Pediatric Sedation Service

[FulfilledDeer]

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So I've been getting more and more interested in Peds/Anesthesia -> CCM and PedsAnesthesia fellowship. Discussions of the combined residencies always seem to bring up "well, you could run a pediatric sedation service too". I understand the general concept of the service, but I'm curious what a day is like for the person running the service. Are you just overseeing things remotely? Running around all day fixing "problems"?




Also, and completely separately, why is there such a focus on no IV for peds induction? I had a couple of surgeries as a kid, and by far the worst was slapping a mask on my face and making me breathe my way out. It was like suffocation (I remember thinking about trying to push the mask off, but someone had my hands). The IV was waaaay better. So much so the first time someone said no IV for peds I honestly thought they were joking.

 

[Mman]

Peds sedation is probably a huge waste of your time financially speaking. Many/most of those kids are medicaid so reimbursement is squat.

 

[IlDestriero]

Kids IVs can be more difficult to begin with, add holding them down while they scream and/or thrash and cry and you're making it more difficult and potentially compromising sterility, safety, and sanity. EMLA only goes so far. If you miss on the first pass, you're screwed.
We sometimes give PO midaz and 50% N2O and place one "awake". The IV team usually places the IV in preop when we have kids that need IV meds, fluids, etc. prior to coming back. They're experts at the awake IV. BUT they rarely place anything bigger than a 22.
Our Peds Sedation service lost a lot of business to us over the last few years. Often, GA/MAC is just better. We're usually more reliable with times and, of course, our post procedure time is usually much less.

 

[FulfilledDeer]

Kids IVs can be more difficult to begin with, add holding them down while they scream and/or thrash and cry and you're making it more difficult and potentially compromising sterility, safety, and sanity. EMLA only goes so far. If you miss on the first pass, you're screwed.
We sometimes give PO midaz and 50% N2O and place one "awake". The IV team usually places the IV in preop when we have kids that need IV meds, fluids, etc. prior to coming back. They're experts at the awake IV. BUT they rarely place anything bigger than a 22.

Our Peds Sedation service lost a lot of business to us over the last few years. Often, GA/MAC is just better. We're usually more reliable with times and, of course, our post procedure time is usually much less.

That's...a great point. I was thinking of kids a little older (8-ish), but I can see why IV is not the best option younger. Maybe that's no longer consider exactly "peds" in an anesthesia sense?

Also, just to clarify, I'm not really looking at running a sedation service, I just can't really conceptualize what that's like as a job. It's just nice to get a sense of the exits as you're staring down a really long road.

 

[Oggg]

Seems like if you do anes, CCM, and peds, you'd be doing peds ICU and peds OR. Don't know if you need peds-cardiac to do pedi hearts.

 

[michigangirl]

What IlD said regarding peds IVs.

With regards to the peds sedation service, when I counsel those interested in the combined track, we do discuss running a peds sedation service as a possibility, but its way down the list-- PICU, peds OR, peds chronic pain are much more plausible given the challenges, time put in, and the risk/benefit from a financial standpoint.

 

[somedumbDO]

Peds sedation is probably a huge waste of your time financially speaking. Many/most of those kids are medicaid so reimbursement is squat.

80% of my kids at my group are public aid this really isn't feasible unless u either use crnas or are salaried at the institution. Our group took over the sedation duties after numerous complaints and a couple of near miss issues. Peds anesthesia really sedates kids better...

 

[imfrankie]

The other benefitting parties need to pony up a stipend for sedation services to offset the reimbursement.

 

[somedumbDO]

They do, it brakes even. It's more a negotiating tool w adm

 

[Arch Guillotti]

There is a peds sedation list-serv which deals with this topic exclusively.

 

[imfrankie]

There is a peds sedation list-serv which deals with this topic exclusively.

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[Giic]

What IlD said regarding peds IVs.

With regards to the peds sedation service, when I counsel those interested in the combined track, we do discuss running a peds sedation service as a possibility, but its way down the list-- PICU, peds OR, peds chronic pain are much more plausible given the challenges, time put in, and the risk/benefit from a financial standpoint.

To be clear, you really don't need a combined track to "run" a Peds Sedation service. In fact, nowadays, hospitalists at a lot of institutions are doing pediatric moderate/deep sedation, and running the service. So peds residency, without PICU or ED fellowship, or anesthesia residency, or anything.

Also, another point of clarification -- I do not think many institutions will hire you just to run a Peds Sedation service. You will have an appointment doing PICU or hospitalist work, or being an anesthesiologist in the OR, and may be asked to do pediatric procedural sedation as part of your job. It is rare for an institution to have the volume of patients for procedural sedation that would warrant hiring someone to do just that.

 

[IlDestriero]

Also, another point of clarification -- I do not think many institutions will hire you just to run a Peds Sedation service. You will have an appointment doing PICU or hospitalist work, or being an anesthesiologist in the OR, and may be asked to do pediatric procedural sedation as part of your job. It is rare for an institution to have the volume of patients for procedural sedation that would warrant hiring someone to do just that.

