1. PICU Analgesia & Sedation Algorithm for Endotracheally Intubated Patients Routine goal directed daily assessment. Use minimal pharmacological agents to achieve individualized analgesia & sedation goals. Monitor for PAD. First line: Non-pharmacological measures Optimize environment, noise reduction, patient position, day/night orientation, family involvement, therapeutic touch, calming music, early mobilization, remove noxious stimuli First line: Non-pharmacological measures Optimize environment, noise reduction, patient position, day/night orientation, family involvement, therapeutic touch, calming music, early mobilization, remove noxious stimuli GOALS ACHIEVED? AVOID pain, awake/alert, settled, comfortable, engaged, mobilize GOALS ACHIEVED? AVOID pain, awake/alert, settled, comfortable, engaged, mobilize PAIN AGITATION Routine acetaminophen and/or NSAID (if appropriate) Routine acetaminophen and/or NSAID (if appropriate) INTERMITTENT OPIOID: Morphine 0.05-0.1 mg/kg/DOSE IV Q1-4H PRN or routine (max 5 mg/DOSE) Fentanyl 1-2 mcg/kg/DOSE IV Q1-2H PRN (max 100 mcg/DOSE) If requiring PRN’s more frequent than Q2H For additional sedation, consider adjuncts: 1.Chloral hydrate 25-50 mg/kg/DOSE PO/PR Q6H PRN or routine (max 1 g/DOSE) 2.Diphenhydramine 0.5-1 mg/kg/DOSE IV/PO Q6H PRN or routine for itch (max 50 mg/DOSE) 3.Propofol rescue: consider PRN or infusion (for no longer than 24 hr) OR bridge to extubation: propofol bolus: 0.5-2 mg/kg/DOSE IV Q30min to Q1H PRN infusion: 0.5-4 mg/kg/hr (if >4mg/kg/hr switch to anaesthetic mode… 80-200 mcg/kg/min. **Requires MD approval) For additional sedation, consider adjuncts: 1.Chloral hydrate 25-50 mg/kg/DOSE PO/PR Q6H PRN or routine (max 1 g/DOSE) 2.Diphenhydramine 0.5-1 mg/kg/DOSE IV/PO Q6H PRN or routine for itch (max 50 mg/DOSE) 3.Propofol rescue: consider PRN or infusion (for no longer than 24 hr) OR bridge to extubation: propofol bolus: 0.5-2 mg/kg/DOSE IV Q30min to Q1H PRN infusion: 0.5-4 mg/kg/hr (if >4mg/kg/hr switch to anaesthetic mode… 80-200 mcg/kg/min. **Requires MD approval) INTERMITTENT LORAZEPAM 0.05-0.1 mg/kg/DOSE IV Q1-4H PRN (max 4 mg/DOSE) INTERMITTENT LORAZEPAM 0.05-0.1 mg/kg/DOSE IV Q1-4H PRN (max 4 mg/DOSE) If requiring PRN’s more frequent than Q2H OPIOID INFUSION(S): titrate to effect Morphine 10-100 mcg/kg/hr or Fentanyl 1-5 mcg/kg/hr (or convert to morphine / HYDROmorphone equivalent) Give PRN’s prior to increasing infusion OPIOID INFUSION(S): titrate to effect Morphine 10-100 mcg/kg/hr or Fentanyl 1-5 mcg/kg/hr (or convert to morphine / HYDROmorphone equivalent) Give PRN’s prior to increasing infusion For additional sedation & analgesia / opioid sparing effect consider: 1.Clonidine 2-5 mcg/kg/DOSE PO Q6H (start after 5 days of opioid infusion to facilitate wean. Max 200 mcg/DOSE) 2.Dexmedetomidine infusion 0.2-1.2 mcg/kg/hr 3.Ketamine infusion 1-20 mcg/kg/min 4.For neuropathic pain consider gabapentin For additional sedation & analgesia / opioid sparing effect consider: 1.Clonidine 2-5 mcg/kg/DOSE PO Q6H (start after 5 days of opioid infusion to facilitate wean. Max 200 mcg/DOSE) 2.Dexmedetomidine infusion 0.2-1.2 mcg/kg/hr 3.Ketamine infusion 1-20 mcg/kg/min 4.For neuropathic pain consider gabapentin If opioid infusion > 24 hr start routine bowel regimen 1 st Line Therapy 2 nd Line Therapy If on opioid / benzo infusion(s) for > 5-7 days consider tapering regimen +/- clonidine NOTES: maintain goals with min. drug therapy. 