Analgesia
&
Conscious Sedation
Narges Daliri, M.D., FAAP
Consultant, Pediatric Emergency
KFSH & RC, Riyadh
Objectives
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Establish definitions.
Select patients.
Goals of procedure.
Discuss the need for institutional protocol.
Discuss equipment and staffing.
Discuss complications
Introduction
• Children are often brought to medical attention
due to painful conditions or they require
diagnostic or therapeutic procedures which are
painful or produce anxiety.
• A child’s pain is felt not only by the child but
also by the parents.
• Presence and severity of pain in infants and
children is underestimated by H.C. providers.
History of Inadequate Treatment
• “Brutane”, until recently, was the analgesic
and sedative most often used:
– total immobilization by several adults and a
papoose via brute strength.
Paris PM. Amer J Emerg Med 1989
Reasons For Inadequate
Analgesia/Sedation
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No ideal sedative.
Fear of side effects.
Fear of addiction.
Inadequate training.
Analgesia
• Patient experiences relief from pain without
sedation.
Non Pharmacological
Intervention
• Child Life Programs:
– Pre-procedural teaching and support.
– Guided Imagery.
– Distraction. (Bubbles, Music, Books)
Such programs:
• Relieve stress and anxiety associated with an
E.D. visit.
• Decrease upset behavior.
• Decrease medication requirement.
• Improve staff efficiency.
• Improve patient/parent satisfaction.
Local Anesthesia
• One of the most basic aspects of
pain control.
Local Anesthetics
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Lidocaine
TAC
LET
EMLA
Lidocaine
• Available forms:
– Viscous (2% & 4%) - Aerosol (1% spray)
– Gel (2%)
– Solution
• 0.5% (0.5mg/ml)
• 1% (10mg/ml)
• 2% (20mg/ml)
– Max. dose 5mg/kg
– Mixed w/ epinephrine provides vasoconstriction,
delayed absorption, decreased lidocaine toxicity.
– Mixed w/ NA bicarb. (9:1) Increases ph, decreases
burning sensation.
TAC
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Tetracaine, Adrenaline, Cocaine
Indication: Wound repair
Route: Topical
Onset: 10 - 15 min.
Duration: 1 hr.
Advantage: Painless application
Disadvantage: No M. membrane, No end
arterioles.
– Dose: 1.5 ml/kg of dilute solution.
LET
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Lidocaine, Epinephrine, Tetrocaine
Indication: Wound repair.
Route: Topical
Onset: 30 min.
Duration: 60 min.
Advantage: Painless application.
Disadvantage: No end arteriols.
Max Dose: 3 ml
EMLA Cream
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Lidocaine, Prelocaine
Indication: Dermal analgesia.
Route: Transdermal
Onset: 60 min.
Duration: 3 – 4 hrs.
Advantage: Painless application.
Disadvantage: Prolonged onset, meth hem.
Pure Analgesics
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Aspirin (10 mg/kg) P.O., rectal.
Acetaminophen (10–15 mg/kg) P.O., rectal.
Ibuprofen (5–10 mg/kg) P.O.
Ketorolac (Toradol) (0.8 mg/kg followed
by 0.4 mg/kg q6 hrs. IV or IM.
Sedative Analgesics
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Morphine (0.1-0.2 mg/kg) I.V., I.M., S.C.
Meperidine (1-2 mg/kg) I.V., I.M.
Codeine (1 mg/kg) P.O.
Fentanyl
Fentanyl (Sublimaze)
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Synthetic opioid.
Rapid onset.
IV, IM, PO (OTFC)
Dose 1 - 2 mcg/kg, Titrate to max of 5 mcg/kg.
Peak effect 1 - 10 min.
Duration of action 1 - 2 hours.
Side effects.
– Chest wall rigidity, larygospasm.
– Vomiting (with citrate lollypops).
Conscious Sedation
Definition
• A medically controlled state of depressed
consciousness that allows patients to
maintain:
– protective reflexes
– patent airway independently
– appropriate response to verbal and physical
stimuli
Goals of Sedation
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Guard patient safety.
Minimize pain of procedure.
Minimize fear and anxiety.
Control behavior.
Provide amnesia.
