1. Kalpesh N. Patel, MD Dept. of Pediatric Emergency Medicine August 1, 2007 Sedation and Analgesia for ED101

2. 2 Objectives  To review sedation/analgesia drugs, doses, and nursing pain protocols  To review pre-sedation workup and checklist  To familiarize you with CHOA sedation policies and practices  To review sedation drugs and dosages  Child Life Services

3. 3 Analgesia  “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” –American Pain Society 1992; Mersky, Bogduk, 1994  Patient’s self-report is the single most reliable indicator of pain.  Unrelieved pain has negative physical and psychological consequences.  There is no diagnostic or therapeutic benefit to being in pain.  Baseline pain rating is obtained at triage.  Studies show that children do not get the same treatment as adults who have similar painful conditions.

4. 4 Assessing Pain  For sedated, unresponsive patients use the Objective Pain Scale (OPS)

5. 5 Assessing Pain  For non-verbal patients use FLACC behavioral scale

6. 6 Assessing Pain  For pre-school and young school age children use the FACES scale by patient self report

7. 7 Assessing Pain  For older school/adolescent patients use the 0-10 Numeric Pain Rating Scale by patient self report

8. 8 Treatment Options  Non-Pharmacologic Treatment: In most situations, parents are the best source of comfort Promote a sense of control to the patient in a developmentally appropriate manner Use treatment rooms away from other patients and create a calm environment. Distraction  Child Life Directed Imagery

9. 9 Treatment Options  Pharmacologic Treatment Mild pain (1-4/10): Acetaminophen and/or Ibuprofen Moderate pain (5-7/10): Ibuprofen and/or Tylenol with codeine Severe pain (8-10/10): Ibuprofen and/or Lortab  Acetaminophen 15mg/kg max of 1000mg  Ibuprofen 10mg/kg max of 800mg  Tylenol with Codeine 1mg/kg max of 60mg  Lortab 0.15mg/kg 12-15 kg: 3.75cc 16-22 kg: 5cc 23-31 kg: 7.5cc 32 + kg: 10cc of elixir or 1 tablet of Lortab 5/500

10. 10 Contraindications  Do not give meds if allergic or hypersensitive  Acetaminophen Known liver dysfunction Prior dose < 4 hrs  Ibuprofen < 6 months of age Known renal dysfunction Prior dose <6 hrs Currently bleeding or known bleeding disorder  Lortab and Tylenol with Codeine Same as acetaminophen contraindications Caution in constipation/abdominal pain

11. 11 Treatment Options  Local Analgesia Cold  Ice  Ethyl Chloride  PainEase Refrigerant Spray Viscous lidocaine EMLA LMX LET  SweetEase (24% sucrose solution) Start giving 2 min prior to procedure

12. 12 Sedation  Levels of Sedation: Minimal Sedation (Anxiolysis) Moderate Sedation (Conscious) Deep Sedation General Anesthesia  Sedation to anesthesia is a continuum and movement into other levels is easy

13. 13 Minimal Sedation  Patient responds to verbal commands  Ventilatory and cardiovascular functions are unaffected  A SINGLE drug given by RN, MD, or dentist  Nitrous Oxide/O2 titrated up to a maximum of 50% in conjunction with local nerve blocks or topical anesthetics.  Criteria: No history of apnea/bradycardia  Vital Signs Q15min of HR, RR and SpO2 for 1 hour, then hourly.

14. 14 Moderate Sedation  Patients respond purposefully to verbal commands or LIGHT tactile stimulation  Maintains protective reflexes including cough and gag. No respiratory support needed  Provided in designated safe areas: OR, PACU, ICU, ED, Radiology  Vital Signs with continuous pulse ox every 5 min

15. 15 Deep Sedation  Patients cannot be easily aroused, but respond purposefully to PAINFUL stimuli.  Ventilatory function may be impaired. May need airway support and spontaneous ventilation may be inadequate.  Cardiovascular function is usually maintained.  VS monitored every 5 min: HR, RR, BP, SpO2, ± ETCO2

16. 16 General Anesthesia  Includes general anesthesia and spinal or major regional anesthesia.  Patients are not arousable to ANY stimuli.  Ventilatory function is often impaired and require assistance.

17. 17 Pre-Sedation Workup  History Allergies  Prior sedation reactions? Medications Past Medical History  Pregnant? Drug Abuse? Apnea, Seizure, Reflux, Snoring? Last Meal Events leading up to need for sedation  Physical Baseline Vitals and LOC Airway Exam Heart & Lungs

18. 18 ASA Classification ClassPhysical status IHealthy patient IIMild systemic disease, no functional limitation IIISevere systemic disease that limits activity IVIncapacitating systemic disease that is a constant treat to life VMoribund not expected to survive 24 hrs without an operation  Add E if emergent/urgent  ASA I and II are usually appropriate candidates  ASA III cases should be individually considered  ASA IV and V, consult anesthesia or ICU

19. 19 NPO Guidelines  A longer fast (8 hours) for fatty meals should be considered  Weigh risks/benefits for emergent situations  As a general rule, we follow >4 hours to be safe for sedation. Breast MilkClear LiquidsMilk and Non- Clear Liquids Solids 4 hours2 hours6 hours

20. 20 Equipment required  Suction – ALWAYS CHECK BEFORE SEDATION  Oxygen delivery system  Airway equipment of appropriate size  Emergency Medications (Code Drugs) Reversal Medications  IV equipment  Monitors Pulse Oximetry Cardiac/Blood Pressure  NG Tube of appropriate size

