PEDIATRIC SEDATION & PAIN MANAGEMENT

 

William F. Coombs, MD

Appropriate relief of pain and anxiety should always be a priority in the overall management of the acutely sick or injured child. Historically, the medical profession has done a poor job of alleviating such symptoms, preferring to focus on the diagnostic evaluation. This attitude has been especially prevalent when taking care of children.

Dramatic advances in procedural sedation techniques along with a greater understanding of the pharmacodynamics of available sedatives and analgesics have led to safer, more effective sedation and analgesia in children, making it easier to provide relief to those patients who require it. The Agency for Health Care Policy and Research, noting the widespread inadequacy of pain management has stated in its guidelines that it is the physician’s "ethical obligation to manage pain and relieve the patient’s suffering" and that such pain management should be at the core of every health care professional’s commitment.

 

GUIDELINES FOR PEDIATRIC SEDATION & ANALGESIA: The first attempts at developing guidelines to provide for uniform and safe management of patients requiring sedation and/or analgesia for diagnostic or therapeutic procedures occurred in 1985 when the National Institutes of Health (NIH) and the American Academy of Pediatrics (AAP) published consensus documents on procedural sedation. Subsequent revisions have attempted to accurately define the various states of sedation encountered when managing these patients. In 1996, the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists published their own guidelines which were in essence a compromise between those proposed by the various subspecialty societies. They rejected the term "conscious sedation", labeling it as imprecise and offered the following definitions, stressing that these states represent different points on a continuum and movement along this continuum can occur in any direction at any time:

 

 

ANALGESIA: Relief of perception of pain without intentional production of a sedated state.

SEDATION/ANALGESIA: Medically induced state of depressed consciousness during which there is a margin of safety wide enough to have a

reasonable expectation that the patient:

a. will be easily aroused

b. will maintain intact protective reflexes

c. will maintain patent airway independently

d. will have appropriate responses to stimulation, commands.

DEEP SEDATION: Medically induced state of depressed consciousness during which it is reasonable to expect that the patient:

a. may not be easily aroused

b. may developed partial or complete loss of protective reflexes

c. may loose ability to maintain independent airway

d. may be unable to respond appropriately to physical stimulation or verbal commands.

GENERAL ANESTHESIA: Medically induced state of unconsciousness during which the patient has:

a. complete loss of protective reflexes

b. inability to maintain independent airway

c. inability to respond to any stimulation or command.

 

Due to the nature of procedures performed in the emergency room, deep sedation is often needed to ensure an appropriate level of analgesia and cooperation. Besides attempting to define the various states of sedation, these guidelines also discuss the preparation that should be undertaken prior to the start of a procedure. It is important to note that these are not absolute rules but rather recommendations which may be adopted, modified, exceeded or rejected according to clinical needs and constraints*. The Joint Commission (JCAHO) does not recommend a specific set of guidelines, it simply mandates that hospitals develop institution-specific policies and procedures regarding procedural sedation that ensure all patients receive "one standard of care" regardless of what area of the hospital it occurs in.

 

PATIENT SELECTION AND MONITORING: Administration of sedatives/analgesics should occur in a facility suitable for appropriate evaluation and monitoring of the patient and for the performance of emergency resuscitative measures if needed. Monitoring and emergency equipment suitable for children of all ages and sizes must be available. This should include a positive-pressure oxygen delivery system, suction apparatus, blood pressure monitor, pulse oximeter, and an emergency crash cart. Reversal agents should be available at bedside when indicated. The practitioner responsible for administering the sedative and monitoring the patient must be someone other than the one performing the diagnostic or therapeutic procedure and should be appropriately trained and certified.

A full evaluation of the patient’s health and medical history should be performed, with consideration given to the physiologic reserve of the patient’s major organ systems, as defined by the ASA physical status classification. Patients who are ASA class I or II are frequently considered appropriate candidates for sedation/analgesia or deep sedation. Patients in ASA class III or IV present special problems that require additional and individual considerations.

