Pediatric Sedation and Pediatric Sedation and AnalgesiaAnalgesiaJan ChandlerRN,MSN, CNS, CPNP

PSAPSAProcedural sedation and

analgesia (PSA) refers to the pharmacologic techniques of managing a child’s pain and anxiety.

AAP definition 1992AAP definition 1992Referred to as “conscious

sedation”A depressed state of

consciousness where the patients were able to retain protective reflexes and “respond appropriately to stimuli”.

Procedural Sedation Re-Procedural Sedation Re-defineddefinedAmerican College of Emergency

Physicians re-named “conscious sedation”

Procedural sedation’s goal was to medicate patients until they can tolerate unpleasant procedures

This sedation was termed “moderate sedation”

Four Levels of SedationFour Levels of SedationJCAHO and American Society of

Anesthesiologist described the 4 levels of sedation.◦Anxiolysis◦Moderate Sedation◦Deep Sedation◦General Anesthesia

Minimal SedationMinimal SedationAnxiolysis or minimal sedation

refers to a drug-induced state in which cognitive and motor function may be impaired.

Moderate SedationModerate SedationModerate sedation is a state of

moderate sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation.

Deep SedationDeep SedationDeep sedation and analgesia is a

drug induced depressed level of consciousness in which children respond purposefully only to repeated or painful stimulation.

General AnesthesiaGeneral AnesthesiaGeneral anesthesia refers to the

drug induced loss of consciousness in which there is no response to painful stimulus.

Sedation for CooperationSedation for CooperationMRICT scanEcho-cardiogram

Sedation for Painful Sedation for Painful ProceduresProceduresLumbar punctureBone marrow aspiration / biopsyRenal biopsyChest tube insertionCentral line insertion

Sedation for Emergency Sedation for Emergency ProceduresProceduresIncision and drainageFracture reduction / splintingRepair of lacerations

Goals of SedationGoals of SedationMood alteration in order to allay the

patient’s fear and anxietyMaintenance of consciousness and

cooperation for those patients who must be awake enough to cooperate throughout the procedure

Elevate the pain threshold with minimal changes in vital signs, protective reflexes and physiologic response

Sedation and Analgesia Sedation and Analgesia GoalsGoals

Achieve adequate sedation with minimal risk

Minimize discomfort and painMinimize negative psychological

response by providing anxiolysis, analgesia, and amnesia

Monitoring and AssessmentMonitoring and AssessmentKey ElementsKey Elements

Pre-procedural criteriaManagement during sedation Post-procedure sedation assessmentRelease from

observation/dismissal/discharge criteria

Patient/child education and discharge instructions

Pre-procedural Pre-procedural ASA patient classificationPre-procedural criteriaFeeding guidelinesProcedure / Site verification and

time out

ASA ClassificationsASA Classifications

• ASA Class

• I: A normal healthy child

• II: A child with mild systemic disease

• III: A child with severe systemic disease

• IV: A child with severe systemic disease that is a constant threat to life

• V: A moribund child who is not expected to survive without the procedure

Pre-procedural CriteriaPre-procedural CriteriaHistory and Physical Informed consentNPO statusBase-line vital signsHeight and weightAdequate staffingEmergency equipment

Health AssessmentHealth AssessmentHeight / weight in kilogramsVital signs including blood pressureNPO status AllergiesCurrent MedicationsSystemic diseases or genetic

conditionsAbility to intubated in the event of an

emergency: size of jaw and ability to open mouth

History of heart murmur or asthma

Informed ConsentInformed ConsentIn an outpatient procedure a

consent will need to be signed by a parent or legal guardian.

In and in-patient procedure consent my often be covered by the general hospital consent.

NPO GuidelinesNPO Guidelines

Age Duration of fasting

(milk, formula, solids)

Duration of fasting

(clear liquids)

Infants who

receive formula or breast milk

6 hours for formula fed infants

4 hours for breast fed infants

2 hours

Children>3 years

8 hours 2 hours

NPO GuidelinesNPO GuidelinesBreast fed infants should be fasted for the

normal interval between feeding

When proper fasting has not been assured or in the case of a true emergency, “the increased risks of sedation must be weighted against its benefits; and the lightest effective sedation should be used. An emergency child may require protection of the airway (intubation) before sedation”

JCAHO StandardsJCAHO StandardsProcedure /Site VerificationMarking the operative siteTime Out before procedure

BRN Scope of PracticeBRN Scope of PracticeNurse Practice ActIt is within the scope of practice

of registered nurses to administer medications for the purpose of induction of conscious (procedural) sedation for short-term therapeutic, diagnostic or surgical procedures.

