pediatric procedural sedation is for young EM doctors and anesthetists and pediatricians. When painful procedures can be managed with minimal to no pain-- why not??? poorly managed pain- leads to PTSD in kids--- would we want that for our kids?

1. PEDIATRIC PROCEDURAL
SEDATION
Murtuza Ghiya
Specialty Registrar,
Emergency medicine,
Bedford Hospital, NHS trust

2. ANY PAINFUL EXPERIENCES?

3. • Children of all ages feel pain

4. Contents
1. Developmental attributes –age wise
2. Principles of sedation
3. Anxiolysis
4. Local anesthesia
5. Procedural sedation
6. Combinations
7. Post sedation monitoring

5. DEVELOPMENTAL ATTRIBUTES

6. Newborn & Infant
( 0 TO 9 MONTHS)
• Pain affects neuro-development
• No Abstraction
• Unable to conceptualize cause and effect,
outcome and benefit
• No concept of time- no anticipation-no
anxiety
• No stranger anxiety

7. Toddler
(AGES 10 TO 36 MONTHS)
• Stranger anxiety
• Lack of temporal abstraction
• Parental presence and even participation -laps
or arms
• Involve the toddler in decision making

8. School-aged
(AGES 4 TO 10 YEARS)
• Can conceptualize time (abstraction)
• "Magical thinking"
• Physical restraint may be challenging

9. Pre-adolescence & Adolescence
(AGES 11 TO 18 YEARS)
• Physical modesty is extreme.
• Cry or even fight.
• Physical restraint is difficult and inappropriate.

10. PRINCIPLES OF SEDATION

15. ANXIOLYSIS
Child- parent -child

16. Non pharmacologic Anxiolysis
• Parental presence---Toddlers/school aged
• Adolescents --- certain history/examination
without parents
• Distraction-(younger children)
picture books, stories , music.
• Distraction-(older children)
video distraction "virtual reality" glasses.

18. Pharmacologic anxiolysis
• Midazolam - relatively short duration of action
• For anxiolysis, - 0.5 milligram/kg PO
• Onset -20 min
• Flavoured oral suspension
(injectable form - mixed with flavored syrup/beverage)
• The IV - can also be given nasally at 0.2 mg/kg, local
nasal irritation.

19. • When IV access is already being used for other
reasons.
• 0.05 to 0.1 milligram/kg IV
• Adverse effects- (higher dose) respiratory
depression
• Self-limited. May consider antidote-
F*u*ma*****

20. LOCAL ANESTHESIA

21. Topical anesthetics
• Pain of IV catheterization/ wound preparation
• Eutectic mixture of prilocaine + lidocaine - cream
• Onset-30 min
• Absorption is minimal, non toxic- even when applied to
open wounds
• For maximum skin absorption, apply beneath occlusive
dressings such as Tegaderm

22. Injectable Local Anesthetics
• Lidocaine
• Slow injection with a small-gauge needle
• Sodium bicarbonate 1:4
• When practical, regional blocks better.

23. PROCEDURAL SEDATION

24. Oral sucrose 25%
• Newborns and infants
• Pacifier dipped into the solution just before
the procedure.
• Procedures such as LP ,IV line, or during IM
immunization injections.

25. Indications for procedural sedation
• Eg- ?

26. Pre Requisites
• Develop your own repertoire
• Keep crash cart ready.
• Written informed consent
( state the alternative option of no sedation!)
• Ideal setting-
1 physician - sedation and airway
+
1physician- performing the procedure

27. Where to draw the line?

28. • Category III or higher may not be candidates
for elective procedural sedation in the ED

31. The Pediatric Sedation Research
Consortium
• “no correlation between fasting status and the
incidence of aspiration or other untoward
outcomes in procedural sedation performed
outside the operating room.”

32. • Vomiting- more common -typically occurring
in the recovery phase of sedation.
• Consider pre treatment using ondansetron.
• In the ED, the theoretic risk of aspiration vs
against the need for sedation

33. Propofol

34. Etomidate

35. ketamine
• Safe and effective in children
• 2nd most commonly used
• "threshold dose” all or none--- for sedation only
and not for analgesia
• >90% children-adequately sedated @ 1.5 mg/kg

36. ketamine
• Dose 1-2 mg/kg I.V
• Onset 1-2 minutes
• Duration- 10-12 minutes

37. ketamine vs propofol
KETAMINE PROPOFOL
Effective sedation +++ ++
Respiratory depression - ++
Hypotension - ++
Need for additional opioid - +
Abolishment of reflexes - ++

38. Fentanyl

39. Combinations
• Always preferable.
• To achieve the triad of
Sedation --- Analgesia--- Anxiolysis
• To avoid undue s/e of a single agent.

