Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0046
C. Mannix
In patients with cerebral palsy, injections of botulinum toxin type A (Botox) into muscle groups to reduce spasticity may decrease spasmodic pain and improve movement by increasing range of motion, thereby facilitating care and potentially lessening contracture development. This procedure requires little time but is painful, and repeated treatments are necessary. The level of sedation used for this procedure varies among institutions and from patient to patient, ranging from no sedation at all to general anesthesia. Minimal to moderate sedation with nitrous oxide is an effective method of sedation for this procedure. The sedationist must be prepared to handle complications such as emesis and aspiration. Injection of the submandibular and parotid glands for sialorrhea is a growing indication for Botox injection; deeper levels of sedation are required for sialorrhea than for spasticity to allow localization of the gland and precise delivery of the treatment.
{"title":"Botox Injections for Spasticity and Sialorrhea","authors":"C. Mannix","doi":"10.1093/med/9780190659110.003.0046","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0046","url":null,"abstract":"In patients with cerebral palsy, injections of botulinum toxin type A (Botox) into muscle groups to reduce spasticity may decrease spasmodic pain and improve movement by increasing range of motion, thereby facilitating care and potentially lessening contracture development. This procedure requires little time but is painful, and repeated treatments are necessary. The level of sedation used for this procedure varies among institutions and from patient to patient, ranging from no sedation at all to general anesthesia. Minimal to moderate sedation with nitrous oxide is an effective method of sedation for this procedure. The sedationist must be prepared to handle complications such as emesis and aspiration. Injection of the submandibular and parotid glands for sialorrhea is a growing indication for Botox injection; deeper levels of sedation are required for sialorrhea than for spasticity to allow localization of the gland and precise delivery of the treatment.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"101 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132596889","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0023
C. Chumpitazi
The incidence of sedation-related adverse events depends on (1) the medications used; (2) the type, duration, invasiveness, and location of the procedure; and (3) patient factors (e.g., age, medical condition, psychological factors). For the purposes of this chapter, moderate adverse sedation-related events represent physiologic change that is extremely likely to lead to significant patient harm if unnoticed or responded to ineffectively by the sedationist. Apnea, airway obstruction, and laryngospasm are examples. The relative likelihood of events of this type (1 of every 400 sedation episodes) provides significant impetus for effective preparation and training so that sedationists can effectively respond to these adverse events or preempt them. Even though they are categorized as “moderate” and may not be associated with harm in and of themselves, these events may certainly progress to produce significant harm.
{"title":"Moderate Adverse Events","authors":"C. Chumpitazi","doi":"10.1093/med/9780190659110.003.0023","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0023","url":null,"abstract":"The incidence of sedation-related adverse events depends on (1) the medications used; (2) the type, duration, invasiveness, and location of the procedure; and (3) patient factors (e.g., age, medical condition, psychological factors). For the purposes of this chapter, moderate adverse sedation-related events represent physiologic change that is extremely likely to lead to significant patient harm if unnoticed or responded to ineffectively by the sedationist. Apnea, airway obstruction, and laryngospasm are examples. The relative likelihood of events of this type (1 of every 400 sedation episodes) provides significant impetus for effective preparation and training so that sedationists can effectively respond to these adverse events or preempt them. Even though they are categorized as “moderate” and may not be associated with harm in and of themselves, these events may certainly progress to produce significant harm.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132166023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0002
J. Chorney, Melissa Howlett
Children often experience stress around medical procedures. High procedural stress can interfere with the quality or outcome of a procedure and the ease with which it is accomplished. High, unmanaged procedural stress is also associated with more pain, longer recovery times, behavioral disturbances, and increased procedural stress and fear about future medical procedures. Both malleable and nonmalleable factors are predictive of children’s procedural stress, as well as their use of coping behaviors. While nonmalleable factors cannot be changed at the time of the procedure, the presence of such factors can alert healthcare providers to children in need of support. Many well-researched strategies are available to target malleable predictors and thereby mitigate procedural stress, such as adequate preparation for both children and parents, and effective use of coping behaviors. Implementation of such strategies can facilitate optimal procedure completion and foster a positive medical experience for children, thereby giving them greater confidence for future medical encounters.
{"title":"The Impacts of Procedural Stress","authors":"J. Chorney, Melissa Howlett","doi":"10.1093/med/9780190659110.003.0002","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0002","url":null,"abstract":"Children often experience stress around medical procedures. High procedural stress can interfere with the quality or outcome of a procedure and the ease with which it is accomplished. High, unmanaged procedural stress is also associated with more pain, longer recovery times, behavioral disturbances, and increased procedural stress and fear about future medical procedures. Both malleable and nonmalleable factors are predictive of children’s procedural stress, as well as their use of coping behaviors. While nonmalleable factors cannot be changed at the time of the procedure, the presence of such factors can alert healthcare providers to children in need of support. Many well-researched strategies are available to target malleable predictors and thereby mitigate procedural stress, such as adequate preparation for both children and parents, and effective use of coping behaviors. Implementation of such strategies can facilitate optimal procedure completion and foster a positive medical experience for children, thereby giving them greater confidence for future medical encounters.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127300940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0057
J. Sturm, Jerard (Mick) Connors
Under current Center for Medicare and Medicaid Services (CMS) regulations, hospitals are responsible for establishing policies and procedures that differentiate anesthesia from analgesia/sedation. They are also responsible for determining the qualifications for practitioners who administer sedation based on nationally recognized guidelines. CMS regulations require the anesthesia service in CMS-certified hospitals to develop hospital policies and procedures governing the provision of all categories of anesthesia services, including specifying the minimum qualifications for practitioners permitted to provide procedural sedation. Additional regulatory bodies such as state survey agencies, which may include departments of health and accrediting organizations, follow CMS interpretive guidelines to determine a facility’s compliance with the Medicare Conditions of Participation. State laws, health department requirements, professional boards, accrediting organization standards, and facility bylaws and policy may exceed CMS requirements.
