Sedation and Analgesia for
Diagnostic and Therapeutic
Procedures
Michael S. Mazurek, M.D.
Associate Professor of Clinical
Anesthesia
Riley Hospital for Children
Overview
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Goals of Sedation
Definitions of Levels of Sedation
Risks and Complications
Clarian Sedation Guidelines by Case
Examples
• Specific Drugs
Goals of Sedation
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Guard the patient’s safety
Minimize pain
Provide anxiolysis
Control behavior
Return the patient to a state in which safe
discharge is possible
Risks and Complications
• AIRWAY, AIRWAY, AIRWAY
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airway obstruction
hypoventilation
apnea
aspiration
• Hemodynamic impairment
Risks and Complications
• Numerous case reports exist describing
complications from sedation and analgesia
• Few large series exist involving a numerator
(adverse events) and a denominator (total
number of sedations)
Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of
Contributing Factors
Pediatrics 2000; 105: 805-814
•4 physicians reviewed adverse
sedation events for probable causes
•95 events were reviewed
Safety Conclusions
• Respiratory events are the most frequent
initiating events
• All areas using sedation have reported
adverse events
Pediatrics 2000; 105: 805-814
Safety Conclusions
• Adverse events involved:
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Multiple drugs
Drug overdose
Inadequate medical evaluation
Inadequate monitoring
Inadequate practitioner skills
Pediatrics 2000; 105: 805-814
Medication Conclusions
• Adverse outcome was associated with all
routes of drug adminstration
• Adverse outcome was associated with all
classes of medication, even when given
within the recommended dose range
• Drugs should not be given at home
• Avoid premature discharge
Pediatrics 2000; 106: 633-644
Reappraisal of Lytic Cocktail/Demerol, Phenergan, and Thorazine
(DPT) for the Sedation of Children
Pediatrics 1995; 95: 598-602
“ The DPT cocktail remains a widely used
sedative and analgesic for pediatric patients.
Neither the combination itself nor its dosage is
based on sound pharmacologic data. There is a
high rate of therapeutic failure as well as a high
rate of serious adverse reactions, including
respiratory depression and death, associated with
its use.”
Clarian Sedation Guidelines
• http://clarianweb.clarian.com/
• Moderate Sedation Guidelines
• Deep Sedation Guidelines
1 year old sedation for an MRI
• What equipment do you need available
before you sedate this patient?
Equipment
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Oxygen supply
Airway equipment of appropriate size
Suction apparatus of appropriate size
Age appropriate emergency cart
Physiological monitoring equipment
1 year old sedation for an MRI
• Do you need a consent for sedation?
• Is the MRI consent enough?
1 year old sedation for MRI
• What is important for your presedation
history?
Presedation Medical Evaluation
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History of sedation/anesthesia problems
Airway problems (obstructive sleep apnea)
Respiratory symptoms
Current medications; drug allergies
Review of systems
NPO status
1 year old sedation for MRI
• Would you sedate the child if they had
formula 2 hours ago?
• What are appropriate NPO guidelines?
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Clear liquids?
Breast milk?
Formula?
Big Mac?
Age
Solids and non-
Clear liquids
clear liquids
Adults/Children
> 36 months old
6 – 8 hours
Children
6 hours
6 – 36 months old
Children
< 6 months old
4 – 6 hours
Clarian Sedation Guidelines 1999
2 – 3 hours
2 – 3 hours
2 hours
1 year old sedation for MRI
• What physical evaluation are you going to
perform before the sedation?
Preoperative Evaluation of the
Upper Airway
• Tongue versus pharyngeal size
• Atlanto-occipital joint extension
• Anterior mandibular space (thyromental
distance
• Dental examination
Risk Classification
• Low – Relatively healthy patient.
• Moderate – Patient with a significant
pathologic process that is difficult to
control.
• High – Patient with a severe pathologic
process that has produced potentially
irreversible end-organ damage.
Patients at Increased Risk
• Prior adverse response to sedation
• Airway problems: OSA, difficult intubation,
or syndrome with airway abnormalities
• Significant respiratory symptoms
• High risk classification
• Delayed gastric emptying or aspiration risk
1 year old sedation for MRI
• How are you going to monitor the patient?
