Pediatric Resident Curriculum for the PICU
UTHSCSA
SEDATION and ANALGESIA in
the PICU
Pediatric Resident Curriculum for the PICU
UTHSCSA
GOALS
• Analgesia for painful diseases and
procedures
• Compliance with controlled
ventilation and routine intensive care
• Amnesia for the periods of sedation
• Reduce the physiological responses to
stress
• Avoid complication
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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.
Pediatric Resident Curriculum for the PICU
UTHSCSA
IDEAL PICU
SEDATIVE/ANALGESIA
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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
Wide therapeutic index
Pediatric Resident Curriculum for the PICU
UTHSCSA
COMMON DRUGS UTILIZED
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Opiates (Narcotics)
Benzodiazepines
Chloral hydrate
Barbiturates
Ketamine
Propofol
Neuroleptics
Paralytics
Pediatric Resident Curriculum for the PICU
UTHSCSA
SITUATIONS REQUIRING
SEDATIVES/ANALGESIA
• MECHANICAL VENTILATION
– Respiratory failure
– Airway
– Neurological
• POST OPERATIVE
• HEAD INJURY
• PULMONARY HYPERTENSION
• PROCEDURES
Pediatric Resident Curriculum for the PICU
UTHSCSA
OPIOIDS
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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
Pediatric Resident Curriculum for the PICU
UTHSCSA
OPIOIDS
ROUTE OF ADMINISTRATION
– IV
– Oral
– Transmucosal
– Transdermal
MODE OF ADMINISTRATION
– Intermittent/on demand (as
necessary)
– Fixed interval
– Continuous infusion
– PCA
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
MORPHINE
• PCA dosing
• IV intermittent
– 0.1 mg/kg q 3 - 4 – Initial dosing: 50
mcg/kg q 10
hrs
minutes until
• IV continuous
comfortable
– 0.05 mg - 0.1
– Demand dose: 20 mg/kg/hr
40 mcg/kg
• PO scheduled
– Lock-out period: 10
minutes
– 0.3 mg/kg q 3 - 4
– 4-hour limit: 0.25
hrs
mg/kg
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
METHADONE
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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
Pediatric Resident Curriculum for the PICU
UTHSCSA
MODE OF ADMINISTRATION
• Intravenous bolus administration
– Common
– PRN - as needed
– Half-life of drug determines interval
– Disadvantage of pain breakthrough
Pediatric Resident Curriculum for the PICU
UTHSCSA
IV BOLUS ADMINISTRATION
Pediatric Resident Curriculum for the PICU
UTHSCSA
CONTINUOUS INFUSION
• Utilized when prolonged analgesia and
sedation needed
• Less labor intensive
• Better analgesia, initial bolus
important
• Need for dedicated IV site
Pediatric Resident Curriculum for the PICU
UTHSCSA
CONTINUOUS INFUSION
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
PCA
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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)
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
LORAZEPAM (ATIVAN)
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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
Pediatric Resident Curriculum for the PICU
UTHSCSA
MIDAZOLAM (VERSED)
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Rapid onset
• Other routes of
administration
Rapid metabolism
– Oral
Good amnesia
– Nasal
Water soluble, no
pain with injection
– Rectal
• Half life 2 -4 hours
– Sublingual
• Hepatic metabolism • Less absorption
with renal excretion
requiring increase
dosing
– Active hydroxymetabolite may
accumulate
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
BARBITURATES
• Sedative
• Respiratory depression dose
dependent
• Negative inotropic effects/vasodilation
- decreased cardiac output
• Decreased cerebral O2 consumption
– CBF
–  ICP
• Anticonvulsant
Pediatric Resident Curriculum for the PICU
UTHSCSA
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.
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
KETAMINE
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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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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
Pediatric Resident Curriculum for the PICU
UTHSCSA
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