pediatric procedural sedation and analgesia

1. -.,/

3. PEDIATRIC PROCEDURAL
SEDATION AND ANALGESIA (PSA)
NOHA EL-ANWAR
LECTURER OF PEDIATRICS
AND PEDIATRIC CRITICAL CARE
CAIRO UNIVERSITY

4. SEDATION VS. ANALGESIA
 Sedation: reduction of the state of awareness. Many sedatives produce
amnesia(Benzodiazepines, barbiturates). Sedative agents have no analgesic
effects
 Analgesia: reduction or elimination of the perception of pain and most have
sedative effects.

5.  Use of sedatives, analgesics, and/or dissociative agents to relieve anxiety and
pain associated with diagnostic and therapeutic procedures.
 Integral part of training, fundamental skills.
 Individualized as per the requirement.
 Procedure, whether it is painful or not ?

6. PROCEDURES REQUIRING SEDATION
(NON INVASIVE, SEDATION)

7. PROCEDURES REQUIRING PSA
(INVASIVE- PAINFUL, ANALGESIA)

8. WHY PROCEDURAL ANALGESIA ??

9. Coaxing and physical restraint is not an alternative:
 Procedure difficulty
 Unsafe
 Psychological trauma
 Stress disorder
 Physiological and behavioral responses can lead to long-lasting negative
effects on the developing nociception system

10. CHALLENGES TO PSA
 Non elective !
 Limited or no prior history
 Time pressures
 Priorities – work balance
 Alternatives – is regional or local techniques appropriate
 Staffing - required personnel and their roles
 Patient selection and individualization paramount

11. HOW LOW SHOULD YOU GO?
Depth of Procedural Sedation:
 Minimal sedation (anxiolytics)
 Moderate: still awake “conscious sedation”
 Deep
 General
Dissociative

13. The targeted depth of sedation and the agents used depend on:
 Anticipated degree of pain
 Allowable amount of motion during the procedure
 Patient Factors:
●Comorbidities (eg, asthma, upper respiratory tract infection)
●Age and development level
●Ability to cooperate
●Degree of anxiety
●Any prior problems with specific medications

14. ASA PHYSICAL STATUS CLASSIFICATION
Increase
d risk of
adverse
events
~9 %
~23 %
Risk of adverse
events (eg.
Hypoxia)*
* Caperell K, Pitetti R. Is higher ASA class associated with an increased incidence of adverse events during procedural sedation in a pediatric emergency
department? Pediatr Emerg Care. 2009 Oct;25(10):661-4. doi: 10.1097/pec.0b013e3181bec7cc. PMID: 21465695.

15. PRE-SEDATION ASSESSMENT
 Laboratory workup has no role.
 Informed consent should be obtained and
documented.
 ASA fasting guidelines for PSA may not be followed
in every case; the risk in individual patients must be
weighed against the risk of delaying an emergent
procedure.

16. ASA FASTING GUIDELINES FOR PSA

17. PREPARATION
 Fasting status
 Focused medical examination
 Assessment of airway
 ASA classification
 Procedural sedation history
 Family anesthetic history
 Age, weight, height should be recorded.

18. EQUIPMENT AND EMERGENCY DRUGS
 Standard non-invasive monitoring should be used in all patients.
 Emergency medications: atropine, epinephrine, hydrocortisone, flumazenil,
naloxone etc., should be available.

19. NON PHARMACOLOGIC
 Behavioral and cognitive approaches:
o Desensitization,
o Distraction,
o Reinforcing Coping Skills,
o Positive Reinforcement,
o Relaxation.
 Complementary to pharmacologic interventions,
may prevent the need for sedation altogether.

20. PHARMACOPEIA
 Ideal agent for procedural sedation and analgesia:
The ideal is
not present
yet !

21. MEDICATION CATEGORIES
1- Sedatives – Hypnotics
2- Analgesics
3- Dissociative Medications
4- Inhalation Medications
5- Reversal Agents
6- Common Combinations

22. MEDICATIONS: SEDATIVES - HYPNOTICS
 A pure sedative-hypnotic drug
 It has an aromatic, pungent odor and a slightly
bitter, caustic taste, which may not be acceptable
to children.
 Chloral hydrate can cause airway obstruction
and respiratory depression at higher doses (75-
100 mg/kg).
 Its unpredictable onset, long duration, and the
lack of a reversal agent make chloral hydrate far
from an ideal sedative.