Monitoring
• Patient response as a guide to level of sedation
– Children may be an exception
• Continuous pulse oximetry
• Ventilation
– Observation, auscultation, or ETCO2
• ECG and BP for all patients under deep sedation
and when indicated for moderate sedation
Ventilation
• Pulse oximeter is not a ventilation monitor
• Impedence Pneumography does not monitor
ventilation
• Observation and auscultation for the
uncovered patient
• ETCO2 for the covered patient
Manpower
• Minimum of two persons:
– One to perform the procedure
– Another to monitor the patient
• The monitoring person may assist with
short, interruptible tasks during moderate
sedation
• The monitoring person may have no other
duties during deep sedation
Documentation
• Clarian Sedation Flowsheet
• Medicines
– Dosages, times, and routes
• Vital signs every 5 minutes
– Minimum SaO2 and RR
– BP and HR if indicated
Post - Sedation
• Observe in quiet environment for resedation
• Impaired patients should be back to
presedation status
• Normal patients should be fully awake
Post - Sedation
• Observe for minimum 1 hour if reversal
agent given
• Physician must perform a post-procedure
evaluation
• Adverse outcomes documented on
flowsheet:
– Conversion to GA, emergency intervention,
respiratory complications, death
1 year old for sedation for MRI
• How are you going to sedate this kid?
3 year old for sedation for head
laceration in the ER
• How are you going to sedate this kid?
10 year old for bone marrow aspirate
• How are you going to sedate this kid?
8 year old for abdominal CT
• How are you going to sedate?
Specific Drugs
• Study the pharmacology of the drugs you
plan on using
• Become an expert on a few, appropriate
drugs
• Start with small doses and titrate to effect
• When combining drugs, decrease the dose
of each component
Specific Drugs
• Sufficient time should elapse before
redosing
• Tailor your drugs to need – if you don’t
need analgesia, don’t give a narcotic
Other Considerations
• Consult a specialist for high risk patients
• Maintain your airway skills
Specific Drugs
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Local Anesthetics
Chloral hydrate
Midazolam, Flumazenil
Fentanyl, Morphine, Naloxone
Propofol
Ketamine
Local Anesthetics
• Use for analgesia
– Greatly reduces need for systemic narcotics
• EMLA (lidocaine 2.5%, prilocaine 2.5%)
– Need 45 – 60 minutes for efficacy
• Epinephrine 1:200,000 (5 mcg/cc)
– Prolongs duration of block
– Decreases bleeding
– Slows systemic uptake
Chloral Hydrate
• Oral/Rectal dose: 25-100 mg/kg, max
100mg/kg or 2gm
• Onset: 15 – 30 minutes
• Peak effect: 30 – 60 minutes
• Duration of action: variable – may persist
for 10 – 20 hours in neonates and toddlers
Midazolam
• Benzodiazepine
– Sedative with no analgesia
• Oral dose: 0.25 – 0.75 mg/kg, max 15 mg
• Pediatric IV dose: 25 – 50 mcg/kg every 5
minutes, max dose 0.4 mg/kg
• Adult IV dose: 1-2 mg every 5 minutes, max
10mg
• Onset: oral 10 – 30 minutes
– IV 3 – 5 minutes
• Duration of action: oral 60 minutes
– IV 20 – 60 minutes
Flumazenil
• Benzodiazepine antagonist for
benzodiazepine overdose
• IV dose: 0.01 mg/kg every 1 minute, no
more than 0.2 mg per dose, max dose 1 mg
• Onset: 1 – 3 minutes
• Duration of action: < 1 hour
Fentanyl
• Pediatric IV dose: 0.5 – 2 mcg/kg every 5
minutes, max dose 3 mcg/kg
• Adult IV dose: 50 – 100 mcg every 5
minutes, max dose 200 mcg
• Onset: 2 – 3 minutes
• Duration of action: 30 – 45 minutes
Morphine
• Pediatric IV dose: 50 – 100 mcg/kg every 5
minutes, max dose 0.2 mg/kg
• Adult IV dose: 2 – 4 mg every 5 minutes,
max dose 12 – 14 mg
• Onset: 5 minutes
• Duration of action: 3 – 5 hours
Naloxone
• Narcotic antagonist for narcotic reversal
• IV dose: 0.1 mg/kg every 2 –3 minutes , no
more than 2 mg per dose with a maximum
dose of 10 mg
• Onset: 1 – 2 minutes
• Duration of action: 45 minutes
Propofol
• Can very quickly induce general anesthesia and
apnea
• Need to give as a continuous infusion
• IV dose: 0.5 – 1.0 mg/kg loading dose followed by
infusion of 25 – 100 mcg/kg/min, titrating to
effect
• Onset: < 1 minute after loading dose
• Duration of action: depends on duration of
infusion
Ketamine
• Produces a dissociative state
• Provides intense analgesia
• IM dose: 2 – 4 mg/kg
– Onset: 5 – 10 minutes
– Duration: 30 – 90 minutes
• IV dose: 0.25 – 0.5 mg/kg
– Onset: 1 – 2 minutes
– Duration: 20 – 60 minutes