Palliative Care For Children General Overview Professor, Faculty of Medicine, University of Manitoba...

Palliative Care

For Children

General Overview

Professor, Faculty of Medicine, University of ManitobaMedical Director, Winnipeg Regional Health Authority Palliative Care ProgramCo-Chair, Canadian Network of Palliative Care for ChildrenPhysician Consultant, Canadian Virtual Hospice

Mike Harlos MD, CCFP, FCFP

Objectives

• To consider the definition of pediatric palliative care

• To consider where pediatric palliative care may fit in the care of seriously ill children

• To consider similarities/differences with palliative care for adults

• To review the prevalence and management of symptoms in children living with life-threatening illness

Prognostic Uncertainty

Pediatric Palliative Care services providers

must acknowledge the uncertainty

involved in determining if a specific

circumstance or condition is life-limiting /

life-threatening

Common Trajectory Of Decline In Progressive Life-Limiting Illness In Children

FunctionalStatus

Time

Decline

Crises(“Scary Dips”) Death

From presentation by Joanne Wolfe at the 16th International Congress on the Care of The Terminally Ill

“Prognostic Irrelevance”

• In the view of patient, family, and/or care

team, there may be unwillingness to even

consider the possibility of death

• Service availability should not only

accommodate prognostic uncertainty, but

should not require acceptance of a threatened

life

“What if…?“What if…?

• What would things look like?

• Time frame?

• Where care might take place

• What should the patient/family expect (perhaps demand?) regarding care?

• How might the palliative care team help patient, family, health care team?

• What would things look like?

• Time frame?

• Where care might take place

• What should the patient/family expect (perhaps demand?) regarding care?

• How might the palliative care team help patient, family, health care team?

Palliative Care… The “What If…?” Tour Guides

Disease-focused Care(“Aggressive Care”)Disease-focused Care(“Aggressive Care”)

Addressing The “What-Ifs…” Silence Is Not Golden

Children (even young children) are very perceptive, and can tell when something serious is happening

Even when pursuing cure for their child, parents are often aware in their “heart of hearts” that things may not unfold as hoped for

Palliative Care has a role in:– helping families navigate through difficult decisions, at times

conflicted about which course is best for their child… “path of least regret”

– ensuring that comfort and quality of life are minimally affected by the impact of illness, tests, and treatments

– facilitating communication about fears and worries, and open dialogue about what to expect

Kreicbergs et al NEJM 2004; 351(12):1175-1186.

Did you talk about death with your child at any time?

Talking about Death with Children … ctd

Yes

n = 147(34 %)

No

n = 282(66 %)

Do you regret having done so? Do you regret not having done so?

No parents regretted having talked with their

children about dying Yes No

Overall:

Sensed Child Aware Of Dying:

Did Not Sense Child Aware:

27%

47% 53%

87%13%

73%

Identify and facilitate communication

What Symptoms

Do Children With

Advanced Illness

Experience?

The Measurement Of Symptoms In Children With CancerCollins JJ, Byrnes ME, Dunkel IJ, Lapin J, Nadel T, Thaler HT et al. J Pain

Symptom Manage 2000; 19(5):363-377.

n = 160 cancer patients receiving treatment

aged 10 – 18 yo

30-item patient-rated instrument (MSAS 10-18)

Inpatients averaged 13 symptoms, outpatients 6.5

Patients who had recently received chemotherapy had more than double the symptoms of those who had not

Symptoms At The End of Life in Children With Cancer

Wolfe J. et al, NEJM 2000; 342(5) p 326-333

10

20

40

50

60

70

30

80

%

Pain Dyspnea Nausea And Vomiting

SuccessfullyTreated

(% Of Affected Children)

27 %16 %

10 %

Pain In Advanced Childhood Illness

Abstract from the 7th International Symposium on Pediatric Pain Stenekes S, Hughes A, Grégoire MC, Frager G 2006

Symptom Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncol Nurses Forum SurveyGoldman A et al; Pediatrics 2006; 117; 1179-1186

Engel JM, Jensen MP, Hoffman AJ, Kartin D. Pain in persons with cerebral palsy: extension and cross validation Arch Phys Med Rehabil 2003; 84(8):1125-1128.

Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Adolesc Med 2003; 157(12):1219-1226.

Hunt and Burne, 1995

Symptoms in Children with Neurodegenerative Illness

% 69

60

4438

3531 31

0

10

20

30

40

50

60

70

80

FeedingProblems

Seizures Constipation RespiratorySymptoms

Pain ExcessSecretions

SleepDisorders

2002 College Of Physicians And Surgeons Of Manitoba Child Health Standards Committee Report

2002 Manitoba Deaths

Unlikely role for Palliative Care in symptom management, though potentially in family and staff support

Potential role for Palliative Care in symptom management as well as family and staff support

“Palliative in Parallel”

Palliative care for children should not be exclusive of ongoing cure-focused care

Can be involved as a parallel process, with a variable profile depending on goals of care and clinical circumstances

It is not unusual for children/families/clinicians to harbour seemingly conflicting thoughts and contradictory goals

There are some situations where one could argue that the standard of care should require involvement of a palliative service… eg:– Phase One Clinical trials

– Organ Transplant waiting lists

Cure-Oriented; Disease-Focused

Palliative

Various Patterns Of Pediatric Palliative Care Involvement

Patient Groups For Pediatric Palliative Care Services

Comfort-focused approach has

been chosen, or disease-focused

interventions not possible

Group 1A

Advanced life-limiting condition from

which death within 12 months would

not be unexpected

Group 1

Children with progressive

life-limiting/life-threatening conditions

who are not expected to survive into

adulthood, but whose prognosis is

anticipated to exceed one year

Group 2

Advanced life-limiting illness with

substantial disease and symptom

burden for whom cure is nonetheless

hoped for, or for whom all aggressive

disease-focused and potentially life-

sustaining options are being pursued

Group 1B

• Medical expert providing anticipatory guidance, well child care

• Medical expert dealing with child and youth maltreatment abuse

• Medical expert dealing with the chronic care of complex problems

• Medical expert dealing with palliative care

• Medical expert dealing with death and bereaved parents

• Procedural skills

• Communicator - working successfully with difficult patients families

• Communicator - working successfully with cultural or socioeconomic differences

• Collaborator - working as a member of a team

• Manager - learning principles of quality management

• Manager - managing an efficient office practice

• Health advocate for individual patients

• Health advocate for disadvantaged children or child health issues

• Scholar - ability to carry out a research project

• Scholar - ability to critically appraise literature

• Professional and ethical issues

Pediatricians’ Sense Of Preparedness For PracticeLieberman L, Hilliard LI; Medical Education 2006; 40: 539–546

















































n = 239 pediatricians certified in Canadian training programs between1999 and 2003

Keeping The Momentum – Recent Developments

2003: Canadian Network of Palliative Care for Children (CNPCC)- see http://cnpcc.ca

March 2006- Pediatric Hospice Palliative Care Guiding Principles And Norms Of Practice, through joint work by the CNPCC and CHPCA

2006: 1st major clinical textbook in pediatric palliative care, The Oxford Textbook of Palliative Care for Children.

2006: The Canadian Council on Health Services Accreditation (CCHSA) released in its standards for Hospice and End-of-Life Care

The Royal College of Physicians and Surgeons of Canada is exploring core competencies in Pediatric Palliative Care

There is increasing interest is there amongst physicians training in Pediatrics

Pain Assessment In Children

Pain can be measured by: – self-report (what children say) – “Gold Standard” – biological markers (how their bodies react)– behaviour (what children do)

Biological and behavioural measures tend to habituate over time; parameters may not be specific to pain.

May deny pain if the questioner is a stranger, if they believe they are supposed to be brave, if they are fearful, or if they anticipate receiving an injection for pain.

Much variability in developmental capacity for children to report and describe pain

Questioning should be patient & use words familiar to the child, eg.– "Do you have any hurt?" – "Is there an ‘owie’ or ‘boo-boo’ in your tummy?"

