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PED-EM-L  August 2009

PED-EM-L August 2009

Subject:

Re: propofol credentialing for children in the ED

From:

Amy Baxter <[log in to unmask]>

Reply-To:

Amy Baxter <[log in to unmask]>

Date:

Fri, 21 Aug 2009 15:41:41 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (162 lines)

Sorry for the tardy reply, Michael - by now you're all probably
credentialled and sedating like the wind!

If not, a few thoughts.  First, at PEMA we are fortunate that deep
sedation falls under the core credentials of our PEM practice.  Our
anesthesiologists for both campuses of Children's Healthcare of Atlanta
signed off on Propofol years ago (nitrous was/is a more difficult battle),
but the CONCEPT has long been ingrained as we run the radiology sedation
service, special procedures, the ED, Heme-Onc, IR, etc.  We maintain this
service by being a rigorously self-policing group, with quality and
monitoring spearheaded by Michael Mallory, and have implemented multiple
improvements and systems over the years.  Our personal credentailling for
ED personnel who want to be part of the sedation service is as follows:

	Credentialing/Qualifying for Pediatric Sedation Services, LLC
	Board Certification in the sub-specialty of PEM
	Maintenance of Airway Skills
		The Airway Course (every 3 yrs)
			Or
		Day in the OR with Anesthesia (every yr)
	CME
		5 hrs per year of sedation related CME
	Participation in sedation nurse education series, once per year (includes
lecture and Mock code)
	2 days of orientation/observation before beginning clinical work 

We have debated in the Society for Pediatric Sedation
http://pedsedation.org meetings about just how many propofol sedations one
needs to do to feel comfortable.  20?  10?  Certainly, getting the hang of
sedating kids with it is an art, and with the incidence of serious adverse
events at much less than 1/20, doing 20 likely won't give you the
experience of rescuing.  Propofol decreases tone so much that you DO get a
lot of experience with repositioning airways as a matter of course,
although if you're using if in the ED with ketamine, perhaps, the tone
issue isn't such a big deal.  This question also surfaces on the
procedural sedation listserve run by one of the SPS pediatric emergency
docs, Mick Connors <[ mailto:pediatric_sedation%40listserve.com
][log in to unmask]>

As far as guidelines go, I'm consistently humbled by the quality of what
the Royal College of Australia Melbourne puts out on pain, sedation, etc.,
but I couldn't find anything from them on propofol.  You may want to check
out...

http://www.rch.org.au/emplibrary/rchcpg/HCGEvidenceTable_procedural_sedation.pdf
     annotated literature list for procedural sedation

"Why do we need a policy on procedural pain management"      has lots on
all aspects of procedural pain up to ketamine but not propofol

Alternately, I found this on the web  from University of Iowa 2003:
Recommendations for Privileging
 

1.	MD must be proficient at intubation, OR there must be dedicated
personnel who are capable of intubation immediately available to the
case.  Names of the dedicated personnel should be documented in the
sedation record.
 
2.	The physician should review the above “Guidelines for Use of Propofol
by Non-Anesthesiologists/Anesthetists,” and indicate in writing that
he/she has read and is familiar with this information.
 
3.	The physician should read, and indicate in writing that he/she has read
and is familiar with, the following publications:
	Byrne MF, Baillie J. Propofol for conscious sedation? Gastroenterology
2002;123:373-8.
	American Society for Gastroenterology. Technology status evaluation
report: propofol use during gastrointestinal endoscopy. Gastrointestinal
Endoscopy 2001;53:876-8.
	Steinbacher DM. Propofol: a sedative-hypnotic anesthetic agent for use
in ambulatory procedures. Anesth Prog 2001;48:66-71.
4.	The physician should attend and observe a minimum of 10 procedures
performed by another MHMH physician who has been credentialed to use
propofol.  This observation should be documented in writing and affirmed
by the signature of both the “credentialed” physician and the applying
physician. 

I'd obviously add Miner's Clinical Practice Guideline and might get rid of
the one that uses the anachronism "conscious sedation", but hey, it was
hip at the time.  I probably wouldn't mention Michael Jackson when you
apply.

Hope this helps some.  At least the lack of overwhelming consensus may
support you making your own up.  "We based this on the guidelines at X
institutions...."   If they require a specific sedation course rather than
an airway course, the SPS puts on a Sedation Provider Course which
emphasizes the 2006 AAP guidelines' focus on rescue from a deeper level of
sedation.  Lots of hands on "holy crap!" simulator stuff, along with great
collateral on the SPS site.  I'm not sure if the exact days are set yet,
but I believe November in Atlanta and, uh, May in Louisville?

Take care,
Amy


Amy Baxter MD FAAP FACEP
Pediatric Emergency Medicine Associates
Director of Emergency Research, Scottish Rite
Clinical Associate Professor, Medical College of Georgia


.Michael Kim <[log in to unmask]> writes:
>Dear Members,
>
>We are faced with a challenge in developing a pediatric propofol
>credentialing guideline in the ED setting here at University of Wisconsin.
>
>As most institutions who have gone through the process know, it is a
>highly sensitive and debated issue which we find ourselves in.
>
>I was hoping to obtain some thoughts and examples of credentialing
>requirements your institution for PEM physicians AND General EM
>physicians in pediatric use of propofol in the ED.
>
>Any thoughts would be helpful.
>
>Thanks in advance.
>
>Michael
>
>
>
>
>
>Michael K. Kim, MD, FAAP
>Director, Pediatric Emergency Medicine
>Associate Professor of Medicine and Pediatrics
>University of Wisconsin School of Medicine and Public Health
>F2/220 Clinical Science Center
>600 Highland Avenue
>Madison, WI 53792-3280
>608-890-7519
>608-262-2641 Fax
>[log in to unmask]
> 
>The information in this message (and the documents attached to it, if
>any) is confidential and may be legally privileged. It is intended
>solely for the addressee. Access to this message by anyone else is
>unauthorized. If you are not the intended recipient, any disclosure,
>copying, distribution or any action taken, or omitted to be taken in
>reliance on it is prohibited and may be unlawful. If you have received
>this message in error, please delete all electronic copies of this
>message (and the documents attached to it, if any), destroy any hard
>copies you may have created and notify me immediately by replying to
>this email. Thank you.
>
>
>
>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://listserv.brown.edu/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:
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