RN Responsibilities / RN Responsibilities / MedicationsMedicationsThe knowledge base includes but

is not limited to:◦Effects of medication◦Potential side effects of the

medication◦Contraindications for the

administration of the medication◦Amount of medication to be

administered

RN Responsibilities / RN Responsibilities / SafetySafetyNursing assessment of the patient to

determine that administration of the drug is in the patient’s best interest.

Safety measures are in force:◦Back-up personnel skilled and trained in

airway management, resuscitation, and emergency intubation.

◦Patient should never be left un-attended◦Registered nursing functions may not be

assigned to unlicensed assistive personnel.

RN Safety ConcernsRN Safety ConcernsContinuous monitoring of oxygen

saturationCardiac rate and rhythmBlood pressureRespiratory rateLevel of consciousnessImmediate availability of an emergency

cart which contains resuscitative and antagonist medications, airway and ventilatory equipment (defibrillator , suction equipment, means to administer 100% oxygen.

Institution ResponsibilitiesInstitution ResponsibilitiesThe institution should have in

place a process for evaluating and documenting the RNs demonstration of the knowledge, skills, and abilities for the management of clients receiving agents to render conscious sedation.

Evaluation and documentation should occur on a periodic basis.

Management During Management During ProcedureProcedurePatient monitoringReportable conditionsSide effects of sedationBenefits of sedationMedications

Monitoring During Moderate Monitoring During Moderate SedationSedation

Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout and after the procedure

Reportable ConditionsReportable Conditions

Oxygen saturation less than 90% or 3% decrease from baseline

Change in vital signs of 20% or moreRespiratory depression or distressCardiac dysrhythmiasDeep sedation or loss of consciousness Inadequate sedation and/or analgesic effect Interventions and patient responseFailure to return to baseline status within one

hour

Nursing ManagementNursing ManagementPersonnelEquipmentMedicationsMedication reversal agentsManagement parametersComplications

Equipment/Supplies Needed for SedationEquipment/Supplies Needed for Sedation

Pulse oximeterCardiac monitor (if CV

disease or arrhythmias detected or anticipated)

Blood pressure cuffCrash cart in vicinityDefibrillatorSuctionEmergency drugs and

resuscitation equipment

Ambu bag & maskSuction (device and

Yaunker catheter)O2 tubing & maskPatent IV siteReversal agents **

at bedsideOral/nasal airway

and ET tube of appropriate size

Medications used for Medications used for Sedation and AnalgesiaSedation and Analgesia

Midazolam (Versed)Midazolam (Versed)

◦ Classification: Benzodiazepine◦ Potent sedative, anxiolytic and amnestic

with no analgesic effects.◦ Action: short-acting CNS depressant.◦ Desired sedation can be achieved in 3 to 6

minutes◦ Indication and uses: to produce sedation,

relieve anxiety, and impair memory of peri-operative events.

◦ Suited for procedures that are not especially painful: central catheter placement, VCUG, CT scan

Versed DosingVersed DosingMidazolam can be given orally,

intravenously, intra-nasally or rectally◦ Dosing:

Neonate dose: IV 0.05-0.2 mg/kg Children dose: Oral: 0.2-.04 mg/kg (max

dose 15 mg) IM: 0.08mg/kg IV: 0.003-0.05 mg/kg (max dose 2.5 mg)

Chloral hydrateChloral hydrateClassification: Sedative/Hypnotic,

Non-barbiturate, no analgesic properties

Dosing◦Neonate: Oral: 30-75 mg/kg/dose

Maintenance dose: 20-40 mg/kg/dose

◦Children: Oral 25-100 mg/kg/dose (max dose of 1 gm for infants & 2 gm for children)

Morphine SulfateMorphine SulfateClassification: Narcotic analgesicAction: opium-derivative, narcotic

analgesic, which is a descending CNS depressant. Immediate pain relief lasts up to 4 to 5 hours.

