Primer on pediatric sedation and analgesia resident lecture

Primer on Pediatric Sedation
and Analgesia
Resident Lecture Series
Rob Parker, DO

Official pediatric teaching
hospital of

hospital of
Overview
• Role of sedation in
critical care
oPrimary medical illness
oPost-operative care
oDiagnostic imaging
oInvasive procedures
oMechanical ventilation
• Elements of sedation
oAnesthesia
oAnalgesia
oAnxiolysis
oAmnesia
• Levels of sedation
oAwake
oModerate
oDeep
oGeneral
• Scoring systems
oSBS
oCOMFORT
oRamsay, Riker, SAS, Harris
• Choosing the right drug
oGoals
oAdvantages/disadvantages
oDosing
oOnset
oDuration
• Sedation and Analgesia
oPICU approach

hospital of
Role of sedation in critical care
• More than 66% of pediatric patients remembered their stay in the PICU.
• 18% had bad memories
• 16% remembered mechanical ventilation and anxiety
• 29% remembered pain from a procedure or movement
• Overall the recollections of patients in the PICU were considered
negative in approximately 15% of the patients

hospital of
• Necessary to minimize the perception of and response to anxiety and
pain as time and medications heal
o Helps prevent adverse events and provide safety
o Inadvertent extubation, loss of lines/drains/tubes
o Facilitate patient-ventilator synchrony
o Optimize oxygenation/ventilation

hospital of
• Adverse effects can occur:
o Tachycardia/hypertension or bradycardia/hypotension
o Ileus
o Interfere with a comprehensive neurologic examination
o Tolerance and tachyphylaxis

hospital of
Elements of Sedation
•Anesthesia
•Analgesia
•Anxiolysis
•Amnesia

hospital of
Anesthesia
• Definition
o Loss of sensation & loss of consciousness
• Examples:
o Dexmedetomidine
o Ketamine
o Propofol
o Lidocaine, Ropivacaine, Bupivacaine

hospital of
Analgesia
• Definition
o Inability to sense pain
• Examples
o Non-sedating Analgesics
– Lidocaine/LMX/Emla
– Acetaminophen
– NSAIDs (Ibuprofen, Ketorolac)
o Sedating Analgesics
– Narcotics (Fentanyl, Morphine, Oxycodone, Methadone)
– Ketamine

hospital of
Anxiolytics
• Definition
o Relief of apprehension, fear, and/or agitation
• Examples
o Benzodiazepines (Midazolam, Lorazepam, Diazepam)
o Chloral Hydrate
o Dexmedetomidine

hospital of
Amnestics
• Definition
o Loss of memory, inability to recall events
• Examples
o Benzodiazepine
o Ketamine

hospital of
Levels of Sedation
Minimal Moderate Deep
• General Description “Anxiolysis” “Conscious” “Deep sleep”
• Responsiveness
• Airway
• Ventilation
• Cardiovascular
“appropriate”
Unaffected
Unaffected
Unaffected
“Purposeful” to light
stimulation
No intervention
Adequate
Maintained
“Purposeful” to pain
stimulation
(±) Intervention
(±) Inadequate
(±) Maintained

hospital of
Sedation Scoring Systems
State Behavioral Scale
-3: Unresponsive No spontaneous respiratory effort
No cough, or coughs only with
suctioning
No response to noxious stimuli
Unable to pay attention to care
provider
Does not distress with any procedure
(including noxious)
Does not move
-2: Responsive only to noxious
stimuli
Spontaneous yet supported
breathing
Coughs with
suctioning/repositioning
Responds to noxious stimuli
Unable to pay attention to care
provider
Will distress with a noxious procedure
Does not move/occasional movement
of limbs or shifting of position
-1: Responsive to touch or
name
Spontaneous but ineffective
nonsupported breaths
Coughs with
suctioning/repositioning
Responds to touch/voice
Able to pay attention but drifts off
after stimulation
Distresses with procedures
Able to calm with comforting touch or
voice when stimulus is
removed
Occasional movement of limbs or
shifting of position
0: Calm and cooperative Spontaneous and effective
breathing
Coughs when
repositioned/occasional
spontaneous cough
Distresses with procedures
Responds to voice/no external
stimulus is required to elicit
response
Spontaneously pays attention to care
provider
Able to calm with comforting touch or
voice when stimulus is
removed
Occasional movement of limbs or
shifting of position/increased
movement (restless,
squirming)
1: Restless and cooperative Spontaneous effective
breathing/having difficulty
breathing with ventilator
Occasional spontaneous cough
Responds to voice/no external
stimulus is required to elicit
response
Drifts off/spontaneously pays
attention to care provider
Intermittently unsafe
Does not consistently calm, despite
5-min attempt/unable to
console
Increased movement (restless,
squirming)
2: Agitated May have difficulty breathing with
ventilator
Coughing spontaneously
No external stimulus required to elicit
response
Spontaneously pays attention to care
provider
Unsafe (biting endotracheal tube,
pulling at catheters, cannot be
left alone)
Unable to console Increased
movement (restless,
squirming, or thrashing side-
to-side, kicking legs)
Curley MA, Harris SK, Fraser KA, et al. State Behavioral Scale: A sedation assessment
instrument for infants and young children supported on mechanical
ventilation. Pediatr Crit Care Med 2006;7:107-14

