Out-of-the Operating Room Pediatric Anesthesia - PowerPoint Presentation

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Out-of-the Operating Room Pediatric Anesthesia

Fiona Patrao, MBBS, MDCorrie Anderson, MD, FAAPSeattle Children’s Hospital Seattle, Washington, USA

Updated 8/2019

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Disclosures

No relevant financial relationships

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Learning Objectives

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Goals of Care for Out-of-OR Anesthesia

Achieve immobility

Avoid patient discomfort and injury

Provide anxiolysis, safe sedation and analgesia

Support patients as they transition from one level of sedation through another

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Why sedate for out of OR procedures?

Ensures a cooperative and still patient- Especially consider sedation in children < 6 years old or developmentally delayed

Reduces a child’s anxiety and stress

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Levels of Sedation

Must know how to support patients as they transition from one level to another

Requires close monitoring of patients

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MINIMAL SEDATION

(previously “anxiolysis”) Minimally depressed level of consciousness

Respond to tactile stimulation and verbal command. MODERATE SEDATION

(

previously “conscious sedation”

)

Further depression - respond purposefully to verbal commands alone or with light tactile stimulation

Patients independently and continuously maintain airway and ventilation

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DEEP SEDATION

NOT easily aroused but respond purposefully following repeated or painful stimulation. Cardiovascular function is usually maintained. GENERAL ANESTHESIA NOT arousable

Cardiovascular function may be impaired.

Deep sedation may require airway support, and GA probably will require positive pressure ventilation

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What is MAC?

 Monitored Anesthesia Care

Anesthesia resources utilized to support life and provide patient comfort and safety during diagnostic/therapeutic procedures

Can range from only monitoring, to monitoring with sedation and can progress to GA and to resuscitation

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Pharmacologic Interventions

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Pharmacologic Options

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Drug

Dose and route

Propofol

IV Bolus: 1-3 mg/kg

IV Infusion dose 100–250 µg/kg/min IV

Dexmedetomidine

Intranasal: 2.5-3 µg/kg, repeat after 30 min with 1-1.5 µg/kg

IV bolus: 0.5-1 µg/kg over 10-15 min

IV infusion: 0.5-1 µg/kg/h (start after giving above bolus dose)

Ketamine

Intramuscular: 3–4 mg/kg IM

IV: 0.5–2 mg/kg IV

N

2

O

Inhalation: 50% in 50% oxygen, up to 70% used by some

Midazolam

Oral: 0.5–0.75 mg/kg

Intranasal: 0.2 mg/kg

IV: 0.025–0.5 mg/kg IV

Fentanyl with Propofol

Fentanyl 1–2 mg/kg IV with Propofol 0.5-1.5 mg/kg IV

Fentanyl with Midazolam

Fentanyl 1–2 mcg/kg IV with Midazolam 0.02 mg/kg IV

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Pharmacologic Options

Combined sedative + analgesics

Ketamine

Dexmedetomidine

N

2

O

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Non-pharmacologic Options

Applicable for short, minimally invasive procedures

Calming and reassurance by parents

For older kids

- Distraction techniques:

TV, video games or other devices

Play

hypnosis

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Non-pharmacologic Options

For babies:

Swaddling, sugar dropsFor infants < 6 months: keep baby fasted for 4 hours, swaddle and then feed right before procedure

“Feed and sleep”

“Fast and feed”

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Dose of ”sugar drops”

Administer 2 mL of 25% sucrose/dextrose solution by syringe into the infant’s mouth (1 mL in each cheek)

Or infant may suck solution from nipple (pacifier) 1-2 min before the start of the procedure

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Challenges of Remote Locations

Patient challenges

Procedure challenges

Shared airway:

GI, Dental clinic

Painful:

burns, bone marrow aspirate

Immobility:

MRI, Proton therapy

Environmental challenges

Lack of equipment

Metal free zones:

MRI

Crowded spaces and difficulty to access patient

Lack of electrical/gas outlets

Remote location of hospital

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Staffing

Fully trained anesthesiologistTrainees should be closely supervised

Additional staff to support anesthesiologist: nurses, technicians

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Evaluate Your Patient

Assess risk ASA Status and Risk:

Organ systemsDevelopment and maturity

Review: past anesthetics, labs, imaging

Airway assessment

Assess and plan appropriate size airway equipment

Difficult airway?