23. MEDICATIONS: SEDATIVES - HYPNOTICS
 Benzodiazepines produce sedation, anxiolysis,
amnesia, and anticonvulsant effects.
 Respiratory depression should be watched for.
 Also via the IM, oral, IN(irritant), and rectal
routes.
 Requires supplemental analgesia for painful
procedures.
 Paradoxical agitation (1-15%) children.

24. MEDICATIONS: SEDATIVES - HYPNOTICS
 Phenobarbital is popular for use during
radiological (non-invasive) procedures.
 It is given in dose of 2-5 mg/kg/dose slow IV or
2-6 mg/kg/dose IM ( max100 mg/dose) by either
route.
 Oral route has been also used and was found to
be better than chloral hydrate.
 Pentobarbital is the best choice in cases of ICT.

25. MEDICATIONS: SEDATIVES - HYPNOTICS
 Etomidate has a rapid onset of action, a short
duration agent with a relatively mild adverse
effect profile.
 It may block cortisol production, and this
appears to be its most significant drawback and
limits its long-term use.
 Etomidate has been found to be more effective
and efficient than pentobarbital and midazolam
and equally safe as propofol.

26. MEDICATIONS: SEDATIVES - HYPNOTICS
 If no ketamine available or CI for ketamine use or in
combination with ketamine
 Good efficacy, apparent safety, and rapid recovery.
 Anticonvulsant activity, antiemesis, and ability to
reduce intracranial hypertension.
 Dose related apnoea, hypotension
 Propofol infusion syndrome seems an unlikely
concern for procedural sedation. The risk factors
include poor oxygen delivery, sepsis, serious
cerebral injury, and high-dose propofol.
 Propofol is at least as effective as midazolam in
providing desired levels of sedation with an early
recovery profile.

27. MEDICATIONS: SEDATIVES - HYPNOTICS
 Selective alpha 2 adrenoreceptor agonist
 very expensive
 Sedative, anxiolytic, and mild analgesic properties with no
depressant effect on respiratory drive.
 In 2008, approval was granted for its use in non-intubated
patients requiring sedation. Although it does not have US
FDA approval for use in children, its use has been well
described in multiple settings.
 Common adverse events: Bradycardia or hypertension.
 Relative contraindications and precautions: Children with
dehydration or reduced cardiac output.
 Absolute contraindications: Patients receiving digoxin or
other medications acting on sinus node or with sinus node
dysfunction.

28. MEDICATIONS: ANALGESICS
 Fentanyl : 75-125x as potent as morphine, peak
effect 2mins and duration of action for 20minutes
 IN > emetogenic
 May cause respiratory depression and hypotension.
 Chest wall rigidity may occur, especially with rapid
IV infusion.
 When combined with propofol, may produce a
state of general anesthesia.
 Remifentanil is an ultra-short-acting opioid agent
that has an onset of action of about 1 min and an
elimination half-life of less than 10 min. It has been
used successfully as a sedative agent in children.

29. MEDICATIONS: ANALGESICS
 With the advent of short-acting opioids,
morphine is no longer preferred for short
procedures.
 Opioid analgesia is an important adjunct to
sedation for children with moderate to severely
painful procedures.
 IV administration of opioids prior to sedation is
associated with increased frequency of oxygen
desaturation, vomiting, and need for positive-
pressure ventilation during sedation.

