1. Sedation, Pain, and Analgesia
Ricardo R. Jiménez, MD
Pediatric Emergency Medicine, Fellow
Emory University School of Medicine
Children’s Healthcare of Atlanta

2. 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.

3. 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

4. Pain management Mild pain Reassurance Tylenol Ibuprofen Ice
Distraction

5. Pain management Moderate and Severe pain Local anesthesia
Parenteral Analgesia and Sedation

6. 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

7. 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

8. Nurse initiated guidelines
Motrin
Lortab
LET
Ela-max/LMX
Upgrading the triage level

9. Ela-max or LMX- 4% lidocaine
Topical Anesthetics - Intact Skin for IV access, Venipuncture, Lumbar Puncture
Ela-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

10. Topical Anesthetics
Viscous lidocaine 2%, Hurricaine Spray(20% Benzocaine) – For oral procedures like peritonsillar abscess

11. 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

12. 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

13. 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

14. 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.

15. Definitions Minimal sedation Moderate sedation Deep sedation
General Anesthesia

16. 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.

17. 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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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

23. 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.

24. Class 1 Unremarkable PMHx
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.

25. 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

26. 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
Light meal

27. Pre-sedation Assessment
Allergies
Medications
Past History
Last meal
Events

28. Physician Pre-assessment Form
A quick history
Focused Physical exam including airway assessment
Previous anesthesia Hx
ASA Class
Candidate suitable?

29. Physician Consent Form
Consent Forms specifically designed for Moderate or Deep Sedation
Goes over risks of sedation, specifically agitation, oversedation, and cardiorespiratory compromise

30. 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.

31. 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

32. 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

33. Modified Aldrete Score
Should have a score of greater than or equal to 13, before discharge

34. 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

35. Medications Benzodiazepines Barbiturates Narcotics Ketamine Propofol
Etomidate

36. 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

37. Benzodiazepines Midazolam - Oral Dose is 0.5 to 0.75 mg/kg orally
Maximum doses are the same as for IV
Onset: minutes
Duration : minutes
Not easily titrated, may cause oversedation
Bitter aftertaste may cause noncompliance, (spitting out dose)
Now formulated as a oral syrup 2mg/ml

38. Benzodiazepines Midazolam - Intranasal/Sublingual
Dose is mg/kg intranasal or sublingual of IV formulation
Onset: 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

39. Benzodiazepines Midazolam -IV Dose: 0.05-0.1 mg/kg IV
Onset: 1 to 3 min
Duration: 10 to 30 min

40. Benzodiazepines Midazolam - Important Considerations
Has NO analgesic effect!
May be reversed with flumazenil(0.01mg/kg IV)
Contraindicated with narrow angle glaucoma and shock

41. Barbiturates
Pentobarbital-Nembutal
Propofol – Diprivan

42. Barbiturates Side effects: Myocardial depression Hypotension
Respiratory depression
Bronchospasm- stimulate histamine release

43. 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

44. 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.

45. 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:
mg/kg IV

46. 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

47. Narcotics
Gold standard for pain management
Fentanyl
Morphine

48. 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: minutes

49. 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

50. Morphine Sulfate
Better for procedures that have a longer duration(30 minutes or greater)
Morphine dose is 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

51. Narcotics
Commonly used in combination with a benzodiazepine (sedative-hypnotic), i.e., Versed, to potentiate effect and provide both amnesia and analgesia

52. Ketamine Provides both analgesia and sedation
Preserves respiratory drive and airway protective reflexes
Helpful in pts with RAD-bronchodilator
Maintains hemodynamic stability

53. Ketamine Dose: 1 to 2 mg/kg/dose IV Onset: seconds
2 to 10mg/kg/dose IM
Onset: seconds
Duration: 10 to 20 min for sedation
40 to 45 min for analgesia

54. Ketamine - Complications
Laryngospasm
Apnea
Hypersalivation
Vomiting
Agitation/Hallucinations/Emergence Reactions
Hypertension
Increased Intracranial and Intraocular Pressure

55. 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

56. Etomidate CNS hypnosis – ultra short acting Hypnotic
Unknown mechanism of action
Imidazole ring

57. Etomidate - Benefits Rapid IV induction
Minimal hemodynamic instability
Minimal respiratory depression
Possible cerebral protection
Indications:
Procedural sedation
RSI – Trauma, CHF

58. Adverse reactions Etomidate Nausea and vomiting – 5%
Causes pain or burning at IV site
Myoclonic movements, may stimulate seizure activity
Inhibits steroid synthesis

59. Etomidate CNS hypnosis – ultra short acting Dose: 0.2-0.5mg/kg IV
Induction 0.3 mg/kg IV over secs
May redose with 0.1mg/kg every 5-10 minutes until procedure is completed or as needed

60. 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.

61. Etomidate Duration 5-10 mins Full recovery in 30 mins
Does not provide analgesia
MAP unchanged
Decreases ICP,CBF,and O2 metab rate

62. Summary - Recovery Monitoring does not end with procedure
Patient must be monitored until defined criteria for discharge are met.
Admission for observation may be indicated if a child is over-sedated or has significant complications from the sedation