Indications
• Painful or anxiety producing procedures.
• Benefits outweigh the risks.
The Spectrum of Sedation
Patients may travel quickly in either direction along this spectrum!
Level of
Consciousness
Awake
Analgesia
Anxiolysis
Hypnosis
Protective
Reflexes
Present
Present
“Conscious
Deep
Sedation”
Sedation
Potential
Potential
Loss
Loss
ED/Transport Mgmt
General
Anesthesia
Total Loss
• Indications
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Fracture, dislocation reduction.
Pediatric Gyne .Exam
F.B. removal.
Laceration repair.
Others
Equipment
• Continuous monitoring:
– Level of consciousness.
– Pulse oximetry.
– Hemodynamics.
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Resuscitative drugs including O2.
Antidotes
Airway equipment.
Suction
Staffing
• Staff physician skilled in airway
management.
– To perform H & P, informed consent.
• R.N. independent observer.
– To monitor patient.
Sedation Protocol
Before
Procedure
Vital Signs
Baseline
Personnel #1
*Consent
(Performs Procedure)
*H & P
Personnel #2
(Monitors Patient)
*
During
After
Procedure
Procedure
Q 5 min.
Q 15 min.
*
*Records meds.
*Discharge
& Dosages
Instructions
Continuous Pulse Oximetry
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Emergency meds, O2
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suction and airway
equipment available
* = Present
KFSH Conscious Sedation Policy
• There must be a documented evaluation of
the patient’s anesthetic risk prior to
administration of conscious sedation using
the ASA rating.
ASA Classification Physical status classification of the American Society of Anesthesiologists
ASA CLASSIFICATION
MEDICAL DESCRIPTION OF PATIENT
COMMENTS
ASA I
No known systemic disease
May have consious sedation
without additional consultation.
ASA II
Mild systemic disease
May have conscious sedation
without additional consultation.
ASA III
Severe systemic disease(s)
Anesthesia consultation at
physicians's discretion
ASA IV
Severe systemic disease that is
a constant threat to life
Mandatory involvement of
Anesthesiology Department
Routes Of Administration
• Transmucosal
– Oral
– Nasal
– Rectal
• I.V.
• I.M.
The Ideal Sedative
• Effective
• Easy and painless to administer.
• Quick and predictable in onset and duration
of action.
• Without side effects.
• THE IDEAL SEDATIVE DOES NOT
EXIST!
Pure Sedative Agents
• Benzodiazepines
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Quick onset of action.
Anxiolytic
Muscle relaxant.
Amnestic
Side Effects
• Respiratory depression with rapid infusion.
• Hypotension
• Paradoxical inconsolability (up to 12%)
Midazolam (Versed)
• Rapid onset.
• Short duration 20 - 30 minutes.
• Dose
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IV 0.1mg/kg max. 5mg., onset 2 - 3 min.
Oral 0.5mg/kg, onset 20 - 25 min.
Intranasal 0.4mg/kg, onset 15 - 20 min.
Rectal 0.5mg/kg, onset 5 - 10 min.
Other Pure Sedatives
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Valium
Lorazepam
Pentobarbitol
Thiopental
Chloral Hydrate
Pentobarbitol (Nembutal)
• Dose, 2 - 6 mg/kg IV
• Duration of action, 2 - 3 hours.
• Side effects
• Respiratory depression.
• Hyperactivity
Chloral Hydrate
• May be administered PO or PR.
• No need for IV.
• Dose, 60 - 120 mg/kg. Best tolerated if given
75mg/kg initially repeated 25 mg/kg X2.
• Onset 20 - 30 min.
• Side effects
• Respiratory depression.
• Arrythmias
• Prolonged sedation.
• Hyperactivity / Vomiting
Propofol
• Experience in emergency department limited.
• Short acting, nonopioid sedative hypnotic.
• Dose, 1 - 2 mg/kg IV over 1 - 2 min followed by
infusion of 6mg/kg/hour.
• Duration, 8 - 11 min.
• Side effects
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Deeper sedation.
Cardiorespiratory depression.
Pain at injection site.
Contraindicated in patients with hypersensitivity to
eggs.