Physical exam

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Prepare Your Patient

Informed consent

Ensure adequate fasting

IV

vs

Inhalational induction

If need/prefer IV first, consider:

Sedation with oral/nasal midazolam or dexmedetomidine, or IM ketamine

EMLA cream (safe from 37 weeks of infancy onwards)

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Prepare Your Patient

Prepare your anesthesia plan based on

your risk assessment

and

YOUR skill set

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Prepare the Environment

Visit the location in advance

Assess space and dimensions:

Can anesthesia equipment pass through the door?

Layout of room:

How will you access patient and equipment efficiently?

Ensure necessities:

Location of O

2

outlets

Suction: central or need independent machines?

Piped

vs

cylinder gases

Electric outlets? Adequate battery charge?

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Prepare for a Crisis

Establish Space:

for induction, emergence, management of crisis

Be prepared:

Identify location of defibrillator and emergency drugs

Battery powered source of light- flashlight

Communication- telephone, extra people

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Anesthesia Equipment Set Up

Airway support

CHECK and ENSURE a reliable O

2

source

Have FULL O

2

cylinder available as backup

Self inflating bag or Mapleson circuit

Suction

Face mask, oral/nasal airway, supraglottic airway, ETT, laryngoscope,

difficult airway tools

Anesthesia machine if possible

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Anesthesia Set Up…

Anesthesia delivery

Monitors: ECG, BP, SpO2, ETCO

2

, temperature

Drugs

IV access

Airway and ventilation

Safe positioning

Temperature regulation

Documentation

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Post Anesthesia Care

Staff to monitor patientnurse or anesthesiologist

Safe transport

Resources

O

2

, airway equipment

Suction

Emergency drugs

Monitors

Prepare for unexpected admissions

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Location Specific Discussions

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Bedside Procedures

Examples: Burns or wound dressings, line placements, chest tubes

Assess patient’s suitability.May be suitable for older children (> 10 to 12 years)

Monitors: ECG, NIBP, SPO

2

, ETCO

2

Airway and suction equipment

Consider PO, nasal or IM sedation prior to placing IV

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Bedside Procedures…

Minimum to moderate sedation only

ketamine, midazolam, dexmedetomidine

Provide analgesia

opioids, NSAIDS, local anesthesia

Airway and O

2

support as needed

Distraction techniques

Music, cartoons, play therapy, parental presence

Repetitive procedures?

Consider neuraxial or regional nerve catheters

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GI Suite

Special considerations:

Shared airway: for EGD (esophago-gastro-duodenoscopy), ERCP

Short procedures: not usually painful. Use short acting drugs

Full stomach risks

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GI Suite…

Examples: EGD, Colonoscopy, Liver Biopsy

Options range from minimum sedation to GA:Spontaneous breathing with boluses of propofol +/- short acting opioids

Spontaneous breathing with TIVA: propofol +/- dexmedetomidine infusions

GA with LMA or ETT

midazolam as needed for anxiety

Consider lidocaine gargles, swish and swallow for less sedated patients.

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GI Suite…

GA with ETT for:ERCPGastro-jejunostomyAny concern for full stomach or unstable airway?

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CT Scans

(Computed Tomography) Special considerations:

Short procedures

Contrast injections

Requires IV placement

Allergic reactions

Exposure to radiation

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CT Scans…

Anesthetic options:If anesthesia machine available: Can consider using volatile agent for induction and maintenance

Other options: propofol, midazolam, ketamine, dexmedetomidine boluses

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CT Scans…

Other considerations

Babies:

Soothing: swaddling, sugar on pacifier

”Fast and Feed”

Some scans require breath holds, prone positioning

May require ETT/ LMA

Inspiratory breath hold- with positive pressure ventilation (PPV)

Expiratory hold or apneic pause: following hyperventilation +/- propofol bolus

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MRI

Special considerations

ImmobilityConfined space No ferromagnetic materials

Programmable VP shunts-reprogram after MRI

Noise protection

Contrast injections

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MRI…

Anesthesia set up:

Monitors

Do not use regular monitors. ALL wires can cause burns

Use only MRI compatible

ECG, NIBP, SPO

2

and ETCO

2

No monitors?

Proceed with caution

Visual inspection of patient and “HAND on PULSE”

Some “MRI-compatible” equipment cannot be taken too close to the scanner.

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MRI…

Infusions managed and patient monitored from control room.

Infusions tunneled through copper channel in wall of control room

Small copper channel on side of door to allow long infusion tubing of critical medications

0

Other options include running tubing under the door, or MRI compatible pumps

.

