Topics discussed in this podcast include natural airway sedation for pediatric intensivists, procedural sedation versus general anesthesia, safety considerations and risk factors, patient and drug selection, appropriate monitoring, and rescue medications. Additionally, the podcast explores practical sedation scenarios such as sedating a three-year-old for an MRI and comparing ketamine to propofol and fentanyl for sedation. They also touch on the use of nitrous oxide for urinary catheter placement.
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Quick takeaways
Thoroughly reviewing the patient's medical chart and obtaining informed consent are crucial steps before performing sedation.
Direct observation, monitoring of vital signs, and the use of entitled capnography are important during sedation to detect complications and ensure patient safety.
Deep dives
Key Point 1: Preparation for Sedation
Before performing sedation, it is crucial to review the patient's medical chart for any previous sedation or anesthesia encounters. A thorough history is taken, including information on allergies, medications, recent illnesses, and fasting. A physical examination, with a focus on the airway, is conducted. Informed consent is obtained from the family, and all necessary equipment and medications, such as a sedation reversal kit, are prepared.
Key Point 2: Monitoring during Sedation
During sedation, direct observation of the patient is important whenever possible. Monitoring of heart rate, blood pressure, and oxygen saturation through pulse oximetry is standard. The use of entitled capnography is highly recommended. It provides valuable information on breathing and cardiac output, helping to detect apnea, airway obstruction, and other abnormalities. The entitled waveform is particularly critical, and its disappearance may indicate severe complications such as laryngospasm.
Key Point 3: Choosing Agents for Sedation
The choice of sedation agents depends on various factors, including the type of procedure and the age of the patient. For a 3-year-old undergoing a 45-minute MRI, propofol is recommended for its quick onset and offset, immobility-inducing effects, and ability to ensure a painless experience. For a 7-year-old needing a bone marrow biopsy, fentanyl is administered for pain relief, followed by propofol for sedation. Nitrous oxide is an effective option for a 4-year-old requiring a urinary catheter insertion, providing sedation, mild analgesia, and reduced distress.
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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