Sedation, Pain, and Analgesia Ricardo R. Jiménez, MD Pediatric Emergency Medicine, Fellow Emory...
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Transcript of Sedation, Pain, and Analgesia Ricardo R. Jiménez, MD Pediatric Emergency Medicine, Fellow Emory...
Sedation, Pain, and Analgesia
Ricardo R. Jiménez, MDPediatric Emergency Medicine, Fellow
Emory University School of Medicine
Children’s Healthcare of Atlanta
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Pain
Pain is subjective Pain may be underestimated Pain may be under treated Studies show that children do not get the same
treatment as adults who have similar painful conditions.
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Pain scales
Visual analog scales for older children with the frowning and smiling faces
Hard to use for infants Sometimes the pain may be exaggerated by the
scales
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Patient Advocate
Goals:• Be the patient’s advocate in terms of pain
control.• Discuss with the parents the best method for
pain control for their child. • This is a very individual choice, with some
parents desiring little or no intervention, and other wanting more methods for anxiolysis and pain control
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Nurse initiated guidelines
Guidelines have been set up for the triage nurses to treat pain as soon as the patient present to the emergency room. Some examples:• Fractures• Sickle Cell Pain crises• Lacerations• IV access, venipuncture• Lumbar punctures
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Topical Anesthetics - Intact Skin for IV access, Venipuncture, Lumbar Puncture
Ela-max or LMX- 4% lidocaineEla-max or LMX- 4% lidocaine• Coin sized amount rubbed into the area and
active at 20 minutes. • Apply over intact skin and cover with a bio-
occlusive dressing. • May be used over abrasions, burns, small
lacerations, and for abscess drainage Pain ease– Cools the skin rapidly to provide
analgesia
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Topical Anesthetics
Viscous lidocaine 2%, Hurricaine Spray(20% Benzocaine) – For oral procedures like peritonsillar abscess
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LET(Lidocaine/Epi/Tetracane) in Triage
Application of LET in triage significantly reduces triage time
Duration of application ranged from 20 to 125 minutes with preservation of wound anesthesia
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Adjunctive techniques
Child life therapist Distraction- video/books/music/singing Parental involvement/comforting with familiar
objects(blankets/toys) Sucrose pacifiers – Study done at Emory showing
significant decrease in pain scale in neonates <1 month
Papoose/immobilization
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Where can we improve?
Apply topicals for all children requiring IV, venipunctures, LPs
Trauma room Think about the babies - Sucrose Procedures
• Check the adequacy of LET for wounds• Strongly consider sedation for any painful
procedure
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Goals
Guard the patient’s safety and welfare Minimize physical discomfort or pain Minimize negative psychological responses to
treatment by providing analgesia, and to maximize the potential for amnesia
Control the patient’s behavior Return the patient to a state in which safe discharge is
possible
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89, 1110.
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Levels of sedation
Minimal:• Normal response to verbal stimulation with
reduction of anxiety. Cardio-respiratory reflexes intact.
Moderate• Somnolence, responds to verbal stimulation may
need tactile stimulation.• Airway and protective reflexes are protected.
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Levels of sedation
Deep sedation• Reduction in consciousness. Pt not easily
aroused by verbal and noxious stimuli. Respond to painful stimuli
• Airway and protective reflexes may be preserved or compromised.
General anesthesia
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Moderate Sedation
AAP/COD Definition:Moderate sedation: a medically controlled state of depressed
consciousness that
(1) allows protective reflexes to be maintained
(2) retains the patients ability to maintain a patent airway independently and continuously
(3) permits appropriate response by the patient to physical stimulation or verbal command, e.g., “open your eyes”.
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89, 1110.
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Deep Sedation
“a medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.”
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89, 1110.
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General Anesthesia
“a medically controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain a patent airway independently and respond verbally to physical stimulation or command.”
Typically, general anesthesia is not recommended for the ER, or any outpatient setting.
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89, 1110.
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Candidates for Moderate and Deep Sedation
Before sedation is undertaken, an assessment is necessary to decide whether they are appropriate candidates for sedation.
