Pediatric Sedation and Analgesia Jan Bazner-Chandler RN,MSN, CNS, CPNP

PSA  Procedural sedation and analgesia (PSA) refers to the pharmacologic techniques of minimizing or eliminating a child’s pain and anxiety related to invasive or potentially frightening treatments & procedures.

Historical Perspective  AAP (American Academy of Pediatrics) seminal article 1992 referred to as “conscious sedation”, & established guidelines for monitoring these patients.  Defined as “a depressed state of consciousness where the patient retains protective reflexes and responds appropriately to stimuli”.  AHCPR (Agency for Health Care Policy & Research) published federal guidelines for management of acute pain in adults & children.

Procedural Sedation Re-defined  American College of Emergency Physicians re-named “conscious sedation” as “moderate sedation” because Procedural sedation’s goal was to medicate patients safely until they can tolerate unpleasant procedures; i.e, they aren’t really “conscious”.

AHCPR Guidelines 1. Provide adequate preparation of children & families for procedure 2. Be attentive to environmental comfort (allow parents to stay, quiet room, sign on door)  3.Combine pharmacological & non- pharmacological options when possible (relaxation & imagery/VR) 4. If procedures will be repeated, provide max S&A for 1 st procedure

Four Levels of Sedation The Joint commission and the American Society of Anesthesiologists (ASA) described the 4 levels of sedation.  Anxiolysis  Moderate Sedation  Deep Sedation  General Anesthesia

Minimal Sedation  Anxiolysis or minimal sedation refers to a drug-induced state in which cognitive and motor function may be impaired. This state does not fall under the sedation monitoring strict guidelines.

Moderate Sedation  Moderate sedation is a state of sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation, and maintains protective reflexes.

Deep Sedation  Deep sedation and analgesia is a drug induced depressed level of consciousness in which patients respond purposefully only to repeated or painful stimulation, and may be accompanied by the loss of protective reflexes.

General Anesthesia  General anesthesia refers to the drug induced loss of consciousness in which there is no response to painful stimulus, and loss of protective reflexes.

Sedation for Cooperation(non-painful but requires the patient to be very still for the duration of the procedure, which may be frightening for the child)  MRI  CT scan  Echo-cardiogram (rarely)  Radiation therapy

Sedation/Analgesia for Painful Procedures  Lumbar puncture  Bone marrow aspiration / biopsy  Renal biopsy  Chest tube insertion/removal  Central line insertion/removal  Peritoneal tap

Sedation for Emergency Procedures  Incision and drainage  Fracture reduction / splinting  Repair of lacerations

Goals of Sedation  Mood alteration in order to allay the patient’s fear and anxiety  Maintenance 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  Complete the procedure safely in minimum time

Sedation and Analgesia Goals  Achieve adequate sedation with minimal risk, minimal time  Minimize discomfort and pain  Minimize negative psychological response by providing anxiolysis, analgesia, and amnesia

Monitoring and Assessment Key Elements  Pre-procedural criteria  Management during sedation (intra-procedural)  Post-procedure sedation assessment  Release from observation/dismissal/discharge criteria  Patient/child education and discharge instructions

Pre-procedural  ASA patient classification/Modified Aldretti Score  Pre-procedural criteria  Feeding guidelines  Procedure / Site verification and time out (Universal Protocol)

ASA 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 Criteria  History and Physical/allergies/sedation hx  Informed consent..for procedure and sedation/analgesia drugs  NPO status  Base-line vital signs  Height and weight  Adequate staffing  Emergency equipment

Health Assessment Height / weight in kilograms Vital signs including blood pressure NPO status Allergies Current Medications (which may affect sedation level) Systemic diseases or genetic conditions Ability to intubated in the event of an emergency: size of jaw and ability to open mouth History of heart murmur or asthma

Informed Consent  a consent will need to be signed by a parent or legal guardian for the procedure & medications, & should be accompanied by a note in the medical record.  What constitutes an ‘informed consent?”

NPO Guidelines AgeDuration 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 hours2 hours

NPO Guidelines  Breast 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. In an emergency situation the child may require protection of the airway (intubation) before sedation”, and emptying the stomach as much as possible.

TJC (The Joint Commission) Standards  Procedure /Site Verification  Marking the operative site  Time out before procedure (Universal Protocol)  All must be documented in the MR

BRN Scope of Practice  Nurse Practice Act  It 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 / Medications  The knowledge base includes but is not limited to:  Effects of medication/appropriateness of order  Onset, peak, duration/reversal meds  Potential side effects of the medication  Contraindications for the administration of the medication  Amount of medication to be administered/safe & therapeutic dose

RN Responsibilities / Safety Nursing 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. One must be PALS certifies) ◦ Patient should never be left un-attended ◦ Registered nursing functions may not be assigned to unlicensed assistive personnel. ◦ RN must have no other duties other than to administer meds & monitor the patient

RN Safety Concerns Continuous monitoring of oxygen saturation Cardiac rate and rhythm Blood pressure Respiratory rate Level of consciousness/response to interventions Immediate availability of an emergency cart which contains resuscitative and antagonist medications, airway and PP ventilatory equipment (bag & appropriate size mask, defibrillator, suction equipment, means to administer 100% oxygen).