 

Evaluation of the patient’s recent food and fluid intake must also occur. NPO guidelines are as follows:

a. Infants < 6 months: no milk or solids for 4 hours prior to procedure

b. Infants > 6 months: no milk or solids for 6 hours prior to procedure

All patients regardless of age are allowed to ingest clear liquids until 2 hours prior to the procedure. In emergent circumstances where NPO guidelines cannot be followed, sound clinical judgement should be exercised and the risks of aspiration vs. benefits of procedure should be weighed very carefully.

 

Most guidelines dictate that the following parameters are monitored carefully:

a. Oxygenation

b. Ventilation

c. Airway

d. Level of Consciousness

Proper documentation calls for the sedator to obtain appropriate informed consent from the parents and to record the patient’s vital signs, oxygen saturation as measured by pulse oximetry, medications given and any remarkable or unexpected events. The frequency of documentation varies with the level of sedation. It is recommended that the HR, RR, BP and O2 sat be recorded prior to the sedation, every 15 min. for sedation/analgesia, every 5 min. for deep sedation, and once again prior to discharge. After the procedure is terminated and sedation is no longer desired, monitoring and recording need to continue until the patient has recovered sufficiently to meet the following discharge criteria:

a. Cardiovascular function and airway patency are satisfactory and stable

b. The patient is easily arousable and protective reflexes are intact

c. The patient can talk and sit up (age appropriate)

d. Hydration is adequate

For the very young or special needs child who is incapable of the usual expected responses, the presedation level of responsiveness or a level as close as possible to the child’s baseline should be achieved. Appropriate discharge instructions include anticipatory guidance regarding sleep, diet and activity, as well specific instructions on how to access care in the event of untoward effects or unexpected complications.

 

PHARMACOLOGIC THERAPY: The ideal drug for sedation or pain control would be painless to administer and easily titratable by virtue of its fast and predictable rate of absorption, onset and duration of action. It would also be reversible, cheap and without side effects or contraindications. Unfortunately such a drug does not exist. There are however many drugs available that when used alone or in combination for the right indications are very effective and relatively safe. In selecting an agent, the physician must consider the effects desired, the risks and benefits and the logistics of administration for each situation. When pure sedation is the desired endpoint, agents such as benzodiapines and barbiturates are excellent choices. These agents however do not inhibit perceptions of pain and should never be used as the sole agent for pain management. They do block sensory input and can be used for painful procedures in conjunction with other agents to provide sedation as an adjunct to analgesia. Sedative analgesics such as narcotics on the other hand are excellent choices for painful procedures. Although they have varying degrees of sedation, they should rarely be used as a single agent for providing control for a painless diagnostic study. Combining different classes of agents can be used to produce an effect not present in either agent alone. Such combinations must be used with caution because they not only enhance desired responses but also adverse effects.

 

PURE ANALGESICS (non-narcotics):

Indications: Relief of mild to moderate pain

Complications: Gastritis, peptic ulcer disease

Specific Agents:

Acetaminophen: Pure analgesic agent with antipyretic properties. Standard Dose is 15mg/kg every 4 hours, can be given orally or rectally, and can be combined with narcotics such as oxycodone and hydrocodone.

Ibuprofen: Nonsteroidal anti-inflammatory agent with analgesic and anti-pyretic properties. Standard dose is 10mg/kg by mouth every 6 hours.

Ketorolac: Nonsteroidal anti-inflammatory agent best suited for relief of biliary and renal colic. Standard dose is 0.4-1.0mg/kg IV or IM.

 

PURE SEDATIVES:

Indications: Sedation for non-painful diagnostic or therapeutic procedures

Complications: Dose dependant respiratory depression

Hypotension

Paradoxical (disinhibitory) effects

Specific Agents:

Benzodiazepines:

Midazolam: Potent sedative with amnesic and anxiolytic properties, a rapid onset and short duration of action. Standard dose is 0.02-0.1mg/kg IV, 0.5-0.7mg/kg orally. When titrating intravenously remember that onset of sedation may take upwards of 2-5 minutes. Although uncommon, younger children might become more anxious and excitated rather than sedated. Whether this represents a paradoxical or disinhibitory effect and whether higher doses would eliminate this is not known.

Barbiturates:

Pentobarbital: Sedative agent best used intravenously for non-painful diagnostic studies. Onset of action is within 1-2 minutes, with duration of 30-60 minutes. Standard dose is 2-6mg/kg IV. It is recommended to start with an initial dose of 2mg/kg and titrate to effect with subsequent doses of 1-2mg/kg every 30 seconds as needed.

