Dr. Pradip Kamat, an expert in natural airway sedation for pediatric intensivists, discusses important topics including procedural sedation vs. general anesthesia, safety considerations and adverse events, patient and drug selection, appropriate monitoring, and common clinical scenarios. The podcast also explores the relevance of sedation outside the ICU, the challenges of studying safety and risk factors in outpatient sedation, factors contributing to adverse events, and the significance of dedicated sedation services in PICUs and sedation training during fellowships.
Procedural sedation is crucial for pediatric intensivists to provide sedation services and fill the gap left by anesthesiologists.
Outpatient sedation is generally safe, with a low incidence of adverse events, but serious adverse events have the potential to cause irreversible harm.
Deep dives
Importance of Procedural Sedation for Pediatric Intensivists
Procedural sedation is vital for pediatric intensivists to develop and refine as a clinical skill set. With the increasing use of MRI imaging, there is a higher demand for sedation outside of the ICU. Pediatricians and sub-specialists are turning to pediatric critical care doctors to fill the gap left by anesthesiologists. It is crucial for ICU doctors to be trained in procedural sedation to provide sedation services, especially after completing their training.
Understanding Procedural Sedation and Differentiating It from General Anesthesia
Procedural sedation, also referred to as natural airway sedation, aims to allow patients to maintain their own airway while undergoing a procedure. It differs from general anesthesia, which involves the placement of devices in the airway. Procedural sedation can be classified into levels ranging from mild to deep sedation, depending on the patient's response to stimuli. Conscious sedation is an outdated term no longer used in the field. Providers typically deal with mild, moderate, or deep sedation, with sedation being a continuum and patients potentially transitioning between levels.
Safety and Risk Factors in Outpatient Sedation
Outpatient sedation is generally safe, with a low incidence of adverse events and almost no mortality. Adverse events during sedation can be divided into minor and serious. Minor events, such as desaturation, hypoxia, coughing, or agitation, are usually self-resolving or easily managed. Serious adverse events, although rare, have the potential to cause irreversible harm. Risk factors for adverse events can include the location of sedation, provider characteristics (experience and risk preference), patient characteristics (age, ASA classification, difficult airways), and practice characteristics. While there are no randomized control trials specifically assessing the safety of procedural sedation, large database studies suggest it is a safe practice.
Dr. Pradip Kamat is an Associate Professor of Pediatrics at Emory School of Medicine and practicing pediatric intensivist at Children's Healthcare of Atlanta. His clinical and research interests are in procedural sedation and education. We are very excited to have him on our podcast.
Dr. Kamat is also active in PICU open access education. Please check out the PICU Doc On Call podcast co-hosted by Rahul Damania and him at https://picudoconcall.org
During our conversation we discuss: 1. Why this topic is so important for PICU physicians 2. Procedural sedation vs. general anesthesia 3. Conscious sedation??? 4. Safety considerations, risk factors and adverse events 5. Patient selection 6. Drug selection 7. Appropriate monitoring 8. Rescue medications.
References and further reading:
Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016 Jul;138(1):e20161212. doi: 10.1542/peds.2016-1212. PMID: 27354454.
Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol. 2014 Aug;44(8):1020-5. doi: 10.1007/s00247-014-2942-z. Epub 2014 May 24. PMID: 24859263.
Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014 Jun;30(6):381-7. doi: 10.1097/PEC.0000000000000143. PMID: 24849275.
Hooper MC, Kamat PP, Couloures KG. Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Pediatr Crit Care Med. 2019 Mar;20(3):259-261. doi: 10.1097/PCC.0000000000001809. PMID: 30431555.
Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020 May;145(5):e20193559. doi: 10.1542/peds.2019-3559. PMID: 32332053.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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