Chapter 15: Sedation, Analgesia, Neuromuscular Blockade and Withdrawal

INTRODUCTION

1. Nonpharmacologic strategies should be used prior to any pharmacologic intervention to reduce pain and anxiety. Sample strategies include, but are not limited, to the following:

   1. Positioning

   2. Massage

   3. Distraction

      1. Music (live or from device)

      2. Technology devices (e.g., video gaming, television, videos, etc.)

   4. Environmental changes

      1. Room temperature

      2. Lighting

   5. Inclusion of family to promote comfort

      1. Story telling

      2. Singing

      3. Soothing touch

   6. Miscellaneous

      1. Bundling (age appropriate)

      2. Non-nutritive suck (age appropriate)

      3. Application/removal of blankets

      4. Application/removal of warm/cool packs

      5. Active and passive range of motion

2. Topical analgesia

   1. Indications

      1. Minor procedures

         1. Intravenous catheter placement (peripheral or central)

         2. Arterial line catheter placement

         3. Lumbar puncture

         4. Phlebotomy

   2. Types available

      1. Lidocaine and prilocaine

         1. Apply to intact skin with occlusive dressing

         2. Remains on skin 20 to 60 min prior to procedure depending on formulation

      2. Buffered lidocaine

         1. Needle-free pressurized delivery system into the subcutaneous tissue

         2. Allow 2 minutes for maximum anesthesia

         3. 1 mL bicarbonate/9 mL 1% lidocaine

      3. Intradermal lidocaine

         1. Needle injection

         2. Maximum dose of lidocaine

            1. 4.5 mg/kg without epinephrine

            2. 7 mg/kg with epinephrine

3. Nonopioid analgesia

   1. Indications

      1. Reduce pain

      2. Minor procedures

      3. Facilitate medical therapies

4. Sedation and analgesia

   1. Indications

      1. Reduce anxiety and pain

      2. Procedures

      3. Facilitate medical therapies

      4. Airway control

      5. Decrease the work of breathing

      6. Decrease oxygen demand

5. Neuromuscular blocking agents (NMBAs)

   1. Important notes

      1. ALWAYS ensure ability to bag-mask ventilate the patient prior to administration of NMBA

      2. ALWAYS be prepared to manage the airway of a patient receiving NMBA

      3. NEVER administer NMBA to a patient without assuring adequate sedation/analgesia beforehand

      4. Ensure routine monitoring of depth of muscle blockade to reduce subsequent weakness and use minimum effective dose

   2. Indications

      1. Facilitate procedures

         1. Surgical relaxation

         2. Endotracheal intubation

         3. Vascular access

      2. Facilitate medical therapies

         1. Decrease O₂ consumption

         2. Prevent shivering (hypothermia)

         3. Reduce metabolic expenditure

         4. Limit mechanical ventilator dyssynchrony

         5. Unconventional modes of ventilation

         6. Transport of patient

6. Medications (See Tables 15-1–15-6)

7. Monitoring sedation level

   1. Tools

      1. No adequate scales to measure sedation in children receiving NMBA

      2. State Behavioral Scale (SBS)

         1. Uses progressive stimuli to evaluate level of sedation

         2. Use in critically ill infants and children ages 6 months to 6 years

      3. Comfort Scale

         1. Measures postoperative pain, nonpain distress, sedation, and analgesia

         2. No pediatric age restriction

   2. Titration

      1. Evidence supports nurse-led sedation algorithms are safe

      2. Use minimum effective dose to reduce prolonged sedation

8. Monitoring for withdrawal syndrome

   During the process of weaning from sedation and analgesia, it is important to monitor for signs of withdrawal.

   1. Variables associated with risk of withdrawal syndrome

      1. Duration of medication therapy

      2. Maximum cumulative dose of medications

      3. Type of opioid (fentanyl and remifentanil associated with more withdrawal than morphine)

      4. Type of sedative

      5. Younger age associated with increased risk of withdrawal syndrome

   2. Tools

      1. Withdrawal Assessment Tool (WAT-1)

      2. Sophia Observation withdrawal Symptoms-scale (SOS)

   3. Strategies for weaning

      1. May transition to alternative medications

      2. May use enteral forms of currently administered medications if available

      3. Ensure monitoring and adequate treatment of intolerable symptoms

      4. Taper one medication class at a time

         1. Taper parenteral narcotic off over 3 days (decrease by 10% every 8 hours)

         2. Then taper sedative off over 5 days (decrease by 20% daily)

      5. Alternate taper (e.g., ...