Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ANALGESIA Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 mg All narcotics may have side effects of sedation, nausea, vomiting, pruritus, and constipation +++ CODEINE ++ Codeine is metabolized into morphine by cytochrome P450 2D6, but this enzyme is absent in up to 10% of the population No longer recommended for use in children due to variable metabolism where non-metabolizers will have minimal to no analgesia, and ultra-rapid metabolizers will be at risk for excessive sedation, respiratory depression, and death +++ FENTANYL ++ 0.001 mg/kg/dose IV with onset in 1–2 minutes; duration: 0.5–1 hour (repeat or higher dosing may result in increased context-sensitive half-life) 0.01 mg/kg/dose transmucosal with onset in 15 minutes (FDA approved for cancer pain only) The transdermal patch is used in chronic pain management for opioid tolerant patients with expected pain management needs of several weeks Caution: Chest wall rigidity may occur with high doses and rapid IV push; reversible with naloxone or neuromuscular paralysis/endotracheal intubation +++ HYDROMORPHONE ++ 0.015 mg/kg/dose IV/SC (usual adult dose 0.4–0.8 mg) with onset in 5–10 minutes; duration: 3–4 hours 0.02–0.08 mg/kg/dose PO with onset in 30–60 minutes (usual adult dose 2–4 mg); duration: 3–4 hours Has no active metabolites +++ MEPERIDINE ++ Rarely used for analgesic purposes due to severe drug interactions (MAO inhibitors) Occasionally used to treat postoperative shivering or medication-induced shaking (e.g., amphotericin-related rigors) Side effects: Tachycardia, seizures, worsens bronchospasm, serotonin syndrome Active metabolite, normeperidine, may accumulate and induce seizures +++ METHADONE ++ 0.1 mg/kg/dose IV with onset in 15–30 minutes; duration: 12–24 hours 0.1 mg/kg/dose PO with onset in 30–60 minutes; duration: 12–24 hours Commonly used as an opioid taper Due to drug accumulation with long half-life, respiratory side effects may not appear until days after drug initiation Baseline ECG is necessary as methadone may prolong QT interval +++ MORPHINE ++ 0.1 mg/kg/dose IV (usual adult dose 2–4 mg) with onset in 5–10 minutes; duration: 3–4 hours 0.1–0.2 mg/kg/dose SC with onset in 10–30 minutes; duration: 4–5 hours 0.3–0.5 mg/kg/dose PO with onset in 30–60 minutes; duration: 4–5 hours Side effects: Nausea, sedation, pruritus, constipation, seizures (in neonates—due to decreased elimination of active metabolite morphine-3-glucuronide) Contraindications: Renal failure (active metabolites may accumulate to cause profound sedation and/or respiratory depression) +++ NALBUPHINE ++ 0.1 mg/kg/dose (usual adult dose 5 mg) with onset in 5–10 minutes; duration: 6 hours Partial opioid agonist, resulting in plateau of analgesic effects but also minimizing risk of respiratory depression May be used to treat opioid-related side effects (e.g., pruritus, nausea/vomiting) by the partial opioid antagonism at the mu receptor Relatively contraindicated in patients on chronic opioids as nalbuphine may precipitate acute opioid withdrawal +++ OXYCODONE ++ 0.1 mg/kg/dose PO with onset in 30–60 minutes; duration: 4–6 hours Active metabolite, oxymorphone, can accumulate in renal failure When oxycodone is made with acetaminophen, this limits its utility in young children due to the toxicity of acetaminophen + NON-NARCOTIC ANALGESICS Download Section PDF Listen +++ +++ ACETAMINOPHEN ++ Antipyretic; weak analgesic Side effects: Hepatic necrosis (overdosage) Usual dose: 10–15 mg/kg PO or rectally every 4–6 hours; adult dose: 325 mg−1g/dose Maximum dose: 4g/day (adults); 90 mg/kg/day (children) Acetaminophen should be administered in a separate formulation from an opioid to reduce the toxic potential of an acetaminophen overdose +++ NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ++ Useful for inflammatory pain Side effects: Platelet inhibition, gastrointestinal irritation, nephrotoxicity Ibuprofen: 5–10 mg/kg PO every 6–8 hours with a maximum of 40 mg/kg/day; adult dose 200–400 mg/dose, maximum 1.2g/day Ketorolac: 0.5 mg/kg/dose IV/IM every 6 hours with maximum 30 mg every 6 hours which is usual adult dose (avoid if post conceptual age <44 weeks versus <6 months depending on institutional protocol) Naproxen: 5–10 mg/kg/dose PO every 8–12 hours with maximum 1000 mg/day; adult dose 250–500 mg/dose; maximum 1000 mg/day +++ ASPIRIN ++ No longer routinely used for analgesia due to side