Thiopental: Ultra-short acting agent which can cause profound respiratory depression and hypotension. Standard dose is 3-5mg/kg IV or 25mg/kg rectally.

Methohexital: Ultra-short acting agent with dose-dependent respiratory depression and apnea but minimal associated cardiovascular side effects. Standard dose is 1mg/kg IV.

Others:

Etomidate: Ultra-short acting sedative hypnotic with onset of action less than 1 minute and duration of 3-5 minutes. Has minimal cardiorespiratory effects. Standard dose is 0.1-0.3mg/kg IV. There is minimal experience in pediatric sedation.

Propofol: Ultra-short acting sedative hypnotic with onset of action within one circulation time following IV administration. Patients are usually awake within 5-10 minutes upon termination of infusion. It has potent dose-dependent respiratory depressant effects and can produce significant hypotension with rapid bolus injection. It has high lipid solubility and is very painful to administer. Standard initial dose is 1-3 mg/kg followed by either repeated boluses or a constant infusion at 25-130 mcg/kg/min.

Choral Hydrate: Sedative hypnotic with a long history of safety in pediatrics. Onset of sedation is unpredictable and can be as long as 40-60 minutes. Recovery time is also prolonged and highly variable, limiting its use in the emergency setting. Standard dose is 25-75mg/kg orally or rectally.

 

SEDATIVE ANALGESICS:

Indications: Moderate to severe pain management

Complications: Respiratory depression, nausea, vomiting

Specific agents:

Narcotics:

Morphine: The "gold standard" against which all other narcotics are compared.

Standard dose is 0.1-0.2 mg/kg IV.

Fentanyl: The most potent of the commonly used narcotics, it has a rapid onset of action (1-10 minutes) and a relatively brief duration of 30-60 minutes.

It has less respiratory and cardiovascular depressive effects than other narcotics but can cause severe respiratory depression and apnea when combined with

benzodiazepines. Standard dose is 1-2 mcg/kg IV. Rapid boluses have been associated with chest wall rigidity and should be avoided.

Non-Narcotics:

Ketamine: It is unique among the sedative analgesics in that it produces a dissociative state between the thalamus and limbic systems, which is characterized by four features: sedation, analgesia, amnesia and catalepsis. It possesses positive inotropic and bronchodilatory effects with preservation of spontaneous respirations and protective airway reflexes. These qualities make it an ideal choice for outpatient procedures, with an excellent safety and efficacy record documented in over 11,000 children*10. The clinical state produced by Ketamine differs from other sedatives in that the patient’s eyes often remain open but with a disconnected stare and marked nystagmus. This "the lights are on but nobody is home" look can be disconcerting to parents and they should be forewarned prior to its administration. Potential side effects of ketamine include increased salivary and tracheobronchial secretions and emergence reactions. The former can be ameliorated by adding atropine (0.01mg/kg) or glycopyrrolate 0.005mg/kg, Max.0.25mg). The latter is uncommon in children under eight years of age and can be reduced by premedication with a benzodiazepine (midazolam 0.05mg/kg mixed in with the ketamine and anti-sialogogue of choice). Laryngospasm following administration of ketamine has been documented in small infants (<3mo) with respiratory tract infections and is therefore contraindicated in this patient population.

DPT cocktail: The most widely used "cocktail" for sedation in the pediatric patient has been the combination of Demerol, Phenergan and Thorazine. Its popularity stems from extensive past experience, reliability and ease of administration by a single IM injection. Recent reports questioning the safety of such combinations along with their unpredictable onset and significantly prolonged duration of action make them poor choices for procedural sedation in the emergency setting.

Inahalation agents:

Nitrous Oxide: The only inhalation agent in common use, usually in concentrations of 50% N2O, 50% O2. It is a safe, effective sedative analgesic with a rapid onset and short duration of action upon withdrawal. It is inexpensive and easy to administer by experienced hands. It is very operator dependent with a substantial learning curve. As with hypnosis, suggestion is very important and the patient must be well prepared in regards to expectations in order to increase efficacy. This method of sedation is best used in older children and adolescents who are more likely to cooperate.

