Sedation, Pain, and Analgesia

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. 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

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. 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

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: 15-20 minutes • Duration : 60-90 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 0.2 -0.5 mg/kg intranasal or sublingual of IV formulation • Onset: 10-15 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: • 2.5-3.5 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: 30-60 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 0.1-0.2 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