hospital of
Ambuel B, Hamlett KW, Marx CM, et al: Assessing distress in pediatric intensive care
environments: The COMFORT scale. J Pediatr Psychol 1992; 17: 95-109

hospital of
Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale
for adult critically ill patients. Crit Care Med. 1999;27:1325-1329
Riker Sedation-Agitation Scale

hospital of
Choosing the right drug - Opiates
• Receptors:
o μ- and κ-receptors are most
important for analgesia
• Inhibit spontaneous neuronal
firing and excitatory
neurotransmitter release.
• Dose dependent and include
sedation and analgesia
• Respiratory depression and
varying levels of bradycardia

hospital of
Choosing the right drug – Fentanyl
• One of the most commonly used
opiates
o synthetic derivative of meperidine
o Potent μ-agonist
o 100x stronger than morphine
• Benefits:
o Rapid onset, distribution, elimination
– Brain – 90sec
– Plasma
– Fat
o Minimal if any histamine release
o Limited cardiovascular effects
• Drawbacks:
o Rigid chest
o Dose dependent respiratory
depression
o Liver metabolism
o Nausea, vomiting, & urinary
retention
o Tachyphylaxis
• Bolus Dose is 1-2mcg/kg over
3-5 minutes
• Continuous infusion 0.03 – 0.05
mcg/kg/min (1.5 – 3 mcg/kg/hr)
• Titrate to effect every 3-5
minutes
• Onset: 1-2 minutes
• Peak effect: 10 minutes
• Duration: 30-60 minutes

hospital of
Choosing the right drug – Morphine
• Primarily sedation and
analgesia but some
anxiolysis and euphoria
o Moderate μ-agonist
• Benefits:
o Many forms available
o Longer duration
o Blunts most types and
intensities of pain
• Drawbacks:
o Histamine release -
vasodilatation
o Decreases release of ACTH,
ADH, prolactin, GH, and
epinephrine
depression
o Liver metabolism
retention
o Tachyphylaxis
• Bolus Dose is 0.05-0.3
mg/kg
• Continuous infusion 10-30
mcg/kg/hr (0.01-0.03
mg/kg/hr)
• Onset: 15-30 min IV
• Peak: 20 min
• Duration: 2-7hrs
o 60% of morphine is converted
to morphine-3-glucuronide
(inactive), and 6–10% is
converted to morphine-6-
glucuronide (1/2 as active)
o Significant 1st pass metabolism

hospital of
Choosing the right drug – Dilaudid
analgesia
oHydrogenated ketone of
morphine
• Benefits:
o6-7x stronger than morphine
oNo active metabolites
despite liver metabolism
oDOC for renal disease,
pancreatitis
oMinimal histamine release
oLess sedating
oAnti-tussive properties
• Drawbacks:
oDose dependent respiratory
depression
oNausea, vomiting, & urinary
retention
oTachyphylaxis
• Bolus Dose is 0.01-0.015
mg/kg q4-6h
mcg/kg/hr (0.003-0.010
mg/kg/hr)
• Onset: 5 min IV
• Peak: 10-20 min
• Duration: 4-5hrs

