SOFA Conference Fall 2018 Pediatric Emergence Delirium and The Use of Precedex Objectives Define emergence delirium and its importance to anesthesia providers Identify risk factors for development of emergence delirium ID: 800281
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Slide1
Adrienne Domanico RN, MSN, CRNASOFA ConferenceFall 2018
Pediatric Emergence Delirium
and The Use of Precedex
Slide2ObjectivesDefine emergence delirium and its importance to anesthesia providersIdentify risk factors for development of emergence deliriumIllustrate pharmacological properties of PrecedexExplain the use of Precedex in the treatment of pediatric emergence delirium
Slide3Definitions“A more or less temporary disorder of the mental faculties, as in fevers, disturbances of consciousness, or intoxication, characterized by restlessness, excitement, delusions, hallucinations, etc.; a state of violent excitement and emotion” – www.dictionary.com“A neuropsychiatric condition that is secondary to a general medical condition and/or its treatments” (Schieveld and Janssen, 2014)Delirium
Agitation
“To move or force into violent, irregular action; impart regular motion too;
to
disturb or excite emotionally, arouse, perturb; to call attention to with
speech
or writing; ruffle, fluster, roil”
– www.dictionary.com
So, what does the literature say…..
Slide4“A wide variety of behavioral disturbances seen in children following emergence from anesthesia” (Chandler et al 2012)“A mental disturbance common in children during recovery of general anesthesia” (Mountain et al 2011)“Characterized by a variety of presentations… during the early stage of emergence from anesthesia” (Dahmani et al., 2010)“A mental disturbance during the recovery from general anesthesia…” (Locatelli et al, 2012)“A dissociative state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolably crying, moaning, kicking, or thrashing” (Reduque and Verghese
, 2012)
WHAT DOES IT ALL MEAN?!?!
… It says this
Slide5Importance“Children get delirious so often and quickly that this is of no importance to us” - Bleuler (1857-1939)So what does ED mean to us?
Slide6Pediatric vs AdultPediatrics can last up to 30 minutes, in about 80% of pediatric cases!!!Most commonly in ages 2-8Adultcan be seen at any agean incidence around 40% but this includes ICU psychosis,
chronic illness,
etc
in addition to emergence
Slide7Stress inducedDisinhibitionAcetylcholineCircadian rhythm disruptionTheories
Slide8Children from ages 2-8Short acting anesthetics/ rapid emergenceRelatively painful procedures/ Sites of surgeryPatients with separation anxietyChild’s temperamentRisk Factors
Slide9Stages of Anesthesia
Slide10Instead of this….… We want this!!!
Slide11PAED Scale
Slide12How can you tell if it’s Pain?
Slide13Let’s review some A & P
Slide14Slide15Mediates sedationCause fluctuations in BPPostsynaptic locations: pancreas, kidney, fatMostly found in CNSAgonists have benefits for us
Alpha 2 receptors
Slide16Slide17Slide18Alpha 2 receptors
Slide19… Or sitting through this presentation
Slide20Highly selective alpha 2:alpha 1 1600:1Sedation and analgesia sparing respiratory driveLess pain medication use in PACULess postop deliriumApproved for MAC sedation in 2010“arousable” sedationMood enhancing effects
Pharmacodynamics
Precedex
(
dexmedetomidine
)
Slide21Distribution half life = 6 minsTerminal elimination half life = 2-3 hrsPlasma binding is 94% and significantly decreased in hepatic impaired subjectsMetabolism = glucuronodation and cytochrome p450 metabolism to undergo almost complete biotransformation and excreted almost entirely through kidneys
No difference in pharmacokinetics for impaired renal patients
Pharmacokinetics
Precedex
Slide22Dose: IV bolus ED treatment: 0.3 – 0.5 mcg/kg (slow IV push) Sedation bolus: 1mcg/kg over 10 minutes Infusion Dosage 0.3-1.2 mcg/kg/hrConcentration: must be mixed 4mcg/mlOnset: 5 minutesPeak: 15-20 minutesElimination half life: 2-3 hoursAnalgesic length of time: 24 hrsSide effects: Hypotension/Hypertension, bradycardiaCosts about $40-50/vial of 200 mcg/ 2mL, single usePrecedex
Slide23Slide24Safety Margin
Slide25Safety Margin
Slide26What about other treatment options?
Slide27Team Propofol… maybe
Slide28No, Really. Dex > Prop
Slide29Besides EA/ED treatment, can Dex do anything else?
Slide30Pearls I’ve Learned0.3- 0.4 mcg/kg is the sweet spotTime it for extubationWorks really well in patients with MR, autism, ADHDCareful with a pre-medThere is no alligator rolling
Some providers are still
not
comfortable
with it but…
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Dawes, J., Myers, D.,
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References