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SEDATION and ANALGESIA in the PICU – Bijapur – Dr. Anand Bhutada

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A presentation on SEDATION and ANALGESIA in the PICU delivered at Bijapur by Dr. Anand Bhutada of Child Hospital Nagpur.

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SEDATION and ANALGESIA in the PICU – Bijapur – Dr. Anand Bhutada

  1. 1. SEDATION AND ANALGESIA IN THE PICU Anand Bhutada Pediatric Intensivist, Child Hospital, Nagpur
  2. 2. Outlines  Introduction  Goals  Definitions  The challenges of PICU sedation  Sedation & Analgesia monitoring  Medications options  Suggested strategies  Precautions  Conclusion & key points
  3. 3. GOALS  Patient comfort  Control of pain  Anxiolysis  Amnesia  Blunting adverse autonomic and hemodynamic responses  Facilitate nursing management  Facilitate mechanical ventilation  Avoid self-extubation or self injury  Reduce oxygen consumption
  4. 4. SEDATION and ANALGESIA  Inadequate analgesia and postsurgical stress response is a metabolic, humoral, and hemodynamic response following injury or surgery  This neuroendocrine cascade leads to increased oxygen consumption, increased carbon dioxide production, and a generalized catabolic state with a negative nitrogen balance
  5. 5. SEDATION/ANALGESIA Sedation (seda/shun) [L. sedatio, to calm, allay]. The act of calming, especially by the administration of a sedative, or the state of being calm. Analgesia (an-al-je/zi-ah) [G. insensibility, from an - privative,negative + algesis, sensation of pain] A condition in which nocioceptive stimuli are perceived but are not interpreted as pain; usually accompanied by sedation without loss of consciousness.
  6. 6. IDEAL PICU SEDATIVE/ANALGESIA  Rapid onset  Predictable duration  No active metabolites  Rapid recovery  Multiple routes of delivery  Easy to titrate  Minimal cardiopulmonary effects  Not altered by renal or hepatic disease  No drug interactions  Antidote available  Wide therapeutic index
  7. 7. COMMON DRUGS UTILIZED  Opiates (Narcotics)  Benzodiazepines  Chloral hydrate  Barbiturates  Ketamine  Propofol  Neuroleptics  Paralytics
  8. 8. SITUATIONS REQUIRING SEDATIVES/ANALGESIA  MECHANICAL VENTILATION  Respiratory failure  Airway  Neurological  POST OPERATIVE  HEAD INJURY  PULMONARY HYPERTENSION  PROCEDURES
  9. 9. FLACC (0-8 YR)
  10. 10. COMFORT SCALE SCORE Intubated, Non paralysed patients (Target 17- 26)
  11. 11. OPIOIDS  First line drugs  Provide analgesia and sedation, NOT amnesia  Act similarly as a class  Produce delayed gastric emptying, decreased intestinal peristalsis, and urinary retention  Narcotic to be used:  Morphine  Fentanyl  Methadone
  12. 12. OPIOIDS ROUTE OF ADMINISTRATION  IV  Oral  Transmucosal  Transdermal MODE OF ADMINISTRATION  Intermittent/on demand (as necessary)  Fixed interval  Continuous infusion  PCA
  13. 13. MORPHINE  Gold standard  Hepatic metabolism  Depresses respiration by altering chemoreceptor sensitivity to CO2  Depresses rate over tidal volume  Decreases sigh frequency  Can cause hypotension due to histamine mediated vasodilation  Can block compensatory catecholamine effect  Prolonged clearance in neonates
  14. 14. MORPHINE  IV intermittent  0.1 mg/kg q 3 - 4 hrs  IV continuous  0.05 mg - 0.1 mg/kg/hr  PO scheduled  0.3 mg/kg q 3 - 4 hrs  PCA dosing  Initial dosing: 50 mcg/kg q 10 minutes until comfortable  Demand dose: 20 - 40 mcg/kg  Lock-out period: 10 minutes  4-hour limit: 0.25 mg/kg
  15. 15. FENTANYL  Synthetic opiate, 100 x more potent than morphine  Rapid onset, highly lipophilic, rapidly crosses BBB, redistributed to fatty tissue  Short distribution t1/2, long elimination t1/2  Minimal hemodynamic effect  Blunts pulmonary vascular responses  May produce “chest wall rigidity”, reversed with relaxants or naloxone