30. MEDICATIONS: DISSOCIATIVE MEDICATIONS
 Dissociative analgesia: Dissociation : “disconnection” of
thalamo-neocortical from limbic system : non-
competitive antagonism at NMDA receptors.
Prevention of cortical centers receiving any sensory
stimuli
 Sub dissociative : <1mg/kg
 Dissociative sedation: profound analgesia, sedation,
amnesia, and immobilization.
 Upper airway muscular tone and protective airway
reflexes are maintained and spontaneous respiration is
preserved
 It is an ideal sedative in patients with bronchospasm,
hypovolemia, and shock.
 Poor choice for CT/MRI – potential motion artifact

31. MEDICATIONS: DISSOCIATIVE MEDICATIONS
 Provides sedation AND analgesia for moderately to
severely painful procedures.
 Common adverse events: Vomiting, IM ketamine
increases the risk of vomiting and the duration of
sedation and recovery.
 Relative contraindications : Age younger than 1year,
active pulmonary infections, known or suspected
cardiac disease, porphyria, thyroid disease, or seizures.
 Absolute contraindications: Age younger than 3
months or patients with known or suspected psychosis.
 ketamine is protective in head injury due to NMDA
blockade and does not increase ICP
 Frequently used in “poorly monitored setting in 3rd
world” with very good safety profile

32. MEDICATIONS: INHALATION MEDICATIONS
 Primarily used in children older than 4 years of
age.
 Provides amnesia, mild to moderate anxiolysis,
mild to moderate sedation, and mild analgesia.
 Common adverse effects: Vomiting and
dysphoria.
 Relatively contraindications and precautions:
Nausea and vomiting.
 Absolute contraindications: Conditions with
trapped gas within body cavities (eg, bowel
obstruction, pneumothorax, middle ear
infection).
 Not found in Egypt !

33. MEDICATIONS: REVERSAL AGENTS
 Dose: Infants and children <5 years old or <20 kg:
IV 0.1 milligrams/kg/dose, IM 0.1
milligram/kg/dose; Children >5 years old or >20
kg: IV 2 milligrams/dose, IM 2 milligrams/dose.
Infants, children, and adolescents: intranasal 4 mg,
endotracheal 2 to 3 times the IV dose
 Onset: One minute
 Duration: 15 to 30 minutes
 Comments: Opiate reversal. The dose can be
repeated every two to three minutes to effect. May
need to repeat doses every 20 to 60 minutes if the
duration of action of opioid used is longer than
naloxone. The onset of action is slightly delayed in
intranasal administration.

34. MEDICATIONS: REVERSAL AGENTS
 Dose: IV 0.01 milligrams/kg (maximum dose 0.2 mg) given
over 15 seconds. May repeat dose after 45 seconds, then
every minute to a maximum total cumulative dose of 0.05
milligrams/kg or 1 mg
 Onset: One minute
 Duration: 45 minutes
 Comments: Benzodiazepine reversal. Avoid use in chronic
benzodiazepine users as it can induce seizures.
 Effective reversal agent for the few patients who develop
significant respiratory depression or apnea after sedation
with midazolam.
 Should not be used in patients with seizure disorders or
those who receive benzodiazepines on a chronic basis
because of the risk of precipitating seizures or withdrawal
symptoms, respectively.

35. MEDICATIONS: COMMON COMBINATIONS

36. MEDICATIONS: COMMON COMBINATIONS
 More rapid recovery times without increase in
adverse effects
 Synergism – reduction of individual doses of drugs,
safer than individual use – less apnea, consistent
sedation
 Ketamine: Analgesia and dissociation, increases HR
and BP, stimulates respiratory drive. Propofol:
decreases HR and BP, amnesia, antiemetic.
 Effective sedation and less vomiting than reported
for ketamine alone and less hypotension than
described with propofol alone.
 Adverse respiratory events including laryngospasm
can still occur.

