Episódios
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Today's sedation podcast is dedicated to discussing how to start a nitrous oxide service. I am delighted to be joined by Mary Kay Ferrell and Laura Mitchell. Mary Kay, a clinical sedation and procedural nurse at the Children's Hospitals and Clinics of Minnesota, who also has over 20 years of experience as a clinical educator for sedation and procedural services. She is a top national expert on the use of nitrous oxide in pediatric sedation, and how to start a nitrous oxide service. She is joined by Laura Mitchell, a child life specialist with the sedation team at Nemours Children's Hospital in Delaware. Laura is also on the executive board of the SPS.
In today’s episode, we share the success of a nitrous sedation program and to help others consider nitrous as an option for their patients.
So Mary Kay How did you first become interested in the use of nitrous oxide?
Actually, the first time I saw nitrous sedation used was in the emergency room. A patient with a dislocated shoulder was brought into our department with nitrous being used for pain control. The paramedic was delivering it with a mask and a small tank. The patient was calm and able to answer questions. When the nitrous was stopped, they were once again in severe pain.
Not too long after that, I witnessed it when my niece broke her ankle playing ball, the drama queen that she was as a teen, very loudly suggested in reasonable pain. After the paramedics started the nitrous she was silent
At that time, we were looking for something to repeat midazolam for our BCG patients during urinary catheterization, our radiology halls often sounded like a torture chamber with kids crying, we noticed that PO midazolam often did not calm down the kids and it didn't do much for the discomfort.
After the exam, they were crabby and sleepy. Often the kids had hallucinations that were very scary. For example, one kid told us that his nurse had four eyes and that his mom looked like a green monster. This is all while there were several people holding the child down to place a catheter, so you can just imagine how scared those kids are inadequate or no sedation parents often reported that their child would not allow them even to change a diaper.
After this type of traumatic experience, they had a horrible fear of health care providers or going to their doctor.
Our sedation department was asked to take over sedation for this procedure. We wanted to try nitrous. We thought if paramedics and dental hygienists could be trained to do it. Why couldn't nurses that were trained in advanced sedation working under the direction of a doctor do what as well?
What led you to consider nitrous as a change in practice for urinary catheter placement needed for BCGs?
Our sedation team understood how pain and distress experienced by a child with painful and distressing procedures sets the tone for future medical interactions.
This can have long term effects with their attitude and willingness to participate in health care now and in the future. We saw this even with parents who had gone through these types of procedures when they were a child, they didn't want to see their own children go through that.
Nitrous is a gas used for pain and anxiety since the 1860s. It is useful in reducing pain and anxiety during minimally invasive procedures common to the pediatric population. Nitrous works fast. The effects start in just a few minutes with a quick recovery to baseline in about five minutes. It has a lengthy history for safety and efficacy efficiency so it's efficient and safe.
So what other procedural considerations could not just be used?
You can consider nitrous possibly with a topical anesthetic for PIVs, IM's, suturing, lumbar punctures, Botox injections, foreign body removal, imaging, subcutaneous implants, GYN exams and
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In this episode, we will be welcoming Dr. Maala Bhatt, the Associate Professor of Pediatrics at the University of Ottawa. She is the Research Director for the Division of Emergency Medicine and a pediatric emergency medicine physician at the Children’s Hospital of Eastern Ontario (CHEO). She is a member of the Society for Pediatric Sedation. She led the development of the first standardized definitions for procedural sedation and has published the largest emergency department procedural sedation cohort, establishing practices associated with the safest sedation outcomes.
Her primary research interest is in the safety of emergencies department procedural sedation. She has published multiple articles and peer review journals on sedation related topics including on fasting before procedural sedation. The first patient case scenario is of an eighteen month old girl scheduled for a brain MRI for a focal seizure which occurred three days ago, and her parents are asking if they have to keep their NPO for so long and whether there is any science behind this practice of fasting before sedation.