Pain AssessmentSelf-Reporting and Developmental Stage

Children have words for pain by about 18 months if age; may prefer the word hurt rather than pain; may use idiosyncratic, family words

Most children > 2 yrs can report presence & location of pain

3 – 4 yrs: cognitive skills to describe pain intensity (eg. “a little”, “a lot”)

4-5 yrs: can use the Poker Chip scale

Can test ability to use pain-rating tools with simple test of seriation

By about 5 yrs – capacity to provide good qualitative and quantitative information

Pain AssessmentSelf-Reporting and Developmental Stage ctd…

5+ yrs can usually rate and score pain; the Bieri Faces Pain Scale may be used– Children point to a face on the scale that matches how they feel.– The child should be trained by asking how he or she would feel

following some minor pain. The child is asked about how much a more serious pain would hurt.

7+ yrs: children can rate pain on a 0 (no pain) – 10 (worst possible pain) scale

8+ yrs are able to describe the quality of the pain experience

Describing how pain affects emotions requires more abstract concepts

Adolescents are quite capable of using scales that use adjectives to describe both affect and sensory intensity

Faces Pain Scale – RevisedChildren Beginning At 3-4 yo

Avoid affective descriptors (eg. “Point to the face that shows how you are feeling”)

May be misinterpreted as “are you happy/sad?”

1. Pain often unrecognized and undertreated. Neonates do feel pain, and analgesia should be prescribed when indicated during their medical care.

2. If something hurts adults, it will hurt newborns, even if they are preterm.

3. Compared with older age groups, newborns may experience a greater sensitivity to pain and are more susceptible to the long-term effects of painful stimulation.

4. Adequate treatment of pain may be associated with ↓complications and ↓ mortality.

5. The appropriate use of environmental, behavioral, and pharmacological interventions can prevent, reduce, or eliminate neonatal pain in many clinical situations.

6. Sedation does not provide pain relief and may mask the neonate's response to pain.

7. Health care professionals have the responsibility for assessment, prevention, and management of pain in neonates.

8. Clinical units providing health care to newborns should develop written guidelines and protocols for the management of neonatal pain.

Anand KJ. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001; 155(2):173-180.

General Principles For The Prevention And Management Of Pain In Newborns

Approach To Analgesia Use In Pediatric Palliative Care

The oral (enteral) route preferred for most children, most of the time

However… many alternate routes available if needed:– IV (peripheral and central)– Subcutaneous– Transmucosal (nasal, buccal, sublingual)– Transdermal / transcutaneous– Spinal (epidural, intrathecal)– Rectal (usually not well tolerated)

Use adjuvants as appropriate The W.H.O. ladder is a good template on which to base

analgesic use Virtually always prescribe laxatives with opioid Rx

Weak Opioids Used In Pediatric Palliative Care

Codeine remains the most commonly prescribed weak opioid, however there are considerations:

Codeine is a pro-drug of morphine, from which its analgesic effect is derived

Up to 10% of the Caucasian population lack the enzyme necessary for transformation of codeine to morphine; perhaps up to 47% of those < 12 yrs old

If 1 mg/kg codeine ineffective, switch to morphine or alternative

Oxycodone:

has some κ receptor agonist activity as well as μ No ceiling dose – can potentially be continued throughout course of

illness

STRONG OPIOIDS

• Children > 3 months are probably at no greater risk of signif. resp depression than adults; younger infants may have ↑ risk due to metabolic immaturity affecting pharmacokinetics

• Morphine elimination t ½ (h):

Preterm infants: 9 – 10 Term Infants: 7 Children: 3 – 4

(Saaranmaa E, Huttunen P, Leppaluoto J, Meretoja O, Fellman V. Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial. J Pediatrics 134[2], 144-150. 1999)

STRONG OPIOIDS ctd

• most commonly use: – morphine– hydromorphone (Dilaudid ®)– fentanyl (IV infusions)– oxycodone– methadone

• DO NOT use meperidine (Demerol®) long-term– active metabolite normeperidine →

seizures

Using Opioids for Breakthrough Pain

• Patient/Family must feel in control, empowered

• Use aggressive dose and interval

• There should be confidence in the effectiveness of the breakthrough dose; empirically and reliably effective

• Patient Taking Short-Acting Enteral Opioids: 50 - 100% of the q4h dose given q1h prn

• Patient Taking Long-Acting Enteral Opioids: 10 - 20% of total daily dose given q1h prn using

short-acting opioid preparation

• Patient On Continuous Parenteral Infusion (non-PCA): 1 – 2 hrs worth of opioid, given q15 minutes prn

