Table Of Content

Procedural Sedation P r o Procedural Sedation for Infants, Children, and Adolescents c e d American Academy of Pediatrics u r a Section on Anesthesiology and Pain Medicine l S e for Infants, Children, and Adolescents d a EdItoRS t i o Joseph d. tobias, Md, FAAP n f Joseph P. Cravero, Md, FAAP o r I n f a n EditoRS Invasive and noninvasive procedures are t Contents include s a common and necessary component in , C Joseph d. tobias, Md, FAAP ■ h the management of infants, children, and i l ■ d Joseph P. Cravero, Md, FAAP adolescents with acute and chronic diseases. r e As technology continues to expand, there n ■ , a are an increasing number of techniques n d that require procedural sedation outside ■ A of the operating room. d ■ o l Authored by experts in a variety of specialties, e ■ s c Procedural Sedation for Infants, Children, e n and Adolescents is a comprehensive guide for ■ ts the initial design and implementation of a procedural sedation program and a tool to ■ educate pediatric health care professionals on medications used for sedation, associated ■ adverse events, and treatment of these JJ oo ss adverse events. ee pp hh P d . C. t ro ab For other pediatric resources, ISBN 978-1-58110-933-7 veia 90000> ros, visit the American Academy , M M d d, of Pediatrics at , F FA AA shop.aap.org. APP 9 781581 109337 AAP PSFICAA COVER SPREAD.indd 1 7/20/15 10:35 AM Procedural Sedation for Infants, Children, and A dolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics Editors Joseph D. Tobias, MD, FAAP Joseph P. Cravero, MD, FAAP American Academy of Pediatrics 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019 American Academy of Pediatrics Publishing Staff Director, Department of Publishing: Mark Grimes Manager, Product Development: Eileen Glasstetter, MS Manager, Publishing and Production Services: Theresa Wiener Manager, Editorial Services: Jason Crase Manager, Art Direction and Production: Linda Diamond Director, Department of Marketing and Sales: Mary Lou White Marketing Manager, Professional Publications: Linda Smessaert, MSIMC Library of Congress Control Number: 2014957782 ISBN: 978-1-58110-933-7 eBook: 978-1-58110-934-4 The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications and dosages and for added warnings and precautions. Product names are mentioned in this publication for identification and informational purposes only and do not imply endorsement by the American Academy of Pediatrics. The American Academy of Pediatrics is not responsible for the content of the resources mentioned in this publication. Web site addresses are as current as possible but may change at any time. The publishers have made every effort to trace the copyright holders for borrowed materials. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. Disclosures: Dr Zempsky indicated an advisory board relationship with Marathon Pharmaceuticals and Vapogenix. Dr Berkenbosch conducts clinical trials sponsored by Grünenthal Group and Janssen Pharmaceuticals with no personal compensation to him. All other contributors disclosed no relevant financial relationships. This book has been developed by the American Academy of Pediatrics. The authors, editors, and contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. Copyright © 2016 American Academy of Pediatrics. All rights reserved. No part of this p ublication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means— electronic, mechanical, photocopying, recording, or otherwise—without prior permission from the publisher (locate title at http://ebooks.aappublications.org; click on © Get Permissions). Printed in the United States of America. MA0753 9-350/0815 1 2 3 4 5 6 7 8 9 10 American Academy of Pediatrics Section on Anesthesiology and Pain Medicine 2014–2015 Executive Committee Members Joseph D. Tobias, MD, FAAP, Chairperson Rita Agarwal, MD, FAAP, Chairperson-Elect Corrie T. M. Anderson, MD, FAAP Courtney A. Hardy, MD, FAAP Anita Honkanen, MD, FAAP Mohamed A. Rehman, MD, FAAP Carolyn F. Bannister, MD, FAAP, Immediate Past Chairperson Liaisons Randall P. Flick, MD, MPH, FAAP, American Society of Anesthesiologists Committee on Pediatric