Download - Sedation and Analgesia for ED101
Kalpesh N. Patel, MD
Dept. of Pediatric Emergency Medicine
August 1, 2007
Sedation and Analgesia for ED101
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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
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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.
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Assessing Pain
For sedated, unresponsive patients use the Objective Pain Scale (OPS)
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Assessing Pain
For non-verbal patients use FLACC behavioral scale
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Assessing Pain
For pre-school and young school age children use the FACES scale by patient self report
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Assessing Pain
For older school/adolescent patients use the 0-10 Numeric Pain Rating Scale by patient self report
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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
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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
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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
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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
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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
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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.
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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
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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
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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.
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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
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ASA Classification
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
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
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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 Milk Clear Liquids Milk and Non-Clear Liquids
Solids
4 hours 2 hours 6 hours 6 hours
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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
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Chloral Hydrate Benzodiazepines
• Midazolam• Diazepam
Barbiturates• Pentobarbital• Thiopental• Methohexital
Opiates• Morphine• Fentanyl
Ketamine Propofol Etomidate
Medications
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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
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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
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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
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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
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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
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Narcotics
Gold standard for pain management Reversed with Naloxone Combination with benzodiazepines can cause
respiratory depression and dosage should be reduced
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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
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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
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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
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Ketamine - Complications
Laryngospasm Apnea Hypersalivation Vomiting Agitation/Hallucinations/Emergence Reactions Hypertension Increased Intracranial and Intraocular Pressure Myoclonus
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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
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
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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
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Consent
Sedation consent must be obtained SEPARATE from procedure consent
Use for sedation beyond SINGLE drug Anxiolysis
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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
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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
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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
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Questions?