PCA Opioids

Allows patients to self administer small amounts of opioids when needed

Usually IV or SQ

Most commonly morphine or hydromorphone

May have a continuous background opioid infusion in addition to PCA boluses

A child able to play a video game can also operate a PCA pump (5 – 6 yo)

Varying policies on whether nurse or parent are allowed to initiate a bolus – doing so will lose the inherent safety of being too drowsy to self-overdose

Ref: Pain In Infants, Children, And Adolescents 2nd Ed, 2003; Schechter, Berde, and Yaster Editors

Agent Intermittent Dose Parenteral Infusion Dose

Codeine Enteral 0.5 – 1.0 mg/kg q4h Not recommended parenterally

Morphine

Sulfate

Enteral 0.2 – 0.3 mg/kg q 4h 0.05 mg/kg IV load over 10 min then 0.01 – 0.03 mg/kg/hrIV/SQ 0.05 – 0.2 mg/kg q 2-4h

HydromorphoneEnteral 30 – 80 micrograms/kg q4h 10 – 20 micrograms/kg IV load

over 10 min then 2 – 8 micrograms/kg/hrIV/SQ 15 micrograms/kg q 2 – 4h

Oxycodone 0.05 – 0.15 mg/kg po q4h N/A

Fentanyl Citrate 0.5 – 2 micrograms/kg IV 0.5 – 2 micrograms/kg/hr IV

Recommended Opioid Analgesic Doses (> 6 Months Age)*

* For infants < 6 months start with ¼ of the pediatric starting dose and titrate

Opioid Side Effects

Constipation – need proactive laxative use

Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol)

Urinary retention Itch/rash – worse in children; may need low-dose naloxone

infusion. May try antihistamines, however not great success

Dry mouth Respiratory depression – uncommon when titrated in

response to symptom

Drug interactions Neurotoxicity (OIN): delirium, myoclonus seizures

Opioid-Induced Pruritus

Not rare; up to 23% in children > 12 yo in one study of long-acting morphine (Zernickow B, Lindena G; Medical and Pediatric Oncology 36:451±458 (2001))

Pathophysiology unclear– opioid receptors are relevant to the modulation of pain

and itch in the central nervous system. – Opioid peptides may also have a peripheral action

potentiating itch due to other agents

Consider switching opioids; may have less pruritus with fentanyl, methadone, oxycodone

Try antihistamines (diphenhydramine, Atarax, trimeprazine) Naloxone 1 – 2 micrograms/kg/hour as an infusion

Adjuvants Used In Palliative Care

General / Non-specific– corticosteroids

Bone Pain– NSAIDs– bisphosphonates– (calcitonin)

Neuropathic Pain– gabapentin– antidepressants– ketamine – topiramate– clonidine– cannabinoids (not yet commonly used for pain)

Gabapentin For Neuropathic Pain

Common Starting Regimen:

– 5 mg/kg hs days 1-3, then

– 5 mg/kg bid days 4-6, then

– 5 mg/kg tid and slowly titrate up

– Usual effective range: 8 – 35 mg/kg/day

Sedation is usual limiting factor.

Doses may need to be rounded of due to the capsule strengths

Intranasal MedsDrug Tmax (min) Bioavailability (%)

Midazolam1,2 11 – 14* 55 – 83

Fentanyl3 5 71

Sufentanil3 10 78

Hydromorphone4 20 – 25 55

1. P. D.Knoester ; Pharmacokinetics and pharmacodynamics of midazolam administered as a concentrated intranasal spray. A study in healthy volunteers; Br J Clin Pharmacol. 2002 May;53(5):501-7

2. Rey E. et al; Pharmacokinetics of midazolam in children: comparative study of intranasal and intravenous administration; Eur J Clin Pharmacol 41(4) 1991; 355-357

3. Dale O, Hjortkjaer R, Kharasch ED; Nasal administration of opioids for pain management in adults; Acta Anaesthesiol Scand. 2002 Aug;46(7):759-70

4. Coda BA, Rudy AC, Archer SM, Wermeling DP; Pharmacokinetics and bioavailability of single-dose intranasal hydromorphone hydrochloride in healthy volunteers; Anesth Analg. 2003 Jul;97(1):117-23

