pediatric sedation and pain management in brief

1. Dr C Abhiram Kumar
Fellow in PICU, Aster CMI Hospital, Bangalore

2. 
 A 6yr old male child with speech delay and ADHD,
seen by the neurologist and was advised MRI brain.
Child was given pedicloryl syrup for the procedure
but was not succesful.
 How would you prepare for the sedation of this
child???

3. 
 A 10 yr old male child was brought to pediatric
hematoncologist for severe anemia and was found to
have pancytopenia. You are called to sedate the child
during the bone marrow procedure.
 What would be your approach and what are the
drugs you can use in this child??

4. 
 A 8year old male child with fever since 6days referred to
your hospital in view of dengue with warning signs and
thrombocytopenia. At arrival you find the child is
irritable, in hypotensive shock and hypoxic. ABG shows
severe metabolic acidosis and lactate of 13. After initial
resucitative measures you have decided to intubate the
child.
 Will you use sedation to intubate this child?
 After intubation how would you sedate him on the
ventilator??

5. 
 Introduction
 Assessment of pain
 Commonly used drugs for analgesia
 Assessment of sedation
 Commonly used drugs for sedation
 Procedural sedation and analgesia

6. 
 Hospitalization in general and admission to PICU
can be a very frightful experience for the child and
the family
 Children often experience pain, anxiety, fear, distress
and agitation during medical treatment
 Children in PICU may be subjected to various
invasive procedures

7. Contributory factors
Separation from parents
Unfamiliar people
Sleep disturbance
Invasive procedures

8.  Pain is defined by IASP as
“an unpleasant
sensory and
emotional
experience
associated with
actual or potential
tissue damage”

9. 
The Pain Pathway

10. 
 Children may not be able to communicate regarding
their pain
 Goal of assessment is to provide the intensity and
location of pain and the effectiveness of the
measures done to reduce the pain
 “Physiologic parameters “or “Elicited behaviors” can
be used but are not reliable
Assessment of Pain in children

11. Self-report measures
Visual analogue scale
Six-Face Pain Scale
Physiologic responses to
nociceptive stimulus
Observational Pain Scale
Behavioral observation
Facial expression
Body movements
Quality of crying

13. 
Pain Management
Non pharmacologic measures
Music therapy
Noise control
Massage and communication
Pharmacologic measures
Non opioid analgesics
Opioid analgesics

15. Opioid Analgesics
Act mainly through opioid
receptors(mu,kappa,delta)
Act through Gproteins and
inhibit adenylyl cyclase
Cause k efflux and prevent Ca
influx resulting in
hyperpolarisation
Provide analgesia and some
sedation but no amnesia

16. 
Morphine:
Prototype analgesic
Half life-1-3 hrs in children
Dose-PO-0.05-0.2mg/kg Q2-4 hrs
CI-0.01-0.03mg/kg/hr
Causes histamine mediated hypotension and bronchospasm
Metabolised in liver and excreted in urine

17. 
Fentanyl:
75-100 times more potent than morphine
Short onset(30-60sec) and ½ life(2hrs)
Doesnot cause histamine release
Highly lipophilic
Chest rigidity on rapid bolus of 3-5mic/kg
Dose- IV-1-2 mic/kg bolus Q1-2 hrs
CI-1-2mic/kg/hr

18. 
Withdrawal syndrome:
 Abrupt discontinuation after prolonged use
 Symptoms: CNS, GI, Autonomic dysfunction
 Minimize by giving drug holiday
 Naloxone is opiate antagonist

19. 
 Sedation is the act of giving a sedative to provide
anxiolysis and comfort to the child
 Inhibits the neuroendocrine effects caused by stress
 Too much sedation or under sedation are harmful
Assessment of sedation

20. 
Levels of sedation

21. 
 Various scales used to assess sedation:
Ramsay’s sedation score
State behavioral scale
COMFORT scale
Bispectral index

25. 
Procedural Sedation and Analgesia
 Defined as the administration of sedative or
dissociative agent with or without analgesics, to
induce a state that allows the patient to tolerate
unpleasant procedures while maintaining
cardiorespiratory function

26. 
Evaluation:
 History and physical examination
 Any previous sedation experience
 Any known allergies
 Any medications
 Last meal
 Airway assessment

27. 
 Airway assessment: Mallampati score

28. 
Preparation:
 Informed consent
 Laboratory tests
 Nil per oral guidelines(NPO)
 Requirements
 Monitoring

29. 
 Nil per oral guidelines

30. 
Requirements:
 Suction
 Oxygen
 Airway
 Pharmacy
 Monitors
 Equipment
 IV access

31. 
Recovery care:
 Observed in appropriately staffed and equipped area
 Monitor oxygenation, ventilation and circulation
 Base line of consciousness achieved

32. 
 Goal of pain and sedation management is to provide
anxiolysis and comfort while maintaining safety
 Children have variable pharmacokinetics and
dynamics which have to be kept in mind while
giving drugs
 Drugs used to achieve sedation should be
individualised
 Preprocedural preparation is important to avoid and
anticipate any untoward complications
Take home message

33. 