Sedation prescreening for pediatric hospital medicine/ general pediatrics provider



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Sedation prescreening for pediatric hospital medicine/ general pediatrics provider
In order to provide safe and effective sedation for pediatric patients in the hospital setting, several factors must evaluated prior to making the decision about executing the sedation by hospitalist provider versus consultation/ referral to anesthesiology service.
A systematic approach to pre screening of these patients is needed to avoid sedation of patients with potential difficult airway or ventilation problems, hemodynamic instability or a combination of these that could lead to serious adverse events or death.
The following information should be routinely and consistently evaluated:


  1. Type of procedure and level of sedation required

  2. NPO times

  3. ASA physical status

  4. Targeted review of history

  5. Sedation/ anesthesia history

  6. Medication and allergies

  7. Physical exam

In general risks of sedation and level of sedation should be weighed based on optimal back up systems in any locations from either anesthesia service or emergency medicine or critical care service. Time to arrival of emergency teams/ help should always be considered when choosing patients and level of sedation.



Type of procedure and level of sedation required

Determine the length of procedure, level of pain and discomfort anticipated and degree of mobility permitted during the study to determine the depth of sedation and choice in sedation regimen. Generally highly painful procedures, procedures lasting > 2hours or those requiring complete immobility in a painful procedure should be considered for general anesthesia and referred appropriately.







Minimal

Moderate

Deep

Anesthesia

Consciousness

Relaxed, impaired cognition likely

Light sleeping or very drowsy

Asleep

Unconscious

Responsiveness

Verbal response, tactile response

Verbally awakens or with light tactile stimuli, purposeful movement to painful stimuli

Verbally unresponsive, responds to painful stimuli

Unresponsive

Airway

Unaffected

Patent

+/- impaired

Impaired

Ventilation

Unaffected

Adequate

Decrease tidal volume and rate

Impaired

CV

Unaffected

Stable

Stable

Can be impaired



NPO times

For all non urgent and non emergent procedures, generally follow ASA (American Society of Anesthesiologists) recommended fasting times for moderate to deep sedation. Minimal sedation NPO times do not have to be followed strictly.




Food

Hours of fasting required

Clear liquids (water, juice w/o pulp, carbonated beverages, clear tea)

2

Breast milk

4

Formula, non-human milk or light meal (toast and clears)

6

Full meal (include fried or fatty foods or meats)

8

In ER settings fasting rules have been altered by guidelines released from by ACEP (American College of Emergency Physicians). One should exercise caution at all times with patients with gastroparesis. Literature has found that significant aspiration seems to be more highly correlated with ASA class rather than NPO times.





ASA status

This is used mainly to stratify the risk of sedation and anesthesia for patients and gives a common language to convey the severity of illness of the patient. It is appropriate for generalist to sedate ASA 1 and 2 however, class 3 should be addressed on case by case basis and referral or consultation with anesthesiologist is recommended. ASA class 4 and above are not generally acceptable for outside OR sedation.




Class

Definition

Examples

I

Healthy patient




II

Mild systemic disease

Age < 12mo

Well controlled asthma

Well controlled epilepsy


III

Severe systemic disease

Morbid obesity

ALL in maintenance

Renal disease on dialysis


IV

Severe systemic disease that is a constant threat to life

Acute heart failure

Sepsis


DIC

V

Moribund patient not expected to survive without the operation

Active intracranial bleed with mass effect


Targeted review of history





  1. Recent illness

    1. Upper respiratory infection – hyper reactive airways persists for 6 weeks. Any ongoing rhinorrhea, congestion are potential risks for laryngospasm during deep sedation.

    2. Gastrointestinal infection with recent dehydration – consider prehydration if using medications with potential hypotension as a side effect.




  1. Respiratory disease

    1. Asthma type and level of control – consider using bronchodilators prior to the procedure if poor control or recent flair. In acute exacerbation would defer to anesthesia.

    2. Chronic lung disease, severity – generally not done by general peds, esp if actively followed by pulmonary or on home oxygen.

    3. Obstructive pattern of breathing or sleep apnea – snoring a common concern, not typically documented clearly as OSA. Would avoid deep sedation esp. propofol due to significant loss of airway tone.

    4. Allergies and severity of symptoms – exercise extreme caution with deep sedation, secretions a definite risk factor for laryngospasm and severe airway compromise.

    5. Larygomalacia and tracheomalacia not candidates for deep sedation




  1. CV

    1. CHF, myocarditis and pulmonary hypertension not candidates for sedation.

    2. Arrhythmias, unrepaired defects with hemodynamic impact. Small ASD, VSD might be acceptable for moderate to deep sedation in an otherwise healthy child.