5. Fisgin T et al; Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study; J Child Neurol. 2002 Feb;17(2):123-6

* Available to the cerebral cortex 2 – 5 min. after nasal use5

Reasonable to start with recommended mg/kg for IV dosing and adjust empirically

http://www.wolfetory.com/nasal.html

Management Of:

• Nausea And Vomiting

• Dyspnea

• Secretions

In Pediatric Palliative Care

Cortex

CTZ

Vestibular

GI

VOMITING CENTRE

Managing Nausea & Vomiting in Palliative CareSome Differences in Children vs. Adults

• Assessment, communication challenges

• Higher risk of extrapyramidal reactions, akathisia, and somnolence with dopamine antagonists in children than adults

– Metoclopramide (Maxeran®)

– Prochlorperazine (Stemetil®)

– Haloperidol (Haldol®)

– Chlorpromazine

• If using dopamine antagonists, consider slow administration (45-60 min.), as well as concomitant use of diphenhydramine (Benadryl®) 0.5 – 1 mg/kg q4-6h po/IV continued for additional 24hrs after dopamine antagonist stopped.

Stimulus Area Receptors

Drugs,

MetabolicChemoreceptor

trigger zone

Motion,

PositionVestibular

Visceral Organs

? Non-specific

CNS

↑ ICP Cerebral cortex

D2 5HT

MM HH11

VOMITING CENTRE

EffectorOrgans

Dopamine Serotonin Histamine Muscarinic

CB1

Cannabinoid

CB1

D2

D2

5HT

5HT

HH115HT

HH11

HH11

MM

MM

From:

Arch. Dis. Child. 2004;89;877-880E S Antonarakis and R D W Hain

Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice

Drug ClassExamples for Breakthrough Nausea (Not necessarily the same as for

Chemotherapy Protocols)

SerotoninAntagonists

• Granisetron1 : ≥ 4 yo: 20-40 mcg/kg/day divided once or twice daily single dose po/IV• Ondansetron2: 0.15 mg/kg/dose enterally/IV q 6-8h

H1 Antagonists• Dimenhydrinate (Gravol®): 1.25 mg/kg q6h (max. 50 mg/dose); not recommended < 2

yo

DopamineAntagonists (Consider concomitant diphenhydramine 0.5 – 1.0 mg/kg)

• Prochlorperazine (Stemetil®): 0.1 – 0.15 mg/kg po/pr q6h • Methotrimeprazine: 1 mo. - 12 y: 0.1 - 0.4 mg/kg continuous infusion over 24h (or 0.025

- 0.1 mg/kg q6h)• Metoclopramide: 0.1 – 0.2 mg/kg po/IV/SQ q6h prn (don’t use if Hx seizures)• Haloperidol: 0.01 – 0.02 mg/kg po/IV/SQ/SL/pr q 8-12h• Domperidone: 1.2 – 2.4 mg/kg/day divided TID – QID (doesn’t cross BBB)

Prokinetics See metoclopramide and domperidone above

Cannabinoids• Dronabinol: 2.5-7.5 mg/m2 q4h prn; alternatively 0.04 to 0.12 mg/kg/day (much lower

dose)• Nabilone: (> 4 yo): < 18 kg: 0.5 mg bid; 18-30 kg: 1 mg bid; >30 kg: 1 mg tid

Corticosteroids Dexamethasone: 1 - 2 mg/kg initially then 0.25-0.5 mg/kg q6h

Antinauseants / Antiemetics

1 Komada Y et al. A randomised dose-comparison trial of granisetron in preventing emesis in children with leukaemia receiving emetogenic chemotherapy. Eur J Cancer 1999; 35(7):1095-1101.2 Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack

Palliative Management

of Secretions

Secretions - Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey

Goldman A et al; Pediatrics 2006; 117; 1179-1186

Managing Secretions in Palliative Patients

Factors influencing approach management: Oral secretions vs. lower respiratory Level of alertness and expectations thereof Proximity of expected death

“Death Rattle” – up to 50% in final hours of life

At times the issue is more one of creating an environment less upsetting to visiting family/friends

Suctioning: “If you can see it, you can suction it”