REVERSAL AGENTS: Available for narcotics and benzodiazepines:

Naloxone (Narcan): Narcotic antagonist

Dose: 0.01 mg/kg - 0.1 mg/kg

How supplied: 1mg/ml, 0.4mg/ml, 0.02mg/ml vials

Flumazenil (Mazicon): Benzodiazepine antagonist

Dose: 0.3mg, repeat Q 1 minute to maximum of 3mg

How supplied: 0.1mg/ml; 5ml, 10 ml vials

NON-PHARMACOLOGIC THERAPY: The involvement of child life specialists in the management of pain and anxiety in the pediatric patient can be invaluable. By providing the patient with age-appropriate information regarding the procedures to be undertaken and teaching appropriate coping strategies, these specialists often succeed in lessening the child’s fear and anxiety, thereby reducing and occasionally eliminating the need for pharmacologic intervention. Distraction techniques such as listening to music with headsets or singing can also be powerful coping strategies. Finally, do not understimate the importance of parental support in reducing the child’s distress.

COMMON PITFALLS:

 

 

CLINICAL APPLICATIONS

 

 

DESIRED EFFECT

 

AGE

OPTIONS

Mod-Severe

Painful Condition

 

Infant

Child

Adolescent

Morphine 0.1-0.2 mg/kg IV
Painless Diagnostic Study Infant Pentobarbital 2-6 mg/kg IV
 

Painless Diagnostic Study

 

Child

Adult

Midazolam 0.1 mg/kg IV

0.5 mg- 0.7mg/kg PO

Sedation - Analgesia Infant

Child

Ketamine 3-4 mg/kg IM

1-2 mg/kg IV

Sedation - Analgesia Child

Adolescent

Fentanyl 1-2 mcg/kg IV combined with Midazolam 0.1 mg/kg IV titrate to effect

or

Nitrous Oxide Inhalation

 

APPENDIX I

 

SEDATIVES

 

SEDATIVE-ANALGESICS

 

MIDAZOLAM

PENTOBARB

THIOPENTAL

METHOXEXITAL

ETOMIDATE

PROPOFOL

FENTANYL

KETAMINE

CLASS Benzodiazepine Short Acting Barbiturate Ultra-short Acting Barbiturate Short acting

Barbiturate

Non-barbiturate Hypnotic Non-barbiturate Hypnotic Synthetic Opiate Dissociative Anesthetic
PEDS DOSE 0.5-.2 mg/kg 2-6 mg/kg 4-6 mg/kg 1 mg/kg IV .3-.4 mg/kg 1.5-3 mg/kg 1-2 ug/kg 0.5-2 mg/kg IV

2-4 mg/kg IM

ADULT DOSE .025-.05 mg/kg -- .5-1 mg/kg   .1-.3 mg/kg .5-1 mg/kg .5-1 ug/kg .5-1 mg/kg
ONSET 30 - 60 seconds 1 - 5 minutes 30 seconds 1-5 minutes 30 seconds 30 seconds 30 seconds 30 seconds
DURATION 15-80 minutes 30 - 60 minutes 3 - 5 minutes 3 - 10 minutes 5 - 10 minutes 5 - 10 minutes 30 - 60 minutes 5 - 15 minutes
EFFECTS - hypotension

- apnea

- skeletal muscle

relaxation

- anti-convulsant

- hypoxia

- apnea

- hypotension

- decreased ICP

- hypotension

- apnea

- decreased ICP

- bronchospasm

- Less cardio-

respiratory

effects than

Thiopental

-relative CV &

respiratory

stability

- myoclonus

- adrenal

suppression

 

 

- hypotension

- apnea

- antiemetic

- myoclonus

- anaphylaxis with

soy & egg allergy

- bradycardia

- apnea

- hypotension

(less than

morphine)

- chest wall

rigidity

- increased HR & BP

- airway reflexes

intact

- bronchodilation

- increased IOP & ICP

- emergence reaction

* NOTE: Reversal Agents

 

 

APPENDIX II

AMERICAN SOCIETY OF ANESTHESIOLOGISTS’

PHYSICAL STATUS CLASSIFICATION

 Class I: A normally healthy patient

Class II: A patient with mild systemic disease

Class III: A patient with severe systemic disease

Class IV: A patient with a severe sytemic disease that is a constant threat to life

Class V: A moribund patient who is not expected to survive, despite medical or surgical intervention

*Generally, patients with physical status category III or more may benefit from consultation with specialist with advanced airway skills and experience with sedation of such patients.

