1. Procedural Sedation in
In The Name Of GOD
Pain Management and
Procedural Sedation in
Infants and Children
SIAMAK YASAMI PGY1

2. Pain and anxiety are very common experiences for patients of all ages in the ED, and both are frequently undertreated.
This is particularly true for children.

8. Oucher Scale

11. ANXIOLYSIS Anxiety potentiates pain, Common examples :
laceration repair
lumbar puncture.

12. NONPHARMACOLOGIC ANXIOLYSIS
Parental presence
Distraction of children
picture books,
stories read aloud
songs, or music

13. PHARMACOLOGIC ANXIOLYSIS
Benzodiazepines are widely used :
anxiolytic, sedative, amnestic, hypnotic
Midazolam :short duration of action.
Intranasal route :more rapid onset of action than the oral route.
No analgesic properties

15. “mucosal atomizer devices” are used for intranasal delivery.

16. Combination of Midazolam & Fentanyl
Luckily, fentanyl
can also be given by the intranasal route

17. Advantage of intranasal administration
More rapid onset of action than the oral route
Higher blood levels (by avoiding “first pass effects”
of the GI system)
No need for IV placement

18. Midazolam: Adverse effects
Paradoxical agitation, particularly at lower doses
Respiratory depression and hypotension, particularly in hypovolemic patients

19. Midazolam for ANXIOLYSIS
Midazolam is more effective
at the higher end of the range (e.g., 0.4 milligrams/kg for the intranasal route).
Oral midazolam has a longer duration of effect :
protect the child from falls for several hours

20. Midazolam may be used IV
A lower dose (0.05 to 0.1 mg/kg IV) is sufficient , for example:
lumbar puncture.
Higher doses can cause a paradoxical reaction , with agitation, confusion, or crying
Both paradoxical agitation and respiratory depression may be treated with flumazenil

21. ANALGESIA NONPHARMACOLOGIC
Immobilization, Ice,
elevation of fractures,
distraction, massage, breathing techniques,
and emotional support

22. ANALGESIA PHARMACOLOGIC
Oral Sucrose for Neonates

23. Sweet-Ease
Reduces physiologic measures of pain ( heart rate), behavioral measures ( time crying), and newborn pain scale scores.

26. Topical Anesthetics for Intact Skin
Phlebotomy
Mediport access, and
Lumbar puncture
EMLA® and LMX®.
EMLA® 2.5% prilocaine and 2.5% lidocaine
LMX® 4% liposomal Lidocaine
The time to maximal effect is up to 60 minutes for EMLA® and 30 minutes for LMX®

27. Topical Anesthetics for Open Wounds
LET® (lidocaine , epinephrine, and tetracaine )
For laceration repairs in children.
It can be applied to fingers, toes, lips, and other end-organ tissues despite the vasoconstriction effects of the epinephrine.

28. How?
LET® should be applied half into the wound and half on cotton (rather than gauze)

29. When?!! Blanching of the skin from the vasoconstriction
effects of epinephrine is a good sign that topical anesthesia has been achieved
20 to 30 minutes

30. Needle-free injection
High-pressure delivery system
J-tip: the most used needle-free injection system for local anesthesia

33. Local Anesthetic Injection
Slow injection with a small-gauge needle
The addition of sodium bicarbonate
(typically in a 1:9 ratio) buffers the acidity.
Must be added immediately before( precipitation)

34. Systemic Analgesia : Oral Agents
Ibuprofen
First-line: mild to moderate pain in children
NSAIDS:
No human studies have demonstrated delay in
fracture healing

35. Hydrocodone
Liquid formulation of hydrocodone plus acetaminophen (7.5 milligrams/500 milligrams per 15 mL) :Lortab

37. Systemic Analgesia Intranasal Fentanyl
1.5 to 2 micrograms/kg comparable to morphine
Intranasal fentanyl and midazolam useful in the prehospital setting.

38. IV NSAIDS
. IV Ketorolac
Musculoskeletal , cholelithiasis , ureterolithiasis.
FDA: in children as young as 24 months. The dose is
1 mg/kg IM (max 30 mg) or
0.5 mg/kg IV (max 15 mg).

39. IV Opiates Morphine 0.1 to 0.2 milligram/kg
Repeat at 10- to 15-minute intervals

40. IV Opiates Fentanyl: less histamine release short duration of action
Hydromorphone : Much higher potency than morphine : Sickle cell pain crisis
Children with prior use of opiates.

41. Fentanyl
Fentanyl in rapid iv bolus: “rigid chest phenomenon,” may require naloxone or neuromuscular blockade.

42. PROCEDURAL SEDATION Benzodiazepines Ketamine Etomidate Propofol
Nitrous oxide

43. Procedural Sedation Five steps: 1. Indications & informed consent.
2. Assess the child : appropriate candidate ?
3. Select sedative agents.
4. Monitor the patient
5. Monitor until recovery.

45. EXAMPLES 0F DIFFICULT INTUBATION
High Mallampati scores : also difficult
bag-mask ventilation
Trisomy 21 :large tongues and cervical spine instability
Pierre Robin’s syndrome with micrognathia.

46. NPO
The question is this:
NPO or not?!

47. No need to NPO
There is no correlation between fasting and aspiration This is particularly true for ketamine

49. Select Medications for Procedural Sedation
READY?

50. Ketamine Effects: Most commonly used medication
Anesthetic, analgesic, and amnestic.
Little risk of respiratory or cardiovascular depression,
Bronchodilatory effects.

51. Ketamine : Since 2011 A clinical practice guideline updated in 2011 :
2011 :
(1)expansion of the guideline to adults;
(2) reduction in age to 3 months;
(3) removal of head trauma as contraindication,
(4) emphasis on IV over IM route when feasible;
(5) Not prophylactic anticholinergics or benzodiazepines
(6) addition of prophylactic ondansetron to prevent vomiting.

52. Ketamine:Dose
Greater than 90% of children are adequately sedated by a ketamine dose of 1.5 milligrams/kg IV: the recommended starting dose
Ketamine may also be administered IM at a dose of 4 to 5 milligrams/kg, but IM administration may cause more vomiting and has a prolonged recovery time

53. Opiate plus Ketamine A fracture : morphine or fentanyl for imaging
No increased adverse events

54. Propofol Ultra-short duration of action (shorter than ketamine)
Antiemetic properties.
No analgesia
Analgesics must administered

55. Propofol Hypotension , Respiratory depression , Apnea.
( Not usually clinically significant.)
Do not administer in mitochondrial disorders

56. Propofol examples: Complete stillness ( neuroimaging )
Reduction of dislocations.

57. Propofol and Ketamine Combination : safe and effective,
Complementary side effects: propofol can cause hypotension and respiratory depression and is an antiemetic, whereas ketamine may cause hypertension
and vomiting .

58. Barbiturates Motionlessness( imaging )
Propofol is largely replacing their use

59. Nitrous Oxide Anxiolysis, sedation, and analgesia.
Useful for minor procedures: IV placement
Maximal effect within a minute
Not effect on hemodynamics, respiratory drive

60. Monitoring
Oxygen during sedation, in the absence of oxygen desaturation? May mask the hypoventilation. If oxygen is administered, it should be in combination with continuous capnography.

61. Postsedation Monitoring
Immediately after the procedure, with the cessation of painful stimuli, oversedation and respiratory depression can develop.

62. Discharge criteria Normal serial vital signs, including blood pressure
and pulse oximetry;
Return to presedation mental status
Ability to sit unaided

63. Thank You for your attention