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MRI…

Anesthetic techniques:

Sedation vs GASedation with midazolam, propofol or ketamine boluses

GA with LMA/ETT with volatile gent

GA with TIVA (Propofol): nasal cannula vs LMA/ETT

Infants

Swaddle

“Fast and Feed”

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Oncology Patients

Example: Bone marrow aspirate, lumbar puncture, line or drain placement

Using central lines -> ensure strict asepsis

Check anticoagulation status

Minimum to moderate sedation only with spontaneous ventilation

Midazolam, propofol or ketamine will lead to deeper level of sedation and require airway support.

Analgesia with opioids

Liberal local anesthesia infiltration

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Oncology Patients

For radiation and gamma knife therapy

Frequent treatments – Long procedures that require immobility and stereotactic head frames

Anesthetic risks and considerations vary

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Dental ClinicsSpecial considerations:

Shared airwayOften anxious/phobic or developmentally delayed patients

If considering sedation -> MAINTAIN airway reflexes to protect from aspiration of blood/oral secretions

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Dental Clinics…

Anesthetic techniques:

Oral/ NasalMidazolam, ketamine, dexmedetomidine

Intramuscular

Ketamine

Inhalational

With N

2

O nasal mask – titrated mixture of up to 70%

Intravenous

Titrating dose of midazolam and/or propofol

GA with ETT

Preferably in hospital with adequate resources

Oral vs nasal ETT with throat pack

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Other considerations…

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Crisis Management

Identify how to activate emergency system

Support staff, phones

Identify location of defibrillator and emergency drugs

Ensure defibrillator working

Battery charged, plugged in and routine testing

Transfer patient to safe location during crisis

Crowd control

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Complications

Hypoxic episodes:

LaryngospasmBronchospasm

Aspiration

Failed sedation

Prolonged recovery

Allergic reactions and anaphylaxis

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Management of anaphylaxis

Severity of symptoms

Intervention

MILD

(Urticaria, flushing)

Remove offending agent

Consider oral dose of diphenhydramine

MODERATE to SEVERE

(Bronchospasm, facial or laryngeal edema, hypotension with tachycardia/bradycardia)

Remove offending agent

100 % high flow O

2

IM Epinephrine (10 µg/kg) – repeat 10 to 15 mins as needed

IV hydrocortisone



2

agonist

for bronchospasm

Antihistamine: IV diphenhydramine (H

1

blocker), IV ranitidine (H

2

blocker)

Intubate for stridor/airway compromise

Treat hypotension

Supine as tolerated, legs elevated

20 ml/kg isotonic fluid bolus, repeat as needed

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Occupational Hazards

Exposure to radiation:

use lead aprons, thyroid lead shields, lead screens

Noise damage: use ear plugs in MRI

Tripping

Inadequate lighting

Accidental injuries to self

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Safety and Improvement

Posters with checklists and reminders

Protocols for using checklists before start of procedure

Emergency phone numbers should be easily visible

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Sample Checklist

Verification

Response

Details

Patient

identity

Name/ DOB/Hospital number

Patient weight

….. kg

Allergies

Yes/No

List allergies

Procedure

Described by surgeon/proceduralist

Consent

Yes/No

O

2

and airway equipment

Available and adequate

Suction

On and working

Medications

Available

Monitors on

Yes/ No

Special precautions?

Yes/ No

labs, metal free area

Adequate nursing/physician staff

Yes/No

Defibrillator/emergency cart available

Yes/No

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Safety and Improvement

Consider QI (Quality Improvement) projects to test and improve protocols

Simulation sessions

Simulate crises in remote locations to identify weaknesses and improve awareness

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Conclusion

Evaluate, assess and prepare the patient

Plan an anesthetic based on patient, location, procedure, available equipment and YOUR skill set

Prepare for:

Changing levels of sedation

Critical events

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References

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018; 128:437–79

Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. July 2016; Vol 138: e20161212-2

Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010;23: 523-31

Cravero JP et al and the Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118:1087–96

Cantlay K, Williamson S, Hawkings J. Anaesthesia for Dentistry. Br J Anaesth. 2005; 5: 71-5

Bell C, Sequeira PM. Nonoperating room anesthesia for children. Curr Opin Anaesthesiol 2005, 18:271-6

Cravero JP, George TB. Review of Pediatric Sedation. Anesth Analg 2004;99:1355–64

Fein JA, Zempsky WT, Cravero JP and the Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of Pan and Anxiety in Pediatric Patients in Emergency Medical Systems. Pediatrics 2012;130;e1391

Sottas CE, Anderson B. Dexmedetomidine: the new all-in-one drug in paediatric anaesthesia? Curr Opin Anaesthesiol 2017;30:441-51