Sedation, Pain, and Analgesia

Ricardo R. Jiménez, MDPediatric Emergency Medicine, Fellow

Emory University School of Medicine

Children’s Healthcare of Atlanta

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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.

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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

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Pain management

Mild pain• Reassurance• Tylenol• Ibuprofen• Ice• Distraction

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Pain management

Moderate and Severe pain• Local anesthesia• Parenteral Analgesia and Sedation

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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

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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

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Nurse initiated guidelines

Motrin Lortab LET Ela-max/LMX Upgrading the triage level

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Topical Anesthetics - Intact Skin for IV access, Venipuncture, Lumbar Puncture

Ela-max or LMX- 4% lidocaineEla-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

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Topical Anesthetics

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

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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

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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

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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

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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.

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Definitions

Minimal sedation Moderate sedation Deep sedation General Anesthesia

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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

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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 6 hours

Light meal 6 hours

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Pre-sedation Assessment

Allergies Medications Past History Last meal Events

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Physician Pre-assessment Form

A quick history Focused Physical

exam including airway assessment

Previous anesthesia Hx

ASA Class Candidate suitable?

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Physician Consent Form

Consent Forms specifically designed for Moderate or Deep Sedation

Goes over risks of sedation, specifically agitation, oversedation, and cardiorespiratory compromise

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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.

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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

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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

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Modified Aldrete Score

Should have a score of greater than or equal to 13, before discharge

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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

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Benzodiazepines Barbiturates Narcotics Ketamine Propofol Etomidate

Medications

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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

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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

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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

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Benzodiazepines

Midazolam -IV• Dose: 0.05-0.1 mg/kg IV

• Onset: 1 to 3 min

• Duration: 10 to 30 min

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Benzodiazepines

Midazolam - Important Considerations• Has NO analgesic effect!

• May be reversed with flumazenil(0.01mg/kg IV)

• Contraindicated with narrow angle glaucoma and shock

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Barbiturates

Pentobarbital-Nembutal Propofol – Diprivan

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Barbiturates

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

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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

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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.

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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

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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

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Narcotics

Gold standard for pain management

Fentanyl Morphine

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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

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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

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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

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Narcotics

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

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Ketamine

Provides both analgesia and sedation Preserves respiratory drive and airway protective

reflexes Helpful in pts with RAD-bronchodilator Maintains hemodynamic stability

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Ketamine

Dose: 1 to 2 mg/kg/dose IV

2 to 10mg/kg/dose IM Onset: seconds Duration: 10 to 20 min for sedation

40 to 45 min for analgesia

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Ketamine - Complications

Laryngospasm Apnea Hypersalivation Vomiting Agitation/Hallucinations/Emergence Reactions Hypertension Increased Intracranial and Intraocular Pressure

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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

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Etomidate

CNS hypnosis – ultra short acting• Hypnotic• Unknown mechanism of action• Imidazole ring

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Etomidate - Benefits

Rapid IV induction Minimal hemodynamic instability Minimal respiratory depression Possible cerebral protection Indications:

• Procedural sedation• RSI – Trauma, CHF

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Etomidate

Adverse reactions• Nausea and vomiting – 5%• Causes pain or burning at IV site• Myoclonic movements, may stimulate seizure

activity• Inhibits steroid synthesis

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Etomidate

CNS hypnosis – ultra short acting• Dose: 0.2-0.5mg/kg IV• Induction 0.3 mg/kg IV over 30-60 secs• May redose with 0.1mg/kg every 5-10

minutes until procedure is completed or as needed

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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.

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Etomidate

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

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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