Sedation, Pain, and Analgesia
Ricardo R. Jiménez, MD
Pediatric Emergency Medicine, Fellow
Emory University School of Medicine
Children’s Healthcare of Atlanta
Pain
 Pain is subjective
 Pain may be underestimated
 Pain may be under treated
 Studies show that children do not get the same
treatment as adults who have similar painful
conditions.
2
Pain scales
 Visual analog scales for older children with the
frowning and smiling faces
 Hard to use for infants
 Sometimes the pain may be exaggerated by the
scales
3
Pain management
 Mild pain
• Reassurance
• Tylenol
• Ibuprofen
• Ice
• Distraction
4
Pain management
 Moderate and Severe pain
• Local anesthesia
• Parenteral Analgesia and Sedation
5
Patient Advocate
 Goals:
• Be the patient’s advocate in terms of pain
control.
• Discuss with the parents the best method for
pain control for their child.
• This is a very individual choice, with some
parents desiring little or no intervention, and
other wanting more methods for anxiolysis and
pain control
6
Nurse initiated guidelines
 Guidelines have been set up for the triage nurses to
treat pain as soon as the patient present to the
emergency room. Some examples:
• Fractures
• Sickle Cell Pain crises
• Lacerations
• IV access, venipuncture
• Lumbar punctures
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Nurse initiated guidelines
 Motrin
 Lortab
 LET
 Ela-max/LMX
 Upgrading the triage level
8
Topical Anesthetics - Intact Skin for IV
access, Venipuncture, Lumbar Puncture
 Ela-max or LMX- 4% lidocaine
• Coin sized amount rubbed into the area and
active at 20 minutes.
• Apply over intact skin and cover with a bioocclusive dressing.
• May be used over abrasions, burns, small
lacerations, and for abscess drainage
 Pain ease– Cools the skin rapidly to provide
analgesia
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Topical Anesthetics
 Viscous lidocaine 2%, Hurricaine Spray(20%
Benzocaine) – For oral procedures like peritonsillar
abscess
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LET(Lidocaine/Epi/Tetracane) in Triage
 Application of LET in triage significantly reduces
triage time
 Duration of application ranged from 20 to 125 minutes
with preservation of wound anesthesia
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Adjunctive techniques
 Child life therapist
 Distraction- video/books/music/singing
 Parental involvement/comforting with familiar
objects(blankets/toys)
 Sucrose pacifiers – Study done at Emory showing
significant decrease in pain scale in neonates <1
month
 Papoose/immobilization
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Where can we improve?
 Apply topicals for all children requiring IV,
venipunctures, LPs
 Trauma room
 Think about the babies - Sucrose
 Procedures
• Check the adequacy of LET for wounds
• Strongly consider sedation for any painful
procedure
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Goals
 Guard the patient’s safety and welfare
 Minimize physical discomfort or pain
 Minimize negative psychological responses to
treatment by providing analgesia, and to maximize the
potential for amnesia
 Control the patient’s behavior
 Return the patient to a state in which safe discharge is
possible
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89,
1110.
14
Definitions
 Minimal sedation
 Moderate sedation
 Deep sedation
 General Anesthesia
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Levels of sedation
 Minimal:
• Normal response to verbal stimulation with
reduction of anxiety. Cardio-respiratory reflexes
intact.
 Moderate
• Somnolence, responds to verbal stimulation may
need tactile stimulation.
• Airway and protective reflexes are protected.
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Levels of sedation
 Deep sedation
• Reduction in consciousness. Pt not easily
aroused by verbal and noxious stimuli. Respond
to painful stimuli
• Airway and protective reflexes may be preserved
or compromised.
 General anesthesia
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Moderate Sedation
 AAP/COD Definition:
Moderate sedation: a medically controlled state of depressed
consciousness that
(1) allows protective reflexes to be maintained
(2) retains the patients ability to maintain a patent airway
independently and continuously
(3) permits appropriate response by the patient to physical
stimulation or verbal command, e.g., “open your eyes”.
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89,
1110.
18
Deep Sedation
 “a medically controlled state of depressed
consciousness or unconsciousness from which the
patient is not easily aroused. It may be
accompanied by a partial or complete loss of
protective reflexes, and includes the inability to
maintain a patent airway independently and
respond purposefully to physical stimulation or
verbal command.”
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89, 1110.
19
General Anesthesia
 “a medically controlled state of unconsciousness
accompanied by a loss of protective reflexes, including the
ability to maintain a patent airway independently and respond
verbally to physical stimulation or command.”
 Typically, general anesthesia is not recommended for the ER,
or any outpatient setting.
American Academy of Pediatrics Committee on Drugs. Pediatrics 1992:89,
1110.
20
Candidates for Moderate and Deep
Sedation
 Before sedation is undertaken, an assessment is
necessary to decide whether they are appropriate
candidates for sedation.
 Candidates for sedation will require pre-procedural
assessments, which include a fairly extensive history
and a focused physical exam.