{"title":"Regulatory Issues","authors":"J. Sturm, Jerard (Mick) Connors","doi":"10.1093/med/9780190659110.003.0057","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0057","url":null,"abstract":"Under current Center for Medicare and Medicaid Services (CMS) regulations, hospitals are responsible for establishing policies and procedures that differentiate anesthesia from analgesia/sedation. They are also responsible for determining the qualifications for practitioners who administer sedation based on nationally recognized guidelines. CMS regulations require the anesthesia service in CMS-certified hospitals to develop hospital policies and procedures governing the provision of all categories of anesthesia services, including specifying the minimum qualifications for practitioners permitted to provide procedural sedation. Additional regulatory bodies such as state survey agencies, which may include departments of health and accrediting organizations, follow CMS interpretive guidelines to determine a facility’s compliance with the Medicare Conditions of Participation. State laws, health department requirements, professional boards, accrediting organization standards, and facility bylaws and policy may exceed CMS requirements.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126879493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0062
Ashwin S Krishna, C. Landers
Pediatric sedation programs benefit from tracking quality metrics and implementing processes to improve the sedation experience. Quality, safe pediatric sedation care involves well-organized, educated teams that track outcomes and constantly review events and situations that need improvement. This requires a multidisciplinary approach, an effort to decrease waste in terms of time and human resources, a focus on equitable care for all patients, and efforts to tailor care to the specific needs of the individual. Tracking appropriate metrics and making changes to pediatric sedation practice and process in order to maintain benchmarks and improve current practice can help institutions improve the quality of the sedation experience for patients, families, and providers. Pediatric sedation programs, regardless of resources, provider type, or institutional constraints, will benefit from using data to create processes that correctly identify and address obstacles to high-quality sedation care.
{"title":"Quality Improvement in Pediatric Sedation","authors":"Ashwin S Krishna, C. Landers","doi":"10.1093/med/9780190659110.003.0062","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0062","url":null,"abstract":"Pediatric sedation programs benefit from tracking quality metrics and implementing processes to improve the sedation experience. Quality, safe pediatric sedation care involves well-organized, educated teams that track outcomes and constantly review events and situations that need improvement. This requires a multidisciplinary approach, an effort to decrease waste in terms of time and human resources, a focus on equitable care for all patients, and efforts to tailor care to the specific needs of the individual. Tracking appropriate metrics and making changes to pediatric sedation practice and process in order to maintain benchmarks and improve current practice can help institutions improve the quality of the sedation experience for patients, families, and providers. Pediatric sedation programs, regardless of resources, provider type, or institutional constraints, will benefit from using data to create processes that correctly identify and address obstacles to high-quality sedation care.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115123518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0034
Amber P. Rogers
Magnetic resonance imaging (MRI) and computed tomography (CT) are among the most common procedures to require some level of pediatric sedation. Although painless, they necessitate immobility for adequate imaging quality. Many children can complete these diagnostic procedures without sedation, and this should be encouraged. If sedation medications are needed, propofol is commonly used to administer deep sedation for these procedures given its fast induction and recovery times, but particularly careful ventilation monitoring with capnography is important for the sedation provider who is physically separated from the patient in the MRI suite. Dexmedetomidine use is increasing in both MRI and CT sedation; its advantages are maintenance of airway tone and possible neuroprotective effects, but its disadvantages are longer induction and recovery times. Safety, efficacy, and efficiency should be carefully considered when coordinating sedation care for MRI and CT procedures.
{"title":"Magnetic Resonance Imaging and Computed Tomography Imaging Sedation","authors":"Amber P. Rogers","doi":"10.1093/med/9780190659110.003.0034","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0034","url":null,"abstract":"Magnetic resonance imaging (MRI) and computed tomography (CT) are among the most common procedures to require some level of pediatric sedation. Although painless, they necessitate immobility for adequate imaging quality. Many children can complete these diagnostic procedures without sedation, and this should be encouraged. If sedation medications are needed, propofol is commonly used to administer deep sedation for these procedures given its fast induction and recovery times, but particularly careful ventilation monitoring with capnography is important for the sedation provider who is physically separated from the patient in the MRI suite. Dexmedetomidine use is increasing in both MRI and CT sedation; its advantages are maintenance of airway tone and possible neuroprotective effects, but its disadvantages are longer induction and recovery times. Safety, efficacy, and efficiency should be carefully considered when coordinating sedation care for MRI and CT procedures.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132077000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0045
J. Barber, J. Cooper
Lacerations, abscesses, and burns are common presenting complaints evaluated in outpatient settings, urgent care centers, and emergency departments. These conditions are often painful, and the treatment procedures may cause additional pain or anxiety. The location and severity of the wound and the chronologic and developmental age of the patient influence the need for local anesthesia or systemic medications to make procedures tolerable for the patient. This section discusses the safe administration of medications to facilitate laceration repair, incision and drainage of abscesses, and burn debridement. General principles of the types of analgesia or sedation that are useful for these procedures are discussed.