1 st line is a single agent (for sedation/analgesia) 2nd line is to progress to an infusion of a single agent and/or add second agent as needed Evaluate goals frequently; for escalation or discontinuation of agents Fentanyl is preferable if hemodynamically unstable or adverse effects with morphine Avoid NSAIDs if increased risk of bleeding / or renal dysfunction. If using ketorolac reassess after 48 hr. Frequency of scoring Q4H and PRN. Document score prior to and 30min post bolus dose or infusion escalation. For larger children & adolescents - beware of absolute dose Ensure patient is adequately sedated and the intermittent doses are optimized BEFORE increasing infusions. INDIVIDUALIZE THERAPY & ADJUST GOALS FREQUENTLY. These guidelines do not apply to patients followed under the acute pain service (APS) For patients with sleep disturbance consider melatonin 3-6 mg/DOSE QHS Analgesia & sedation monitoring use: FLACC Wong Baker Faces Numeric scale COMFORT score p-CAM-ICU for delirium WAT-1 for withdrawal OPIOID EQUIVALENCY: 100mcg Fentanyl= 2mg HM = 10mg Morphine inj. INTERMITTENT OPIOID: Morphine 0.05-0.1 mg/kg/DOSE IV Q1-4H PRN or routine (max 5 mg/DOSE) Fentanyl 1-2 mcg/kg/DOSE IV Q1-2H PRN (max 100 mcg/DOSE) INTERMITTENT OPIOID: Morphine 0.05-0.1 mg/kg/DOSE IV Q1-4H PRN or routine (max 5 mg/DOSE) Fentanyl 1-2 mcg/kg/DOSE IV Q1-2H PRN (max 100 mcg/DOSE) If requiring PRN’s more frequent than Q2H If opioid infusion > 24 hr start routine bowel regimen If opioid infusion > 24 hr start routine bowel regimen

2. Opioid and Benzodiazepine Infusions Tapering Algorithm Routine goal directed daily assessment. Individualize analgesia & sedation taper. Monitor for withdrawal (WAT-1 scores done Q4H & PRN) < 5 days of continuous IV infusions LOW RISK OF WITHDRAWAL Discontinue IV infusions Continue intermittent agents PRN and consider switching to longer acting agents END POINTS any 1 of the following >3 PRN’s in 3 hours WAT-1 scores > 3 Cardiorespiratory instability and/or Ventilator dysynchrony despite PRN doses RESUME infusion(s) at 50% of original dose Adjust dose(s) to achieve GOALS WAT-1 scores < 3 on 2 separate occurrence's HIGH RISK OF WITHDRAWAL >5-7 days of continuous IV infusions HIGH cumulative dose Increase infusion(s) to 80% of original dose Reduce IV infusion(s) by 50% Consider alternating if on two different infusions (ie. narcotic & benzo) Continue intermittent agents PRN ANY 1 of ENDPOINTS met? WAT-1 scores >3 Continue to WEAN by 10-20% Q4-24H as tolerated Continue intermittent agents PRN for WAT-1 scores > 3 *IF PATIENT IS IN WITHDRAWAL: Administer PRN doses of opioid / or benzodiazepine to treat symptoms, based on WAT-1 scores > 3 Consider increasing background infusion by 10-20% to achieve targets. Consider clonidine 2-5 mcg/kg/DOSE PO/NG Q6H (taper over 48 hours once opioids and benzodiazepines are discontinued) Monitor for delirium using p-CAM-ICU score **IF PATIENT HAS DELIRIUM: 1.Discontinue / minimize use of opioids & benzos 2.Discontinue anticholinergic meds ie. diphenhydramine, ranitidine, dimenhydrinate, etc. 3.Institute non-drug measures: sleep hygiene, day/night activity, noise reduction, orientation 4.Consider atypical anti-psychotic (quetiapine, olanzapine, risperidone, chlorpromazine, haldol) NOTE: Length of taper will depend on number of infusion days as well as maximum doses reached to achieve analgesia & sedation targets. Dexmedetomidine may be used as a strategy to reduce narcotic infusion dose. If continued for > 7 days wean infusion by 0.2-0.5 mcg/kg/hr Q8-24H; then consider clonidine. If transferring to floor complete narcotic infusion order set. Tolerating wean, WAT-1 score < 3 Consider discontinuing infusion Switch to intermittent opioid & benzo (either IV or enteral) Convert to longer acting agents (hydromorphone, morphine & lorazepam) For patients with sleep disturbance consider melatonin 3-6 mg/DOSE QHS OPIOID EQUIVALENCY: 100mcg Fentanyl= 2mg HM = 10mg Morphine IV