hospital of
Choosing the right drug – Remifentanil
analgesia
o Newer synthetic opiate
o Potent μ-agonist with mild κ and δ
effects
• Benefits:
o Very fast acting with fast offset
o Allows for neuro exam
o No histamine release
o Reduces cerebral oxygen use
o Metabolism is by nonspecific
esterases so safe in renal/liver
failure
• Drawbacks:
depression
o Mild bradycardia and hypotension
retention
o Rapid tolerance
o Expensive
• No bolus needed
• Continuous infusion
o 0.1 to 0.5 mcg/kg/min for sedation
o 0.75 to 2 mcg/kg/min for balanced
anesthesia
o 4 mcg/kg/min for loss of
consciousness
• Onset: near instant
• Half life: 8 min

hospital of
Choosing the right drug – Benzodiazepines
• Most commonly used
agents for sedation
oSedation, anxiolysis,
euphoria (limbic system),
reduced skeletal muscle
tone (through spinal BZD
receptors), anticonvulsant
properties, and
neuroendocrine effects
oAnterograde amnesia
• Dose dependent effects
• Can be opioid sparing
• Can observe
paradoxical reactions
• Can see cardic
depression
• Augment the function
GABAA receptor at the
postsynaptic membrane
oIncrease the frequency of
chloride channel opening
events which leads to
inhibition of the action
potential

hospital of
Choosing the right drug - Midazolam
• Anxiolysis and amnesia
oImidazobenzodiazepine
oWater soluble
oMany forms
o8x stronger than diazepam
• Benefits:
oFast acting
oRelative hemodynamic
stability
oAnticonvulsant properties
• Drawbacks:
oNo analgesia
oExtensively protein bound
with 1st pass metabolism
oInfusions can accumulate
• Bolus dose 0.05 – 0.1
mg/kg
mcg/kg/min (0.05-0.35
mg/kg/hr)
• Peak: 5-7 min
• Duration: 20-30 min

hospital of
Choosing the right drug - Lorazepam
• Anxiolysis and amnesia
oWater soluble
oMany forms
• Benefits:
oShorter acting but longer
duration
oLess lipid soluble
oRelative hemodynamic
stability
• Drawbacks:
oPropylene glycol
preservative
oMore drip interactions
oProlonged in pts with
renal/kidney disease
• Bolus dose 0.05 – 0.1
mg/kg
mcg/kg/min (0.05-0.35
mg/kg/hr)
• Peak: 60-120 min
• Duration: 4-8 hours
oMetabolism varies and can
last over 15 hours in some
situations

hospital of
Choosing the right drug –
Dexmedatomidine
• Anesthesia, analgesia, and
anxiolysis
o Centrally acting a-2 agonist
– 1600-1700:1 more a-2 selective
• Benefits:
o Deep sedation that mimics
natural sleep
o Reductions in ventilator days,
delirium, tachycardia/HTN, and
opioid sparing
o Minimal respiratory depression
o Minimal, if any, withdrawal
• Drawbacks:
o Bradycardia and hypotension
o Tolerance can develop
o Expensive
• Bolus of 0.5-1 mcg/kg over
15-20 min
• Continuous infusion 0.004-
0.02 mcg/kg/min (0.2-1.2
mcg/kg/hr)
o Some studies show safety up to
2.7mcg/kg/hr
• Onset: 15-30 min

hospital of
Choosing the right drug - Propofol
• Anesthesia and amnesia
o Potentiation and direct activation of
GABAA receptors.
o Increase extracellular dopamine and
may block dopamine reuptake
o Contains soybean and egg
derivatives
• Benefits:
o Rapid acting and easily titratable
o Reduces airway resistance
o Anticonvulsant properties
o Antiemetic properties
o Lowers ICP
• Drawbacks:
o Propofol infusion syndrome
– Rhabdo, metabolic acidosis, renal
failure, cardiac failure
o Suppresses sympathetic activity
– Hypotension, bradycardia
o Pain with injection
o Doesn’t interact well
•Bolus dose 1-3
mg/kg
•Continuous infusion
25-100 mcg/kg/min
•Onset: 30 seconds
•Duration: 3-10 min