  16. 16. FENTANYL  IV intermittent dosing  1-2 mcg/kg q 1-2 hrs  IV continuous dosing  1-2 mcg/kg/hr  Transdermal delivery system available  Not recommended in children less than 12 yrs  25,50,75,100 mcg/hr  25 mcg/hr is equivalent to 15 mg morphine in a 24 hr period
  17. 17. METHADONE  Equipotent to morphine  Minimal hemodynamic effects  Long half life  Sedation and euphoric properties less pronounced than morphine  Useful for pain control and abstinence PO dosing  0.1 mg/kg q 4-8 hrs  50 % oral bioavailability  Drug accumulation with repeated doses caused by extensive protein binding
  18. 18. MODE OF ADMINISTRATION  Intravenous bolus administration  Common  PRN - as needed  Half-life of drug determines interval  Disadvantage of pain breakthrough
  19. 19. IV BOLUS ADMINISTRATION
  20. 20. CONTINUOUS INFUSION  Utilized when prolonged analgesia and sedation needed  Less labor intensive  Better analgesia, initial bolus important  Need for dedicated IV site
  21. 21. CONTINUOUS INFUSION
  22. 22. PCA  Patient controlled analgesia  Allows patient to administer a preset amount of narcotic at preselected intervals  Improved analgesia with decreased narcotic use  Option to include low basal rate  Nurse controlled analgesia  Eliminates delay  Allows delivery via a closed system
  23. 23. PCA
  24. 24. OPIATE SIDE EFFECTS  RESPIRATORY DEPRESSION  Reversal - Nalaxone (Narcan)  Full reversal 0.1 mg/kg  Partial reversal - titrate to effect  Half life is less than narcotics  IV,IM,Sub Q, ETT  Abrupt reversal may result in nausea, vomiting, sweating, tachycardia, increased BP, and tremors
  25. 25. OPIATE SIDE EFFECTS  Pruritis  Individual variability and susceptibility, alleviated by Benadryl  Tolerance  Need for increase in dose to achieve the same effect  Generally develops after 2-3 days of frequent/continuous use  Greater with fentanyl  Treated by increasing the dose as needed
  26. 26. OPIATE SIDE EFFECTS  DEPENDENCE  Physiological state leading to abstinence syndrome on withdrawal of the drug  Generally develops after 7-10 days of sustained use  Symptoms include: mydriasis, tachycardia, goose bumps, muscle jerks, vomiting, diarrhea, seizures, fever, hypertension  Treated with gradual withdrawal of the drug
  27. 27. OPIATE SIDE EFFECTS  DEPENDENCE  In general the longer the period of treatment the longer the period of withdrawal needed  A child is at risk for dependence if they have been on narcotics for a week  Finnegan scoring to monitor adequate weaning dose  Weaning strategies can vary, typically 10% decrease per day  Do not spread the dosing interval beyond the normal dosing interval, rather decrease the dose  Can substitute methadone and wean q 48 hrs over a longer time period
  28. 28. BENZODIAZEPINES  First line agents for sedation  Provide hypnosis, anxiolysis, antegrade amnesia, and anticonvulsant activity  NO ANALGESIA  Can cause abstinence syndrome after prolonged use  Mechanism in the limbic system via the inhibitory neurotransmitter, gamma aminobutyric acid (GABA)
  29. 29. DIAZEPAM (VALIUM)  Sedating, variable amnesia, anxiolytic  Irritating to veins, pain in PIV  Multiple active metabolites  Advantage for prolonged sedation  Disadvantage for rapid arousal  Not recommended for continuous infusion  Half-life 12-24 hrs  Hepatic metabolism
  30. 30. LORAZEPAM (ATIVAN)  Improved amnesia  No active metabolites  Half life 4-12 hours  Metabolized by glucuronyl transferase  Less influence from other drugs  Better preserved in patients with liver disease
  31. 31. MIDAZOLAM (VERSED)  Rapid onset  Rapid metabolism  Good amnesia  Water soluble, no pain with injection  Half life 2 -4 hours  Hepatic metabolism with renal excretion  Active hydroxy- metabolite may accumulate  Other routes of administration  Oral  Nasal  Rectal  Sublingual  Less absorption requiring increase dosing