Anesthesia Constance S. Houck, MD, FAAP, American Academy of Pediatrics Committee on Drugs Staff Jennifer Riefe, MEd Contributors/Reviewers Editors Joseph D. Tobias, MD, FAAP Joseph P. Cravero, MD, FAAP Chief, Department of Anesthesiology and Associate Professor of Anaesthesia Pain Medicine Harvard Medical School Nationwide Children’s Hospital Senior Associate, Divisions of Perioperative Professor of Anesthesiology and Pediatrics Anesthesia and Pain Medicine The Ohio State University Boston Children’s Hospital Columbus, OH Boston, MA Chapter Authors John W. Berkenbosch, MD, FCCM, FAAP Joanne R. Hojsak, MD Professor of Pediatrics and Pediatric Critical Associate Professor Care Department of Pediatrics, Pediatric Critical Director, University Children’s Sedation Service Care Medicine University of Louisville Icahn School of Medicine at Mount Sinai Kosair Children’s Hospital Kravis Children’s Hospital at Mount Sinai Louisville, KY New York, NY 5: Medications Part 1: Sedatives and Anxiolytics 8: Specific Clinical Scenarios Joseph P. Cravero, MD, FAAP Gregory A. Hollman, MD, FAAP Associate Professor of Anaesthesia Professor of Pediatrics Harvard Medical School Division of Pediatric Critical Care Medicine Senior Associate, Divisions of Perioperative Medical Director, Diagnostic and Anesthesia and Pain Medicine Therapy Center Boston Children’s Hospital University of Wisconsin Boston, MA American Family Children’s Hospital 1: Pediatric Sedation: The Past, Present, Madison, WI and Future 9: Non-pharmacologic Interventions in 7: Complications of Procedural Sedation Children During Medical and Surgical Procedures Eric W. Fleegler, MD, MPH, FAAP 11: Pediatric Sedation Credentialing and Assistant Professor of Pediatrics Privileging Harvard Medical School Division of Emergency Medicine Constance S. Houck, MD, FAAP Boston Children’s Hospital Associate Professor of Anaesthesia Boston, MA Harvard Medical School 4: Monitoring for Procedural Sedation Senior Associate, Division of Perioperative Anesthesia Cheryl K. Gooden, MD, FAAP Boston Children’s Hospital Associate Professor of Anesthesiology Boston, MA and Pediatrics 4: Monitoring for Procedural Sedation Icahn School of Medicine at Mount Sinai 10: Topical and Local Anesthetic Agents Kravis Children’s Hospital at Mount Sinai New York, NY Pradip P. Kamat, MD, MBA, FAAP 8: Specific Clinical Scenarios Director, Children’s Sedation Services Children’s at Egelston Assistant Professor of Pediatrics Emory University Atlanta, GA 7: Complications of Procedural Sedation Contributors/Reviewers v Marc S. Leder, MD, FAAP Thomas A. Taghon, DO, MHA Attending Physician, Department of Vice Chair, Quality Improvement Emergency Medicine Department of Anesthesiology and Pain Nationwide Children’s Hospital Medicine Clinical Professor of Pediatrics Nationwide Children’s Hospital The Ohio State University Clinical Assistant Professor of Anesthesiology Columbus, OH The Ohio State University 6: Medications Part 2: Ketamine, Nitrous Oxide, Columbus, OH and Opioids 12: Quality Improvement and Assurance Kristine K. Murray, CCLS Joseph D. Tobias, MD, FAAP Child Life Specialist, Diagnostic and Chief, Department of Anesthesiology and Therapy Center Pain Medicine University of Wisconsin Nationwide Children’s Hospital American Family Children’s Hospital Professor of Anesthesiology and Pediatrics Madison, WI The Ohio State University 9: Non-pharmacologic Interventions in Columbus, OH Children During Medical and Surgical 2: The Pre-sedation Evaluation Procedures 6: Medications Part 2: Ketamine, Nitrous Oxide, and Opioids Daniel M. Roke, MD, FAAP 10: Topical and Local Anesthetic Agents Assistant Professor Division of Pediatric Anesthesiology Joshua C. Uffman, MD Vanderbilt University Director, Procedural Sedation and Off-Site Medical Director, PATCH Clinic Anesthesia Monroe Carell Jr Children’s Hospital at Department of Anesthesiology and Pain Vanderbilt Medicine Nashville, TN Nationwide Children’s Hospital 3: Documentation and Parental Instructions Clinical Assistant Professor of Anesthesiology for Pediatric Sedation The Ohio State University Columbus, OH Sandra P. Spencer, MD, FAAP 12: Quality