Institution Responsibilities  The institution should have in place a process for evaluating and documenting the RN’s training & competency for the management of clients receiving procedural sedation.  Evaluation and documentation should occur on a periodic basis.

Management During Procedure  Patient monitoring  Reportable conditions  Side effects of sedation  Benefits of sedation  Medications

Monitoring During Moderate Sedation  Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout and after the procedure

Reportable Conditions  Oxygen saturation less than 90% or 3% decrease from baseline  Change in vital signs of 20% or more  Respiratory depression or distress  Cardiac dysrhythmias  Deep sedation or loss of consciousness  Inadequate sedation and/or analgesic effect  Interventions and patient response  Failure to return to baseline status (within 2 points of Pre- Aldretti score within one hour)

Nursing Management  Personnel  Equipment  Medications  Medication reversal agents  Management parameters  Complications

Equipment/Supplies Needed for Sedation  Pulse oximeter  Cardiac monitor (if CV disease or arrhythmias detected or anticipated)  Blood pressure cuff  Crash cart in vicinity  Defibrillator  Suction  Emergency drugs and resuscitation equipment  Ambu bag & mask  Suction (device and Yaunker catheter)  O 2 tubing & mask  Patent IV site  Reversal agents ** at bedside  Oral/nasal airway and ET tube of appropriate size

Medications used for Sedation and Analgesia

Midazolam (Versed)  Classification: Benzodiazepine  Potent sedative, anxiolytic and amnestic with no analgesic effects. Potent respiratory depressant.  Action: fast acting, 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-procedural events.  Suited for procedures that are not especially painful: central catheter placement (with analgesia), voiding cysto- urethrogram (VCUG), CT scan, MRI

Versed Dosing  Midazolam can be given orally, intravenously, intra-nasally or rectally  Dosing:  Neonate dose: IV mg/kg  Children dose: Oral: mg/kg (max dose 15 mg) IM: 0.08mg/kg IV: mg/kg (max dose 2.5 mg)

Chloral hydrate  Classification: Sedative/Hypnotic, Non-barbiturate, no analgesic properties  Action:  Dosing  Neonate: Oral: mg/kg/dose Maintenance dose: mg/kg/dose  Children: Oral mg/kg/dose (max dose of 1 gm for infants & 2 gm for children)  Onset: 30 minutes to one hour  Duration: 4 to 8 hours

Morphine Sulfate  Classification: Narcotic analgesic  Action: opium-derivative, narcotic analgesic, which is a descending CNS depressant. Immediate pain relief with IV administration, peak analgesia at about 20 minutes, lasts up 2 to 4 hours.

Morphine Surlfate Morphine dosing  Neonate : IV 0.05 mg/kg **Neonates may require higher dose range- (0.1 mg/kg)  Children: Oral: mg/kg IV: mg/kg (max dose 10 mg/dose)  Adolescents: Oral 5-8mg/dose IV: 3-4 mg/dose

Meperidine (Demerol)not used much in peds  Classification: Narcotic Analgesic  Action: 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)

Fentanyl  Classification: potent opioid analgesic/respiratory depressant; fast and short-acting  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

Ketamine/only used under anesthesiologist’s supervision  Classification: 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.

Ketamine  Dosing  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 Agents  Benzodizepine antagonist antidote: (Romazicon/flumazinil)  Naloxone Hydrochloride narcotic antagonist (Narcan) (Figure out doses before hand, don’t draw up but be ready)

Flumazenil (Romazicon) Classification: Benzodiazepine antagonist Action: reverse the effects of procedural sedation and reverses paradoxical reaction ◦ 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: 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)  Classification: Narcotic antagonist  Uses: narcotic overdose, post-operative narcotic depression  Dosing  Neonate: 0.1 mg/kg/dose  Children IM/IV/SC: mg/kg May repeat dose every 2-3 minutes (max dose is 2 mg/dose.

Allergic Reactions  Nursing 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.  Paradoxical reaction to versed

Post-Procedural Management

Post-Procedural Monitoring  Parameters and accompanying timeframes:  Monitor every 15 minutes post-procedure until:  child sips clear fluids  child returns to prior mobility status  Child returns to within 2 points of pre-procedural Aldretti score

Post-Procedural Monitoring  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; reversal agents may not outlast sed/opioid drug effects. - “Emergence phenomena”

Monitoring Discharge Criteria  The 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 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