg PO x 1 after 30min if needed
Intranasal sedation
- Give 1mL at a time alternating nare. Contraindicated if significant URI
- Midazolam 0.2mg/kg IN
- Fentanyl 2mcg/kg IN
Cincinnati Children's Hospital Protocol
Side Effects
- Desaturation
- Stimulate
- Try pressure behind ear
- Jaw thrust
- Nasal airway
- BVM
- NIV
- LMA
- Intubation
- Stimulate
Disposition
- Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs [5]
- Not necessary to tolerate oral challenge [6]
See Also
References
- ↑ http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
- ↑ 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
- ↑ Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
- ↑ Cincinnati Children's Hospital "The Pocket" 2010-2011
- ↑ Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91
- ↑ Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627