21. 21  Chloral Hydrate  Benzodiazepines Midazolam Diazepam  Barbiturates Pentobarbital Thiopental Methohexital  Opiates Morphine Fentanyl  Ketamine  Propofol  Etomidate Medications

22. 22 Chloral Hydrate  Unknown mechanism of action  Contraindicated in hepatic or renal disease  May have paradoxical excitement  Side Effects: Hypotension Cardiopulmonary depression GI upset  Simethicone  Dose: 25-100 mg/kg PO/PR Max 1 gram in infants 2 grams in children  Onset: 30-60min  Duration 4-8 hours

23. 23 Benzodiazepines - Midazolam  The most commonly used sedation agent in children and adults  Provides potent sedation, anxiolysis, and amnesia  Shorter acting than other benzodiazepines  May be given IV, PO, IN, IM, or PR  Bitter aftertaste so mix in Syrpalta  Burns in nose  PO Dose: 0.5-1 mg/kg, max 20mg Onset: 15 min Duration: 30-90 min  Intranasal or Sublingual Dose: 0.2-0.5 mg/kg, max 10 mg Onset: 10-15 minutes Duration: 60 minutes  IV Dose: 0.05-0.1mg/kg, max 0.6mg/kg or 10mg Onset: 2-3 min Duration: 60-90 min

24. 24 Benzodiazepines  Has NO analgesic effect!  Contraindicated with narrow angle glaucoma and shock  May be reversed with flumazenil (0.01mg/kg IV)  If a reversal agent is required the patient must be observed for an additional 2 hours from the time the reversal agent is given

25. 25 Barbiturates - Pentobarbital  Drug of choice for head trauma, Status Epilepticus  Side effects: Myocardial depression Hypotension Respiratory depression Bronchospasm- stimulate histamine release  Contraindications: liver failure CHF hypotension  NO Analgesia!  Dose: 2-6 mg/kg/dose PO/PR/IM 1-3 mg/kg/dose IV Max dose is 150mg  Onset: 15-60 min  Duration: 1-4 hours

26. 26 Propofol  Ultra short acting sedative  Dose dependent level of sedation with rapid recovery time  Profound respiratory depressant and causes apnea  May depress cardiac output and cause severe hypotension  Attending needs to be present during the entire infusion!  Dose: 1-3 mg/kg IV Repeat 0.5mg/kg Q2-3 min  Contraindicated in patients with egg or soybean allergy.  IV site pain – use 1% lidocaine

27. 27 Narcotics  Gold standard for pain management  Reversed with Naloxone  Combination with benzodiazepines can cause respiratory depression and dosage should be reduced

28. 28 Fentanyl - IV  Preferred opioid because of rapid onset, elimination, and lack of histamine release  Rapid IV administration can cause chest wall rigidity and apnea  Respiratory depression may last longer than the period of analgesia  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

29. 29 Morphine Sulfate  Better for procedures that have a longer duration ( ≥ 30 minutes)  Histamine release can cause flushing and itching  Dose: 0.1-0.2 mg/kg IV/IM/SQ, max 15 mg  Onset: 5-10 minutes  Duration: 2-4 hours

30. 30 Ketamine  Provides both analgesia and sedation  Releases endogenous catecholamines Preserves respiratory drive and airway protective reflexes Bronchodilator effect Maintains hemodynamic stability  Rapid infusion causes respiratory depression and apnea  Dose: 1 to 2 mg/kg IV 3 to 5mg/kg IM  Onset: 1 minute IV  Duration: 60 min for sedation 40 to 45 min for analgesia

31. 31 Ketamine - Complications  Laryngospasm  Apnea  Hypersalivation  Vomiting  Agitation/Hallucinations/Emergence Reactions  Hypertension  Increased Intracranial and Intraocular Pressure  Myoclonus

32. 32 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

33. 33 Etomidate  Ultra short acting hypnotic  Unknown mechanism of action  Rapid IV induction  Minimal respiratory depression or hemodynamic instability  Possible cerebral protection  Contraindications: Seizure disorder Children < 2 y/o  Dose: 0.2-0.5 mg/kg IV  Induction 0.3 mg/kg IV over 30-60 sec  Duration 5-10 min  Full recovery in 30 min  Re-dose with 0.1mg/kg every 5-10 minutes as needed

34. 34 Etomidate  Does not provide analgesia  Adverse reactions Nausea and vomiting – 5% Causes burning infusion pain, decreased with lidocaine Myoclonic movements, may stimulate seizure activity Inhibits steroid synthesis

35. 35 Consent  Sedation consent must be obtained SEPARATE from procedure consent  Use for sedation beyond SINGLE drug Anxiolysis

36. 36 Post-Procedure  Reassessed and monitored by RN or PALS Certified LPN.  VS every 10 minutes until discharge criteria met  For prolonged complications, admission to the appropriate area is recommended, i.e., floor or ICU  Family given written discharge instructions and verbalize understanding

37. 37 Discharge  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

38. 38 Special Considerations  Infants < 52 weeks gestation + chronologic age MUST be admitted for monitored observation for 12 hours minimum without apnea.  Residents and fellows must have sedation reviewed and approved by attending before administration  Beware of patients in Radiology

39. 39 Questions?