Candidates for sedation will require pre-procedural assessments, which include a fairly extensive history and a focused physical exam.
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ASA Score
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
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Candidates for Moderate and Deep Sedation
ASA Class I or II: Are frequently considered appropriate candidates. Suitability for sedation is good to excellent.
ASA Class III: Present with special problems which require individual consideration in determining appropriateness. Suitability is intermediate to poor: consider benefits relative to risks
ASA Class IV and V: Suitability is poor; benefits rarely out weigh risks. Require a consultation with an anesthesiologist, intensivist, neonatologist, or emergency medicine physician to determine appropriate management.
Kraus, and Green: Sedation and anlagesia for procedures in children. NEJM 342:939,2000.
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Physical Status Classification from the American Society of Anesthesiologists(ASA)
Examples of patients• Class 1 Unremarkable PMHx• Class 2 Mild asthma, controlled SZ,
controlled diabetes, anemia• Class 3 Moderate to severe asthma, pneumonia,
moderate obesity, uncontrolled SZ or DM• Class 4 Severe BPD, advanced degrees of
pulmonary, cardiac, hepatic, renal, or endocrine insufficiency
• Class 5 Septic shock, severe trauma
Kraus, and Green: Sedation and anlagesia for procedures in children. NEJM 342:939,2000.
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Candidates for Moderate and Deep Sedation
Infants that are at least 6 weeks old and were full term(>38 weeks)
Premature infants whose chronological age + gestation age is greater than 52 weeks
Healthy infants not meeting these criteria may be candidates, but MUST be monitored a minimum of 12 hours without apnea post procedure to qualify for discharge
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ASA Recommendations for fasting before elective procedures
Ingested material Minimum fasting time
Clear liquids 2 hours
Breast milk 4 hours
Infant formula 6 hours
Non human milk 6 hours
Light meal 6 hours
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Physician Pre-assessment Form
A quick history Focused Physical
exam including airway assessment
Previous anesthesia Hx
ASA Class Candidate suitable?
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Physician Consent Form
Consent Forms specifically designed for Moderate or Deep Sedation
Goes over risks of sedation, specifically agitation, oversedation, and cardiorespiratory compromise
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Personnel
“Sedation must be administered by personnel capable of rapidly identifying and treating cardiorespiratory complications, including respiratory depression, apnea, partial airway obstruction, emesis, and hypersalivation. They must understand the pharmacology of the sedatives they use and be proficient at maintaining airway patency and assisting ventilation if needed.”
“At least two experienced people medicating the patient. are required, usually a physician and a nurse or respiratory
therapist.” During the procedure, nurse or respiratory therapist, must have no
other duties except monitoring.
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Monitoring
Blood pressure Pulse Respiratory rate Airway status Oxygen saturation-continuously Pain assessment Document each of the above every 5 minutes for the duration
of the procedure
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Discharge Criteria
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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Discharge Criteria - Complications
If a reversal agent is required the patient must be observed for an additional 2 hours from the time the reversal agent is given
For prolonged complications, admission to the appropriate area is recommended, i.e., floor or ICU
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Benzodiazepines
Midazolam(Versed)• The most commonly used sedation agent in children and
adults• Excellent safety record • Provides potent sedation, anxiolysis, and amnesia• Shorter acting than other benzodiazepines• Water soluble, so eliminates burning on administration IV• May be given IV, PO, IN, IM, or PR
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Benzodiazepines
Midazolam - Oral• Dose is 0.5 to 0.75 mg/kg orally• Maximum doses are the same as for IV• Onset: 15-20 minutes• Duration : 60-90 minutes• Not easily titrated, may cause oversedation• Bitter aftertaste may cause noncompliance, (spitting out
dose)• Now formulated as a oral syrup 2mg/ml
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Benzodiazepines
Midazolam - Intranasal/Sublingual• Dose is 0.2 -0.5 mg/kg intranasal or sublingual of IV
formulation• Onset: 10-15 minutes• Duration: 60 minutes• Similar side effects as oral route• Intranasal route burns when administered, and children
generally do not cooperate with administration.• Sublingual has same problem with bitter taste as oral
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Benzodiazepines
Midazolam -IV• Dose: 0.05-0.1 mg/kg IV
• Onset: 1 to 3 min
• Duration: 10 to 30 min
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Benzodiazepines
Midazolam - Important Considerations• Has NO analgesic effect!