All the big Children's Hospitals will have a sedation service.

 

[imfrankie]

To be clear, you really don't need a combined track to "run" a Peds Sedation service. In fact, nowadays, hospitalists at a lot of institutions are doing pediatric moderate/deep sedation, and running the service. So peds residency, without PICU or ED fellowship, or anesthesia residency, or anything.

Also, another point of clarification -- I do not think many institutions will hire you just to run a Peds Sedation service. You will have an appointment doing PICU or hospitalist work, or being an anesthesiologist in the OR, and may be asked to do pediatric procedural sedation as part of your job. It is rare for an institution to have the volume of patients for procedural sedation that would warrant hiring someone to do just that.

I think a person could easily make a career out of pediatric sedation work. It wouldn't be my choice for full-time, but it's important, high volume work in certain centers.

 

[michigangirl]

To be clear, you really don't need a combined track to "run" a Peds Sedation service. In fact, nowadays, hospitalists at a lot of institutions are doing pediatric moderate/deep sedation, and running the service. So peds residency, without PICU or ED fellowship, or anesthesia residency, or anything.

I don't think anyone got the message that you need to be double or triple boarded to head a peds sedation service. The OP wanted to know whether this was a plausible option given their plans to do the combined residency.

 

[GA8314]

Hello,

The only ASA Recommendation regarding Moderate Sedation (level II sedation) is the following:

Recommendations. In patients receiving intravenous medications for sedation/analgesia, vascular access should be maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression. In patients who have received sedation– analgesia by nonintravenous routes, or whose intravenous line has become dislodged or blocked, practitioners should determine the advisability of establishing or reestablishing intravenous access on a case-by-case basis. In all instances, an individual with the skills to establish intravenous access should be immediately available.

Can one of the pediatric folks please provide their expertise on your policies for IV requirements in pediatric moderate sedation. Not deep (level III). Moderate only.

Do you require IV access if IM, intranasal, or rectal analgesia is given??

***I can not find, easily, an ASA policy statement regarding this issue, other than the generic version copied above, which does not distinguish between adults and peds pts......

 

[urge]

I don't think anyone got the message that you need to be double or triple boarded to head a peds sedation service. The OP wanted to know whether this was a plausible option given their plans to do the combined residency.

I didn't get the message but was wondering why it would come up when talking about a Ped/CCM fellowship trained anesthesiologist. Why would anyone train so much to do the silliest cases in house? Seems like an oxymoron to me.

Leave the sedation to the CCM pediatricians and go do some real work in the OR or ICU.

Otherwise let it fall on the anesthesia schedule as another off site location to cover.

 

[urge]

Hello,

The only ASA Recommendation regarding Moderate Sedation (level II sedation) is the following:

Recommendations. In patients receiving intravenous medications for sedation/analgesia, vascular access should be maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression. In patients who have received sedation– analgesia by nonintravenous routes, or whose intravenous line has become dislodged or blocked, practitioners should determine the advisability of establishing or reestablishing intravenous access on a case-by-case basis. In all instances, an individual with the skills to establish intravenous access should be immediately available.

Can one of the pediatric folks please provide their expertise on your policies for IV requirements in pediatric moderate sedation. Not deep (level III). Moderate only.

Do you require IV access if IM, intranasal, or rectal analgesia is given??

***I can not find, easily, an ASA policy statement regarding this issue, other than the generic version copied above, which does not distinguish between adults and peds pts......

There is no policy. You can do whatever you want until you have a bad outcome or two. Then all those cases will fall on the anesthesia schedule as an off site location. We will then insist on an IV, BP, EKG, pulse ox and CO2 monitoring.

You can be ahead of the ball or behind the ball. Your choice.

 

[WholeLottaGame7]

Hello,

The only ASA Recommendation regarding Moderate Sedation (level II sedation) is the following:

Recommendations. In patients receiving intravenous medications for sedation/analgesia, vascular access should be maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression. In patients who have received sedation– analgesia by nonintravenous routes, or whose intravenous line has become dislodged or blocked, practitioners should determine the advisability of establishing or reestablishing intravenous access on a case-by-case basis. In all instances, an individual with the skills to establish intravenous access should be immediately available.

Can one of the pediatric folks please provide their expertise on your policies for IV requirements in pediatric moderate sedation. Not deep (level III). Moderate only.

Do you require IV access if IM, intranasal, or rectal analgesia is given??

***I can not find, easily, an ASA policy statement regarding this issue, other than the generic version copied above, which does not distinguish between adults and peds pts......

Our sedation service (run by peds anesthesia) will do moderate sedation with intranasal midaz/precedex without an IV. Use it frequently for kids getting non-contrasted MRIs that are too young for googles, etc. Those kids do get standard monitors, but it's an RN down there with anesthesiologist backup.