Kalpesh N. Patel, MD

Dept. of Pediatric Emergency Medicine

August 1, 2007

Sedation and Analgesia for ED101

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Objectives

To review sedation/analgesia drugs, doses, and nursing pain protocols

To review pre-sedation workup and checklist To familiarize you with CHOA sedation policies and

practices To review sedation drugs and dosages Child Life Services

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Analgesia

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

– American Pain Society 1992; Mersky, Bogduk, 1994

Patient’s self-report is the single most reliable indicator of pain.

Unrelieved pain has negative physical and psychological consequences.

There is no diagnostic or therapeutic benefit to being in pain. Baseline pain rating is obtained at triage. Studies show that children do not get the same treatment as

adults who have similar painful conditions.

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Assessing Pain

For sedated, unresponsive patients use the Objective Pain Scale (OPS)

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Assessing Pain

For non-verbal patients use FLACC behavioral scale

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Assessing Pain

For pre-school and young school age children use the FACES scale by patient self report

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Assessing Pain

For older school/adolescent patients use the 0-10 Numeric Pain Rating Scale by patient self report

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Treatment Options

Non-Pharmacologic Treatment:• In most situations, parents are the best source of

comfort• Promote a sense of control to the patient in a

developmentally appropriate manner• Use treatment rooms away from other patients

and create a calm environment.• Distraction

Child Life• Directed Imagery

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Treatment Options

Pharmacologic Treatment• Mild pain (1-4/10): Acetaminophen and/or Ibuprofen• Moderate pain (5-7/10): Ibuprofen and/or Tylenol with

codeine• Severe pain (8-10/10): Ibuprofen and/or Lortab

Acetaminophen 15mg/kg max of 1000mg Ibuprofen 10mg/kg max of 800mg Tylenol with Codeine 1mg/kg max of 60mg Lortab 0.15mg/kg

• 12-15 kg: 3.75cc• 16-22 kg: 5cc• 23-31 kg: 7.5cc• 32 + kg: 10cc of elixir or 1 tablet of Lortab 5/500

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Contraindications

Do not give meds if allergic or hypersensitive Acetaminophen

• Known liver dysfunction• Prior dose < 4 hrs

Ibuprofen• < 6 months of age• Known renal dysfunction• Prior dose <6 hrs• Currently bleeding or known bleeding disorder

Lortab and Tylenol with Codeine• Same as acetaminophen contraindications• Caution in constipation/abdominal pain

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Treatment Options

Local Analgesia• Cold

Ice Ethyl Chloride PainEase Refrigerant Spray

• Viscous lidocaine• EMLA• LMX• LET

SweetEase (24% sucrose solution)• Start giving 2 min prior to

procedure

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Sedation

Levels of Sedation:• Minimal Sedation (Anxiolysis)• Moderate Sedation (Conscious)• Deep Sedation• General Anesthesia

Sedation to anesthesia is a continuum and movement into other levels is easy

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Minimal Sedation

Patient responds to verbal commands Ventilatory and cardiovascular functions are

unaffected A SINGLE drug given by RN, MD, or dentist Nitrous Oxide/O2 titrated up to a maximum of 50%

in conjunction with local nerve blocks or topical anesthetics.

Criteria:• No history of apnea/bradycardia

Vital Signs Q15min of HR, RR and SpO2 for 1 hour, then hourly.

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Moderate Sedation

Patients respond purposefully to verbal commands or LIGHT tactile stimulation

Maintains protective reflexes including cough and gag. No respiratory support needed

Provided in designated safe areas:• OR, PACU, ICU, ED, Radiology

Vital Signs with continuous pulse ox every 5 min

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Deep Sedation

Patients cannot be easily aroused, but respond purposefully to PAINFUL stimuli.

Ventilatory function may be impaired. • May need airway support and spontaneous

ventilation may be inadequate. Cardiovascular function is usually maintained. VS monitored every 5 min: HR, RR, BP, SpO2,

± ETCO2

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General Anesthesia

Includes general anesthesia and spinal or major regional anesthesia.

Patients are not arousable to ANY stimuli. Ventilatory function is often impaired and require

assistance.

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Pre-Sedation Workup

History• Allergies

Prior sedation reactions?• Medications• Past Medical History

Pregnant? Drug Abuse? Apnea, Seizure, Reflux, Snoring?

• Last Meal• Events leading up to need for

sedation Physical

• Baseline Vitals and LOC• Airway Exam• Heart & Lungs

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ASA Classification

Class Physical status

I Healthy patient

II Mild systemic disease, no functional limitation

III Severe systemic disease that limits activity

IV Incapacitating systemic disease that is a constant treat to life

V Moribund not expected to survive 24 hrs without an operation

Add E if emergent/urgent ASA I and II are usually appropriate candidates ASA III cases should be individually considered ASA IV and V, consult anesthesia or ICU

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NPO Guidelines

A longer fast (8 hours) for fatty meals should be considered

Weigh risks/benefits for emergent situations As a general rule, we follow >4 hours to be safe for

sedation.