 

APPENDIX III

Appropriate NPO orders for Patient Undergoing

Sedation for Elective Non-Emergency Procedures

  1. Infants 0 to 6 months:

a. Solids until six (6) hours before procedure

b. Breast milk or formula until four (4) hours before procedure

c.     Clear Liquids (water, apple juice, flat 7-Up, Pedialyte) until two (2) hours before the procedure.

 

2. Ages 6 months and older*:

a. Solids, milk or formula until six (6) hours before the procedure

b. Clear liquids (water, apple juice, flat 7-Up, Pedialyte) until two (2) hours before the procedure.

For emergency procedures, sound clinical judgement should be exercised by the sedation credentialed physician in determining the appropriate time interval between last PO intake and sedation procedure. If possible, such patients may benefit from delaying the procedure and administering appropriate pharmacological treatment to reduce gastric volume and increase gastric pH. When proper fasting has not been assured the increased risks of sedation shall be carefully weighed against its benefits, and the lightest effective sedation should be used. An emergency patient may require protection of the airway before sedation.

 

APPENDIX IV

EMERGENCY EQUIPMENT AND MEDICATIONS

 Necessary On-Site Equipment

            IV catheters (16 to 24 gauge)

            Tourniquets, alcohol wipes, adhesive tape, assorted syringes

            Intravenous tubing and fluids

            Pediatric drip and regular drip, extension tubing, stopcocks, sterile gauze pads

 

 

Suggested Emergency Drugs

Oxygen Flumazenil

Atropine Naloxone hydrochloride

Epinephrine (1:1,000, 1:10,000) Hydrocortisone

Dopamine Methylprednisolone

Isoproterenol Diphenhydramine hydrocholoride

Phenylephrine Albuterol by inhalation

Sodium bicarbonate Glucose (50%)

Calcium chloride or calcium gluconate Aminophylline

Lidocaine Racemic epinephrine

Succinylcholine Ammonia spirits

Diazepam

Modified from the AAP Guidelines

  

 

APPENDIX V

SPECIAL CIRCUMSTANCES REQUIRING CONSULTATION

 Patient Factors:

 

Procedural Factors:

 

Miscellaneous Factors:

 

REFERENCES

Paris, PM Steward RD (Eds): Pain Management in Emergency Medicine: Appleton & Lange, East Norwark, CT, 1988.

Selbst SM, Clark M: Analgesic Use in the Emergency Department: Ann Emerg Med, 1990; 19:1010-13.

Wilson JE, Pendleton, JM: Oligoanalgesia in the Emergency Department: Am J. Emerg Med, 1989; 7:620-3.

Clinical Practice Guideline: Acute Pain Management: Operative or medical procedures and trauma. Agency for Health Care Policy and Research, US Department of Health and Human Services, AHCPR Pub. No. 92-0032. Rockville MD, 1992.

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatr 1992; 89:1110-15.

Sacchetti A, Schafermeyer R, Gerardi, M, Graneto J, Fuerst RS, Cantor R, Santamaria J, Tsai Ak, Dieckmann RA, Barkin R. Pediatric Analgesia and Sedation. Ann Emerg Med, February 1994; 23:237-50.

Wright SW, Chudnofsky CR, Dronen CR, et al. Midazolam Use in the Emergency Department. Am J Emerg Med 1990; 8:97-100.

Chudnofsky CR, Wright SW, Dronen SC, et al. The Safety of Fentanyl use in the Emergency Department. Ann Emerg Med 1989; 18:635-39.

Green SM, Nakamura R, Johnson NE. Ketamine sedation for Pediatric Procedures: Part 1 A Prospective Series. Ann Emerg Med 1990; 19:1024-32.

Green SM, Johnson NE. Ketamine Sedation for Pediatric Procedures: Part 2, Review and Implications. Ann Emerg Med 1990; 19:1033-46.

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