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PED-EM-L  February 2008

PED-EM-L February 2008

Subject:

Re: pediatric sedation

From:

Carlos Abanses <[log in to unmask]>

Reply-To:

Carlos Abanses <[log in to unmask]>

Date:

Fri, 1 Feb 2008 17:30:14 -0600

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text/plain

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John,  I guess this is kind of like how many physicians does it take to screw in a light bulb?  (Insert your own punch line of choice)  But the truthful answer is it depends on where the light bulb is located, right in front of you or 60 feet up in the dead center of a large room. If you're sedating for a CT or MRI it does not take any other physician because you are directly watching the patient.  If you're sedating for a fracture reduction or lumbar puncture where you  the physician are doing the procedure and cannot watch the monitor then that is where you can run into complications.  There have been case reports published in annals 2005 of physicians trying to monitor the patient and do the procedure with bad outcomes.  Hence the AAP and ASA both state "There must be 1 person available whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration. At least 1 individual must be present who is trained in, and capable of, providing advanced pediatric life support and who is skilled in airway management and cardiopulmonary resuscitation; training in pediatric advanced life support is required."(PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2587-2602)  Those are the only requirements.  The rest becomes your comfort and what you have to work with.  If I am doing an LP at 3 AM I will have 2 nurses in the room.  One to hold and one to push more medicines as needed after my bolus and to record vital signs.  Does the other person need to be a nurse?  Not really.  It could be a respiratory therapist that may be more capable of managing the child's airway.  If you are going to fix a complicated facial laceration that will take you 1/2 hour then you need one person dedicated to not helping you but to be observing the patient and pushing your medicine.  This all assumes that you feel confident in a nurse pushing your medicine and monitoring the patient and are willing to take that responsibility.  Now if you have a second physician handy and available, that takes the burden of responsibility away from you and you can focus on doing your task and not what's going on with the patient every time a monitor beeps.  A second physician also helps tremendously when the patient will be sedated for a long period of time and may need some airway manipulation.  You don't want to break your sterile field, fix the airway go back to suturing, then break your field again and so on (assuming you need a sterile field for suturing completely another debate, then again I see docs with sterile gloves for an I&D).  Having someone skilled to give the medication without nursing error and to manage your airway  is a great resource.  Again it's just what you have available to you and what your comfort level is if anything goes wrong.  
 Third point is that you can not bill for doing the procedure and the sedation.  So at times some physicians will prefer to use a second physician so not to take on the aforementioned increased nursing and medical risk without any increased compensation (fee for service groups).  Other facilities will prefer their doctors to have a second doctor sedate to generate more income for the hospital. Hope this helps Juan Carlos Abanses, MD
 > Date: Thu, 31 Jan 2008 08:44:03 -0600> From: [log in to unmask]> Subject: Re: pediatric sedation> To: [log in to unmask]> > I am wondering if the discussion group could comment on whether a 2nd physician must be present to do the sedation, or if it's okay, for anticipated brief procedures, that the one physician do both the procedure and the sedation. Thanks.> > JGBoulet > ----- Original Message ----- > From: Carlos Abanses > To: [log in to unmask] > Sent: Wednesday, January 30, 2008 10:42 PM> Subject: Re: pediatric sedation> > > I understand the issue of emesis with ketamine but why treat it with benzo and not a antiemetic like Zofran prior to the procedure? If you premedicate with zofran you might find you do not have the RN puke scale or the longer stay or increased risk for desaturation. As for the emergence reaction it tends to be far less common in younger children and more common in females. Sherwin et al in Ann Emerg Med. 2000 Wathen et al Ann emerg med 2000 both showed no difference in emergence reaction with versed. A trick taught to me during my years in KC was a bit of simple guided imagery prior to sedation. I'm not usually the touchy feely type but asking kids what they want to dream about and telling them to start thinking about it just takes seconds and seems to work well. Additionally letting the parents know that they will have vivid dreams as they awake and to talk to them about things they like and enjoy helps.> > > § > –> As for ETCO2 monitoring it is a helpful adjunct that can give you a good idea of how deeply sedated the patient is for a simple non-painful procedure like MRI or if the patient is needing airway repositioning. Also if you completely lose your wave form you know you either have a malfunction or laryngospasm prior to their desaturation. It can be much less reliable then pulse oximetry at times for patients that continue to breathe out of their mouths or when sedating for endoscopy where the scope often interferes with the ETCO2. > And at other times like during an MRI when you may have a brief time where the pulse ox is not picking up well it is reassuring to have ETCO2. Thus it is a nice safety and back up that can give you a lot of information by just watching the wave form that helps in assessing the overall gestalt of how the patient is doing.> > Juan Carlos Abanses, MD> Date: Wed, 30 Jan 2008 09:40:58 -0800> From: [log in to unmask]> Subject: Re: pediatric sedation> To: [log in to unmask]> > I have to echo Jay's sentiments here. I was a rabid "no evidence for benzo's" person for a long while and felt they just contributed to prolonged recovery times, but my patients also had an unusually high incidence of emesis during recovery, especially for patients who required more than one dose of Ketamine because of unexpected delays in completing the given procedure. Of course, my reticence regarding benzos had to do with the lack of evidence of their mitigation of "emergence phenomenon," but when I looked closer, there did appear to be reasonable evidence that they might reduce vomiting during recovery. I began using Versed at a dose in the 0.05mg/kg range and have anecdotally experienced a large drop in the amount of vomiting my patients have experienced.> > While I don't have data to back up my impression, we are all aware of the "RN's complaining about cleaning up puke" scale and I can safely say that the reduction of noise along these lines has been significant....> > > R. David Smith, MD> Medical Director, Pediatric Emergency Services> Children's Acute Care> Cape Fear Valley Medical Center> Fayetteville, North Carolina> > > > AS WE KNOW, NO STRONG EVIDENCE FOR MIDAZ USE , ESPECIALLY IN THE YOUNG > (PREADOLESCENT AGE)....> > I disagree with you here. It depends on what you define as "strong" evidence. I would > refer you to Dr. Roback's work that showed that in controlled trials the group > that received midazolam prior to ketamine had a lower incidence of nausea & emesis during recovery. This may have to do with GABA receptor inhibition in the chemoreceptor trigger zones for emesis.> > > Thanks> > Jay (Pershad)> Le Bonheur> > For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > > ____________________________________________________________________________________> Be a better friend, newshound, and > know-it-all with Yahoo! Mobile. Try it now. http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ > > For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> _________________________________________________________________> Need to know the score, the latest news, or you need your Hotmail®-get your "fix".> http://www.msnmobilefix.com/Default.aspx> For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > For more information, send mail to [log in to unmask] with the message: info PED-EM-L> The URL for the PED-EM-L Web Page is:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
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