The second case is one of a seven year old boy with a forearm fracture which requires redaction and casting under procedural sedation. The patient had eaten a peanut butter sandwich an hour before the fall. Join us as we dive into this insightful discussion with Dr. Bhatt on fasting before procedural sedation and how previous fasting guidelines came about, and what is changing about that. Enjoy!
Show Highlights
Our understanding of aspiration and its risk factors with respect to the history of fasting guidelines (02:16)The risk for aspiration during procedural sedation (04:52)The aspiration risk for children prior to sedation when drinking clear liquids (05:38)Advantages and disadvantages of prolonged fasting in children with respect to clear liquids (06:51)Current guidelines being followed today in procedural sedation (08:31)The association between pre-procedural fasting duration and the incidence of sedation related adverse outcomes during emergency department sedation of children (10:43)Dr. Bhatt’s thoughts on the 2016 study reporting on the association between aspiration and patient and procedure factors (12:26)Changes in practice that may come about from different publications stating that fasting is not a risk factor for aspiration (15:46)Understanding that NPO time on its own is not a predictor for aspiration (17:45)Additional Resources
Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children
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In this episode, we will be welcoming Dr. Kevin Couloures, a clinical associate professor of pediatrics at Stanford University and a pediatric critical care physician at the Lucile Packard Children’s Hospital and the California Pacific Medical Center in California. He has been with the Society for Pediatric Sedation for maNy years and is currently the vice-chair for the research committee and the Pediatric Sedation Research Consortium, the research arm of the Society for Pediatric Sedation.
The first patient case today is that of a four year old boy who needs a brain MRI for a focal seizure he had two days ago. The patient has no allergies and is previously healthy. He was sedated using a propofol bolus and is maintained on a propofol infusion in the MRI. It’s going to be a very insightful episode so don’t miss out.
Show Highlights
Why the monitoring of a patient undergoing procedural sedation is so important (01:32)How to classify intended levels of sedation (03:08)The monitoring tools used in pediatric procedural sedation (05:00)Monitoring a child who is receiving mild, moderate or deep sedation (05:24)The ideal monitoring for a patient who just went through a procedure and is waiting for discharge (07:37)Role of pulse oximetry and capnography in procedural sedation (08:43)Bispectral (Bispectral index monitor) analysis during pediatric procedural sedation outside the operating room and its role (12:12)Recommended monitoring for short hematology oncology procedures such as lumbar punctures (13:24)Information available from the pediatric sedation research consortium about monitoring (14:40)Dr. Couloures’ personal clinical pearls regarding physiologic monitoring of patients undergoing procedural sedation (16:00)Additional Resources
www.Capnography.comBispectral analysis during procedural sedation in the pediatric emergency department
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In this episode, we will be welcoming Dr. Mary Landrigan-Ossar, a Senior Associate in Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children’s Hospital. Dr. Landrigan is also an Assistant Professor of Anesthesia at Harvard Medical School. She has been involved with the Society for Pediatric Sedation for a long time and serves on the executive committee as well as the board of directors.
Dr. Landrigan comes on to help us gather insight on how sedation practitioners should approach procedural sedation in high risk patients outside of the operating room where they focus on pre-screening prior to procedural sedation. Join us to learn more
Show Highlights
Why it’s so important to assess a child’s risk profile prior to procedural sedation (01:29)Patient risk factors associated with sedation related adverse events (03:02)Concerns regarding the sedation of infants where the infants are under 3 months of age (04:50)How prematurity poses a risk for sedation related adverse events (06:24)The relation between obesity and increased risk for adverse events in procedural sedation (07:58)Risks posed to procedural sedation by children that have upper respiratory tract infections (09:11)Scenario where a child snores like an adult while sleeping or has noisy breathing during sleep (11:07)Dealing with children who have heart disease when they are presented for procedural sedation (13:34)Different instances where sedation practitioners should be very cautious and consult an anesthesiologist (17:53)Clinical pearls in sedating high risk patients and the necessary careful pre-screening required for such patients (20:08)Resources:
Society of Pediatric Sedation Website
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In this episode, we will be welcoming Dr. Megan Peters and Dr. Abdallah Dalabih to have a chat with us about how to develop a sedation regimen for patients undergoing procedural sedation outside the operating room. Dr. Peters is the Assistant Professor of Pediatrics at the University of Wisconsin School of Medicine and Public Health. She is a pediatric intensivist and the Director of Pediatric Sedation Program at American Family Children’s Hospital. Dr. Dalabih is the Associate Professor of Pediatrics at the University of Arkansas for Medical Sciences and is also a pediatric intensivist.