Improvement and Assurance Attending Physician, Department of Emergency Medicine William T. Zempsky, MD, MPH, FAAP Nationwide Children’s Hospital Chief, Division of Pain and Palliative Medicine Assistant Professor of Clinical Pediatrics Connecticut Children’s Medical Center The Ohio State University Professor of Pediatrics Columbus, OH University of Connecticut School of Medicine 6: Medications Part 2: Ketamine, Nitrous Oxide, Hartford, CT and Opioids 10: Topical and Local Anesthetic Agents Michael J. Stoner, MD, FAAP Attending Physician, Department of Emergency Medicine Nationwide Children’s Hospital Assistant Professor of Clinical Pediatrics The Ohio State University Columbus, OH 6: Medications Part 2: Ketamine, Nitrous Oxide, and Opioids vi Contributors/Reviewers American Academy of Pediatrics Reviewers Board of Directors Reviewer Anthony D. Johnson, MD, FAAP Committees, Councils, and Sections Committee on Drugs Section on Cardiology and Cardiac Surgery Committee on Medical Liability and Risk Section on Emergency Medicine Management Section on Gastroenterology, Hepatology, and Committee on Pediatric Emergency Medicine Nutrition Committee on Substance Abuse Section on Hematology/Oncology Council on Quality Improvement and Section on Oral Health Patient Safety To those who care for and comfort children. You hold my hand, your pace is slow. You give me time for my stride to grow. I follow you and learn your ways. You teach me how to walk my days. Your steps are big, mine are small. We stroll together, through it all. Take my hand, don’t let go. But hold it loose, to let me grow. —Anonymous To my wife, Julie, and my boys, Drew and Michael, who inspire, guide, and love me unconditionally; buddies forever. —Joseph D. Tobias, MD, FAAP To my family—who have taught me everything I know about love and humanity, in all aspects of life. —Joseph P. Cravero, MD, FAAP Contents Foreword ............................................................................................................xi Charles J. Coté, MD, FAAP Preface.............................................................................................................xiii Joseph D. Tobias, MD, FAAP Joseph P. Cravero, MD, FAAP Chapter 1 Pediatric Sedation: The Past, Present, and Future ...........................1 Joseph P. Cravero, MD, FAAP Chapter 2 The Pre-sedation Evaluation ...........................................................11 Joseph D. Tobias, MD, FAAP Chapter 3 Documentation and Parental Instructions for Pediatric Sedation .........................................................................27 Daniel M. Roke, MD, FAAP Chapter 4 Monitoring for Procedural Sedation .............................................43 Eric W. Fleegler, MD, MPH, FAAP Constance S. Houck, MD, FAAP Chapter 5 Medications Part 1: Sedatives and Anxiolytics ...............................61 John W. Berkenbosch, MD, FCCM, FAAP Chapter 6 Medications Part 2: Ketamine, Nitrous Oxide, and Opioids ............91 Marc S. Leder, MD, FAAP Sandra P. Spencer, MD, FAAP Joseph D. Tobias, MD, FAAP Michael J. Stoner, MD, FAAP Chapter 7 Complications of Procedural Sedation...........................................115 Joseph P. Cravero, MD, FAAP Pradip P. Kamat, MD, MBA, FAAP Chapter 8 Specific Clinical Scenarios ...........................................................137 Cheryl K. Gooden, MD, FAAP Joanne R. Hojsak, MD Chapter 9 Non-pharmacologic Interventions in Children During Medical and Surgical Procedures ..................................................177 Kristine K. Murray, CCLS Gregory A. Hollman, MD, FAAP x Contents Chapter 10 Topical and Local Anesthetic Agents ...........................................205 Constance S. Houck, MD, FAAP William T. Zempsky, MD, MPH, FAAP Joseph D. Tobias, MD, FAAP Chapter 11 Pediatric Sedation Credentialing and Privileging ........................225 Gregory A. Hollman, MD, FAAP Chapter 12 Quality Improvement and Assurance ...........................................253 Thomas A. Taghon, DO, MHA Joshua C. Uffman, MD Index ...............................................................................................................285