Morphine SurlfateMorphine SurlfateMorphine dosing

Neonate : IV 0.05 mg/kg **Neonates may require higher dose range- (0.1 mg/kg)

Children: Oral: 0.1-0.3mg/kg IV: 0.03-0.05 mg/kg (max

dose 10 mg/dose) Adolescents: Oral 5-8mg/dose IV: 3-4 mg/dose

Meperidine (Demerol)Meperidine (Demerol)

Classification: Narcotic AnalgesicAction: Synthetic narcotic

analgesic and CNS depressant, similar but slightly less potent than Morphine

Dosing◦ Neonate: IV 0.5 mg/kg/dose◦ Child: oral / SC / IM 1-2 mg/kg/dose (max 100

mg/dose)◦ Child IV: 0.5 – 1 mg/kg/dose (max 100 mg/dose)

FentanylFentanylClassification: potent opioid

analgesic Useful for short painful procedures

such as bone marrow aspiration, chest tube placement and fracture reduction.

Dosing for patients over 2 years of age◦1 to 3 mcg/kg/dose over 3 to 5 minutes◦May be repeated in 30 to 60 minutes

KetamineKetamineClassification: general anesthetic

producing both analgesia and sedation while maintaining airway tone.

Action: blocks association pathways, inducing a dreamlike state of mind before producing a sensory blockage.

Uses: especially useful for short, painful procedure.

KetamineKetamineDosing

◦Neonate: 0.5mg-mg/kg◦Children: Oral 6-10mg/kg in liquid—

poor absorption when given orally IV: 0.5 mg-mg/kg IM: 3-7 mg/kg

Reversal AgentsReversal AgentsBenzodizepine antagonist

antidoteNaloxone Hydrochloride narcotic

antagonist

Flumazenil (Romazicon)Flumazenil (Romazicon)Classification: Benzodiazepine

antagonistAction: reverse the effects of

procedural sedation◦ Neonates: IV 2-10 mcg/kg every minute

times 3 doses◦ Children: Initial dose: IV: 0.01 mg/kg,

max initial dose 0.2 mg/dose◦ Repeat doses: 0.0005-0.01 mg/kg (max 0.2

mg repeated at 1 minute intervals◦ Max total dose: 1 mg or 0.05 mg/kg

(which ever is lower)

Naloxone (Narcan)Naloxone (Narcan)Classification: Narcotic

antagonistUses: narcotic overdose, post-

operative narcotic depressionDosing

◦Neonate: 0.1 mg/kg/dose◦Children IM/IV/SC: 0.01 -0.1 mg/kg

May repeat dose every 2-3 minutes (max dose is 2 mg/dose.

Allergic ReactionsAllergic ReactionsNursing alert: If procedure

involves infusion of a contrast material – watch for allergic reaction

Hives, rash, flushing, uticaria, laryngeal edema, hypotension

Benadryl would be the drug of choice for an allergic reaction.

Post-Procedural Post-Procedural ManagementManagement

Post-Procedural Post-Procedural MonitoringMonitoring

Parameters and accompanying timeframes:◦Monitor every 15 minutes post-

procedure until: child sips clear fluids child returns to prior mobility status

Post-Procedural Post-Procedural MonitoringMonitoring

Parameters and accompanying timeframes:◦Monitor continuously if:

child has history of cardiac or respiratory disease

Excessive sedation used Vital sign instability O2 desaturation during procedure

◦ If reversal agent used Recovery assessment must continue for 2

hours following the final dose - “Emergence phenomena”

Monitoring Discharge Monitoring Discharge CriteriaCriteriaThe following discharge criteria should be

included, but not limited to: -adequate respiratory function-stability of vital signs-preoperative level of consciousness

-intact protective reflexes-return of motor/sensory control

-absence of protracted nausea-adequate state of hydration

Outpatient ConsiderationsOutpatient Considerations

All outpatients must receive post-sedation precautions and be discharged from the area

Written instructions must include: ◦Post procedural complications◦Activity limitations◦Bathing instructions◦Plan for follow-up care:

Emergency numbers Next physician appointment date