37. COMPARATIVE PROPERTIES OF DIFFERENT DRUGS

38. COMPARATIVE PROPERTIES OF DIFFERENT DRUGS
Agent Initial IV dose
Repeat IV dose
(as needed to achieve desired
level of sedation)
Onset
(minutes)
Duration
(minutes)
Ketamine 1 to 2 mg/kg; When given with
propofol: 0.5 mg/kg
0.5 to 1 mg/kg; repeat every 5
- 10 mins
1 to 2 15 to 30
Propofol 6 months to 2 years of age: 1
to 2 mg/kg IV bolus dose
2 years of age and older: 0.5 to
1 mg/kg IV bolus dose
0.5 mg/kg every 3 - 5 mins,
titrating as needed up to 3
mg/kg.
≤0.5 5 to 15 after single bolus dose
Dexmedetomidine 1 to 3 mcg/kg loading dose
(over 10 minutes), followed by
0.5 to 1 mcg/kg
--- 5 to 10 30 to 70
Fentanyl 1 to 2 mcg/kg Repeat 0.5 to 1 mcg/kg every 3
to 5 minutes
<3 to 5 30 to 60 after a single dose
Midazolam 6 months to 5 years of age:
0.05 to 0.1 mg/kg IV, maximum
single dose 2 mg
6 to 12 years of age: 0.025 to
0.05 mg/kg IV, maximum single
dose 2 mg
Over 12 years of age: 1 to 2 mg
IV
repeat after 2 - 5 mins, then:
6 months to 5 years of age: 0.2
mg/kg per dose (maximum total
dose 6 mg)
6 to 12 years of age: 0.1 mg/kg
(maximum total dose 6 mg)
Over 12 years of age: 1 to 2 mg
(maximum total dose 10 mg)
1 to 3 15 to 60, depending upon total
dose administered
Etomidate 0.1 to 0.3 mg/kg IV 0.05 mg/kg every 3 - 5 mins;
up to 0.6 mg/kg total dose
≤0.5 5 to 15

39. Agent Dose Onset
(minutes)
Duration
(minutes)
Nitrous oxide (N2O) 50 to 70 % N2O
administered with oxygen
typically delivered
through a demand valve
system with scavenging
capability
<0.5 Recovery typically within
3 to 5 minutes of
cessation of N2O delivery
Midazolam 0.25 to 0.5 mg/kg PO or
SL, maximum 20 mg
0.2 to 0.3 mg/kg IN,
maximum 10 mg
Buccal dosing is as for IN
20 to 30 30 to 60
Dexmedetomidine 2.5 to 3 mcg/kg IN 20 to 30 30 to 45
Ketamine 4 to 5 mg/kg IM 5 to 10 30 to 60

40.  PSA for Non painful Procedures :
Midazolam, Phenobarbital, Nitrous Oxide
 PSA for Minor Painful Procedures :
Fentanyl, Sub-dissociative dose ketamine, Dexmedetomidine
 PSA for Major Painful Procedures:
Propofol, Etomidate, Ketamine, Ketofol

41. POST PROCEDURAL CARE
 Observation : until alert, orientated and HD stable, normal age appropriate vital signs
 Observe for complications :
Aspiration risk
Laryngospasm : rare (0.4%)
Hypotension/CVS instability
Hypoventilation
Ketamine: recovery agitation, dreams, hallucinations, de-personalisation in 7.6% children (1.4%
significant)
 Written and verbal instruction, time and date specific follow up (Parent information sheet)

42. SUMMARY
 Practicing safe PSA is fundamental skill.
 Individualized as per the requirement.
 Targeted depth of desired sedation.
 Pre-sedation assessment, requirement, equipment and premeditations.
 Non pharmacologic interventions is a must !
 Different Sedatives, Analgesics, Dissociative agents and Common combinations used.
 Reversal agents should be thereby.
 PSA for different painful procedures.

43. REFERENCES
 Stern J, Pozun A. Pediatric Procedural Sedation. 2021 Sep 2. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan–. PMID: 34283466.
 Mahajan C, Dash HH. Procedural sedation and analgesia in pediatric patients. J Pediatr Neurosci.
2014;9(1):1-6. doi:10.4103/1817-1745.131469.
 Caperell K, Pitetti R. Is higher ASA class associated with an increased incidence of adverse events during
procedural sedation in a pediatric emergency department? Pediatr Emerg Care. 2009 Oct;25(10):661-4.
doi: 10.1097/pec.0b013e3181bec7cc. PMID: 21465695.
 https://www.youtube.com/channel/UCyQ4ieAnEwDQs9iZLwH9H8w
 Cravero JP, Roback MG. Selection of medications for pediatric procedural sedation outside of the
operating room. In the: https://www.uptodate.com/contents/selection-of-medications-for-pediatric-
procedural-sedation-outside-of-the-operating-room. Last updated:Feb 09, 2022.