Pediatric Procedural Sedations

meandragonbrett · Aug 21, 2002

WOW!! He wants to intubate MRI pts!! We use a Combination of Demerol and Versed for our Sedation on all patients and RNs aren't allowed to monitor it b\c Versed is considered an anesthesia drug so a CRNA or MDA must be present. Why on EARTH would he intubate a MRI pt??? I don't understand that one! We only use Propofol in the unit for pts on a vent. as far as sedation goes. That's just about the only drug they use in the OR for anesthesia purposes.

Alley Cat · Aug 28, 2002

In reviewing the cases in question, guess this doc thought the patients were at high risk for having respiratory problems while on the MRI table... He's stated that infants 1 year of age and under he will probably plan on intubating, and any child with a history of respiratory problems. Has also required patients have NOTHING after midnight, not even seizure meds with sips of water, even though he doesn't want any MRI procedures scheduled before 10 am at the earliest due to ICU rounds and early am committee meetings. This is causing problems with several pediatricians in town, who don't want their kids dehydrated. This is NOT the way I've been used to doing things, and also not the way the current literature reads. He thinks I'm being difficult, but at least 3 other nurses are also questioning him when they take care of his sedation patients. We used to do 3-4 MRI's/week, now we're down to 1 (if we're lucky). I'm seeing a pattern, and management doesn't get it. (He thinks he's going to take over ALL the peds. sedations, and I don't see how he can do that and do ICU patients.) Maybe it's just me, but I get a really bad feeling about this. :confused:

dhenceroth · Aug 28, 2002

Our moderate sedation policy allows for dose limited amounts of morphine, versed, valium on peds pts.. Chloral hydrate is used for sleep EEGs. If your physician is doing alot of intubating, then he is NOT doing "moderate" sedation, but administering anesthesia. Is he credentialed to administer anesthesia? Someone in PI should be monitoring this outcome (intubations / use of reversal agents....JCAHO requirement) I have seen ketamine used in some peds sedation protocols, however not propofol. Our Med. staff chose not to allow those drugs (e.g. ketamine, propofol) in the policy because not all the physicians would be knowledgeable enough to use them safely.

Pediatric Critical Care Columnist · Aug 28, 2002

Propofol should be used with extreme caution in children, even for procedural sedation. It has been associated with a number of pediatric deaths due to dysrhythmias, particularly problematic when used for long-term (ie longer than a few hours) sedation. Our unit lost a patient to this very thing last winter, and he technically wasn't a peds patient, being 16 years old at the time. The drug we use most these days is midazolam (Versed); it has a fairly rapid onset of action, even in the oral dosage, doesn't depress respiratory drive in sedative doses, has a short half-life and seems to leave no lingering after effects. In the PICU where I work, we use it for a lot of procedures, and have asked to have it included in our code drug tray, because that is the first thing the docs ask for; what we have to offer them is lorazepam. In the last few years I've seen a move from thiopental and succinylcholine for intubation to midazolam and rocuronium or vecuronium. We have also moved to more midazolam infusions for longer-term sedation , although morphine is still the usual.

My developmentally delayed (but very aware) son received a midazolam cocktail prior to some dental work recently. Within ten minutes of his last slurp, he was drowsy; another ten minutes and he was asleep. He wasn't so out-of-it that he didn't notice the local being injected, but was very relaxed for the rest of the procedure. Total time "out" was about 2 hours. By suppertime he was back to normal.

talkall · Aug 29, 2002

someone tell me whats wrong? all our mri kids that arent old enought get a GA for it is this so strange????

Alley Cat · Aug 31, 2002

The issue is not that the kids are getting anesthesia (and yes, this individual is qualified for ketamine and propofol as an intensivist), but that it seems like it's being the first thing used. The other staff who have been doing these longer are used to using nembutal and versed for mri's; if the sedation is unsuccessful (not tolerated, child has paradoxical reaction), then the mri is rescheduled with an anesthesiologist on hand. My original concern was that it seemed like overkill. Propofol is used by this doc because it supposedly has less respiratory depressant effect. The only other time I've seen propofol used is in the OR and mostly on adult patients, so I'm just learning about it. I'm NRP and PALS certified, and the majority of my prior working experience has been ICU, so I'm used to patients being "down and out" for procedures. Outpatient care is a whole different ballgame, so that's why I'm asking questions. Thanks for the input, everyone. :)

Alley Cat · Aug 31, 2002

Originally posted by dhenceroth
[someone in PI should be monitoring this outcome (intubations / use of reversal agents....JCAHO requirement). [/b]

Our risk management department has developed a data collection tool for all sedation patients throughout the facility. We are filling them out with all of the required information. Also, our policy is pretty much like yours. This gentleman was asked by the MRI radiologist and our service line director (ie, physician liaison) to take on the MRIs in addition to his responsibilities as peds intensivist, and just has some different ways of doing things than we were previously used to.