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ICU Sedation ModelsHome in the PICU
James Hertzog, MDNemours Children’s ClinicAlfred I. duPont Hospital for Children
Why a PICU Sedation Service?• increasing number of subspecialty
procedures• increasing recognition of
advantages of deep sedation: patient comfort, ideal operating conditions, efficiency
• desire to optimize patient safety
Why a PICU Sedation Service?• limitations in Anesthesia personnel
availability• desire to avoid the OR/parent
satisfaction?/practitioner satisfaction?
• AAP/ASA guidelines• increasing JCAHO attention
Getting Started
• involve the Department of Anesthesiology and the Department of Pediatrics
• be consistent with published guidelines: AAP, ASA, JCAHO
Scheduling
• elective procedures for ambulatory, ward, and PICU patients
• defined time slots during the day M-F that can be booked
• urgent/emergent procedures for ward and PICU patients at discretion of team
Screening
• current and past medical history• ASA physical status• experience with
anesthetics/sedatives• intercurrent illness• occurrence of allergic reactions to
medications or soy and egg proteins• fasting status
Screening
• PE of airway, cardiorespiratory, neurologic
• significant labs
• screening done at time of procedure• fasting guidelines, time of procedure
provided by subspecialist beforehand
Pre-Procedure
• informed consent for anesthesia/sedation and procedure
• intravenous access-peripheral canula inserted or CVL accessed
Procedure
• cardiorespiratory monitoring: continuous ECG, respiratory, SpO2, intermittent (q1-3 min) NIBP
• pediatric intensivist – monitors CR, neurologic status continuously– administers propofol/other agent to
maintain desired level of sedation/anesthesia
– provides supportive measures as needed
Procedure
• PICU RN – monitors vital signs– provides written documentation of
course of sedation/anesthesia on a standardized form
– assists with supportive measures as needed
• neither involved directly with procedure
Procedure
• equipment at bedside– BVM– tonsillar suction catheter– equipment for maintaining airway
patency and tracheal intubation
• supplemental oxygen via blow-by
Post-Procedure
• monitoring continues after the procedure until patient awake and able to ingest clear liquids
Post-Procedure
• discharge when meet predefined criteria defined by AAP– stable and satisfactory airway
patency and hemodynamics– intact protective airway reflexes– able to talk and sit unaided if age
appropriate– adequate state of hydration
Billing
• Anesthesia CPT codes– 01999 (unlisted procedure)– 00520 (bronchoscopy)– 00532 (central venous access)– 00740 (upper GI endoscopy)– 00810 (lower GI endoscopy)
Billing
• Anesthesia CPT codes– 00702 (percutaneous liver biopsy)– 01112 (bone marrow
aspiration/biopsy)– 00635 (diagnostic or therapeutic
lumbar puncture)
Billing
• other CPT codes– 99141: sedation (moderate) ± analgesia-
IV, IM, inhalational– 99241: office consultation new or
established patient– 99251: inpatient consultation new or
established patient• key components: problem focused hx and PE,
straightforward decision making, 15-20 min
Billing
• other CPT codes– 90780: IV infusion for
therapy/diagnosis, administered by MD or under direct supervision of MD, up to 1 hour
– 90781: IV infusion for therapy/diagnosis, administered by MD or under direct supervision of MD, each additional hour, up to 8 hours
Advantages
• geographically localized-all done in one place
• resource utilization-all of the components are already available
• flexibility-PICU open 24/7• comfort level
Challenges
• geographically localized-can’t provide service for procedures that can’t be brought to the PICU
• resource utilization-what if all the beds are full or the RNs have assignments?
• managing the scheduling