effects, but continues to be utilized for anti-platelet effects in specific situations (e.g., Kawasaki disease, vascular shunts, etc.) Side effects: Reye’s syndrome (avoid in children with varicella or influenza) +++ KETAMINE ++ Low dose infusions of 0.1–0.2 mg/kg/h may utilized for analgesia (especially in patients on chronic opioids as part of a weaning regimen) and higher dose infusions (e.g., 0.5–2 mg/kg/h) or boluses (2 mg/kg IV or 4 mg/kg IM) may be used for sedation Side effects: Excess salivary secretions (prevent with glycopyrrolate pretreatment), nystagmus, increased ICP (though cerebral perfusion pressure maintained given increased mean arterial pressure), emergence delirium +++ DIAZEPAM ++ 0.05–0.1 mg/kg/dose IV every 6–8 hours for muscle spasms and anxiolysis 0.1–0.2 mg/kg/dose PO every 6–8 hours (usual adult dosing 2–10 mg) Prolonged half-life can lead to late onset of side effects which are sedation, respiratory depression, and hypotension and can be worsened by coadministration of opioids + NON-PHARMACOLOGIC METHODS OF ANALGESIA Download Section PDF Listen +++ ++ Distraction, music, play Acupuncture, massage, and hypnosis are other methods of analgesia usually requiring trained practitioners + PATIENT-CONTROLLED ANALGESIA Download Section PDF Listen +++ ++ Indicated for acute/chronic pain of known etiology as well as preemptive pain management. Cardiorespiratory monitoring is required. Six or 7 years is minimum age to control a Patient-Controlled Analgesia (PCA). Parents and nurses can also be trained to administer a PCA for younger patients or those with developmental delay Minimum developmental age of about 7 years to self-administer PCA ✓ Parents and nurses can also be trained to administer PCA to younger patients and those with developmental delay Route: IV or rarely SC Dosing for PCA: ✓ Morphine: Basal dose 10–20 μg/kg/h; bolus dose 10–20 μg/kg; lockout 8–10 minutes, four to six boluses per hour; maximum dose per hour: 100–150 μg/kg ✓ Hydromorphone: Basal dose 3–4 μg/kg/h; bolus dose 3–4 μg/kg/h; lockout 8–10 minutes, four to six boluses per hour; maximum dose per hour: 15–20 μg/kg ✓ Fentanyl: Basal dose 0.25–1 μg/kg/h; bolus dose 0.25–1 μg/kg; lockout 8–10 minutes, two to three boluses per hour; maximum dose per hour: 2 μg/kg + SEDATION Download Section PDF Listen +++ +++ SEDATION IS A CONTINUUM ++ Minimal Sedation (anxiolysis): A drug-induced state in which cognitive function and coordination may be impaired. Patients respond normally to verbal commands. Protective airway reflexes are maintained. Ventilatory and cardiovascular functions are unaffected Moderate Sedation: A drug-induced state of depressed consciousness. Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. There is significant loss of orientation to environment, with moderate impairment of gross motor function. Protective airway reflexes are maintained. Ability to maintain patient airway and cardiovascular function are usually maintained. There may be mild alterations in ventilatory responsiveness Deep Sedation: A drug-induced state of depressed consciousness or unconsciousness from which a patient is not easily aroused. Patients may respond purposefully to painful stimulation. May be accompanied by a partial or complete loss of protective reflexes, which may include the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained General Anesthesia: Drug-induced loss of consciousness with loss of protective reflexes, inability to maintain patent airway, and loss of purposeful response. Cardiovascular function may be impaired + PREPARATION FOR SEDATION Download Section PDF Listen +++ +++ PATIENT-RELATED FACTORS ++ Pre-sedation Assessment (Table 3-1 and Figure 3-1): Essential to identify high-risk patient populations to both anticipate and reduce adverse sedation events NPO Guidelines (American Society of Anesthesiology [ASA]): ✓ No clear liquids for 2 hours before sedation ✓ No breast milk for 4 hours prior to sedation ✓ No formula for 6 hours prior to sedation ✓ No solids/milk for 8 hours prior to sedation ✓ In an emergency situation: Delay sedation if possible or use lightest possible level of sedation. Consider elective intubation for airway protection ASA Classification: I: Normal healthy patient II: Mild systemic disease III: Severe systemic disease IV: Severe systemic disease associated with significant dysfunction and potential threat to life V: Critical medical condition where operative