CHAPTER 3: Analgesia and Sedation

ANALGESIA

ANALGESIA IS THE DIMINUTION OR ELIMINATION OF PAIN IN THE CONSCIOUS PATIENT.

• Even neonates demonstrate behavioral and hormonal changes in response to painful procedures

• Children do not have to understand the meaning of pain nor do they have to communicate pain to experience pain

• Preemptive analgesia may decrease post-injury opioid requirements

ASSESSMENT OF PAIN

• Observational-behavioral measures

  • ✓ Useful in infants and toddlers (who do have physiologic and behavioral responses to pain, such as increased heart rate, blood pressure, respiratory rate, crying, flushing, facial expressions, and body movements)

  • ✓ Example: FLACC (Face, Leg, Activity, Cry, Consolability) Behavioral Pain Scale (Merkel SI, et al. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293–297)

• Self-report

  • ✓ OUCHER scale combines numeric and faces scales, making it appropriate for young children (available at http://www.oucher.org)

  • ✓ Faces scale: The child is asked to point to the face that best describes his/her own pain (available at http://www.wongbakerfaces.org)

  • ✓ Verbal numeric pain rating: Useful in developmentally normal children 6–7 years of age (or older). Pain is rated from 0 to 10 (0 is no pain and 10 is the worst pain imaginable)

LOCAL ANESTHESIA

EUTECTIC MIXTURE OF LOCAL ANESTHETICS (EMLA)

• 2.5% Lidocaine/2.5% Prilocaine

• Apply to intact skin; complete anesthesia in 60–90 minutes

• Use for blood drawing/IV placement, bone marrow aspiration, lumbar puncture in non-emergent settings

• May use liposomal lidocaine (LMX) for faster onset; topical lidocaine only; anesthesia in 30 minutes

• Contraindications: Methemoglobinemia, age less than 1 month

LIDOCAINE, EPINEPHRINE, TETRACAINE (LET)

• Used for dermal lacerations; apply to open wound

• Contraindicated in areas supplied by end-arteries (digits, pinna, nose, penis)

VISCOUS LIDOCAINE

• For older children who can expectorate

• Combine with diphenhydramine and Maalox in equal parts (1:1:1) to create “magic mouthwash” (can also exclude lidocaine if mouth sores create a concern for systemic absorption)

• Usual dose: 15 mL of undiluted mixture to “swish and spit” (not swallow); maximum dose is 4.5 mg/kg or 300 mg of lidocaine component (up to every 3 hours). Smaller amounts work well

LIDOCAINE JELLY

• Used for nasogastric tube placement and urethral catheterizations

INJECTABLE LOCAL ANESTHETIC

• Buffer with 1 mL (1 mEq/mL) sodium bicarbonate (NaHCO₃) per 9 mL lidocaine or 0.1 mL NaHCO₃ per 10 mL bupivacaine to reduce pain associated with injection

• Enhance efficacy and duration by using in combination with epinephrine

• Contraindicated in areas supplied by end arteries (digits, pinna, nose, penis)

NARCOTIC ANALGESICS

• All doses referred to here are equianalgesic doses

• All opioids can be reversed with naloxone hydrochloride (Narcan) 0.01 mg/kg IV/IM/SC/ETT; naloxone can be repeated every 2 minutes as needed to maximum of 10 ...