He is the Director of Pediatric Sedation Programs at Arkansas Children’s Hospital. One of the hypothetical cases is where the patient is a three year old boy who needs an MRI with contrast for a prolonged focal seizure which occurred four days ago. He is previously healthy, has no significant past medical history and has not been exposed to anesthesia or procedural sedation in the past. He has no known drug allergies and on examination, his physical exam is unremarkable with normative vital signs for his age. He is also appropriately NPO. Stay tuned to learn more from Dr. Peters and Dr. Dalabih!
Show Highlights
Factors to consider when creating a sedation regimen for a child who will undergo procedural sedation (01:18)Examples of painful, non-painful and distressing procedures (02:45)How to go about choosing a sedation regimen for patients in line with the guidelines of the American Academy of Pediatrics (05:22)Sedation for a child who has proven allergies such as anaphylaxis (06:55)Second hypothetical case: 5 year old girl with symptoms consistent with acute lymphocytic Leukemia and requires procedural sedation for a diagnostic bone marrow aspiration and biopsy with a lumbar puncture (10:09)Procedural sedation for a 6 year old girl who has autism spectrum disorder and requires procedural sedation in order to undergo venipuncture, ECD, and Echo (13:36)9 year old with a distal radius and ulna fracture from a recent fall on his right arm requiring reduction and casting of the fracture (16:12)The importance of using a multidisciplinary team approach to sedation for (18:05)Additional Resources
Is Orally Administered Pentobarbital a Safe and Effective Alternative to Chloral Hydrate for Pediatric Procedural Sedation?
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In this first episode of the Society for Pediatric Sedation (SPS) Podcast, we will be discussing the use of intranasal medication in procedural sedation for children. We will be joined by Dr. Carmen Sulton, the Assistant Professor of Pediatrics at Emory University School of Medicine and Director of Children Sedation Services at Egleston campus in Atlanta. Dr. Sulton is well published in the field of pediatric procedural sedation including a recent paper on the use of intranasal Dexmedetomidine published in Pediatric Emergency Care in 2020. The paper uses patient outcomes data from the Pediatric Sedation Research Consortium database, the research arm of the Society for Pediatric Sedation.
In our case today, we have a five months old infant who requires an MRI of his brain. The patient is an ex-32 week premature infant with a history of difficult IV access. There’s no history of upper respiratory tract infection, no snoring, heart disease, or any medication allergy in this infant. The MRI is needed for a focal seizure that occured two weeks ago and the patient doesn’t require an IV since this is not a contrasted MRI. Dr. Sulton will generously share with us why intranasal medications are needed in procedural sedation and so much more, so don’t miss out if this is a topic of interest for you.
Meet your hosts:
Pradip Kamat, MD, MBA - Associate Professor of Pediatrics and Critical Care Physician at Emory University School of Medicine and Children’s Healthcare of Atlanta/Egleston.
Anne Stormorken, MD - Professor of Pediatrics and Critical Care Physician at UH Rainbow Babies and Children’s Hospital and Case Western Reserve School of Medicine of Cleveland, OH.
Show Highlights
Diving into how intranasal medications work (01:58)Circumstances where intranasal medications must not be used for procedural sedation (04:35)How she uses Dexmedetomidine and Midazolam (06:28)Research findings on the success rate with the use of intranasal medications (09:14)Other medications that can be used intranasally for procedural sedation (11:42)Optimizing the efficacy of intranasal medications when delivering them (12:09)Giving IV sedation where there is intranasal medication failure (13:23)Large dataset studies that support the successful use of intranasal medications in procedural sedation (14:23)Additional Resources
The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children