Ketamine
• Has been used over the past 20 years in the
ED with success and efficacy.
• Derivative of phencyclidine.
• Provides analgesia, sedation, amnesia.
• Protective airway reflexes preserved.
• Decreases bronchospasm.
• Dose
– IV 0.25 to 1 mg/kg loading dose followed by
0.5mg/kg q 3 - 5 min.
– IM 4 mg/kg
– PO 10mg/kg
– Onset of action. 1 minute.
– Duration of action. 20 - 30 min.
• Concomitent meds.
– Atropine 0.01mg/kg IV.
– Glycopyrrolate 5 mcg/kg IV.
– Midazolam 0.05mg/kg IV.
• Side effects.
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Increased secretions.
Increased HR and BP.
Emergence phenomenon.
Emesis
Increased intracranial and intraocular pressure.
• Contraindication
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Patients < 3 month old
Glaucoma
Thyroid disorder.
Psychosis
Head injury
Chronic lung disease.
Nitrous Oxide
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Colorless, odorless gas.
Used 50/50 mixture with O2.
Safe and effective.
Wash-out with 100% O2 for 5 minutes.
Patient controlled titration. (Demand Valve)
Onset of action, 3 - 5 minutes.
Duration 3 - 5 minutes.
• Action
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Mild analgesia.
Sedation, amnesia.
Anxiolytic
Detached attitude towards pain.
• Side Effects
– N. & V.
– Agitation
– Diffusional Hypoxia
• Contraindication
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Impaired mental status.
Pregnancy
Pneumothorax
Bowel obstruction.
Children < 5 years.
Full stomach.
Reversal Agents
• Naloxone
– Dose for reversal. IV or IM
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Titrate 0.01 - 0.1 mg/kg to desired effect.
May need multiple doses.
Onset of action 1 - 2 min.
Duration of action 20 - 60 min.
• Flumazenil
– Dose IV or IM
• Pediatrics 0.01 - 0.2 mg/kg (max. 0.2mg) May be
repeated. Half dose q 1 min.
• Adults 0.2 mg bolus to total 1mg. May repeat q 10
min.
• Onset of action 1 - 5 min.
• Duration of action 20 - 60 min.
Management of Complications
• Respiratory Depression
– Airway and breathing techniques
• Laryngospasm
– Succinylcholine and intubation
• Hypotension
– Fluid bolus
• Chest wall rigidity
– Narcan usually effective
– Succinylcholine and intubation
Patient Discharge Criteria
• Patient Discharge Criteria
• Return to baseline verbal skills.
– Understand and follow directions.
– Appropriately verbalize.
• Return to baseline muscle control function.
– If infant can sit up unattended.
– Children can walk unattended.
• Return to baseline mental status.
• Patient or responsible person with patient can
understand discharge instructions.
Discharge Instructions
Your child has been given some type of sedative
or pain medication as part of his or her ED visit
today. Medications of this type can cause the
child to be sleepy, less aware, not think clearly,
or more likely to stumble or fall. Because of
this he or she should be watched closely for the
next eight hours. In addition, please observe
the following precautions:
• No eating or drinking for the next two hours. If
your child is an infant he or she may be fed half a
normal feeding one hour after discharge.
• No play that requires normal childhood
coordination, such as bike riding, skating, or use of
swing sets or monkey bars for the next 24 hours.
• No playing without adult supervision for the next
eight hours. This is especially important with
children who normally are allowed to play outside
alone.
• No bath, showers, cooking, or using possibly
dangerous electrical devices such as curling irons
without adult supervision for the next eight hours.
If you notice anything unusual about your child
or have any questions, please call the ED
immediately.
“Pearls”
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Be familiar with a few techniques.
Be open to new ideas.
Use appropriate agent(s) for the situation.
Don’t forget the pain of minor medical conditions.
Incremental titration of dose to desired effect.
Flavorings for oral, sublingual, and nasal
preparations.
• Don’t forget high risk patients.
• Therapeutic dose is one that accomplishes the
therapeutic goal.
“Few things a doctor does are more
important than relieving pain. Pain is soul
destroying…the quality of mercy is
essential to the practice of medicine; here
of all places it should not be strained.”
Angell M. Nejm, 1982