hospital of
Choosing the right drug - Ketamine
• Anesthesia, amnesia,
anxiolysis and analgesia
o Phencyclidine derivative that
works at NMDA receptor
o Hepatic metabolism and renal
excretion
• Benefits:
o Hemodynamic stability
o Spontaneous breathing with
preserved airway reflexes
o Bronchodilator
o Dissociative sedation
• Drawbacks:
o Sialagogue
o Emergence phenomenon
o Rise in ICP
o Myocardial depressant due to
catecholamine depletion
o Laryngospasm
o Lowers seizure threshold
• Bolus 1-2 mg/kg IV
• Continuous infusion 0.5-2
mg/kg/hr
o Rarely used except in asthma
or palliative care
• Onset: 0.5 – 2 min
• Duration: 1-2 hours

hospital of
Choosing the right drug - Pentobarbitol
• Anesthetic
oOxybarbiturate with
medium duration
oPotentiate effect of GABA
by binding to GABAA
receptor
• Benefits:
oGood, deep sedation
oDecrease cerebral
metabolic demand
• Drawbacks:
oIdiosyncratic, hyperkinetic
reaction
oDecreased HR and
hypotension
oTolerance and dependence
• Bolus of 1-2 mg/ kg
• Continuous infusion of
1-10 mg/kg/h
• Onset: nearly instant
• Peak: 3-5 min

hospital of
Choosing the right drug - Quetiapine
• Atypical Antipsychotic
oDopamine and Histamine
antagonist
• Benefits:
oImproved interactability
with normalization of
routine
oDecreased need for other
sedatives
• Adverse Effects:
oQT prolongation
oElevation of liver enzymes
oMetabolic syndrome
• Guidance:
oUse p-CAM ICU
assessment of CAPD
(Cornell Assessment for
Pediatric Delirium)
• PRN of 0.5 mg/ kg
• Initial Dosing
1.5mg/kg/day div TID
• Max Dosing 6mg/kg/day

hospital of
Common PICU Approach
• Continuous Sedation agents of choice:
o Begin with combination of 2 continuous infusions - an opioid with dexmedetomidine or
a benzodiazepine
• First choice agents
o Morphine or Fentanyl with Precedex
• Second choice agents
o Dilaudid, remifentanil
o No second choice for precedex so would substitute versed
• Adjunctive agents:
o May use ativan, phenobarbital/pentobarbital, seroquel as scheduled or intermittent
PNR medications

hospital of
PICU Approach
• Continuous infusion + PRN
o Morphine:
– Begin with 0.1-0.3 mg/kg then continuous infusion beginning at 0.01-0.03 mg/kg/hr
– PRN usually matches what the patient receives in the hour
o Fentanyl:
– Begin with bolus of 1-2 mcg/kg then continuous infusion beginning at 0.5 – 1 mcg/kg/hr
– PRN usually matches what the patient receives in the hour
o Precedex
– Begin with bolus of 0.5 – 1 mcg/kg given over 15-20 minutes then continuous infusion at 0.25 mcg/kg/hr
– PRN 0.5 mcg/kg over 15 minutes every 2-4 hours
• Goal SBS of 0 to -1:
o If SBS -2 or -3 then first wean opioid by 10% followed by prededex if needed
o If SBS 1 to 2, follow algorithm for PRN medications and adjust infusion rates as needed
• PRN’s
o Start with PRN’s per algorithm above. If requiring >3, non-procedural, PRN’s, in a row, increase infusion by 10-20%
o Choose PRN/infusion based on suspected condition
– If pain is suspected, bolus and increase opioid
– If anxiety is suspected, bolus and increase precedex
o May consider Ativan 0.05-0.2 mg/kg to maximum of 5 mg/dose Q2h prn
o Consider atypical antipsychotic if delirium suspected
– Seroquel 1.5mg/kg/day div TID up to max of 6mg/kg/day
o If above ineffective and nearing max dosing of above, consider adding
– Versed infusion: Bolus with 0.05 – 0.1 mg/kg then continuous infusion beginning at 0.05 mg/kg/hr 0.35 mg/kg/hr with
PRN’s as above
– PRN Pentobarbital 1-3 mg/kg q2h with consideration of Phenobarbital (10-20 mg/kg load then dose 5 - 6 mg/kg/day
divided q12h)

hospital of
•Questions?

Primer on pediatric sedation and analgesia resident lecture

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Primer on pediatric sedation and analgesia resident lecture

Similar to Primer on pediatric sedation and analgesia resident lecture (20)

More from Robert Parker

More from Robert Parker (7)

Recently uploaded

Recently uploaded (20)

Primer on pediatric sedation and analgesia resident lecture