    3. Unexplained syncope or pending evaluation by cardiology as well as true diagnosis of dysautonomia should not be done by a generalist.




  1. Renal and Liver disease – significant in terms of choosing your drugs based on metabolism of the medications/ clearance pathways.




  1. Heme – Anemia of Hgb less than 8 consider transfusion, for sickle cell patients very clear protocol for pre-hydration should be in place and avoiding hypoxia is critical, or ideally patient referred to anesthesia.




  1. GI – consider referral for vomiting patients, those with significant gastroparesis, increased abdominal girth and ascites.




  1. Genetic syndromes that should be avoided

    1. Achondroplasia - difficult airway secondary to narrow nasal passages, macroglossia, prominent mandible and OSA as well as cervical spine instability

    2. Beckers and Duchene muscular dystrophy – hypoventilation and aspiration risk, Succinylcholine can cause hyperkalemic cardiac arrest.

    3. CHARGE - choanal atresia or stenosis, micrognathia, short neck, laryngomalacia, subglottic stenosis and CV disease.

    4. Cornelia De Lange - choanal atresia, micrognathia, short neck and aspiration.

    5. Cri du Chat - micrognathia, long/floppy epiglottis, laryngeal deformity with diamond-shaped vocal cords, pharyngeal muscle hypotonia, CV defects

    6. DiGeorge - choanal atresia, micrognathia, laryngo/tracheomalacia and short trachea, conotruncal heart defects.

    7. Downs - macroglossia, pharyngeal muscle hypotonia = OSA, micrognathia, atlantoaxial instability (8.5% incidence) and hypotonia

    8. Familial Periodic Paralysis – Arrhythmia secondary to K abnormalities.

    9. Ehlers-Danlos – aortic root abnormalities, TMJ dysfunction, atlanto-axial

    10. Goldenhar - Unilateral/asymmetric hypoplasia of the facial bones and muscles, limited mouth opening, deviation/hypoplasia of the mandible, micrognathia.

    11. Homocystinurea – pectus, spontaneous pneumothorax, thrombotic embolic events, coronary artery disease

    12. Hunters and Hurlers – Critical airway – DO NOT sedate these patients

    13. Klippel – Feil - Facial asymmetry, micrognathia, torticollis, short/webbed neck with limited mobility/progressive fusion of upper cervical spine, or more rarely hypermobility that can lead to neuro impairment = careful manipulation

    14. Marfan’s - OSA from pharyngeal laxity, atlanto axial instability, TMJ joint laxity=damage to cervical spine and TMJ with distraction, spontaneous pneumothoraces, Aortic or pulmonary artery dilation.

    15. Nager critical airway, DO NOT sedated these patients

    16. Noonan’s – micrognathia, pulmonic stenosis and HOCM

    17. Pierre Robin – spectrum of microglossia, vagal hyperactivity

    18. Treacher Collins - micrognathia, microstomia, choanal atresia, mandibular hypoplasia, pharyngeal hypoplasia, OSA, and narrow airway may necessitate a trach.

    19. Turner – micrognathia, short webbed neck, aortic coarctation

    20. VACTERL – airway and cardiac abnormalities

    21. Williams - Distorted aortic valve leaflets can obstruct either main coronary artery, abdominal aortic coarctation, prolonged QTc, 3% sudden death



Sedation/ Anesthesia History





  1. Need for general anesthesia in the past – any complications

  2. Any history of emergence reactions or paradoxical reactions, what medications used. Vomiting or prolong recovery times?

  3. Previous failed sedation

  4. Family history of malignant hyperthermia or severe adverse effects/ anaphylaxis.


Medications and Allergies

Medications – establish if the child is on any baseline sedating medications.


Allergies – true allergy to sedative versus adverse effect. Propofol should not be used in patients with anaphylaxis to eggs and soy.


Physical Exam

General Body mass index above 95% generally considered high risk for airway management and ventilation difficulties.


Airway/ HEENT

Ability to open mouth fully (history of XRT to face/ neck area)

Mandibular length

Mallampati classification





Class

Structures Visualized

I

Soft palate, fauces, uvula, anterior and posterior pillars

II

Soft palate, fauces, uvula

III

Soft palate and base of the uvula

IV

Soft palate is not visible at all


http://medinfo2.psu.ac.th/anesth/education/image/it1.gif
Mallampati, SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-434

Remainder of exam to cover CV, GI, CNS and Respiratory.



For comments questions and suggestions contact preisber@bcm.edu

Krista Preisberga, MD FAAP

Assistant Professor of Pediatrics

Sedation Provider

Department of Pediatrics and Anesthesiology



Baylor College of Medicine


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