intervention is critical to survival ++Table Graphic Jump LocationTABLE 3-1 Pre-Sedation Assessment View Table||Download (.pdf) TABLE 3-1 Pre-Sedation Assessment History ✓ Allergies and adverse reactions ✓ Current medications ✓ Indication for procedure ✓ Previous sedation/anesthesia history ✓ History of upper airway problems, OSA, snoring ✓ Prematurity and corrected gestational age (if applicable) ✓ Major medical illnesses, physical abnormalities (e.g., facial dysmorphisms, scoliosis, syndromes, etc.), neurologic problems, developmental delays ✓ Review of systems addressing active pulmonary, cardiac, renal, hepatic, and metabolic concerns ✓ Current or recent illnesses (e.g., upper respiratory infection, fever, anemia, etc.) ✓ Relevant family hx (e.g., anesthesia-related complications) Examination ✓ Age ✓ Weight ✓ Vital signs (including blood pressure, heart rate, respiratory rate, oxygen saturation) ✓ Cardiovascular exam ✓ Lung exam ✓ Neurologic exam ✓ Mental status ✓ Airway status (see Figure 3-1 for Mallampati Classification) ++ FIGURE 3-1 Mallampati Classification of pharyngeal structures. (Reproduced with permission from Bruncardi FC, Anderson DK, Billar TR, et.al. Schwartz’s Principles of Surgery, 10th ed. New York, NY: McGraw Hill; 2014.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ PROCEDURAL CONSIDERATIONS ++ Duration of procedure Painful versus nonpainful Position for procedure Need for immobility Age and ability to cooperate with instructions +++ PROVIDER-RELATED FACTORS ++ Dedicated sedation providers. Require at least two providers—one to administer sedation and one to monitor the sedation ✓ Providers require airway skills, advanced life support skills, experience managing complications, and ability to rescue patient from a level of sedation which is deeper than anticipated ✓ Traditionally administered by anesthesiologists, intensivists, and emergency medicine physicians with RN, CRNA, NP, or PA support ✓ Increasing number of pediatric hospitalists performing sedation within a dedicated sedation program and with similar outcomes and complication rates Equipment (can use SOAPME acronym) ✓ Suction—Apparatus including catheters (Tonsil, Yankauer) ✓ Oxygen—Supply and age-appropriately sized positive pressure oxygen delivery system ✓ Airway—Size-appropriate equipment (nasopharyngeal and oropharyngeal airways, facemask, bag-valve-mask, etc.) ✓ Pharmacy—Medications for sedation, sedative antagonists and resuscitation, intravenous fluids ✓ Monitors—Pulse oximeter, blood pressure, end-tidal CO2 detector, stethoscope ✓ Extra equipment—Special equipment or drugs for the given case Monitoring: ✓ Continuous pulse oximetry, heart rate, and end-tidal monitoring ✓ Vital signs with blood pressure monitored every 15 minutes for minimal sedation and every 5 minutes for moderate or deep sedation ✓ Consider full cardiorespiratory monitoring for specific cases (e.g., ketamine) ✓ Backup system for emergencies: Highly trained and reliable (e.g., code team, 911) + OVERVIEW OF SEDATIVE DRUGS Download Section PDF Listen +++ ++ Anxiolytics—Make patients more comfortable ✓ Benzodiazepines (e.g., diazepam, midazolam, lorazepam): Provide anxiolysis and amnesia. Often used as premedication or as adjunct with analgesics. Administered PO, IV, IN, IM, or PR ✓ Nitrous oxide: Anxiolytic with some analgesia effect. Administered via inhaled delivery system Analgesics—Achieve pain control ✓ Lidocaine (e.g., LMX): Local analgesia at the procedure site. Administered topically or SQ ✓ Opioid agonists (e.g., fentanyl, morphine): Dose-dependent analgesia and sedation. Often used in conjunction with anxiolytics or hypnotics. Administered PO, IV, or IN ✓ Ketamine: Dissociative sedative with analgesic and amnestic properties. Administered PO, IV, or IM Hypnotics—Achieve sleep/immobility, especially useful for noninvasive procedures ✓ Chloral hydrate: Produces sleep with mild to moderate respiratory depression. Currently with limited manufacturing resources. Administered PO or PR ✓ Barbiturates (e.g., pentobarbital): Potent sedative, hypnotic and anesthetic properties. Administered PO, IV, or PR ✓ Central α2 adrenergic agonists (e.g., clonidine, dexmedetomidine): Sedative, anxiolytic, and sometimes analgesic properties. Administered PO, IN, or IV ✓ Etomidate: Short-acting anesthetic and amnestic. Especially useful in settings of hemodynamic instability. Administered IV ✓ Propofol: Sedative, hypnotic, and