• May be reversed with flumazenil(0.01mg/kg IV)
• Contraindicated with narrow angle glaucoma and shock
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Barbiturates
Side effects: Myocardial depression Hypotension Respiratory depression Bronchospasm- stimulate histamine release
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Pentobarbital - Nembutal
Barbituate that is commonly used for radiologic procedures like CT scans which require children to be still.
Dose: • 2-6 mg/kg/dose PO/PR/IM• 1-3 mg/kg/dose IV• Max dose is 150mg
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Propofol
Propofol - Alkyl phenol(Diprivan) Dose dependent levels of AMS, from sedation to
general anesthesia. Advantage of a rapid recovery time. Must be monitored extremely closely.
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Propofol – Important concerns
Profound respiratory depressant, and causes apnea. May depress cardiac output and cause severe
hypotension IV site pain –requires mix of lidocaine and Propofol
with loading dose. Contraindicated in patients with egg or soybean
allergy. Dose:
• 2.5-3.5 mg/kg IV
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Propofol
Requires intensive patient monitoring• Pulse oximeter• Cardio-respiratory monitor
• End tidal CO2
Experience and familiarity of usage by physician Attending needs to be present during the entire
procedure
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Fentanyl - IV
Preferred opioid because of rapid onset, elimination, and lack of histamine release
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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Fentanyl - IV
Rapid IV administration can cause chest wall rigidity and apnea
Combination with benzodiazepines can cause respiratory depression and dosage should be reduced
Respiratory depression may last longer than the period of analgesia
May be reversed with Narcan
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Morphine Sulfate
Better for procedures that have a longer duration(30 minutes or greater)
Morphine dose is 0.1-0.2 mg/kg IV with a max of 15 mg/dose slow IV push. Titrate to effect slowly.
Onset:5-10 minutes Duration: 2-4 hours Same dose may given IM or SQ
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Narcotics
Commonly used in combination with a benzodiazepine (sedative-hypnotic), i.e., Versed, to potentiate effect and provide both amnesia and analgesia
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Ketamine
Provides both analgesia and sedation Preserves respiratory drive and airway protective
reflexes Helpful in pts with RAD-bronchodilator Maintains hemodynamic stability
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Ketamine
Dose: 1 to 2 mg/kg/dose IV
2 to 10mg/kg/dose IM Onset: seconds Duration: 10 to 20 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
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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
CNS hypnosis – ultra short acting• Hypnotic• Unknown mechanism of action• Imidazole ring
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Etomidate - Benefits
Rapid IV induction Minimal hemodynamic instability Minimal respiratory depression Possible cerebral protection Indications:
• Procedural sedation• RSI – Trauma, CHF
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Etomidate
Adverse reactions• Nausea and vomiting – 5%• Causes pain or burning at IV site• Myoclonic movements, may stimulate seizure
activity• Inhibits steroid synthesis
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Etomidate
CNS hypnosis – ultra short acting• Dose: 0.2-0.5mg/kg IV• Induction 0.3 mg/kg IV over 30-60 secs• May redose with 0.1mg/kg every 5-10
minutes until procedure is completed or as needed
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Etomidate
Important considerations!• Pre-treat with fentanyl 1-2 mcg/kg to reduce
myoclonus• Pre-treat with lidocaine 0.5mg/kg to
reduce burning with injection• Contraindicated with seizure disorder• Contraindicated in children< 2 y.o.
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Etomidate
• Duration 5-10 mins• Full recovery in 30 mins• Does not provide analgesia• MAP unchanged• Decreases ICP,CBF,and O2 metab rate