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ASA Score
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Class
Physical status
I
Healthy patient
II
Mild systemic disease, no functional limitation
III
Severe systemic disease that limits activity
IV
Incapacitating systemic disease that is a constant treat
to life
V
Moribund not expected to survive 24 hrs without an
operation
Candidates for Moderate and Deep
Sedation
 ASA Class I or II: Are frequently considered appropriate
candidates. Suitability for sedation is good to excellent.
 ASA Class III: Present with special problems which require
individual consideration in determining appropriateness.
Suitability is intermediate to poor: consider benefits relative to
risks
 ASA Class IV and V: Suitability is poor; benefits rarely out
weigh risks. Require a consultation with an anesthesiologist,
intensivist, neonatologist, or emergency medicine physician to
determine appropriate management.
23
Kraus, and Green: Sedation and anlagesia for procedures in children. NEJM
342:939,2000.
Physical Status Classification from the American Society of
Anesthesiologists(ASA)
 Examples of patients
• Class 1
Unremarkable PMHx
• Class 2
Mild asthma, controlled SZ,
controlled diabetes, anemia
• Class 3
Moderate to severe asthma, pneumonia,
moderate obesity, uncontrolled SZ or DM
• Class 4
Severe BPD, advanced degrees of
pulmonary, cardiac, hepatic, renal, or
endocrine insufficiency
• Class 5
Septic shock, severe trauma
Kraus, and Green: Sedation and anlagesia for procedures in children. NEJM
342:939,2000.
24
Candidates for Moderate and Deep
Sedation
 Infants that are at least 6 weeks old and were full
term(>38 weeks)
 Premature infants whose chronological age +
gestation age is greater than 52 weeks
 Healthy infants not meeting these criteria may be
candidates, but MUST be monitored a minimum of 12
hours without apnea post procedure to qualify for
discharge
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ASA Recommendations for fasting before elective
procedures
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Ingested material
Minimum fasting time
Clear liquids
2 hours
Breast milk
4 hours
Infant formula
6 hours
Non human milk
6 hours
Light meal
6 hours
Pre-sedation Assessment
 Allergies
 Medications
 Past History
 Last meal
 Events
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Physician Pre-assessment Form
 A quick history
 Focused Physical
exam including airway
assessment
 Previous anesthesia
Hx
 ASA Class
 Candidate suitable?
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Physician Consent Form
 Consent Forms specifically
designed for Moderate or
Deep Sedation
 Goes over risks of sedation,
specifically agitation,
oversedation, and
cardiorespiratory compromise
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Personnel
 “Sedation must be administered by personnel capable of rapidly
identifying and treating cardiorespiratory complications, including
respiratory depression, apnea, partial airway obstruction, emesis,
and hypersalivation. They must understand the pharmacology of
the sedatives they use and be proficient at maintaining airway
patency and assisting ventilation if needed.”
 “At least two experienced people medicating the patient.
 are required, usually a physician and a nurse or respiratory
therapist.”
 During the procedure, nurse or respiratory therapist, must have no
other duties except monitoring.
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Monitoring
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Blood pressure
Pulse
Respiratory rate
Airway status
Oxygen saturation-continuously
Pain assessment
Document each of the above every 5 minutes for the duration
of the procedure
Discharge Criteria
 Vitals are appropriate for age
 Child has appropriate activity for age
 Appropriately responds to verbal stimuli
 Oxygen saturation returns to normal baseline
 Maintains airway appropriately
 Modified Aldrete score of > 13
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Modified Aldrete Score
 Should have a
score of greater
than or equal to 13,
before discharge
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Discharge Criteria - Complications
 If a reversal agent is required the patient must be
observed for an additional 2 hours from the time the
reversal agent is given
 For prolonged complications, admission to the
appropriate area is recommended, i.e., floor or ICU
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Medications
 Benzodiazepines
 Barbiturates
 Narcotics
 Ketamine
 Propofol
 Etomidate
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Benzodiazepines
 Midazolam(Versed)
• The most commonly used sedation agent in children and
adults
• Excellent safety record
• Provides potent sedation, anxiolysis, and amnesia
• Shorter acting than other benzodiazepines
• Water soluble, so eliminates burning on administration IV
• May be given IV, PO, IN, IM, or PR
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Benzodiazepines
 Midazolam - Oral
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Dose is 0.5 to 0.75 mg/kg orally
Maximum doses are the same as for IV
Onset:
15-20 minutes
Duration :
60-90 minutes
Not easily titrated, may cause oversedation
Bitter aftertaste may cause noncompliance, (spitting out
dose)
• Now formulated as a oral syrup 2mg/ml
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Benzodiazepines
 Midazolam - Intranasal/Sublingual
• Dose is 0.2 -0.5 mg/kg intranasal or sublingual of IV
formulation
• Onset:
10-15 minutes
• Duration: 60 minutes
• Similar side effects as oral route
• Intranasal route burns when administered, and children
generally do not cooperate with administration.
• Sublingual has same problem with bitter taste as oral
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Benzodiazepines
 Midazolam -IV
• Dose: 0.05-0.1 mg/kg IV
• Onset: 1 to 3 min
• Duration: 10 to 30 min
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Benzodiazepines
 Midazolam - Important Considerations
• Has NO analgesic effect!
