Sedation Services at Children Healthcare of Atlanta

David Banks, MD david.banks@pemaweb.com

In the late 1990’s, as pediatric MRI imaging services came of age, pediatric hospitals were faced with a growing need for quality pediatric sedation services. Many institutions met this need initially by assembling experienced nurses and having them manage the sedations.  By the early 2000’s, the nurse-run services were being replaced by physician services, as the Joint Commission developed new standards for deep sedation services.  In compliance with Joint Commission standards, both Children’s campuses Scottish Rite and Egleston developed physician run sedation services.  Pediatric Sedation Services (PSS) was developed on the Scottish Rite campus by the PEMA physician group, and Children’s Sedation Services (CSS) was formed as a combined effort by the critical care and pediatric emergency medicine teams at the Egleston campus.  Both PSS and CSS have grown in volume and scope of services and, as a system, represent one of the largest pediatric procedural sedation services, performing over 11,000 cases per year.  

Services Provided

The sedation services at CHOA provide predominantly “deep sedation,” where the requirements for completing a study involve the patient lying completely still, typically for imaging studies such as MRI, CT, nuclear medicine/PET imaging, or for Auditory Brainstem Response (ABR) hearing studies.  We also provide deep sedation for difficult or painful procedures, commonly referred to as “procedural sedation,” where the patient not only needs to be deeply asleep, and reasonably still, but also have the pain of the procedure appropriately managed.  Deep procedural sedation is provided in multiple areas across the system, including the AFLAC Cancer Centers (bone marrow studies or lumbar punctures for intrathecal chemotherapy,) the emergency departments (fracture reduction, abscess drainage, complex wound management), and interventional radiology (difficult LPs, PICC line placement, percutaneous drainage of appendiceal abscesses).  Deep sedation services account for approximately 95% of the sedation services’ consultations.

In some situations, moderate sedation is appropriate to meet the patient’s needs. One example would be an older patient undergoing lumbar puncture for intrathecal chemotherapy.

Our services also provide anxiolysis for patients undergoing minor procedures that are minimally painful but associated with significant patient stress.  Typical circumstances where anxiolysis is provided include obtaining IV access in challenging situations when the vascular access team is required and for bladder catheterization in a patient with urologic issues requiring a VCUG.

Most patients are also managed in conjunction with Child Life Services to help relieve the patient’s stress and anxiety.

Medications typically utilized by our sedation teams are:

– Deep

propofol, dexmedetomodine, methohexital, ketamine, and fentanyl

– Moderate

fentanyl and midazolam

– Anxiolysis

nitrous oxide gas

midazolam

Preparing Patients and Families for Sedation

The majority of the patients that receive sedation are electively scheduled cases that are previewed well in advance of their appointment and are prescreened for appropriateness for the sedation services. Our current involves having each case reviewed by an experienced sedation nurse in advance. Families are contacted in advance to assure the patient’s appropriateness for the sedation service.  Some of these patients may be deemed to be higher risk and may be referred to the anesthesia service for management.  Specific conditions that may result in referral to the anesthesia service include:

  • Difficult airway
  • Patients with a Z score of >2.5 for BMI for age (patients whose comparative weights are overweight for age based on an international standard scale)
  • Laryngomalacia or stridor at rest
  • Poor airway tone
  • Excessive secretions, GERD
  • Chronic lung disease resulting in O2 requirement of ventilator support
  • Congenital heart disease with R to L shunts or pulmonary hypertension
  • Certain metabolic disorders
  • Patients with significant medical complexity

After screening, families are then given pre-procedure instructions that include arrival time, a discussion of NPO times, and instructions on whether to take the morning dose of routine medications on the day of the procedure. For purely elective procedures, families are encouraged to reschedule if the child is ill just before or at the time of the scheduled procedure.

NPO Guidelines:

Heavy, greasy meal                8 hours

Solids, milk/formula               6 hours

Breastmilk                              4 hours

Clear liquids                            2 hours

 

Be Selective.  Weigh All the Risks

Sedation is not without short term and long-term risks.  As sedationists, we are comfortable managing the well-known short-term risks of deep sedation, including depressed respiratory drive, hypoxemia, and loss of airway tone with subsequent airway obstruction.  These events occur in approximately 1 in 20 deep sedations, and the sedation team is prepared to manage them.  However, if the case is truly elective, and the patient is at greater risk on the day of the procedure due to respiratory illness or other medical issues, then rescheduling for 3 or 4 weeks later may allow the study to be obtained with less risk.

Long term risk of deep sedation and anesthesia is still unclear.  Recent studies demonstrate that pups of multiple species exhibit neuro-developmental delay following prolonged or repeated exposure to propofol, ketamine, sevoflurane, or halothane. Large human population studies associate cognitive delay later in life in children that experienced multiple anesthetic exposures prior to age 3 years. However, there is no direct link demonstrating harm from deep sedation/anesthesia in human studies.

As a result of these studies, in December 2016, the FDA issued a Drug Safety Communication warning that “repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.”

Interpreting animal studies that appear to demonstrate harm from sedation and anesthetic agents is difficult, as the methodologies and logistics of performing these studies are quite challenging.  Drawing conclusions from large human population studies is also fraught with difficulty, as there is no way to assess the effects of potential co-morbidities and surgical complications in patients receiving multiple anesthetics. In an attempt to keep this all-in perspective, it is crucial to remember that there are numerous studies delineating the deleterious effects on children of inadequate sedation or incomplete pain management during difficult or painful procedures. And we have all seen the devastating effects of delayed diagnosis of certain serious medical conditions.

The Society for Pediatric Sedation has been at the forefront of research in the field of pediatric sedation since its inception in 2007.  I recommend visiting the SPS website- www.pedsedation.org and www.SmartTots.org for more information regarding this research.

With all this in mind, please judiciously consider what sedated test you order. Is it necessary or will the results change your patient care?  As providers of healthcare to children, we should all be certain that any study or procedure that has been prescribed for any child is truly indicated, and that the risk-benefit ratio for potential short and long-term risks of harm has been carefully assessed.

For questions or concerns about ordering imaging studies and sedation services for all the CHOA facilities, contact:  404-785-2787 (Monday-Friday)

On weekends or after hours, you may contact the departments directly: 404-785-1487 for Egleston and 404-785-4698 for Scottish Rite.

Thank you for choosing Children’s and entrusting your patients to us.

 

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