{"title":"Cutaneous","authors":"J. Barber, J. Cooper","doi":"10.1093/MED/9780190659110.003.0045","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0045","url":null,"abstract":"Lacerations, abscesses, and burns are common presenting complaints evaluated in outpatient settings, urgent care centers, and emergency departments. These conditions are often painful, and the treatment procedures may cause additional pain or anxiety. The location and severity of the wound and the chronologic and developmental age of the patient influence the need for local anesthesia or systemic medications to make procedures tolerable for the patient. This section discusses the safe administration of medications to facilitate laceration repair, incision and drainage of abscesses, and burn debridement. General principles of the types of analgesia or sedation that are useful for these procedures are discussed.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"60 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134079461","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0025
Peter Chin, Sarah L Walls
This section summarizes the risks and complications of sedation. Topics include what should be discussed with parents when obtaining consent. The sedation plan should be discussed with parents during the consent process. “Material” risks should be disclosed, including both minor but frequent events such as nausea, and rare but severe complications such as cardiac arrest. Limits of sedation should also be discussed. Written consent should be documented in an anesthesia (or sedation)-specific consent form. This section also includes the topic of anesthesia- and sedation-related neurotoxicity. Data from animal and human studies are reviewed, with emphasis on larger human studies either recently completed or underway.
{"title":"Risks of Sedation","authors":"Peter Chin, Sarah L Walls","doi":"10.1093/MED/9780190659110.003.0025","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0025","url":null,"abstract":"This section summarizes the risks and complications of sedation. Topics include what should be discussed with parents when obtaining consent. The sedation plan should be discussed with parents during the consent process. “Material” risks should be disclosed, including both minor but frequent events such as nausea, and rare but severe complications such as cardiac arrest. Limits of sedation should also be discussed. Written consent should be documented in an anesthesia (or sedation)-specific consent form. This section also includes the topic of anesthesia- and sedation-related neurotoxicity. Data from animal and human studies are reviewed, with emphasis on larger human studies either recently completed or underway.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131009576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED/9780190659110.003.0012
E. Mack, Rhea Vidrine
Procedural sedation is associated with potential complications generally involving airway obstruction or hypoxemia that if not properly managed may lead to temporary or permanent harm to the patient. Equipment necessary to deal with these common complications and a checklist approach to ensuring the presence of this equipment are discussed here.
{"title":"Presedation Preparation","authors":"E. Mack, Rhea Vidrine","doi":"10.1093/MED/9780190659110.003.0012","DOIUrl":"https://doi.org/10.1093/MED/9780190659110.003.0012","url":null,"abstract":"Procedural sedation is associated with potential complications generally involving airway obstruction or hypoxemia that if not properly managed may lead to temporary or permanent harm to the patient. Equipment necessary to deal with these common complications and a checklist approach to ensuring the presence of this equipment are discussed here.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131348345","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med/9780190659110.003.0011
Deb LaViolette
The process of prescreening procedural sedation patients has a critical impact on the safety, efficiency, and quality of a sedation service. Prescreening is a multilevel process that ideally starts at the time of scheduling and allows the sedationist to discern physical or mental health issues that may put the patient at higher risk during a sedated procedure. Foreknowledge of risk indicators enables the sedationist to be better prepared or to refer the patient to a different setting for the procedure. Prescreening also ensures that the patient and family have the logistical information needed for them to be in the correct place at the correct time and properly prepared so that the sedation can be completed safely and efficiently. Prescreening also affords excellence in patient satisfaction.
{"title":"Prescreening","authors":"Deb LaViolette","doi":"10.1093/med/9780190659110.003.0011","DOIUrl":"https://doi.org/10.1093/med/9780190659110.003.0011","url":null,"abstract":"The process of prescreening procedural sedation patients has a critical impact on the safety, efficiency, and quality of a sedation service. Prescreening is a multilevel process that ideally starts at the time of scheduling and allows the sedationist to discern physical or mental health issues that may put the patient at higher risk during a sedated procedure. Foreknowledge of risk indicators enables the sedationist to be better prepared or to refer the patient to a different setting for the procedure. Prescreening also ensures that the patient and family have the logistical information needed for them to be in the correct place at the correct time and properly prepared so that the sedation can be completed safely and efficiently. Prescreening also affords excellence in patient satisfaction.","PeriodicalId":188400,"journal":{"name":"The Pediatric Procedural Sedation Handbook","volume":"129 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114370968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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