Breast Milk Clear Liquids Milk and Non-Clear Liquids

Solids

4 hours 2 hours 6 hours 6 hours

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Equipment required

Suction – ALWAYS CHECK BEFORE SEDATION Oxygen delivery system Airway equipment of appropriate size Emergency Medications (Code Drugs)

• Reversal Medications IV equipment Monitors

• Pulse Oximetry• Cardiac/Blood Pressure

NG Tube of appropriate size

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Chloral Hydrate Benzodiazepines

• Midazolam• Diazepam

Barbiturates• Pentobarbital• Thiopental• Methohexital

Opiates• Morphine• Fentanyl

Ketamine Propofol Etomidate

Medications

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Chloral Hydrate

Unknown mechanism of action

Contraindicated in hepatic or renal disease

May have paradoxical excitement

Side Effects:• Hypotension• Cardiopulmonary

depression• GI upset

Simethicone

Dose: 25-100 mg/kg PO/PR• Max 1 gram in infants

2 grams in children Onset: 30-60min Duration 4-8 hours

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Benzodiazepines - Midazolam

The most commonly used sedation agent in children and adults

Provides potent sedation, anxiolysis, and amnesia

Shorter acting than other benzodiazepines

May be given IV, PO, IN, IM, or PR

Bitter aftertaste so mix in Syrpalta

Burns in nose

PO• Dose: 0.5-1 mg/kg, max

20mg• Onset: 15 min• Duration: 30-90 min

Intranasal or Sublingual • Dose: 0.2-0.5 mg/kg,

max 10 mg• Onset: 10-15 minutes• Duration: 60 minutes

IV• Dose: 0.05-0.1mg/kg,

max 0.6mg/kg or 10mg• Onset: 2-3 min• Duration: 60-90 min

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Benzodiazepines

Has NO analgesic effect! Contraindicated with narrow angle glaucoma and shock May be reversed with flumazenil (0.01mg/kg IV) If a reversal agent is required the patient must be

observed for an additional 2 hours from the time the reversal agent is given

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Barbiturates - Pentobarbital

Drug of choice for head trauma, Status Epilepticus

Side effects:• Myocardial depression

• Hypotension

• Respiratory depression

• Bronchospasm- stimulate histamine release

Contraindications:• liver failure

• CHF

• hypotension

NO Analgesia!

Dose: • 2-6 mg/kg/dose PO/PR/IM• 1-3 mg/kg/dose IV• Max dose is 150mg

Onset: 15-60 min Duration: 1-4 hours

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Propofol

Ultra short acting sedative Dose dependent level of

sedation with rapid recovery time

Profound respiratory depressant and causes apnea

May depress cardiac output and cause severe hypotension

Attending needs to be present during the entire infusion!

Dose:• 1-3 mg/kg IV• Repeat 0.5mg/kg Q2-3

min Contraindicated in patients

with egg or soybean allergy. IV site pain – use 1%

lidocaine

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Narcotics

Gold standard for pain management Reversed with Naloxone Combination with benzodiazepines can cause

respiratory depression and dosage should be reduced

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Fentanyl - IV

Preferred opioid because of rapid onset, elimination, and lack of histamine release

Rapid IV administration can cause chest wall rigidity and apnea

Respiratory depression may last longer than the period of analgesia

Dose is 1-2mcg/kg over 3-5 minutes

Titrate to effect every 3-5 minutes

Onset: 1-2 minutes Peak effect: 10 minutes Duration: 30-60 minutes

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Morphine Sulfate

Better for procedures that have a longer duration ( ≥ 30 minutes)

Histamine release can cause flushing and itching

Dose: 0.1-0.2 mg/kg IV/IM/SQ, max 15 mg

Onset: 5-10 minutes Duration: 2-4 hours

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Ketamine

Provides both analgesia and sedation

Releases endogenous catecholamines• Preserves respiratory

drive and airway protective reflexes

• Bronchodilator effect• Maintains hemodynamic

stability Rapid infusion causes

respiratory depression and apnea

Dose: 1 to 2 mg/kg IV

3 to 5mg/kg IM Onset: 1 minute IV Duration:

• 60 min for sedation• 40 to 45 min for

analgesia

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Ketamine - Complications

Laryngospasm Apnea Hypersalivation Vomiting Agitation/Hallucinations/Emergence Reactions Hypertension Increased Intracranial and Intraocular Pressure Myoclonus

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Ketamine - Contraindications

Age of 3 months or younger Active pulmonary disease or infection Procedures resulting in large amounts of oral

secretions or blood History of airway instability, tracheal surgery, or

tracheal stenosis Intracranial hypertension (head injuries,

hydrocephalus, mass) Cardiovascular disease Glaucoma or acute globe injury Psychiatric illness Full meal within 3 hours

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Etomidate

Ultra short acting hypnotic Unknown mechanism of

action Rapid IV induction Minimal respiratory

depression or hemodynamic instability

Possible cerebral protection Contraindications:

• Seizure disorder• Children < 2 y/o

Dose: 0.2-0.5 mg/kg IV Induction 0.3 mg/kg IV over

30-60 sec Duration 5-10 min Full recovery in 30 min Re-dose with 0.1mg/kg

every 5-10 minutes as needed

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Etomidate

Does not provide analgesia

Adverse reactions• Nausea and vomiting – 5%• Causes burning infusion pain, decreased with

lidocaine• Myoclonic movements, may stimulate seizure

activity• Inhibits steroid synthesis

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Consent

Sedation consent must be obtained SEPARATE from procedure consent

Use for sedation beyond SINGLE drug Anxiolysis

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Post-Procedure

Reassessed and monitored by RN or PALS Certified LPN.

VS every 10 minutes until discharge criteria met For prolonged complications, admission to the

appropriate area is recommended, i.e., floor or ICU Family given written discharge instructions and

verbalize understanding

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Discharge

Vitals are appropriate for age Child has appropriate activity

for age Appropriately responds to

verbal stimuli Oxygen saturation returns to

normal baseline Maintains airway appropriately Modified Aldrete score of > 13

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Special Considerations

Infants < 52 weeks gestation + chronologic age MUST be admitted for monitored observation for 12 hours minimum without apnea.

Residents and fellows must have sedation reviewed and approved by attending before administration

Beware of patients in Radiology

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Questions?