RT Book, Section A1 Rozenfeld, Ranna A. SR Print(0) ID 1152487503 T1 Sedation, Analgesia, Neuromuscular Blockade and Withdrawal T2 The PICU Handbook YR 2018 FD 2018 PB McGraw-Hill Education PP New York, NY SN 9781259834370 LK accesspediatrics.mhmedical.com/content.aspx?aid=1152487503 RD 2024/03/28 AB 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:PositioningMassageDistractionMusic (live or from device)Technology devices (e.g., video gaming, television, videos, etc.)Environmental changesRoom temperatureLightingInclusion of family to promote comfortStory tellingSingingSoothing touchMiscellaneousBundling (age appropriate)Non-nutritive suck (age appropriate)Application/removal of blanketsApplication/removal of warm/cool packsActive and passive range of motionTopical analgesiaIndicationsMinor proceduresIntravenous catheter placement (peripheral or central)Arterial line catheter placementLumbar puncturePhlebotomyTypes availableLidocaine and prilocaineApply to intact skin with occlusive dressingRemains on skin 20 to 60 min prior to procedure depending on formulationBuffered lidocaineNeedle-free pressurized delivery system into the subcutaneous tissueAllow 2 minutes for maximum anesthesia1 mL bicarbonate/9 mL 1% lidocaineIntradermal lidocaineNeedle injectionMaximum dose of lidocaine4.5 mg/kg without epinephrine7 mg/kg with epinephrineNonopioid analgesiaIndicationsReduce painMinor proceduresFacilitate medical therapiesSedation and analgesiaIndicationsReduce anxiety and painProcedures Facilitate medical therapiesAirway controlDecrease the work of breathingDecrease oxygen demandNeuromuscular blocking agents (NMBAs)Important notesALWAYS ensure ability to bag-mask ventilate the patient prior to administration of NMBAALWAYS be prepared to manage the airway of a patient receiving NMBANEVER administer NMBA to a patient without assuring adequate sedation/analgesia beforehandEnsure routine monitoring of depth of muscle blockade to reduce subsequent weakness and use minimum effective doseIndicationsFacilitate proceduresSurgical relaxationEndotracheal intubationVascular accessFacilitate medical therapiesDecrease O2 consumptionPrevent shivering (hypothermia)Reduce metabolic expenditureLimit mechanical ventilator dyssynchronyUnconventional modes of ventilationTransport of patientMedications (See Tables 15-1–15-6)Monitoring sedation levelToolsNo adequate scales to measure sedation in children receiving NMBAState Behavioral Scale (SBS)Uses progressive stimuli to evaluate level of sedationUse in critically ill infants and children ages 6 months to 6 yearsComfort ScaleMeasures postoperative pain, nonpain distress, sedation, and analgesiaNo pediatric age restrictionTitrationEvidence supports nurse-led sedation algorithms are safeUse minimum effective dose to reduce prolonged sedationMonitoring for withdrawal syndromeDuring the process of weaning from sedation and analgesia, it is important to monitor for signs of withdrawal.Variables associated with risk of withdrawal syndromeDuration of medication therapyMaximum cumulative dose of medicationsType of opioid (fentanyl and remifentanil associated with more withdrawal than morphine)Type of sedativeYounger age associated with increased risk of withdrawal syndromeToolsWithdrawal Assessment Tool (WAT-1)Sophia Observation withdrawal Symptoms-scale (SOS)Strategies for weaningMay transition to alternative medicationsMay use enteral forms of currently administered medications if availableEnsure monitoring and adequate treatment of intolerable symptomsTaper one medication class at a timeTaper parenteral narcotic off over 3 days (decrease by 10% every 8 hours)Then taper sedative off over 5 days (decrease by 20% daily)Alternate taper (e.g., narcotic taper every Monday and sedation taper every Friday)Select a wean plan and evaluate patient tolerance of wean; adjust as neededMedications (see Table 15-7)