Sedation and Analgesia for ED101

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

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

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

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

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

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. ASA Classification • 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. 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.

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

22. 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 Chloral Hydrate

23. 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 Benzodiazepines - Midazolam

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. 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 Barbiturates - Pentobarbital

26. 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 Propofol

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

28. 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 Fentanyl - IV

29. 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 Morphine Sulfate

30. 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 Ketamine

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

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. 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 Etomidate

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

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. 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. 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. Questions?