40. Discuss
• Midaz + fentanyl
• Midaz + morphine
• Fentanyl + propofol
• Propofol + ketamine
• Ketamine + midaz
• Etomidate + propofol

41. Postsedation monitoring and recovery
• Immediately post-procedure---removal of
painful stimulus
• Paradoxical over sedation and respiratory
depression
• Despite ketamine + ondansetron, nausea and
vomiting may occur

42. Discharge criteria
1. Stable serial vital signs, including blood
pressure and pulse oximetry.
2. Return to pre-sedation mental status;
3. Ability to sit unaided

43. Written Discharge Advice
• Watch for vomiting
• Abnormal somnolence
• Restrict activities to bare minimum

44. Conclusions
• Break the cycle
• Approach changes as age changes
• Never ignore neonatal pain
• Different drugs for different procedures
• Rational drug combinations
• ? Ketamine underused
• Vomiting common complication
• Lets put a smile on the face

45. THANK YOU

46. SUCROSE

49. MALLAMPATTI- SUPINE VS SITTING

51. LET EMLA

53. EMLA
• A concern with EMLA is the risk of systemic absorption; however, absorption is
minimal and should not produce toxic plasma levels with routine dosing, even
when applied to open wounds.[4]
• When applied to the skin, an anesthetic response occurs within 45 to 60 minutes
and lasts for one to two hours after removal. Additionally, the site of application
can affect the duration of analgesia; areas with increased vasculature can increase
drug clearance.[3]
• , and the manufacturer recommends the following: age 0-3 months or < 5 kg
should receive 1 g over 10 cm2 skin for up to 1 hour; age 3-12 months and > 5 kg
should receive 2 g over 20 cm2 skin for up to 4 hours; age 1-6 years and > 10 kg
should receive 10 g over 100 cm2 skin for up to 4 hours; and age 7-12 years and >
20 kg should receive 20 g over 200 cm2 skin for up 4 hours.[4]
• For maximum skin absorption, EMLA should be applied beneath occlusive
dressings such as Tegaderm.[5]
• Because of the risk of methemoglobinemia, EMLA use should be avoided in
neonates with a gestational age of less than 37 weeks and in infants under the age
of 1 year who are receiving concomitant therapy with agents such as phenytoin or
acetaminophen.[4]

54. Dosing for EMLA is age- and weight-
based
• < 5 kg should receive 1 g over 10 cm2 skin
• > 5 kg should receive 2 g over 20 cm2 skin
• > 10 kg should receive 10 g over 100 cm2 skin
• > 20 kg should receive 20 g over 200 cm2 skin
for up 4 hours.[4]

55. Flumazenil
• Usual Pediatric Dose for Reversal of Sedation
• IV:
Infants and Children:
Benzodiazepine reversal when used in conscious sedation or general anesthesia:
Initial dose: 0.01 mg/kg (maximum dose: 0.2 mg) given over 15 seconds; may repeat 0.01 mg/kg
(maximum dose: 0.2 mg) after 45 seconds, and then every minute to a maximum total cumulative
dose of 0.05 mg/kg or 1 mg, whichever is lower; usual total dose: 0.08 to 1 mg (mean: 0.65 mg)
Management of benzodiazepine overdose: Minimal information available; initial dose: 0.01 mg/kg
(maximum dose: 0.2 mg) with repeat doses of 0.01 mg/kg (maximum dose: 0.2 mg) given every
minute to a maximum total cumulative dose of 1 mg; as an alternative to repeat bolus doses, follow
up continuous infusions of 0.005 to 0.01 mg/kg/hour have been used; further studies are needed.
• Usual Pediatric Dose for Benzodiazepine Overdose
• 1 to 17 years:
Initial dose: 0.01 mg/kg IV over 15 seconds.
Repeat doses: 0.01 mg/kg given over 15 seconds; may repeat 0.01 mg/kg after 45 seconds, then
every minute to a maximum total cumulative dose of 0.05 mg/kg.
Continuous IV infusion: 0.005 to 0.01 mg/kg/hr was used in a premature neonate (gestational age:
32 weeks) exposed to high doses of diazepam intrapartum.
Myoclonus, benzodiazepine induced: IV: 0.078 mg/kg once was effective in a single full-term
neonate who was receiving continuous infusion midazolam

56. • Why is pethidine c/I in paediatric
• Tramadol in pediatrics?
• Mechanism of analgesia for sucrose?
• Pics- pierre robin syndrome, trisomy 21
• Stranger anxiety at?
• Toddler?
• Amnestic
• Guided imagery
• Flumazenil dose
• LET- topical vs mucous membrane.
• Eutectic?
• Nurse maids elbow
• Mallampati – adult vs paeds– Cormack Lehane
• Intranasal midaz
• Fenta repiratory depression