  32. 32. MIDAZOLAM  Reports of dystonia and choreoathetosis post infusion, greater risk in neonates  Heparin decreases protein binding, increases free drug  Disadvantage cost  20 kg patient  80 $/day compared to Ativan = 30 $/day
  33. 33. BENZODIAZEPINES SIDE EFFECTS  RESPIRATORY DEPRESSION  Less than narcotics, but potentiated with narcotics  Dose related  Reversal  Flumazenil - benzodiazepine receptor antagonist  Contraindicated in patients with chronic benzo use for seizures, mixed overdose, TCA’s - may result in seizures
  34. 34. BENZODIAZEPINES SIDE EFFECTS  Choreoathetoid movement disorder  Tolerance  As with narcotics may need to increase dose following 2-3 days use  Dependence  Withdrawal carefully and slowly if on greater than 7-10 days  Signs of withdrawal - tremor, tachycardia, hypertension,  Rapid withdrawal may promote seizures
  35. 35. CHLORAL HYDRATE  Sedative hypnotic agent  Metabolized in the liver to its active form, trichlorethanol  Half life 8-12 hours  Oral or rectal administration  Onset of action delayed  Paradoxical reaction in some older children  Not to exceed 100 mg/kg/day - i.e.: 25mg/kg/q 6 hrs  Caution in children < 3 months or with hepatic dysfunction
  36. 36. BARBITURATES  Sedative  Respiratory depression dose dependent  Negative inotropic effects/vasodilation - decreased cardiac output  Decreased cerebral O2 consumption  CBF   ICP  Anticonvulsant
  37. 37. BARBITURATES  Useful in patients with increased ICP  Short acting barbiturate useful for sedation for procedure/imaging in hemodynamically stable child  Alkaline solution, often incompatible with TPN or meds.
  38. 38. MAJOR TRANQUILIZERS  Phenothiazine  Thorazine  Butyrophenones  Droperidol  Haloperidol  Common in adult ICU, uncommon in PICU  Side effects hypotension due to alpha blockade and extrapyramidal effects  At times useful in the difficult to sedate child
  39. 39. KETAMINE  Dissociative IV anesthetic  Good amnesia and somatic analgesia  Anesthetic state classically described as a functional and electrophysiological dissociation between the thalamoneocortical and limbic system  Chemically related to phencyclidine and cyclohexamine  Water and lipid soluble  Quickly crosses blood-brain barrier, < 30 seconds
  40. 40. KETAMINE  Redistribution half-life 4.7 minutes  Elimination half-life 2.2 hours  Clinical effects evident within one minute, resolution within 15 - 20 minutes of dose  Bronchodilation  Sialagogue -“promoting the flow of saliva”  Administer with an anticholinergic  Atropine or Robinol  Minimal net hemodynamic effect  Negative inotrope  Central effect - HR, SVR  Good choice in shock or status asthmaticus
  41. 41. KETAMINE  Risk of laryngospasm  Risk of emesis/aspiration  Increases ICP , globe pressure  Seizure inducing  Emergent reactions, hallucinations  Improved with administration of a benzodiazepine  IM: 2 - 4 mg/kg dose q 30 minutes - 1 hour  IV  Intermittent dosing  1 -2 mg/kg dose q 30 minutes to 1 hr  Continuous dosing  1 - 3 mg/kg/hr
  42. 42. PROPOFOL  Sedative/hypnotic  Dose dependent - conscious sedation to general anesthesia  Rapid onset (20-50 seconds)  Quick recovery ( within 30 minutes of d/c)  Lack of active metabolites  Metabolized in liver  Excreted in urine
  43. 43. PROPOFOL  Lipid emulsion, reports of anaphylaxis  Soybean oil, egg lecithin, and glycerol  Decreased ICP, may lower CPP  Decreased sympathetic tone  Contraindicated in hemodynamically unstable  Moderate respiratory depression  Pain with injection/infusion site  Improved with use of 1% lidocaine  0.5 mg/kg
  44. 44. PROPOFOL  Neurologic sequela  Opisthotonic posturing  Myoclonic movements  Metabolic acidosis reported with use > 24 hrs  Contraindicated for long term use  Doses  1 - 3 mg/kg induction  20 - 100 mcg/kg/min  Increase infusion rate 5-10 mcg/kg/min increments of 5 - 10 minutes

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