Suctioning

Increased Secretions

Mucosal Trauma

Atropine Eye DropsFor Palliative Management Of Secretions

• Atropine 1% ophthalmic preparation

• Local oral effect for excessive salivation/drooling

• Dose is usually 1 – 2 drops SL or buccal q6h prn

• There may be systemic absorption… watch for tachycardia, flushing

Glycopyrrolate For Palliative Management Of Secretions

Enteral: 40 – 100 micrograms/kg 3 – 4 times daily

• 2006 British National Formulary For Children• IWK Health Centre (Halifax) Formulary

Refs:

Parenteral: 4 – 10 micrograms/kg 3 – 4 times daily (10x the enteral dose)

IWK Health Centre (Halifax) FormularyRef:

• Less sedating than scopolamine (doesn’t cross the blood-brain barrier), longer acting, however not as effective

• Useful where patient is still alert; scopolamine will cause sedation and delirium in awake patients

Scopolamine For Palliative Management Of Secretions

Transderm-V ® (Scopolamine)

Age Dose

1 month – 3 yrs 250 micrograms every 72 hours (1/4 patch)

3 – 10 yrs 500 micrograms every 72 hours (1/2 patch)

10 – 18 yrs 1 mg every 72 hours (one patch)

Ref: 2006 British National Formulary For Children

Intermittent SQ/IV: 10 micrograms/kg (max. 600 micrograms) q 4h

Continuous SQ/IV: 40-60 microgram/kg/day (1.67 – 2.5 microgram/kg/h)

2006 Rainbow Hospice GuidelinesRef:

Dyspnea

In

Pediatric Palliative Care

DYSPNEA

• An uncomfortable awareness of breathing

• Not the same as tachypnea, which is a fast rate of breathing

• “...the most common severe symptom in the last days of life” (Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 – 98)

• Increasing incidence as death nears (approx. 80 %); pneumonia at the end of life

• Anti-tumor: chemo/radTx, hormone, laser

• Infection

• Anemia

• CHF

• SVCO

• Pleural effusion

• Pulmonary embolism

• Airway obstruction

TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE

Opioids in Dyspnea

Uncertain mechanism

Comfort achieved before resp compromise; rate often unchanged

Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration

Dosage should be titrated empirically; may easily reach doses commonly seen in adults

May need rapid dose escalation in order to keep up with rapidly progressing distress

Agent Intermittent Dose Parenteral Infusion Dose

Codeine Enteral 0.5 – 1.0 mg/kg q4h Not recommended parenterally

Morphine

Sulfate

Enteral 0.2 – 0.3 mg/kg q 4h 0.05 mg/kg IV load over 10 min then 0.01 – 0.03 mgkg/hrIV/SQ 0.05 – 0.2 mg/kg q 2-4h

HydromorphoneEnteral 30 – 80 micrograms/kg q4h 10 – 20 micrograms/kg IV load over 10 min

then 2 – 8 micrograms/kg/hrIV/SQ 15 micrograms/kg q 2 – 4h

Oxycodone 0.05 – 0.15 mg/kg po q4h N/A

Fentanyl Citrate 0.5 – 2 micrograms/kg IV 0.5 – 2 micrograms/kg/hr IV

Lorazepam 0.05 mg/kg IV/SL

Midazolam

IV0.025 – 0.05 mg/kg titrated

carefully, with 2-3 min. between fractions

• Infusion would be guided by prn doses• “…neither surgical anesthesia nor fatal

intoxication is produced by benzodiazepines in the absence of other drugs with CNS-depressant actions; an important exception is midazolam, which has been associated with decreased tidal volume and respiratory rate” (Goodman & Gilman)

Nasal 0.1 mg/kg in each nostril

po/SL

Child 1 month–18 years 0.5 micrograms/kg (max. 15 mg)

30–60 minutes before procedure

Methotrimeprazine 0.025 - 0.1 mg/kg q6h po/SQ 0.1 - 0.4 mg/kg/24 hr IV/SQ

Recommended Opioid And Sedative Doses For Dyspnea (> 6 Months Age)*

* For infants < 6 months start with ¼ of the pediatric starting dose and titrate

Palliative Care For Children General Overview Professor, Faculty of Medicine, University of Manitoba...

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