• May be reversed with flumazenil(0.01mg/kg IV)
• Contraindicated with narrow angle glaucoma and shock
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Barbiturates
 Pentobarbital-Nembutal
 Propofol – Diprivan
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Barbiturates
Side effects:
 Myocardial depression
 Hypotension
 Respiratory depression
 Bronchospasm- stimulate histamine release
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Pentobarbital - Nembutal
 Barbituate that is commonly used for radiologic
procedures like CT scans which require children to be
still.
 Dose:
• 2-6 mg/kg/dose PO/PR/IM
• 1-3 mg/kg/dose IV
• Max dose is 150mg
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Propofol
 Propofol - Alkyl phenol(Diprivan)
 Dose dependent levels of AMS, from sedation to
general anesthesia.
 Advantage of a rapid recovery time.
 Must be monitored extremely closely.
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Propofol – Important concerns
 Profound respiratory depressant, and causes apnea.
 May depress cardiac output and cause severe
hypotension
 IV site pain –requires mix of lidocaine and Propofol
with loading dose.
 Contraindicated in patients with egg or soybean
allergy.
 Dose:
• 2.5-3.5 mg/kg IV
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Propofol
 Requires intensive patient monitoring
• Pulse oximeter
• Cardio-respiratory monitor
• End tidal CO2
 Experience and familiarity of usage by physician
 Attending needs to be present during the entire
procedure
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Narcotics
Gold standard for pain management
 Fentanyl
 Morphine
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Fentanyl - IV
 Preferred opioid because of rapid onset,
elimination, and lack of histamine release
 Dose is 1-2mcg/kg over 3-5 minutes
 Titrate to effect every 3-5 minutes
 Onset:
1-2 minutes
 Peak effect:
10 minutes
 Duration: 30-60 minutes
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Fentanyl - IV
 Rapid IV administration can cause chest wall
rigidity and apnea
 Combination with benzodiazepines can cause
respiratory depression and dosage should be
reduced
 Respiratory depression may last longer than the
period of analgesia
 May be reversed with Narcan
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Morphine Sulfate
 Better for procedures that have a longer
duration(30 minutes or greater)
 Morphine dose is 0.1-0.2 mg/kg IV with a max of 15
mg/dose slow IV push. Titrate to effect slowly.
 Onset:
5-10 minutes
 Duration: 2-4 hours
 Same dose may given IM or SQ
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Narcotics
 Commonly used in combination with a
benzodiazepine (sedative-hypnotic), i.e.,
Versed, to potentiate effect and provide both
amnesia and analgesia
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Ketamine
 Provides both analgesia and sedation
 Preserves respiratory drive and airway protective
reflexes
 Helpful in pts with RAD-bronchodilator
 Maintains hemodynamic stability
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Ketamine
 Dose: 1 to 2 mg/kg/dose IV
2 to 10mg/kg/dose IM
 Onset: seconds
 Duration: 10 to 20 min for sedation
40 to 45 min for analgesia
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Ketamine - Complications
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Laryngospasm
Apnea
Hypersalivation
Vomiting
Agitation/Hallucinations/Emergence Reactions
Hypertension
Increased Intracranial and Intraocular Pressure
Ketamine - Contraindications
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Age of 3 months or younger
Active pulmonary disease or infection
Procedures resulting in large amounts of oral secretions or blood
History of airway instability, tracheal surgery, or tracheal stenosis
Intracranial hypertension(head injuries, hydrocephalus, mass)
Cardiovascular disease
Glaucoma or acute globe injury
Psychiatric illness
Full meal within 3 hours
Etomidate
CNS hypnosis – ultra short acting
• Hypnotic
• Unknown mechanism of action
• Imidazole ring
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Etomidate - Benefits
 Rapid IV induction
 Minimal hemodynamic instability
 Minimal respiratory depression
 Possible cerebral protection
 Indications:
• Procedural sedation
• RSI – Trauma, CHF
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Etomidate
Adverse reactions
• Nausea and vomiting – 5%
• Causes pain or burning at IV site
• Myoclonic movements, may stimulate seizure
activity
• Inhibits steroid synthesis
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Etomidate
CNS hypnosis – ultra short acting
• Dose: 0.2-0.5mg/kg IV
• Induction 0.3 mg/kg IV over 30-60 secs
• May redose with 0.1mg/kg every 5-10
minutes until procedure is completed or as
needed
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Etomidate
Important considerations!
• Pre-treat with fentanyl 1-2 mcg/kg to reduce
myoclonus
• Pre-treat with lidocaine 0.5mg/kg to
reduce burning with injection
• Contraindicated with seizure disorder
• Contraindicated in children< 2 y.o.
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Etomidate
• Duration 5-10 mins
• Full recovery in 30 mins
• Does not provide analgesia
• MAP unchanged
• Decreases ICP,CBF,and O2 metab rate
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Summary - Recovery
 Monitoring does not end with procedure
 Patient must be monitored until defined criteria for
discharge are met.
 Admission for observation may be indicated if a child
is over-sedated or has significant complications from
the sedation
62