anesthetic properties. Administered IV Sedative antagonists ✓ Flumazenil: Short-acting agent that reverses benzodiazepine-induced sedation (use cautiously in patients with seizure disorders, as benzodiazepine reversal can induce seizures) ✓ Naloxone: Short-active agent that reverses opiate-induced sedation + SEDATION-RELATED COMPLICATIONS Download Section PDF Listen +++ ++ Airway obstruction Laryngospasm Hypoventilation and apnea Vomiting/Aspiration Cardiovascular instability + POST-SEDATION RECOVERY AND DISCHARGE Download Section PDF Listen +++ ++ Patient recovery should be monitored with vital signs at regular intervals until patient is awake and interactive Patients should only be discharged once specific criteria have been met: Stable vital signs, adequate pain control, return to level of consciousness that is similar to baseline for that patient, adequate head control and muscle strength to maintain patent airway, adequate hydration (tolerates oral challenge), and nausea/vomiting should be controlled + PROCEDURE-SPECIFIC SEDATION Download Section PDF Listen +++ +++ COMPUTED TOMOGRAPHY (CT) SCAN ++ Need for relative immobility but not analgesia Young infants often can be swaddled and may not require sedation. Patients 6 weeks–3 years old are the most likely age group to require sedation Option 1: PO Pentobarbital 2–4 mg/kg PO 30 minutes before procedure; repeat ½ dose 20–30 minutes after initial dose if patient still moving. Maximum dose: 100 mg or 8 mg/kg. Works well in infants <10kg who do not require an IV for the procedure. Can use in conjunction with IN versed or fentanyl if need additional sedation Option 2: IV Pentobarbital 2–3 mg/kg slow IV push with titration to response. Give in increments of 1–3 mg/kg IV. Time to sedation is 2–5 minutes and time to recovery is 1–2 hours. Maximum 100 mg/dose or about 10 mg/kg Midazolam and fentanyl are unreliable in producing sedation with immobility but can be used as an adjunct to hypnotics to decrease total dose of longer acting medications +++ MAGNETIC RESONANCE IMAGING (MRI) ++ Need for relative immobility but not analgesia. Study typically lasts >45 minutes Young infants can often be swaddled or placed in an immobilizer device and may not require sedation. Children often require sedation until 6–8 years of age but older children, especially those with developmental delays, claustrophobia, ADHD, and/or anxiety, may require sedation as teenagers IV Pentobarbital 2–3 mg/kg; maximum dose 100 mg/dose with titration to response. Give in increments of 1–3 mg/kg. Can use in conjunction with IV midazolam (0.05–0.1 mg/kg with maximum of 2.5 mg max/dose) and fentanyl (1 μg/kg with maximum of 100 μg/dose) to reduce total pentobarbital dose required +++ LUMBAR PUNCTURE ++ Infants younger than 2 months are not routinely sedated for this procedure Midazolam 0.05–0.1 mg/kg IV given 3–5 minutes before lumbar puncture significantly decreases anxiety in older children. Repeat 0.1 mg/kg IV doses as needed to achieve adequate sedation. Maximum 2.5 mg/dose Fentanyl 1–2 μg/kg IV given via slow push over 3–5 minutes can provide analgesia. Repeat 1 μg/kg IV doses as needed to achieve adequate sedation. Maximum dose 100 μg/dose Can use midazolam and fentanyl together to achieve moderate to deep sedation as indicated. Can consider adding ketamine or pentobarbital as needed, depending on patient-specific characteristics (see options below) +++ PAINFUL PROCEDURES SUCH AS FRACTURE REDUCTION/INCISION AND DRAINAGE/BURN DEBRIDEMENT/CENTRAL VENOUS LINE ++ Option 1: Midazolam IV (0.05–0.1 mg/kg with maximum of 2.5 mg/dose) plus fentanyl (1–2 μg/kg with maximum dose of 100 μg/dose). Titrate additional doses as needed to achieve adequate sedation Option 2: Ketamine (0.5–2 mg/kg with maximum of 100 mg/dose) slow IV push. Titrate additional doses as needed to achieve adequate sedation. Consider atropine or glycopyrrolate premedication to decrease secretions. Can use midazolam and fentanyl adjuncts if needed to reduce total ketamine dose Option 3 (for longer procedures, ≥30 minutes): Midazolam IV (0.05–0.1 mg/kg with maximum of 2.5 mg/dose) plus fentanyl (1 μg/kg with maximum dose of 100 μg/dose) plus pentobarbital IV (2–3 mg/kg with maximum dose of 100 mg/dose) When using combination of sedatives/analgesics, start with lowest dose possible and give additional doses as needed to achieve desired depth of sedation. The rate of complications increases with polypharmacy